Every finding on record at Grafton County Nursing Home

Based on observation, interview, and record review, the facility failed to identify personal humidifiers in their Water Management Plan in which Legionella and other opportunistic waterborne pathogens could grow and spread. There were humidifiers on 3 of 4 units observed. (Granite, Profile and Maple Units). Findings include: Review on 3/31/26 of the facility's policy titled Legionella Water Management Program, revised on 3/7/25 revealed, . 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 5.c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including the following. (6) misters, atomizers, air washers and humidifiers. Review on 3/31/26 of the facility's Staff Education for Legionella Disease dated March 3, 2026, revealed Possible pathways for exposure to Legionella Bacteria that humidifiers were listed. Observation on 3/31/26 at 1:00 p.m. and on 4/1/26 at 9:49 a.m. of the Granite Unit revealed that there were humidifiers in rooms 204, 211, 212, 215 and 217. Observation on 4/1/26 of the Profile Unit revealed that there were humidifiers in rooms [ROOM NUMBERS]. Observation on 4/1/26 at 9:45 a.m. of the Maple Unit revealed there was one humidifier in room [ROOM NUMBER]. Review on 4/1/26 of the facility's Water Management Program does not identify that there are humidifiers in use in the facility or controls to prevent the growth of Legionella and other opportunistic waterborne pathogens. Interview on 4/1/26 at 12:08 p.m. with Staff F (Infection Preventionist) confirmed humidifiers were in use in the building but not included in the Water Management Plan.

Based on interview and record review it was determined that the facility failed to report allegations of abuse to the state survey agency for 2 allegations of abuse reviewed residents. (Resident identifiers are #11, #29, #55, and #82). Findings include:Resident #11 Review on 3/31/26 of Resident #82's medical record revealed a nursing note dated 3/27/26 at 9:04 p.m. revealed Staff L (Licensed Practical Nurse) entered Resident #82's room and observed Resident #11 laying back in the recliner. Brief pulled off, pajama pulled up above pelvis. Resident #82 kneeling down in front of recliner attempting to have sex with Resident #11. Further review of the nursing note revealed that Staff L notified Staff H (Director of Nurses) and Staff G (Administrator) and Staff H informed Staff L to allow social services to contact the families on Monday. Review on 3/31/26 of Resident #82 and Resident #11's medical record, revealed that Resident #82 had a BIMS (Brief Interview for Mental Status) score of 02, indicating severe cognitive impairment on the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/13/26, and Resident #11 had a BIMS score of 00, indicating severe cognitive impairment on the Quarterly MDS with an ARD of 2/6/26. Interview on 4/1/26 at approximately 2:50 p.m. with Staff L confirmed that when he/she entered Resident #82's room he/she observed Resident #82 kneeling in front of the chair exposed completely and manually trying to enter Resident #11. Staff L further confirmed that he/she separated the residents, notified Staff H immediately, and placed Resident #82 on 1:1 safety checks. Interview on 4/1/26 at approximately 11:50 a.m. with Staff H who confirmed that he/she was notified by Staff L of the interaction between Resident #82 and Resident #11 and it was not reported to the State Agency. Interview 04/01/2026 at approximately 2:30 p.m. with Staff G confirmed that it was not reported to the State Agency. Review on 4/1/26 of the facilities policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating Revised September 2022 revealed .Reporting Allegations to the Administrator and Authorities 1.Suspicion must be reported immediately to the administrator and to other officials according to state law .2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons' or agencies: a. the state licensing/certification agency responsible for surveying/licensing the facility. b. the local/state ombudsman. c. the residents' representative. Adult protective services (where state law provides jurisdiction in long-term care). e. Law enforcement officials. f. The residents' attending physician; and g. The facility medical director. 3. immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Resident #29 Review on 3/31/26 of resident #29's medical record revealed a nurses note, dated 3/10/26 at 4:34 a.m., that read .LNA [Licensed Nursing Assistant] staff witnessed resident coming out of [pronoun omitted] room and grabbing the back of peers wheelchair and shaking it back and forth aggressively. Interview on 4/1/26 at approximately 1:45 p.m. with Staff J (LNA) revealed that on 3/10/26 they had witnessed Resident #29 shake and push forward the wheelchair of Resident #55 while yelling at him/her. Interview on 4/1/26 at approximately 2:30 p.m. with Staff G (Administrator) confirmed the incident on 3/10/26 involving Resident #29 and Resident #55 was not reported to the State Survey Agency (SSA) or other law enforcement.

Based on observation, interview, and record review, the facility failed to ensure that a resident with limited mobility receives appropriate services and equipment to maintain or improve mobility for 1 of 2 residents reviewed for position and mobility in a final sample of 27 residents. (Resident identifier is #4).Findings include:Resident #4Review on 3/31/26 of Resident #4's care plan revealed the following intervention for their activities of daily living care plan, initiated on 7/9/25, .Dependent on application of AFO [Ankle Foot Orthosis] prior to OOB [out of bed] to right lower leg [sic].Review on 4/1/26 of Resident #4's medical record revealed a Physician order, dated 3/2/26, OT [Occupation Therapy] Consult- have R [right] AFO sent for repair (broken strap). Further review of the medical record revealed no indication that an OT consult had been completed or that anyone had been contacted about the AFO needing repair.Interview on 3/31/26 at approximately 10:00 a.m. with Resident #4 revealed they had told their provider that their foot rolls out of the AFO and it causes them pain when worn. Resident #4 stated that no one has come into see them or talk to them about the AFO since they spoke to their provider a few weeks ago.Observation on 3/31/26 at approximately 10:00 a.m. of Resident #4's room revealed an AFO lying on their bed with the ankle strap missing.

