Every finding on record at East Ridge Rehabilitation and Nursing Center

Based observations, record reviews, and interviews the facility failed to properly store medications in one (2nd floor medication room) out of two sampled, in one (3rd floor supply room) out one sampled, in four out of four medications carts sampled and for two (Resident #2 and Resident #4) out of three residents sampled. Observations included: Staff leaving medications and medication carts unlocked and unattended, controlled substance record not reconciled on the 2300 cart, unopened eye drops with instructions to refrigerate until opened and opened insulin with no open date stored in the 3400 medication cart, and expired medications contained in the 2nd floor emergency kit and 3rd floor supply room. There were two medication rooms, four medication carts, one supply room and 63 residents residing in the facility at the time of survey. The findings included:1) Observation on n 08/19/2026 at 9:26 AM of medication administration for Resident # 4 being completed by Staff D, Registered Nurse (RN) revealed Staff D, RN verified the physician's order, placed one Aspirin 81 mg tablet into a cup, closed the computer screen and locked cart, knocked on resident's door, entered room, introduced self and verified Resident #4's identity. Staff D, RN then placed the medication on top of the nightstand and went to the bathroom to wash hands leaving the medication unattended.Record review of Resident #4's clinical records revealed the resident was admitted to the facility on [DATE] with diagnosis that included: Displaced fracture of medial malleolus of left tibia.On 08/19/2026 at 9:33 AM, Staff D, a Registered Nurse, was questioned about the facility's policy regarding medication storage during administration. Staff D, RN replied, I am required to keep the medication within eyesight at all times.2) Observation on 08/19/2026 at 9:47 AM on the facility's 2nd floor revealed a bag of unattended medication on the 2400 medication cart.On 08/19/2026, at 9:55 AM, Staff E, RN returned to the medication cart and was informed of the identified concern. When asked about the facility's policy and procedure regarding medication storage, Staff E stated: The medications should be locked up. These medications are to go back to pharmacy.3) On 08/19/2026, at 9:47 AM, during a medication storage inspection conducted in the second-floor MED ROOM alongside the Assistant Director of Nursing revealed an Emergency Kit from the pharmacy containing 10 medications, including antibiotics, with expiration dates of July 2026.4) Observation on 08/19/2026 at 10:10 AM in the 3300 hallway an insulin was found on top of the nursing desk. Staff A, RN, was informed and stated: I left it there to return to the pharmacy because it is expired.5) On 08/19/2026 at 10:25 AM an inspection of the 3rd floor supply room with Staff C, LPN revealed eight bottles of expired over the counter medications. Staff C, LPN stated, The nurses and the central supply person checks when pills are received. The policy says no expired meds are to be stored.During an interview on 08/19/2026 at 10:48 AM the central supply personnel: Stated, I place the orders and then when I get the shipment and check the expiration dates. I also check the room every two weeks and dispose of expired medications.6) On 08/19/2026 at 10:36 AM, a cart check conducted with Staff D, RN on the 3400-medication cart revealed an unopened eye drop labeled for refrigeration and an opened Lantus insulin without an open date. Staff D, RN was unsure why the insulin was not dated and stated that the eye drop should be refrigerated and administered at night. During an interview on 08/19/2026 at 11:03 AM the Assistant Director of Nursing revealed nurses are to keep medications in eyesight at all times. Medications that need to be sent back to the pharmacy should be stored in the medication room until they are picked up. We use the emergency kit as a backup. All nurses are responsible for checking the medication room and if a nurse notices any expired medication, it should be removed. Medications should always be kept locked in the medication room or cart. 7) On 08/19/2026, at 12:02 PM a cart inspection was conducted with Staff B, RN on the 2300 cart. The cart was found to be unlocked, and two controlled substance logs for Alprazolam and Oxycodone prescribed for Resident #2 had not been reconciled to match the amounts in the bingo card.A review of Resident #2's Medication Administration Record dated 8/19/2026 at 11:20 AM showed that Alprazolam 0.25 mg tablets and Oxycodone 7.5-325 mg tablets were given to Resident #2. However, the last signature on the bingo card was recorded at 00:21 (12:21 AM) on 8/19/2026, and the remaining amount did not match what was documented on the form. Staff B, RN was questioned about the identified concerns and the procedures for reconciling controlled substances and medication storage. Staff B,RN stated: I am supposed to sign at the time I take out the pill and keep the med cart locked at all times.Review of Resident # 2' physician orders revealed orders order dated 8/13/2026 for oxycodone-Acetaminophen 7.5-325 mg; Give one tablet by mouth every four hours for non-acute pain and order dated 8/15/2026 for Alprazolam Oral Tablet 0.25 mg; Give one tablet by mouth four times a day related to Anxiety disorder. During an interview on 08/20/2026 at 5:50 PM the Director of Nursing stated: Medications should be locked in the medication carts, and the carts are to be locked, and the nurse keeps the key. Medications always need to be in the nurses' eyesight. There should not be any expired medications in the medication or supply rooms. There should be no expired medications on the medication cart. Record review of the facility's policy and procedure titled, Storage of Medication dated 03/01/2026 indicated: PolicyIt is the policy of East Ridge Rehabilitation & Nursing Center that all medications used in the care of residents - medications and treatments for sexually transmitted infections (STIs) - are procured, stored, secured, and monitored in a manner that protects resident safety, preserves medication integrity, and prevents diversion, in accordance with:42 CFRS483.45 and related F-Tags (F755, F756, F757, F758, F759, F760, F761) governing pharmacy services in long-term care facilitiesDrug Enforcement Administration regulations (21 CF Part 1301) governing controlled substancesState Department of Health / Board of Pharmacy regulations applicable to skilled nursing facilitiesThe facility's consultant pharmacist recommendations and Pharmacy & Therapeutics guidanceManufacturer storage and handling guidelinesInfection control, medication error prevention, and resident rights/confidentiality standards (including HIPAA)All medications, biologicals, and related supplies must be stored to protect against diversion, contamination, tampering, degradation, and unauthorized resident or visitor access.VI. PROCEDUREA. General Storage RequirementsAll medications shall be stored in locked medication carts, locked medication rooms/cabinets, or automated dispensing systems approved by the facility.Medication carts must be locked and either attended or secured (e.g., locked to a wall bracket or stored in a locked medication room) whenever the nurse is not directly at the cart. E. Controlled SubstancesSchedule II-V medications are stored in a double-locked system (a locked box or drawer within the already-locked medication cart or medication room).A perpetual inventory/count sheet is maintained for each controlled substance; counts are reconciled by two licensed staff at each shift change (change-of-shift count).Any discrepancy is reported immediately to the charge nurse, DON, and Administrator, and is investigated per facility policy and DEA/state reporting requirements.Destruction of discontinued, unused, or expired controlled substances is witnessed by two authorized staff (or performed via a DEA-registered reverse distributor) and documented on a controlled substance destruction record H. Emergency Medication Kit (E-Kit)The E-Kit is stored in a locked container within a secured area accessible to licensed nursing staff at all times.Contents are limited to the state-approved emergency drug list and are inventoried and sealed with a tamper-evident lock; the seal number is logged each shift.Any use of E-Kit contents requires a physician's order, immediate replacement request to pharmacy, and documentation in the resident's record and the E-Kit log.I. Expiration & DisposalExpired medications are removed from active stock immediately upon identification and placed in a designated, clearly labeled expired/destroy container pending disposal.Disposal of non-controlled medications follows state environmental and pharmacy board regulations (e.g., authorized take-back or reverse-distribution programs); controlled substances follow the witnessed destruction process in Section E.All disposal/destruction is documented with date, medication, quantity, method, and staff signatures.

Based on observation, interview and record review, the facility failed to promote dignity and respect for three Residents (Resident #48 and Resident # 4) out of 20 sampled residents. As evidenced by facility staff observed standing while feeding Resident #48 and observation of Resident #4's indwelling urinary catheter drainage bag without a privacy cover. There were 69 residents residing in the facility at the time of the survey. The findings include Resident #48 On 02/23/2026 at 8:51 AM, Staff D, Certified Nursing Assistant (CNA) was observed standing next to the bed feeding Resident #48 from the breakfast tray located on the overbed table in front of the resident. Staff D, CNA and Resident #48 were the only persons in the room at the time of the surveyor's observation. Review of Resident #48's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Traumatic Subarachnoid Hemorrhage without loss of consciousness, subsequent encounter. Interview on 02/23/2026 at 8:51 AM, Staff D, CNA stated: I know I am supposed to be sitting and feeding the resident, the resident's husband was using the chair, that is why I was standing up. Review of the facility policy and procedure titled Meal Services and Dignified feeding assistance dated 07/2025 states: The facility shall provide meal services in a safe, sanitary, dignified, and homelike manner that promotes resident choice, infection prevention, nutritional adequacy, and respect for individuality. All staff assisting with meal service and feeding must: Follow proper food handling and infection control techniques. Promote dignity by sitting at eye level when assisting residents. Provide meals in a manner that enhances resident choice and self-determination. Resident #4 Observation on 02/25/2026 at 09:23 AM revealed Resident #4's indwelling catheter drainage bag was visible from the hallway without a privacy bag in place and was anchored to the left side of the bed Record review of Resident #4's clinical records revealed the resident was admitted on [DATE] with a re-entry on 10/15/2025 with a diagnosis of obstructive and reflux uropathy. Physician orders dated 2/18/2026 through 2/24/2026 indicated the resident has an indwelling urinary catheter for urinary retention. Review of Resident #4's admission Minimum Data Set, dated [DATE] indicated the resident had moderate cognitive impairment, uses a wheelchair and requires partial to moderate assistance activities of daily living. Review of the care plan dated 1/29/2026 identified the resident as having an indwelling catheter related to obstructive uropathy and included interventions to monitor intake and output, assess tubing for kinks each shift, monitor for signs and symptoms of urinary tract infection and catheter-related complications Interview on 02/25/26 at 11:25AM, Staff F, Certified Nursing Assistant revealed indwelling urinary catheter drainage bag should be inside a privacy bag and then attached to the side of the bed, it is not ok to see the bag when you walk into the room and the visible urine. Interview on 02/25/2026 at 11:32AM, Staff E revealed urinary drainage bag should not be touching the floor and it should be covered with a privacy bag.

Based on observations, record review and interviews, the facility failed to provide safe and secure storage of biologicals for two Residents (#20 and #83) out of 20 residents sampled. There were 69 residents residing in the facility at the time of the survey. The findings include.Resident #20During the initial observational tour of the facility on 02/23/2026 at 8:46 AM Resident #20 was in bed awake, there was one ointment on the bedside table and one cream on top of the dresser.On 02/24/2026 at 8:00 AM Resident #20 was in bed asleep, an ointment remained on bedside table (Photographic evidence) Resident # 83On 02/23/2026 at 8:59 AM Resident #83 was observed in bed awake, bed in the lowest position, a bottle of eyedrops on the overbed table (Photographic evidence available)On 02/24/2026 at 8:04 AM three (3) tubes of biologicals observed on the bedside table (Photographic evidence available)On 02/25/2026 at 8:17 AM Resident #83 was in bed asleep, wheelchair next to the bed, a bottle of eyedrops on the overbed table. Interview on 02/25/2026 8:21 AM Registered Nurse (Staff C) assigned to the 2300 and 2400 unit stated: During my rounds if medications are found in the residents' rooms-if the resident is alert and oriented, I ask the resident about the medication and educate the resident about all medications needing to be stored on the nursing cart, any narcotics found are reported to the nursing supervisor for further investigation. Interview on 02/25/2026 at 8:24 AM Certified Nursing Assistant (Staff B) stated: If I find any medications in the residents' rooms, I notify the nurse of my findings. Interview on 02/25/2026 at 9:13 AM Certified Nursing Assistant (Staff A) stated: During rounds or at any time on my shift, if I find medications in the residents' room, I notify the nurse and follow up to make sure the medications are removed from the room. Review of the facility policy and procedure titled Medication Labeling and Storage revision date 02/2023 states: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.Policy Interpretation and ImplementationMedication Storage4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observations, interviews, and record review, the facility failed to demonstrate that effective action plans were implemented and sustained to correct identified quality deficiencies related to repeated deficient practice for F761 Label/Store Drugs and Biologicals. There were 69 residents residing in the facility at the time of the survey. The findings include. Review of the facility's survey history revealed that during a recertification survey with an exit date of 02/19/2025, the facility was cited under F761 - Label/Store Drugs and Biologicals after failing to ensure appropriate storage of medications on the medication cart for one of three medication carts observed. Observation revealed loose pills in different compartments of the medication drawer and the narcotics lock box was left unlocked in one of two medication rooms. During the current survey with an exit date of 02/26/2026, repeated deficient practice was identified under F761 Label/Store Drugs and Biologicals. Related medications and biologicals at two residents' bedsides. Interview on 02/26/2026 at 2:03 PM, the Director of Nursing (DON) revealed the facility has a Quality Assessment and Assurance (QAA) Committee that meets at least quarterly; however, meetings are held monthly on the first Thursday of each month, with the last meeting conducted on 02/19/2026. The QAA committee includes the required members such as the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Admissions, Social Services, MDS, Activities, Dietary, Wound Care, Restorative Nurse, Infection Preventionist, Therapy, Central Supply, Housekeeping, Maintenance, Committee Physician, Pharmacy, and other department representatives. The purpose of the QAA committee is to identify potential risks and benefits, determine when a process or intervention is not working effectively. Issues within departments are identified through routine communication and meetings; when concerns arise, meetings are called as needed, and periodic QAPI meetings review quality measures to support ongoing performance improvement. The Administrator, DON, and Medical Director meet frequently to address quality concerns, and a daily morning clinical meeting is held to discuss residents' clinical The DON stated the QAA committee determines issues to focus on based on safety risks, infection control concerns, and staff education needs identified during routine monitoring. Review of policy and procedure titled QAPI Program Systematic Analysis and Systemic Action issued on 11/28/2019, revised on 10/23/2025 revealed that the facility will take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

