Every finding on record at Grandvue Medical Care Facility

Based on observation and interview, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings Include:On 4/20/2026 at 11:42 AM observed Certified Nursing Assistant (CNA) P use a probe thermometer to take temperatures of a food item they were reheating in the microwave. The probe thermometer was observed to not have a protective sheath covering on it as it was being pulled from storage in the drawer. CNA P wiped the thermometer with an alcohol wipe prior to inserting it in the food product. Prior to placing the thermometer back into the drawer, CNA P wiped the thermometer again but did not place a protective sheath onto the cleaned thermometer prior to placing it in the drawer. On 4/20/2026 at 3:18 PM observed four plastic wine goblets being stored in the cabinet below the Courtyard ice machine. One of the goblets was observed directly touching the open drain line pipe where the ice machine drain line discharges into the floor drain. On 4/21/2026 10:25 AM the Certified Dietary Manager (CDM) Q stated that those goblets are not used for food service and that they were not sure why those would ever have been stored in that cabinet under the ice machine.According to the 2022 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. On 4/20/2026 at 12:11 PM observed the copper pipe drain line that comes from the Lemon Tree dining room ice machine discharging into a drain line in the employee kitchen downstairs. The end of the drain line was observed corroded for approximately 5 inches and the tip hanging above the drain was coated with black mildew and mineral build up. On 4/20/2026 at 3:18 PM observed the ice machine drain line in the Courtyard dining room indirectly connected to the floor drain by having the drain line inserted down into the floor drain pipe.According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. P

Based on interview and record review, the facility failed to protect residents' rights to be free from verbal and mental abuse by a resident for two Residents (#4 & #62) of four residents reviewed for resident-to-resident abuse.Findings include:Resident #62 (R62)Review of the Electronic Medical Record (EMR) revealed R62 was originally admitted to the facility on [DATE], with diagnosis including generalized anxiety disorder, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 12/15, revealing that R62 had moderate impairments with thinking and memory.During an initial interview on 4/20/26 at 10:45 AM R62 stated residents had been wandering into her room. R62 stated recently Resident #9 (R9) had come into her room swearing and yelling at her to get out. R62 stated R9 had even called her names using swear words. R62 did not like R9 cursing at her or calling her names using swear words or that R9 was even in her room. R62 stated she felt nervous around R9, especially when R9 was wandering around the unit yelling at staff and residents. R62 felt no one on the unit was safe during R9's outburst episodes.Resident #4 (R4)Review of the EMR revealed R4 was admitted to the facility on [DATE] with diagnosis including chronic pain, major depressive disorder, and surgical amputation of left leg. The MDS indicated a BIMS score of 12/15 on 2/3/26, meaning R4 had moderate impairments with thinking and memory.During an initial interview on 4/20/26 at 11:21 AM, R4 stated R9 came into R4's room last week and stated, get the (expletive) out of my room. R4 indicated he asked R9 to leave the room as it was not R9's room but his. R9 then pushed R4's wheelchair across the room and raised his fist at R4 while swearing more, before leaving R4's room. R4 stated he is now uneasy around R9 and afraid of what R9 may do.R9Review of the EMR revealed R9 was admitted to the facility on [DATE] with diagnosis including vascular dementia unspecified severity with agitation, major depressive disorder, anxiety disorder, attention and concentration deficit and cognitive communication deficit. MDS indicated a BIMS score of 9/15, revealing R9 had moderate impairments with thinking and memory.On 4/20/26 at 11:36 AM, an interview was conducted with R9's Resident Representative (RR) S, who stated she was aware R9 had been going into other residents' rooms including the episode last week where he was yelling at other residents.Review of R9's EMR revealed the following progress notes:4/14/26 at 7:08 PM: Since nearly the start of shift, resident stated that if Satan was here, I would kill him.4/14/26 at 8:30 PM: Resident propelling self in w/c (wheelchair) past room. and stood in doorway with R62 standing in her room by her bed as R9 was in alcove of rooms yelling at R62 F**k you, f**k you, f**k you! and calling her (R62) a f**king b**ch as well as flipping her off because he wanted to use her bathroom. He told her he can use whatever bathroom he wanted around here because he owns the place.4/14/26 9:00 PM: Resident insisting he needed to go inside so he wanted to get out of bed. Once in w/c safely, he came into hallway where Certified Nursing Assistant (CNA) was assisting residents in rooms. He was continuing to invade other resident rooms, stating that he owned this place and was pushing past stop signs on doors, and opening doors that were closed trying to get into their rooms. He was adamant that nobody else had permission to live here because it was his house and that he needed to see the lease and their signatures of every person that had a room here.4/15/26 4:29 PM: Staff reported resident entering female room.kicking the door.4/16/26 8:05 AM: CC (Care Coordinator) was given a report by day nurse that resident had been a 1:1 (high-intensity intervention where a dedicated staff member continuously monitors a single patient) ed last night. Called the night nurse that worked the neighborhood to ask what happened. RN stated that resident was going from room to room screaming at other residents that they needed to leave his home because they were not paying the lease.4/16/26 9:58 PM: was yelling in hallway and pounding on the wall in room.4/17/28 9:20 PM: up going into others' rooms (females) drinking lots of coffee and trying to get behind the nurses' station, watching nurses pass meds. Was given snacks.still wandered around the halls and went into others' roomsOn 4/21/26 at 11:41 AM R9 was observed sitting in his wheelchair raising his fist at random staff and residents as they passed by his room.On 4/22/2026 at 10:41 AM an interview was conducted with Social Worker (SW) T she stated she was aware of the incidents where R9 had gone into resident rooms and yelled at the residents. She stated she has not followed up with any of the residents regarding these incidents or how they felt about them. SW T had started saying I think it's because we are.tapering off the statement, then said I am not going to make excuses, I haven't done it.A follow up interview was conducted on 4/22/26 at 10:50 AM with R4 who stated R9 had banged on his closed door a few times, and R9 looks at R4 meanly and raises his fist to R4 when they pass in the hallway. R4 stated he is quite annoyed with R9's actions that keep R4 on his toes. R4 stated he is plenty capable of taking care of R9 but is trying not to utilize his former [NAME] arts or military training in order to make the tormenting from R9 go away.A phone interview was conducted with CNA O on 4/22/25 at 12:44 PM who stated she was working the night of 4/14/26 and was aware of R9's behaviors that night unfortunately. She stated R9 was more difficult to redirect than usual. CNA O stated staff had attempted interventions but R9 continued to yell at residents and go into rooms. She also stated she felt the resident across the hallway interacts with R9 in a manner that intensifies his behaviors when he starts to act out. CNA O stated they have told administration the men in that area should be separated to help control the issues with R9.Review of the facility's policy named Freedom from Abuse, Neglect and Exploitation last reviewed/revised on 1/28/26 indicated in part. each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to: facility staff, other residents.Procedure.4. Verbal Abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.7. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation.The Facility will:Not use verbal, mental, sexual or physical abuse, corporal punishment, exploitation, misappropriation of resident property, or involuntary seclusion.6. The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents:b. Observe resident behavior and their reaction to other residents, roommates, tablemates. Place residents in accommodations and environments that keep them calm. f. Take appropriate actions when abuse, neglect or exploitation is suspected. 7. Identification of Abuse, Neglect, and Exploitation e. Verbal abuse of a resident overheard.

Based on observation, interview, and record review, the facility failed to notify the State Agency (SA) of verbal and physical resident-to-resident altercations for three Residents (#4, #9, & #10) of four residents reviewed for abuse.Findings include: Resident #10 (R10) Review of R10's Electronic Medical Record (EMR) revealed initial admission to the facility on 3/26/25 with diagnoses including dementia with behavioral disturbance, delirium, restlessness and agitation, and psychotic disorder. Review of Section C: Cognitive Patterns in R10's most recent Minimum Data Set (MDS) assessment, dated 3/20/26, revealed her cognitive skills for daily decision making as, severely impaired-never/rarely made decisions. Further review of MDS Section E: Behaviors revealed R10 exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) and wandering that occurred between four to six days per week. On 4/20/2026 at 12:40 PM, the Nursing Home Administrator (NHA) was observed holding hands with R10 and walking up and down the hall. R10 was previously observed walking into the dining room during the lunch time meal where she reached out and contacted the back of a seated resident's head before redirection by staff. Review of R10's EMR revealed the following Physical Aggression Initiated reports in the previous three months: 2/8/26: [R10] walked into the Hydrangea Room and took cup from [resident name] who was sitting at one of the tables. [Resident name] told her it was her cup and they had a few words spoken in an angry tone. [R10] then threw her arm out and slapped [resident name] on the left side of her face with her open hand. 2/15/26: .[R10] entering [resident name's] personal space and when redirected, [R10] becoming agitated with staff member and calling that staff member an [expletive] and ended up taking her open hand and making contact to [resident name] in [sic] side of head. 2/18/26: [R10] was in dining room wandering when she approached [resident name], swatted her on the side of the head unprovoked. 3/3/26: [R10] observed ambulating on [hallway] near room [ROOM NUMBER]. [Resident name] walking past [R10]. [R10] taking open hand and making contact to [resident name's] shoulder. 4/2/26: CNA [Certified Nursing Assistant] informing this nurse that [R10] was in LR [living room] and picked up a rubber nerf ball, told a [resident name] to shut up and threw the ball in [resident name's] direction. Tbe [sic] ball did make contact with [resident name's] face. 4/3/26: [R10] was touching [resident name's] face, [resident name] swatted this [R10] away and said stop it then [R10] slapped [resident name] in the back of the head/neck. On 4/22/2026 at 12:32 PM, an interview was conducted with the Director of Nursing (DON) who verified she is part of the administration team, along with the NHA, who is made aware of all resident-to-resident interactions. The DON stated if incidents occur in common areas during off hours, security camera footage can be reviewed off facility premises. When asked why R10's previous six resident-to-resident incidents were not reported to the SA as instances of physical and/or verbal abuse, the DON stated it was because in each instance there was not an outcome, either mental or physical, or it could not be substantiated as abuse as determined by the administration team who reviewed the incident. Review of a witness statement written on 2/8/26 by CNA U surrounding the same dated incident read, in part: Describe events leading to incident/fall – [R10] can in + [and] randomly went + took [resident's] drink, which upset [resident]. [R10] gave it back but they had words w/ [with] each other + then [R10] smacked {resident] in the face. Your suggestions to prevent reoccurrence? I tried to calmly redirect [R10], but she wanted nothing to do with coming w/ me. She did walk w/ me after she slapped [resident]. I am not sure how to stop [R10] from randomly doing these things. Review of a witness statement written on 2/15/26 by CNA V surrounding the same dated incident read, in part: [R10] was aggressively reaching toward another resident. I touched her elbow in an effort to gently redirect. [R10] became agitated with me calling me an expletive and then proceeded to strike another resident on the right side of the head. Review of a witness statement written on 2/18/26 by CNA W surrounding the same dated incident read, in part: Describe events leading to incident/fall – [R10] walked up to another resident and cuffed them upside their head completely unprovoked. On 4/22/2026 at 11:53 AM, an interview was conducted with Licensed Practical Nurse (LPN) X who confirmed R10 had a long history of resident-to-resident interactions. LPN X stated, [R10] flips on a switch, there's no indication she will get physical. she can hit people in the side of the head for no reason. LPN X stated R10 has not caused any major injuries and although has advanced dementia and likely does not know what she is doing in most cases, she is intending harm during these resident-to-resident altercations. LPN X verified all resident-to-resident interactions are reported to administration as incidents of abuse. On 4/22/2026 at 12:22 PM, an interview was conducted with CNA Y regarding R10's behaviors. CNA Y stated there is no rhyme or reason for the outbursts and they largely remain unpredictable. CNA Y stated, [R10] can just walk up to somebody and cuff them in the back of the head. When asked the intentions of R10, CNA Y stated, It's not a love tap. she's trying to hurt them. Resident #9 (R9) Review of R9's EMR revealed initial admission to the facility on 9/4/24 with diagnoses including vascular dementia, unspecified severity with agitation, major depressive disorder, social exclusion and rejection, and attention and concentration deficit. Review of Section C: Cognitive Patterns in R9's most recent Minimum Data Set (MDS) assessment, dated 3/11/26, revealed his cognitive skills for daily decision making as, moderately impaired thinking and memory. Further review of MDS Section E: Behaviors revealed R9 exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) resident rejected evaluation or care that is necessary to achieve the resident's goals for health and wellbeing, and wandering that occurred between one to three days per week. Review of R9's EMR revealed the following Physical Aggression Initiated report in the previous three months: 3/20/26 . It happened at nurse station on Valleyview A Hall area. This resident was using the resident I Pad at nurse station and it happened that R9 was there, I am not sure what triggered the incident because it was happening behind me. When this nurse turned notice both resident were hitting each other on their hands. When i asked R9 if he hit this resident he said yes. When this nurse attempted to prevent R9 from follow this female resident for more aggression, he hit this nurse in the back with his can (sic) Review of R9's EMR revealed he has had 47 Behavioral/Mood Note documented in the last three months, with behaviors including, verbal and physical aggression towards staff and residents. A Behavioral/Mood Note on 4/14/26 stated Resident propelling self in w/c past rooms , and stood in doorway with resident . standing in her room by her bed as resident was in alcove of rooms yelling at her, (expletive) you, (expletive) you, (expletive) you! and calling her a (expletive, expletive) as well as flipping her off because he wanted to use her bathroom. He told her he can use whatever bathroom he wanted around here because he owns the place. On 4/16/26 a Nursing Note stated .report by day nurse that resident had been a 1:1 (a staff member continuously monitors a high-risk patient) last night. Called the night nurse that worked the neighborhood to ask what happened. RN stated that resident was going from room to room screaming at other residents that they needed to leave his home because they were not paying the lease. On 4/16/26 Resident #4 (R4) was verbally assaulted and physically threatened by R9. On 4/22/26 at 11:30 AM an interview was conducted with the DON, who stated she was not aware of the incidents on 4/14/26 through 4/16/26 as they were not documented in Risk Management. Therefore, she could not properly have investigated them or reported them. Review of the facility policy titled, Freedom from Abuse, Neglect and Exploitation, reviewed 1/28/26, read, in part: .Residents must not be subject to abuse by anyone, including, but not limited to: facility staff, other residents. Physical Abuse includes, but not limited to hitting, slapping, pinching and kicking. Verbal Abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility will: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation or resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protected services where state law provides for jurisdiction in long-term care facilities) in accordance with State law.