Based on interview and record review, the facility failed to ensure that 2 of 2 allegations of abuse were investigated and reported to the State Agency. (Resident identifiers are #11, #29, #55, and #82).Findings include:Resident #11 Review on 3/31/26 of Resident #82's medical record revealed a nursing note dated 3/27/26 at 9:04 p.m. revealed Staff L (Licensed Practical Nurse) entered Resident #82's room and observed Resident #11 laying back in the recliner. Brief pulled off, pajama pulled up above pelvis. Resident #82 kneeling down in front of recliner attempting to have sex with Resident #11. Further review of the nursing note revealed that Staff L notified Staff H (Director of Nurses) and Staff G (Administrator) and Staff H informed Staff L to allow social services to contact the families on Monday. Review on 3/31/26 of Resident #82 and Resident #11's medical record, revealed that Resident #82 had a BIMS (Brief Interview for Mental Status) score of 02, indicating severe cognitive impairment on the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/13/26, and Resident #11 had a BIMS score of 00, indicating severe cognitive impairment on the Quarterly MDS with an ARD of 2/6/26. Interview on 4/1/26 at approximately 2:50 p.m. with Staff L (Licensed Practical Nurse) confirmed that when he/she entered Resident #82's room he/she observed Resident #82 kneeling in front of the chair exposed completely and manually trying to enter Resident #11. Staff L further confirmed that he/she separated the residents, notified Staff H immediately, and placed Resident #82 on 1:1 checks. Interview on 4/1/26 at approximately 11:50 a.m. with Staff H (Director of Nursing) revealed no investigation was initiated. Review on 4/1/26 of the facilities policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating Revised September 2022 revealed. Reporting Allegations to the Administrator and Authorities. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. Investigating Allegations. 1. All allegations are thoroughly investigated . 4. The administrator is responsible for keeping the resident and his/her representative (sponsor) informed of the progress of the investigation. Resident #29 Review on 3/31/26 of resident #29's medical record revealed a nurses note, dated 3/10/26 at 4:34 a.m., that read .LNA [Licensed Nursing Assistant] staff witnessed resident coming out of [pronoun omitted] room and grabbing the back of peers wheelchair and shaking it back and forth aggressively. Interview on 4/1/26 at approximately 1:45 p.m. with Staff J (LNA), revealed that on 3/10/26 they had witnessed Resident #29 shake and push forward the wheelchair of Resident #55 while yelling at them. Interview on 4/1/26 at approximately 12:45 p.m. with Staff H (Director of Nursing) revealed the incident on 3/10/26 involving Resident #29 and Resident #55 had not been investigated.

Based on observation, interview and record review the facility failed to maintain a safe/clean equipment for 3 of 3 residents reviewed for environment in a final sample of 27 residents. (Resident identifiers are #41, #63 and #100.)Findings include:Review on 4/1/26 of the facility's admission Procedures and Resident Information Guide revealed .Humidifiers To prevent unwanted and unnecessary illness, GCNH ([NAME] County Nursing Home) exclusively permits non-filter humidifiers. These are not provided, so either the resident or family/friend would need to purchase one. If a humidifier is brought in, nursing staff will need to be aware of it to ensure that it is on the cleaning schedule.Interview on 4/1/26 at approximately 8:51 a.m. with Staff C (Registered Nurse) revealed that Unit Aides have a book that lists residents with humidifiers and tracks cleaning. Interview on 4/1/26 at approximately 9:00 a.m. with Staff E (Licensed nursing Assistant) revealed that the Unit Aide Book did not contain any information about which Resident's had humidifiers or a tracking of cleaning dates. Interview on 4/1/26 at approximately 12:39 with Staff H (Director of Nursing) Confirmed the above. Review on 4/2/26 of the Facility's Humidifier Maintenance revised on 4/17/17 revealed .1. Nursing Staff Responsibilities .b. Ensure the device is unplugged from the electrical outlet daily. c. Ensure device if emptied, rinsed thoroughly with water, and refilled with fresh tap water in a daily basis when in use.2. Housekeeping Staff's Responsibilities: a. Housekeeping will clean humidifiers with a 1:2 solution of acetic acid and water on a monthly schedule .Resident#41Observation on 4/1/26 at approximately 9:34 a.m. of Resident #41's room revealed a Pelonis humidifier plugged in in the resident's room. Further observation revealed that the unit was turned off.Interview on 4/1/26 at approximately 10:12 a.m. with Resident #41's family revealed that they bought the resident the humidifier and staff were made aware. Review on 4/1/26 of the Owner's manual for Resident #41's humidifier revealed . clean the humidifier regularly, typically once a week, to remove limescale and debris from the water tank and other components Remove the water tank, add a bleach solution (1 spoon bleach per gallon of water) to the tank, tighten the cap and shake well, then place the tank back on the base and let sit for 20 minutes.Observation on 4/2/26 at approximately 9:28 a.m in Resident #41's room with Staff H (Director of Nursing) revealed that Resident #41's humidifier was plugged into the wall outlet and displayed that the water tank was empty.Resident #63Observation on 4/1/26 at approximately 9:18 a.m. revealed that Resident #63 had a Breezome humidifier in his/her room.Interview with Resident #63 revealed that he/she did not know how often the humidifier was cleaned. Review on 4/2/26 of the Manufacturer's instructions revealed . Cleaning and Maintenance .Water Tank Remove the water tank and its cover to rinse under the tap water. Fill some acid cleaner in the water tank for around 15 minutes, then descale with a cleaning brush Clean all parts of the water reservoir with a soft cloth Trouble shooting, Problem Stop working after a period of use and the red light flashes, possible cause, the filter (located at the bottom of water tank) hasn't been cleaned .Resident #100Observation on 3/31/26 at approximately 10:13 a.m. of Resident #100's room revealed a Vick's humidifier. Review on 4/2/26 of the manufacturer's instruction for Resident #100's Vick's Filterfree Plus Cool mist Humidifier revealed .Weekly Cleaning .To properly clean your humidifier we recommend separate processes of Scale Removal and Disinfecting .Scale Removal .3. Add 2 cups undiluted, distilled vinegar to the water tank. Replace Tank Cap and swish vinegar solution around in Tank. Place Tank on base Allow vinegar to remain in Tank on Base for 15 to 20 minutes Disinfecting 1. Add 1 tsp. (teaspoon) to 1 gallon (3.8 L (Liter)) of water and add to water tank. Replace Tank Cap, Swish solution around in Tank. Place Tank on Base .2. Allow the bleach solution to remain in Tank and on Base for 15-20 minutes.Interview on 4/02/26 at approximately 9:26 a.m. with Staff C (RN) revealed that all humidifier units are cleaned with vinegar. Further interview revealed that Staff C did not know that specific manufacturers required a bleach solution.Interview on 4/2/26 at approximately 9:30 a.m. with Staff H confirmed that the facility was not following specific manufacturer's instructions for cleaning of individual humidifiers.