Based on observation, record review and interviews, the facility failed to follow infection prevention and control procedures for the environment and three Residents (Resident #17, Resident #20 and Resident, #83). As evidenced by Two Urinals, one Spirometer, and one Adult Brief were not stored in compliance with infection control standards. There were 69 residents residing in the facility at the time of the survey. The findings include.During the observational tour on 02/24/2026 at 7:42 AM an Adult Brief was observed stored between the wall and the handrail in the 2300 hallway next to room [ROOM NUMBER] (photographic evidence). On 02/24/2026 at 7:56 AM Resident #17 was in bed with eyes closed and the Spirometer stored on the overbed table was uncovered.On 02/25/2026 8:19 AM Resident #17 was in bed with eyes closed and the Spirometer remained stored on the overbed table uncovered. Observation on 02/24/2026 at 8:00 AM revealed Resident #20 in bed awake there was an uncapped Urinal on the bedside table.On 02/25/2026 at 8:10 AM Resident #20 was in bed with eyes closed and an uncapped Urinal was observed on the bedside table. On 02/23/2026 at 8:59 AM Resident #83 was in bed awake, an uncapped Urinal was on the bedside table.On 02/24/2026 at 8:04 AM Resident #83 was in bed asleep, there was an uncapped Urinal on the bedside table partially filled with a yellow-colored liquid.On 02/25/2026 at 8:17 AM Resident #83 was in bed asleep, there was an uncapped Urinal on the bedside table partially filled with a yellow-colored liquid. Interview on 02/25/2026 at 8:21 AM Registered Nurse (Staff C) assigned to the 2300 and 2400 units stated: Oxygen equipment to include mask, tubing, and Spirometers when not in use are stored in clear plastic bags. The oxygen equipment is changed every Friday night and placed in clear plastic bags labeled with the date. Urinals are stored in a clear plastic bag covered in the bathroom. At bedtime the urinals are stored on the bedrails with a cover on top for use. Soiled briefs are disposed of in a closed plastic bag in the soiled utility room bin. This is to prevent cross contamination between residents and risk of infection for staff and residents.' Interview on 02/25/2026 at 8:24 AM Certified Nursing Assistant (Staff B) revealed oxygen equipment when not in use is stored in a clear plastic bag in the resident's drawer; urinals are stored in the bathroom in clear plastic bags when not in use, dirty adult briefs are placed in the soiled utility room for pick up by housekeeping to prevent infection control issues. Interview on 02/25/2026 at 9:13 AM Certified Nursing Assistant (Staff A) stated urinals are stored in a clear plastic bag in the bathroom. Soiled diapers are disposed of in a closed plastic bag in the soiled utility room bin. Oxygen equipment when not in use is stored in a clear plastic bag in the resident's drawer. This is done to avoid contamination or infection issues. Review of the facility policy and procedure titled Infection Control Prevention and Control Program dated 02/21/23 states: The facility shall establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observations interviews and record review, the facility failed to provide appropriate storage of medications on the medication cart for one (1) of three (3) medication carts observed. As evidenced by during observation of one out of three (3) medication carts loose pills were noted in different compartments of the medication drawer and in one out of two medication rooms Narcotics Lock Box was left unlocked. There were 74 residents residing at the facility at the time of the survey. The findings included: On 2/17/25 at 9:00 AM during observation of medication Cart # 3400 with Registered Nurse (RN), (Staff C), three (3) round white pills and several pieces of empty medication packaging were found in the second drawer of the medication cart. Interview on 02/17/2025 at 9:05 AM Registered Nurse (RN), (Staff C) revealed she would don gloves, pick up the pills, try to identify the pills and dispose them in the drug buster in the medication cart. Furthermore, the medication carts are cleaned daily on every shift. On 02/17/25 at 10:00 AM, observation of the medication storage room on the facility's second floor with the Assistant Director of Nursing (ADON) (Staff A). The narcotic lock box in the medication refrigerator noted unlocked. The ADON, Staff A attempted to close the lock box with several keys available and was unable to close the lockbox. The lockbox contained an emergency kit with 5 vials of insulin and one (1) vial of Ativan. Interview on 2/17/25 at 10:00 AM ADON, Staff A stated: The lock for the narcotic lockbox in the refrigerator is warped (unable to be locked), I will need to put a work order in for it to be repaired, this issue was not reported to me prior to today. Review of the facility policy and procedures titled Storage of Medications revised April 2007 states: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 1.Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation interview and record review the facility failed to follow pharmaceutical procedures as per facility policy. As evidenced by during observations of one of two Medication storage rooms reviewed, the narcotics lock box in the medication refrigerator was noted unlocked. and Resident #180's medication was being given in tablet form and the order documented capsule. There were 74 residents residing at the facility at the time of the survey. The findings included: On 02/17/25 at 10:00 AM during observation of the medication storage room on the facility's second floor with the Assistant Director of Nursing (ADON); the narcotic lock box in the medication refrigerator was left unlocked. The lock box contained an emergency kit with 5 vials of insulin and one (1) vial of Ativan The ADON, attempted to close the lock box with several keys available and was unsuccessful unable to close the lockbox. Interview on 2/17/25 at 10:00 AM, the ADON stated: The lock for the narcotic lock box in the refrigerator is warped (unable to be locked), I will need to put a work order in for it to be repaired, this issue was not reported to me prior to today. On 2/17/25 at 9:20 AM during medication administration observation for Resident #180 with Licensed Practical Nurse (LPN), (Staff B) the Electronic Medication Administration Record (EMAR) documented Meloxicam 7.5 Milligram (MG), give 1 capsule twice a day for pain. Review of Resident #180's Bingo Card for Meloxicam 7.5 MG documented Meloxicam 7.5 MG, give 1 tablet twice a day for pain. Interview on 02/17/25 at 10:32 AM regarding the Meloxicam 7.5 MG tablet, Staff B, LPN stated: I will call pharmacy to verify the order, if the order should be capsule or tablet. The resident has been administered tablets since 2/7/25 twice a day. Interview on 02/17/25 at 10:32 AM; the facility's Consultant Pharmacist stated: The Meloxicam 7.5 MG tablet can be given to the resident with physician authorization because it is the same dose, and we can get an order to correct the EMAR, chances are the documentation is human error. Review of the facility's policy and procedure titled Storage of Medications revised April 2007 states: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Review of the facility policy and procedure titled Administering Medications revision date 12/2012 states: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 3. Medications must be administered in accordance with the orders, including any required time frame. 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right route of administration before giving the medication.