Based on interview and record review, the facility failed to investigate resident-to-resident abuse for three Residents (#4, #9, & #62) of four residents reviewed for investigation of abuse.Findings include:During an initial interview on 4/20/26 at 10:45 AM Resident #62 (R62) stated residents had been wandering into her room. R62 stated recently Resident #9 (R9) had come into her room swearing and yelling at her to get out. R62 stated R9 had even called her a (expletive, expletive). R62 did not like that R9 had called her that or been in her room.While conducting an initial interview with Resident #4 (R4) on 4/20/26 at 11:21 AM, R4 stated R9 came into their room last week and stated, get the (expletive) out of my room. R4 indicated he asked R9 to leave the room as it was not R9's room but his. R9 then pushed R4's wheelchair across the room and raised his fist at R4 swearing at R4 some more, before R9 left the room. R4 stated he is now uneasy around R9 and afraid of what R9 may do.A review of R4's Electronic Medical Record (EMR) indicated a progress note on 4/14/26 that read Resident insisting he needed to go inside so he wanted to get up out of bed. Once in w/c (wheelchair) safely, he came into hallway where CNA (Certified Nursing Assistant) was assisting residents in rooms of 108. He was continuing to invade other resident rooms, stating that he owned this place, and was pushing past stop signs on doors, and opening doors that were closed trying to get into their rooms. He was adamant that nobody else had permission to live here because it was his house and that he needed to see the lease and their signatures of every person that had a room here. On 4/21/26 at 10:02 AM, the Director of Nursing (DON) was asked to provide all accidents and incidents for R4, R9, R62 for the past three months. When the paperwork for accidents and incidents was provided, the 4/16/26 date was not included. When asked if this was a complete list and all paperwork of the accident and incidents for R4, R9, and R62, the DON stated that it was.On 4/22/26 at 10:35 AM, and interview was conducted with Registered Nurse (RN) K regarding the process for resident-to-resident incidents. RN K stated that for any resident-to-resident incident in which a resident goes into another resident's room and yells at another resident, the nurse should complete a resident-to-resident risk assessment in the facility's risk management documentation to start an investigation.On 4/22/2026 10:46 AM, a request was made to the DON for risk management documentation for resident-to-resident incidents for R4 from 4/14/26 to 4/16/26. At approximately 11:30 AM, the DON stated there were none. The DON stated she had initiated risk management for verbal aggression at that time to begin the investigation process.Review of the facility's policy titled Freedom from Abuse, Neglect and Exploitation last revised/reviewed on 1/28/26 indicated in part. 8. Investigation of Alleged Abuse, Neglect and Exploitation. When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted.

Based on interview and record review, the facility failed to ensure the Long-Term Care Ombudsman was notified of a resident's discharge from the facility and ensure pertinent medical records were sent to the receiving provider upon transfer for two Residents (#3 & #6) of two residents reviewed for discharge practices. Findings include: Resident #3 (R3)Review of the Electronic Medical Record (EMR) for R3 indicated a transfer to the emergency department occurred on 3/12/26. Review of the documentation provided to the Long-Term Care Ombudsman in March, indicated they were not notified of the resident's discharge from the facility.Further review of R3's EMR revealed the facility failed to ensure medical documentation was communicated to the receiving hospital.Resident #6 (R6)Review of the EMR for R6 indicated a transfer to the emergency department occurred on 1/1/26. Review of the documentation in R6's EMR revealed the facility did not send medical documentation to the receiving provider.On 4/21/26 at 4:20 PM, an interview was conducted with the Nursing Home Administrator (NHA) who confirmed R3 was omitted from the March transfer list sent to the Long Term Ombudsman.On 4/21/26 at 4:25 PM, an interview was conducted with the Director of Nursing (DON) who verified she could not show proper documentation was sent to the local hospital for R3 and R6 during their transfers out of the facility.Review of policy titled, Transfer and Discharge including Against Medical Advice, dated 8/6/25, read in part Policy: It is the policy of Grandvue Medical Care Facility (GMCF) to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered.7. Emergency Transfers/Discharges - initiated by GMCF for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified).d. Complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents:Resident status, including baseline and current mental, behavioral and functional status and recent vital signs;Current diagnosis, allergies and reasons for transfer/discharge;Contact information of the practitioner responsible for the care of the resident;Resident representative information including contact information;Current medications (including when last received), treatments, most recent relevant lab and/or radiological findings and recent immunizations;Special instructions or precautions for ongoing care to include precautions such as isolation or contact;Special risks such as risk for falls, elopement, bleeding or pressure injury and/or aspiration precautions;Comprehensive care plan goals, andAny other documentation, as applicable, to ensure a safe and effective transition of care. A copy of any Advance Directive, Durable Power of Attorney, DNR or Withholding or Withdrawing of Life-Sustaining Treatment forms should be sent with the resident.j. Social Work Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list.

Based on interview and record review, the facility failed to provide hospice documentation for one Resident (#8) of one resident reviewed for hospice care services. This deficient practice resulted in the potential for uncoordinated care between the provider and the hospice care service. Findings include: Review of R8's Electronic Medical Record (EMR) revealed admission to the facility on 7/17/25 with active diagnoses that included frontotemporal neurocognitive disorder (a progressive brain disorder that primarily affects the frontal and temporal lobes). R8 was unable to complete the 4/28/26 Brief Interview for Mental Status (BIMS) score on the Minimum Data Set (MDS) assessment but was noted to have severely impaired cognition. The MDS assessment also documented R8's participation in hospice care.Review of R8's Physician Orders read, in part, ADMIT to [Hospice Name] .Active 10/13/25. On 4/21/26 at approximately 11:33 AM, review of R8's EMR revealed a Hospice Care Plan created on 7/21/25. Review of the MISC (miscellaneous) tab in the EMR found no Hospice Health Aide visit notes pertaining to the care and services provided to R8 by the Hospice Agency during January 2026 through April 2026.Review of the [Hospice Agency] binder, located in the nursing room, for R8 revealed no further documentation of Hospice Health Aide visit notes from January 2026 through April 2026.During an interview on 4/22/26 at 10:28 AM, Licensed Practical Nurse (LPN) D was asked about the [Hospice Agency] care provided to R8. LPN D stated the hospice agency would sometimes communicate with the facility staff but was unable to tell this Surveyor where the documentation was located if it wasn't in R8's EMR or Hospice Binder. During an interview on 4/22/26 at 11:16 AM with Nursing Care Coordinator/Staff Z regarding R8's Hospice Health Aide documentation, Staff Z stated they have not been given any documentation from that Hospice Agency in quite some time.During an interview with the Director of Nursing (DON) on 4/22/26 at 12:00 PM regarding R8's hospice documentation, the DON confirmed it was missing from R8's EMR.Review of the Hospice Care policy, provided on 4/1/26 at approximately 11:30 a.m., revealed the following, in part: .The facility will initiate and maintain a medical record on each hospice resident. Hospice staff will document progress information on hospice forms, leaving a copy of such notes with the facility. The facility will retain these notes as a part of the resident's permanent record .Review of the Services Agreement Contract with [Hospice Agency Name] and [Facility Name] read, in part, .Facility and Hospice shall each designate in writing a representative to communicate with each other.to ensure that the needs of Hospice patients are addressed and met twenty-four hours a day. The Hospice and Facility representatives shall document and keep written records of all such communications and shall document that the services provided are furnished in accordance with the terms of this Agreement.

Based on observation, interview, and record review the facility failed to store respiratory equipment in a sanitary manner for two Residents (#35 & #47) of two residents reviewed for respiratory care.Findings include:Resident #35 (R35)On 4/20/26 at 11:21 AM, an observation was made of R35's nebulizer mask intact (put together) and sitting on the nightstand not stored in a bag. R35 was asked when the last time he used his nebulizer mask to which he replied, I used it yesterday. R35's nebulizer medication cup was noted to have some condensation remaining inside.During an observation on 4/21/26 at 10:15 AM, R35's nebulizer mask was sitting on their nightstand intact, open to air and not stored in a bag. On 4/22/26 at 10:04 AM, R35's nebulizer mask was observed intact and sitting on his night stand not stored properly in a bag.Resident #47 (R47)On 4/20/26 at 11:04 AM, an observation was made of R47's room. R47 was absent from her room, and her nasal cannula tubing was observed lying on the floor. The floor where the nasal cannula was lying had visible dirt and crumbs. R47's nebulizer mask was observed intact and not stored in a bag.R47's nebulizer mask on 4/22/26 at 9:05 AM, was observed intact and not stored properly in a bag. R47's oxygen concentrator was running, and her nasal cannula was lying on the floor.On 4/22/26 at 9:15 AM, an interview was conducted with Registered Nurse (RN) G / Infection Preventionist regarding the storage for respiratory equipment. RN G stated, Respiratory equipment should be stored in a bag when not in use and nebulizer masks are to be rinsed and dried after use.On 4/22/26 at 9:25 AM, an interview was conducted with RN C who was asked about respiratory equipment storage and replied, It is to be stored in a bag when not in use and if the nasal cannula is on the floor that should be thrown away.Review of policy titled, Oxygen, Administration of, dated 8/6/25, read in part, Policy: It is the policy of Grandvue Medical Care Facility (GMCF) that supplemental oxygen will be provided for residents by order of a physician.Procedure.Bags for storage of nasal cannula when not in use.

This deficient practice pertains to Intake 2711152.Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from verbal abuse by a staff member for one Resident (#1) of three residents reviewed for abuse and neglect. This deficient practice resulted in psychosocial harm and mental anguish for Resident #1 based on the reasonable personal concept.Findings Include:Resident #1 (R1)Review of the Electronic Medical Record (EMR) revealed R1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including dementia, aphasia (a language disorder that impairs a person's ability to communicate, affecting speaking and understanding), overactive bladder, urinary incontinence, and need for assistance for personal care. Review of Section C: Cognitive Patterns in R1's most recent Minimum Data Set (MDS) assessment, dated 12/15/25, revealed his, cognitive skills for daily decision making were severely impaired.Review of an Incident Summary to the State Agency (SA) written by the Director of Nursing (DON) on 1/7/26 at 5:33 PM read, in part: On December 31, 2025, a staff member, social worker [Social Worker (SW) A], overheard another staff member state, you're being a complete [expletive] to resident [R1]. [SW A] approached the two CNAs (certified nursing assistants) who were in the room with the resident. [CNA B] denied making the statement and indicated [CNA/Perpetrator E] had made the statement. Type of Alleged Incident: Abuse. Was the Alleged Incident Verified (Substantiated): Yes . Conclusion: [CNA/Perpetrator E] did not follow the care plan and did not employ sound dementia approach.She committed mental abuse, by making verbal, derogatory remarks to [R1].On 1/12/26 at 11:55 AM, an interview was conducted with SW A who verified she was entering her office on the morning of 12/31/25 when she heard somebody down the hall state, You're being a complete [expletive]. SW A stated she entered R1's room where she found CNA B bagging trash and witnessed CNA/Perpetrator E quickly leave the room. SW A stated she informed CNA B what was overheard. CNA B then indicated CNA/Perpetrator E had made the statement toward R1.On 1/21/26 at 11:26 AM, R1 was observed at a seating area at the end of the corridor. An interview was attempted but R1 was unable to answer questions related to the event on 12/31/25. On 1/21/26 at 5:03 PM, a telephone interview was conducted with CNA B who verified she had been assisting R1 with cares on the morning of 12/31/25. CNA B stated R1 had been known to be combative with cares at times, so it usually required the assistance of two CNAs for safety and deescalation. CNA B recalled R1 was in a good mood at that time and was amenable for assistance with a brief change with the help of one aide. CNA B stated R1 was lying in bed, and she had almost completed fastening a clean brief but could not roll R1 to get both sides of the brief attached. CNA B stated she summoned CNA/Perpetrator E for assistance but believed the loud tone of her voice and speed at which she was working may have upset R1. CNA B said they were attempting to leave the room to allow R1 to calm down, but R1 independently stood up from bed, ripped off his brief, and began walking toward the door to the hallway. CNA B stated she tried to redirect R1 by closing the curtain so he did not walk into the hallway unclothed during which he had nudged CNA B and laid hands on CNA/Perpetrator E. CNA B recalled R1 eventually decided to lay back down and said a rude remark under his breath which prompted CNA/Perpetrator E to state, You're being a complete [expletive].On 1/21/26 at 11:03 AM, a telephone interview was conducted with CNA/Perpetrator E who verified she assisted CNA B with R1's cares on the morning of 12/31/25. CNA/Perpetrator E stated R1 became combative after standing up from the beside while they were attempting to secure his brief. CNA/Perpetrator E alleged R1 had twisted her wrist and arm and was attempting to push CNA B. CNA/Perpetrator E stated after the situation calmed and R1 was situated back in bed, she turned around to walk out of the room when R1 kicked her in the back. CNA/Perpetrator E admitted , That's when I called him an [expletive] without even thinking about it. When CNA/Perpetrator E was asked if R1 heard her make a derogatory remark toward him she replied, He probably did, I was still in the room.On 1/21/26 at 2:02 PM, a telephone interview was conducted with R1's Durable Power of Attorney (DPOA) H regarding the incident on 12/31/25. DPOA H stated she was informed of the scenario and voiced, I just feel bad for [R1].Review of the facility policy titled, Freedom from Abuse, Neglect and Exploitation, reviewed 2/5/25, read, in part: .each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse. Verbal Abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The facility will: Not use verbal, mental, sexual or physical abuse. The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators: . Verbal abuse of a resident overheard.