Based on observation, interview, and record review, the facility failed to ensure that medications were removed from use from 2 of 4 medication carts observed and failed to ensure that medication carts were secured/locked when unattended on 1 of 4 units observed. (Resident identifiers are #23 and #55). Findings include:Maple Unit Short Cart Observation on 3/31/26 at 1:11 p.m. of the Maple Unit Short Hall Cart with Staff A (Licensed Medication Aide) revealed a bottle of Timolol Maleate solution for Resident #55 with pharmacy instructions to instill 1 drop in each eye twice daily for glaucoma expires in 28 days after opening. Handwritten on the box was opened on 2/27 and expires on 3/27 (28 days). Interview on 3/31/25 at 1:11 p.m. with Staff A confirmed the above finding. Review on 4/1/26 of the manufacturer's instructions for Timolol Maleate Ophthalmic Solution, provided by the facility, revealed, . the unit dose container should be. used within one month after the foil package has been opened. Meadow Unit Long Hall Cart Observation on 3/31/26 at 1:33 p.m. of the Meadow Unit Long Hall Cart with Staff B (Registered Nurse) revealed a bottle of for Latanoprost Solution 0.005% for Resident #23. Handwritten on the pill container was written opened on 2/9/26 and expires on 3/23/26 (42 days). Interview on 3/31/26 at 1:33 p.m. with Staff B confirmed the above and revealed that the medication had been administered and should have been discarded. Review on 4/1/26 of the manufacturer's instructions for Latanoprost Solution, provided by the facility, revealed, . Once a bottle is opened for use, it may be stored at room temperature. for 6 weeks. [42 days]. Profile Long Hall Cart Observation on 3/31/2026 at approximately 12:25 p.m. of Profile Unit medication cart was unlocked with no nursing staff present. Interview on 3/31/2026 at approximately 12:30 p.m. with Staff D (Registered Nurse) confirmed above findings. Review on 3/31/2026 of facility policy titled Medication Labeling and Storage revised February 2023 revealed, .Medication Storage.4. Compartments (including, but not limited to,.carts.) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not let unattended if open or otherwise potentially available to others.5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, interview and record review, it was determined that the facility failed to offer the residents a nourishing snack at bedtime while having more than 14 hours between the evening meal and the breakfast meal for 4 of 4 units reviewed and without Resident Council consent. Findings include: Interview on 1/29/25 at approximately 2:15 p.m. at Resident Council (5 residents in attendance) revealed that HS (Hour of Sleep) snacks were not offered. The residents stated snacks were available when they asked for them. Review on 1/29/25 of the facility's scheduled meal service times revealed that the Supper meal time starts at 5:00 p.m. and the Breakfast meal time starts at 8:00 a.m. Further review revealed that the schedule of meal times indicated that the facility offered snacks at bed time (approximately 7:00 p.m.). Meadow Unit Interview on 1/29/25 at 3:23 p.m. with Staff R (Licensed Nursing Assistant (LNA)) revealed that he/she worked the evening shift and that snacks were given to residents that requested them and not offered to everyone. Interview on 1/29/25 at 3:29 p.m. with Staff S (LNA) revealed that he/she worked the evening shift and that snacks were given to residents when they requested them and not offered to everyone. Staff S revealed that most residents on the unit would not be able to ask for a snack due to memory issues. 26364 Granite Unit Interview on 1/29/25 at approximately 3:15 p.m. with Staff I (LNA), Staff J (LNA), Staff K (LNA), and Staff L (LNA) on the Granite Unit revealed that HS snacks are not offered routinely. Snacks are available if a resident asks for them. 38218 Maple Unit Interview on 1/29/25 at approximately 3:15 p.m. with Staff C (LNA) and Staff D (LNA) on the Maple Unit revealed that HS snacks are not offered routinely. Snacks are available if a resident asks for them. Profile Unit: Interview on 1/29/25 at 3:38 p.m. with Staff KK (LNA) and Staff LL (LNA) revealed that they work 3-11 shift. Resident were not offered snack in the evenings. Snacks are available if a resident asks for them. 51399 45419 47129

Based on record review, interview, and policy review, it was determined that the facility failed to follow standards of practice for the complete medical records as it related to the pronouncement of death in 1 out of 1 record reviewed for death documentation and for the incorrect documentation of weights for 1 resident out of a final sample of 24 residents. (Resident identifier is #120 and Resident #42) Findings include: Resident #120 Review on 1/31/25 at 12:30 p.m. of Resident #120's medical record revealed that on 12/11/24 an entry by Staff N (Licensed Practical Nurse (LPN)) on the Progress Notes stated the following: Resident passed away at 02:58 a.m., Pronounced by an RN [Registered Nurse] at 0305 [3:05 a.m.]. DON [Director on Nursing] notified and called caseworker twice by no answer and left a message for call back. Funeral home arranged. Interview on 1/31/25 at 1:00 p.m. with Staff E (Director of Nursing) revealed the Registered Nurse pronouncing the death would document in the record per facility policy. Review on 1/31/25 of the facility policy titled Death of a Resident - Implementation and Documentation, revised 11/10/22, revealed that All information pertaining to a resident's death, i.e. date, time of death, name and title of individual pronouncing the resident is dead, etc., must be recorded in the nurse's notes. Resident #42 Review on 1/29/25 at 9:00 a.m. of Resident #42 medical record revealed that on 12/20/24 Resident #42's weight was recorded as 156.3 pounds. Further review of the weight record revealed that on 12/27/24 the weight was recorded as 194.7 pounds. On 1/03/25 weight was recorded as 193.7 pounds, on 1/9/25 weight was recorded at 156.6 pounds, and no other documentation regarding the discrepancy was identified. Interview on 1/29/25 at 12:30 p.m. with Staff V (LPN) revealed that if there is any discrepancy with the weights 3 pounds above or below then staff reweigh the next day for accuracy. Further interview with Staff V revealed that there was no reweights to verify accuracy documented for the 12/27/24, 1/3/25, and 1/9/25. Review on 1/29/25 of the Facility policy titled: Weigh Assessment and Intervention: Weight Assessment 3. Any weight change of 5% or more since the last weight assessment is retaken. a. If the weight is verified, nursing will immediately notify the dietitian in writing .

