Every finding on record at Elm Crest Retirement Community

Based on observation, clinical record review, staff interviews, and policy review the facility failed to maintain infection control practices for 2 of 3 residents reviewed (Residents #3 and #2). The facility failed to perform hand hygiene and change gloves when completing resident cares, failed to ensure use of enhanced barrier precautions (EBP) when required, and failed to maintain a catheter bag off the floor. The facility reported a census of 37 residents.Findings include:1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] documented active diagnoses including stroke (brain blood clot or bleed) and benign prostatic hyperplasia (enlarged prostate gland). Resident #3's MDS assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #3's MDS assessment documented Resident #3 depended on staff for toileting hygiene, continuously experienced bowel incontinence, and maintained an indwelling urinary catheter (tube inserted into the bladder to drain urine). On 8/6/26 at 9:32 AM Staff A, Certified Nurse Assistant (CNA), and Staff B, CNA, entered Resident #3's room, displaying an Enhanced Barrier Precautions (EBP) sign on Resident #3's door. Staff A and Staff B washed their hands, applying gowns and gloves. Staff A completed catheter care with Staff B assisting. Staff C, CNA, entered Resident #3's room, applied gloves, didn't perform hand hygiene, didn't put on a gown, and applied a medicated powder to Resident #3's groin area, touching Resident #3's groin area. Staff A removed gloves, didn't perform hand hygiene or apply new gloves, assisted Staff B to apply a new brief on Resident #3, and transferred Resident #3 from the bed to a recliner, touching Resident #3's clothing, bedding, and mechanical lift. 2. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented active diagnoses including heart failure (heart pumping weakness) and kidney failure (kidney dysfunction). Resident #2's MDS assessment documented a BIMS score of 13, indicating intact cognition. Resident #2's MDS assessment documented Resident #2 depended on staff for care, always experienced bowel incontinence, and maintained an indwelling urinary catheter. On 8/6/26 at 12:00 PM Staff D, CNA, and Staff E, CNA, entered Resident #2's room, displaying an EBP sign on Resident #2's door. Staff D and Staff E washed hands, applying gowns and gloves. Staff D removed Resident #2's brief, completed care to Resident #2's buttocks, removed gloves, completed hand hygiene, and applied new gloves. Staff E placed a graduated cylinder (measuring container) on the floor with a paper towel under the cylinder, emptied Resident #2's catheter bag into the cylinder, and cleansed the catheter bag drain tube tip with an alcohol swab. Staff E, wearing the same gloves, emptied the cylinder into the toilet, touched the sink faucet handle to control water flow, and rinsed the cylinder. Staff E removed gloves, completed hand hygiene, and applied new gloves. Staff D completed Resident #2's catheter care, and with Resident #2 remaining in bed, staff lowered the bed with the catheter bag attached to the bed without a dignity bag (privacy bag), resting on the floor. Staff E removed gloves, touched the front of her gown, smoothed her hair with bare hands, and removed her gown. Without performing hand hygiene or wearing gloves, Staff E gathered bagged trash, transported the trash across the hallway to a utility room, and touched Resident #2's room door handle and the utility room door handle. Staff E stated she'd complete hand hygiene when returning to Resident #2's room. The Enhanced Barrier Precautions Policy dated 2026 directed EBP as an infection control intervention designed to reduce transmission of multidrug-resistant organisms (drug-resistant bacteria) employing targeted gown and glove use during high-contact resident care activities. The policy instructed staff to obtain an order for EBP for residents maintaining an indwelling medical device (catheter). The policy identified high-contact care activities including dressing, transferring, providing hygiene, changing briefs or assisting with toileting, and device care. The Hand Hygiene Policy dated 2026 instructed staff to perform hand hygiene after handling contaminated objects, before performing resident care procedures, before applying and after removing personal protective equipment (PPE) including gloves, and during resident care when moving from a contaminated body site to a clean body site. On 8/10/26 at 11:32 AM the Director of Nursing (DON) stated staff must keep catheter bags in dignity bags attached to the bed below the bladder and off the floor, when residents remain in bed. The DON stated staff must complete hand hygiene before applying gloves, after removing gloves, and before exiting resident rooms. The DON stated they expected staff to wear a gown and gloves when applying treatments to the groin area for residents maintaining catheters and placed on EBP.

Based on record review, observation, and interview, the facility failed to ensure staff followed proper incontinence care and catheter care techniques for 2 of 2 residents (Resident #3, Resident #2) reviewed for catheter care. The facility reported a census of 37 residents.Findings include:1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of stroke (brain blood clot or bleed) and benign prostatic hyperplasia (enlargement of the prostate blocking urine flow). The MDS assessment identified Resident #3 depended on staff for toileting hygiene, always experienced bowel incontinence, and maintained an indwelling urinary catheter (tube inserted into the bladder to drain urine). The assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. On 8/6/26 at 9:32 AM watched Staff A, Certified Nursing Assistant (CNA), and Staff B, CNA, enter Resident #3's room, wash their hands, and apply gowns and gloves. With Resident #3 lying in bed, Staff A didn't hold the catheter at the insertion site and took a new wipe, wiping down catheter tubing 3 times over the same areas with the same side of the wipe. Staff A, using a new wipe, cleansed around the meatus (opening at head of penis), wiping the same area repeatedly with the same side of the wipe. Staff A cleansed the shaft of the penis, wiping up and down on the shaft of the penis with the same side of the wipe. Staff A and Staff B turned Resident #3 to his side, and Staff A cleansed the buttocks, wiping up and down the buttocks with the same side of the same wipe, then cleansed between Resident #3's buttocks with a new wipe. Staff A and Staff B applied a new brief and transferred Resident #3 from bed to a recliner. 2. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of heart failure (heart pumping weakness) and kidney failure (kidney dysfunction). The MDS assessment identified Resident #2 depended on staff for care, always experienced bowel incontinence, and maintained an indwelling urinary catheter. The assessment documented a BIMS score of 13, indicating intact cognition. On 8/6/26 at 12:00 PM observed Staff D, CNA, and Staff E, CNA, enter Resident #2's room, wash their hands, and apply gowns and gloves. Staff E cleansed Resident #2's buttocks and between the buttocks using a new wipe for each swipe. Staff D removed gloves, completed hand hygiene, and applied new gloves. Staff E placed a graduated cylinder (measuring container) on the floor with a paper towel under the cylinder, emptied Resident #2's catheter bag into the cylinder, cleansed the catheter bag drain tube tip, wiped further up the tubing closer to the catheter bag, and cleansed the outside and inside of the tip with the same alcohol wipe. Staff E emptied, rinsed, and stored the cylinder. After Staff D completed Resident #2's catheter care, Staff E held the catheter at the insertion site and wiped Resident #2's catheter with an alcohol swab from there holding down approximately 3 inches. With Resident #2 remaining in bed, staff lowered the bed and attached the catheter bag to the bed, lying on the floor as staff didn't place the catheter bag in a privacy bag. The Catheter Care Policy dated 2026 directed privacy bags remain available and catheter drainage bags remain covered at all times.The policy instructed the procedure for a male:Gently grasp penis, draw foreskin back if applicable.Using circular motion, cleanse the meatus with a clean cloth moistened with water and soap.With a new moistened cloth, starting at the urinary meatus moving down, cleanse the shaft of the penis.With a new moistened cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place so as not to pull on the catheter.The policy instructed the procedure for a female:Gently separate the labia (vaginal skin folds) to expose the urinary meatus.Wipe from front to back with a clean cloth moistened with water and soap.Use a new part of the cloth or different cloth for each side.With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as not to pull on the catheter. On 8/10/26 at 11:32 AM the Director of Nursing (DON) stated they expected the staff to hold the catheter at the insertion site, wipe down the catheter away from the insertion site with a wipe (not alcohol swabs), and complete 1 swipe with each wipe. The DON stated staff should cleanse the penis by wiping around the head, then proceed with a new wipe around the shaft of the penis, working away from the head of the penis.