Based on record review and interviews, the facility failed to ensure one (Resident #2) out of three sampled residents received care and treatment in accordance with professional standards of practice related to the timely reporting of a fall to the resident's physician resulting in a delay in care for a fracture. X-rays at the hospital revealed Resident # 2 incurred an acute fracture involving the right superior and inferior pubic rami. There were 69 residents residing in the facility at the time of the survey. The findings included: Review of the facility's policy and procedures titled, Provision of Quality Care date issued: 4/18/2023 states: Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. Policy Explanation and Compliance Guidelines: 1. Each resident will be provided with care and services to attain or maintain his/her highest practical physical, mental, and psychosocial well-being. 2. A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan. 3. Responsibility for interventions on the care plan will be clearly identified. 4. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the residents' care plan, and the residents' choices. 5. To ensure persons are qualified, department heads, in collaboration with facility leadership and the HR department, will be responsible for verifying credentials of all employees prior to hire, and oversight to ensure ongoing employee competency, and education regarding areas of employee weaknesses. 6. Policies and procedures will reflect current professional standards of practice. All employees are responsible for following established policies and procedures. b. Violations of policies and procedures will result in disciplinary action up to and including termination. During observation on 01/06/25 at 9:50 AM, Resident #2 was in bed awake, bilateral floor mats were present, the bed was in its lowest position, the call light was on the bed, there was no distress noted from the resident. On 01/07/25 at 8:10AM, resident #2 was in the wheel chair in the residents room receiving care, there was no distress noted. On 01/08/25 at 7:53AM, resident #2 was sitting at the side of bed receiving care from the Certified Nursing Assistant (CNA) (Staff D), the resident had nonskid socks and shoes on feet. The bilateral floor mats were present, no distress noted. Review of the medical records for Resident #2 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Superior rim of Right Pubis Fracture, History of Venous Thrombosis and Embolism, Contusion of other Urinary and Pelvic Organs, Generalized muscle Weakness, Other Abnormalities of Gait and Mobility, Pain. Resident #2 was discharged to the hospital on 12/21/24 and readmitted on [DATE]. Review of the Physician's Orders Sheet for January 2025 revealed, Resident #2 had orders that included but were not limited to: May use protective devices as needed such as floor mats, May use protective devices as needed heel floaters, Falls Risk Assessment (Quarterly), Bilateral floor mattress apply while resident in bed every shift. Medications included: Tramadol 50 mg tablet, 1 tab By Mouth Every 6 Hours as needed for Pain. Record review of Resident # 2's Annual Minimum Data Set (MDS) dated [DATE] revealed, Section C for Cognitive Patterns documented Brief Interview for Mental Status Score is 6 on a 0-15 scale indicating the resident is cognitively impaired. Section GG for Functional status documented the resident is dependent for care and requires assistance with mobility. Section H for Bowel and Bladder documented the resident has a ostomy and is always incontinent of bladder. Section J for Health Conditions documented no falls since readmission, no pain medications received in the last 5 days. Section N for Medications documented resident is receiving antianxiety, antidepressant, anticoagulant, and Hypoglycemic medications. Section O for Special Treatments documented no special treatments received. Section P for Restraints documented no alarms or restraints used. Record review of Resident #2 's Care Plans Reference Date 12/25/24 revealed: Resident have a potential for complications related to fractured status post fall with left hip fracture. Closed fracture of left superior and inferior pubic ramus and femoral. History of Right Femur fracture, Status post Fall sustained pubic ramus fracture. Resident will remain free of complications such as infection related to fracture through next review Interventions-Please provide me with patient teaching regarding my fracture and prevention of further incidents, Please keep my physician informed of any changes in my condition, Please monitor for edema to my affected extremity, Please monitor my vital signs. Resident has a potential to fall related to: Impaired mobility, Impaired balance and gait. History of falls; Psychotropic drug use, status post fall sustained superior and anterior pubic ramus fracture. 09/25/23 Resident had an actual fall. Resident was observed ambulating without assistance and fell . 11/10/23 Resident was found on the floor in the bathroom. 03/01/24 Resident was found on the floor in the room. 06/19/24 Resident was found on the floor in the room. 12/06/24 Resident was heard yelling out from the room, found next to the bed, sitting straight up on her bottom. 12/20/24 Resident was observed on floor near the bed, laying on her right side. Resident would like to remain free from injury through date of next review. Interventions: May use floor mats next to bed per orders. Bilateral floor mattress apply while resident is in bed. Please be sure that my personal belongings are within my reach. Please take me to the toilet before and after my meals as well as before and after my activities. Please remind me to lock my wheelchair brakes and to ring for assistance when I need to transfer. Fall precautions: Keep my room clutter free and well lit. My call light within reach. My bed in low locked position. Review of the nursing progress notes for Resident #2 documented, 12/20/24 at 19:17(7:17pm), the resident was medicated with Tylenol 500mg X 2 tabs at approximately 9:30 am for (L) knee pain with a pain level of 6/10. Reevaluated one hour later the resident denied pain. The oncoming nurse to continue to monitor pain to (L) knee as the resident was observed holding the knee at times during the shift. 12/20/24 at 23:35(11:35pm), 911 dispatched to facility, family at bedside with resident, per family request refused transportation to hospital, under monitor and rounding, awaiting STAT Xray from [ ]Care. 12/21/24 at 6:48 AM, Results of Xray to skull, Right knee, Pelvis/hip revealed - demonstrate no acute fracture, results sent to resident's Physician (MD). Resident continue to yell for pain to right side during movement, propel with pillows and kept comfortable. Daughter at bedside, pain management in place. Colostomy in place and active, stoma is pink and moist, cleaned and kept dry. Bed in lowest position with call bell placed within reach. Safety measures maintained. 12/21/24 at 1:33PM, Stat Xray of Right knee, Skull and Pelvis done in facility as per order, resident yelling in pain when x-ray was being done, went to sleep immediately after x-ray was completed. Daughter at bedside. Bed in lowest position with call bell place within reach. Safety measures maintained. 12/21/24 at 17:44(5:44pm) Resident received in bed with her daughter in recliner at the bedside. Vitals within Normal Limits, Temperature 97.6, respirations unlabored. Daughter stated the resident has pain on movement to her leg. All routine meds provided and tolerated. Resident was medicated with Tylenol 500 mg X 2 for pain, blood sugar monitored, and coverage given as needed. Daughter assisted with breakfast, resident ate approximately 50 %. Instructions received from physician to send the resident to the hospital report from [ ]Care stated the resident's right superior and inferior pubic rami are not diagnostically visualized and not cleared for an acute finding .further evaluation by Computed Tomography (CT) Scan is needed. Daughter/ granddaughter requested the resident be sent to the hospital. All necessary documents were prepared, and a call was placed to the ambulance service. Resident left the facility at approximately 10:30 am with the ambulance service. Resident's daughter was informed of time of transfer to hospital. The Nursing Supervisor also informed of the time of transfer to the. The resident's daughter called at approximately 3:45 pm to inform the nurse the resident will be kept overnight as there's a hematoma to the thigh and Labs will be done, if there's internal bleeding the resident will remain in the hospital, Registered Nurse appreciated the call. Review of x-rays completed at the facility on 12/21/14 at 1:45 AM revealed: Pelvis Views- The non-visualized portion cannot be fully cleared without additional radiographs. Similar old left inferior pubic ramus fracture. Conclusion: 1. Moderate bilateral hip arthrosis. No obvious or acutely displaced fracture given only a single view. 1. Without an orthogonal view, a nondisplaced out of plane fracture cannot be excluded. Additionally, due to positioning, the right superior and inferior pubic rami are not diagnostically visualized and can therefore not be cleared for an acute finding. 2. Given the history of trauma, there should be low threshold for further evaluation by CT scan. Review of x-rays completed at the hospital on 12/21/24 at 3:32AM revealed: Pelvis View- Findings/Impressions-Diffuse severe bony demineralization reduces anatomic sensitivity. Acute fractures are suggested involving the right superior and inferior pubic rami. Review of the facility's Falls list dated 01/01/24-01/01/25 revealed: Resident was listed on the Incident/Falls List; 3/01/24, 12/20/24. Review of the Resident #2 Fall Risk assessment revealed: the most recent assessments were completed on: 12/26/24-Score 13 indicating resident is at high risk for falls 11/06/24- Score 14 indicating resident is at high risk for falls 09/08/24-Score 17 indicating resident is at high risk for falls Review of the Facility's Abuse/ Neglect Log from January 2024-January 2025 revealed: Resident was listed on Neglect Log 12/2024; Resolution: Unsubstantiated Review of the facility in-services revealed: Abuse/Neglect Training-Reviewed, most recently completed for all nursing staff on 12/20/24-12/21/24, 10/17/24-10/30/24, 8/26/24-8/27/24. Accidents/Hazards-Falls, Fractures: Reviewed, most recently completed for all nursing staff on 12/20/24-12/21/24, 10/17/24-10/30/24, 8/26/24-8/27/24. Interview on 01/07/25 at 10:34 AM Director of Nursing (DON) Risk Manager/Grievance Coordinator stated once a fall occurs with a resident, the nurse assesses the resident, provide the care the resident needs in the moment, reach out to the Physician (MD) to inform the MD of the incident, receives any necessary orders from the MD depending on the nature of the fall and the findings of the nurse-pain, discomfort, type of fall, injuries. The MD may order x-rays, resident transport to hospital, neurological checks for the resident etc. The nurse should report the incident/fall as soon as possible after care is rendered to the resident and the resident is safe. In this incident, the nurse did not report the incident in a reasonable amount of time to the MD. The resident fell on [DATE] around 3 AM, Licensed Practical Nurse (LPN) (Staff A) reported the incident on 12/20/24 around 8pm when she arrived for her next shift, she worked the 7PM-7AM shift, and she had the same assignment as the prior shift. Once the incident was reported by Staff A, the MD and family were called, the MD ordered resident to be sent to the hospital, the family declined the MD's orders, the MD ordered x-rays of the hip and pelvic area, the x-rays were inconclusive. After further discussions with the family, they agreed to send the resident to the hospital on 12/21/24. We stayed in communication with the hospital and the family, there was some concern about the resident's hemoglobin and the family later advised us that the resident had a fracture of the right superior and inferior pubic rami. On 12/20/24, Staff A was removed from the schedule; and has not returned to work as of today, we reported the incident as neglect to all the pertinent agencies and personnel. Our investigation concluded that Staff A failed to report the fall in a timely manner, but we could not conclusively report if the untimely reporting of the incident caused any harm to the resident. The 7AM-7PM Registered Nurse (Staff C) reported the resident was acting differently and complained of knee pain, upon further assessment by Staff C, the resident did not complain of any pain, I reached out to the resident's daughter and the daughter stated the resident did not report any issues or pain to her. This incident/fall was reported as neglect because Licensed Practical Nurse (LPN) Staff A did not follow the fall protocols of notifying the MD and other facility staff in a timely manner, the incident was not reported as an adverse incident because the injury was not the fault of the facility, all the necessary fall precautions were in place for the resident, the resident is a high risk for falls based on her fall assessment score which is completed quarterly and as needed, the bed was in lowest position, personal items were in reach, rounding was completed at minimum every 2 hours, call lights were being answered immediately, and bilateral floor mats were in place. This resident and the family were educated on fall precautions and the importance of calling for assistance for toileting and transfers when needed. The resident also participates in activities throughout the day at the facility and is closely monitored by staff. The resident was readmitted to the facility on [DATE] with a diagnosis of Acute superior and inferior pubic rami fracture with hematoma in the right hemipelvis. Plan of care: Non-surgical management, Physical therapy, Occupational therapy, and pain control. On 1/7/25 at 11AM, attempted to contact Staff A via phone, a message left for a return call. Interview on 01/08/25 at 9:45AM with the Administrator (NHA), it was reported I received information from staff about Resident #2's fall around 11:30PM on 12/20/24. I spoke with the DON and gave instructions for the Staff A to be sent home, I called the resident's daughter because I saw her number on my phone as missed call and we discussed the fall that happened with her mother. The resident's daughter did not want the resident to go to the hospital that night. On 12/21/24 when I came into work I saw the resident's daughter leaving the facility, we had a conversation in the parking lot, at that time the results of the facility x-rays had come back and there was no fractures but a recommendation for a CT Scan, the resident's daughter agreed to send her to the hospital after our conversation. On 12/21/24 later in the day and the next day, I called the resident's daughter for an update on the resident and to see if she needed anything. On Sunday night 12/22/24, I received a text from the resident's daughter stating the hospital's CT scan showed a pubic fracture and her mother has to be seen by an orthopedist. On 12/25/24, the resident was readmitted to the facility. This incident was not reported as an adverse incident because the facility had all fall precautions in place for this resident, patient teaching, the lowest bed, bilateral floor mats, non-skid socks, rounding and monitoring with supervision. We reported the incident as neglect because the nurse did not report the incident in a timely manner to the pertinent facility staff, but did complete an assessment and care for the resident immediately after the fall occurred. Staff A was taken off the schedule immediately, and the facility has since terminated her employment. Interview on 01/08/25 at 11:30AM via telephone with Certified Nursing Assistant (CNAs) (Staff B) whom worked on the 11-7PM shift stated, the resident #2 was assigned to me the night she fell , I was in the resident's room about 30 minutes prior to her falling, I heard the resident screaming around 3 AM, myself and the Staff A went into the resident's room, the resident was on the floor at the foot of the bed, we placed the resident back in the bed, the nurse started to assess the resident and checking her body, the resident was then placed in the wheelchair and placed in the recreation area by the nursing station to be closely monitored throughout the night. After the resident was placed in the wheel chair, I went back to my assigned duties for the rest of my shift. Interview on 01/08/25 at 11:40AM via telephone with LPN Staff C whom worked on the 7AM-7PM shift stated on 12/20/24 at the beginning of my shift the resident was sitting by the television area in her wheelchair, she was restless, I asked Staff A what was going on with the resident, she stated the resident was very restless throughout the night, and she gave her the prescribed medication Xanax, during my shift the resident complaint of pain to her knee once, I do not remember which knee it was, I gave her Tylenol and she was doing well, I did not have any other issues with the resident. I found out the next day when I came to work that the resident had fallen out of bed the day before my shift started. The outgoing nurse Staff A on 12/20/24 never reported to me that the resident had fallen. Review of the facility's policy and procedures titled, Accidents Care and Supervision dated 04/20/23 states: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. 1. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. 2. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. 1. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc. 2. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. 3. Evaluations also look at trends such as time of day, location, etc. 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: 1. Communicating the interventions to all relevant staff 2. Assigning responsibility 3. Providing training as needed 4. Documenting interventions (e.g., plans of action developed through the QAA Committee or care plans for the individual resident) 5. Ensuring that the interventions are put into action 6. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice 7. Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully 8. Facility-based interventions may include, but are not limited to: 9. Educating staff ii. Repairing the device/equipment iii. Developing or revising policies and procedures i. Resident-directed approaches may include: i. Implementing specific interventions as part of the plan of care ii. Supervising staff and residents, etc. iii. Facility records document the implementation of these interventions 4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: 1. Ensuring that interventions are implemented correctly and consistently 2. Evaluating the effectiveness of interventions 3. Modifying or replacing interventions as needed 4. Evaluating the effectiveness of new interventions 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: 1. Defined by type and frequency 2. Based on the individual resident's assessed needs and identified hazards in the resident environment

Based on observation, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Residents complained the call lights were left unanswered for over 15 minutes in multiple occasions when they called for assistance. There were 68 residents residing in the facility at the time of the survey. The findings included: On 11/28/23 at 10:38 AM, during the resident council meeting, several residents reported that sometimes staff take more than 15 minutes to answer the call lights. The residents then stated, The staff don't come to the rooms unless a resident presses the call button for assistance. They do rounds once in a while. Review of the facility's undated policy and procedure for the call light revealed: Purpose: It is the policy of East Ridge Retirement to have a functioning call system so that Residents can feel safe and call for assistance when needed. Key Procedural Points: 6. Some residents may not be able to use their call light. Be sure to check on these residents frequently. 7. Answer the resident's light as soon as possible. 42532 During an interview with resident # 266 on 11/27/23 at 09:27 AM. The resident stated that the call light to ask for assistance was never responded to. The resident stated that the staff didn't know if the resident had an emergency, because they didn't come to the resident's room when the call light was activated. During a tour by the facility hallways on 11/29/2023 at 11:40 AM, the call light for assistance was observed to be on in room # 2314 for more than 10 minutes. A nurse was in a room taking care of a resident, the Certified Nursing Assistant (CNA) was not around. Interview with Administrator on 11/29/2023 at 11:42 AM. The Administrator stated, one CNA was on her break and the other one on the floor should have attended to the call for resident's assistance. The Administrator stated the CNA will take care of the resident as soon as possible. During a tour by the facility on 11/30/2023 at 09:54 AM, the call light for assistance was observed on in room # 2308 the light was observed to be on for more than 15 minutes. Staff B, Registered Nurse was at the medication cart close to the room. Staff A, Certified Nursing Assistant was in the area, no one responded to the call light. Interview with Staff A on 11/30/2023 at 09:56 AM. She stated, she was on her way to respond to the call light. She stated, she did not go because the nurse was close to the room to respond to the call. Interview with Staff B on 11/30/2023 at 09:58 AM. She stated, she was preparing medication for one resident, and she thought the CNA would respond to the call light.

Based on observations, record review and interviews, the facility failed to respond to grievances for one out of one resident (Resident #44) reviewed for grievances. The resident's family member (Brother) established communication with the facility concerning complaints regarding the resident's loss of items, but no grievance was filed. There were 68 residents residing in the facility at the time of the survey. Findings included: On 11/28/2023 at 12:24 PM, Resident #44 stated that he lost his pajamas about 2 weeks ago. He stated that he told his brother about it and believed that his brother spoke to the nurse over the phone about it. He stated, he had not found the pajamas yet. Review of Resident #44's face sheet revealed an admitted [DATE]. Review of Resident #44's Minimum Data Set (MDS) assessment dated [DATE] to identify his cognitive patterns showed a BIMS (Brief Interview for Mental Status) score of 11, indicating moderate cognitive impairment. Review of the facility's grievance file from October 10, 2023 to November 26, 2023 revealed no grievance was filed on behalf of Resident #44. On 11/30/2023 at 08:09 AM, Resident #44 stated that he didn't tell the staff, but he was certain that he told his brother about his missing property over the phone; however, he didn't know for certain that his brother told the staff. On 11/30/2023 at 10:34 AM, during an interview with Resident #44's brother regarding the missing pajamas, Resident #44's brother stated, Yes, he told me that he lost his pajamas just the bottom part, a gray bathrobe, and some shirts. I called the facility and they transferred me to the laundry. I spoke to a guy there. They said they would take care of it, but I haven't had a chance to talk to them again. On 11/30/2023 at 12:42 PM, during an interview with the Environmental Services Manager (ESM) regarding Resident #44's loss items, she stated, Since I've been here, a month ago, we have some complaints, about 4 of them. It's mostly because the names are not showing in the resident's clothes. That apparently, my team lead [Staff C] received a call on Thanksgiving Day. They found the clothes the next day, and he took them to the room. He said, that he didn't report it because he received the call directly and he took the clothes to the resident. On 11/30/2023 at 12:53 PM, during an interview with Staff C (Environmental Services Team Lead) regarding the loss items, Staff C stated, I don't know when the clothes were brought down. When I received the call on Thanksgiving Day, I went and looked for them. The clothes were not missing. They were just not delivered yet to the resident. They were already washed, packed, and was waiting to put in the bag to send to the resident. The next day, the clothes were delivered to the resident's room, November 24th. From the time we pick up the clothes, we have 3 days to deliver them. I didn't report it because I found them. Review of the facility's undated grievance policy and procedure revealed: Policy statement: The resident, family members, and/or legal representative have the right to voice complaints about treatment, care or violation of resident rights without fear of discrimination or reprisal. Policy Interpretation and implementation: To ensure that resident's, families', and/or legal representative's grievances or complaints are promptly evaluated and appropriate action taken, the following procedure is established. This procedure highlights four (4) elements in regard to grievances. 1. Designation of Employee Handling Grievances: Should a resident, resident's family or resident's legal representative have a grievance in regard to treatment or care that is, or fails to be furnished,he/she may take said grievance to the Social Services Director or designee if he/she is not available. The Social Services Director is designated to receive and process complaints to resolution. If the Social Services Director cannot handle the complaint satisfactorily, he/she refers it to the Administrator or Executive Director. 2. Documentation of Grievance: It shall be the responsibility the receiving Supervisory Staff member or Licensed Nurse to write the grievance and forward it to the Social Service Director. A tracking log is utilized for complaints and/or grievances. Such details shall be included so that specific remedial action can be taken. The details of the written grievance, having been reviewed and agreed to by the person bringing the grievance, shall be forwarded to the Social Services Director for follow-up action. Final review of the report is done by the Administrator.