Based on interview and record review, it was determined that the facility failed to ensure that a resident obtained routine dental care for 2 of 2 residents reviewed for dental in a final sample of 24 residents (Resident identifiers are #25 and #63). Findings include: Resident #25 Interview on 1/29/25 at 11:35 a.m. with Resident #25 revealed that he/she had dentures but he/she doesn't wear them as they hurt because they don't fit right. Resident #25 stated that he/she had told staff but had not seen a dentist. Review on 1/29/25 of Resident #25's medical record revealed Resident #25's latest Brief Interview for Mental Status (BIMS), dated 12/4/24, revealed that Resident #25 scored a 15 (indicating cognitively intact). Interview on 1/31/25 at approximately 8:30 a.m. with Staff U (Registered Nurse) confirmed that Resident #25 had complained that his/her dentures hurt when he/she had them in so he/she did not wear them. Interview on 1/31/25 at approximately 1:59 p.m. with Staff E (Director of Nursing) revealed that the facility was unable to find documentation from the dentist they had been seen by a dentist since Resident #25's dentures had been realigned in November. Resident #63 Interview on 1/30/25 at 8:18 a.m. with Resident #63 revealed that he/she had issues with their teeth and had not seen a dentist since her teeth were cleaned by the hygienist in September 2024. Review of Resident #63's medical record revealed Resident #63's latest Brief Interview for Mental Status (BIMS) dated 11/1/24 revealed that Resident #63 scored a 13 (indicates cognitively intact). Review on 1/31/25 of Resident #63's dental notes dated 9/24/24 revealed the following: Findings: Visible decay Additional Notes: Lost filling #7, recurrent caries #8, missing crown with extensive decay #30. Recommendations: Urgent needs identified, evaluation with dentist ASAP Interview on 1/31/25 at 2:00 p.m. with Staff E confirmed that Resident #63 had not been seen by a dentist for follow up after 9/24/24.

Based on interview and record review, it was determined that the facility failed to identify resident preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 3 residents reviewed for behavioral-emotional in a final sample of 24 residents. (Resident identifier is #38.) Findings include: Review on 1/31/25 of Resident #38's medical record revealed that Resident #38 was admitted to the facility on ,d+[DATE]. Further review of Resident #38's medical record revealed the following progress notes: Dated 1/5/25, Resident expressed to LNA [Licensed Nursing Assistant] this am, that [pronoun omitted] grew up in foster care with a Father figure who was inappropriate with [pronoun omitted] growing up and [pronoun omitted] feels uncomfortable with male caregivers. Nurse updated care plan to not have male caregivers at this time. Dated 1/7/25, [name omitted] disclosed that [pronoun omitted] was SA'd [sexually assaulted] many years ago, which has resulted in trauma symptoms including panic when physically touched by males and anxiety. [pronoun omitted] said [pronoun omitted] didn't know [pronoun omitted] would have a reaction with a male caregiver until a recent incident. [pronoun omitted] wanted to share that the boy did nothing wrong. [pronoun omitted] was very kind and explained what [pronoun omitted was going to do. but [pronoun omitted] reaction was instant and controllable for [pronoun omitted] ., written by Staff H (Social Services). Review on 1/31/25 of Resident #38's care plans revealed that there was no interventions regarding male caregivers added to Resident #38's care plan in place for Resident #38's history of sexual abuse until 1/7/25. Interview on 1/31/25 at approximately 12:30 p.m. with Staff F (Administrator) revealed that there is no assessment to determine if trauma has occurred with residents on admission. Interview on 1/31/25 at approximately 12:45 p.m. with Staff G (Social Service Director) revealed that he/she meets with residents as they are admitted to the facility and does not ask specific questions in regards to identifying past trauma. Further interview revealed that Staff G likes to develop a relationship prior to asking specific questions.

Based on observation, interview, and record review, it was determined that the facility failed to provide appropriate adaptive equipment to maintain their ability to carry out Activities of Daily Living (ADL's) for 2 of 2 residents reviewed for ADL's in a final sample of 24 residents. (Resident identifiers #5 and #58) Findings include: Resident #5 Observation 1/30/25 from approximately 8:45 a.m. to 9:10 a.m. revealed that Resident #5 was eating in his/her room alone from a styrofoam container. Review on 1/31/25 of Resident #5's care plan revealed that Resident #5 has a lip plate per resident request. Observation on 1/31/25 at approximately 9:00 a.m. revealed that Resident #5 was eating in his/her room from a styrofoam container with intermittent assistance. Interview on 1/31/25 at approximately 9: a.m. with Staff Q (Licensed Nursing Assistant) confirmed that Resident #5 was eating from a styrofoam container and did not have a lip plate. Resident #58 Observation on 1/30/25 at approximately 9:00 a.m. revealed that Resident #58 was eating his/her meal from styrofoam container with weighted utensils. Observation on 1/31/25 at approximately 8:50 a.m. revealed that Resident #58 was eating his meal from a styrofoam container. Interview on 1/31/25 at approximately 8:10 a.m. with Staff Q confirmed that Resident #58 was eating from a styrofoam container. Review on 1/31/25 of Resident #58's care plan revealed that Resident #58 had an intervention to use a lip plate and weighted utensils to maximize independence with eating. Review on 1/31/25 of the facility's policy titled, Assistance with Meals, revised March 2022, revealed .Residents Who May Benefit from Assistive Devices: 1. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups .

Based on observation, record review, and interview, it was determined that the facility failed to determine if a device was a restraint for 1 of 1 resident reviewed for restraints in a final sample of 24 residents (Resident identifier is #58). Findings include: Observation on 1/30/25 from 8:05 a.m. to 8:20 a.m. revealed that Resident #58 was sitting in their wheelchair with a lap tray prior to being served breakfast. Observation on 1/31/25 at approximately 8:20 a.m. of Resident #58 revealed that Resident #58 was alone in his/her room with the lap tray attached to his/her wheelchair prior to breakfast being served. Review on 1/31/25 of Resident #58's medical record revealed Resident #58's latest Brief Interview for Mental Status (BIMS), dated 11/25/24, revealed that Resident #58 scored a 9 (indicating moderate cognitive impairment). Review on 1/31/25 of Resident #58's medical record revealed that there was no pre-restraining assessment. Review on 1/31/25 of facility policy, Use of Restraints, revised April 2017, revealed .1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts normal access to one's body.3 lap cushions and trays that the resident cannot remove .6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment .

Based on interview and record review, it was determined that the facility failed to conduct annual reviews of it's infection prevention and control programs policies and procedures which had the potential to effect the facility census of 118 residents. Findings include: Review on 1/31/25 of the facility's infection prevention and control program policies revealed that not all of the policies had been reviewed annually. Interview on 1/31/25 at 2:05 p.m. with Staff F (Administrator) revealed the facility did not have a process for reviewing policies annually and they were only updated when needed. Interview on 1/31/25 at 2:14 p.m. with Staff HH (Infection Preventionist) revealed that the facility did not conduct a review of it's infection prevention and control policies annually.