Based on clinical record review, facility investigation file review, resident and staff interviews, and policy review the facility staff failed to follow the facility's fall policy and protocol to notify the charge nurse in order to complete an assessment in a timely manner and begin interventions after a resident had a fall for one of three residents reviewed for injuries of unknown origin and nursing supervision (Resident #1). The facility reported a census of 41 residents. The facility corrected the deficient practice per past noncompliance on 2/17/26 through the following actions: *The facility DON and Administrator began an investigation when the bruises were discovered on Resident #1 on 2/4/26.*The facility sent Resident #1 to the Emergency Department (ED) on 2/4/26 for evaluation. *The facility interviewed residents with BIMS >13 if they had a fall, what to do if they fall, if they felt safe at the facility. *Staff Education was provided on Unexplained Injuries, Fall Prevention to include reporting falls, and Compliance in reporting allegations of Abuse, Neglect and Exploitation and change in condition. ALL staff meeting was held on 2/17/26.*The new certified nursing assistant (CNA) was paired up with a more seasoned staff and provided 3 additional days of orientation (in addition to initial the 6 days of orientation she had when she started working at the facility on 12/29/25. Findings include:A facility self-report to the Department of Inspections, Appeals and Licensing (DIAL) submitted on 2/5/26 at 8:52 AM revealed an allegation of abuse between staff to a resident occurred on approximately 2/3/26. The incident summary revealed on 2/4/26, a CNA reported the resident had bruises to her right forehead, right eye and right hip. The resident stated she rolled out of bed. The resident complained of nausea and vomiting and was sent to the Emergency Department (ED) for evaluation. The facility began an investigation when the resident transferred to the hospital.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had diagnoses of nontraumatic intracranial hemorrhage (bleeding into the brain tissue not caused by trauma), cerebrovascular accident (CVA) (stroke), hemiplegia (paralysis on one side of the body), aphasia (inability to speak, write or read) and muscle weakness. The MDS indicated the resident had impaired short-term and long-term memory, and severely impaired decision-making skills. The MDS recorded the resident had no falls and no behaviors. The resident had impaired range of motion to her upper extremity on one side and bilateral lower extremities, and had dependence on staff for bed mobility, transfers and toileting.The Care Plan created on 10/31/25 and revised on 2/8/26 revealed Resident #1 had a stroke and had a risk for falls related to right sided paralysis. The resident required assistance with transfers and toileting. The Care Plan directed to use two staff for assistance with transfers and toileting, implement fall prevention/reduction precautions per the facility protocol, and ensure the call light was within reach. The following interventions were added related to a concern for a fall that had occurred: 2/4/26 - scoop mattress (added to the care plan on 2/8/26). 2/6/26 - do not leave resident alone on the commode and reinforce the need to call for assistance (added to the care plan 2/8/26). 3/18/26- store the commode in the bathroom when not in use. 5/21/26 -bed at lowest position and place a fall mat at the bedside whenever the resident was in bed. (added to the care plan on 5/22/26)A Fall Risk assessment dated [DATE] and 2/4/26 revealed the resident had a risk for falls. The Progress Notes for Resident #1 revealed the following: a. On 1/23/26 at 7:31 AM, resident required assistance of two with a gait belt for transfers and toileting or a bedside commode.b. On 1/24/26 at 8:20 PM, a Skin Check revealed skin warm and dry, and skin color WNL (within normal limits). c. On 1/31/26 at 8:21 PM, a Skin Check revealed the resident had a bruise to the right front axilla and an abrasion to her left lateral foot. d. On 2/3/26 at 3:03 PM, resident moved to 209A.e. On 2/4/26 at 10:56 AM, Staff A, Registered Nurse (RN), notified by certified nursing assistant (CNA), that the resident had bruising. A bruise found on the right forehead measured 2 centimeter (cm) x 3 cm, under the right eye 1 cm x 2 cm, and right upper hip/thigh 9.5 cm x 10 cm. The resident left the facility to go to the ED. At 3:30 PM, resident returned to the facility. At 4:13 PM, order for Ceftin (an antibiotic) for a UTI (urinary tract infection). After the resident returned to the facility she had an emesis (vomiting). Order obtained for Zofran (antiemetic used to prevent and treat nausea and vomiting) every 6 hours.f. On 2/5/26 at 4:53 AM, Staff B, Licensed Practical Nurse (LPN), documented the resident had an unwitnessed fall and received bruises to the right side of her body. She had a bump on the left side of her face above the eye and a big bump on the left upper outer thigh. Neuro (checks) at baseline. The resident denied pain.g. On 2/5/26 at 12:44 PM, the IDT (Interdisciplinary Team) met to review the bruising of unknown origin. The resident was assessed by the DON (Director of Nursing) on 2/4/26 at approximately 10:30 AM to verify the location and extent of bruising. The family and provider were notified promptly after the assessment completed. Resident transferred to the ED for an evaluation. An investigation was initiated by the DON and the Administrator.Incident reports reviewed from 1/1/26 to 6/8/26 revealed Resident #1 had a fall incident on 3/18/26 at 2:23 AM and 5/21/26 at 11:34 PM, and an injury of unknown origin on 2/4/26 at 11:00 AM. The injury of unknown origin incident report completed by the DON revealed a CNA reported the resident had bruising to the forehead, right eye and right hip. The nurse notified the DON. Resident reported she rolled out of bed. Resident was sent to the ED for evaluation. A Fax Notice to the Physician's Assistant, on 2/4/26 revealed the resident had an unwitnessed fall. The injuries included the following: Right hip = Length (L) 10 cm x Width (W) 9.5 cmRight eye = L 2 cm x W 1 cmLeft forehead = L 3 cm x W 2 cm An After Visit Summary dated 2/4/26 revealed Resident #1 was seen in the ED for bruising and diagnosed with contusions to her forehead and right hip, a minor head injury, and a UTI. Bruising consistent with some type of a fall but resident had no fracture. Suspect a mild concussion due to vomiting once but otherwise neuro status at baseline. The After Visit Summary indicated that Fall prevention at the nursing home is a must.An x-ray of the right hip and pelvis dated 2/4/26, revealed resident had pain and bruising to her right hip. The resident had a prior stroke and could not communicate what happened. X-ray results revealed no fracture. The facility Census report dated 2/2/26 revealed Resident #1 resided in a private room, and had no roommate at that time. A Notification of Room Change revealed Resident #1 had a room change on 2/3/26 at 12:00 PM and moved from room [ROOM NUMBER]A to 209A. The Facility Investigation Summary revealed on 2/4/26 at approximately 10:30 AM, Staff E, CNA, reported she saw bruising on Resident #1's right forehead, right eye and right hip while giving Resident #1 a bath. Resident #1 was assessed by Staff A, RN, and the DON. Resident #1 had complained of nausea and had an emesis prior to the assessment. Resident #1 was able to answer yes and no questions and provide short answers. Resident #1 said No when asked if she fell. Resident #1 replied yes when asked if she rolled out of bed. Resident #1 was then asked how she got back into bed and she replied, they picked me up. Resident #1 was sent to the hospital ED for further evaluation. An investigation was initiated by the DON and the facility administrator. Resident #1 returned to the facility with a diagnosis of UTI and suspected mild concussion related to vomiting once, though no testing or imaging was performed to confirm this diagnosis. A scoop mattress was put in place as an intervention.The staff who worked 2/2/26 - 2/4/26 provided written statements. During the interview process it was revealed that on 2/2/26 at approximately 9:00 PM, Staff C, agency CNA, and Staff D, CNA, assisted Resident #1 to the commode. Staff C left the room and Staff D stayed with the resident until she was finished, then Staff D left the room to find a second person for the transfer. When Staff D and Staff C returned to Resident #1's room, she was on the floor between the commode and the bed. Staff C reported he asked if she was in pain and looked her over for bruising and didn't see any. During the interview with Staff C, he stated that I should have reported it but she looked ok. Staff D reported that she and Staff C went into Resident #1's room and found Resident #1 on the floor. Staff D asked Staff C what room number they were in so she could walkie for help. Staff C instructed Staff D not to report the incident. Staff D reported she was scared and did not know what to do as she was a new CNA and had not been involved in a fall before. Through the facility's investigation it was revealed that on 2/2/26 that Staff C and Staff D did not follow the facility's Fall Policy and Procedures and failed to report the incident. Per policy, the resident should have been assessed by a nurse prior to being moved. The policy then required a mechanical lift used to assist a resident off the floor. Resident #1's care plan was updated to include not leaving her alone on the commode as an intervention for the fall.The Facility Investigation File included the following written Staff Statements: Staff Q, Certified Medication Aide (CMA) and Restorative Aide (RA), wrote: On 2/2/26 about 8:00 AM, a CNA came to me saying Resident #1 was in pain. APAP (Tylenol) was given at that time. I helped the CNA set Resident #1 up, pulled up her pants and placed her in the wheelchair. I did not notice anything out of the ordinary. Staff F, CNA, wrote: On 2/3/26, I was not assigned to the [NAME] hall and did not have any contact with Resident #1. Staff G, agency CNA, wrote: I worked on 2/3/26 from 10 PM to 6 AM and was assigned to the North/West hall. Staff G had no knowledge of Resident #1 having a fall and did not hear anyone call for help. Staff H, CNA, wrote: I was the CNA for Resident #1 last night. Resident #1 was perfectly fine when Staff H put Resident #1 to bed around 8:00 PM. Resident #1 had no bruises on her body, and she was very aware and normal. Her bed was lowered and she was positioned in the middle (of the bed). Staff H peeked in on Resident #1 before leaving her shift and did not notice Resident #1 on the floor.Staff B, agency LPN, wrote: On 2/3/26, I worked the overnight shift from 10 PM to 6 AM. After I got report and checked all of the residents. Nothing seemed out of normality. I did rounds on the South side and checked on Resident #1. I did not see any bruises on the right side. It was hard to get a complete look as her right side is next to the roommate's bed and the curtain was in the way. The left side had no bruises. It seemed unlikely that she would fall on her right side as the beds are too close together and her roommate is alert. I did not hear or see anything on my shift that would lead me to believe anyone had any knowledge of a fall. I do apologize for overlooking the injury. I looked at it on 2/5/26. Bruises are on the right side of her face and body. The hip and above the left eye looked swollen or had a hematoma. Staff I, CNA, wrote: My only involvement with Resident #1 on 2/3/26 was I helped give report with Staff H to help Staff L understand his assignments. I did not help put Resident #1 to bed. I brought Resident #1 down to supper and saw nothing that seemed like she had fallen. Staff O, CNA, wrote: On 2/3/26, I worked on the South hall (assigned to rooms 212A- 216). Around 3:30 PM, we dropped to 5 staff so I then had rooms 208 - 213B. Resident #1 was in her recliner when I checked on her. I talked to her and told her Staff I and I would be back soon to get her up for supper. We went back in to get her up about 15 minutes later. At that time, Resident #1 went to the dining room for supper. At 6:00 PM, Staff H took over that section of the hall. Staff K, LPN, wrote: I was working on 2/3/26 but did not work with Resident #1. A typed note signed by Staff R, agency CNA, revealed: On 2/3/26, Staff C and I took Resident #1 to the commode at approximately 3:15 PM. We transferred her with a two person stand pivot. I did not see any bruising to her face or hip. She did not complain about anything. We finished cares and put her back in the recliner. I gave her the call light and walked out of the room. Staff J, CNA, wrote: I got Resident #1 up on 2/4. I noticed Resident #1 had a big bruise on her forehead when I brushed her hair. Staff J reported it immediately to Staff P and to the nurse. Staff L, CNA, wrote on 2/4/26: I worked on the South wing where 209A was last night and assisted her roommate. I did not witness Resident #1 on the floor at any time during the shift. Staff E, agency CNA, wrote: I was assisting residents at breakfast this morning (2/4) and looked over at Resident #1 and asked if she was ok. She said no, and tears came to her eyes and she started to vomit. Staff E noticed Resident #1 had a black eye and bruise on her forehead, and took Resident #1 to her room. Staff E gave Resident #1 a bath and noticed her right hip had a bruise. Staff E called the charge nurse. The charge nurse looked at it. Staff E noted she had worked with Resident #1 on 2/3/26 in the AM and there were no bruises or anything at that time. Staff A, RN, wrote on 2/4/26: I was told by Staff M, LPN, that they just took Resident #1 out of the dining room and she was vomiting. After entering the room, the CNA's pointed out the bruises on her forehead and right eye. It was decided to give Resident #1 a bath because she had diarrhea and vomiting. During the bath, Staff E called me and reported Resident #1 had a hematoma on her right hip and thigh. Staff A showed the DON after Resident #1 was placed in bed. Resident #1 stated no when asked if she fell. Resident stated yes when asked if she rolled out of bed. I asked Resident #1 how she got back into bed and she stated they picked me up. Nothing was passed on in shift report about a fall. Staff P, CNA, wrote: I came in at 4:17 AM, and went to 209A room around 4:30 AM and checked her brief. The brief was wet so Staff P changed Resident #1 and rolled her. Staff P thought it was a bit dark and did not see anything on Resident #1's right side. Staff M, LPN, wrote on 2/4/26: A CNA in the dining room asked if we had the blue puke containers. I said no, why, what's going on. The CNA proceeded to say the resident was throwing up. Another CNA rushed to get the resident to her room. The CNA's gave the resident a quick bath and laid the resident down. The CNA's reported bruises to another nurse on duty. Staff M came to the resident's room to get a set of vital signs and saw the DON and another nurse in the room looking at bruises on the resident. Nothing was passed along in report from the night shift. Staff S, CNA, wrote: Resident #1 showed no signs of injury. She was pleasant to staff. She was sound asleep in bed when I was in her room at 8:00 PM or so. Staff T, CNA, wrote on 2/4/26 at 7:30 AM: I helped Staff J with Resident #1. We rolled her to the right to change her in bed. We got her dressed in bed and then put the resident into the wheelchair, then put her finger glove and sling on. I did not notice anything about her. Staff C, agency CNA, note dated 2/6/26 revealed: On Monday 2/2/26 on the evening shift, Staff D and I put Resident #1 on the bedside commode before putting her to bed. We gave her the call light before leaving the room. While she was on the commode, Staff D dressed her into a gown. Staff C left the room to attend to another resident. Staff D came to get Staff C to transfer Resident #1 off the commode. We found her on the floor. We picked her up and sat her on the bed and asked her if she hurt. She stated no. I checked her over for any bruises on her body and head. I did not see anything at that time. Staff D, CNA, wrote the following statement dated 2/8/26: Staff C and I walked into Resident #1's room and put her on the commode. Staff C sat her down and I just pulled down her pants. I then gave her the call light and made sure she was okay. Staff C and I walked out of the room to give her privacy. We were not even gone five minutes and the call light came on, so we knocked and went in. Staff C was in front of me and saw her laying on the floor first. She was laying on her left side. I pulled out my walkie talkie and asked Staff C what room number it was, and he told me not to say anything because she had no bruises and appeared to not be hurt. Staff C then picked Resident #1 up and sat her back onto the commode to let her finish. We did not leave the room this time. Staff C then stood her up, Staff D wiped her, and then we sat her down and changed her gown because BM had gotten on it. Staff C laid Resident #1 down in bed. In an interview on 6/4/26 at 9:00 AM, Staff A, RN, confirmed she worked on 2/2/26, 2/3/26 and 2/4/26 on the day shift. Staff A stated a CNA assisted Resident #1 to the stool because Resident #1 had loose stools. The CNA came to tell the nurse that Resident #1 had bruising on her forehead under her hair(line). The CNA's decided to give the resident a bath and found a bruise on the resident's right hip when the staff got her into the bath. The bruise was a large purple hematoma and had a knot. Staff A reported she did not remember if Resident #1 had any falls prior to this time but no one had reported that Resident #1 had a fall or any other concerns about Resident #1 in shift report. Resident #1 did not have behaviors or situations when she tried to self-transfer. Staff A reported she did not even know if the resident could roll out of bed. Resident #1 required assistance of two staff and a gait belt for transfers. Staff A believed the scoop mattress was implemented after they found the bruises on Resident #1. Staff A stated she had not been aware of any staff not reporting something to her, however the CNA's were very concerned when they came to her when they saw the bruises.In an interview on 6/4/26 at 9:45 AM, Staff L, CNA, reported he was unable to recall Resident #1. He had only worked at the facility for three months. The surveyor read the statement Staff L wrote on 2/4/26. Staff L stated he vaguely recalled the resident or anything. He did not believe there were any bruises on the resident. What he wrote in his statement is true. Staff L reported he got a little orientation when he started working at the facility. He got a paper that showed the residents and what he needed to do for the residents and how they transferred. He asked questions if he was not sure about something. Staff L stated if a resident had a fall, he would let the charge nurse know. (Per staff assignment/ schedule, Staff L was in training with Staff O for the dates 2/2/26 to 2/4/26.In an interview on 6/4/26 at 10:10 AM, Staff B, agency LPN, reported she recalled an incident about bruises on Resident #1. The bruises did not happen on her shift when she worked though. Resident #1 was sleeping and lying on her side when Staff B checked on the resident that night (2/2/26). At that time, Staff B stated she did not see any bruises but she did not roll the resident over to look at her other side while she was sleeping. She only saw the side that was not covered. Staff B reported she knows Resident #1 did not fall on her shift. There was a male CNA working on the night shift. It was his first night there and he wanted help for everything. The other CNA was getting annoyed with him asking for assistance all of the time. The other CNA that was working was a small girl and could not pick a resident up by herself. Staff B said nothing was reported to her about any concerns or falls that night. Staff B stated she heard that Resident #1 was up for breakfast and that was when the staff noticed the bruises. Staff B reported she had already gone home but she wrote a statement when she came into work the next day. Staff B also reported Resident #1 had a roommate in the room with her. The roommate was alert and oriented. The roommate would have screamed and said something if Resident #1 had a fall. Staff B stated she had not had any staff that did not report things to her. She would have reported if something happened. In an interview on 6/4/26 at 10:30 AM, Staff O, CNA, reported she would immediately get the nurse if she noticed a change in condition or if the resident had a fall. She would also make sure the resident was safe if the resident had a fall. She would get the resident up or do what was needed after the nurse did an evaluation. Staff O confirmed she worked on 2/2/26, and she had worked with Resident #1 prior to this date. Staff O reported she only gave a snack to Resident #1 and talked to her in the hall when she passed by but she did not provide care and had no physical/ hands on contact with the resident. Staff O reported she had not had a coworker tell her not to report something. Staff O said she would report if she saw or heard something.In an interview on 6/4/26 at 11:01 AM, Staff R, agency CNA, reported she did not recall a resident by the name of Resident #1. She never worked at the facility in 2/2026. In an interview on 6/4/26 at 11:05 AM, Staff Q, Restorative Aide, reported she was unaware of Resident #1 having any falls and she had never seen Resident #1 fall. Staff Q reported she had not observed Resident #1 trying to get up on her own but she had seen Resident #1 try to move her chair when she did not want to attend an activity or something. Staff Q confirmed she had not seen bruises on Resident #1. Staff Q reported she always let the nurse know if a resident had a fall, a bruise or other skin condition. In an interview on 6/4/26 at 11:20 AM, Staff H, CNA, reported Resident #1 needed the assistance of two staff and a gait belt for transfers and had dependence on staff to move her. Staff H stated she would not try to move Resident #1 by herself because it was hard to move her. Resident #1 tells them what she needs and used her call light. Resident #1 had a hard time talking but she could say a full word and Staff H could tell what Resident #1 wanted by the resident's facial expression and when she pointed at things. Staff H reported she had never observed Resident #1 trying to get up on her own. When Resident #1 was awake, she stayed in bed until staff could get her up. Staff H reported she heard that Resident #1 had falls but Staff H had not been present when Resident #1 fell. Staff H confirmed she was working at the facility on 2/3/26 night. Staff H put Resident #1 in bed on the evening of 2/3/26 and lowered the bed to the floor. The next day the DON sent her a text and wanted to know what happened. Staff H heard that Resident #1 may have had a fall and then some bruises showed up. Staff H did not see any bruises on Resident #1 when she transferred her on 2/3/26 evening. Staff H asked the resident what happened. The resident told her that someone picked her up and put her in bed. It was a guy. It was a day or two after the bruises were found that the resident told her that. Staff H reported she would call the nurse on the walkie or report to the nurse as soon as she observed a bruise or skin condition. Staff H stated she had not seen any staff be rough with a resident. She would tell the nurse or the DON if she saw something or had a concern. Staff H reported Resident #1 had a fall mat and they lowered the bed all of the way. Lowering the bed had always been an intervention that was in place but the fall mat was added after bruises were found on her. The fall mat was put in place because the facility staff thought the resident had rolled out of bed because Resident #1 said someone picked her up and put her back into bed.In an interview on 6/4/26 at 1:03 PM, Staff E, agency CNA, reported she worked the day shift on 2/2, 2/3 and 2/4/26. On 2/4/26 she looked over at Resident #1 in the dining room and asked Resident #1 if she was ok. Resident #1 vomited. Staff E lifted up Resident #1's hair and called the nurse over. Staff E went to give Resident #1 a bath and noticed a large purplish/blue bruise on her hip. Staff E stated she then called the nurse into the shower room and reported to the nurse what she saw. There were no falls or anything unusual reported during shift change. Prior to this day, Resident #1 was a fall risk and they checked on her more than usual. Staff E stated she did not ever see Resident #1 fall. Resident #1 did not use her call light much. The interventions that were in place prior to the incident with Resident #1 were: Do not leave the resident alone on the commode and use two staff for assistance. A fall mat placed on the floor was added after the bruises were found because the resident had a questionable fall. Staff E confirmed she had not had any staff tell her not to report things. She always reported to the nurse whenever she had a concern. It was safer to report than not to report anything. She would also report if she saw staff being rough with a resident. In an interview on 6/4/26 at 1:35 PM, Staff D, CNA, reported she had worked at the facility since 1/2026. Resident #1 required assistance of two staff for transfers and used the commode. Staff did most of Resident #1's cares for her because Resident #1 was paralyzed on one side of her body and could not do anything. Resident #1 used her call light on a rare occasion. Resident #1 never tried to get out of bed without assistance. Staff D reported she believed Resident #1 had fallen on the floor besides the one other time when Resident #1 fell off the commode when Staff D was working. The surveyor asked Staff D to talk about the incident when the resident fell off the commode. Staff D stated she was new to the facility. She had only worked at the facility less than two months when the incident happened. She and Staff C, CNA, walked into the room and put Resident #1 on the commode. Staff C said we will give her a few minutes. They gave Resident #1 the call light and left the room. When the call light was on, Staff D and Staff C came back to Resident #1's room and found Resident #1 on the floor. Resident #1 was lying face down and bent over like she was trying to fix something. Staff C looked Resident #1 over and instructed Staff D not to say anything because she had no bruises and she was not bleeding. Staff D stated she did not say anything at the moment but when the DON asked her a few days later about if she knew anything that happened, then Staff D told the DON about the incident. At that time, the resident had bruises to her forehead and arms. Staff D stated she felt deeply sorry about what happened, and to this day she thinks about it. Staff D reported she had a cheat sheet that she looked at to know what was needed for the residents and how they transferred. Resident #1 had always required the assist of two for transfers since Staff D had worked at the facility. A fall mat placed on the floor was added after the incident. Staff D reported on the day Resident #1 fell off the commode, that was the first time Staff D had ever experienced a resident that had had a fall and she did not know what to do at the time. Staff D stated now, if a resident had a fall she would not leave the resident's side, call for someone on the walkie talkie, and let the nurse do an assessment before they got the resident back up.In a follow up interview on 6/4/26 at 2:20 PM, Staff D reported she had six shifts of orientation on the evening shift, and then she got three additional days of training on the hall where Resident #1 resided after Resident #1 had the fall. Staff D oriented with another staff person showing her how to do things, how to care for each resident, how to lift the residents, and different procedures. They went over what to do in a fire. She also took dependent adult abuse training and completed some on-line education on Healthcare Academy. In a follow up interview on 6/8/26 at 5:48 PM, Staff D reported Resident #1 had a fall a few days later (after she fell off the commode) and when the facility started to investigate that fall, the bruises or injury did not match up with that fall. Staff D stated the facility had a book with policies but the facility management or staff did not go over specific policies with her. They just told her to go to the nurse about things. If a resident had a change in condition or she noticed a skin issue, she would go to the nurse. If a resident had a fall, she would also go and let the nurse know. In an interview on 6/8/26 at 8:10 AM, Staff N, RN, confirmed per the schedule that she worked the night shift on 2/2/26 and 2/3/26. Staff N stated she did not notice any bruises on Resident #1 at that time but she had seen bruises on this resident from time to time a while ago. Staff N reported she had noticed Resident #1's legs a little over the edge of the bed when she went in to see the resident so she would move her over on the bed. Resident #1 wiggles and will work herself out of bed. She had falls in the past and had a mat on the floor by her bed due to a history of a fall. Staff N reported she was unsure exactly when the mat was put in place as an intervention. In an interview on 6/8/26 at 9:30 AM, Staff I, CNA, reported she noticed some bruises just showed up on Resident #1 one day when she worked. She told the nurse about it. She was not aware that the resident had had any falls or injury. Resident #1 used a commode and required the assistance of two and a gait belt for stand pivot transfers. Staff I stated interventions for Resident #1 included placing the bed in a low position. A mat placed by the resident was a new intervention after bruises were found. Staff I stated she had never had anyone tell her not to report something if the resident had a change in condition or a fall/incident. She would report it to the nurse immediately. In an interview on 6/8/26 at 11:05 AM, Staff J, CNA, reported she was the one who found the bruises on Resident #1 and reported it to the charge nurse because she did not get anything in report about Resident #1 having bruises or anything. The resident had bruises on her scalp, a bruise on her hip, and on her arm. Staff J stated the nurse came and did an assessment and also called the DON. Resident #1 has always required assistance of two staff for transfers with a gait belt and toileting. Resident #1 had never tried to get up on her own, and she used her call light. In an interview on 6/8/26 at 1:25 PM, the DON, confirmed she and the Interim Administrator were involved in the investigation of bruises that were found on Resident #1. The DON believed Staff A, RN, came to her and told her Resident #1 had bruises on her and the staff did not know what it is from. Resident #1 was in the tub when the staff found the bruises, and staff noticed Resident #1 had extensive bruising when they got Resident #1 back to her room. The DON stated she helped moved Resident #1 to a new room the day before and did not see any bruising at that time. Resident #1 was sent to the ED for evaluation since she was vomiting and had bruising. The DON stated she called staff and tried to find out what happened. She thought it happened the night before so she called the staff who worked that night. When they did not figure anything out from the staff who worked the night shift, she broadened out their investigation and talked to staff that worked on the evening and day shift. She also requested all staff to fill out a statement. The DON reported she spoke with Staff C, agency CNA, that worked that evening. She requested him to fill out the form. He kind of held back a while. She noticed Staff C had not filled anything out so she approached him and said she needed his statement before he left that night, then he finally said he put Resident #1 on the commode. Staff C was in the room with Staff D, then Staff C went to do something else and when he came back, Resident #1 was on the ground. The DON reported Resident #1 had no falls previously that she can recall. Keeping the bed in a low position was on Resident #1's care plan already due to the resident had a risk for falls and paralysis. The interve