Based on observations, interviews and record review, the facility failed to ensure the proper washing of the dishes and utensils by not having an operable final rinse temperature gauge on the high temperature dish machine. This has the potential to affect 54 out of 59 residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the High/Low Temperature Dish Machine Policy and Procedure (no written date available) documented: Policy-It is the policy of the community to ensure the high temperature dish machine is reaching all required wash and rinse temperatures, in compliance with State and Federal regulations. Procedure: 2) Make sure the machine is functioning properly. A malfunctioning or improperly maintained machine that fails to clean tableware adequately can increase the risk of cross contamination the next time it comes into contact with food or beverages; 3) Check the gauges. Compare their readings with the minimum temperatures, chemical concentrations and pressure measurements listed on the date plate; 4) High temperature or heat sanitizing machines will show a minimum rinse temperature of 180 degrees and a minimum wash temperature of 150 degrees to 160 degrees and 5) Low temperature or chemical sanitizing machines show a minimum rinse and wash temperatures of 120 degrees to 140 degrees. First observation of the high temperature dish machine on 11/07/22 at 2:26 PM with Staff C, Utility Worker revealed the pre wash was at 146 degrees F (Fahrenheit), the wash was at 156 degrees F and the final rinse was at 136 degrees F. The machine displayed a probe error message on it. Interview with by Staff C, Utility Worker on 11/07/22 at 2:27 PM. He stated, The final rinse is supposed to be 180 degrees. Second observation of the high temperature dish machine on 11/07/22 at 2:32 PM with Staff C, Utility Worker and the Food and Service Beverage Director revealed the pre wash was at 146 degrees F, the wash was at 163 degrees F and the final rinse was at 135 degrees F. Interview with the Food and Service Beverage Director on 11/07/22 at 2:33 PM. He stated, I am not familiar with this machine. I don't know what the final rinse temperature is supposed to be. I will call the technician to come out and service the dish machine. Third observation of the high temperature dish machine on 11/07/22 at 2:38 PM with Staff C, Utility Worker and the Food and Service Beverage Director revealed the pre wash was at 146 degrees F, the wash was at 166 degrees F and the final rinse was at 135 degrees F. Review of the Dish Machine High Temperature Log dated 11/07/22 documented for breakfast the wash temperature was 160 degrees F and the rinse was 180 degrees F. Interview with the Senior Director of Operations on 11/07/22 at 2:40 PM. He stated, We will wash all dishware and utensils by hand, until the dish machine is fixed. Interview with the Administrator on 11/07/22 at 3:07 PM. He stated, The dish machine has an error message on it and the technician has been contacted and will be coming out today to fix the dish machine. The staff will be washing all dishes and utensils by hand, until the dish machine is repaired. Interview with the Senior Director of Operations on 11/08/22 at 8:13 AM. He stated, The technician came on yesterday at 8:30 PM for the probe to fix it and he could not. The parts have to be ordered and it will take 7-10 days for the probe to arrive. The machine can be a high or low temperature dish machine. We will be running it at a low temperature dish machine until the probe is replaced. With a low temperature dish machine, the rinse can be at 120 degrees F. In-service was provided for all dishwashers on yesterday on the high temperature dish machine, reading error codes and proper reporting. The technician placed a tag on the dish machine that reads switch to cold sanitizer, until probe comes in. Breakfast was served on disposables today for precaution and lunch will be served on regular dishware. Review of the In-service Sign-In Sheet dated 11/07/22 for all dishwashers. The topics discussed were the high temperature dish machine, reading error codes and proper reporting. Interview with the Senior Director of Operations on 11/08/22 at 12:03 PM. He stated, We tested the dish machine again and the sanitizer levels were not where they needed to be. We made the decision to continue serving the resident on disposables for safety. Review of the Dish Machine High Temperature Log dated 11/08/22 documented for lunch the dish machine was out of order. Fourth observation of the high temperature dish machine on 11/08/22 at 3:37 PM with the Food and Service Beverage Director and the Senior Director of Operations was operating as a low temperature dish machine. The sanitizer was at 50ppm.

Based on observations, interviews and record review the facility failed to ensure the high temperature dish machine final rinse cycle was working properly. This has the potential to affect 54 out of 59 residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the High/Low Temperature Dish Machine Policy and Procedure (no written date available) documented: Policy-It is the policy of the community to ensure the high temperature dish machine is reaching all required wash and rinse temperatures, in compliance with State and Federal regulations. Procedure: 2) Make sure the machine is functioning properly. A malfunctioning or improperly maintained machine that fails to clean tableware adequately can increase the risk of cross contamination the next time it comes into contact with food or beverages; 3) Check the gauges. Compare their readings with the minimum temperatures, chemical concentrations and pressure measurements listed on the date plate; 4) High temperature or heat sanitizing machines will show a minimum rinse temperature of 180 degrees and a minimum wash temperature of 150 degrees to 160 degrees and 5) Low temperature or chemical sanitizing machines show a minimum rinse and wash temperatures of 120 degrees to 140 degrees. First observation of the high temperature dish machine on 11/07/22 at 2:26 PM with Staff C, Utility Worker revealed the pre wash was at 146 degrees F (Fahrenheit), the wash was at 156 degrees F and the final rinse was at 136 degrees F. The machine displayed a probe error message on it. Interview with by Staff C, Utility Worker on 11/07/22 at 2:27 PM. He stated, The final rinse is supposed to be 180 degrees. Second observation of the high temperature dish machine on 11/07/22 at 2:32 PM with Staff C, Utility Worker and the Food and Service Beverage Director revealed the pre wash was at 146 degrees F, the wash was at 163 degrees F and the final rinse was at 135 degrees F. Interview with the Food and Service Beverage Director on 11/07/22 at 2:33 PM. He stated, I am not familiar with this machine. I don't know what the final rinse temperature is supposed to be. I will call the technician to come out and service the dish machine. Third observation of the high temperature dish machine on 11/07/22 at 2:38 PM with Staff C, Utility Worker and the Food and Service Beverage Director revealed the pre wash was at 146 degrees F, the wash was at 166 degrees F and the final rinse was at 135 degrees F. Review of the Dish Machine High Temperature Log dated 11/07/22 documented for breakfast the wash temperature was 160 degrees F and the rinse was 180 degrees F. Interview with the Senior Director of Operations on 11/07/22 at 2:40 PM. He stated, We will wash all dishware and utensils by hand, until the dish machine is fixed. Interview with the Administrator on 11/07/22 at 3:07 PM. He stated, The dish machine has an error message on it and the technician has been contacted and will be coming out today to fix the dish machine. The staff will be washing all dishes and utensils by hand, until the dish machine is repaired. Interview with the Senior Director of Operations on 11/08/22 at 8:13 AM. He stated, The technician came on yesterday at 8:30 PM for the probe to fix it and he could not. The parts have to be ordered and it will take 7-10 days for the probe to arrive. The machine can be a high or low temperature dish machine. We will be running it at a low temperature dish machine until the probe is replaced. With a low temperature dish machine, the rinse can be at 120 degrees F. In-service was provided for all dishwashers on yesterday on the high temperature dish machine, reading error codes and proper reporting. The technician placed a tag on the dish machine that reads switch to cold sanitizer, until probe comes in. Breakfast was served on disposables today for precaution and lunch will be served on regular dishware. Review of the In-service Sign-In Sheet dated 11/07/22 for all dishwashers. The topics discussed were the high temperature dish machine, reading error codes and proper reporting. Interview with the Senior Director of Operations on 11/08/22 at 12:03 PM. He stated, We tested the dish machine again and the sanitizer levels were not where they needed to be. We made the decision to continue serving the resident on disposables for safety. Review of the Dish Machine High Temperature Log dated 11/08/22 documented for lunch the dish machine was out of order. Fourth observation of the high temperature dish machine on 11/08/22 at 3:37 PM with the Food and Service Beverage Director and the Senior Director of Operations was operating as a low temperature dish machine. The sanitizer was at 50ppm.

Based on record review and interviews, the facility failed to ensure the nursing staff were current with required trainings for one (Staff #12) out of three staff trainings reviewed. A performance review was not conducted to ensure the nursing staff completed in-service education training at least once every 12 months. The findings included: Record review of Staff #12, Licensed Practical Nurse (LPN) employee file documented the following: The Elder Justice Act (Abuse) Training completed on 4/19/2021; Alzheimer's Disease and Related Disorder: Activities Training completed on 4/13/2021; Dementia Care: Performing ADLs Training on 5/30/21 and Dementia Care: Managing Challenging Behaviors Training completed on 5/30/21. The Elder Justice Act (Abuse) Training was due on 4/19/22 and not completed; Dementia Care: Understanding Alzheimer's Disease Training was due on 4/19/22 and not completed; Dementia Care: Performing ADLs Training was due on 5/30/22 and not completed and the Dementia Care: Challenging Behaviors and Direct Care Staff Training was due on 5/30/22 and not completed. Interview and record review with the Human Resources Generalist on 11/08/22 at 2:42 PM. She stated, The staff is past due on her training. That is an oversight on my part. She should have completed her abuse training on 4/19/22 and Alzheimer's/Dementia Care Training on 4/19/22 and 5/30/22. A subsequent interview on 11/08/22 at 3:28 PM. She revealed that the staff member was removed from the schedule this week so that she must complete the training by this Sunday. Interview with the Administrator on 11/09/22 at 11:15 AM. He stated, The expectation is for staff to receive abuse and dementia care training yearly. We use a computer based programs for all our training. We give them certain deadline dates throughout the year to complete the trainings. A subsequent interview on 11/09/22 at 11:34 AM. He stated, I don't have a policy on required trainings for staff. I spoke with Human Resources and she let me know the staff has been removed from the schedule to complete the trainings and will not be back on the schedule until she completes the training.

Based on observations, interviews and record review the facility failed to ensure residents received a Preadmission Screening and Resident Review (PASRR) Level I screening and a Level II screening for two (Residents #44, Resident #30) out of three residents reviewed for PASRR. Resident #44 did not receive a PASRR Level I before admission to the facility and Resident #30 did not receive a PASRR Level II after admission to the facility. There were a total of 59 residents residing in the facility at the time of this survey. The findings included: 1) Observation of Resident #44 on 11/07/22 at 12:06 PM revealed the resident sitting in a wheelchair in the 3rd floor dining room, eating lunch. Record review of the Demographic Face Sheet for Resident #44 documented the resident was admitted on [DATE] with a diagnosis of atrial fibrillation, diabetes mellitus, hypertension, major depressive disorder, psychosis, peripheral vascular disease and arteriosclerosis heart disease. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #44 dated 8/15/22 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 09 out of 15 indicating cognitive impairment and the resident required extensive assistance with one person physical assistance for ADLs (Activities Daily Living). Review of the Physician's Order Sheet (POS) for October 2022 and November 2022 documented the resident received Escitalopram Oxalate 5 mg tab 1 tab PO daily for depression, Seroquel 50mg tab 1 tab PO BID for psychosis and Seroquel 200 mg tab 1 tab PO HS for psychosis. Review of the Care Plans for Resident #44, written 3/25/22 documented the resident received antipsychotic and antidepressant medications. Review of the PASRR for Resident #44 revealed the PASRR Level I was not found in the electronic chart nor the paper chart. Interview with the Social Worker on 11/09/22 at 10:20 AM. He stated, I looked through her hospital admission records and it was not found. I will contact medical records to see if it is in the thin out chart. Interview with the Administrator and the Social Worker on 11/09/22 at 1:18 PM. The Administrator revealed that they could not find a PASRR Level I for the resident. 2) Observation of Resident #30 on 11/09/22 at 12:28 PM revealed the resident sitting up in bed, with TV on and eating lunch. Record review of the Demographic Face Sheet for Resident #30 documented the resident was admitted on [DATE] with a diagnosis of Parkinson's disease, dementia, psychosis, peripheral vascular disease, Alzheimer's disease and arteriosclerosis heart disease. Review of the Minimum Data Set (MDS) Admission Assessment for Resident #30 dated 3/08/22 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score not scored indicating severe cognitive impairment and the resident required extensive assistance with one person physical assistance for ADLs (Activities Daily Living). The resident was not evaluated for PASRR Level II. Review of the Physician's Order Sheet (POS) for October 2022 and November 2022 documented the resident received Quetiapine 50mg tab 1 tab PO BID for psychosis. Review of the Care Plan for Resident #30, written 3/01/22 documented the resident received an antipsychotic medication. Review of the PASRR for Resident #30 revealed the PASRR Level I was done on 3/01/22 with a diagnosis of Dementia and Psychosis which were checked on the form. The form documented no PASRR Level II was required. A PASRR Level II was required if a resident who has or may have a serious Mental Disorder (MD), Intellectual Disability (ID) or a Related Condition. Interview with the Social Worker on 11/09/22 at 10:26 AM. He stated, I will check into the PASRR Level II. Interview with the Administrator and the Social Worker on 11/09/22 at 1:18 PM. The Administrator revealed that a PASRR Level II was not done for the resident. He stated, There is nobody who has access to the PASRR system since they left, referring to former staff members. We are working to obtain access so that we can complete a Level I and Level II for the residents. We are in the process of correcting it. A PASRR Policy and Procedure was requested from the Administrator and he revealed that they don't have one.