Based on record review and interview, it was determined the that the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the residents' status for 2 out of 2 residents reviewed for dental in a final sample of 24 residents (Resident Identifiers are #25 and #63). Findings include: Resident #25 Review on 1/31/25 of Resident #25's Annual MDS, Assessment Reference Date (ARD) of 6/5/25, revealed under section L0200: Oral/Dental Status was coded none of the above were present indicating that Resident #25 did not wear dentures. Interview on 1/31/25 at 8:31 a.m. with Staff U (Registered Nurse) confirmed that Resident #25 had worn dentures in June at the time of the assessment. Resident #63 Review on 1/31/25 of Resident #63's Annual MDS, with ARD of 11/1/24, revealed under section L0200: Oral/Dental Status was coded none of the above were present indicating that Resident #63 had no dental issues. Review on 1/31/25 of Resident #63's dental notes dated 9/24/24 revealed that Resident #63 had a lost filling, a cavity, and a missing crown with extensive decay. Interview on 1/31/25 at 1:52 p.m. with Staff T (MDS Coordinator) confirmed the above findings and that the MDS was coded incorrectly for Resident #25 and Resident #63.

Based on interview and record review, it was determined that the facility failed to obtain laboratory services as ordered by a physician for 1 resident in a final sample of 25 residents. (Resident identifier is #58.) Findings include: Review on 2/8/24 of Resident #58's physician orders revealed a physician order to draw laboratory tests for Lithium level, Comprehensive Metabolic Panel (CMP), Depakote level (i.e. Valproic acid level), and Complete Blood Count (CBC) every 3 months. Review on 2/8/24 of Resident #58's active medication list revealed physician orders for Lithium Carbonate Extended Release 450 milligram (mg) 1 tablet by mouth at bedtime for bipolar disorder with a start date of 6/22/23 and Depakote Sprinkles 125 mg 3 capsules (375 mg) by mouth twice a day for bipolar disorder with a start date of 6/22/23. Review on 2/8/24 of Resident #58's medical record revealed that the most recent Lithium level, CMP, Depakote level, and CBC results were obtained on 8/15/23. Interview on 2/8/24 at approximately 1:00 p.m. with Staff G (Licensed Practical Nurse) confirmed the above findings.

Based on observation, interview, and record review, it was determined that the facility failed to provide services or assist a resident in making appointments to maintain good foot health for 1 of 2 residents reviewed for foot care in a final survey sample of 25 residents (Resident Identifier is #26). Findings include: Interview on 2/6/24 at 10:26 a.m. with Resident #26 revealed that he/she had not seen a podiatrist in a long time, his/her toenails were long, broken, and that his/her feet hurt. Resident #26 revealed that he/she had a diagnosis of diabetes. Observation on 2/7/24 at 2:00 p.m. of Resident #26's feet with Staff H (Registered Nurse) revealed that the right foot's nails were long, thick, and curling past the tip of the toes. There were jagged edges and a band-aid on the middle toe. The left foot's nails were very thick and curled. Interview on 2/7/24 at 2:00 p.m. with Staff H revealed that Resident #26 needed a band-aid on his/her toenail because it was long, jagged, and getting caught on his/her socks. Staff H confirmed that Resident #26 needed his/her nails trimmed and revealed that nursing staff did not cut Resident #26's toenails. Staff H revealed that Resident #26 would be added to the podiatry list. Review on 2/8/24 of Resident #26's Weekly Skin Assessment - (Licensed Nurse) revealed the following; 11/8/23 Nails need trimming by podiatrist; 12/13/23 Toenails long and very thick - on the podiatrist list for foot care; 12/27/23 Nails needing attention from podiatry - on list; 1/3/24 Toenails to be trimmed by podiatrist; 1/10/24 Toenails to be trimmed by podiatrist; 1/17/24 Toenails need podiatry; 1/24/24 toenails thick and long; 2/7/24 Toenails need podiatry, on the list. Review on 2/7/24 of the facility's Podiatrist Schedule for the Profile Unit revealed that Resident #26 was added to the list on 2/7/24 and had been seen on 6/27/23. Review on 2/7/24 of Resident #26's physician's progress note dated 6/27/23 revealed that he/she had been seen by the podiatrist on 6/27/23 for diabetic foot care. Further review of this note revealed .Examination is significant for painful mycotic, dystrophic incurvated ingrown nails on the right and left foot x10 . Patient will return to the office as needed . Review on 2/8/24 of Resident #26's care plan revealed the following; Under Activities of Daily Living an intervention with a start date of 2/23/20 to be seen by a podiatrist to have toenails trimmed. This intervention was resolved on 12/14/23. Under Requires Assist with Self Care Task an intervention with a start date of 11/14/23 that Resident #26 was a diabetic so toenails need to be trimmed by podiatrist. Under Diabetes Mellitus an intervention with a start date of 2/23/20 to refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Interview on 2/8/24 at 11:15 a.m. with Staff K (Advanced Practice Registered Nurse) revealed that he/she was not aware that Resident #26 had not been seen by the podiatrist since last June and that he/she could be sent out to get podiatry care. Interview on 2/8/24 at 11:33 a.m. with Staff A (Director of Nursing) revealed that Resident #26 should be seen by the podiatrist at least quarterly to have toenails trimmed. Interview on 2/8/24 at 1:23 p.m. with Staff A confirmed that Resident #26 had not been seen by podiatry for nail care since last June and that Staff H had added his/her name to the podiatry list on 2/7/24 or would be sent out for care. Interview on 2/8/24 at 1:34 p.m. with Resident #26 revealed that his/her feet and toenails hurt. Review on 2/8/24 of the facility's policy titled Nursing Care of the Older Adult with Diabetes Mellitus revised November 2020 revealed, .Complication Associated with Diabetes . f. foot complications - neuropathy, dry skin, calluses, poor circulation, ulcers . Skin and Foot Care . 7. Toenails should only be trimmed by personnel qualified to do so (this can be regular associates, and does not have to be a podiatrist) .