Based on observation, interview and record review, the facility failed to ensure that residents were served meals according to the residents' specific needs for 5 of 46 residents reviewed. The facility reported a census of 47 residents. Findings include: The facility Menu for Week 3 of a 4-week rotation, showed that on 1/12/26 the lunch meal would include: diced chicken on rice, topped with sweet and sour sauce, stir fry vegetables, fortune cookie and fruit cocktail. The Mechanical Soft (texture modified foods for people who have soft and easy to eat if resident has difficulty swallowing) therapeutic menu showed that the chicken would be ground, no changes with the rice or the sauce, broccoli florets instead of the stir fry veggies, omit the fortune cookie and substitute peach and or pears for the fruit cocktail. The menu was signed by the dietician on 6/19/25. The following was found in the facility electronic record Orders tab:a. Resident #9 had an order dated 10/15/24 at 2:35 PM, for a regular diet, mechanical soft texture, thin consistency, small bites alternating small sips of liquids. Double swallow if needed. b. Resident #25 had an order dated 7/14/25 at 11:26 AM, for a regular diet, mechanical soft texture, thin consistency. c. Resident #31 had an order dated 8/12/25 at 2:07 PM for a regular diet mechanical soft texture, thin consistency for ground meat. Encourage small bites/sips and alternate solids straw with liquids cut up additional mech soft solids into bite sized pieces excluding cookie/sand.d. Resident # 47 had an order dated 10/21/25 at 12:40 PM for a regular diet mechanical soft texture, thin consistency ground meats.e. Resident #48 had an order dated 10/31/25 at 11:15 AM for a regular diet mechanical soft, nectar thick liquid consistency, ground meat with gravy/sauce. In an observation of the lunch service on 1/12/26 at 11:45 AM, Residents #9, #25, #31, #47, and #48 had been served a sweet and sour sauce that included pineapple chunks. On 1/12/26 at 2:23 PM, the Dietician was surprised to learn that the mechanical soft diets had been serviced pineapple chunks in the sweet and sour sauce. She said that it was her understanding that they were using a red sauce that had ground fruit. The Dietician agreed that the mechanical soft diet should not include chunk pineapple, and that she had recently provided education to the kitchen staff on the different diets. She said that they should have recognized, or asked questions about the fruit chunks. According to the facility policy titled: Therapeutic Diets dated 2017, the facility would provide a therapeutic diet that was individualized to meet the clinical needs and desires of a resident to achieve outcome/goals of care. The therapeutic diets should coincide with the therapeutic diets on the menu extensions. The Registered Dietitian Nutritionist (RDN) would approve all therapeutic diets menu extensions. A list of approved diets would be available for the nursing staff. Diets would be offered as ordered.

Based on observations, staff interviews, and policy review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. The facility failed to maintain a clean kitchen environment. The facility reported a census of 47 residents. Findings include: Continuous observation on 1/11/26 at 9:35 AM during the initial kitchen walk through identified the following concerns: a. The chocolate milk cooler contained dirty crates, walls with the appearance of spilled chocolate milk and a black residual along the hinge of the lid. The cooler did not contain an internal thermometer.b. The cooler containing white milk, sour cream and cottage cheese displayed frost along the inside cooler walls. The thermometer was upside down. c. The left side of a side by side refrigerator contained an unidentified and undated opened food item in a clear storage container. The right side of the refrigerator also contained a dirty towel on the bottom. d. Another side by side refrigerator contained a metal basin with separate containers of brown lettuce, partially uncovered shredded cheese and unidentifiable white substance. e. The dry pantry contained a strong odor with a trash can observed to be over half full with the odor more prominent when opened. The pantry contained boxes of food on the floor and stacked broken cardboard boxes. f. 2 large dry good storage containers did not have labels identifying the food item or when it was opened. g. The 3 door side by side freezer in the pantry containing vegetables and desserts did not have an internal thermometer. h. A 2 door side by side freezer in the pantry did not contain an internal thermometer. i. The walk-in cooler revealed 4 boxes and 3 bags of food on the floor, undated opened chocolate milk, and a basin with melting ice containing food and opened liquid items.j. The main kitchen contained 2 carts that were dirty with food items left on them. k. The ceiling and vents throughout the main kitchen had various shades of brown to black discoloration and areas that appeared to have a discolored raised fuzzy texture. l. A ceiling tile was noted to be missing near the chocolate milk cooler.m. Slow dripping water from the ceiling was noted near a fire suppressant sprinkler. Review of the facility's 12/25 Refrigerator/Freezer logs revealed no data entered for 12/20 and 12/21/25. The facility's Weekly Cleaning Charts for the previous 6 months revealed the following:a. The facility provided documents for 10 weeks from 7/20/25 to 1/6/26.b. The facility did not provide Weekly Cleaning Charts for the month of October.c. The facility provided only 1 Weekly Cleaning Chart for the month of November.d. Each of the 10 logs reviewed were not thoroughly completed. The facility's Monthly Cleaning Charts for the previous 5 months revealed the following:a. The facility provided monthly logs for 7/25 - 12/25 with no log present for the month of 8/25. b. The only documentation noted for 8/25 was on the 7/25 Monthly Cleaning Chart and revealed deliming occurred on 8/1/25, the ice cream machine was cleaned on 8/7 and 8/17/25, and ice machines cleaned on 8/13/25.c. Review of the logs provided the facility failed to ensure the completion of the monthly cleaning requirements. On 1/11/26 at 9:40 AM Staff D, Dietary Aide (DA), stated she had not noticed the water dripping from the ceiling until questioned and shown during the initial kitchen walk through. The staff stated the ceiling had a history of dripping if it was storming, but it was not storming on this date. The staff disclosed the kitchen did not have a Certified Dietary Manager (CDM) and the Administrator was overseeing the kitchen. During a follow up interview on 1/13/26 at 11:10 AM Staff D stated the ceiling tile had been missing for over a month. The staff further disclosed that staff did not always complete cleaning logs while doing the cleaning in the kitchen. On 1/11/26 at 9:50 AM Staff E, Cook, stated he had not observed water dripping from the ceiling. On 1/12/26 at 1:44 PM the Registered Dietitian (RD) and Administrator stated they had been jointly covering the responsibilities of the kitchen as there was not currently a CDM. The RD and Administrator reviewed the photos of the kitchen taken during the initial walk through and provided the following responses: The RD stated the unidentified/dated food in the side by side was prunes, and had likely been moved from the freezer to the refrigerator. The RD acknowledged that the item should be dated. The RD and Administrator acknowledged the chocolate milk cooler was dirty and should not be kept that way. The RD and Administrator stated the basin with the lettuce, cheese and the other food item needed to be covered or discarded. The RD stated the facility had truck delivery on Friday (11/9/25) and the delivery personnel will just place items on the floor in the pantry or walk-in cooler. The staff stated if food came in later on Friday the kitchen staff would not have had time to put it away, but acknowledged there was a full day from date of delivery to date of the initial walk through. The RD stated when looking at bulk containers, it was expected items should be dated and labeled. The Administrator and RD acknowledged the kitchen needed to have cleaning completed. The Administrator stated the kitchen cleaning routine may not be as formal now as it was prior to the CDM leaving in November. The RD stated prior to CDM leaving there was a coordinated effort between the dietary staff and maintenance for cleaning/upkeep of the ceiling in the kitchen. The Administrator stated she was unaware of a missing tile, and the RD could not answer the length of time the tile had been missing. The RD and Administrator stated ceiling should be cleaned or possibly have tiles replaced. The facility's General Sanitation of Kitchen Policy, dated 2017, revealed the kitchen staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. The document provided that employees were required to initial and date when specific assigned tasks were completed.

Based on observation, resident interview, staff interview, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility reported a census of 47 residents. Findings include: 1. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Interview on 1/11/26 at 12:16 PM with Resident #1 revealed that the food is often cold when it should be warm. 2. Review of Resident #13's MDS dated [DATE] revealed a BIMS score of 13 out of 15, indicating intact cognitive functioning. Interview on 1/11/26 at 2:20 PM with Resident #13 revealed that the food is not always warm. 3. Review of Resident #34's MDS dated [DATE] revealed a BIMS score of 9 out of 15, indicating moderate cognitive impairment. Interview on 1/11/26 at 11:55 AM with Resident #34 revealed that food does not taste very good, and that it is not always hot when it should be. 4. Review of Resident #44's MDS dated [DATE] revealed a BIMS score of 12 out of 15, indicating moderate cognitive impairment. Interview on 1/11/26 at 11:25 AM with Resident #44 revealed that the food is not always hot when it should be. Observation on 1/12/26 at 12:50 PM the room trays were sent to the north hallway. One tray was observed to be delivered while the cart sat for 3 minutes in the hallway. The cart was then sat across from the nurses station on the north hallway, and waited to be delivered for approximately 8 minutes. The facility Menu for Week 3 of a 4-week rotation, showed that on 1/12/26 the lunch meal would include: diced chicken on rice, topped with sweet and sour sauce, stir fry vegetables, fortune cookie and fruit cocktail. The Mechanical Soft therapeutic menu showed that the chicken would be ground, no changes with the rice or the sauce, broccoli florets instead of the stir fry veggies, omit the fortune cookie and substitute peach and or pears for the fruit cocktail. The menu was signed by the dietician on 6/19/25. In an observation of the lunch service, upon serving the last resident's meal, at 12:55 PM, Staff C, Dietary Staff checked the temperature of the ground chicken and it was 110 degrees Fahrenheit (F) On 1/12/26 at 2:23 PM, the Dietician agreed that the ground meat should have maintained the temperature at a higher level throughout the service and thought there might be an element out on that particular steam table since everything else on the table was up to temp at the end of service. A facility policy titled: Food Temperatures, dated 2017, showed that the temperatures of all food items would be taken and properly and recorded prior to service of each meal. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees F. Food would be transported as quickly as possible to maintain temperatures for delivery and service. If food transportation time was extensive, food would be transported using a method that maintains temperatures. Food preparation and service areas would avoid holding foods in a temperature danger zone of 41 – 135 degrees F.

Based on observation, family and staff interviews, clinical record review and policy review, the facility failed to ensure that staff used safe transferring techniques for 1 of 4 residents reviewed. Resident #4 had many falls and required 2 staff assistance. On 9/12/25 he had another fall while being transferred from the toilet to the wheel chair with just one staff. The facility reported a census of 46 residents. Findings include:According to the Minimum Data Set (MDS) dated [DATE], Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive deficit.) The resident had impairment on both sides of the lower extremities. He required substantial assistance with sit to lying, and toilet transfers. His diagnoses included renal insufficiency, neurogenic bladder, diabetes mellitus and Cerebrovascular Accident (CVA) and chronic pain. The Care Plan (CP) for Resident #4 showed that he was at risk for falls because he was unsteady on his feet, and needed assistance. On 4/7/25, the CP was updated to include and intervention that 2 staff would assist for transfers until he was cleared by Physical Therapy (PT.) On 9/12/25, an intervention was added to the CP that Resident #4 would be an assist of 2 with transfers when there was no grab bar available. Resident #4 needed assistance with dressing, personal hygiene and bathing due to CVA. He had moderate cognitive impairment, and was not always able to understand others. On 11/13/25 at 8:30 AM, Resident #4 was sitting at the breakfast table. He was in a wheel chair, looked confused, and there was a catheter tube along the side of his leg. The Nursing Notes for Resident #4 included the following: a. On 4/7/25 at 7:45 PM, the resident was found on the floor in his room in front of the wheel chair. The intervention was to not have resident alone in his room b. On 4/9/25 at 9:37 PM, he was lowered to the floor while being transferred to bed. The intervention was to have 2-person assistance. c. On 4/30/25 at 4:59 PM, the resident was lowered to the floor when being transferred by 2 Certified Nurse Aides (CNA.) They did not put his shoes on or put on gripper socks. d. On 9/12/25 at 2:51PM, the resident slide to the floor in front of the toilet in the tub room. He was leaning against the wheel chair and reported no pain or injury. A Fall Risk Assessment, dated 9/12/25 at 11:53 AM, showed that Resident #4 was found to be at risk for falls with 1-2 fall in the previous 3 months. A notification to the doctor on 4/9/25, showed that the resident was showing decreased weakness and was unable to transfer with 1 assist as usual. Staff requested services for Physical Therapy/Occupational Therapy (PT/OT) evaluation and treatment. An Occupational Therapy Discharge summary dated [DATE], showed that OT had provided visual and written instructions to demonstrate how to provide transfers with a walker and that the resident needed assistance of 2 staff. A Physical Therapy Treatment Encounter note dated 8/8/25, showed that Resident #4 needed maximum assistance of 2 to go from sit to supine, and maximum assist of 2 to complete bed mobility and transfers. On 11/13/25 at 9:25 AM, PT staff acknowledged that on 4/10/25, PT/OT started working with Resident #4. When he was discharged , they kept him an assist of 2 and shared a video for staff on how to properly transfer him with 2 staff. On 11/13/25 at 1:15PM Staff D, CNA, said that on 9/14/25, a staff member from PT helped her get Resident #4 to the toilet off the shower room. They transferred him to the toilet and left him alone for a little while. Staff D then went back in by herself to get him off the toilet and into the wheel chair. She said that she used a gait belt and pivoted him to the wheel chair, but he wasn't back far enough on the seat and he slid down onto the floor. Staff D said that she wasn't sure if he was a 1 or 2 assist at the time, things change so often.On 11/13/25 at 11:45 AM, a family member for Resident #4 said that she visits the resident every day. She said that the resident was able to stand with the walker and turn to the bed or toilet and there would be 1 or 2 staff assisting him, it just depended on who was working. On 11/13/25 at 12:20 PM, Staff C, CNA, said that Resident #4 required 1 assistance for transfers, but can be two sometimes. On 11/13/25 at 12:00 PM, the Director of Nursing (DON) said that she was not working at the facility when Resident #4 had the fall in September. She acknowledged that according to the recommendations from therapy, they should be using 2 staff to transfer the resident. According to the undated facility policy titled: Fall Prevention Program, each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Each resident risk factor and environmental hazards would be evaluated when developing the resident comprehensive plan of care. Interventions would be monitored for effectiveness the plan of care would be revised as needed.