Based on observation, interview, and record review, the facility failed to monitor and record accurate weights per standard practice of care for one Resident (R1) of three residents reviewed for weight loss. This deficient practice resulted in R1 having a significant weight loss with no interventions. Findings include: This citation pertains to intake 2690422Review of R1's Electronic Medical Record (EMR) revealed admission to the facility on 9/25/25 with diagnoses including Alzheimer's disease. R1's Care Plan revealed R1 was independent with cueing and supervision as needed. R1 received a 3/15 on the Brief Interview for Mental Status (BIMS) in September 2025, indicating severe cognitive impairment. Review of the Facility Reported Incident read, in part, On December 3, 2025, the resident was found to have a 25.5 lb. (pound) weight loss. Upon further investigation, it was discovered the same staff member had charted weights on this resident for the last 8 weekly weights .Staff recorded inaccurate weights for a resident, resulting in missed significant weight loss. The staff member falsified weight as well as vital sign date for this resident .the investigation concludes that abuse, neglect, did occur. On 12/16/25 at approximately 11:35 a.m., R1 was observed sitting in the dining room waiting for the lunch meal service to begin. R1 appeared thin. When interviewed, R1 stated, I am tired in my head. I don't feel like eating. Review of R1's weights from 9/25/25 through 12/3/25 revealed the following weights:9/25/25 205.2 lbs; weight obtained by Certified Nurse Aide (CNA) D9/26/25 205.6 lbs; weight obtained by CNA A9/27/25 202.5 lbs; weight obtained by CNA E9/28/25 202.0 lbs; weight obtained by CNA E 10/1/25 202.2 lbs; weight obtained by CNA A10/8/25 202.4 lbs; weight obtained by CNA A10/15/25 201.6 lbs; weight obtained by CNA F10/29/25 202.1 lbs; weight obtained by CNA A11/5/25 202.3 lbs; weight obtained by CNA A11/12/25 202.0 lbs; weight obtained by CNA A11/19/25 201.7 lbs; weight obtained by CNA A11/26/25 201.9 lbs; weight obtained by CNA A12/1/25 178.2 lbs; weight obtained by Licensed Practical Nurse (LPN) G12/2/25 176.4 lbs; weight obtained by LPN [NAME] 12/17/25 at 10:05 a.m. an interview was conducted with R1's Designated Power of Attorney (DPOA) H who stated R1 was admitted in September at 205 pounds which was their usual body weight. R1 was started on Haldol (antipsychotic medication used to treat delirium behaviors) and that is when DPOA H noticed a change in R1's appetite and appearance. DPOA H stated they notified the facility around November 13th, 2025, with serious concerns and the facility responded, stating R1 had not lost any weight from admission. DPOA H stated they contacted the facility again near the end of November 2025, and the facility responded the resident had not lost any weight. DPOA H stated they began to get very frustrated with the facility when R1 was observed wearing sweatpants and a belt because of how much R1 had lost weight. DPOA H stated they are very upset at how the facility handled their concerns and felt the facility did not respond appropriately. An interview was conducted with the Director of Nursing (DON) on 12/17/25 at 10:24 a.m. The DON stated the facility reviewed video footage and confirmed CNA A did not consistently obtain weights and falsified documentation. CNA A was able to clearly describe how to obtain and document weights in her interview, she just didn't want to do it. On 12/17/25 at 10:46 a.m. a phone interview was attempted with CNA A. This Surveyor was unable to leave a voicemail as the mailbox was full, and CNA A did not return the call. Review of CNA A's 'Nurse Aide Skills Performance Checklist' dated 10/2/25 revealed a 'Vital Sign Skills' assessment which included 'Measure/record weight' with a 'Satisfactory' or 'Unsatisfactory' check mark. CNA A's vital sign skills assessment was left blank in the measure/record weight checklist. An interview was conducted with Registered Nurse (RN)/Education Director C on 12/17/25 at 11:32 a.m. RN C stated, when performing a CNA skills performance checklist, I don't tell them I am coming and only observe what they (CNA) are doing at the moment. I only check off what I see on the floor. An interview was conducted with Registered Nurse/Care Coordinator B on 12/17/25 at 11:57 a.m. RN B stated that a care conference was held on 12/17/25 at approximately 11:00 a.m. with the facility physician. RN B stated that the physician indicated that R1 would likely not regain the weight that was lost.Review of the facility's Freedom from Abuse, Neglect and Exploitation policy reviewed on 2/5/25 read, in part, It is the policy of [Facility Name] that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .

This deficient practice pertains to Facility Reported Incident (FRI) MI00153071. Based on observation, interview, and record review, the facility failed to maintain a complete and accurate medical record following an unwitnessed fall for one Resident (#1) of 3 residents reviewed for medical records. Findings include: Resident #1 (R1) Review of R1's electronic medical record (EMR) revealed initial admission to the facility on 8/21/23 with diagnoses including dementia, repeated falls, bone density disorder, and cognitive communication deficit. Review of R1's most recent Minimum Data Set (MDS) assessment, dated 5/9/25, revealed a Brief Interview for Mental Status (BIMS) score of 2/15, indicative of severe cognitive impairment. Review of the facility investigation report received by the State Agency (SA) on 5/14/25 at 1:39 PM read, in part: Incident Summary: On May 4, 2025, [R1] was discovered on the floor in another resident room .During the early morning hours of May 6, staff noted a bruise to [R1's] left heel . an x-ray was ordered. At 11:04 AM, on May 7, the x-ray results returned with the diagnosis of superior calcaneus [heel] fracture . Investigation Summary: On May 6, 2025, the night house supervisor, [Licensed Practical Nurse (LPN) B] reported to the [Director of Nursing (DON)] [R1] had a large bruise to her left heel. [LPN B] also reports skin tears to [R1's] right forearm. [LPN B] completed a chart review and found no note regarding an injury . [Certified Nursing Assistant (CNA) E] informed [LPN B] [R1] had been observed on the floor, in another resident room, on May 4. The two [LPN B and CNA E] feel the bruising and skin tears likely came from that incident . On 5/15/25 at 2:45 PM, R1 was observed sitting in a wheelchair with her left leg propped up on an elevated footrest covered with a soft cast and bandages. LPN D reported R1 had just returned to the facility after undergoing orthopedic surgery on her left heel at a local hospital. On 5/15/25 at 12:09 PM, an interview was conducted with LPN D who verified she was on duty when R1 was found on floor in another resident's room by CNA E on 5/4/25. LPN D stated although she was not the nurse responsible for R1's direct care on 5/4/25, she responded first to the report that CNA E had discovered R1 on the floor. LPN D recalled R1 was observed in a sitting position on the floor with her legs extended and right arm resting on the bed frame. LPN D stated after a brief assessment, R1 was assisted into the hallway as the resident who occupied the room was becoming distressed with the commotion. LPN D stated she observed a skin tear on top of R1's right forearm and vaguely recalled covering the wound with a band-aid. LPN D stated Registered Nurse (RN) C then came over to further assess R1. On 5/15/25 at 11:46 AM, a telephone interview was conducted with RN C who confirmed R1 was under her direct care when she was discovered on the floor in another resident's room on 5/4/25. RN C stated by the time she walked over, R1 was already in the hall and LPN B had completed a skin assessment. RN C stated R1 had an open spot on her right forearm that was bleeding. RN C stated LPN D had already covered the area with a band-aid but later in the day it had increased in size, so she covered it with non-stick gauze and tape. RN C stated R1 had a care plan that indicated she liked to sit on the floor, she did not count the incident as a fall and therefore did not complete a corresponding event report in R1's EMR. Review of R1's plan of care revealed a focus area initiated 8/21/23 which read: FALLS: High risk of falls r/t [related to] high risk medications for behavior disturbances/symptoms, confusion, gait/balance problems, poor communication/comprehension, unaware of safety needs, wandering, deformities of feet, walks on her toes, incontinence, falls with fractures, pain, osteoporosis. A care planned fall intervention, initiated 9/6/23, read: Per her sister, [R1] often sits down right on the floor when at home. If you witness this happening, it is intentional and not a fall . On 5/15/25 at 12:22 PM, an interview as conducted with CNA E who confirmed she found R1 sitting on the floor in another resident's room on 5/4/25 after responding to a motion alarm. CNA E stated she had not witnessed R1 sitting on the floor but instead found her in a seated position with both legs extended. CNA E stated R1 had a visible skin tear on her right forearm. In the late evening on 5/5/25, CNA E stated she saw bruising on R1 left heel as LPN A was applying medicated lotion. CNA E stated she immediately reported the finding to LPN A. On 5/15/25 at 12:32 PM, a telephone interview was conducted with LPN A who verified she discovered bruising to R1's left heel while providing care in the late-night hours of 5/5/25. LPN A stated she had not been on duty for the previous couple days, but CNA E informed her R1 had been previously found sitting on the floor in a resident room. When LPN A asked CNA E if she informed the on-duty nurse, CNA E stated she had but the nurse stated R1 was care planned to be able to sit on the floor, so it had not been counted as a fall. LPN A stated, I was confused because [R1's] care plan states that sitting on the floor had to be witnessed and this was not. LPN A stated she also observed two skin tears on R1's right arm located both above and below her elbow. LPN A recalled one skin tear was covered with a piece of gauze and paper-tape and the other just had a band-aid. LPN A stated, Nobody mentioned the skin tears, they were not reported or charted about. I was not able to verify where those had come from. LPN A relayed her concerns to the night house nurse supervisor, LPN B and completed a note in R1's EMR. LPN A stated the incident should have been recorded in R1's EMR as a Risk Management Event per facility policy. Review of R1's EMR revealed a progress note written by LPN A on 5/5/25 at 11:16 PM which read: During this shift I noticed two skin issues (tears) to resident's right arm. And a large bruise to resident's left heel that looks as though it is starting to wrap around the ankle as well. The two skin issues (tears) both have been attended to. The one further up on the arm has a band-aid applied, and the other one looks to have a non-stick [bandage] and paper tape . CNA [CNA E] alerted me to a possible situation that occurred .where resident was . observed sitting on one resident's blue mat. This could be a probable situation where these skin tears and bruise could have originated . On 5/15/25 at 12:47 PM, a telephone interview was conducted with LPN B who verified she was the night house supervisor on 5/5/25-5/6/25. LPN B stated she could not find any documentation regarding R1's skin tears or bruising to the left heel. LPN B stated she notified the on-call provider because, the concern was R1 didn't sit on the floor on 5/4/25 but likely fell. When LPN B was asked about facility protocol after a fall or discovering skin integrity issues she stated, The normal protocol would be to do the Risk Management documentation . I don't know why it was not done. Review of the radiology report of the left foot dated 5/7/25 read, in part: This is a fracture involving the superior calcaneus . Review of an undated document completed by Care Coordinator (CC) F titled Nursing Post Fall Evaluation, read, in part: When notified of skin + [and] pain concerns from NOC [night shift] nurse, we noted a charting from 5/4 stating [R1] sat on floor in another resident room - unwitnessed. Now w/ [with] skin tears noted to R [right] arm and L [left] heel bruising . reviewed CP [care plan] fall focus - clearly states if you witness [R1] sitting on the floor it is [not] a fall - this was unwitnessed. Therefore, proper action from NN [night nurse] was required - risk mngment [management] - unwitnessed fall . On 5/15/25 at 3:35 PM, an interview was conducted with Care Coordinator (CC) F who verified a risk management document should have been completed for R1's unwitnessed fall and skin tears. On 5/15/25 at 3:45 PM, a follow-up phone call was conducted with RN C regarding facility risk management documentation protocol. When asked why risk management documentation was not completed after the unwitnessed fall, RN C stated, Because I thought [R1] sat down . It was a busy time of day. When asked why risk management documentation was not completed for R1's skin tears, RN C replied, Because it wasn't really a skin tear . it was like [R1] just bumped it and it was bleeding. And later in the day, it looked like an abrasion . so I covered it so it wasn't open and passed it along in verbal report. On 5/15/258 at 3:15 PM, an interview was conducted with the DON regarding expectations following an unwitnessed fall or skin tear. The DON stated risk management documentation should be completed for any unwitnessed fall or skin abnormalities. Review of the undated Facility Policy titled, Skin Injuries read, in part: .If an injury is identified on a resident, please complete the Risk Management . What Needs to have a Risk Management completed? See list below: .skin tear.