Based on observation, interview, and record review it was determined that the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities to meet the interests of and support the physical, mental, and psychosocial well-being for 3 out of 3 residents reviewed for activities in a final sample of 25 residents (Resident Identifiers #89, #19, and #40). Findings include: Interview on 2/6/24 at approximately 10:00 a.m. with Resident #89's representative revealed that he/she was concerned about lack of engagement on the unit. The representative further stated that there were much fewer activities than he/she thought there would be to engage Resident # 89. Observation on 2/6/24 at approximately 9:45 a.m. of the common area revealed 4 residents present with no activities being offered. Interview on 2/6/24 at approximately 3:15 p.m. with Staff J (Licensed Nursing Assistant) revealed that there are 1:1 and independent activities on the Meadow Unit with no structured activities being offered. Interview on 2/8/24 at approximately 8:10 a.m. with Staff I (Licensed Practical Nurse) revealed that there is only one structured activity per day and no activities on weekends. Review on 2/8/24 of January 2024 activity calendars revealed: Meadow Unit Every Saturday consists of A.M. and P.M. Going With The Flow. Every Sunday the 7th, 14th, and 21st A.M. independent activities and P.M. gospel tape Sunday the 28th A.M. gospel tape and P.M. independent activities No activities January 1st, 2nd, and 3rd due to flu January 4th A.M. morning greetings, 2 p.m. music in the activity room January 5th A.M. activity time P.M. independent activities January 8th A.M. 1:1 visits PM showtime January 9th A.M. ball toss P.M. activity time January 10th 10:00 a.m. church service P.M. Bingo in the activity room January 11th A.M. independent activities P.M. Root beer floats P.M. Bingo in the activity room January 12th A.M. activity time P.M. independent activities January 15th A.M. activity time P.M. 1:1 visits January 16th A.M. independent activities PM manicures and hand massages January 17th A.M. 1:1 visits P.M. bingo in the activity room January 18th A.M. catholic priest visits 2 P.M. music in activity room January 19th A.M. 1:1 visits P.M. activity time January 22nd A.M. 1:1 visits PM showtime January 23rd A.M. reading and reminiscing P.M. cooking group January 24th A.M. 1:1 visits P.M. bingo in the activity room January 25th A.M. 1:1 visits 1-3 P.M. Country Store visits January 26th A.M. activity time P.M. January birthday cart January 29th Special breakfast P.M. 1:1 visits January 30th A.M. 1:1 visits 2 P.M. music in the activity room. January 31st A.M. activity calendar up and visits, P.M. Bingo in the activity room 47129 Granite Unit: Review on 2/6/24 of the Granite activity calendars for September 2023 - February 2024 revealed: Every Saturday consisted of AM & PM Going With The Flow; Every Sunday consisted of Gospel Tape or Church Services and Independent Activities. Resident #40 Interview on 2/6/24 at 12:38 p.m. with Resident #40 revealed that Resident #40 was very bored on the weekends. Resident #40 stated that activities slowed down and then just stopped. He/she sat in their room and watched TV or did nothing. Review on 2/7/24 of Resident #40's Activities - Annual/Significant Change Participation Review dated 2/21/23 revealed that Resident #40 liked music programming, church/chapel, arts & crafts, cooking groups, social gatherings, games, exercise groups, and more. Resident #19 Interview on 2/7/24 at 8:40 a.m. with Resident #19 revealed that there were no group activities scheduled on the weekends Resident #19 stated that there was nothing going on, they have to do their own thing. He/she goes to church service when it's scheduled because it's the only thing to do on a Sunday. Interview further revealed that they were short staffed and only one activity aide worked on the weekends. Review on 2/7/24 of Resident #19's Activities - Annual/Significant Change Participation Review dated 12/19/23 revealed that Resident #19 liked to attend bingo, music, religious programs, and other programs of choice. Interview on 2/7/24 at 10:30 a.m. with the facility's Resident Council (15 residents) revealed that approximately 7 of the residents that attended, complained about the lack of weekend activities. 1 resident stated, It is so boring, I just sit in my room and do nothing. Interview on 2/7/24 at 1:00 p.m. with Staff D (Assistant Activities Director) revealed that on the weekends they have one activity aid working who covers the 4 units in the facility for activities. Staff D confirmed that on Saturdays Going With The Flow was scheduled and what that consisted of was letting the residents self-guide what they wanted to do. On Sundays, they had a religious service which was either a service with a local pastor, a service on the TV or gospel music, and independent activities which consist of residents independently doing what they liked such as reading, crossword puzzles, coloring, or playing cards with other resident but nothing is structured or set up by the activity aid. Interview on 2/7/24 at 2:26 p.m. with Staff C (Licensed Nursing Assistant) revealed that Staff C worked every Saturday and Sunday and there were no structured activities except for church services. Staff C stated that the residents were very bored and they have voiced their frustrations. Interview on 2/8/24 at 9:38 a.m. with Staff F (Registered Nurse) revealed that Staff F worked every other weekend and that there were no structured activities scheduled on the unit. Staff F stated that the residents were bored and they have asked for more to do on the weekends. Review on 2/9/24 of the facility policy titled Activities Dept. - Activities Program dated 5/2000 revealed: .Purpose: An ongoing program of activities is designed to meet the needs of each resident. .Policy Interpretation and Implementation . 1. Our activity program is designed to encourage restoration to self care and maintenance of normal activity which is geared to the individual resident's needs. 6.B. Are offered at hours convenient to the residents, including evenings, holidays and weekends . Review of the facility's assessment revealed: .Activities: The Activity Department is responsible for ensuring residents of [NAME] County Nursing Home participate in meaningful and stimulating activities. The majority of programming is designed based on feedback from the [NAME] County Nursing Home resident council and also through federal regulatory requirements. Not all of our residents are able to participate in programs, therefore the Department ensures both active and passive residents realize benefits from the numerous programs offered. activities. The majority of programming is designed based on feedback from the [NAME] County Nursing Home resident council and also through federal regulatory requirements. Not all of our residents are able to participate in programs, therefore the Department ensures both active and passive residents realize benefits from the numerous programs offered. of programming is designed based on feedback from the [NAME] County Nursing Home Resident Council and also through federal regulatory requirements. Not all of our residents are able to participate in programs, therefore the Department ensures both active and passive residents realize benefits from the numerous programs offered .