Based on clinical record review, observation, facility document review, staff interviews and facility policy review, the facility failed to use safe transfer techniques for 1 of 3 residents. Resident #37 had fell in the bathroom and sustained bruising and a skin tear after staff assisted him without the use of a gait belt or proper footwear. The facility also failed to implement new interventions with repeat falls to reduce the risk for Resident #37. The facility reported a census of 43 residents. Findings include: According to the Admission Minimum Data Set (MDS) assessment dated [DATE], Resident #37 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 11 (minimal cognitive deficit.) He required substantial/max assistance for toileting hygiene and transfers. Resident #37 had diagnosis including anxiety disorder, Post Traumatic Stress Disorder (PTSD) and Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation. The MDS documented the resident had fallen in the last month. According to a Nursing Advanced Skilled Evaluation note dated 9/18/24 at 10:02 AM, upon admission, Resident #37 was able to move all extremities and his gait was unsteady with poor balance. The Care Plan dated 9/24/24 for Resident #37 documented he was at high risk for falling due to falls at home preceding admission here. The care plan listed a goal the resident will not have a fall related injury. The care plan directed staff with the following interventions: -Fall risk evaluation. -Labs when ordered. -Monitor for side effects of medication: cardiac and psychotropic medications as ordered. -Toileting per urinary/bowel section of this care plan. The toileting plan created on 9/24/24 and revised on 11/5/24 documented intervention for staff to assist with transfer to the toilet. Offer and assist with toileting before and after meals, at bedtime and as needed. The Progress Notes for Resident #37 documented the following: On 10/29/24 at 10:39 PM one assist with transfer to wheelchair, toilet and bed. One assist for bedtime ADL's (activities of daily living). Education on call light location and use. Encouraged to voice needs. On 10/29/24 at 11:28 PM resident hit the back of his head on the glove holder in his bathroom removed the skin flap to a healed skin tear. Measures 1.3 cm x 0.5 cm. On 10/29/24 at 11:45 PM it is unknown how long the wound has been present. The resident reports when up to the bathroom he hit the back of his head on the glove holder box on the wall by the stool. On 11/1/24 at 6:09 PM moderate assistance of 1 with most ADL's. One assist with toileting. Some confusion noted at times. Pleasant and cooperative with staff. On 11/2/24 at 8:30 AM fall at 7:45 AM in resident's room. Nurse 2 rooms down from resident when aide asked to immediately come to the resident's room. Observed resident lying on his back with his head propped against the air/heat unit. Noted blood on the unit and on the residents head and arms. Pressure applied with towel and ice. Noted skin tear with heavy amounts of bleeding. When asked what happened the resident stated he was trying to go to the bathroom so he got up and fell . Resident sent to the local emergency room for evaluation. On 11/2/24 at 12:28 PM call to hospital for update and notified the resident has a C3 fracture and will need to be referred to neurologist. On 11/2/24 at 4:16 PM the hospital called and resident being admitted . To have an MRI tomorrow. Dressing being applied to scalp and C-collar on. On 11/3/24 at 9:41 PM resident returns from the hospital. able to pivot transfer and take several steps. 15 minute visual checks initiated. The Discharge MDS dated [DATE] for Resident #37 documented the resident had an unplanned discharge to the hospital. The MDS documented the resident had fallen since admission/entry or the prior assessment and had an injury. The Care Plan for Resident #37 directed staff with the following interventions updated on 11/4/24: -15 minute visual checks upon return from the hospital. -Replace old gripper socks with new gripper socks. The Progress Notes for Resident #37 documented the following: On 11/4/24 at 10:31 AM reviewed incident thoroughly with IDT team. New interventions: replace old gripper socks with new, 15 minute checks upon return from the hospital, Social Services to check with family for permission to place sign in room reminding resident to use his call light and wait for staff assistance prior to rising. On 11/6/24 at 11:16 AM IDT team met and reviewed incident on 11/4/24. Current interventions are 15 minute checks, replace old gripper socks with new socks and staff to prompt resident to and from meals and activities. On 11/6/24 at 11:41 AM late entry for November 4, 2024 at 3:40 PM interview with resident completed by Administrator and DON. The resident stated he got up out of bed, and sat himself in his wheelchair at bedside. He stated he stood upright and his feet went out from underneath him and he started to fall backwards so he leaned forward losing his balance and fell to the floor. The resident stated he hit his head on the armoire in his room during the fall to the floor. He could not remember if he put on his call light or not. On 11/6/24 at 11:51 AM reviewing incident with IDT team. Current interventions are every 15 minute checks, replace gripper socks, discarded gripper socks with little grippers left and ordered more. An Incident Report dated 11/6/24 at 10:25 PM, documented Resident #37 was up to the bathroom with assistance of one when he let go of his walker, reached out to grab the handle attached to the toilet, and lost his balance. A staff member was present and able to lower him to the floor. The nurse came in to assess the situation and noted that the resident was not wearing a gait belt. He had on one gripper sock with the grippers on the top of his foot, and a black sock on the other foot that did not have grippers. The resident sustained a skin tear to his elbow and his right foot was turned outward. He was sent to the emergency room for evaluation. The Care Plan for Resident #37 lacked updates/new interventions following the fall on 11/6/24. According to the Emergency Department Provider Notes dated 11/7/24 at 1:11 AM, Resident #37 had a large band-aid over the top of his head. No other areas of erythema, edema or ecchymosis. Range of motion without pain or discomfort. Minimal discomfort mid portion of the neck with no crepitus of step-off. The resident able to walk with his walker with no other injuries or trauma. A Post Fall Evaluation dated 11/7/24 at 8:43 AM, documented Resident #37 reason for fall was he lost his balance and fell in front of the stool while being assisted by staff with no gait belt or proper footwear. The resident had a trauma wound to the scalp related to a fall on 11/2/24, with partial flap loss and full thickness stripping of the skin. The skin tear measured; 10.5 centimeters (cm) x 5 cm x 0.1 cm. There was epidermis and dermis tissue loss with a yellow wound bed. The left posterior elbow skin tear measured 1 cm x 1.5 cm with edges non-attached and area bleeding was acquired on 11/6/24. In an observation on 11/12/24 at 10:54 AM, Resident #37 was laying in bed with supplemental oxygen per nasal cannula and had a bandage on the top of his head. The resident said that he lost his balance and fell . On 11/12/24 at 3:50 PM, Staff B, Registered Nurse (RN) stated that she remembered the fall in the bathroom. She had just started her shift when a Certified Nurse Aide (CNA) told her they needed her in the room of Resident #37. When she walked into the room, the resident was on the bathroom floor, his back was up against the wall, and the walker was next to the toilet. He was wearing one gripper sock that was upside down with the grips on the top, and a black sock that was not gripper. He did not have a gait belt on. The nurse noticed that his right foot was turned outward and he had a skin tear on his right elbow that was bleeding. They sent him to the emergency room and they found that he didn't have any broken bones. On 11/13/24 at 8:40 AM, Staff C, Certified Nurse Aide (CNA), stated that she worked at the facility just 2 times. She said she had limited orientation and was only given verbal report on the status of residents. She said that she wasn't able to get into the electronic chart to find resident information because she didn't have access. She said that on 11/6/24 she had gotten report from other CNAs that Resident #37 required 2 staff assistance. There had been another CNA in with her initially, but that aide left the room and went to help another resident. She walked Resident #37 to the bathroom with help of the walker, but when he got into the bathroom, he let go of the walker, reached out to grab the handle next to the toilet and he missed and started to go down. Staff C said that she had ahold of the resident with her arm under his armpit and lowered him to the floor. Staff C acknowledged that she had not used a gait belt because he had a walker, she didn't think he needed one. She added that there weren't any gait belts in the resident's room for her to use. On 11/13/24 at 12:25 PM, the Administrator, Director of Nursing (DON) and Nurse Consultant said that before a new staff (CNA) member was put on the floor, they were given verbal report from the previous shift. They were given access to the electronic chart so they could check on specifics needs of the residents. They said that they had an orientation checklist but they were unable to locate a list for Staff C. On 11/14/24 at 10:38 AM, the DON said that it was their policy to always use a gait belt and gait belts were kept in the resident's rooms. She said that agency staff were taught that they must use them as well as checking for the proper footwear before transferring a resident. According to a facility policy titled: Gait Belt Use updated on 3/22/07, gait belts would be used for residents needing limited, extensive or total assistance with manual transfers and/or ambulation.

Based on observation, facility record review, staff interviews and policy review the facility failed to follow proper sanitation to prevent the spread of illness according to professional standards by serving residents on dishes that had not been rinsed in the hot water dish machine at an appropriate temperature to prevent the spread of illness. The facility reported a census of 43 residents. Findings include: Observation on 11/12/24 at 9:50 AM of a high temperature dish machine in use revealed a temperature of 140 degrees for the wash cycle and 170 degrees for rinse cycle. Observation of 3 loads of dishes ran though the dish machine with temperatures of 140 degrees for wash and 170 degrees for rinse. Review of document titled, Temperature Monitoring Form -1 Compartment Dishmachine for the month of October documented wash temperatures under 150 degrees on 10/24, 10/28 and 10/3 and rinse temperature under 180 on 10/1, 10/3, 10/5, 10/6, 10/20, 10/25, 10/27, 10/28 and 10/29. On 11/12/24 at 10:00 AM Staff M, Dietary Aide stated when the temperatures are below 150 degrees for wash and 180 degrees for rinse she notified the kitchen manager was at the facility. Staff M stated if he was not at the facility the dishes still needed to be washed and in the past she just kept washing them and putting them away to use. Staff M stated if the temperature during the rinse cycle was above 150 degrees she felt that was hot enough because the food temperature only needed to be 135 to be safely served. Staff M stated that she put the dishes away that were washed with the temperatures below 150 degrees for wash and less than 180 degrees for rinse. Staff M stated that she would continue to wash dishes and eventually the temperature would get to 180 degrees and she would draw an arrow on the temperature log acknowledging the temperature had reached above 180. Staff M ran a temperature strip through the dish machine that would change to a dark brown if a temperature above 170 was reached. Staff M acknowledged the strip did not change color. Staff M stated that the temperature was checked with a strip twice a day. Staff M opened a book and revealed a bag of used temperature strips with dates on them. Staff M acknowledged that all strips in the bag did not have any color change indicating there was not a temperature above 170 reached. On 11/12/24 at 10:30 AM Staff N, Certified Dietary Manager acknowledged that the dish machine was not reaching a minimum of 180 degrees on the rinse cycle. Staff N stated the company that does maintenance on the dish machine was at the facility on 11/8/24. Staff N stated the dish machine not reaching 180 degrees on the rinse cycle was addressed then. Staff N stated he would be calling the company that does maintenance on the dish machine right away to repair the issue. Staff N acknowledged that none of the strips that were dated in the bag utilized during previous tests had revealed that a temperature above 170 had not been met. Staff N stated dishes would be cleaned with the 3 sink process until the dish machine was repaired or the facility would utilize the dish machine on the assisted living side of the facility. On 11/12/24 at 10:45 AM the Administrator stated the facility's expectation was the temperature on the wash cycle of the dish machine would be above 150 degrees and above 180 degrees on the rinse cycle. The Administrator stated the facility would be calling the company that does maintenance on the dish machine to have it repaired. The Administrator stated the facility's expectation was the staff would notify the kitchen manager if the temperatures were not being met during the wash and rinse cycles. The Administrator stated if the staff were not able to get a hold of the kitchen manager the staff would call the Administrator. The Administrator stated the facility's expectation was dishes would not be used if temperatures of 150 degrees were not met on the wash cycle and / or if a temperature of at least 180 degrees was not met on the rinse cycle. On 11/12/24 at 2:30 PM Staff P, Dish Machine Maintenance Technician stated the most recent service at the facility was completed on 11/6/24. Staff P stated he was the technician that serviced the machine on 11/6/24. Staff P stated on 11/6/24 he was at the facility for routine service and monthly maintenance. Staff P stated his company was not at the facility on 11/8/24. Staff P stated there was never a service request for a concern about low temperatures from the dish machine wash or rinse cycle. Staff P stated the last time his company was at the facility prior to 11/6/24 was in August and that was related to an issue in laundry. Staff P stated the last temperature he could find obtained by the company that he worked for was in May and the temperature was 186. Staff P stated he did not look at or obtain a temperature from the dish machine when at the facility on 11/6/24. Staff P stated the wash cycle should be a minimum of 150 and the rinse cycle should be a minimum of 180 on the hot water dish machine. Staff P stated he had run several cycles on 11/12/24 at the facility and the dish machine never reached 180 for the rinse cycle. Review of undated policy titled, Cleaning Dishes / Dish Machine revealed that prior to use staff would verify proper temperatures and machine function. Confirm that soap and rinse dispensers are filled and have enough cleaning product for the shift. Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitation. Thermal strips may be used as verification that the temperature is adequately hot, but cannot verify actual temperatures. Those machines installed after the Food Code 2001 were implemented must automatically dispense detergents and sanitizers, and must incorporate visual means or other visual audible alarm to alert the user to any concerns (such as the soap or sanitizer not dispensing properly). High temperature dish machine wash cycle should be 150 degrees - 165 degrees and rinse cycle should be 180 degrees.

Based on clinical record review, observations, staff interviews, and facility policy review the facility failed to use universal infection control measures and Enhanced Barrier Precautions (EBP) during cares for 3 of 3 residents (Resident #9, #33 and #21). The facility reported a census of 43 residents. Findings include: 1. Review of Resident #33's Minimum Data Set (MDS) assessment dated [DATE] revealed diagnosis of renal insufficiency, neurogenic bladder, and septicemia. The MDS further revealed that Resident #33 utilizes an indwelling catheter. Review of Resident #33's Electronic Healthcare Record (EHR) page titled diagnosis revealed a diagnosis of carrier or suspected carrier of methicillin resistant staphylococcus aureus (MRSA) dated 2/13/23. Review of Resident #33's Care Plan with a review date of 9/18/24 revealed special instructions for enhanced precautions. Observation 11/13/24 at 10:33 AM Staff I Certified Nurse Assistant (CNA) donned gloves without hand hygiene, and then placed a barrier on the floor. Alcohol swab utilized to clean drainage port pre and post drainage. No gown was donned during the procedure. Interview 11/13/24 at 10:45 AM with Staff I CNA revealed she should have completed hand hygiene, and was unaware of the enhanced barrier precautions for residents with catheters. 2. Review of Resident #9's MDS assessment dated [DATE] revealed diagnosis of hemiplegia, seizure disorder, traumatic brain injury, and gastrostomy status. The MDS further revealed that Resident #9 utilizes a feeding tube. Review of Resident #9's EHR page titled diagnosis revealed a diagnosis of carrier or suspected carrier of methicillin resistant staphylococcus aureus (MRSA) dated 3/1/18. Review of Resident #9's Care Plan with a review date of 9/12/24 revealed special instructions for enhanced precautions. Review of Resident #9's EHR page titled Physician's Orders revealed an order for water flushes five times a day via G-tube (Gastrostomy tube). Observation 11/13/24 at 11:03 AM Staff L Registered Nurse (RN) completed hand hygiene. Resident #9 obtained the supplies for Staff L. Staff L then checked G-tube placement. Staff L then gave water order per gravity through Resident #9's G-tube. No gown was donned during the procedure. Interview 11/13/24 at 11:11 AM with Staff L RN revealed she was unaware that gowns should be worn when completing g-tube cares. Interview 11/13/24 at 10:53 AM with the Director of Nursing (DON) revealed her expectation would be for hand hygiene and personal protective equipment (PPE) to be completed at the appropriate times. The DON further revealed that Enhanced Barrier Precautions (EBP) should be followed when caring for catheters. Interview 11/13/24 at 10:56 AM with the Administrator revealed her expectations for hand hygiene to be completed at appropriate times as well as EBP to be followed at the appropriate times. Review of a facility provided policy titled, Enhanced Barrier Precautions with a date of March 2024 documented: a. EBP are indicated for residents with any of the following: 1. Infection or colonization with a CDC-targeted MRO when contact precautions do not otherwise apply; or 2. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. Centers for Disease Control and Prevention website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), visited 11/14/24 and updated 7/12/22 revealed recent changes included, additional rationale for the use of Enhanced Barrier Precautions (EBP) in nursing homes, including the high prevalence of multidrug-resistant organism (MDRO) colonization among residents in this setting. Expanded residents for whom EBP applies to include any resident with an indwelling medical device or wound (regardless of MDRO colonization or infection status). Expanded MDROs for which EBP applies. Clarified that, in the majority of situations, EBP are to be continued for the duration of a resident's admission. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status and Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. 41785 3. According to the MDS assessment dated [DATE], Resident #21 had a BIMS score of 12 (moderate cognitive deficit). She required partial assistance with toileting, dressing and transfers. The Care Plan updated on 10/16/24, showed that Resident #21 had a history of visual and swallowing deficits as well as left side unawareness related to a stroke. The electronic record showed that Resident #21 had orders for the following: -Dated 4/7/24 at 10:15 AM; Refresh Solution 1.4-0.6 % (Polyvinyl Alcohol-Povidone PF) Instill 2 drops in both eyes as needed for dry eyes. -Dated 8/8/24 at 3:00 PM; Patanase Nasal Solution (Olopatadine HCl (Nasal)) 2 sprays in both nostrils two times a day for nasal congestion. In an observation of the medication pass on 11/13/24 at 7:12 AM, Staff A, Licensed Practical Nurse (LPN) prepared oral, nasal and ocular (eye) medications. Staff A set the medications on the bedside stand and administered the nasal medication to both nostrils. With the same gloved hands, she administered eye drops to both eyes. On 11/14/24 at 11:04 AM, the Director of Nursing (DON) said that she taught the nurses to change gloves between medications of different routes. She said the nurses should have changed gloves after the nose contact and washed hands before putting on a second pair of gloves. A facility policy titled: Handwashing/hand hygiene, single-use disposable gloves should be used when in contact with a resident who was on contact precautions. The use of gloves did not replace hand washing/hand hygiene.

Based on staff interviews, clinical record review, facility document review and policy review the facility failed to ensure that all residents were treated with dignity and respect for 1 of 14 residents reviewed. A staff member was demanding, forceful and demeaning to Resident #96 when she became restless and tried to get out of her chair unassisted. The facility reported a census of 43 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #96 had a Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive deficit). She required set up assistant for eating, and substantial assistance with sit to stand chair transfers. Her diagnosis included diabetes mellitus, urinary tract infection and arthritis. The Care Plan for Resident #96, dated 9/19/24, showed that she was admitted to hospice and was at high risk for falls due to poor mobility. The resident needed assistance with ambulation, transfers and bed mobility. Resident #96 used anti-anxiety medication related to anxiety disorder and was crying often. Staff were directed to use non-medical interventions including activities, distraction and calm reassurance. If the resident became resistive, staff were to leave her alone in a safe position for a few minutes and retry. In the facility Statement from Staff F dated 9/26/24, Staff F, Registered Nurse (RN) stated at the time of the incident, she was in the dining room and heard Staff D say don't do that. She looked in her direction and she noticed Resident #96 trying to stand up. Staff F stated she was concerned that the resident would trip on her wheelchair peddle and was solely focused on that and making sure she didn't trip so she didn't see what happened with Staff D. Staff F stated she then heard Staff D say she bit me. Staff F informed Staff D to go get the other nurse to help her while she stayed with the resident. A little while later the aide, Staff H, informed her that he saw Staff D push Resident #96's forehead away. The facility Interview with Staff D dated 9/26/24 at 12:00 PM documented Staff D told the Administrator she was with Resident #96 in the dining room waiting for supper to be served. The resident tried to stand up from her wheelchair and Staff D encouraged her to sit down to stay safe and explained that dinner would be coming soon. As she was about to walk away the resident tried standing up again, Staff D touched her shoulder and Resident #96 told her to get her hands off her. The resident then grabbed Staff D's hand and bit her right behind her right thumb. Staff D stated she lightly pushed the residents head back as she was panicking and trying to get Resident #96 to stop biting her. Staff D stated she didn't push hard as she knew the resident is elderly and she could hurt her if she did. Staff D stated the nurse, Staff F, was around and she got her attention and told her what happened. On 11/12/24 at 2:36 PM, Staff H stated that he was working the evening of 9/26/24 and saw Staff D sitting with Resident #96. He said that she was a CSA and not trained to monitor residents. A CSA was responsible for helping with filling waters, serving meals and stocking supplies so he didn't know if someone had asked her to monitor the resident. Staff H said that he saw Resident #96 bite the hand of Staff D. The resident was sitting and Staff D was standing next to her, as the resident tried to stand up on her own, Staff D became annoyed, and held the resident's hand or arm. He said that she used a very firm voice and ordered the resident to stay seated. He then saw Resident #96 take the staff's hand, put it up to her mouth, and bite her. Staff D then pulled her hand away from the resident and smacked the resident on the forehead. The aide then left the dining room area to find the nurse. On 11/12/24 at 2:44 PM, Staff E, Licensed Practical Nurse (LPN), stated that she was working the evening of 9/26/24 and Resident #96 was very agitated that evening. She said that Staff D was aggressive in her interaction with the resident. She used a harsh voice and told the resident what to do, rather than redirecting her and being patient. Staff E did not see the resident bite the CSA, but later, Staff H came and told her that Staff D had pushed the resident on the forehead after she got bit. Staff E attended to the resident and tried to get her to eat after the incident, but she was even more agitated and wouldn't eat. On 11/12/24 at 3:30 PM Staff F, RN stated that she heard Staff D say let go of me! She assumed that Resident #96 had been trying to get up on her own because she had been restless. Later, Staff H came and told her that Staff D hit the resident's head with her hand after she had bitten her. She said that Staff D had been a new staff member. On 11/14/24 at 10:27 AM, Staff D stated that on the evening of 9/26/24, Resident #96 kept trying to stand up. The nurses were aware and had been telling her to sit back down. Staff D said that the nurses asked her to sit with the resident. She said that she had been educated to get a CNA or nurse for resident interactions such as this, but the nurses were busy. At one point, Staff D put a hand on the resident's shoulder and that was when the resident grabbed her hand and bit her. She explained that she was very new to the position and that this was the first time she had dealt with an agitated resident. She said that she wasn't thinking, and she was getting annoyed with her, used a harsh tone and said sit down! On 11/14/24 at 10:20 AM, the Nurse Consultant (NC) and Administrator maintained that Staff D did the best she could, even though she was not trained to walk with or physically attend to residents. They said that she was trying to get the resident to sit down and the only other option was to allow her to fall. They maintained that it happened too quickly for her to get help from trained staff even though there were several others in the dining room area. A facility policy titled: Dignity, revised in February 2021, showed that each resident would be care for in a manner that promoted and enhanced his or her sense of wellbeing, level of satisfaction with life and feeling of self-worth and self-esteem. When assisting with care, staff would speak respectfully to residents. Staff were expected to treat cognitively impaired residents with dignity and sensitivity to address the underlying motives for behavior.