Based on interview and record review, the facility failed to follow physician orders for readmission to the facility in two Residents (#25 and #15) of three residents reviewed for quality of care following hospitalization . This deficient practice resulted in rehospitalization for excessive clotting times following a history of GI bleed for R25 and rehospitalization with worsening urosepsis for R15. Findings include: Resident #25 (R25) A nursing progress note in the Electronic Medical Record (EMR) dated [DATE] at 3:06 PM documented R25 had hypoxia (low oxygen level), a gray color to the skin, increased confusion, and a blood pressure of ,d+[DATE]. The physician was notified and R25 was transferred to the Emergency Department (ED) and admitted to the hospital. A hospital discharge summary dated [DATE] documented R25 with an INR result of 12.9 upon arrival to the ED on [DATE]. The discharge summary recapped concerns identified in the hospital including acute blood loss anemia, acute GI (gastrointestinal) bleeding, and supratherapeutic (exceeding therapeutic limits) INR. The discharge summary reflected R25 required blood transfusions while hospitalized . A GI scope was performed and identified evidence of upper GI bleeding with blood clots within the stomach. R25 was admitted to the facility on [DATE] with a primary diagnosis of memory deficit following cerebral infarction (stroke). The EMR revealed R25 had a prosthetic heart valve and was prescribed the anticoagulant warfarin (a blood thinning medication that can result in excessive bleeding and death if given in excessive doses). A care plan Focus for R25 documented, in part: BLEEDING [sic]: At risk for uncontrolled bleeding from use of Coumadin [warfarin] therapy related to aortic valve replacement . The care planned goal was to maintain the INR (International Normalized Ratio, a blood test for warfarin that measures blood clotting times) between 2.5 - 3.5. R25 returned to the facility on [DATE] with an INR of 1.26. Physician's orders included tight INR control and resume warfarin on [DATE]. The Medication Administration Record (MAR) documented R25 received warfarin 3 milligrams (mg) on [DATE] despite the physician's order from the hospital to resume the medication on [DATE]. A nursing progress note in the EMR on [DATE] at 9:04 AM documented R25's provider was notified to discuss R25 experiencing a change in condition overnight. The progress note reflected R25 had a systolic blood pressure in the 80's, hypoxia, lethargy, and crackles throughout the lung fields. R25 was transferred back to the ED on [DATE] where a laboratory draw identified an INR of 5.1. A hospital discharge summary dated [DATE] documented, in part: . I spoke with nursing at [name of facility redacted], patient has reportedly only received a single 2.5 mg dose of warfarin on [DATE] that is increased his INR from 1.26 on [DATE] to 5.61 today .warfarin has been held, suggest a recheck of INR tomorrow .continue to hold warfarin therapy until INR between 2 and 3, recommend reducing dosage on reinitiation, close monitoring every other day . R25 returned to the facility on [DATE]. The MAR documented warfarin was administered to R25 on [DATE] and [DATE] despite the physician's order to withhold the medication. A nursing progress note on [DATE] at 3:55 PM documented the provider was notified and made aware the warfarin was not placed on hold when R25 returned from the hospital. The provider again ordered the medication to be withheld until laboratory testing of INR was returned. A laboratory report dated as obtained on [DATE] and dated as reported to the facility on [DATE], documented INR results > (greater than) 10. A provider's note in the EMR dated [DATE] at 12:00 AM documented, in part: . [R25] presents for evaluation due to elevated INR. Preliminary result from yesterday's draw is INR > 10 .CCC [Clinical Care Coordinator] discovered that patient's Coumadin was not held since readmission to the facility. Discussed with CCC option to perform reversal using available Vit [vitamin] K in the facility and to closely monitor INR by checking daily or every other day. However, given patient's very recent hospitalization for suspected GI bleed leading to anemia and acute hypoxia, CCC is concerned that patient is at higher risk for bleeding. Facility has limited ability to check INRs in a timely manner . R25 was transferred back to the ED on [DATE] for a supratherapeutic INR. The CCC (Registered Nurse (RN) N) and Assistant Director of Nursing (ADON) were interviewed on [DATE] at 10:12 AM. RN N said warfarin is monitored through INRs to ensure the medication is within therapeutic parameters for a resident. RN N confirmed the therapeutic range for R25 was an INR between 2.5 - 3.5. The ADON said there was also an order to monitor for bleeding each shift, and the order to monitor for the side effects of bleeding should be on the TAR (Treatment Administration Record) for nurses to document each shift. The medical record for R25 was reviewed with RN N. No order was found to monitor R25 for bleeding, nor did the TAR contain an entry for nurses to document monitoring for the side effect of bleeding. RN N was asked about the supratherapeutic INRs and subsequent hospitalization s for R25 in [DATE]. RN N said the INRs for R25 got wonky in January. RN N said, This mess might have been prevented with a point of care INR machine. RN N expressed challenges with the contracted laboratory provider, including the lab not open or available when needed, specimen collections were required to be obtained before 4:00 PM, and there was no availability to obtain laboratory draws on weekends. RN N explained the laboratory courier picks up labs at 4:00 PM on weekdays only, then the specimens were taken to (city approximately 50 miles from facility) to then be shipped to out of state within the country to conduct the testing. RN N asserted, I don't know how that's feasible! I've had heated [NAME] about this lab. RN N said the facility is not notified timely of laboratory results. RN N said laboratory results are not known until the next day or several days after laboratory specimens were obtained. RN N was asked why warfarin continued being administered to R25 when the discharge summary from the hospital dated [DATE] directed the medication to be withheld. RN N did not provide an explanation. The Director of Nursing (DON) was interviewed on [DATE] at 12:42 PM. The DON was asked why the warfarin was administered despite an order to withhold the medication. The DON said she suspected the facility did not receive the discharge summary dated [DATE] or the instructions from the hospital until [DATE] because that was the date the discharge summary was entered into R25's EMR. The DON said the provider did not enter the order to hold the warfarin in the EMR. The DON explained the facility practice was for providers to enter their own orders in the EMRs. The Medical Director (MD) was interviewed on [DATE] at 12:50 PM. The MD said he would not have been concerned about INR draws being obtained after being identified as supratherapeutic if the resident was not receiving warfarin. The MD said he was not notified until today ([DATE]) that R25 received warfarin when it should have been withheld. Resident #15 (R15) R15 was admitted to the facility on [DATE] with a primary diagnosis of acute pulmonary edema (buildup of fluid in the lungs). A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R15 was cognitively intact. The MDS documented R15 was independent with dressing, personal hygiene, bed mobility, transfers, and ambulation. No history of genitourinary surgeries or concerns were reflected in the MDS. A nursing progress note in the EMR dated [DATE] at 9:00 AM documented the provider was notified of R15 experiencing a change of condition including vaginal itching, burning with urination, increased frequency of urination, constant dribbling of urine, and a change in the appearance of the urine. The appearance of the urine was documented as thick, creamy, with an abnormal color. The note reflected R15 was lethargic, weak, non-ambulatory, and required lift equipment for transfers. The note documented a concern for infection. A nursing progress note in the EMR dated [DATE] at 12:00 PM documented the provider was notified of a preliminary urinalysis results showing bacterial growth and concern for possible UTI (urinary tract infection). The provider prescribed antibiotics. A progress note dated [DATE] at 10:15 AM documented R15 began vomiting and experienced hypotension (low blood pressure), rapid heart rate and respirations, and severe burning with urination. R15 was sent to the ED on [DATE] and was admitted to the hospital for UTI (Urinary Tract Infection), sepsis (a life-threatening complication resulting from an infection), acute kidney injury, and others. The urine test in the hospital showed Lactobacillus (a type of bacteria). R15 was discharged back to the facility on [DATE] with orders to administer amoxicillin (an antibiotic) 875 mg twice daily. Review of the MAR revealed the amoxicillin was not administered to R15. The amoxicillin order was not reflected on the February 2025 MAR. A nursing progress note dated [DATE] at 8:45 AM documented the provider was notified R15 had not received any antibiotics since returning from the hospital after the inpatient stay for urosepsis. The note revealed an on-call provider was contacted on [DATE] and [DATE] but the on-call provider was unable to access R15's chart or receive the fax of the hospital discharge. The nursing progress note of [DATE] at 8:45 AM documented, in part: .Today I'm concerned [R15] is becoming septic again AEB [As Evidenced By]: lethargic, confused with inability to answer questions .rhonchus lung sounds .RR [respiratory rate] 40, HR [heart rate] 100 .indwelling foley catheter shows blood clots, sediment, and milky/pink colored urine .Concerns for rebound sepsis vs. heart failure fluid overload or both The note documented the provider's response was to send R15 to the ED. R15 was transferred back to the ED and admitted to the hospital on [DATE] for Urosepsis. Review of a nursing progress note dated [DATE] at 4:35 PM revealed the provider who discharged R15 from the hospital on [DATE] contacted the facility regarding R15 not receiving amoxicillin as prescribed. The note documented, in part: .I let [hospital provider] know we were not able to get any further antibiotic recommendations from our telehealth on call providers Saturday [[DATE]] and Sunday [[DATE]]. He stated that in the future if there are problems like this to please contact the hospitalist on call at the hospital . R15 returned to the facility on [DATE] and was subsequently placed on comfort measures. R15 expired [DATE]. The DON and MD were interviewed on [DATE] at 1:00 PM. The DON said R15 returned to the facility with orders for amoxicillin but R15 was allergic to penicillin. The MD said he was not notified of R15 not receiving amoxicillin as prescribed by the hospital provider. The MD said the nurse practitioner was notified on [DATE] and assessed R15. The nurse practitioner ordered R15 sent to the ED. Neither the MD nor DON provided an explanation why the medical director or hospital was not notified when the on-call provider failed to prescribe a different antibiotic when the allergy was identified.

Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with the required committee members resulting in the potential for quality-of-care concerns for all 93 residents in the facility. Findings include: A review of the facility QAPI sign in sheets on 3/30/25 at 11:00 a.m., revealed the following: Meetings were held on4/17/24, 5/15/24, 6/19/24, 7/17/24, 10/16/24, 11/20/24, 12/18/24, 1/15/25, and 2/19/25. The meeting held on 7/17/24: The Medical Director or designee did not attend. The facility did not have a QAPI meeting in August 2024 or September 2024. The Medical Director or designee, who is a required committee member, did not attend the QAPI meeting during the quarter of July, August, and September. During an interview on 3/20/25 at 11:26 a.m., the Director of Nursing (DON) reported she was unaware the Medical Director did not attend the meeting and offered to provide proof the Medical Director did attend via zoom for the 7/17/24 meeting. The missing attendance record was not provided by survey exit on 3/20/25 at 2:00 p.m.

Resident #34 (R34) Review of the Minimum Data Set (MDS) assessment, dated 2/28/2025, revealed R34 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury and seizure disorder. Review of R34's EMR revealed the following progress note: 3/5/2025 19:23 Nursing Note . Resident was sent to the hospital for possible sepsis. Running fever, elevated BP (blood pressure) and pulse. Resident was sitting up in bed in pain this evening, all muscles engaged. Skin was red and blotchy. Ambulance was called. ER (Emergency Room) in [local acute care hospital] was called. Review of the facility document titled, Notification of Transfer and Bed Hold Authorization, dated 3/5/2025, revealed the document did not include a reason for R34's transfer out of the facility. Based on interview and record review, the facility failed to notify the resident and/or resident representative in writing with the reason for a transfer out of the facility for four Residents (#15, #25, #87, #34) of four residents reviewed for transfer and/or discharge. Findings include: Resident #87 (R87) Review of R87's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including dementia and Parkinson's disease. Review of the facility census report revealed R87 was hospitalized from [DATE] - 3/13/25. Review of a progress note dated 3/11/25 at 12:39 PM read, in part: Resident being transported to [acute care hospital] d/t (due to) swelling in LLE (left lower extremity) and thigh . Review of a facility document titled, Notification of Transfer and Bed Hold Authorization, dated 3/11/25, did not reveal the reason for transfer for R87. Resident #25 R25 was admitted to the facility on [DATE] with a primary diagnosis of memory deficit following cerebral infarction (stroke). The EMR revealed R25 was transferred to the hospital on the following dates: 1/6/25, 1/10/25, 1/14/25, and 1/19/25. The documents Notification of Transfer and Bed Hold Authorization did not reveal the reason for the transfers to the hospital for R25 on these dates. Resident #15 R15 was admitted to the facility on [DATE]. The primary diagnosis of R15 was acute pulmonary edema (buildup of fluid in the lungs). The EMR revealed R15 was transferred to the hospital on the following dates: 2/12/25, 2/17/25, 2/27/25, and 3/11/25. The documents Notification of Transfer and Bed Hold Authorization did not reveal the reason for the transfers to the hospital for R15 on these dates. The Assistant Director of Nursing (ADON) was interviewed on 3/20/25 at 9:18 AM. The ADON was asked if the facility had written notifications of transfer for residents and resident representatives. The ADON provided bed hold information but did not provide written notifications of transfer. A policy was requested. The ADON and Director of Nursing (DON) were interviewed on 3/20/25 at 9:50 AM. The DON said there were no written notifications of transfer issued to residents or resident representatives. The ADON said the facility had a documented procedure and provided an undated document Notice of Resident Transfer of Discharge Process. The document read, in part: . Notice Requirements Before Transfer/Discharge, the facility must provide written notice to any Resident or Resident Representative . 3. The Social Worker/designee will complete the Notice of Resident Transfer or Discharge and, as soon as is practicable, will mail said notice . When a signed notice is returned, it will then be placed in the Resident's hard chart . The DON was queried regarding the form referenced in the written procedure. The DON provided a blank copy of a form titled Notice of Resident Transfer or Discharge. The form included the necessary written requirements for transfers. The DON was again asked if the forms for written notification of transfers had been completed for the residents who had been transferred to the hospital. The DON reiterated the forms had not been completed. The ADON said the form used to be used but could not explain why the facility had stopped providing written notifications of transfer.

Based on observation, interview, and record review, the facility failed to properly label medications and dispose of expired or discontinued medications in three medication carts of four medication carts reviewed and one medication room of two medication rooms reviewed for medication storage. Findings include: On 3/18/25 at 12:35 PM, the Valleyvue B medication cart was observed. The medication cart had an insulin pen containing glargine, with an expiration date of 3/9/25 which remained accessible for administration in the medication cart supply. On 3/18/25 at 12:37 PM, an interview was conducted with Registered Nurse (RN) L, who was asked if the insulin pen was still usable. RN L looked at the pen and immediately threw it out replying, The resident does not use it that often. The pen should have not been in the medication cart. On 3/18/25 at 12:51 PM, the Lakevue B medication cart was observed. The medication cart had a box of two auto-injector pens containing epinephrine 0.3 mg (milligrams). The printed expiration date on the box was 1/2025. An insulin pen was also observed with a date written when it was opened on 3/17/25, but no expiration date was observed. On 3/18/25 at 12:53 PM, an interview was conducted with RN M, who was asked what kind of allergy the resident had related to the availability of an emergency pen (epinephrine) and replied, They are allergic to bee pollen, clonazepam (anti-anxiety agent), and honeybee venom. RN M visualized the epinephrine and confirmed the medication was expired. When asked about the insulin pen, RN M said insulin pens are required to reflect the expiration date, so staff are aware when the medication is expired. On 3/18/25 at 3:06 PM, the Lakevue A medication cart was observed, and was found to have an antipsychotic medication haloperidol liquid, with dispensed date of 2/4/25 which contained no expiration date after opened. The medication cart also had an insulin lispro pen with opened date of 3/15/25 and was labeled to be expired on 4/26/25. The insulin pen was identified as having an incorrect expiration date and should have been labeled to expire on 4/12/25, a 28-day period, not a 42-day period. The medication cart also contained two other insulin pens observed to be dated incorrectly. On 3/18/25 at 3:20 PM, an interview was conducted with RN L, who was asked if the insulin pens were dated correctly for expiration dates and replied, No. Apparently someone does not know how to do math. On 3/18/25 at 1:16 PM, a review of the narcotic book for Valleyvue B was conducted and was found to have a discontinued controlled substance medication remaining in the active medication supply. The medication was Lorazepam 0.5 mg, with dispensed date of 1/24/25 and physician order to be discontinued on 2/7/25. On 3/18/25 at 2:55 PM, an interview was conducted with RN L, who was asked when discontinued medications in the medication cart should destroyed. RN L replied, As soon as possible. That same resident had morphine as well and that was discontinued and destroyed. I really don't know why that medication (Ativan 0.5 mg) is still in the medication cart. On 3/18/25 at 3:21 PM, an observation was made of the medication storage room located on Lakevue. A bottle of geri-tussin (cough syrup) 16 ounces with expiration date of 10/24 was observed in the medication room supply. RN M had a surprised look of her face when this Surveyor handed her the expired medication. On 3/19/25 at 9:44 AM, an interview was conducted with the Director of Nursing (DON) who was made aware of the medication storage findings. The DON replied, Expired medications are to be thrown out if they are expired. Narcotics that have been discontinued are to be destroyed with management as soon as possible, within a few days, and we are here Monday through Friday. Insulin pens are to be correctly dated after being opened with an expiration date. The DON confirmed medication carts and medication storage rooms are audited weekly by nursing and was not sure why expired medications were left in the active medication supply areas. The DON stated, Obviously the staff need to be re-educated on the process because things are being missed and overlooked. Review of policy titled, Unused Medications, Disposal of, dated 10/16/24, read in part, Policy: It is the policy of (facility name) that all unused medications will be disposed of safely and legally .DEA (Drug Enforcement Administration) controlled substances: 1. DEA controlled substance medication (narcotic) cannot be returned to the pharmacy .2. Two of the following personnel types must be present to witness destruction: a. Director of Nursing b. RN Care Coordinator c. Neighborhood Nurse d. Registered Pharmacist e. Certified Pharmacy Technician f. RN or LPN (Licensed Practical Nurse) Consultant Nurse employed by the pharmacy 3. Controlled medications are destroyed via the Drug Buster Drug Disposal System . Review of policy titled, Labeling of Medications and Biologicals, dated 10/23/24, read in part, Policy: It is the policy of (facility name) to ensure all medications and biologicals used in the facility will be labeled in accordance with current guidance . Review of facility document titled, Insulin Storage Recommendations, dated 2022, read in part, .Cartridges/Pens .insulin lispro and insulin glargine pen, opened up to 28 days . Review of facility document titled, Medication Storage and Labeling, undated, read in part, .Medication Carts .All opened medications are labeled with an open date and an expiration date. The expiration date may be the circled manufacturer expiration .Insulin Pens .Verify open date and expiration date . Review of facility document titled, Medication Storage Audit, undated, read in part, Drugs and biologicals are correctly/securely stored .7. DC'd (discontinued) and/or expired meds removed .11. Medications have expiration dates . Review of policy titled, Medication Storage, dated 10/30/24, read in part, Policy: It is the policy of (facility name) to ensure all medications will be stored in the medication cart and/or medication rooms according to the manufacturer's recommendations and regulatory guidelines and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessment documentation was accurate for one Resident (#23) of 19 residents reviewed for assessments. This deficient practice resulted in the potential for lack of appropriate care and services. Findings include: Resident #23 (R23) Review of R23's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE] with diagnoses including: Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or stroke, hemiplegia (paralysis that affects one side of your body), and dementia. Section P revealed a wander/elopement alarm was used daily. R23 scored a 5 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment. During an observation on 3/18/25 at 1:11 p.m., R23 had a [Name Brand] alarm on her left ankle and was seated in a wheelchair while propelling the wheelchair in a secured/locked unit of the facility. During an interview on 3/19/25 at 10:41 a.m., Licensed Practical Nurse (LPN) A reported R23's balance had declined since admission in 2013, and the resident does not walk around the secured unit of the facility anymore. When asked who assesses the use of the alarms for residents, LPN A stated they did not know. During an interview on 3/20/25 at 8:41 a.m., Director of Nursing (DON) reported that the facility fills out risk assessments for residents who need an alarm upon admission, quarterly, and as needed. The DON reviewed the Electronic Medical Record (EMR) for R23 which revealed the last risk assessment was completed on 8/9/24. During an interview on 3/20/25 at 9:12 a.m., Housekeeping Aide B reported R23 does not try to get out of the doors of the locked unit of the facility since [R23] does not walk and is in a wheelchair. During an interview on 3/20/25 at 9:16 a.m., Nursing Neighborhood Assistant C reported R23 does not try to leave out any of the exit doors. During an interview on 3/20/25 at 9:18 a.m., Nursing Neighborhood Assistant D reported R23 watches TV, has snacks during the day, and sleeps a lot, but does not try to leave the locked unit. During an interview on 3/20/25 at 9:26 a.m., Activity Aide/Certified Nursing Assistant (CNA) E stated, I cannot recall the last time I saw [R23] head towards an exit. During an interview on 3/20/25 at 9:29 a.m., CNA F reported R23 used to walk towards the exits seven years ago. During an interview on 3/20/25 at 9:31 a.m., Registered Nurse (RN) G reported R23 goes to the dining room and propels the wheelchair around the locked unit of the facility but has not tried to leave the locked unit over the past year. During an interview on 3/20/25 at 10:08 a.m., Social Worker H reported that R23 had not tried to leave the locked unit in the past year and the LPN/Care Coordinator will do a risk assessment for the alarm for residents that try to elope. During an interview on 3/20/25 at 10:15 a.m., LPN/Care Coordinator I stated, It had been at least a year since [R23] tried to leave the locked unit .the residents are assessed quarterly and I did not realize I missed the assessment . During an interview on 3/20/25 at 10:29 a.m., the DON acknowledged R23 should be assessed quarterly for the [Name Brand] alarm and R23 had not tried to leave the facility. The DON reported the facility had a policy on the alarm assessment which was requested at the time of this interview. During an interview on 3/20/25 at 10:48 a.m., Registered Nurse/MDS/Assistant Director of Nursing (RN/MDS/ADON) J stated, R23 has not had an elopement incident in over a year .there is no need for [R23] to have the [Name Brand] alarm at this time .R23 should have been assessed quarterly for the [Name Brand] alarm as part of the quarterly MDS assessment . Review of facility policy titled Elopement and Wandering Resident last reviewed 2/5/25, read in part .Alarms are not a replacement for necessary supervision .[Facility name] shall establish and utilize a systematic approach to monitoring and managing residents including identification and assessment .evaluation and analysis of hazards and risks .and monitoring for effectiveness and modifying interventions when necessary . A facility policy regarding the assessment or use of alarms was not provided upon exit of the facility on 2/20/25 at 2:00 p.m.