Based on observation, record review and interviews, the facility failed to follow the respiratory care plan for 1 (Resident #366) out of 25 sampled residents. There were 59 residents admitted to facility during the survey. The finding included: Observation of resident #366 on 11/07/22 at 08:50 AM revealed, the resident had oxygen on at 3 liters/minute via nasal cannula. Observation of resident #366 on 11/08/22 at 01:30 PM revealed, the resident was sitting up in a chair, and the oxygen concentrator was observed to be set at 3liters/minutes and the resident was receiving the oxygen via a nasal cannula. Observation of resident # 366 on 11/09/22 at 08:27 AM revealed, the resident was receiving oxygen at 3 liters/minute. During medical record review, it was noted resident #366 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, Pleural Effusion, Congestive Heart Failure, Hypertension, Cerebral Infarction, and Acute Respiratory Failure with Hypoxia. During the review of the residents physician orders it was noted the resident had a physician order dated 10/6/22 for oxygen 2 liters minute via nasal cannual (NC) as needed (prn) for shortness of breath (SOB)/congestion. During the review of the residents care plan dated 10/5/22 for the category of Compromised Respiratory, the problem was documented as - I am at risk for compromised respiratory status due to diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, Pnuemonia. The goal was, I will maintain my current respiratory status with my present regime and symptom control through the next review. One of the listed approaches included: Please provide oxygen as ordered by my physician. It was noted the care plan was not followed since the resident was receiving the oxygen at 3 liters/minute. During interview with the Assistant Director of Nurses (ADON) on 11/09/22 at 09:20 AM, the ADON was informed about the oxygen being at 3 liters per minute. During the review of the facility's policy and procedure for Oxygen Administration, revised on 2/4/21 and reviewed on 10/4/22, the purpose is documented as: The purpose of this procedure is to provide guidelines for safe oxygen administration. The section for procedure includes: 1. Verify physician's orders. During interview with the ADON on 11/09/22 at 02:25 PM, it was reported the physician changed the oxygen level to 3 liters per minute. The ADON reported, the oxygen had been observed to be set at 3 liters/minute prior to the order being changed.

Based on observation, record review and interview, the facility failed to provide a safe environment free of accident and hazards for One (Resident #18) out of one resident reviewed for fall precautions. As evidenced by Resident # 18 with history of multiple falls bilateral floor mats were not on the floor beside the resident's bed while the resident was in bed. There were 59 residents residing in the facility at the time of this survey. The Findings Included: On 11/07/22 at 08:50 AM observed resident in room in bed, oxygen (02) running via nasal cannula (NC) at three liters per minute (3 LPM), bilateral floor mats, one (1) mat on the left side of bed facing the bed on the floor, other floor mat folded behind left side of bed (Photo available). On 11/08/22 at 08:25 AM, observed resident out of bed in wheelchair, 02 running via NC at 3 LPM, stated he is having a good day. On 11/09/22 at 11:00 AM, observed resident out of bed in wheelchair in hallway, 02 running via NC at 3 LPM, no distress noted Review of the medical records for Resident #18 revealed resident was originally admitted to the facility on [DATE], readmitted on [DATE]. Clinical diagnoses included but not limited to: Encounter for palliative care, Abnormalities of gait, Muscle weakness, Hypertension, Alzheimer's Disease, Unspecified Dementia and Major Depressive Disorder. Review of the Physician's Orders Sheet for November 2022 revealed Resident #18 had orders that included but not limited to: fall precautions: may use protective devices as needed such as floor mats. Medications included: Gabapentin 300 Milligram (mg) capsule 1 cap by mouth at bedtime for neuro pain. Clonidine 0.1 mg tablet 1 tablet every 8 hours as needed for hypertension. Sertraline 25 mg tablet 1 tablet by mouth every day at bedtime for depression behavior. Mirtazapine 7.5 mg tablet-1 tablet by mouth at bedtime for depression behavior. Seroquel 50 mg tablet-1 tablet by mouth twice a day for periods of agitation, calling out, trying to get out of bed. Record review of Resident #18 's Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns indicated Brief Interview for Mental Status Score (BIMS) is a 5, on a 0-15 scale indicating the resident is cognitively impaired. Section E for behaviors indicated resident had no behaviors exhibited and no potential indicators of psychosis. Section G for Functional Status indicated resident is total dependence for Activities of Daily Living (ADLs) with two (2) persons assistance. Section H for Bowel and Bladder indicated resident is always incontinent of bowel and bladder. Section J for Health Conditions indicated resident received schedule pain medications in the last 5 days, no shortness of breath, life expectancy of less than six (6) months, and one (1) fall since admission, entry, or reentry. Section N for Medications indicated resident received antidepressants, diuretics, and anticoagulants in the last 7 days. Section O for Special Treatments, Procedures and Programs indicated resident received hospice care in the last fourteen (14) days. Section P for restraints indicated no restraints used on resident. Review of the facility's incident tracking report documented: on 10/30/22 at 15:00 resident observed on the floor with his back against the bed, resident did not say how he got on the floor. Documentation dated 8/30/22 at 10:15 AM-during morning rounds resident found lying on floor mat between his bed and wheelchair, head to assessment was performed, no skin issues, denied pain, able to move all extremities. Documentation dated 8/25/22 at 5:40-during rounds patient seen sitting on floor next to his bed, no complaint of pain or discomfort, no apparent injury. Documentation dated 8/05/22-resident stated he fell in his room last night and got back to bed without assistance, no injuries. Record review of Resident #18 's Care Plans Reference Date 4/22/22 revealed: Resident have a potential to fall. Related to impaired mobility, Impaired balance, and gait. History of falls. Psychotropic drug use. Interventions include fall precautions: Keep my room clutter free and well lit. My call light within reach. My bed in low locked position, please schedule Physical Therapy screen/evaluation as needed, please schedule Occupational Therapy screen/evaluation as needed. Resident had an actual fall. I stated I fell during the night and got myself back to be without any assistance. 8/25/22 I was found on the floor, next to my bed. I stated I was trying to get out of bed and slid to the floor. 8/30/22 I was found on the floor mat between bed and wheelchair, I stated I was trying to transfer myself to bed and I slid from the wheelchair. Approaches includes place floor mats next to my bed, Please schedule Physical Therapy screen/evaluation as needed, Please remind me to ring for assistance when I need to transfer, Please check me early in the morning and I assist me to use toilet/urinal as needed, Please offer to place me back to bed after breakfast to rest. Review of nursing progress notes dated 10/31/22 timestamped 16:52:08 documented: Radiology Report received: Sacrum/Hips Bilateral conclusion: No acute Abnormality seen. Lumbar spine conclusion: Degenerative spondylosis. Report was sent to Physician (MD), no new orders at this time. Hospice nurse made aware. Copy will be kept for record on resident chart. Resident in stable condition at the moment; Continue oxygen (O2) at three (3) Liters per minute by nasal cannula as per MD order. Denies any pain or discomfort during shift. Will continue to monitor. Review of Nursing progress notes dated 10/30/22 timestamped 23:54: 03 documented: Reports received, resident had an X-RAY of Bilateral Hips and Lumbosacral area ordered, Technician arrived around 11:15 pm, X-RAY completed, resident tolerated procedure well, pending results. During an interview on 11/09/22 at 11:07 AM, Certified Nursing Assistant (CNA) (Staff A) stated; it is my first day on this floor I am now learning about the residents I usually work on the second floor; I really do not know much about the patient and about the floor mats. I have worked with this resident several times, I know this resident is a high risk for falls, the fall precautions we have in place for this resident are-patient very near to nursing stations, he has the two-floor mattress, and the staff knows that when the patient is in bed, the bed must be in low position and the two floor mats must be by the bed. On 11/09/22 at 12:06 PM the Director of Nursing (DON) was told about the resident's floor mats. The DON stated, I have been here since September 2022, I have met this resident a few times, we discuss the falls in the clinical morning meetings, we let all the departments know what is going on with resident's falls, I created a detailed fall reporting packet so it can help us with the root cause analysis, it basically helps you get more information about the fall from the person who witnessed the fall. The Point of care, Certified Nursing Assistant (CNA) documentation have all the information related to residents' care for the CNAs to look at, when the CNAs go in the system, they have to acknowledge that they read the information. The CNA logs on to the point of care documentation every day and based on their assignments the resident they are taking care of will show up. The nurses can access the point of care documentation for their assigned patients on the computer system. We have several fall interventions for this resident on the fall care plans, we discuss and try to come up with patient centered care plans for each resident and provide interventions based on location and frequency of the fall, task being done, disease process, labs etc. This resident had a couple of falls when he first came in, he was seen by the psychologist, he was placed on Seroquel on 9/27/22, that seems to help with his agitation and falling during transfer. He has been in and out of the facility, he is what we call a life care resident-he has bought into the community to age in place. Prior to going to the hospital, he lived in the Assisted Living Facility (ALF) on campus and came to the skilled nursing home on 7/18/22, he went to the hospital and came back 7/27/22. He had another hospital visit, on his return from the hospital on 8/4/22 he came back as hospice, and he is going to stay in the skilled nursing long term. To make sure that all staff are aware of the resident's point of care we have started reeducating the staff and doing in-services about floor mats-if you see them in the room ask questions and check the point of care documentation. If the floor mats are not a part of the care plans, we will be removing them from the room moving forward. Review of the undated facility's policy and procedures titled, Safety and Supervision of Residents, states: Our Facility strives to make the environment as free from accidents and hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Facility Oriented Approach to Safety: Step 4-Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents.

Based on observation, record review and interviews, the facility failed to provide appropriate catheter care for 2 out of 25 sampled residents (Resident #365 and Resident #366). There were 59 residents admitted to the facility at the time of the survey. The findings included: 1. Observation of resident # 365 on 11/08/22 at 01:12 PM revealed the resident was sitting up in chair, and his catheter bag was observed to laying directly on floor. (photo obtained) During record review, it was noted the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to Left Femoral Neck fracture, Prostate Cancer, Bony Metastatasis, Cervical Stenosis, Fall, and Urinary Tract Infection (UTI) at the hospital. Record review revealed a physician order dated 10/30/22 for Foley catheter care every shift diagnosis (DX) obstructive uropathy. During the review of the residents admission minimum data set (MDS) dated [DATE], was incomplete. During the review of resident #365 care plan for Urinary Incontinence/Indwelling Catheter started on 10/28/22 revealed, the problem was documented as Since I have an indwelling catheter, I have a potential for an infection related to Obstuctive Uropathy, Prostate Cancer. The goal was urinary output will be within normal range of greater than or equal to 200 cubic centimeters (cc) per shift and the resident will be free of symptoms of UTI (Urinary Tract Infection). The approaches included, Monitor and measure output every shift, monitor and report signs of urinary tract infection, maintain catheter below bladder level, change catheter as ordered, catheter care every shift, please place a dignity bag over my urinary catheter bag. During interview with the Assistant Director of Nurses (ADON) on 11/09/22 at 09:20 AM, the ADON was informed about the resident #365 and #366 catheter bags being observed directly on the floor on 11/7/22. During the review of the facility's policy and procedure for Catheter Care, Urinary dated revised on 7/9/21 and reviewed on 10/4/22, the purpose was documented as: The purpose of the procedure is to prevent catheter-associated urinary tract infections. The infection control section documents, use standard precautions when handling or manipulating the drainage system. 2. Observation of resident #366 on 11/07/22 at 08:50 AM revealed, the residents catheter bag was observed directly on the floor. The urine was amber in color with sediment in the catheter tubing. (photo obtained) During medical record review, it was noted resident #366 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, Pleural Effusion, Congestive Heart Failure, Hypertension, Cerebral Infarction, and Acute Respiratory Failure with Hypoxia. During the review of the resident #366 physician orders revealed an order dated 10/6/22 for catheter care, use leg bag as needed and replace urinary bag when in bed. During the review of the residents comprehensive minimum data set (MDS) dated [DATE] documented in Section H, Indwelling catheter. During the review of resident #366 care plan for Urinary Incontinence/Indwelling Catheter started on 10/05/22 revealed, the problem was documented as Since I have an indwelling catheter, I have a potential for an infection related to Obstuctive Uropathy. The goal was urinary output will be within normal range of greater than or equal to 200 cubic centimeters (cc) per shift and the resident will be free of symptoms of UTI (Urinary Tract Infection). The approaches included, Monitor and measure output every shift, monitor and report signs of urinary tract infection, maintain catheter below bladder level, change catheter as ordered, catheter care every shift, please place a dignity bag over my urinary catheter bag.