Based on clinical record review and staff interviews the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment during the required timeline for 1 of 14 residents reviewed (Resident #35). The facility census was 43. Findings include: Resident #35's MDS Quarterly assessment dated [DATE] revealed Section GG (Functional Abilities) lacked data or reason for non-assessment. The previously completed Quarterly MDS dated [DATE] was completed in its entirety. On 11/13/24 at 11:19 AM the Director of Nursing (DON) stated the MDS is completed with coordination between the facility MDS Coordinator and Corporate MDS Consultant. The DON reviewed the MDS dated [DATE] and could not explain why Section GG had not been completed, and would expect the document to be completed in its entirety. On 11/13/24 at 11:25 AM Staff G, MDS Coordinator, stated she was not in the position in August of 2024 and could not provide details why Section GG was not completed. On 11/13/24 at 2:00 PM, the Administrator stated she would defer to nursing on the completion of the MDS assessment. On 11/13/24 at 8:13 AM, the Physical Therapist Assistant (PTA) stated she completed Section O of the MDS and provided input to the MDS Coordinator for Section GG. The Long-Term Care Survey Process form labeled MDS Indicator Facility Rate Report for the survey ending 11/14/24 generated by the MDS assessments completed by the facility listed a total number of assessments as 42. The CMS RAI Version 3.0 Manual dated October 2024 revealed The Quarterly Assessment is an Omnibus Budget Reconciliation Act (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident ' s status between comprehensive assessments to ensure critical indicators of gradual change in a resident ' s status are monitored. The document further revealed the OBRA/Interim completion of Section GG utilized the assessment period as the Assessment Reference Date (ARD) plus 2 previous calendar days. The section is completed using a 6 point scale and if the area was not attempted the reason is to be coded. The facility provided policy, Comprehensive Assessments, revised October 2023 revealed the comprehensive assessment included the completion of the MDS, and were completed in accordance with the criteria of the RAI User Manual.

Based on electronic health record review, document review, policy review and staff interviews the facility failed to provide a comprehensive care plan that included goals or interventions for a diagnosis of methicillin-resistant staphylococcus aureus (MRSA) and or enhanced barrier precautions (EBP) related to the diagnosis of a multidrug-resistant organism (MDRO) for 1 of 5 residents reviewed (Resident #22). The facility reported a census of 43 residents. Finding include: The Electronic New Order dated 7/4/24 for Resident #22 documented a new order for Bactrim DS and a diagnosis of carrier or suspected carrier of methicillin resistant Staphylococcus aureus. Review of Resident #22's MDS dated [DATE] documented no active diagnosis of MDRO. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #22 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of Resident #22's Care Plan documented no focus, goals or interventions for a diagnosis of MRSA. On 11/14/24 at 8:30 AM Staff G stated she started writing care plans for the residents at the facility at the end of August or the beginning of September. Staff G acknowledged there was not a care plan created with the diagnosis of MRSA. Staff G stated a care plan with a focus, goal, or intervention in place should have been created with the diagnosis of MRSA. On 11/14/24 at 8:41 AM the DON stated Resident #22 should have a sign outside her door related to enhanced barrier precautions. The DON acknowledged there was no sign related to enhanced barrier precautions currently. The DON acknowledged there was not a care plan created with the diagnosis of MRSA. The DON stated a care plan with a focus, goal, or intervention in place should have been created with the diagnosis of MRSA. On 11/14/24 at 9:59 AM Staff Q, Nursing Consultant stated the facility's expectation was that a care plan would have been developed with the diagnosis of MRSA and or the requirement of enhanced barrier precautions. Review of policy revised 3/22 titled, Care Planning - Interdisciplinary Team documented comprehensive person centered care plans are based on resident and developed by an interdisciplinary team. Review of policy revised 10/23 titled, Comprehensive Assessment documented the facility conducts comprehensive, accurate, standardized, reproducible assessments of each resident ' s functional capability using the Resident Assessment Instrument (RAI) specified by CMS.

Based on clinical document review, resident interview, staff interview, and policy review the facility failed to provide services to increase mobility or prevent a loss in mobility for 1 of 2 residents (Resident #12) reviewed. The facility reported a census of 43 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 9/25/24 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further documented diagnosis of hypertension, diabetes mellitus, and neuropathy. The document further revealed the resident was severely visually impaired. Review of Resident #12's Care Plan revealed a focus area for ambulation restorative nursing program due to neuropathy and diabetes created on 4/8/24. The goal revealed the ability to ambulate 500 feet daily through the next quarter with a goal date of 3/19/25. Interventions included referral to therapy if needed, registered nurse (RN) to evaluate and make changes to the program, and the staff to report the changes in participation to nursing staff. Review of Resident #12's restorative program document for the last 30 days (10/15/24 to 11/13/24) revealed the task was to walk to and from meals with assist of 1, gait belt and walker to distance as tolerated. The document revealed 29 instances of the resident ambulating for a total of 19 days. On 2 days there were instances of documentation entry for multiple times. The document revealed on 10/16 there were entries for amounts of 10 at 12:27, 10 at 12:28, and 6 at 12:28. On 10/17/24 there were entries for amounts of 10 at 12:28, 10 at 12:28, and 5 at 12:28. On 10/30/24 the document revealed an amount of 75 at 8:55. The document revealed on 11/13/24 the amount of 30. The document revealed 40 entries indicating not applicable and 1 entry of Resident #12 not available. There were no refusal entries for Resident #12. On 11/12/24 at 11:58 AM Resident #12 stated there were lots of new nurses. The resident further stated she was supposed to walk to the dining room for every meal, and now she doesn ' t walk to meals anymore. On 11/13/24 at 11:10 AM observed Resident #12 walking with the Restorative Aide continuously from the chapel to the dining room. The observation revealed the resident walked this distance for 3 complete cycles and was returned to her room at the end of the session. On 11/13/24 at 11:20 AM the Director of Nursing (DON) reviewed the walking task document and stated the Certified Nursing Assistants (CNAs) were able to walk the resident to meals. The DON acknowledged Resident #12 was not being walked to meals as the program was written. On 11/13/24 at 2:04 PM the Administrator stated if a restorative program was written only for the Restorative Aide to complete then would expect that staff to complete as written. If the program was written for walking and CNAs could complete, then she would expect CNAs to complete the program. The facility provided policy, Restorative Nursing Services, revised 7/17, revealed the goals and objectives are individualized, resident-centered, and the resident would be included in determining the goals. The document further revealed the goals may include but were not limited to maintaining independence and self esteem, and maintaining physiological resources.

Based on observations, clinical record review, and staff interviews the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 1 residents reviewed, requiring the use of a nebulizer (Resident #6). The facility reported a census of 43 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #3 had a Brief Interview for Mental Status (BIMS) score of 9/15 indicating mild cognitive impairment. The MDS documented diagnoses that included heart failure, hypertension, and asthma/chronic obstructive pulmonary disease (COPD) or chronic lung disease. Resident #3's Physician Orders dated 9/27/24 revealed Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML. 1 vial inhale orally 3 times a day for shortness of breath and wheezing with a start date of 9/27/24. An additional order with a start date of 9/29/23 revealed to clean NEB mask with soap and water after each use in the room, letting air dry, every 24 hours as needed. There was no current order for oxygen tubing change. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 12/23 through 11/13/24 found 1 instance of the NEB mask being cleaned on 10/12/24. A Care Plan for Resident #3 identified a focus area of COPD dated 7/25/24. Interventions included giving aerosol or bronchodilators as ordered with monitoring for side effects. An additional focus area of altercation in respiratory function was identified with interventions including administering prescribed respiratory treatments as ordered, and assessments of lung sounds and oxygen saturations as needed. An observation on 11/12/24 at 10:15 AM revealed Resident #3 had a nebulizer present with tubing wrapped, connected to the nebulizer without a date sitting on a washcloth on the nightstand. An observation on 11/13/24 at 11:39 AM revealed Resident #3's nebulizer present on the nightstand with tubing, mask, and cup all attached, placed on a washcloth. Observation further revealed no documentation of last change or who had completed. On 11/13/24 at 11:50 AM Staff J, Registered Nurse (RN) stated nebulizer tubing is changed weekly, primarily on the overnight shift. Staff J further stated when the tubing is changed the nurse should put a piece of tape on tubing indicating date changed with initials. On 11/13/24 at 11:55 AM Staff K, Health Unit Coordinator (HUC) stated the TAR would reflect the order to change the tubing/mask to ensure the order was completed. On 11/13/24 at 2:00 PM the Administrator stated the expectation would be for staff to follow the facility policy for nebulizer management. On 11/14/24 at 7:57 AM the Director of Nursing (DON) stated the oxygen tubing and mask should be changed and manager per policy. The DON acknowledged without a piece of tape on the tubing it would be hard to know when the tubing was last changed. The DON further concurred that without the TAR reflecting the need to change the tubing or mask it would be hard to know if or when it had last been changed. The facility provided policy, Administering Medications through a Small Volume (Handheld) Nebulizer, revised 10/10, revealed the following: *Disconnection of the T-piece, mouthpiece and medication cup when the treatment is completed. *Rinse and disinfect the nebulizer equipment according to facility protocol or following the instructions provided, and allow to air dry on a paper towel. *When the equipment is completely dry, store in a plastic bag with the resident's name and the date on it. *Change the equipment and tubing every 7 days or according to facility protocol.

Based on observations, clinical record review, and staff interviews, the facility failed to review and revise the care plan to reflect the resident's current status for 4 of 4 residents reviewed (Resident #1, #2, #3, #4). The facility reported a census of 44 residents. Findings include: 1. Record review of the Minimum Data Set (MDS) assessment for Resident #1, dated 5/1/24 documented a Brief Interview of Mental Status (BIMS) score of 99 indicating a severe cognitive impairment. The resident was frequently incontinent of bladder. The resident completed wheelchair mobility with partial/moderate assistance for distances up to 150'. The resident required partial moderate assistance for transfers and substantial/maximal assistance for toilet hygiene. The MDS revealed the resident did not have a toileting program (scheduled, prompted or bladder training). The MDS also documented diagnosis of fractures, Alzheimer's Disease, Non-Alzheimer's Dementia, other displaced fracture of the upper end of the left humerus subsequent for fracture with routine healing. The document revealed the resident received an active range of motion 2 days in the look back period. Resident's Short Term Post Falls Care Plan dated 3/25/24 indicated routine toileting schedule. Review of Resident #1's Care Plan revealed the resident's restorative nursing program for transfers was on hold due to a pelvic fracture in 2/24. The resident does not have current restrictions due to the pelvic fracture. Resident #1 had a focus area that indicated the resident is independent with walking in the room and corridor with a walker, and may use a wheelchair. The interventions for staff indicated the resident requires 2 staff for all transfers and does not ambulate. An intervention on 3/2024 indicated staff will inform the resident it is time to toilet or lie down vs. asking as the resident may refuse and then attempt a self transfer later. Observed Resident #1 on 7/19/24 at 11:57 AM self propelling a wheelchair using bilateral lower extremities (BLE) in the hallway. On 7/19/24 at 1:05 PM the resident refused assistance for wheelchair mobility and followed staff and another resident into the day room. On 7/20/24 at 1:27 PM Resident #1 self propelled the wheelchair from the dining room to the day room without signs or symptoms of pain, and without assistance. The distance was over 100 ' . On 7/20/24 at 1:58 PM Staff E, Certified Nursing Assistant (CNA), assisted Resident #1 to the bathroom. The resident required assistance x1 for transfers, hygiene, and clothing management. Staff F, CNA, stated on 7/19/24 at 5:00 PM Resident #1 stands really well and required limited assistance of 1 for transfers. On 7/20/24 at 11:36 AM Staff F, CNA, stated the resident liked to self transfer. Staff stated if the resident was taken to the bathroom, she would remain with her to prevent self transferring. The staff stated even with staff present the resident may attempt to get up or complete transfers prior to cues for completion. Staff B stated on 7/20/24 at 3:08 PM the resident transfers easily with 1 assist. The staff stated the resident will continue to attempt to self transfer. 2. Record review of Resident #2's Admission MDS assessment dated [DATE] revealed a BIMS score of 13 indicating intact cognition. The resident had a fracture of the neck of the right femur. At the time of admission the resident required partial/moderate assistance for transfers, supervision or touching assistance for walking 10' . Resident #2's Care Plan revealed interventions of modified independence using a 4 wheeled walker and walking with a wheeled walker, gait belt and assistance of 1 using a gait belt. An activity of daily living (ADL) intervention for resident indicated to provide assistance for putting on edema wear every morning and taking off every evening. The ADL interventions further included assisting resident with hygiene, setting up clothes for getting dressed in the morning, assist of 1 with toileting and moderate assistance with toileting hygiene, and having a toileting schedule. A Progress Note dated 7/19/24 revealed Resident #2 was moderate independent using a 4 wheeled walker for transfers and ambulation with plan to discharge to home on 7/23/24. On 7/19/24 at 12:54 PM observed the resident walking independently using a 4 wheeled walker. The resident was not wearing edema garments. On 7/21/24 at 9:27 AM observed the resident walking alone with a 4 wheeled walker. On 7/20/24 at 3:08 PM Staff B, CNA, stated the resident currently uses a walker and gait belt. 3. Record review of Resident #3's MDS assessment dated [DATE] revealed a BIMS score of 13 indicating intact cognition. The resident was dependent for toileting, required substantial/maximal assistance for transfers, frequently incontinent, and diagnosis including cerebrovascular accident (CVA) with hemiparesis of the non dominant side, long term anticoagulants, unspecified atrial fibrillation. The document further provided the resident had not fallen since the last assessment, and was on a restorative nursing program for active range of motion, transfers, and dressing. Resident #3's Care Plan, revised date of 4/10/24, revealed the resident required maximum assistance x2 staff for stand pivot transfers and required 2 staff assist for toileting. Review of occupational and physical therapy recommendations dated 2/23 and 2/27/23 revealed the resident required minimal/moderate assistance of 1-2 staff. On 7/19/24 at 12:30 PM J, Restorative Nurse, stated Resident #3 would stand at the bar, pull to stand, and walk distances greater than 100 ' using a walker and wheelchair behind. The resident would complete Restorative Nursing close to 5x/week for approximately 30 minutes a session. On 7/20/24 at 1:18 PM Staff H, CNA/Certified Medication Aide (CMA) stated Resident #3 required 1-2 staff assistance for transfers. The resident would actively participate in transfers. On 7/20/24 at 3:01 PM Staff B stated the resident would complete transfers with assistance x1-2 staff. On 7/20/24 at 3:25 Staff I, Registered Nurse (RN), stated Resident #3 completed transfers with 1-2 staff and walked with Restorative Nursing. 4. Record review of Resident #4's Significant Change MDS assessment dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. The resident required substantial/maximal assistance for toileting, partial/moderate assistance for hygiene, upper body dressing, partial/moderate assistance for sit to stands, and substantial/maximal assistance for transfers. Resident #4 participated in a restorative program for range of motion, transfers, and dressing and/or grooming. Resident #4's Care Plan indicated an intervention for receiving Percocet routinely per hospice orders for a focus area of pain. The document revealed an intervention for notification to hospice with signs/symptoms of respiratory distress. Resident #4's Care Plan had fall interventions of visual checks every 30 minutes until the end of shift dated 11/7/23 and visual checks every 15 minutes until the end of the 10-6 shift dated 12/16/22. Review of Resident #4's Clinical Physician Orders revealed hospice services were discharged on [DATE]. On 7/20/24 at 12:15 PM observed the resident being pushed by his spouse back to his bedroom. On 7/21/24 at 9:42 AM observed the resident self propelling his wheelchair from the dining room to his bedroom. On 7/19/24 at 1:25 Resident #4 s spouse stated the resident had been discontinued from hospice services as he was no longer needing them after a year and half. The spouse stated the staff were keeping a closer eye on the resident as a result of his falls. On 7/21/24 at 10:45 AM the Director of Nursing (DON), provided blank documents the facility would use for completion of visual accountabilities for a resident. The staff concurred according to Resident #4's Care Plan it would appear 15 minute accountabilities would still be in place for the 10-6 shift. The staff was unsure if this was still occurring as documentation could not be located. On 7/21/24 at 11:10 AM Staff C, and Staff D, Administrator, expected the care plans to reflect the residents' current needs and provide guidance for staff to assist the residents with their care and safety. The facility document Person Centered Care Plans dated 2024 revealed the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment, describe the services that are to be furnished to attain or maintain the resident's highest practicable level of well-being and who is responsible. The document further revealed the interventions are chosen after data gathering, proper sequencing of events, consideration of the problem areas and causes, and clinical decision making.