Based on observation, interview and record review, the facility failed to update the person-centered care plan for the management and prevention of wounds for one Resident (#53) of one resident reviewed for pressure injuries, resulting in the potential for unmet care needs. Findings include: Resident #53 (R53) Review of the Minimum Data Set (MDS) assessment, dated 12/27/2024, revealed R53 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease and dementia. R53 was rated as having severe cognitive impairment and was dependent on staff for all transfers and bed mobility. On 3/18/2025, at 12:11 p.m., R53 was observed seated in a high-back wheelchair in her room. R53 appeared confused and smiled when asked questions but appeared to be unable to understand the questions being asked and could not participate in an interview. Review of R53's electronic medical record (EMR) revealed the following progress note: 3/18/2025, [9:37 a.m.]. Alert Note. resident with red firm area on left glute. skin intact. resident current with air mattress topper. request for air mattress. open area of coccyx [tailbone] with 99% slough, serosanguinous exudate [drainage]. educated CNA [Certified Nursing Assistant] on the importance of turning schedule. CNA verbalized understanding and confirmed repositioning. An observation of R53's wound care, conducted by Licensed Practical Nurse (LPN) Q, on 3/19/25 at 11:43 a.m., revealed R53 had a wound located on the medial aspect of her right upper buttock. The wound was covered in black eschar (dry dead tissue). Two smaller wounds were noted on R53's left, medial buttock, both wounds were covered in yellow slough (moist, dead tissue). Review of a provider note, dated 3/6/2024 at 12:00 a.m., revealed the following: Assessment and Plans . There is a Kennedy ulcer [unavoidable skin breakdown which occurs as part of the dying process] noted to the coccyx. Review of R53's pressure ulcer risk assessment, dated 3/3/2025, revealed R53 was unable to make frequent or significant changes [in position] independently. During an interview on 3/20/2025 at 9:43 a.m., CNA R was queried as to how care staff were aware of what care needs R53 had. CNA R reported CNA staff refer to the Kardex (bedside care plan report) which is in a binder outside the Resident's room. CNA R reported she floats to all units in the facility and relies on the bedside care plan reports to know what type of assistance residents require. When asked how staff knew how often a resident should be repositioned or weight offloaded, CNA R reported staff would refer to the care plan report for specific information. CNA R stated residents are usually repositioned every two hours when in bed. Review of R53's Visual/Bedside Individual Care Service Plan Report, found in a black binder located in a pocket on the wall outside the Resident's room, revealed the following: Skin Care/Pressure Relief: Calmoseptine (type of medicated ointment) to open pressure area and protective ointment to peri areas of incontinence . Bed Mobility: dependent for significant position changes. Wedges for repositioning support/pressure relief. It was noted the bedside care plan report contained no information related to how often R53 should be repositioned or how often weight should be offloaded from R53's wound. A review of R53's comprehensive care plan, revealed the following: Pressure/Skin Injury: The resident has a history of pressure ulcer development [related to] immobility, age related fragility, anti-platelet therapy. Date Initiated:4/08/2024 . Interventions: Encourage repositioning throughout the day and night if you see that the resident has not done so herself. Date Initiated: 4/09/2024. It was noted the care plan did not include information on how often R53 should be repositioned nor was the care plan updated to reflect R53's dependence on staff for position changes. During an interview on 3/20/2025 at 9:36 a.m., Nursing Care Coordinator and Registered Nurse (RN) S reviewed R53's current care plan and confirmed R53's care plan was not updated to reflect the presence of the Kennedy ulcer and did not include an intervention to turn and reposition R53 at least every two hours for comfort and to attempt to prevent new wounds from forming. RN S confirmed R53 should be repositioned at least every two hours. Review of the facility policy titled, Baseline Care Planning and Resident Centered Care Planning, revised 2/19/2025, revealed the following: The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

F770 Grandvue Based on interview and record review, the facility failed to ensure laboratory services were provided to meet the needs of one Resident (#25) of one resident reviewed for laboratory services. Findings include: Resident #25 A review of the Electronic Medical Record (EMR) for R25 revealed admission to the facility on [DATE] with a primary diagnosis of memory deficit following cerebral infarction (stroke). R25 had a prosthetic heart valve and was prescribed the anticoagulant warfarin (a blood thinning medication that can result in excessive bleeding and death if given in excessive doses). A review of the Medscape information on Warfarin revealed the safety and efficacy is dependent on maintaining an INR (International Normalized Ratio, a blood test that measures blood clotting) within a specified target range. A review of the EMR revealed R25 was transferred to the hospital on [DATE], [DATE], and [DATE] where R25 was determined to have supratherapeutic (exceeding therapeutic limits) INR results. When R25 was transferred back to the facility after a hospitalization on [DATE], the hospital discharge instructions directed, in part: Check INR every 24 hours to monitor downward trend . A nursing progress note dated [DATE] at 1:30 PM documented the provider was made aware of the hospital specifying daily INRs. The note indicated concern the facility did not have lab availability on Saturdays or Sundays. The response from the provider was to allow R25 to return to the facility with INRs to be drawn on Wednesday ([DATE]), Friday ([DATE]), and Monday ([DATE]) and to hold warfarin through Wednesday [DATE]. Review of the EMR demonstrated the laboratory draw was obtained on [DATE]. The laboratory report read Test not performed. Specimen submitted in expired/outdated collection device. The laboratory report documented the specimen was obtained on [DATE] but not reported until [DATE]. R25 was transferred to the hospital Emergency Department on [DATE] and the hospital obtained an INR. The EMR of R25 revealed laboratory results were not reported for at least 24 hours after laboratory specimens were collected. The results of an INR collected on [DATE] was reported to the facility on [DATE]. A laboratory report containing critical results was obtained on [DATE] and reported to the facility [DATE]. The results of an INR collected on [DATE] was reported to the facility on [DATE]. A laboratory result collected on [DATE] was reported on [DATE]. The Clinical Care Coordinator (Registered Nurse (RN) N) was interviewed on [DATE] at 10:12 AM. RN N expressed challenges with the facility's provider of laboratory services. RN N said the lab was not open or available when needed and said the laboratory was closed on weekends, so they were unable to obtain laboratory specimens on weekends. RN N said the laboratory courier required all specimens to be ready for pick-up by 4:00 PM Monday through Friday so evening lab draws were an impossibility. RN N explained the lab specimens were picked up at 4:00 PM and taken to (the name of a city approximately 50 miles from the facility) to then be shipped to another state in the USA to conduct the testing. RN N asserted, I don't know how that's feasible! I've had heated [NAME] about this lab. RN N confirmed the facility is not notified of lab results until the next day or several days later. The Assistant Director of Nursing (ADON) was interviewed on [DATE] at 9:23 AM. The ADON said the facility obtained a contract with a new laboratory services provider about a year ago. The ADON said the facility experienced many issues and concerns with the new laboratory provider, and management was aware of the nurses' concerns with the new provider of laboratory services. The policy titled Laboratory and Ancillary Medical Services dated as reviewed [DATE] read, in part: . It is the policy of [name of facility redacted] to provide laboratory and ancillary medical services . Laboratory services will be provided by a contracted laboratory. Emergency and after hours services will be provided .

F883 Grandvue Based on interview and record review, the facility failed to administer recommended pneumococcal vaccinations or document the clinical reasons for withholding the pneumococcal vaccinations in three Residents (#36, #75, and #15) of five residents reviewed for immunizations. Findings include: Resident #36 (R36) A nurse progress notes in the EMR (Electronic Medical Record) on 12/3/24 documented R36 was confused with no verbal response to questioning. R36 had a temperature of 101.4 degrees Fahrenheit and a heart rate of 122 beats per minute. The on-call provider was notified and ordered R36 transferred to the Emergency Department (ED) for evaluation. R36 was subsequently admitted to the hospital with Pneumonia. A review of the EMR for R36 revealed an [AGE] year-old resident admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating R36 was cognitively intact on admission. The MDS documented the pneumococcal vaccinations for R36 were up to date. A vaccination consent form signed by R36 on 6/5/24 documented R36 wished to receive the pneumococcal vaccines indicated per CDC (Centers for Disease Control) guidelines, including a PCV20 (type of pneumococcal vaccine). An immunization report for R36 was reviewed on 3/20/25 and revealed R36 received the PCV13 vaccination on 5/18/15 and a PPSV23 vaccination on 10/31/07. No further pneumococcal vaccinations were administered to R36, including the PCV20 recommended by the CDC and requested on the consent form signed by R36. There was no physician's documentation in the Electronic Medical Record (EMR) for R36 indicating the physician addressed the request for administration of PCV20 for R36. Resident #75 (R75) R75 was an [AGE] year-old resident admitted to the facility on [DATE]. A vaccination consent form was signed by the resident representative on 8/8/23 requesting vaccinations if indicated per CDC guidelines, including the PCV20. An admission MDS dated [DATE] documented the pneumococcal vaccinations for R75 were up to date. An immunization report for R75 was reviewed on 3/20/25 and revealed R75 received PCV13 on 10/5/16 and PPSV23 on 6/1/18. No further pneumococcal vaccinations had were administered to R75, including the PCV20 recommended by the CDC and as requested on the consent signed by the resident representative of R75. The EMR of R75 did not contain physician documentation indicating the physician had considered the PCV20 for R75. No documentation by the physician could be found that the physician had discussed the PCV20 with the resident representative of R75. Resident #15 (R15) R15 was a [AGE] year-old resident admitted to the facility on [DATE]. An MDS assessment dated [DATE] documented a BIMS of 14 indicating R15 was cognitively intact. The MDS documented the pneumococcal vaccination for R15 was up to date. A vaccination consent form was signed by R15 on 5/8/24 requesting to receive vaccinations if indicated per CDC guidelines, including the PCV20. An immunization report for R15 was reviewed on 3/20/25 and revealed R15 received the PCV13 on 12/11/15 and the PPSV23 on 10/6/17. No further pneumococcal vaccinations had been administered to R15, including the PCV20 recommended by the CDC and requested by R15 on the consent. There was no physician's documentation in the Electronic Medical Record (EMR) of R15 indicating the physician addressed the request for administration of PCV20 for R15. The Infection Preventionist (IP) was interviewed on 3/20/25 at approximately 11:00 AM. The IP confirmed R36, R75, and R15 did not receive the PCV20 in accordance with their wishes as documented on the vaccine consent forms. The IP was asked if there was any documentation that the vaccinations had been considered for administration. The IP said it was up to the provider to consider the vaccination and to document in the residents' EMR. The IP admitted the provider had not documented consideration of vaccination with PCV20 for R36, R75, or R15. The CDC pneumococcal vaccine recommendations PCV20 or PCV21 Vaccination for Adults 65 or Older (www.cdc.gov/vaccines/hcp/admin/downloads/job-aid-SCDM-pneumococcal-508.pdf) includes, in part: Adults [AGE] years of age or older have the option to receive supplemental PCV20 or PCV21 (not both) if they previously completed the pneumococcal vaccine series with both PCV13 and PPSV23 and meet the following criteria: 1. Previously received one dose of PCV13 (but not PCV15, PCV20, or PCV21) at any age, and 2. Previously received all recommended doses of PPSV23 (including 1 dose of PPSV23 at or after [AGE] years of age) The determination to administer PCV20 or PCV21 is based on a shared clinical decision-making (SCDM) process between a patient and their health care provider . Consider: Increase risk of exposure to PCV20 or PCV21 serotypes [variations of a virus] may occur among people who are living in: Nursing homes or other long-term care facilities . The policy titled IP Pneumococcal Vaccine (Series) dated as reviewed 6/10/24 documented in part: . It is the policy of [the facility] to offer our residents immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations . A series of vaccinations will be offered per current CDC guidelines . The resident's medical record must include documentation that indicates at a minimum, the following: a. The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization. b. The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal .

This deficiency pertains to Facility-Reported Incident intake #MI00143534 Based on interview and record review, the facility failed to ensure one Resident (#292) of one resident reviewed for significant medication errors received the correct medication as ordered by the physician. This deficient practice resulted in R292 receiving an unprescribed antipsychotic medication. Findings include: On [DATE] the facility self-reported a medication error involving R292. The facility investigation report revealed R292 was admitted to the facility on [DATE] with admission orders that included Aricept (a medication for Alzheimer's type dementia). The investigation reported the facility's pharmacy provider dispensed Aripiprazole (also known as Abilify, an antipsychotic medication for schizophrenia-type disorders) instead of the Aricept that was prescribed. The investigation acknowledged nurses at the facility dispensed Aripiprazole to R292 instead of the Aricept prescribed by the resident's physician. An onsite investigation was conducted on [DATE]. R292 was admitted to the facility [DATE] with a diagnosis of dementia among others. A Minimum Data Set (MDS) Assessment was completed on [DATE]. According to section E of the MDS, R292 did not experience any hallucinations or delusions, and did not display any behavioral concerns toward himself or others. Section N did not have antipsychotic medication usage reflected in the coding. Section I of the MDS did not indicate any psychiatric disorders that would warrant consideration of an antipsychotic medication. A review of R292's Medication Administration Record (MAR) revealed R292 was administered Aripiprazole instead of Aricept from [DATE] through [DATE], for a total of forty-seven doses of the incorrect medication before the error was identified. The MAR revealed seven nurses had administered the incorrect medication for forty-seven days. The medical record of R292 revealed the medication error was identified on [DATE]. The facility Medical Director was notified on [DATE] and stated, it is a significant medication error. Staff A was interviewed on [DATE] at 2:30 p.m. Staff A confirmed he was a Registered Nurse (RN) and was previously in a nurse manager position at the facility. Staff A said he currently worked as the facility social services director. Staff A said the MAR for R292 correctly reflected the order for Aricept, but nurses administered Aripiprazole because pharmacy had linked the Aripiprazole medication to Aricept in the electronic MAR. Staff A confirmed Aripiprazole was administered to R292 but signed by nurses on the electronic MAR as Aricept. Staff A was asked if nurses should know the difference between Aricept and Aripiprazole. Staff A stated, I'm not going to answer that. The seven nurses involved in administering the incorrect medication to R292 were interviewed on [DATE] and [DATE]. The interviews were reviewed during onsite investigation on [DATE]. The nurses signed the interviews confirming they incorrectly administered Aripiprazole instead of Aricept to R292. The pharmacy director was interviewed on [DATE] at 2:42 p.m. The pharmacy director stated the medication error for R292 started when the Aripiprazole was incorrectly entered by the pharmacy's order entry technician and released by the pharmacist. The pharmacy director said side effects of Aripiprazole included in part: drowsiness, fatigue, lethargy, weakness, increase risk for falling, and low-grade fever. The medical record of R292 revealed the resident experienced four falls without injury during the time the resident was receiving Aripiprazole. R292 was assessed by the nurse practitioner (NP) on [DATE]. The NP visit note read in part: . Significant medication error. Consultation was made with the pharmacist and the Medical Director regarding this patient's plan of care. Abilify (Aripiprazole) 10 mg was administered from [DATE] - [DATE] in place of the patient's Aricept 10 mg daily. The patient does have symptoms to include lethargy, weakness, intermittent hallucinations, lower extremity edema, and low-grade fever. A physician note dated [DATE] read in part: . With acute hypotension as above and chronic intermittent hypotension (suspect multifactorial- Parkinson's, medication side effect (Abilify). R292 expired [DATE]. The death certificate documented the cause of death as Atrial fibrillation with rapid ventricular response (a heart condition). The death certificate documented other significant conditions contributing to R292's death were Parkinsons Disease (a disorder of the nervous system) and Lewy Body Dementia (a progressive dementia). The Director of Nursing (DON) was interviewed on [DATE] at 3:15 p.m. The DON confirmed the nurses should have identified the medication error sooner. The DON conveyed the facility had already implemented corrective action and provided documentation that supported efforts to correct the deficient practice. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included nurse education, review of all residents receiving Aripiprazole and Aricept to determine any discrepancies (there were no further discrepancies identified), review by the facility's interdisciplinary team, notifiction to pharmacy manager, grievance filed for ability to link Aricept and aripiprazole, skilled therapists assessment of R292 with no decline in ADL or cognitive ability, facility audits with submission to facility QAPI Committee. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to maintain proper temperature of two products being served to residents from a hot steam table unit. 2. Failing to properly cool and store food which was leftover and planned to be served at a later date. These deficient practices have the potential to result in food borne illness among any and all 82 residents of the facility. Findings include: 1. On 4/25/23 at approximately 7:30 AM, the initial tour was conducted of the kitchen and associated satellite kitchens serving residents. During this observation period breakfast was being served. Temperatures of food on the steam table in the south wing's dining area were measured using a Super Fast steel probe Thermapen and found a pan of breakfast sausage was being held at 128 F. An interview was conducted Dietary Aide (DA) B at this time about the temperature of the food. DA C stated she had measured the food eight minutes ago and reported the temperature was 165 F. DA C could not explain how the food had lost that temperature in a short time. On 4/26/23 at approximately 11:35 AM, a stainless steel pan of chicken noodle soup was observed in a small steam table in the [NAME] View dining room. The temperature was measured using the same steel probe thermometer as above and found the soup was 118 F. 2. On 4/26/23 at approximately 7:50 AM, observations of the walk in cooler, in the main kitchen were conducted. A stainless steel pan of sliced turkey, covered with gravy was observed on the shelf, along with other foods being stored for future resident meals, and recognized from the previous day's meal serving. Certified Dietary Manager (CDM) A was requested to demonstrate the pan of turkey had been cooled appropriately. CDM A stated We didn't do cooling logs for that. When asked to explain why, CDM A stated the pan was not going to be served to the residents, rather was going to be served to staff in the basement staff area. When asked why it would make a difference as to whom it was going to be served, related to proper handling of the food, CDM A replied that it was thought that since it was not for residents' consumption, it did not have to be done and the kitchen staff did not have adequate time to perform proper cooling of the food. The FDA Food Code 2017 states: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54 C (130 F) or above; 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); P and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less.