Based on observation, record review and interviews, the facility failed to provide respiratory services regarding oxygen for one (Resident #366) out of 25 sampled residents. There were 59 residents admitted to facility during the survey. The finding included: Observation of resident #366 on 11/07/22 at 08:50 AM revealed, the resident had oxygen on at 3 liters/minute via nasal cannula. Observation of resident #366 on 11/08/22 at 01:30 PM revealed, the resident was sitting up in a chair, and the oxygen concentrator was observed to be set at 3liters/minutes and the resident was receiving the oxygen via a nasal cannula. Observation of resident # 366 on 11/09/22 at 08:27 AM revealed, the resident was receiving oxygen at 3 liters/minute. During medical record review, it was noted resident #366 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, Pleural Effusion, Congestive Heart Failure, Hypertension, Cerebral Infarction, and Acute Respiratory Failure with Hypoxia. During the review of the residents physician orders it was noted the resident had a physician order dated 10/6/22 for oxygen 2 liters minute via nasal cannual (NC) as needed (prn) for shortness of breath (SOB)/congestion. During the review of the residents care plan dated 10/5/22 for the category of Compromised Respiratory, the problem was documented as - I am at risk for compromised respiratory status due to diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, Pnuemonia. The goal was, I will maintain my current respiratory status with my present regime and symptom control through the next review. One of the listed approaches included: Please provide oxygen as ordered by my physician. It was noted the care plan was not followed since the resident was receiving the oxygen at 3 liters/minute. During the review of the residents comprehensive minimum data set (MDS) dated [DATE] documented in Section O - Special Treatment included the resident was receiving oxygen therapy while not a resident, but was not checked for while a resident. During interview with the Assistant Director of Nurses (ADON) on 11/09/22 at 09:20 AM, the ADON was informed about the oxygen being at 3 liters per minute. During the review of the facility's policy and procedure for Oxygen Administration, revised on 2/4/21 and reviewed on 10/4/22, the purpose is documented as: The purpose of this procedure is to provide guidelines for safe oxygen administration. The section for procedure includes: 1. Verify physician's orders. During interview with the ADON on 11/09/22 at 02:25 PM, it was reported the physician changed the oxygen level to 3 liters per minute. The ADON reported, the oxygen had been observed to be set at 3 liters/minute prior to the order being changed.

Based on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area; as evidenced by repeated deficient practices for F690 Bowel/Bladder Incontinence, Catheter, Urinary Tract Infection, F812 Food Procurement, Store/Prepare/Serve Sanitary, and F689 Accident Hazards/Supervision/Device. These repeated deficient practices have the potential to affect all 59 residents residing in the facility at the time of this survey. The finding included: Review of the facility's survey history revealed, the facility was cited F812 Food Procurement, Store/Prepare/Serve Sanitary during a complaint survey with exit date of 03/12/2019, during the recertification and Relicensure survey with exit date of 10/02/2020 and again during this Recertification Relicensure survey with exit date of 11/09/2022. The facility was cited F689 Accident Hazards/Supervision/Devices during a complaint survey with exit date of 07/20/2022 and during this survey with exit date 11/09/2022. Interview with Administrator on 11/09/2022 at 3:51 PM. Administrator stated that the QAPI (Quality Assurance and Performance Improvement) meetings are held on the last Thursday of each month. The team members included the Administrator/ Risk Manager, the Medical Director, Director of Nursing, (DON), Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Coordinator, Social Services Director, Activities Director, Rehabilitation Director, Restorative Staff, Medical Records, Human Resources, Dietary and Dietitian, Nursing Supervisors, Pharmacy Consultant, Maintenance Director, and Housekeeping Director. Administrator stated that for the care of catheters, staff will receive In-services training for the proper placement of the catheter and the bag to cover it for privacy. For Food Procurement will be in-service education training for dietary staff to prevent the issues with the dish machine temperature. He stated the correction action was to call the service provider and the provider came and convert the machine to a low temperature at the sanitation solution. Administrator stated for Infection Prevention and Control, staff will receive in-services training to follow infection control standards to proper placement and care of catheters.

Based on record review and interview, the facility failed to respond to and resolve a grievance in a timely manner for one (Resident # 7) out of three grievances reviewed. This has the potential to affect sixty-five residents residing in the facility at the time of the survey. The findings included Review of the facility's policy titled Grievance Policy and Procedure dated 6/7/22 revealed: Policy interpretation and Implementation: To ensure residents, families, and/or legal representative's grievances or complaints are promptly evaluated, and appropriate action taken, the following procedure is established. The procedure highlights (4) elements regarding grievances. 1. Designation of employee handling grievances: Should a resident, resident's family, or resident's legal representative have a grievance regarding treatment or care that is, or fails to be furnished, he/she may take said grievance to the Social Service Director or designee. The Social Service Director is designated to receive and process complaints to resolution. Review of grievances should be completed with (72) hours of filing. Review of the grievance log revealed Resident # 7 filed a grievance on 5/26/22 related to receiving improper food. Date of the grievance 5/26/22. The grievance was forwarded to Food and Beverage Director. Situation or Grievance: Resident receives food she does not select (milk) and does not receive what she does select (French toast, pancakes selected, and she got eggs instead). She received corn chowder instead of chicken noodle soup today for dinner. Resolution: Food and Beverage Director and Dietary Manager visited Resident on 6/8/22. Dietary Manager in-serviced staff on resident meal selection/selective menu on 6/9/22. The grievance was signed by the Dietary Manager, Social Worker and Administrator on 6/13/22. Record review of the demographic face sheet revealed Resident # 7 was admitted to the facility on [DATE] and discharged home on 6/14/22. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #7 had a BIMS (Brief Interview for Mental Status) of 15 out of 15 indicating intact cognition. Review of Resident # 7's Nutrition assessment dated [DATE] revealed no specific dietary preferences except that she avoids high tyramine foods due to migraines. Review of the assessment revealed no reference to the grievance filed on 5/26/22. Review of the interdisciplinary progress notes revealed no additional dietary progress notes and no preference updates. Interview with the Food and Beverage Director on 7/20/22 at 11:32 AM, revealed Resident # 7 filed a grievance regarding not receiving the correct food items on her tray. The Food and Beverage Director reported, I went to visit the resident with the Dietary Manager (Staff D) on 6/8/22. She reported the same concerns. We went back to the diet aides who assist the resident to mark the menu and input the preferences into the meal tracker system. We conducted an in-service regarding the selective menu and the importance of honoring resident preferences. I was made aware of the grievance on the date we visited the resident. The Registered Dietitian (RD) filed the grievance on 5/26/22 and I believe it was brought to my attention on 6/8/22. The RD sends the grievances out by email so I would have to check my email to check the dates for sure. I cannot explain why the resident was not visited for about 11 days after the grievance was filed by the RD. Interview with the Director of Social Services on 7/20/22 at 3:44 PM, revealed he has been working in the facility for about 2 months. The Director of Social Services stated, I am the Grievance Officer. The protocol is to report any grievance to the administrator and the appropriate department head within 24 hours unless it involves abuse and then it is 2 hours. The investigation should be launched the same day and we strive to resolve grievance within 3 days. The grievance related to food preferences for this resident was actually reported directly to the Dietitian and then the Dietitian gave it directly to me. If this grievance was reported on 5/26/22, it would have been a bit long to wait until 6/8/22 to resolve the problem. Interview with the Food and Beverage Director on 7/20/22 at 4:04 PM, revealed he did some research on this grievance, the Food and Beverage Director reported that it was filed the RD on 5/26/22. She told me about it verbally. On 6/2/22 I emailed the RD that we would follow up. The Dietary Manager was on leave from 6/1/ to 6/7 so we did not go to see the resident to address the issues until 6/8/22. This should have been resolved within 72-hours. Going forward we cannot wait if someone is on leave, it must be handled within the proper time frame.

Based on interview and record review, the facility failed to ensure that the prevention of an avoidable decline for resident number four (#4) due to the lack of coordinating the interdisciplinary assessment, care and services that were provided. This has the potential to affect one of five sampled residents. The facility is required to ensure that all residents' highest level of functional well-being is maintained. The findings include: A record review of the Annual MDS with an Assessment Reference Date of 12-28-13 for R#4 has the admitted noted of 2-12-2013. The Active [DIAGNOSES REDACTED]. Care Plan for Skin Condition dated 3-08-14 revealed skin condition related to surgical wound status [REDACTED]. Blister on the right side of the hand and skin tear to lower left thigh. On 3-31-14 at 7:30 AM, the resident was observed briefly receiving Assisted Daily Living (ADL) care from the attending Certified Nurse Assistant who had requested for assistance from another staff with positioning/pillows and ADL care at that time. The resident was observed to be well groomed and had a bandage covering the right hand. On 3-31-14 at 9:05 am the resident was observed in bed. There was a gauze-type bandage on the right hand of the resident. The resident is well groomed and dressed. The resident was not verbally responsive and had her eyes closed. The resident had some involuntary movement of the right hand back and forth, up and down and across the upper chest area. The gauze was clean to sight. There was black writing on the outer area that had tape on it that was unable to be read. On 03-31-14 a record review of the Nursing Home Reports was conducted. The form has noted that the only report submitted by the facility was a "new" report was created on 3-12-14 at 11:35am for an incident that occurred on 02-25-2014. The form does not have a Federal Immediate Report or a Federal 5-day Report conducted by the facility. On 3-31-14 at 10:05 am record review revealed the resident had an Minimum Data Set (MDS) completed that was for a significant change in condition that had an assessment referenced date of 3-13-14. On 3-31-14 at 11:01 am the Hospice Nurse is in the room at this time. The resident was observed in bed, well groomed and dressed. The resident eyes were closed and she was not verbally responsive. She was making the involuntary movement of the right hand back and forth. The Hospice nurse reported that the staff just replaced the bandage to the right hand. There was a date written on the bandage (03-31-14). The Hospice nurse stated that the resident received Hospice services 03-06-14. She stated that she visits the facility on Monday, Tuesday, Wednesday and Thursdays because she had other residents on Hospice here too. She stated that the C N A's come to see this resident 5 times a week. She said that the bandage to the right hand was changed every day and as needed. She stated that the resident's speech was limited and she was not able to make her needs known. She stated that they will look for grimacing or facial expressions as a sign of pain. She said that the mattress was an air mattress, which was provided by the facility, not Hospice. She was able to show that the resident had heel floaters to prevent sores On 03-31-14 at 12:46 pm the interim Administrator reported that the adverse incident they have was investigated already by DCF the day after the incident occurred on 2-26-14 at 1:30pm; on 2-27-14 at 12:30pm; on2-28-14 at 9am and on 3-05-14 at 9:00am. She states that DCF will be sending a final report in which they ruled out this case as abuse/neglect. She stated that the facility in the case of the R#4 they did not file an Immediate Federal Report. She stated that the facility spoke with several different people from AHCA and DCF was here the next day. She stated that they completed the adverse report but was not aware that the Abuse needed to be reported because they did not consider the incident as a case of abuse. On 03-31-14 at 1:20pm the electronic record review of the C N A Daily Charting in the computer for R#4 was conducted for the dates of February 22, 2014 through February 25, 2014. -Appliances noted that included a High back wheel chair and Hand Roll to left hand. Skin Precautions has noted to -Alternating pressure mattress with heels floating. Ensure that I have two pillows in place under my right arm to keep it elevated. -Resident is on a scheduled repositioning program -Bed Mobility Support Provided -Use side rails per Resident Care Guide. On 03-13-14 at 3:00 pm the Medical Record Director provided a copy of the C N A Dialy Charting Notes. A review of the hard copy of the C N A Daily Charting notes revealed that for Bathing:Nail Care (Fingernails and Toenails) guidance noted is to check the condition of the fingernails and toenials. If action is required to notify the nurse and press "Notes" and enter the nurses initials. A review revealed that there was a check mark in the box for this section on February 22, 2014 for the 7:00am to 3:00pm shift. There is no check mark for the 3pm to 11pm shift or the 11pm to 7am shift. On February 23, 2014 there was a check mark in the box only for the 7am to 3pm shift. On February 24, 2014 there was a check mark in the box for the for all three shifts. On February 25, 2014 there was a check mark in the box for the 11pm to 7am shift only. On 04-01-14 at approximately 2:00 pm during an interview conducted with the C N A from the 7am to 3pm shift for the East Wing. She explained that whenever the R#4 receives any type of messages to the hand and senory stimulation the check mark is placed in the computer to indicate that is what care was provided. She confirmed the check mark indicates the care was given. On 3-31-14 at 5:20 pm interview with the Director of Nursing (DON) revealed that the sock thaat found on the right hand of R#4 was a knitted type of sock that belonged to the resident. The other sock was found in her belongings. The sock that was on the hand was sent to the hospital. The DON described the sock as blue and black with a cow head on it and a bright colored band around the top of the sock. The DON stated that the incident was not reported on the first day. He stated that they ruled out that the incident was an act of abuse. The DON explained the he is currently acting as the Interim Risk Manager at that time.The DON admits that the facility staff did not know how the sock got on the residents hand. He stated that the incident was thoroughly investiagted and confirmed that it was reported as an adverse incident. He stated that they did not complete a Federal report. He explained that as a result of the investigation it was unable to determine why the sock was placed on the residents hand and who intitially placed the sock on the residents hand. He stated that the nurse on the 7pm to 7am shift on the 2-24-14 saw the sock on the residents hand. He stated that from the investigation the sock was not discovered on the residents hand until 1:30pm on the 02-25-14. The C N A went to prepare the resident for activities. A brief review of the Incident Investigation report was conducted at this time with the DON. He states that from the investigation it was determined that there were some staff that had seen the sock on the resident but no one knew when it was originally placed on the residents hand or exactly why the sock was being used. There were several staff that did not see the resident wearing the sock. He admits that there were no care plans, physicians orders or [DIAGNOSES REDACTED]. On 3-31-14 at approximately 6:01 pm the DON presented the sock for observation. The sock is a fuzzy, soft textured, thick and ankle length. The sock is blue in color on the heel and toe area with a black and white cow type print and bright pink colored band on the upper portion. There is an embroidered picture of a cow face sewed on the pink upper band. On the bottom of the sock is a plastic white label with that had the residents name. The inside surface area of the sock is not smooth as the outer surface area. The inside has a large number of loose black and white strings that are hanging. The DON stated that the sock was not care planned for, it was not ordered by the physician and the reason for the use of the sock was not determined or documented. On 04-01-14 conducted a record review of the electronic nurse notes, care plans and the C N A Daily Charting. A review of the medical record prior to R#4 discharge on 2-25-14 revealed that there was no documentation relating using the sock to cover the hand, why the sock was used to cover the right hand or if the appropriate Medical/Health care provider was informed of the use of the sock to cover R#4 right hand. A record review of the Care Plans for R#4 that were dated for 01-08-14 was reviewed in the computer. A copy was provided by the Medical Record Director on 04-01-14 at 12:21 pm. The record review revealed that only the following care areas had care plans which were Cognitive Loss/Dementia, Communication, Urinary Incontinence, Psychosocial Well-Being, Activities, Falls, Nutritional Status, Pressure Ulcers, [MEDICAL CONDITION] Drug Use, Advance Directive, Skin Condition and Hypertension. There were no care plans relating to the use of a sock or device for covering the right hand. A record review of the Interdisciplinary (Nurses') Notes dated for 01-09-14 01-13-14, 01-16-13, 01-23-14, 01-25-14, 01-30-14, 02-01-14, 02-06-1402-20-14 and 02-25-14. The Interdisciplinary (Nurses') Notes dated on 02-25-14 at 18:17pm by the attending Licensed Practical Nurse-LPN had noted that at 1:30pm the treatment nurse was called to the resident's room by the attending C N A who stated that when she was performing personal care on the resident. When she tried to remove a sock that had been put on the resident hand, she noticed discoloration to the right index finger. On assessment the resident was found with a sock partially removed and the inside string from the sock wrapped around the resident's index finger, leaving the finger dark and swollen. The supervisor was notified. The sock was cut away leaving the string still wrapped tightly around the finger. We were unable to remove the string so the physician was notified and he ordered the resident to be sent to the hospital. 911 was called and arrived at 2pm. The resident left the facility via stretcher and ambulance for Jackson South Hospital. The Interdisciplinary (Nurses') Notes do not have any documentation relating to the use of the sock applied to right hand of R#4, why the sock was used and if any of the medical staff were aware that the sock was being used. On 04-14-14 a review of the physician progress notes [REDACTED]. Her sister was in a wheelchair at her bedside on the left. She was stroking the patient's arms and hands. Patient was moving her arms and trying to make sounds. The sister stated she spoke to her at times. "She is doing okay and is stable. She had no complaints. Patient is talking and moving more. She is holding her own and is doing fairly well. She seems comfortable. Patient reportedly talks more at times. Patient is eating more. The blood pressure is controlled. Patient sleeps and awakens to eat. Her appetite is good. Patient spends time out in her chair. Patient is more alert and is verbal at times. Her eyes are closed most of the time. Patient is less somnolent. She continues to eat with assistance. She has a history of Alzheimer's type Dementia. Her bowel and urinary functions are satisfactory. The plan noted is to continue with orders as written. The patient is receiving Restorative Therapy. Monitor for any aspiration. Maintain Nutrition, Skin Care, and Fall Precautions. Monitor bowel function. The patient is not capable of making health care decisions." The patient's son (POA) information is noted. Additional physicians' notes reviewed were those dated on 01-16-14 01-22-14, 01-27-14, 01-29-14, 01-31-14, 02-03-14, 02-10-14 and 02-19-14 had noted that the Patient's right hand is contracted and spastic. The physician's notes do not note any treatment or orders relating to R#4's right hand. On 04-01-14 at 2:59 pm the Director of Nursing submitted the facility Care Plan Policy. It is noted that the policy of the East Ridge Health Center to conduct care plan meeting in compliance with state and federal regulations. The development of the interdisciplinary care plans for residents are written and completed from the assessments of the resident. "The residents written care plan is developed from the assessment should include -a medical plan of care -a comprehensive interdisciplinary plan of care based on the needs of the individual resident -Measurable objectives and timetables to meet a resident needs that are identified in the comprehensive assessment. -the type and frequency of services required to provide the necessary care for the resident to attain and maintain his/her highest practicable well-being -a listing of services provided within and outside the facility to meet those needs -an explanation of the service goals."