Based on clinical record review, staff interviews, and policy review the facility failed to provide the needed services in accordance with professional standards by not completing assessments on individuals who sustained ground level falls with major injury for 2 of 4 residents (Resident #1 and #3) reviewed and failed to implement facility protocol by transferring without a full body lift after a fall for Resident #1. The facility reported a census of 44 residents. Findings include: 1. Record review of the Minimum Data Set (MDS) assessment for Resident #1, dated 5/1/24 documented a Brief Interview of Mental Status (BIMS) score of 99 indicating a severe cognitive impairment. The resident was frequently incontinent of bladder. The MDS also documented diagnosis of fractures, Alzheimer's Disease, Non-Alzheimer's Dementia, and other displaced fracture of the upper end of the left humerus subsequent for fracture with routine healing. The MDS, Change of Status, assessment dated [DATE] for Resident #1 documented a BIMS score of 00 indicating a severe cognitive impairment. The resident was frequently incontinent of bladder. The MDS also documented diagnosis of fracture of the right pubis, subsequent for fracture with routine healing, other fracture of the left pubis, subsequent for fracture with routine healing, dementia with mood disturbance, Alzheimer's disease with last onset. Resident #1's Progress Note titled, N Adv - Post Fall Evaluation, dated 3/26/24 provided it was a late entry for the fall on 3/25/24 at 4:15 PM. Review of the assessment noted the vitals within the assessment were dated 3/29/24. The vitals provided on the assessment were 4 days post the fall. Further review of the document noted it was completed by a different staff on 3/29/24 at 11:42 AM. 2. Record review of Resident #3's MDS assessment dated [DATE] revealed a BIMS score of 13 indicating intact cognition. The resident was dependent for toileting, required substantial/maximal assistance for transfers, frequently incontinent, and diagnosis including cerebrovascular accident (CVA) with hemiparesis of the non dominant side, long term anticoagulants, unspecified atrial fibrillation. The document further provided the resident had not fallen since the last assessment, and was on a restorative nursing program for active range of motion, transfers, and dressing. Resident #3's Progress Note titled, N Adv - Post Fall Evaluation, dated 6/18/24 revealed the N Adv- Post Evaluation document had incomplete sections including contributing factors, medication changes, vitals, actioned clinical suggestions, and comments. The Progress Notes further revealed the resident was moved to the bed with subsequent transfer to the hospital. On 7/20/24 at 3:01 PM, Staff B Certified Nursing Assistant (CNA), stated the resident was on the floor upon entering the bathroom. The staff stated the resident was alert and talking. Staff A with the nurse and a float staff picked the resident up off the floor and placed in a wheelchair. Staff B stated he left the room at that time. On 7/20/24 at 3:15 PM Staff A, Licensed Practical Nurse, stated the Resident #3 fell while on break. The resident was seated in her wheelchair when the staff approached the room. The resident was responding and talking with staff. The staff stated the resident became unresponsive when transferred to the bed. Staff A stated she left the room to call 911 and when returned the resident was alert, talking, and rubbing the staff's cheek. Staff A stated an assessment post fall included taking the resident's blood pressure first, and completing an assessment on the floor. The staff further revealed if it were safe to get the resident up, a non weight bearing lift would be used to get the resident up and move to either a chair/wheelchair or bed. If the fall was unwitnessed, neuro checks were completed for 72 hours. If witnessed and no head injury vitals are completed for 72 hours. The staff stated the assessment would be completed with documentation in the Fall Evaluation in the EHR. On 7/20/24 at 3:42 PM Staff C, Registered Nurse, Director of Nursing, stated the nurse would complete an assessment before the resident is allowed to get up from the floor. Staff C stated the staff utilize a dependent mechanical lift if the resident is unable to assist in getting up. Staff C stated the staff are to follow the complete fall assessment/packet. On 7/21/24 at 10:00 AM Staff C expected the N Adv Post Evaluation would be completely finished as soon after the fall as possible. The staff expected that staff would not leave until documentation was completed. Staff C stated she has called staff back to work to complete assignments. The staff stated with Resident #1 the nurse was a traveling nurse and refused to come back to complete the documentation. Staff C completed the document with the available information. The staff indicated she was not aware of the different date with the vitals in the N Adv Post Evaluation from the date of the fall. Staff C indicated she was not aware that the N Adv Post Evaluation was not fully completed for Resident #3. On 7/21/24 at 10:40 AM Staff D, Administrator, indicated she would expect that the assessment(s) and needs of the resident were to be completed and documented by the nurse on duty immediately. The facility policy and procedure titled Fall Risk Prevention Program dated 7/24 revealed documentation after fall needs to be completed to prevent further falls. Documentation should include all risk factors, possible causes, interventions and effectiveness. The undated facility document, Fall Scene Investigation, revealed the following: Never move/lift a resident until a nurse has evaluated the person. Use Hoyer (full body mechanical lift) to get ALL residents off the floor. Fill out the Risk Management in Point Click Care. Fill out the Fall Risk Assessment in Point Click Care.

Based on observation, interview, and service record review the facility failed to keep the ice machine clean and sanitary. The facility reported a census of 40 residents. Findings include: In a tour of the kitchen on 10/2/23 at 8:15 AM, discovered the inside the ice machine had a protective cover hanging just above the ice that contained random, round, dark, dirt spots. On 10/3/23 at 11:57 AM, the Dietary Manager (DM) looked at the spots reported that he did not know what the substance may be. He put a barrier down on the ice, got a washcloth and rubbed the black spotted substance off. He said that he did not clean the machine himself, as the facility had a contracted company that cleaned it but he wasn't sure how often. The Marking Refrigerator servicing company invoice, reflected that were last at the facility on 12/9/22. At that time they emptied the ice machine and cleaned it.

Based on observation, interview, and policy review the facility failed to ensure that staff practiced recommended hand hygiene to prevent the spread of pathogens during the meal service. The facility reported a census of 40 residents. Findings include: On 10/2/23, from 11:41 AM through 11:50 AM, observed Staff D, Dietary Aide, set up the resident tables in the dining room for the lunch meal. She picked up the container of glasses filled with water and on the top of rim with ungloved hands. Throughout the entire observation time, Staff D did not wash her hands or use hand sanitizer. On 10/5/23 at 9:00 AM, the Dietary Manager said that he expected his staff to grab the water glassed from the bottom of the glass and not put their hands on the rim when serving, or at least use disposable gloves. The Hand Washing/Hand Hygiene policy dated 2019, instructed all personnel to follow handwashing/hand hygiene procedures to prevent the spread of infections.

Based on observation, interview, and operator manual review the facility failed to ensure that staff used safe transfer techniques for 1 of 3 residents reviewed (Resident #22). Resident #22 required the use of a sit to stand mechanical lift for transfers. As the staff transferred Resident #22, they failed to tighten the belt around her torso before moving her from the wheel chair to the bed. Findings include: Resident #22's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. She required extensive assistance from two persons for bed mobility, transfers and toilet use. The Care Plan Focus revised 8/7/23 indicated that Resident #22 had a risk for falls due to cognitive impairment and impaired mobility. She had a fall risk score of 12 as of 7/9/23, indicating high risk for falls. The Intervention dated 8/14/20 directed to use an assist of two with the sit to stand mechanical lift for transfers. On 10/2/23 at 1:37 PM observed Staff A, Certified Nurse Assistance (CNA), and Staff B, CNA, use the mechanical sit to stand lift to transfer Resident #22 from her wheelchair to her bed. While still seated, the staff attached the belt around her torso and lifted her to a standing position. Without tightening the belt after she stood, the staff moved her to the bed. Resident #22's arms appeared parallel to the floor with the harness in her armpits. The EZ Way Smart Stand Operator's Guide, reviewed on 6/14/23, instructed that when raising the patient, as they are raised simultaneously tighten the safety strap buckled around the torso.

Based on clinical record reviews, interviews and facility policy review, the facility failed to assure residents were free of significant medication errors for one of four residents reviewed (Resident # 1) . The facility identified a census of 60. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented [DIAGNOSES REDACTED].#1. The same MDS documented a Brief Interview of Mental Status score of 7 which indicated moderate cognitive impairment. Resident #1 required the assistance of one with bed mobility, transfer, ambulation, toileting, dressing, hygiene and bathing. She received scheduled and PRN (as needed) pain medications, had frequent pain that limited daytime activities, she rated the pain at 3 on a ,[DATE] scale and received no opioid (narcotic) pain medications during the assessment period. The care plan problem created [DATE] identified the resident reported frequent, moderate pain in the right shoulder that historically interfered with day to day activity. She recently reported back pain since a fall on [DATE] and took PRN (as needed) pain medication. The care plan directed staff to administer pain medication as ordered by the physician. The Progress Note dated [DATE] at 2:07 AM documented the resident had gross hematuria (visible blood in the urine). The resident complained of flank pain but she fell on [DATE] and complained of flank pain since that time. Staff notified the physician by fax (facsimile), received an order for [REDACTED]. The Progress Note dated [DATE] at 11:00 PM documented staff found Resident #1 sitting on the floor next to the nightstand in her room. The resident stated she was trying to go to the driveway. She sustained a small scratch to the right elbow. Staff initiated neurological checks per facility protocol and completed 15 minute checks of the resident for the rest of the shift. The Progress Note of [DATE] at 12:36 PM recorded staff faxed the resident's urine culture report to the physician and received an order for [REDACTED]. The Progress Note dated [DATE] at 2:33 AM documented the resident voided scant amounts of urine with no hematuria noted. The Progress Note dated [DATE] at 10:27 AM documented the resident slept in the recliner and had some confusion. Staff updated the resident's responsible party regarding the resident's condition. The responsible party declined an offer of hospice services at this time and requested the resident be kept comfortable. The Progress Note dated [DATE] at 10:34 AM documented the resident experienced increased difficulty with transfers, could not follow commands or hang onto a walker. Staff administered [MEDICATION NAME] and [MEDICATION NAME] for complaints of back pain. The Progress Note dated [DATE] at 3:50 AM documented staff observed the resident's call light come on and heard her walker fall. Staff found Resident #1 sitting on the floor her with back against the night stand. She complained of coccyx (tailbone) pain but also stated it had been hurting for days. The resident sustained [REDACTED]. Staff notified the family and the physician. The Progress Note dated [DATE] at 12:03 PM documented staff visited with both of the resident's daughters about the resident's decline. The resident had a poor appetite, did not want to get dressed or get out of bed and just wanted to sleep. The resident's family gave permission to contact hospice; staff contacted the on-call physician and received an order for [REDACTED]. The Progress Note dated [DATE] at 10:30 PM documented staff found the resident on her knees on the floor with her torso laying across the bed. The resident cried out in pain when attempting to stand and complained of right leg pain when touched. The resident transferred to the hospital for evaluation. On [DATE] at 3:20 AM, Resident #1 returned from the hospital with orders to discontinue blood thinning medications and to schedule an appointment as soon as possible to see the physician assistant-certified (PAC) and to call the clinic regarding palliative care. The hospice Medication Orders dated [DATE] directed to staff administer 5 mg of [MEDICATION NAME] sulfate (a narcotic pain medication) using a 20 mg/milliliter(ml) solution (0.25 ml) every 6 hours for pain. The orders also directed staff to administer 1 mg of [MEDICATION NAME] (a medication used to treat anxiety) 2 mg/ml (0.5 ml) solution at bedtime (HS). The orders instructed to discontinue multiple resident medications and treatments. Review of the January, (YEAR) Medication Administration Record [REDACTED]. During interview on [DATE] at 2:10 PM Staff B, LPN, stated she came on duty for the night shift around 10:00 PM on [DATE] and completed narcotic count with Staff A. Staff B stated the narcotic count had been correct for all medications. Resident #1 had a scheduled dose of [MEDICATION NAME] solution at midnight so she checked the narcotic record prior to administration and discovered Staff A documented she administered 5 ml (100 mg) of [MEDICATION NAME] solution, rather than prescribed 0.25 ml (5 mg). The narcotic record for the [MEDICATION NAME] sulfate documented the facility received a 30 ml bottle of 20 mg/ml solution on [DATE] at 7:50 PM. The narcotic record contained the label to administer 0.25 ml (5 mg) by mouth or sublingual (under the tongue) every 6 hours and every hour PRN. Staff A documented she administered 5 ml (100 mg, 20 times the ordered dose) of [MEDICATION NAME] solution at 8:00 PM; Staff B called Staff A to verify the actual dose she administered as the narcotic count had been correct at shift change and 25 ml remained in the bottle. Staff A told Staff B she did administer 5 ml of [MEDICATION NAME] solution as she had to draw up 5 syringes as the syringe old measured 1 ml at a time. Staff B stated she did not administer the midnight scheduled dose as the resident did not respond to stimuli at this time; she immediately called the hospice nurse and physician. The hospice physician questioned her nursing skills and asked why it took 5 hours to report the error. Staff B stated she informed the physician she had not made the error and did not realize the error until she went to administer the dose scheduled at midnight. The hospice physician declined to order a [MEDICATION NAME] injection (medication used to reverse effects of narcotic pain medications) as it would not be effective and there was not much more he could do. The physician ordered to hold the [MEDICATION NAME] until after 2:00 AM and then resume administration as previously ordered. Staff A stated she did not administer the scheduled 6:00 AM dose of [MEDICATION NAME] as the resident remained nonresponsive to stimuli at the end of her shift and she reported this to the oncoming nurse. Review of the Narcotic Record for the [MEDICATION NAME] 2 mg/ml oral concentrate revealed Staff A received a 30 ml bottle on [DATE] at 7:50 PM. The Narcotic Record contained the label to administer 0. 5 ml (1 mg) orally or sublingually at HS. Staff A documented she administered 1 ml (2 mg which is twice the ordered dose) [MEDICATION NAME] at 8:00 PM along with the [MEDICATION NAME] sulfate. The Progress Notes dated [DATE] at 1:41 AM documented the resident's blood pressure (BP) measured ,[DATE], her respirations 15 per minute and the oxygen saturation of the resident's blood measured 92% (normal is = or > 90%). The resident opened eyes with physical stimuli and responds with ,[DATE] words when questioned. The Progress Note dated [DATE] at 7:30 AM documented the resident's BP measured ,[DATE], respirations at 10 per minute with noted apnea (a temporary stop in breathing). Staff measured her oxygen saturation at ,[DATE]% and then applied oxygen at 2 liters per minute (LPM). The resident did not respond to a sternal rub (painful stimulus). Staff notified hospice staff who indicated staff would come to assess the resident. At 9:30 AM, hospice staff assessed the resident and physician ordered to discontinue the routine [MEDICATION NAME] and HS [MEDICATION NAME], keeping the medications PRN only. Hospice staff advised the resident should have nothing by mouth except oral care until awake and alert and safe to swallow. The Progress Note dated [DATE] at 2:45 PM documented the resident showed mouth breathing, an oxygen saturation level 97% with oxygen at 2.5 LPM. Staff provided oral care at this time. The Progress Note dated [DATE] at 9:27 PM documented he resident repositioned every ,[DATE] hours, respirations slow and regular at 10 per minute, oxygen saturation level 90% with oxygen on at 2.5 LPM with no apnea (absence of breathing) noted. the resident moaned with eye drop application. The Progress Note dated [DATE] at 2:26 AM documented the resident's BP ,[DATE] and respirations 15 per minute with oxygen saturation at 92% with oxygen on at 2.5 LPM. Staff continued to reposition her every hour to 2 hours and provided oral care. The resident did not open her eyes to verbal or physical stimuli and exhibited facial twitching with oral care. The Progress Note dated [DATE] at 5:46 AM documented the resident acted like her feet were ticklish and sated 'no' when staff checked the pulses in her feet. Resident #1 opened her eyes after several requests to do so and indicated she wanted to get up but staff encouraged her to remain in bed to rest. The resident responded to simple yes and no questions appropriately. Staff completed oral care for the resident to which she replied 'good. The Progress Note dated [DATE] at 10:36 AM documented hospice staff ordered a complete metabolic profile and complete blood count for Resident #1. The resident exhibited jerky movements with her legs/arms, did not talk but reacted to touch. The Progress Note dated [DATE] at 11:54 PM documented the resident's feet, calves and knees felt cool to touch, she had no response to verbal or physical stimuli and moist frothy respirations. The resident's oxygen saturation level measured 80% on oxygen at 3 LPM. The resident's lung sounds revealed crackles in the lower lobes with an audible moist wheeze with every expiration. Staff notified the resident's daughter and she requested to keep the resident comfortable. The Progress Note dated [DATE] at 10:47 AM documented comfort cares continued and family present at the resident's bedside. An entry at 12:53 PM documented the resident was declining, family were present and they requested hospice staff come to the facility. The Progress Note dated [DATE] at 6:04 PM documented the resident died at 4:40 PM with the resident's family and hospice nurse at the bedside. During interview on [DATE] at 11:05 AM, Staff A stated she is a new nurse. She worked the 2:00 PM-10:00 PM shift on [DATE] and was responsible for Resident #1. Staff A stated she was very busy and behind in medication pass and certified nursing assistants (CNA's) has been constantly reporting Resident #1 as restless, anxious, trying to get out of bed and in pain. Staff A stated she wanted to give the resident her [MEDICATION NAME] and [MEDICATION NAME] as soon as it arrived to help the resident to calm down. She stated she was hurried and she did not check the medication label or the Narcotic Sheet for the amount to be administered. Staff A knew the order instructed to administer 5 mg of [MEDICATION NAME]; she must have gotten 5 mg (dose) and 5 ml (amount) mixed up and administered 5 ml. She stated she did not know of the [MEDICATION NAME] error until the next day when the Director of Nursing brought it to her attention. Again, she stated she know the order was for 1 mg and must have gotten 1 mg (dose) and 1 ml (amount) mixed up. Staff A stated she failed to follow the 5 rights of medication administration but has since been educated on the importance of doing so. Review of the facility's education provided to Staff A revealed the following: a. Rights of Medication Administration: 1. Right person 2. Right medication 3. Right dose 4. Right route 5. Right documentation During interview on [DATE] at 12:07 PM, the PA-C stated she had cared for Resident #1 for many years and was very upset about the [MEDICATION NAME] and [MEDICATION NAME] errors. The errors violated the standard nursing practice to follow the 5 rights. The PA-C also stated staff did not inform her of the [MEDICATION NAME] error and she learned about that error from the resident's family member. Resident #1 had been declining over a month or so. However, the PA-C stated the excessive [MEDICATION NAME] and [MEDICATION NAME] doses contributed, or hastened, the resident's death. The resident could not eat or drink which contributed to the failure of multiple bodily systems. If the resident had not received the [MEDICATION NAME] and [MEDICATION NAME] overdoses, she would have had more time to spend with her family. During interview on [DATE], the Administrator stated Staff A's employment would be terminated today. The facility suspended Staff A on [DATE], provided 40 hours of 1:1 education with the facility's staff development coordinator and then she returned to work as a CNA in April. Staff A failed to use a gait belt to transfer a resident while working as a CNA. Staff A worked as a CNA in the facility before becoming a nurse and knew of the facility's gait belt policy, so the facility chose to terminate her employment for her disregard of that policy. The facility abated the situation of immediate jeopardy to resident health and safety on [DATE] after educating staff on the 5 rights of medication administration return demonstrations on that training.