Based on interview and record review, it was determined that the facility failed to complete a Preadmission Screening and Resident Review (PASARR) for an individual who required greater than 30 days of nursing services (Resident identifier is #26) and failed to follow up with a PASARR Level II to determine if additional services were required for 3 of 4 residents reviewed for PASARR in a final survey sample of 25 residents (Resident Identifiers #9 and #33). Findings include: Review on 2/8/24 of the facility's policy titled Admission Criteria revised March 2019 revealed, . 9. All new admission and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority . Resident #26 Review on 2/7/24 of Resident #26's medical diagnoses in the medical record revealed that Resident #26 was admitted to the facility with a diagnosis of bipolar disease. Review on 2/7/24 of Resident #26's PASARR Level I screen form dated 10/23/18 revealed under Section 2A: Suspected Diagnosis of Mental Illness was checked yes, documented bipolar and inpatient hospital psych unit or facility and medication management were both checked as occurring in the past 2 years. Further review of this form revealed hospital discharge was checked and signed by a physician on 10/23/18 certifying that Resident #26 would require less than 30 days of nursing facility services. Below this read Note: If the [nursing facility name omitted] stay is 30 days or longer, a new [PASARR] screen and resident review must be performed within 40 calendar days of admission. Interview on 2/8/24 at 8:06 a.m. with Staff M (Social Worker) confirmed that Resident #26 did not have another PASARR completed within 40 days of admission and it should have been done. 47129 Resident #9 Review on 2/7/24 of Resident #9''s electronic medical record revealed that Resident #9 was admitted to the facility on [DATE] and had a diagnosis of paranoid schizophrenia. Review on 2/7/24 of Resident #9's Level I PASARR form (completed on 10/13/22 and signed by a medical professional) revealed: Section 2A: Suspected Diagnosis: Schizophrenia/schizoaffective and Psychiatric Treatment History (Within Past 2 Years): Associated with a mental health agency were checked. Section 2B: Interpersonal Function: Significant communication difficulties was checked. Section 2C: Concentration/Task Limitation: Other: Immobility limits completion, was checked. Section 8: Level I Screening Summary: Length of stay requesting for Level II: Long Term Care, was checked. Resident #33 Review on 2/7/24 of Resident #33's electronic medical record revealed that Resident #33 admitted to the facility on [DATE] with a diagnosis of major depressive disorder. Review on 2/7/24 of Resident #33's Level I PASARR form (completed on 9/13/19 and signed by a medical professional) revealed: Section 2A: Suspected Diagnosis: Major depression and Medication management were checked. Section 2B: Interpersonal Function: Easily upset/anxious and Social isolation were checked Section 2C: Concentration/Task Limitation: Serious loss of interest in tasks and hobbies was checked. Section 2D: Adaptation to Changes: Appetite disturbance and Irritability were checked Section 8: Level I Screening Summary: Length of stay requesting for Level II: Long Term Care was checked. Interview on 2/8/24 at 8:06 a.m. with Staff M revealed that Resident #9 and Resident #33 never had a Level II PASARR as required from both of their PASSAR Level I screening. Interview on 2/8/24 at 8:10 a.m. with Staff A (Director of Nursing) confirmed the above.

Based on interview and record review, it was determined that the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) prior to the last covered day of Medicare services for 2 out of 3 residents reviewed for advanced beneficiary protection notification (Resident Identifiers #58, and #69). Findings include: Resident #58 Review on 2/7/24 of the Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #58 was discharged from Medicare Part A Services on 8/23/23 and remained at the facility. Review on 2/7/24 of Resident #58's Skilled Nursing Facility (SNF) Beneficiary Notification Review form, completed by the facility, revealed that Resident #58 was admitted to Medicare Part A services on 7/3/23 and the last covered day was 8/23/23 and that the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Further review of this form under Question 2 Was a NOMNC form CMS-10123 provided to the resident? was checked No. Resident #69 Review on 2/7/24 of the Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #69 was discharged from Medicare Part A Services on 1/9/2024 and remained at the facility. Review on 2/7/24 of Resident #69's SNF Beneficiary Notification Review form, completed by the facility, revealed that Resident #69 was admitted to Medicare Part A services on 11/3/23 and the last covered day was 1/9/24 and that the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Further review of this form under Question 2 Was a NOMNC form CMS-10123 provided to the resident? was checked No. Interview on 2/7/24 at 10:00 a.m. with Staff A (Director of Nursing) revealed that the NOMNC form CMS-10123 was not provided to Residents #58 or #69. Interview on 2/7/24 at 11:40 a.m. with Staff L (Social Services Assistant) confirmed the above findings. Interview further revealed that the NOMNC form CMS-10123 was not being completed nor provided to residents. Review on 2/7/24 of form instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 revealed A Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plan') must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing . services .The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Review on 2/7/24 of the facility's policy titled Transfer or Discharge, Facility-Initiated, dated October 2022, revealed .Non-Payment as a Basis for Discharge .4. In situations where a resident's Medicare coverage may be ending, the facility will comply with the requirements . F582 .

Based on observation interview, and record review, it was determined that the facility failed to post the nurse staffing information in a prominent place readily accessible to visitors. The facility also failed to ensure that the nurse staffing information was accurate and had the actual hours worked by licensed and unlicensed nursing staff per shift for 31 out of 31 days of nurse staffing postings. Findings include: Observation and review on 2/7/24 at approximately 1:00 p.m. with Staff A (Director of Nursing) revealed that the nurse staffing posting was a half size sheet of paper posted on a bulletin board with multiple other postings on the first floor approximately a few feet from an elevator. Observation also revealed that the nurse staffing posting was dated 2/6/24 to 2/7/24 with a resident census of 100 residents and no posting of actual hours worked by licensed and unlicensed nursing staff per shift. Interview on 2/7/24 at approximately 1:00 p.m. with Staff A confirmed the above findings. Staff A stated that the above observation was the only nurse staffing posting in the facility. Staff A also stated that visitors use different entrances and may utilize a different elevator to go to the second floor units, which would not have access to the nurse staffing information. Further interview with Staff A confirmed that the resident census for 2/6/24 to 2/7/24 at the beginning of the shift was 99 residents and not 100 residents. Interview on 2/7/24 at approximately 1:00 p.m. Staff B (Scheduler) revealed that he/she posts the nurse staffing information daily at approximately 2:30 p.m. for the upcoming shifts. Staff B stated that he/she does not update the nurse staffing information at the beginning of each shift. Review on 2/7/24 of the nurse staffing postings from 1/6/24 to 2/6/24 revealed that there were no postings of actual hours worked by licensed and unlicensed nursing staff per shift. Interview on 2/7/24 at approximately 2:24 p.m. with Staff A confirmed the above findings.