Based on observation, interview, and record review, the facility failed to prevent falls with major injuries for two Residents (#1 and #3) of six residents reviewed for falls, and failed to properly assess four residents for the use of power lift recline chair remote controls (#1, #4, #5, #6). This deficient practice resulted in harm for Resident #1 (subarachnoid hemorrhages, pain and marked overall decline) and Resident #3 (left [CONDITION(S)], pain, and a functional decline), and the potential for other residents to sustain injuries from falls from remote control chairs. Findings include: Resident #1: Review of Resident #1's Minimum Data Set (MDS) assessment, reference date 12/04/20, revealed diagnoses including dementia, heart failure, stroke, kidney disease, depression, and anxiety. Resident #1 required two-person assistance for bed mobility, transfers, and toileting, one-person assistance for dressing, and supervision for eating. The Brief Interview for Mental Status (BIMS) was administered, and revealed a score of 99, which indicated the resident was unable to complete the assessment, indicating severe cognitive impairment. An earlier BIMS assessment on 9/03/20 revealed a score of 1/15, indicating severe cognitive impairment. The assessment revealed Resident #1 had unclear speech, was sometimes understood, and had impaired vision. Resident #1 demonstrated no range of motion impairment for the upper extremities on the 12/04/20 assessment. Review of the facility document, Resident #1's 5 Day Investigation Report, received 1/14/20, revealed, Reported incident: On December 21, 2020, at 3:38 PM, [CNA (Certified Nurse Aide) K] entered the resident's [Resident #1's] room and found [Resident #1] laying on her right side on the floor. The resident was assessed [by RN B] .and found to have a large hematoma to her right temple [side of head] area. After physician consult, it was decided [Resident #1] should be transported to [the local hospital Emergency Department]. Computed tomography revealed multiple subarachnoid hemorrhages .Conclusion: The resident fell when alone in her room and [Resident #1] is unable to report the details of her fall .Reconstructing the incident indicates that the resident likely pressed the remote [control] to her chair, causing it to lift her forward and onto the floor. The witness statements corroborate the reconstruction of resident's fall. She [Resident #1] is at increased risk for falls and bleeding. Review of Resident #1's Emergency Department document, dated 12/21/2020, titled, Final Report, revealed, [AGE] year-old female resident of a local nursing home presents by ambulance with decreased level of consciousness after a fall. Fall was unwitnessed but we believe she [Resident #1] dropped her remote and was using her lift chair to get up when she fell forward, striking her head. She was found on the floor with decreased level of consciousness .Medical Decision Making: CT [Computerized Tomography] scan of the head shows subarachnoid bleed of bilateral frontal lobes and parietal lobe [sections of the brain assisting with cognitive, sensory, and motor function]. Discussed with [Resident #1's] daughter the diagnosis [and] grave prognosis and she understands .She [Resident #1] will be transferred back to nursing home [sic - with] the order for hospice consultation and comfort care only. She [daughter] was given scripts [prescriptions] for [MEDICATION(S)] [Lorazepam - for agitation] and [MEDICATION(S)] [[MEDICATION(S)] -for pain] .Assessment/Plan: 1. Subarachnoid bleed .hospice consultation. 2. Head injury .3. Fall .4. UTI [urinary tract infection] . Review of the witness statement by CNA K, dated 12/21/20, revealed, .Do you have any idea how this could of [sic] happened? Resident [#1] grabbed her remote [control] from recliner [chair] and hit [the] button; [the] chair rose up all the way up and [Resident #1] fell out. Resident [#1] does always play with all her chords [sic] around her especially call light. Chord [sic] for chair [recliner chair] is inches from the top of arm rest [of recline chair]. When I walked in [the] chair was up all the way in [the] air. Resident [was] on [her] right side on the floor . Review of the witness statement by RN B, dated 12/21/20, Resident #1's nurse on 12/21/20, revealed, When did you last see the resident? Sitting in [her] [power lift] recliner as I walked by.[Resident #1] got a hold of the chair controller and lifted the chair up to its highest position. [Resident #1] lifted herself up in the lift chair and fell out onto the floor . During a phone interview on 1/19/21 at 4:30 p.m., CNA K stated, .I was an aide on the floor .I seen [sic] her call light go off .I went in there, and she [Resident #1] was laying on the floor, with the [power lift] recliner chair [raised] all the way up .[Resident #1] was conscious. She wasn't talking .I immediately got the nurse .We called an ambulance right after that. CNA K was asked to describe the chair, and responded, It [the power lift recline chair] was bluish/greenish in color . CNA K stated the staff used the chair to assist with sit to stand transfers to complete with one-person assistance; otherwise Resident #1 required two-person assistance for transfers. CNA K was asked about Resident #1 'playing with the cords.', per her witness statement. CNA K stated, She [Resident #1] likes to pull the call light and tap the buttons .She always used the call light to call somebody [for assistance] . During a phone interview on 1/19/21 at 5:30 p.m., CNA M confirmed she was Resident #1's afternoon aide. CNA M stated, .This is a resident [#1] who used her call light frequently. The last time I was with her that day she was sitting in her [power lift] recliner as she did every day. The call light was in her lap. The chair remote control to my recollection was in the pocket of her chair on the right side. We would put it in that pocket or hang it on her tray table; we would never put it on her lap. She did not use it typically .She would play with the cords, mostly the call light but there was a time or two it was the cord to the remote too . CNA M reported toileting had been completed in the last hour before the fall. CNA M reported Resident #1 had attempted self-transfers from the recline chair in the last couple months, and she had reported this to an unknown nurse, but did not report to the nurse when Resident #1 fidgeted with her call light or remote control cord. During an interview on 1/14/21 regarding Resident #1's 12/21/20 fall, RN B stated, .I gave her [Resident #1's] medications; she was in her [power lift] recliner. She had put her light on. [CNA K] was going to answer the light. She [CNA K] was at the doorway and heard her fall .She [Resident #1] lifted the chair all the way up and it dumped her on the floor. It's a living room chair that lifts [a person from a seated position to a standing position] by a button [remote control] .She did hit her head; the left side of her head was on the floor . RN B confirmed Resident #1 did use her call light to communicate her needs. RN B reported most of the time staff put the recliner chair remotes in the side pocket of the chairs. When asked about Resident #1's injuries, RN B reported, You could see the bruising already [on her head]; it hadn't broken the skin, there was no bleeding. She [Resident #1] wasn't talking. She usually spoke . During an observation of Resident #1's [power lift] recline chair, with Maintenance Director, Staff F on 1/14/21 at 1:10 p.m., Staff F explained, This is [Resident #1's] chair .It is operational to the best of our knowledge. We didn't see anything that gave us pause about it .We do an inspection when the chair is brought in .There are no other inspections completed. Staff F reported since this incident all recline style chairs [including manual and power lift] in the building were inspected, adding, We have not added any [other] inspections in maintenance. Staff F reported the manufacturer's date on the chair was 2017. During this same observation, Surveyor noted Resident #1's recliner chair was a blue cushioned upright power lift living room style chair, with a remote control with two raised buttons, which maneuvered the chair from a recline position, to a seated position, and then to an upright/partial standing position. The chair seat to floor height was measured with Staff F, which at the highest height increased to approximately 27 inches (at the back seam of the chair seat to the floor) when it was in an upright position. (Typical floor to seat height for most standard chairs ranges from 16 to 22 high, Standard and Ideal Office Chair Heights (See List) - Ergonomic Trends, ergonomic trends.com, accessed 1/21/21.) The chair and remote appeared to be operational with no concerns found during the observation. There was a fabric pocket on the right side of this chair, where the remote control was stored. The remote control for the chair position was attached to the right side of the chair via a black curled electric cord, and the chair itself was plugged into an electrical socket for power operation during this observation by Staff F. A maintenance work order form provided by the Director of Nursing [DON] verified this chair was new, and provided to Resident #1 on 11/24/20. Staff F verified the chair was inspected at that time with no concerns found. Review of the manufacturer's directions for the Power Lift and Recline Chair Owner's Manual [Vendor Name], provided by the DON on 1/19/21, revealed on page 5, .Your [Vendor name] power lift chair is a medical device. Therefore, you are required to exercise caution when operating it to ensure your personal safety and that of others around you. Page 6 revealed, .Do not operate this product if you have any medical conditions that result in limited, debilitating mental or physical capacity. You should consult your doctor before using this product. The final page of the manual (not numbered) revealed in a warning box, .Only the occupant should operate it [the power lift recline chair]. Review of Resident #1's, Fall Risk Evaluation, dated 12/21/20, revealed, Score: 18: At risk for falls .Level of consciousness: Intermittent confusion. Ambulation status: Chairbound .assist with elimination [toileting]. Vision status: Poor. Gait/balance: .Decreased muscle coordination. Requires use of assistive devices . Review of Resident #1's current Care Plan, accessed 1/20/21, revealed, Falls: I am at high risk for falls r/t [related to] confusion, gait/balance problems, poor communication/comprehension, vision/hearing problems .Revision date 12/21/20: I have recently started to attempt to stand up or transfer without assistance. DO NOT give me the remote to the [power lift] recliner as I am not able to use the controls safely. I may not have my feet elevated when I am in my room along [sic - alone] . This Care Plan intervention was added after Resident #1 had the fall with injury from the power lift recline chair. Review of Resident #1's MAR (Medication Administration Record), revealed one dose of [MEDICATION(S)] 0.5 mg prn (as needed) had been administered on 1/23/21 [after return to the facility]. Further review revealed [MEDICATION(S)] (Solution 20 mg/ml) 0.5 ml had been administered, two doses on 12/22/21 and one dose on 12/23/21. Resident #1 was not on [MEDICATION(S)] or [MEDICATION(S)] prior to her fall, demonstrating increased pain after the fall with injury. Resident #3: Review of Resident #3's MDS assessment, reference date 12/29/20, revealed diagnoses including dementia and [CONDITION(S)] (high cholesterol). Resident #3 required two-person assistance for bed mobility, transfers, walking, dressing, and toileting, and supervision and set up for eating. The BIMS was administered, and revealed a score of 99, which indicated the resident was unable to complete the assessment, indicating severe cognitive impairment. Review of the facility document, Resident #3's 5 Day Investigation Report .received 1/14/20, revealed, Reported incident: On January 12, 2021, at 8:35 p.m., the resident [Resident #3] fell in his room. He experienced pain, left leg shortening, and external rotation. He [Resident #3] was sent to [nearby hospital in region]. At midnight, the facility was notified he had received a left leg [hip]. fracture .Investigation: .Upon entering the room, resident [#3] [was] noted to be lying on his left side at the end of his bed, with [his] head near wall and dresser. He began to complain of pain during assessment of legs and hips. Upon attempting to stand the resident [#3], it was noted his left leg was not bearing weight .CNA [H] reports she had cared for the resident, assisting him to use the toilet and helped him into bed. She further states the resident had gone to bed with regular socks on. Conclusion: The resident [#3] fell when alone in his room, fracturing his left hip. He fell while wearing regular socks, which may have contributed to the fall . Review of Resident #3's hospital discharge summary, dated 1/15/21, revealed, Diagnosis this visit: Intertrochanteric fracture of left femur [left [CONDITION(S)]], metabolic [CONDITION(S)] [neurological (nerve) disorder in the brain not caused by primary structural abnormalities but rather from systemic illness] . Review of Resident #3's operative/procedure (surgical) report, dated 1/13/21, revealed, Operation performed: Trochanteric femoral nail; left hip [fracture repair by internal fixation device (pin/nail) to hold the bones together to support the hip] . Review of Licensed Practical Nurse (LPN) L's witness statement revealed, What was the resident [#3] doing prior to this incident? .Sleeping in his bed. [Resident #3] attempted to transfer/walk on his own .Do you have any idea how this could have happened? Unsteady; improper footwear . During a phone interview on 1/19/21 at 3:55 p.m., LPN L reported she was approaching Resident #3's room as she was alerted Resident #3's alarm sounded when she heard him fall. LPN L stated, That's when I noted him [Resident #3] on the floor. He speaks but not in sentences, he was saying 'ow'. He was not capable of telling me what happened .he was grimacing [in pain] .When the CNA [J] and I went to assist him, I noticed he didn't put that foot down .Once I got him on the bed I touched his hips and I could feel his hip didn't feel right .His leg [left] was shorter than the other and rotated outward, and I saw it was probably a fracture, and I knew I needed to get him out [of the facility] for an assessment . Surveyor asked what Resident #3 was wearing. LPN L stated, Blue socks. They were not gripper [non-slip] socks . LPN L was asked what type of footwear was reflected in the Care Plan for Resident #3. LPN L stated, I believe his Care Plan did say 'gripper socks', and I normally put gripper socks on someone who ambulates, even if it's not alone [with staff]. So just to be safe we put gripper socks on him (normally) .One person can walk with him generally [prior to the fall] . During an interview on 1/14/21 at 4:30 p.m. with the Nursing Education Director, Registered Nurse (RN) I and CNA H, CNA H confirmed she was taking care of Resident #3 on the afternoon shift on 1/12/21, the date of Resident #3's fall, and was asked what occurred. CNA H stated, So the night that [Resident #3] fell , he was laying in [his] bed and I was in with another resident. When I came out from the [other] resident [room] I was with, I found out he [Resident #3] had fallen. I put him to bed that night and he was sleeping. He got up and fell .He [Resident #3] was wearing regular socks. I had looked at his Care Plan. It was a brief look; I saw he was extensive [assist] for transfers. I didn't look for that [type of footwear to be worn]. Usually you should always put grippy [gripper] socks on someone with an alarm but I didn't . CNA H explained she had received a reeducation from the facility which included reviewing resident Care Plans to see which residents ambulate and wear gripper socks. Resident #3 was unavailable for observation and interview, as he remained at the hospital during the 1/14/21 survey observations. Review of Resident #3's Care Plan prior to the 1/12/21 fall revealed, .I have self-care deficit r/t [related to] to advanced dementia .TRANSFERS: Independent to limited assistance .Activities: [Resident #3] is dependent on staff for meeting emotional, intellectual, and social needs r/t Cognitive deficits .At risk for falls related to confusion and frequent wandering .Ensure that appropriate, non-slip footwear is on at all times, date initiated: 09/23/2020 . Review of Resident #3's .Fall Risk Evaluation .dated 12/29/2020, revealed, Score 10, At risk [for falls]. Level of consciousness/mental state: Disoriented x 3 [to person, situation, and time] at all times .Balance problem while standing, balance problem while walking . Review of Resident #3's Stop and Think Post Fall Huddle . dated 1/12/21, revealed, .[Resident #3] did not have on grip socks, but had on regular socks .How could we have prevented the fall? Followed Care Plan for appropriate footwear Review of Resident #3's Medication Administration Record (MAR), accessed 1/19/21, revealed eight separate doses of (scheduled) [MEDICATION(S)] [Hydrocodone-Acetaminophen (5-325 mg) (pain medication)] [scheduled twice a day] had been administered since Resident #3's return to the facility from the hospital on 1/15/21, and three additional doses [as needed] had been administered on 1/15/21, 1/16/21, and 1/18/21. Resident #3 was not on [MEDICATION(S)], or any other pain medication prior to his fall. Review of Resident #3's progress notes since return to the facility revealed Resident #3 required a full body lift for functional transfers, demonstrating a significant functional decline since the fall with left [CONDITION(S)]. During a phone interview with the Assistant Director of Nursing (ADON) on 1/19/21 at 2:49 p.m., the ADON confirmed Resident #3's Care Plan was not followed at the time of this fall, and the lack of gripper socks (or appropriate footwear) likely contributed to his fall with injury. Residents #4, #5 & #6: During observations on the memory care units on 1/14/21, from approximately 2:00 p.m to 3:00 p.m., this Surveyor observed three power lift recliner chairs with remote controls, with CNA C, belonging to Residents #4 and #6, and observed the chair belonging to Resident #5 with memory care unit manager, RN G. It was noted these power recline lift chairs observed in each resident's room had different remote button styles, and the varying number of buttons on the remote control of each chair. During an interview on 1/14/21 at approximately 2:15 p.m., Resident #6 was observed dressed and wearing appropriate footwear, seated in the dining room. Surveyor attempted to interview the resident, and noted Resident #6 was oriented to himself, but was unable to engage in meaningful conversation. It was evident Resident #6 struggled with cognitive impairment. During an interview on 1/14/21 at approximately 2:37 p.m., Resident #4 was observed well-groomed and seated in a beige Geri chair [nursing home padded positional chair with wheels], positioned in a partial recline position. Resident #4 was oriented to herself, and could answer simple yes/no questions, with decreased response time noted. During an observation on 1/14/21 at 4:07 p.m., Resident #5 was observed dressed and wearing appropriate footwear, seated in the dining room in a manual wheelchair with antiroll backs on the wheels [to prevent the wheelchair from moving backwards.] She was oriented to herself and engaged in pleasant conversation with staff, who provided redirection/verbal cues as needed. During an interview on 1/14/21 at 2:51 p.m., RN G reported Resident #5 needed the recliner to maintain an upright posture due to [CONDITION(S)] (chronic obstructive pulmonary disease) diagnosis which caused respiratory (breathing) challenges, and conveyed Resident #5 often slept in the chair. RN G added staff more recently used the remote control stand feature to assist her to stand, as she recently needed two person assistance with transfers due to advanced arthritis and bone spurs (calcium deposit causing a bony protrusion) on her feet. During an interview on 1/14/21 at approximately 4:25 p.m., the DON was asked for any evidence of recliner/resident assessment for the safe use of power lift recline chairs in the facility. The DON had earlier provided copies of progress notes for Residents #1, #4, #5, and #6, which revealed evaluation of Residents' recline chairs safety, completed by the restorative nurse. The DON conveyed there were no assessments completed respective to resident assessment (functional ability-physical, cognitive, sensory, and safety assessment) for safe use power lift recline chairs in the facility. Review of Resident #4's MDS assessment, reference date 11/23/20, revealed diagnoses including dementia and anxiety. Resident #4 required two-person assistance with bed mobility, transfers, dressing, and toileting, and eating with set up. The BIMS was administered, and revealed a score of 5/15, indicating severe cognitive impairment. Resident #4's current physician orders revealed Resident #4 was receiving comfort care only. Review of Resident #5's MDS assessment, reference date 10/29/20 , revealed diagnoses including Alzheimer's disease, depression, and anxiety. Resident #5 required one-person assistance with bed mobility, transfers, walking, dressing, and toileting, and eating with set up. The BIMS was administered, and revealed a score of 99, indicating the assessment could not be completed, showing severe cognitive impairment. Review of Resident #6's MDS assessment, reference date 10/19/20 , revealed diagnoses including Alzheimer's disease, dementia, and anxiety. Resident #6 required two-person assistance with bed mobility, transfers, and toileting, one-person assistance with walking and dressing, and eating with supervision and set up. The BIMS was administered, and revealed a score of 99, indicating severe cognitive impairment. Review of Resident #4's, #5's, and #6's progress notes respectively revealed recent behavioral incidents, which showed these cognitively compromised residents required close monitoring, frequent redirection, and had limited personal safety awareness. Review of Resident #4's nursing progress note, dated 12/02/20, revealed, Resident still upset and hallucinating .[Resident #4] unsafe in her recliner [chair]. Review of Resident #4's, Fall Risk Evaluation, dated 12/03/20, revealed, Score: 18: At risk for falls .Level of consciousness/mental state: Disoriented at all times Ambulation status: Chairbound .assist with elimination. Gait/balance: Balance problems while standing .Decreased muscle coordination. Requires use of assistive devices . Review of Resident #5's, Fall Risk Evaluation, dated 10/30/20 (most recent), revealed, Score: 14: At risk for falls .Level of consciousness: Intermittent confusion. Ambulation status: Ambulatory/incontinent .Gait/balance: .Decreased muscle coordination. Requires use of assistive devices . Review of Resident #6's, Fall Risk Evaluation, dated 1/14/21, revealed, Score: 14: At risk for falls .Level of consciousness: Intermittent confusion. Ambulation status: Ambulatory/incontinent. Gait/balance: .Decreased muscle coordination. Requires use of assistive devices . Review of Resident #4's, #5's, and #6's current Care Plans revealed evidence of cognitive impairment and limited safety awareness: Resident #4's current Care Plan, accessed 1/20/21, revealed, High risk for falls, related to gait/balance issues, poor awareness to safety limitations, and history of frequent falls .[Resident #4] is not able to consistently operate the remote of her [power lift] reclining chair. As such, she is not safe to rest in the chair with the footrest up unattended. Make sure the remote of chair [recliner chair] is out of reach to reduce the risk of [Resident #4] unintentionally raising [sic] chair too far . Resident #5's current Care Plan, accessed 1/20/21, revealed, .I cannot use the remote for my reclining chair; keep the remote out of my reach . Resident #6's current Care Plan, accessed 1/20/21, revealed, At risk for falls related to history of falls, gait/balance issues and poor safety awareness .I am not safely able to operate the footrest of my reclining chair. Make sure the remote is out of my reach and do not leave [resident] unattended with footrest up . Review of the policy, Falls, Assessment, Evaluation, Prevention, and Management ., provided via email by the DON on 1/19/21 at 12:43 p.m., revised 7/08/20, revealed, .Evaluation .Care Coordinator will: a. Identify any risks/problems and initiate a safety care plan. B. Ensure interventions are put into place and are effective. During a phone interview with the Nursing Home Administrator (NHA) and the DON on 1/19/21 at 1:34 p.m., a policy related to equipment safety and resident assessment was requested. In response, the DON reported there was no policy specific to chair equipment safety, and explained a risk assessment form had been newly developed [after Resident #1's fall], and added to the EMR (Electronic Medical Record] resident documentation to address this area.