Based on record review and staff interviews and review of policy and procedures, the facility failed to provide adequate supervision to ensure against hazards during a wheelchair transfer (Resident #15). A staff person pushed Resident #15 in a wheelchair without the resident resting feet on the foot pedals. The staff member instructed the resident to lift feet during the transfer. The resident lowered her foot and propelled out of the wheelchair and onto the floor. This fall resulted in a fractured hip. The facility reported a census of 63 residents and the sample consisted of 10 residents reviewed. Findings include: 1. Resident #15 had a Minimum Data Set (MDS) assessment with a reference date of 5/16/17. Resident #15 had a Brief Interview for Mental Status (BIMS) score of 4. A score of 4 represented the resident had a severe cognitive behavior. The MDS indicated Resident #15 required extensive assistance of 2 or more people with bed mobility, transfer and toilet use. The MDS indicated the resident usually used a wheelchair. Resident #15 had [DIAGNOSES REDACTED]. The Care Plan dated 5/24/17 identified Resident #15 had a focus area with activity of daily living (ADL) deficit due to Alzheimer's disease and muscle weakness. The interventions included and directed the staff that the resident required extensive assist for wheelchair (wc) locomotion upon request and able to self-propel wc within facility. The Care Plan identified another focus for a risk of falls. The interventions included and initated on 7/27/14, directed the staff to assure the resident's feet are placed on the wc pedals when staff pushed the resident in the wc. The Progress Notes, written by Staff I, Licensed Practical Nurse (LPN), dated 6/20/17 at 7:55 p.m. identified documentation regarding falls. The notes identified the Certified Nursing Assistant (CNA) was called to the room. Resident #15 was on the floor in front of her wc on her left side. The CNA reported she pushed the resident in a wc and out of the bathroom; had washed and put on pajamas. The note indicated the resident put a foot on the floor and she fell forward out of the wc and landed on her left side and hit head on the floor. The left leg rotated outward and resident grimaces and voiced pain with movement of her left leg. The staff assisted the resident up into her wc and then transferred with 2 staff assistance and a gait belt to the bed. The resident continued to complain of left hip pain in bed and transferred to the hospital emergency room (ER). Record review of the hospital History and Physical dated 6/20/17, identified Resident #15 came into the emergency room after she fell out of the wc. The reported indicated the resident's x-ray highly suspicious for an intertrochanteric hip fracture and referred to orthopedics (branch of medicine dealing with bone injuries). Record review of the Orthopedic Consultation dated 6/21/17 identified the x-ray showed a minimally displaced anterior intertrochanteric fracture of the left hip. Record review of the hospital Discharge Summary dated 6/26/17 indicated the resident status [REDACTED]. The summary identified the resident has dementia and advanced age as well as renal insufficiency, [DIAGNOSES REDACTED] (low thyroid function) and hypertension (elevated blood pressure). The resident transferred back to the facility for comfort cares for end of life secondary to failure to thrive, poor intake and poor urine output. A written statement by the Director of Nursing (DON) dated 6/23/17 identified Staff H, CNA stated she transferred Resident #15 into the wc with the gait belt and took her to the toilet with her feet on the pedals. After transferring resident back into the wc when finished, she turned the resident toward the beds. Staff H stated she did not put Resident #15's feet on the pedals. Staff H asked the resident to lift her feet and she did. They got as far as the first bed and she (the resident) started to lean forward and went to the floor. Staff H did not see the resident put her foot down (off of the foot pedals). Review of the document titled Policy & Procedure for Transporting Residents in Wheelchair and Use of Wheelchair Pedals, dated 6/21/17, directed the staff to always use wheelchair pedals, if you are pushing a resident in a wheelchair. The policy also documented if the resident needs assistance, place pedals on the wheelchair and put their feet on the pedals. On 10/31/17 at 2:00 p.m., Staff H CNA, was interviewed and stated she took Resident #15 to the bathroom using the wc. Staff H stated the foot pedals were locked in front of the wc but not down so the resident could use. Staff H confirmed the resident's feet were not on the wc pedals when she moved her out of the bathroom toward her bed. Staff H stated the resident held her feet up when being pushed but then dropped a foot to the floor and fell forward out of the wc. Staff H stated she should have flipped the foot pedals down as they were right there. On 11/2/17 at 7:55 a.m. the Director of Nursing was interviewed and stated her expectation for staff when pushing a wc is to use the foot pedals. Review of the Certificate Of Death, with a file date of 8/2/17, identified the date of death as 8/29/17. The physician listed the immediate cause of death as failure to thrive and the other significant condition listed is fall; hip fracture.

Based on record review, facility policy, and staff interviews, the facility failed to administer all medications as ordered by the physician for one of four residents (Resident #1). The facility reported a census of 63 residents. Findings include: 1. Review of the face sheet for Resident #1 revealed the resident [AGE] years old and [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #1 dated on [DATE] revealed a Brief Interview for Mental Status score of 11 (represents moderately impaired cognition). Review of the nurses notes for Resident #1 dated on [DATE] at 9:58 AM revealed; Resident was given another resident's morning medications (Resident #2) by mistake. The pharmacy had been called regarding side effects for [MEDICATION NAME] 200 milligram (mg) dose and [MEDICATION NAME] 75 mg dose. The progress notes reported identified the medication/s may cause increased drowsiness and dizziness. Staff took Resident #1 back to his/her room via wheelchair. The resident is unresponsive and drooling from side of mouth. The resident does not open eyes when spoken to, color pale, temperature 97 degrees, pulse 60 beeps per minute, respiratory rate at 8 and blood pressure 68/no read. Oxygen saturation at 96% while on room air. 911 called and taken to Emergency (ER). The ambulance report dated [DATE] documented at 9:34 a.m. dispatched for an [AGE] year old who was given the incorrect medications, and had a sharp decrease in mental status, needing a transport from the nursing home. Review of the medical center History and Physical dated [DATE] revealed accidental ingestion of high-dose [MEDICATION NAME] and [MEDICATION NAME]. admitted into acute care in stable but guarded condition. The resident was initially admitted for observation but due to persistent mental status changes will be admitted for acute care. The physician documented he reiterated to the family the changes are most likely related to the medications (accidental ingestion). Due to the resident ' s age and slow metabolism, it will take longer to get this (medications) out of his/her system. The physician stated he was worried about potential aspiration with his/her somnolence and concern for aspiration pneumonitis. The report documented the current medications as follows: [MEDICATION NAME] for anixety.5 mg 1 p tablet (tab) prn (as needed); [MEDICATION NAME] 100 mg daily; Tylenol 500 mg ,[DATE] every ,[DATE] hours prn; [MEDICATION NAME] sulfate 325 mg daily; calcium [MEDICATION NAME] with vitamin D 1 tab daily; Eliquis 5mg twice daily; [MEDICATION NAME] 112 mcg daily; [MEDICATION NAME] 10 mg daily; [MEDICATION NAME] 10 mg daily; and eye drops. Review of the Medication Administration Record (MAR) for Resident #1 revealed the AM medications that had not been given the morning of [DATE] are: [MEDICATION NAME] 500 mg 2 tablets (pain), [MEDICATION NAME] 5 mg (anti-depressant), [MEDICATION NAME] 100 mg 1 capsule (stool softener), Eliquis 5 mg 1 tablet (heart drug), [MEDICATION NAME] 10 mg (heart drug). Review of the Medication Administration Record for Resident #2, (the record of medications that was given to Resident #1 by mistake) revealed the following medications ordered at 8 AM, [MEDICATION NAME] ER 25 mg by mouth, [MEDICATION NAME] 75 mg by mouth,[MEDICATION NAME] mg and [MEDICATION NAME] 200 mg by mouth and [MEDICATION NAME] 50 mcg by mouth ordered to be given at 7 AM. Review of the Medication Error Report dated [DATE] for Resident #1 revealed the following medications given to the resident by mistake: [MEDICATION NAME] ER 25 mg (high blood pressure medication), Multivitamin, [MEDICATION NAME] 75 mg (antipsychotic medication), [MEDICATION NAME] 50 mcg (micrograms, [MEDICAL CONDITION] hormone replacement),[MEDICATION NAME] mg (anti-[MEDICAL CONDITION]), [MEDICATION NAME] 200 mg (antipsychotic medication). An untitled form from the facility dated [DATE] documented an update that the resident had been given antibiotics for aspiration pneumonia. The physician assistant reported it will be ,[DATE] days and they are just waiting for his/her liver and kidneys to clear and they had been in contact with poison control daily. The nursing home progress noted dated [DATE] documented the resident returned from the hospitalization with a [DIAGNOSES REDACTED]. During an interview on [DATE] at 1:49 PM, Resident #1's primary care physician stated it was a major injury and would have died if the facility had not acted right away. During an interview on [DATE] at 10:20 AM, Staff A, Licensed Practical Nurse (LPN) stated she was at her med cart that morning [DATE] setting up medications for Resident #2 when her grandmother Resident #1 entered and said good morning, she then picked up the med cup that had medication for Resident #2 and gave them to her grandmother without thinking. She stated when she returned to her med cart, she realized what she had done because Resident #2's medication record was up on her screen. She explained it to her grandmother and her supervisor right away. She spoke to her supervisor and before Resident #1 finished breakfast he/she had a change of condition, taken back to his/her room, 911 had been called and sent out to the ER. She stated since the incident, all the nurses have reviewed the 6 rights of medication administration with her. During an interview on [DATE] at 4:45 PM, Staff B, Registered Nurse (RN) stated that because of unavoidable interruptions in the facility she always will double check the medications in the med cup against the MAR just before she administers them to the resident. She stated that the nurses are always thinking and planning two steps ahead and they have other resident names in their head, so they have to be careful for their own safety. During an interview on [DATE] at 11:30 AM, Staff D, RN stated they are expected to follow the 6 rights of medication administration, never click off their MAR with photo until they have it completed. They are able to lock the screen so no one can see it, but the person they are giving med's to is still on the screen when it is unlocked. During an interview on [DATE] at 11:40 AM, Staff C, RN stated she will always leave the resident she is giving med's to locked up on her screen and she will leave it there until she has completed the medication administration, then she will sign them off when finished. If she is interrupted, she will lock the cart, lock the screen, leave and complete what was needed then she can bring up the same person she had up just before walking away. During an interview on [DATE] at 11:15 AM, Staff E, LPN stated she will always do one at a time, do her best not to be interrupted but if she is, she will lock the cart, the screen and the person she had been working on prior will still be on the MAR, she then will review the MAR and take it from there. Review of the Medication Administration Policy & Procedure revealed the following procedure; 1. wash hands, 2. bring the med cart to where the medications are to be administered, 3. check the electronic medication administration record (e-mar), 4. read the order entirely, 5. remove the medication 6. if any discrepancy, check the physician's orders [REDACTED].>7. if the label is wrong, check with the pharmacy, 8. use appropriate measuring device and read all special instructions, 9. check the appearance of the drug, crush only when indicated, 10. initial the e-mar as each medication is removed from the cassette, 11. identify each resident by checking the picture in the e-mar, ,[DATE]. (did not apply in this incident)