Based on observation, interview and record review the facility failed to ensure that resident number four (R#4) was free from neglect during the provision of treatment and care by the staff. This has the potential to affect one of five sampled residents. The residents should be free from any incidence of abuse or neglect while in the nursing home setting. The findings include: On 3-31-14 at 7:30 am resident #4 was observed briefly receiving Assisted Daily Living (ADL) care from the attending Certified Nurse Assistant who had requested for assistance from another staff with positioning/pillows and ADL care at that time. The resident had a bandage covering the right hand. Review of Discharge Summary for R#4 dated 02/28/14 from Jackson Health System revealed that she was transferred to Jackson South Hospital after the facility noticed her right index finger was dark with a string around the finger. "The patient was immediately seen by a hand surgeon, who proceeded with emergent right index finger amputation and debridement or adjacent tissue." On 03-31-14 a record review of the Nursing Home Reports for East Ridge Retirement Village, INC was conducted. The form noted that the only report submitted by the facility was a "new" report that was created on 3-12-14 at 11:35 am for an incident that occurred on 02-25-2014. The form does not have a Federal Immediate Report or a Federal 5-day Report conducted by the facility. On 3-31-14 at 9:05 am the resident was observed in bed. There was a gauze-type bandage on the right hand of the resident. The resident was not verbally responsive and had her eyes closed. The resident had some involuntary movement of the right hand back and forth, up and down and across the upper chest area. The gauze was clean to sight. There was black writing on the outer area that has tape on it that was unable to be read it at that time. On 3-31-14 at 10:05 am record review revealed the resident had an Minimum Data Set (MDS) completed that was for a significant change in condition that had an assessment referenced date of 3-13-14. Care Plan for Skin Condition dated 3-08-14 revealed skin condition related to surgical wound status [REDACTED]. Blister on the right side of the hand and skin tear to lower left thigh. On 3-31-14 at 11:01 am the HOSPICE Nurse is in the room at this time. The resident is observed in bed. The resident eyes are closed and not verbally responsive. She was making the involuntary movement of the right hand back and forth. The Hospice nurse reported that the staff just replaced the bandage to the right hand. There was a date written on the bandage (03-31-14). The Hospice nurse stated that the resident received Hospice services 03-06-14. She stated that she visits the facility on Monday, Tuesday, Wednesday and Thursdays because she had other residents on Hospice there too. She stated that the C N A's come to see this resident 5 times a week. She said that the bandage to the right hand is changed every day and as needed. She stated that the resident's speech is limited and she was not able to make her needs known. She stated that they will look for grimacing or facial expressions as a sign of pain. She said that the mattress was an air mattress which was provided by the facility, not Hospice. She was able to show that the resident had heel floaters to prevent sores. On 03-31-14 at 12:46 pm the interim Administrator reported that the adverse incident they have was investigated already by DCF the day after the incident occurred on 2-26-14 at 1:30pm; on 2-27-14 at 12:30pm; on2-28-14 at 9am and on 3-05-14 at 9:00am. She stated that DCF will be sending a final report in which they ruled out this case as abuse/neglect. She stated that the facility, in the case of the R#4, they did not file an Immediate Federal Report. She stated that the facility spoke with several different people from AHCA and DCF was here the next day. She stated that they completed the adverse report but was not aware that the Abuse needed to be reported because they did not consider the incident as a case of abuse. On 03-31-14 at 1:20 pm, the electronic record review of the CNA Daily Charting in the computer for R#4 was conducted for the dates of February 22, 2014 through February 25, 2014. "-Appliances noted that included a High back wheel chair and Hand Roll to left hand. Skin Precautions has noted to -Alternating pressure mattress with heels floating. Ensure that I have two pillows in place under my right arm to keep it elevated. -Resident is on a scheduled repositioning program -Bed Mobility Support Provided -Use side rails per Resident Care Guide" On 03-13-14 at 3:00 pm the Medical Record Director provided a copy of the CNA Daily Charting Notes. A review of the hard copy of the CNA Daily Charting notes revealed that for Bathing: Nail Care (Fingernails and Toenails) guidance noted is to check the condition of the fingernails and toenails. If action was required to notify the nurse and press "Notes" and enter the nurses initials. A review revealed that there was a check mark in the box for this section on February 22, 2014 for the 7:00am to 3:00pm shift. There was no check mark for the 3pm to 11pm shift or the 11pm to 7am shift. On February 23, 2014 there was a check mark in the box only for the 7am to 3pm shift. On February 24, 2014 there was a check mark in the box for the for all three shifts. On February 25, 2014 there was a check mark in the box for the 11pm to 7am shift only. On 04-01-14 at approximately 2:00 pm during an interview conducted with the CNA from the 7am to 3pm shift for the East Wing. She explained that whenever the R#4 receives any type of messages to the hand and sensory stimulation the check mark is placed in the computer to indicate that is what care was provided. She confirmed the check mark indicates the care was given. On 3-31-14 at 5:20pm interview with the Director of Nursing (DON) revealed that the sock that was found on the right hand of R#4 was a knitted type of sock that belonged to the resident. The other sock was found in her belongings. The sock that was on the hand was sent to the hospital. The DON described the sock as blue and black with a cow head on it and a bright colored band around the top of the sock. The DON stated that the incident was not reported on the first day. He stated that they ruled out that the incident was an act of abuse. The DON explained the he is currently acting as the Interim Risk Manager at that time. The DON admits that the facility staff did not know how the sock got on the residents hand. He stated that the incident was thoroughly investigated and confirmed that it was reported as an adverse incident. He stated that they did not complete a Federal report. He explained that as a result of the investigation it was unable to determine why the sock was placed on the residents hand and who initially placed the sock on the residents hand. He stated that the nurse on the 7pm to 7am shift on the 2-24-14 saw the sock on the residents hand. He stated that from the investigation the sock was not discovered on the residents hand until 1:30pm on the 02-25-14. The C N A went to prepare the resident for activities. A brief review of the INCIDENT Investigation report was conducted at this time with the DON. He states that from the investigation it was determined that there were some staff that had seen the sock on the resident but no one knew when it was originally placed on the residents hand or exactly why the sock was being used. There were several staff that did not see the resident wearing the sock. He admits that there were no care plans, physicians orders or [DIAGNOSES REDACTED]. On 3-31-14 at approximately 6:01 pm the DON presented the sock for observation. The sock is a fuzzy, soft textured, thick and ankle length. The sock is blue in color on the heel and toe area with a black and white cow type print and bright pink colored band on the upper portion. There is an embroidered picture of a cow face sewed on the pink upper band. On the bottom of the sock is a plastic white label with that had the residents name. The inside surface area of the sock is not smooth as the outer surface area. The inside has a large number of loose black and white strings that are hanging. The DON stated that the sock was not care planned for, it was not ordered by the physician and the reason for the use of the sock was not determined or documented. On 04-01-14 conducted a record review of the electronic nurse notes, care plans and the CNA Daily Charting. A review of the medical record prior to R#4 discharge on 2-25-14 revealed that there was no documentation relating using the sock to cover the hand, why the sock was used to cover the right hand or if the appropriate Medical/Health care provider was informed of the use of the sock to cover R#4 right hand. A record review of the Care Plans for R#4 that were dated for 01-08-14 was reviewed in the computer. A copy was provided by the Medical Record Director on 04-01-14 at 12:21pm. The record review revealed that only the following care areas had care plans which were Cognitive Loss/Dementia, Communication, Urinary Incontinence, Psychosocial Well-Being, Activities, Falls, Nutritional Status, Pressure Ulcers, [MEDICAL CONDITION] Drug Use, Advance Directive, Skin Condition and Hypertension. There were no care plans relating to the use of a sock or device for covering the right hand. A record review of the Interdisciplinary (Nurses') Notes dated for 01-09-14 01-13-14, 01-16-13, 01-23-14, 01-25-14, 01-30-14, 02-01-14, 02-06-1402-20-14 and 02-25-14 revealed the Interdisciplinary (Nurses') Notes dated on 02-25-14 at 18:17pm by the attending Licensed Practical Nurse-LPN had noted that at 1:30pm the treatment nurse was called to the resident #4's room by the attending CNA who stated that when she was performing personal care on the resident. When she tried to remove a sock that had been put on the resident hand, she noticed discoloration to the right index finger. On assessment the resident was found with a sock partially removed and the inside string from the sock wrapped around the resident's index finger, leaving the finger dark and swollen. The supervisor was notified. The sock was cut away leaving the string still wrapped tightly around the finger. We were unable to remove the string so the physician was notified and he ordered the resident to be sent to the hospital. 911 was called and arrived at 2pm. The resident left the facility via stretcher and ambulance for Jackson South Hospital. The Interdisciplinary (Nurses') Notes did not have any documentation relating to the use of the sock applied to right hand of R#4, why the sock was used and if any of the medical staff were aware that the sock was being used. On 04-14-14 a review of the physician progress notes [REDACTED]. The patient is receiving Restorative Therapy. Monitor for any aspiration. Maintain Nutrition, Skin Care, and Fall Precautions. Monitor bowel function. The patient is not capable of making health care decisions. The patient's son (POA) information is noted. Additional physicians' notes reviewed were those dated on 01-16-14 01-22-14, 01-27-14, 01-29-14, 01-31-14, 02-03-14, 02-10-14 and 02-19-14 had noted that the Patient's RIGHT Hand is contracted and spastic. The physician's notes do not note any treatment or orders relating to R#4's right hand. On 04-01-14 at 2:59 pm the Director of Nursing submitted the facility Care Plan Policy. It is noted that the policy of the East Ridge Health Center to conduct care plan meeting in compliance with state and federal regulations. The development of the interdisciplinary care plans for residents are written and completed from the assessments of the resident. The residents written care plan is developed from the assessment should include: "-a medical plan of care -a comprehensive interdisciplinary plan of care based on the needs of the individual resident -Measurable objectives and timetables to meet a resident needs that are identified in the comprehensive assessment. -the type and frequency of services required to provide the necessary care for the resident to attain and maintain his/her highest practicable well-being -a listing of services provided within and outside the facility to meet those needs -an explanation of the service goals." Record review of Abuse Prevention Policy presented as Exhibit C East Ridge Retirement Village revealed that facility has in place Policy and Procedures to prevent abuse. Policy has a Policy Abuse Prevention Statement that states "It is a goal of this facility to establish a resident-sensitive and secure environment to assure proper and respectful treatment of [REDACTED]. The facility will not tolerate any abuse and will promptly and thoroughly investigate any allegation of abuse, neglect, misappropriation of resident property and all resident injuries of known and unknown origin." The facility policy includes the following components: "I- Policy Implementation (Pre-Employment screening) listing the requirements that would be met for all potential candidates for employment prior to employment such as: License/ Certification verification, Criminal background check, Drug screen, Reference check, Personal Interview, Health Examination with current TB immunization. II- Orientation and Training: Completion of orientation checklist for new employees in their Departments, Completion of annual mandatory Abuse Prevention in service for all employees, Ongoing education and training for employees will include appropriate intervention for behavioral episodes, how to report any reasonable suspicion of crime or knowledge of allegations without fear of reprisal, Clear definition of all types of abuse, Identification of signs and symptoms of abuse. III- Reporting allegations of abuse. IV- Investigation of Incidents and Allegations. V- Education of Residents/ Families. VI- Protection of residents during investigation."