Based on observation, record review and interview the facility failed to ensure that 1 resident in the survey sample of 24 residents received adequate supervision to prevent an accident with injuries of fractured ribs and a hematoma to the back of the head. (Resident identifier is #11.) Findings include: Resident #11. Review, of the 8/11/10 Resident Incident Report during the 8/31/10 to 9/3/10 recertification survey, revealed that this resident experienced an fall on 8/11/10 at 8:55 a.m. when the resident's rolling walker tipped over on the sidewalk out in the garden while the resident was being transported by Staff D, LNA. The resident fell back and hit the back of the head. This resident was taken to the emergency room for evaluation on 8/11/10. Review of the 8/11/10 hospital Diagnostic Imaging Report revealed that the resident's diagnostic report states, "Minimally displaced fractures involve the left fourth through seventh ribs laterally". Review of an 8/11/10, 9:00 hand written statement by Staff D revealed that Staff D wrote, "I was pushing (resident's name omitted) on her rolling walker out in the yard out by Meadow. We hit a very uneven bit of sidewalk and she fell backward and hit her head." Review of an 8/11/10 statement written by Staff B, RN DON, revealed that Staff B wrote, "... According to the LNA, (name omitted), she was pushing (resident name omitted) who was sitting on her rolling walker outside so she could go to her physician appointment. As (LNA name omitted) was pushing the rolling walker it hit an uneven surface outside in the garden area and the rolling walker tipped sideways. (LNA name omitted) was unable to stop the fall and (resident name omitted) fell sideways into the flower bed." "... I counseled (LNA name omitted) re: proper transportation of a resident. ..." Review of an 8/12/10 Report of Fall written by Staff B revealed that Staff B wrote, "... An LNA was transporting (resident name omitted) to our own vehicle for the physician's visit. (Resident name omitted) was sitting on the seat of the rolling walker and being wheeled outside when the rolling walker hit the lip of an uneven surface which caused the rolling walker to go backward. The LNA was unable to stop the fall and the resident went backwards. The LNA immediately notified the nurse who did a full body assessment. The nurse found that (resident name omitted) sustained a hematoma to the occiput area of her skull and ice was applied. (Resident name omitted) also complained of pain in the left rib area and pain in the left hip area. ..." Review of a Memo dated 8/12/10 sent from Staff B to All Nursing Staff regarding Safe Work Practices revealed that Staff B instructed staff, "Whenever a resident is being transported for any reason, You MUST place the resident in a wheel chair." On 9/2/10 Staff B was interviewed in the late p.m. and Staff B stated that Staff D was facing this resident and pushing this resident backwards in the resident's rolling walker while this resident was seated on her rolling walker seat. Staff B stated during the 9/2/10 interview that Staff D was counseled at the time of the 8/11/10 investigation interview on the proper transportation of a resident in a wheel chair rather than in a rolling walker. On 9/3/10 an observation of the piece of uneven sidewalk in the garden was made with Staff B present. Staff B stated to the surveyor during the observation that the sidewalk had been repaired where the transition in the side walk was not smooth. The observation showed that the ground surface between the two sections of the sidewalk where the resident's rolling walker tipped over were not level and that the transition area had been repaired with concrete.

Based on observation, record review and interview the facility failed to ensure that 1 of 24 sampled residents was free from neglect during care when an accident occurred and the resident sustained [REDACTED]. (Resident identifier is #11.) Findings include: Resident #11. Review, of the 8/11/10 Resident Incident Report during the 8/31/10 to 9/3/10 recertification survey, revealed that this resident experienced a fall on 8/11/10 at 8:55 a.m. when the resident's rolling walker tipped over on the sidewalk out in the garden while the resident was being transported by Staff D, LNA. The resident fell back and hit the back of the head. This resident was taken to the emergency room for evaluation on 8/11/10. Review of the 8/11/10 hospital Diagnostic Imaging Report revealed that the resident's diagnostic report states, "Minimally displaced fractures involve the left fourth through seventh ribs laterally". Review of an 8/11/10, 9:00 hand written statement by Staff D revealed that Staff D wrote, "I was pushing (resident's name omitted) on her rolling walker out in the yard out by Meadow. We hit a very uneven bit of sidewalk and she fell backward and hit her head." Review of an 8/11/10 statement written by Staff B, RN DON, revealed that Staff B wrote, "... According to the LNA, (name omitted), she was pushing (resident name omitted) who was sitting on her rolling walker outside so she could go to her physician appointment. As (LNA name omitted) was pushing the rolling walker it hit an uneven surface outside in the garden area and the rolling walker tipped sideways. (LNA name omitted) was unable to stop the fall and (resident name omitted) fell sideways into the flower bed." "... I counseled (LNA name omitted) re: proper transportation of a resident. ..." Review of an 8/12/10 Report of Fall written by Staff B revealed that Staff B wrote, "... An LNA was transporting (resident name omitted) to our own vehicle for the physician's visit. (Resident name omitted) was sitting on the seat of the rolling walker and being wheeled outside when the rolling walker hit the lip of an uneven surface which caused the rolling walker to go backward. The LNA was unable to stop the fall and the resident went backwards. The LNA immediately notified the nurse who did a full body assessment. The nurse found that (resident name omitted) sustained a hematoma to the occiput area of her skull and ice was applied. (Resident name omitted) also complained of pain in the left rib area and pain in the left hip area. ..." Review of a Memo dated 8/12/10 sent from Staff B to All Nursing Staff regarding Safe Work Practices revealed that Staff B instructed staff, "Whenever a resident is being transported for any reason, You MUST place the resident in a wheel chair." On 9/2/10 Staff B was interviewed in the late p.m. and Staff B stated that Staff D was facing this resident and pushing this resident backwards in the resident's rolling walker while this resident was seated on her rolling walker seat. Staff B stated during the 9/2/10 interview that Staff D was counseled at the time of the 8/11/10 investigation interview on the proper transportation of a resident in a wheel chair rather than in a rolling walker. On 9/3/10 an observation of the piece of uneven sidewalk in the garden was made with Staff B present. Staff B stated to the surveyor during the observation that the sidewalk had been repaired where the transition in the side walk was not smooth. The observation showed that the ground surface between the two sections of the sidewalk where the resident's rolling walker tipped over were not level and that the transition area had been repaired with concrete. This resident was not free from neglect with injuries on 8/11/10 when Staff D used a walking assistive device as a riding transportation device when taking this resident from the building through the garden to a vehicle in the parking lot.