Based on observation, record review and staff interview, the facility failed to provide adequate supervision and implement interventions identified to prevent accidents for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 64 residents. Findings include: According to the Minimum Data Set (MDS) assessment, dated 8/20/13, Resident #1 scored 9 on the Brief Interview for Mental Status (BIMS) indicating cognitive impairment. Resident #1 required staff assistance with activities of daily living (ADL's) including two staff to assist with bed mobility, walking in room, dressing, toilet use, and personal hygiene; and one staff to assist with transfers. Resident #1 demonstrated unsteadiness, and only able to stabilize with staff assistance when moving from a seated to a standing position, walking, turning around, moving on and off the toilet and surface to surface transfer. The MDS documented Resident #1 frequently incontinent of bowel and bladder. Resident #1's [DIAGNOSES REDACTED]. Resident #1 had a fall without a major injury. A Fall report dated 7/27/13 at 1:45 p.m. documented Kitchen staff saw Resident #1 stand from the wheelchair at the table and fall down landing on his/her shoulder, but did not hit his/her head. Staff wrapped a left elbow skin tear with gauze. The report identified Resident #1 with a gait imbalance and impaired memory. The Care Plan dated 8/28/13 identified Resident #1 with an ADL deficit due to a CVA with impaired cognition. The interventions included extensive assist of 1 for toileting, and extensive assist of 1 for transfers. The resident used a wheelchair for locomotion. The care plan identified Resident #1 frequently incontinent of urine and stool. The interventions included to provide peri care when found wet or soiled. The care plan identified Resident #1 at risk for falls due to vertigo, anxiety, Alzheimer's disease, decreased mobility, psychotropic med use, pain med use, poor balance, incontinence of bladder, and wandering. The interventions included: a. Encourage to wear nonskid footwear for mobility attempts. b. Floor alarm on when in bed. c. Have call light accessible. d. Keep room clutter free. e. Redirect as needed. f. Sit stand alarm on at all times. A Fall report dated 9/13/13 at 1:15 p.m. documented staff observed Resident #1 lying on his/her back in his/her room. Resident #1 had 3 skin tears on the left elbow and 1 on the right elbow. Resident #1 stated trying to get up from his/her wheelchair to get in bed, and his/her feet got twisted on the foot pedals and he/she fell on the floor, hitting his/her head on the wall. The predisposing environmental factors included furniture, and poor lighting. The predisposing physiological factors included confusion, incontinence, gait imbalance, and impaired memory. Other information documented Resident #1's feet got twisted on the wheelchair foot pedals while trying to get up. An Acute Care Plan dated 9/13/13 identified the acute care problem of falls/injury. The care plan identified Resident #1's feet got twisted in the foot pedals while trying to get up. The alarm sounded. The new intervention directed to take Resident #1 to the toilet and lay down immediately after meals. Staff were educated to take Resident #1 to the bathroom and lay down immediately after meals. A Physician's Telephone Order dated 9/21/13 at 3:00 p.m. documented Resident #1 had a left proximal clavicle fracture, to wear a sling on the left arm for 1 week for comfort. a). A Fall report dated 10/1/13 at 8:55 p.m. documented a Certified Nursing Assistant (CNA) told the nurse Resident #1 fell to the floor. When the nurse went to Resident #1's room, he/she sat with his/her legs sprawled out and a CNA holding his/her back up on the carpeted area. Resident #1 stated needing to go to the bathroom and fell . Staff educated Resident #1 to use the call light when needing help. The new intervention was to toilet Resident #1 before and after meals. The predisposing physiological factors included incontinence and gait imbalance. The Progress Notes dated 10/1/13 at 9:22 p.m. documented a CNA stated Resident #1 fell in his/her room. Resident #1 stood by his/her wheelchair trying to get in to the bathroom when his/her pants got caught around the wheelchair pedal causing Resident #1 to fall. Staff noted Resident #1's pants were wet and he/she stated trying to go to the bathroom. Resident #1's alarm sounded. Resident #1 moved all extremities. Resident #1 seen throughout the shift wandering the hallways. The Progress Notes dated 10/2/13 at 1:46 a.m. documented Resident #1 complained of pain in the left hip. Resident #1 had his/her left leg over his/her right ankle. After moving the left leg with some assist from Resident #1, the left leg appeared shorter with external rotation of the foot. Staff notified the emergency room (ER), and the physician okayed transfer. At 2:15 a.m. they received a call from the ER and Resident #1 had a fractured hip. A Radiology Report dated 10/2/13 documented Resident #1 had a moderately angulated intertrochanteric fracture of the left femur. A History and Physical dated 10/2/13 documented Resident #1 could not give any history due to dementia and a history of stroke. Resident #1's spouse stated he/she fell at the retirement home resulting in a fracture of the left hip. Resident #1 had been very fall prone secondary to a stroke about a year ago. An Operative Report dated 10/2/13 documented Resident #1 had reduction and fixation of the left hip with a sliding hip screw. In a hand written note on the x-ray report from 10/02/13 dated 10/31/13 Resident #1's physician wrote Resident #1 had underlying osteoporosis. Resident #1 had other fractures from this (ie. lumbar compression fracture). It seems apparent that the underlying bone disease caused the hip fracture ... and then he/she fell . A Major Injury Determination Form dated 10/1/13 documented at 8:45 p.m. a CNA saw Resident #1 standing by his/her wheelchair with the collar of his/her pant leg caught on the wheelchair pedal and Resident #1 fell on top of the CNA's foot with his/her back to the CNA. The circumstances of the incident causing the injury: Resident #1 caught his/her pant leg. The physician determined after reviewing the circumstances, injury, and prognosis of the resident, he believed the injury sustained was a major injury. A Physical Therapy Plan of Care dated 10/7/13 documented Resident #1 had a [DIAGNOSES REDACTED]. Resident #1 referred for decreased bilateral lower extremity strength, decreased functional independence and mobility, and decreased ambulation tolerance. Resident #1's prior level of function with contact guard assist (CGA) for bed mobility and transfers and ambulated up to 300 feet with a front wheeled walker. Resident #1's current level of function maximum assist of 2 with bed mobility and transfers, and unable to ambulate. The Occupational Therapy Plan of Care dated 10/8/13 documented Resident #1 referred for left hip fracture. Resident #1 suffered a left hip fracture on 10/2/13 due to a fall. Resident #1 complained of increased pain in his/her back and left lower extremity. Therapy necessary for strengthening, endurance, safety training with resident and staff, ADL retraining, balance. b). During an observation 10/25/13 at 12:18 p.m. Resident #1 sat in the wheelchair at the dining room table. An alarm box hung on the back of the wheelchair. The alarm cord hung and not plugged in to the box. The Surveyor asked Staff I Certified Nursing Assistant (CNA) about it at 12:18 p.m.. Staff I stated the cord should be plugged in to the alarm box for it to work. Staff I plugged the cord in to the box. The alarm beeped when she plugged it in indicating it worked. Interviews: During an interview on 10/31/13 at 12:12 p.m. the MDS/Care Plan Coordinator stated the intervention on the acute care plan after the 09/13/13 fall, to toilet and lay down after meals was the intervention in place to prevent falls. During an interview on 10/30/13 at 9:01 p.m. Staff A Licensed Practical Nurse (LPN) stated she worked Resident #1's hall the evening he/she fell . After supper Resident #1 stated the need to go to the bathroom. She told Staff F CNA to take Resident #1 to the bathroom. Staff A assumed Staff F took Resident #1 to the bathroom. After Resident #1 fell , Staff A noticed Resident #1's pants were wet and asked what he/she was doing. Resident #1 stated he/she tried to go to the bathroom. Staff A checked Accunurse (where CNA's document cares) and Resident #1 had not toileted since 2:30 p.m. Staff A stated staff were supposed to ask every 2 hours. Staff A talked to the staff working and no one toileted Resident #1 after 2:30 p.m. Staff A stated Staff F made excuses and said Resident #1 didn't need to go when she directed her to toilet him/her. Staff F said she thought other staff took Resident #1 to the bathroom. Staff A stated Resident #1 was unsteady on his/her feet and would lose his/her balance. Staff A stated she added the intervention to toilet before and after meals because he/she had not toileted since 2:30 p.m. and he/she said he/she tried to go to the bathroom. She said they talked to her the next day about Staff G's statement about Resident #1 wanting to go to bed so they implemented the intervention regarding his/her pants so they would not get caught on the foot pedal. Staff A stated Resident #1 would attempt self-transfers to the toilet, but would also try self-transfer for other reasons. In a written statement dated 10/2/13 Staff G CNA stated last night (10/1/13) at 8:45 p.m. Resident #1's chair alarm sounded and she went to see what went on. The front of Resident #1's wheelchair blocked the entry to the bathroom. Resident #1 attempted to self-transfer from the wheelchair to bed. Resident #1 told Staff G he/she wanted to lay down. Resident #1's left leg was on the outside of the left foot pedal and he/she tried to move his/her right leg. Resident #1's pant leg caught on the peg of the left foot pedal. Resident #1 lost his/her balance and Staff G caught him/her and lowered him/her to the floor. Resident #1's left buttock sat on Staff G's left foot and his/her back against her left shin. During an interview on 10/29/13 at 4:23 p.m. Staff G CNA stated the evening Resident #1 fell she heard an alarm going off and didn't see anyone so she went to see about it. Resident #1 stood in front of the wheelchair with his/her left foot on the left side of the left foot pedal. Resident #1 tried to move his/her right foot around the left pedal. Resident #1 started to fall and Staff G got to him/her and eased him/her down to the floor with his/her buttocks on Staff G's foot and his/her back against Staff G's shin. Staff G stated Resident #1's wheelchair faced angled in the bathroom doorway. Staff G stated she asked Resident #1 what he/she was doing, and he/she said he/she wanted to go to bed. Staff G didn't know when Resident #1 toileted. She saw Resident #1 in the dining room and wheel him/herself down the hall after supper. Staff G stated when they saw Resident #1 go into his/her room, they told the staff on his/her hall, because he/she had a tendency to self-transfer. During an interview on 10/30/13 at 12:15 p.m. Staff D CNA stated the evening Resident #1 fell she answered his/her alarm early in the shift 2:30 to 2:45 p.m.. She said when she got to Resident #1's room he/she was already going in to the bathroom. She assisted Resident #1. Staff D did not toilet Resident #1 after that. She said most residents were on a 2 hour schedule for toileting. If a resident didn't have to go when asked, she would approach them again within a short time. She said residents had to use the wheelchair foot pedals when staff pushed them. When residents were independently mobile they didn't have to use the foot pedals. During an interview on 10/29/13 at 4:30 p.m. Staff F CNA stated she got assigned to Resident #1's hall the evening he/she fell . Staff F saw Resident #1 in the hall after supper and the nurse told her he/she needed to use the restroom, but when she asked Resident #1 he/she said he/she didn't need to go. That was the last time she talked to Resident #1 until after the fall, sometime between 6:30 to 7:00 p.m. She said he last toileted around 2:30 p.m. She said Resident #1 would let them know when he/she needed to go to the bathroom, he/she would open the door and go in the bathroom. Resident #1 would stand up and set the alarm off. After the fall Staff F cleaned Resident #1 up. Resident #1 had incontinence of bladder. During an interview on 10/30/13 at 3:45 p.m. Staff B CNA stated she worked the evening Resident #1 fell . She worked 6 p.m. to 10 p.m. She never worked on Resident #1's hall. Staff B stated she might have wheeled Resident #1 to the dining room for supper. She did not toilet him that evening, and didn't know if anyone else did. Staff B stated she takes residents who need assistance with toileting to the bathroom every couple of hours. During an interview on 10/30/13 at 2:23 p.m. Staff C Registered Nurse (RN) stated the evening Resident #1 fell , she thought his/her alarm went off a couple of times. She thought they sounded for a long time, and when she went to check, someone was with Resident #1. She could not remember who. She thought 1 time they toileted Resident #1, but didn't know what time. During an interview on 10/31/13 at 3:48 p.m. Staff H CNA stated she worked 6 p.m. to 10 p.m. (10/01/13). She did not recall toileting Resident #1 or doing anything else with him/her. During an interview on 10/30/13 at 9:57 a.m. Staff K CNA stated Resident #1 used the bathroom a lot. If Resident #1 didn't ask, she would offer before and after meals and before bed. Staff K stated Resident #1 would try to go to the bathroom him/herself. During an interview on 10/30/13 at 10:05 a.m. Staff L Restorative aide (RA)/CNA/Certified Medication Aide (CMA) stated she worked with Resident #1 with therapy or if his/her alarm went off. Resident #1 would work his/her way to the bathroom and try to get him/herself up. During an interview on 10/30/13 at 10:13 a.m. Staff M CNA stated Resident #1 would attempt to get up to the bathroom a lot. She said if he/she toileted routinely it worked better; before and after meals and then lay down. If Staff M saw Resident #1 head toward his/her room, staff would intervene. She said if Resident #1 didn't want to go to the bathroom, she would re-approach a short time later. During an interview on 10/30/13 at 10:26 a.m. Staff I CNA stated she worked with Resident #1 some. She toileted him/her before and after meals. She would go back within 1/2 hour if he/she declined. During an interview on 10/30/13 at 10:35 a.m. Staff O Registered Nurse (RN) stated Resident #1 toileted before and after meals and bedtime. If Resident #1 said no, went back in 5-10 minutes. She said Resident #1's alarm went off a lot. She said when Resident #1 self-propelled, the foot pedals were off. Resident #1 had alarms at all times. During an interview on 10/30/13 at 10:53 a.m. Staff P RN stated if Resident #1's alarm went off, he/she usually tried getting up to the bathroom, or getting out of bed. They toileted Resident #1 before and after meals, bedtime and in between if needed. If Resident #1 declined they would re-approach a sort time later. She stated Resident #1's alarms should be plugged in and turned on at all times. During an interview on 10/30/13 at 11:01 a.m. Staff Q CNA stated Resident #1 would try to go to the bathroom on his/her own. They routinely toileted him/her before and after meals. If Resident #1 declined she would go back 20 to 30 minutes and check again. The bathroom was very important to Resident #1. During an interview on 10/30/13 at 11:36 a.m. Staff R CNA stated prior to the fall with a fracture, Resident #1 would try to go to the bathroom him/herself, and staff would assist him/her when the alarm went off. Staff R stated they would toilet Resident #1 before and after meals. If Resident #1 said he/she didn't need to go, they would ask a little later, no more than an hour. Staff R stated Resident #1 would push the foot rest part of the foot pedals up.

Based on observations, record review, and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and the facility failed to follow the planned Care Plan to promote safety measures for the residents (Residents #2, #9). The facility reported a census of 63 residents. Findings include: 1. Resident #2 had a MDS (Minimum Data Set) assessment with a reference date of 5/21/2013. The MDS identified the resident had multiple [DIAGNOSES REDACTED]. The MDS documented the resident had no falls during the assessment period. The resident required extensive assistance of staff for transfers and bed mobility. Ambulation in the room and corridor did not occur during the assessment period. The Care Plan, revised on 2/11/2013 identified the resident at risk for falls due to a cognitive impairment. The resident had a history of [REDACTED]. a. The resident to wear non-skid footwear. b. After Ativan (anti-anxiety) given, staff are to transfer the resident with 2 staff (member) assist. c. Be sure the resident's non-footwear fit well or use non- skid socks. d. CNA (Certified Nursing Assistant) to ask for additional assistance to transfer if resident upset. e. Floor alarm on either side of the bed when in bed. f. Keep room free of clutter. g. Sit in wheelchair at meals. h. Sit stand alarm on when in wheelchair, implemented on 4/5/12. i. Have resident eat with others and put to bed first after meal, effective date 4/11/13. On 7/22/13 at 4:07 PM, observation revealed the resident in the tilt back wheelchair with a chair alarm (attached) in place on the wheelchair. The Integrated Notes dated 3/29/13 at 7:50 PM documented the resident in the common area and fell head first out of the wheelchair onto the floor. The resident received a large goose egg bump to the left forehead. Staff documented the plan to put the resident to bed first after supper. Interview with the MDS Coordinator on 7/23/13 at 9:20 AM revealed the resident had a gradual decline and took only a few steps in the corridor. The resident resided in the Alzheimer ' s unit in February and transferred out of the unit in June 2013. The resident no longer met the criteria, did not ambulate and had been placed in the wheelchair on a permanent basis. An incident report identified the resident experienced a fall on 4/11/2013. The incident description reflected a nurse observed the resident on the floor in front of the wheelchair and next to the table in the unit. The fall was not witnessed. At the time of the fall, the resident was eating supper late because of sleeping through supper. The resident had no apparent injury. Record review of an assessment for recent falls revealed: a. The resident had a history of [REDACTED]. b. The resident had no memory or recall ability. c. The resident confined to a wheelchair and disorientated. Review of the Incident Report dated 6/10/13 at 1:15 PM revealed the resident found on the floor face down in front of the wheelchair. The resident noted with large gaping laceration to left forehead when the nurse attempted to assess the resident. Review of the Medical Practitioner Progress Notes dated 6/10/13 at 6:15 PM revealed the resident arrived at the hospital by ambulance. The resident fell forward out of his/her wheelchair and hit head on the floor. The resident required stitches to the forehead. The Nursing Progress Notes dated 6/18/13 at 2:30 PM documented a Hospice entry noting 15 stitches had been removed from the resident's head wound. On 7/24/13 at 9:50 AM with Staff E6, Registered Nurse (RN) was interviewed and stated the resident had been toileted and in a wheelchair in the lobby area. A second resident's alarm sounded and both she and the CNA assisted the second resident to the bathroom. Staff E6 stated suddenly they heard the housekeeper voice say "oh" "oh" "oh" and saw Resident # 2 on the floor. Staff E6 stated they transferred the alarm to the recliner but did not transfer the resident to the recliner prior to assisting the second resident. On 7/24/2013 at 1:40 PM, Staff A22, Certified Nursing Assistant (CNA) was interviewed and stated she had toileted Resident # 2 and placed the resident back into the wheelchair. She placed the wheelchair in front of the recliner and removed the chair alarm from the wheelchair and placed the alarm on the recliner. The resident remained in the wheelchair and did not get transferred to the recliner before a second resident's alarm triggered and the charge nurse and she assisted the second resident. They took the second resident to the bathroom and left Resident # 2 unattended. They heard the housekeeper say "oh" "oh" and the charge nurse looked out and saw the resident had moved the wheelchair to the nurse's station and found on the floor. The resident had fallen forward and onto the floor. The resident had a large gaping wound on the forehead and a skin tear on the arm. 2. Resident #9 had a MDS assessment with a reference date of 7/2/13 which identified [DIAGNOSES REDACTED]. According to the MDS, the resident required extensive assistance of 2 or more persons with transfers and bed mobility. The assessment documented the resident experienced 1 fall without injury during the assessment period. Review of a fall risk assessment tool dated 6/30/13 documented a score of 21, indicating the resident was at high risk. Review of the care plan, updated on 7/9/13 documented a focus on risk for falls due to poor balance, incontinent of bladder, decreased muscle coordination, safety impairment, psychotropic drug use, decreased mobility, cognitive impairment, wandering, and antidepressant use. The care plan instructed the staff to attempt to keep a sit/stand alarm on at all times and place a motion alarm on the floor facing the bed when the resident lay in bed. Review of the progress notes dated 6/28/13 at 23:50 (11:50 PM) documented the resident was observed on the floor lying on his/her right side. The staff assisted the resident from the floor. The progress notes documented the bed alarm was not on the bed and did not sound. The progress notes also documented the floor alarm was on but not sounding. The progress note documented the resident did not suffer major injuries. The printable incident view form dated 6/28/13 at 23:42 (11:43 PM) documented the immediate action taken after the fall was to talk with the CNAs (Certified Nursing Assistant) about use of the bed alarm and placement at bedtime. During an interview on 7/24/13 at 12:40 PM with Staff M, LPN (Licensed Practical Nurse), she stated at the time of the fall, she was called the room by the call light which had been pulled by the resident's roommate. Staff M stated that the resident said he/she had slid out of bed. Staff M stated the motion sensor was on but she didn't hear it. Staff M also stated she observed the bed alarm lying on a chair. Staff M stated she reminded the staff to make sure the resident had all of his/her alarms and in place at alarm checks. 3. Observation on 7/22/13 at 11:00 AM revealed the following: a. McKesson shampoo & body wash under the sink in the solarium, an 8.5 fluid ounce bottle partially used. The bottle instructed to use caution and for external use only. Avoid contact with eyes and in case of eye contact flush with water and contact a physician. Review of the undated MSDS (material safety data sheet) revealed the following: a. Eyes: Flush with clear water for 15 minutes. b. Swallowed: If patient is conscious and alert, dilute by drinking large quantities of water. Allow vomiting to occur then get medical attention. Always get medical attention when product is swallowed or when signs and/or symptoms of significant or persist.