Based on interview and record review the facility failed to ensure that the resident number four (R#4) was properly assessed before the care and treatment was implemented. This has the potential to affect one of eight sampled residents. The comprehensive assessment must be completed in an effort to determine and develop the appropriate plan of care, services and treatment. The findings include: Review of Discharge Summary for R#4 dated 02/28/14 from Jackson Health System revealed that she was transferred to Jackson South Hospital after the facility noticed her right index finger was dark with a string around the finger. "The patient was immediately seen by a hand surgeon, who proceeded with emergent right index finger amputation and debridement or adjacent tissue." A record review of the Annual MDS with an Assessment Reference Date of 12-28-13 for R#4 has the admitted noted of 2-12-2013. The Active [DIAGNOSES REDACTED]. On 3-31-14 at 7:30am the resident was observed briefly receiving Assisted Daily Living (ADL) care from the attending Certified Nurse Assistant who had requested for assistance from another staff with positioning/pillows and ADL care at that time. The resident was observed to be well groomed and had a bandage covering the right hand. On 3-31-14 at 9:05 am the resident was observed in bed. There was a gauze-type bandage on the right hand of the resident. The resident was well groomed and dressed. The resident was not verbally responsive and had her eyes closed. The resident had some involuntary movement of the right hand back and forth, up and down and across the upper chest area. The gauze was clean to sight. There was black writing on the outer area that had tape on it that was unable to read. On 03-31-14 a record review of the Nursing Home Reports for East Ridge Retirement Village, INC was conducted. The form noted that the only report submitted by the facility was a "new" report created on 3-12-14 at 11:35am for an incident that occurred on 02-25-2014. The form does not have a Federal Immediate Report or a Federal 5-day Report conducted by the facility. On 3-31-14 at 10:05 am record review revealed, the resident had an Minimum Data Set (MDS) completed that was for a significant change in condition that had an assessment referenced date of 3-13-14. On 3-31-14 at 11:01 am the Hospice Nurse is in the room and the resident in bed, well-groomed and dressed. The resident's eyes were closed and she was not not verbally responsive. She was making the involuntary movement of the right hand back and forth. The Hospice nurse reported that the staff just replaced the bandage to the right hand. There was a date written on the bandage (03-31-14). The Hospice nurse stated that the resident received Hospice services 03-06-14. She states that she visited the facility on Monday, Tuesday, Wednesday and Thursdays because she had other residents on Hospice here too. She stated that the CNA's come to see this resident 5 times a week. She said that the bandage to the right hand was changed every day and as needed. She stated that the resident's speech was limited and she was not able to make her needs known. She stated that they would look for grimacing or facial expressions as a sign of pain. She said that the mattress was an air mattress which was provided by the facility, not Hospice. She was able to show that the resident had heel floaters to prevent sores. On 03-31-14 at 12:46 pm the interim Administrator reported that the adverse incident they had was investigated already by DCF on the day after the incident occurred on 2-26-14 at 1:30pm; on 2-27-14 at 12:30pm; on 2-28-14 at 9am and on 3-05-14 at 9:00am. She stated that DCF will be sending a final report in which they ruled out this case as abuse/neglect. She stated that the facility, in the case of the R#4, did not file an Immediate Federal Report. She stated that the facility spoke with several different people from AHCA and DCF was here the next day. She stated that they completed the adverse report but was not aware that the Abuse needed to be reported because they did not consider the incident as a case of abuse. On 03-31-14 at 1:20 pm the electronic record review of the CNA Daily Charting in the computer for R#4 was conducted for the dates of February 22, 2014 through February 25, 2014. -Appliances noted that included a High back wheel chair and Hand Roll to left hand. Skin Precautions has noted to -Alternating pressure mattress with heels floating. Ensure that I have two pillows in place under my right arm to keep it elevated. -Resident is on a scheduled repositioning program -Bed Mobility Support Provided -Use side rails per Resident Care Guide On 03-13-14 at 3:00 pm the Medical Record Director provided a copy of the CNA Dialy Charting Notes. A review of the hard copy of the C N A Daily Charting notes revealed that for Bathing: Nail Care (Fingernails and Toenails) guidance noted is to check the condition of the fingernails and toenials. If action is required to notify the nurse and press "Notes" and enter the nurses initials. A review revealed that there was a check mark in the box for this section on February 22, 2014 for the 7:00am to 3:00pm shift. There is no check mark for the 3pm to 11pm shift or the 11pm to 7am shift. On February 23, 2014 there was a check mark in the box only for the 7am to 3pm shift. On February 24, 2014 there was a check mark in the box for the for all three shifts. On February 25, 2014 there was a check mark in the box for the 11pm to 7am shift only. On 04-01-14 at approoximatley 2:00 pm during an interview conducted with the C N A from the 7am to 3pm shift for the East Wing. She explained that whenever the R#4 received any type of messages to the hand and senory stimulation the check mark was placed in the computer to indicate that was what care was provided. She confirmed the check mark indicated the care was given. On 3-31-14 at 5:20 pm, interview with the Director of Nursing (DON) revealed that the sock that was found on the right hand of R#4 was a knitted type of sock that belonged to the resident. The other sock was found in her belongings. The sock that was on the hand was sent to the hospital. The DON described the sock as blue and black with a cow head on it and a bright colored band around the top of the sock. The DON stated that the incident was not reported on the first day. He stated that they ruled out that the incident was an act of abuse. The DON explained the he was currently acting as the Interim Risk Manager at that time.The DON admited that the facility staff did not know how the sock got on the resident's hand. He stated that the incident was thoroughly investiagted and confirmed that it was reported as an adverse incident. He stated that they did not complete a Federal report. He explained that as a result of the investigation it was unable to determine why the sock was placed on the resident's hand and who intitially placed the sock on the resdients hand. He stated that the nurse on the 7pm to 7am shift on the 2-24-14 saw the sock on the resident's hand. He stated that from the investigation the sock was not discovered on the resident's hand until 1:30pm on the 02-25-14. The C N A went to prepare the resident for activities. A brief review of the Incident Investigation report was conducted at that time with the DON. He stated that from the investigation, it was determined that there were some staff that had seen the sock on the resident but no one knew when it was originally placed on the resdients hand or exactly why the sock was being used. There were several staff that did not see the resident wearing the sock. He admited that there were no care plans, physcians orders or [DIAGNOSES REDACTED]. On 3-31-14 at approximatley 6:01 pm the DON presented the sock for observation. The sock is a fuzzy, soft textured, thick and ankle length. The sock is blue in color on the heel and toe area with a black and white cow type print and bright pink colored band on the upper portion. There was an embrodered picture of a cow face sewed on the pink upper band. On the bottom of the sock was a plastic white label with that had the resdients name. The inside surface area of the sock was not smooth as the outer surface area. The inside had a large number of loose black and white strings that are hanging. The DON stated that the sock was not care planned for, it was not ordered by the physician and the reason for the use of the sock was not determined or documented. On 04-01-14 conducted a record review of the electronic nurse notes, care plans and the C N A Daily Charting. A review of the medical record prior to R#4 discharge on 2-25-14 revealed that there was no documentation relating using the sock to cover the hand, why the sock was used to cover the right hand or if the appropriate Medical/Health care provider was informed of the use of the sock to cover R#4 right hand. A record review of the Care Plans for R#4 that were dated for 01-08-14 was reviewed in the computer. A copy was provided by the Medical Record Director on 04-01-14 at 12:21pm. The record review revealed that only the following care areas had care plans which were Cognitive Loss/Dementia, Communication, Urinary Incontinence, Psychosocial Well-Being, Activities, Falls, Nutritional Status, Pressure Ulcers, [MEDICAL CONDITION] Drug Use, Advance Directive, Skin Condition and Hypertension. There were no care plans relating to the use of a sock or device for covering the right hand. A record review of the Interdisciplinary (Nurses') Notes dated for 01-09-14m 01-13-14, 01-16-13, 01-23-14, 01-25-14, 01-30-14, 02-01-14, 02-06-1402-20-14 and 02-25-14. The Interdisciplinary (Nurses') Notes dated on 02-25-14 at 18:17pm by the attending Licensed Practical Nurse-LPN had noted that at 1:30pm the treatment nurse was called to the resident ' s room by the attending C N A who stated that when she was performing personal care on the resident. When she tried to remove a sock that had been put on the resident hand, she noticed discoloration to the right index finger. On assessment the resident was found with a sock partially removed and the inside string from the sock wrapped around the resident's index finger, leaving the finger dark and swollen. The supervisor was notified. The sock was cut away leaving the string still wrapped tightly around the finger. We were unable to remove the string so the physician was notified and he ordered the resident to be sent to the hospital. 911 was called and arrived at 2pm. The resident left the facility via stretcher and ambulance for Jackson South Hospital. The Interdisciplinary (Nurses') Notes do not have any documentation relating to the use of the sock applied to right hand of R#4, why the sock was used and if any of the medical staff were aware that the sock was being used. On 04-14-14 a review of the physician progress notes [REDACTED]. Her sister was in a wheelchair at her bedside on the left. She was stroking the patient's arms and hands. Patient was moving her arms and trying to make sounds. The sister stated she spoke to her at times. She was doing okay and was stable. She had no complaints. Patient was talking and moving more. She was holding her own and was doing fairly well. She seems comfortable. Patient reportedly talked more at times. Patient was eating more. The blood pressure was controlled. Patient sleeps and awakens to eat. Her appetite is good. Patient spends time out in her chair. Patient is more alert and is verbal at times. Her eyes are closed most of the time. Patient is less somnolent. She continues to eat with assistance. She has a history of Alzheimer ' s type Dementia. Her bowel and urinary functions are satisfactory. The plan noted is to continue with orders as written. The patient is receiving Restorative Therapy. Monitor for any aspiration. Maintain Nutrition, Skin Care, and Fall Precautions. Monitor bowel function. The patient is not capable of making health care decisions. The patient's son (POA) information is noted. Additional physicians' notes reviewed were those dated on 01-16-14 01-22-14, 01-27-14, 01-29-14, 01-31-14, 02-03-14, 02-10-14 and 02-19-14 had noted that the Patient's RIGHT Hand is contracted and spastic. The physician's notes do not note any treatment or orders relating to R#4's right hand. On 04-01-14 at 2:59 pm the Director of Nursing submitted the facility Care Plan Policy. It is noted that the policy of the East Ridge Health Center was to conduct care plan meeting in compliance with state and federal regulations. The development of the interdisciplinary care plans for residents are written and completed from the assessments of the resident. "The residents written care plan is developed from the assessment should include -a medical plan of care -a comprehensive interdisciplinary plan of care based on the needs of the individual resident -Measurable objectives and timetables to meet a resident needs that are identified in the comprehensive assessment. -the type and frequency of services required to provide the necessary care for the resident to attain and maintain his/her highest practicable well-being -a listing of services provided within and outside the facility to meet those needs -an explanation of the service goals."