Based on interview and record review, the facility failed to implement their policy for reporting to the State Agency (SA) multiple unwitnessed falls with fractures, resident to resident altercations, and alleged statements of mistreatment and or abuse for five residents (#3, #5, #10, and #18) and two Supplemental Sampled Residents (#S51,and #S53) out of 15 residents reviewed for abuse/neglect reporting from a total sample of 23 residents. The Facility was placed in Immediate Jeopardy (IJ) on 3/23/17 at 11:16 a.m. as a result of the facility's failure to protect residents from abuse and/or neglect by not implementing the Abuse, Neglect and Exploitation Policy (dated 2/12/17) as regards investigating and reporting potential abuse and significant bodily injury for the following six Residents (#3, #5, #10, #18, #S51, #S53) out of the facility population of 112 vulnerable residents. This deficient practice placed all residents at risk for serious harm, injury and/or death. The Administrator was notified of the Immediate Jeopardy on 3/23/17 at 11:16 a.m. On 3/22/17 during the annual recertification survey the incidents listed below were reviewed. The completed investigation and reporting files for these events, with the potential for multiple types of abuse, were requested. The facility was unable to provide evidence to show the incidents had been thoroughly investigated and reported to the SA, according to the Facility Abuse, Neglect and Exploitation policy and procedure (Revised 2/22/17) to rule out abuse. On 10/7/16 on the 100 Hallway, Resident #10 was found on the floor in her room with an unwitnessed significant injury, which was later confirmed to be a right wrist fracture. Resident #10 was found lying on her right side in front of recliner. The ordered exit alarm was not sounding, according to the incident report, dated 10/7/16. Facility was asked for a full investigation. The facility did not provide documentation showing they had ruled out physical abuse. On 10/11/16 in the 500 Hall Dining Room, Resident #18 was observed by staff being slapped across the face by Resident #S50. The Facility could not provide documentation to rule out willful resident to resident abuse. On 12/22/16 on the 600 Hallway, Resident #3 was heard yelling for help and reported that a Resident (#S52) had struck her, and Resident #S52 was witnessed exiting the room of Resident #3. No documentation of interviews were provided as requested with additional Residents in the surrounding area, no staff interviews were produced to determine if Resident #S52 was abusing other residents on the unit. No documentation was provided to rule out willful physical abuse had occurred. On 2/16/17 on the 500 Hallway, Resident #S53 alleged that she had been left uncovered without clothing in her room. Resident #S53 told her physician of this event. Resident #S53 believed a male resident found her this way and it bothered her. The Facility failed to provide witness statements, and interviews with residents nearby to rule out the potential for sexual abuse. On 2/19/17 on the 400 Hallway, the family of Resident #S51 witnessed staff exhibiting alleged verbal abuse towards Resident #S51. Per the facility incident report (2/19/17), the family member stated, A Certified Nurse Aide (alleged perpetrator) sort of threw her hands up, stated, I guess I can't help you, and left the room. The facility failed to thoroughly investigate for verbal abuse, staff burnout, or neglect. On 2/22/17 on the 500 Hallway, Resident #5 was found on the floor in her bathroom with an unwitnessed significant injury that was later confirmed to be a left [MEDICAL CONDITION]. There were no witnesses identified to this event. No witness statements or a completed investigation was provided for the time of this incident. The Facility failed to thoroughly investigate to rule out the potential for physical abuse. According to the facility policy and procedure titled: Abuse, Neglect and Exploitation revised, 2/12/17, the facility failed to follow 7. Investigation of alleged Abuse, Neglect and Exploitation . c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement . 13. In response to allegations of abuse, neglect, expoitation or mistreatemnt, the facility will: a. Ensure that all alleged violations involving abuse, negelct, expoitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immedicately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . The Immediate Jeopardy was removed on 3/23/17 at 4:10 p.m., when the Administrator and Director of Nursing (DON) completed the following, confirmed by this Surveyor by observation and record review: 1. Investigation of Alleged Abuse, Neglect and Exploitation. When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: a. Interviewing the involved resident, if possible, and document responses. If resident is cognitively impaired, interview the resident several times and compare responses. b. If there is no discernable response from the resident, or if the resident's response is incongruent with that of a reasonable person, interview the resident's family, responsible parties, or other individuals involved in the resident's life to gather how he/she believes the resident would react to the incident. c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. d. Document the entire investigation chronologically. 2. Resident Protection after Alleged Abuse, Neglect and Exploitation The facility will make efforts to protect all residents after alleged abuse, neglect and/or exploitation. Examples of ways to protect a resident from harm during an investigation of abuse, neglect and exploitation may include, but are not limited to: a. Temporary (less than 24 hours) separation from other residents if a resident's behavior poses a threat of abuse or violence b. Temporary or permanent room or roommate change, where incompatibility creates the potential abuse c. Safeguard valuables in a locked area (document in the medical record the items secured and the location.) d. Involve family members to sit with resident e. Temporary one on one supervision of a resident f. Engage resident in diversionary activities g. reassignment of nursing staff duties h. Time off for nursing staff i. Involve clergy, social services, and/or counselors as appropriate. j. Increased supervision of staff and/or residents k. Protection of staff and/or residents from retaliation. 3. Response and Reporting of Abuse, Neglect and Exploitation Anyone in the facility can report suspected abuse to the (State) abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse will: a. Respond to the needs of the resident and protect them from further incident b. remove the accused employee(s) from resident care immediately c. Notify the Director of Nursing and Administrator d. Initiate the investigation immediately by obtaining witness statements e. As directed by the Director of Nursing or Administrator or based on nursing judgement: i. Notify the attending physician, resident's family/legal representative and Medical Director. ii. Contact the State Agency and the local Ombudsman office to report the alleged abuse. iii. If a crime, or suspicion of a crime has occurred, notify the local law enforcement agency. f. Monitor and document the resident's condition, including the response to medical treatment or nursing interventions. g. Document all actions taken in the medical record Although the Immediate Jeopardy was removed, the facility's noncompliance with F226 continued at a patterned level with the potential for more than minimal harm, pending the completion and maintained complaince: 3/22/17 - 6pm Placed 50 copies of Witness Statements at each of the four Nurse Stations when above education. 3/23/17 - 11:30am Administrator and Director of Nursing were provided with training (via phone) from (Nursing Home Administrator consultant) on the elements of a thorough abuse investigating and reporting of such. 3/23/17 - 12:15pm All Department Heads were informed of the need for immediate plan of correction and were re-educated on the Abuse, Neglect and Exploitation policy and the Witness Statement form. All Dept. Heads were assigned to provide a copy of Abuse, Neglect and Exploitation policy and assigned to educate their entire staff with the requirement that all working staff be re-educated by the end of his/her shift. 100% of employees working 3/23/17 between the hours of 1pm and Midnight will be re-educated on the Abuse, Neglect and Exploitation policy. Employees not working this day will be educated on his/her next scheduled day to work. All employees on leave of absence will be re-educated that this re-education is mandatory prior to his/her next day of work. This re-education will be tracked by the Administrator and Director of Nursing to ensure compliance is 100%. 3/23/17 - 1:15pm All Social Workers assigned to interview all interview able residents (identified as interviewable through the MDS PHQ data) using the following six questions: 1. Do you feel safe here? 2. Do you feel staff treat you with respect? 3. Are your needs being met here? 4. Can you tell me if you have any current concerns? 5. Would you feel comfortable telling someone if something was bothering you? 6. Who would you talk with? 3/23/17 - Administrator and Director of Nursing will review, with Social Workers, all resident interview answers done on 3/23/17 by 11pm. Any concerns will be investigated and reported per policy. 3/23/17 - Administrator and/or Director of Nursing will review ALL Accident/Incident reports daily for three months and implement actions/investigations according to policies 'Fall Prevention' and 'Abuse, Neglect and Exploitation'. All of the above corrections will be verified by the State Agency before the facility is deemed in compliance. Findings include: During the annual re-certification survey dated from 3/20/17-3/23/17, the Director of Nursing (DON) was asked by this Surveyor for the three past Abuse and Neglect investigations that were not reported to the State Agency (SA) for review on 3/22/17. A document titled (Facility name) Investigation - February 19, 2017 was in the folder. Resident #S51 is a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. that occurred on 2/18/17 during the afternoon shift. FM OO stated: (CNA PP) was assisting her mother adjust her pillows, (CNA PP) sort of threw up her hands, stated I guess I can't help you and left the room. An interview was conducted with the DON on 3/22/17 at 2:30 p.m., requesting the interview statements from the other residents on the unit regarding the care provided by CNA PP, and interview statements by the charge nurses to reveal any concerns with the performance of CNA PP. The DON stated she didn't collect any other statements from residents or from CNA PPs coworkers. I interviewed the resident (#S51) and the CNA (PP) . that was all. A document tilted (Facility Name) Investigation - February 16, 2017 was also in the investigation folder and not reported to the SA. Resident #S53 reported to her attending physician (Staff RR) during rounds on 2/16/17 at 10:00 a.m., that she (Resident #S53) had been left uncovered - without clothes on (in her room). Registered Nurse (RN) BB informed the DON immediately. According to the investigation report, Resident #S53 was admitted to the facility on [DATE] and she was moderately cognitively impaired with a BIMS (Brief Interview of Mental Status) score of 7/15. Her admission Diagnoses: [REDACTED]. An email from RN BB to the DON on 2/16/17 at 11:22 a.m., revealed the facility was aware of the occurrence stated above on the midnight shift. Resident #S53 had made a simular statement to RN SS the night before. Although several staff members were interviewed, the facility failed to notify the Administrator/Director of Nursing when the statement was first verbalized on the midnight shift to RN SS, and failed to obtain written statements from all staff involved. The facility failed to report this allegation to the SA as well. This was confirmed during the interview with the DON on 3/22/17 at 2:30 p.m. Resident #3 A review was conducted of Resident #3's INCIDENTS/ACCIDENTS electronic charting for incidents which occurred between the dates of 12/15/16 through 2/07/17. On 12/22/16 at 6:45 p.m., Certified Nurse Aide (CNA) GG heard Resident #3 shouting .get her out of my room .she hit me . CNA GG redirected Resident S#52 out of her room. CNA GG notified Licensed Practical Nurse (LPN) KK and the Administrator. The incident was unwitnessed. A review of Resident #3's medical record revealed she was [AGE] years old, had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident had scored 1/15 on the Brief Interview of Mental Status (BIMS) assessment, indicating severely impaired cognition. A review of Resident #S52's Behavior Care Plan dated 2/28/17, written by Social Worker (SW) NN, revealed Resident #S52 was [AGE] years old and was diagnosed with [REDACTED].wandering .rummaging .can react physically if feeling threatened . On 3/20/17, during the initial tour at 10:20 a.m., Resident S#52 was observed residing on the secured 500/600 unit. On 3/21/17 at 3:50 p.m., the DON was asked for the complete investigation and reporting details of the resident to resident altercation. The DON stated since there was no injury, she had asked a few questions of the staff, the incident was not investigated any further and was not reported to the state agency. On 3/22/17 at 3:07 p.m., Unit Manager/Registered Nurse (RN) W was interviewed about the 12/22/16 Resident to Resident altercation. RN W said, .if (#S52) feels threatened she could strike out .after (12/22/16) incident (#S52) was made a 1:1 (someone watching her at all times) .I don't make that decision (when to report altercations to the SA) .not involved with the investigation (possible abuse) . On 3/22/17 at 3:20 p.m., an interview was conducted with the DON pertaining to the facility policy on abuse. The areas in the policy under how to conduct an investigation was very specific. When this was pointed out to her, specifically about not following their policy in regards to not having interviews with signed statements,which included residents as well as staff, the DON had nothing to say. The facility failed to follow the policy: lack of a complete and thorough investigation, lack of written and signed statements by staff involved with the incident, lack of interview statements of residents regarding feeling safe, and not reporting within the required 24 hour hour period the Resident to Resident altercation to rule out potential abuse. Resident #5 A review of Resident #5's medical record revealed she had been admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS assessment dated [DATE] revealed the Resident had scored 4/15 on the BIMS assessment, indicating severely impaired cognition. On 3/20/17 at 10:37 a.m. an interview was conducted with RN W regarding Resident #5. When asked if there had been any falls, RN W stated, Yes, She had a fall with a [MEDICAL CONDITION] in February 2017. A review of the Incident Nurse Charting documentation for a fall dated 2/22/2017 revealed the following, . 7:40 p.m. Bathroom. (Resident) sitting on the floor, in her bathroom, her back to the door frame . Resident crying out in pain with ROM (range of motion) to her left knee. Faint abrasion to her back . Transferred to emergency room . It appears resident was attempting to transfer herself to the toiled .Witnesses: None . A review of the Physician Progress Assessment note dated 2/27/17 revealed, .1) status/post: surgical repair of fracture left hip . On 3/20/17 at 2:00 p.m., the DON was asked to provide the completed investigation and reporting details for Resident #5's 2/22/2017 fall. On 3/21/17 at 4:00 p.m. the DON was asked for the completed investigation of the unwitnessed fracture, including witness statements from staff who were interviewed. On 3/22/17 at 9:20 a.m., the DON provided one witness statement written by RN Y regarding the 2/22/2017 fall dated on 3/22/17. On 3/22/17 at 12:16 p.m., the DON was interviewed regarding the lack of investigation regarding the unwitnessed fall resulting in fracture. When asked where the interviews and investigations were, the DON reported that she only had the witness statement from RN Y dated for that morning. When asked if Resident #5 had a roommate at the time of her unwitnessed fall, the DON reported, Yes. When asked if the Roommate had been in the room at the time of the fall, the DON stated, I dont know. When asked if it would have been possible for the roommate to have pushed Resident #5, the DON stated, I dont know. When asked to confirm that the DON had not documented any investigation when the incident occured, the DON nodded and stated, I understand. The facility failed to follow their policy to complete a thorough investigation, collect witness statements, and report the injury of unknown origin to rule out potential abuse. According to the MDS assessment dated [DATE] Resident #18 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #18 had a Brief Mental Interview per staff assessment signifying Resident #18 as severely cognitively impaired with inattention and disorganized thinking continuously. According to a 03/23/17 print-out of Resident #S50 Social Service Progress notes dated 10/14/16 through 11/08/16 indicates Resident #S50 is a [AGE] year old female with consistent physical behaviors/interactions with other residents. According to the facility Incident/Accident report dated 10/12/16, indicated an altercation between Resident #18 and #S50 on 10/11/16 at 4:15 p.m It was recorded on this report under Incident Type: potential for bruising. Under Possible Factors it was recorded Resident #18 was slapped on the left side of her face by Resident #S50. Under Physician Notification: was recorded no need to notify. Under Actions was recorded continue to observe. Under Notification: the report was blank and under Notification(s): notification attempted, but did not indicate to whom. There was no documentation of Administrator notification or of DON notification. An Incident /Accident report completed on 11/01/16 for an incident on 11/01/16 which indicated another altercation between Resident #18 and #S50. It was recorded under Incident Type: Resident (#18) was sitting in wheelchair by nursing office on HZV A (Horizonvue A hall) when resident (#S50) slapped resident (#18) on the right side of face. Under Physician Notification: it recorded no need to notify. Under Notification: it was blank and under Notification(s): N/A (not applicable). The DON recorded the incident. No documentation of investigative interviews were provided of the incidents involving Residents #18 and #S50. No documentation was provided on the administrator being notified. No documentation was provided for either incident to indicate an investigation was done to rule out willful physical abuse had occurred or for a report filed with the state of the resident to resident altercations. On 3/22/17 at 4:50 p.m. an interview was conducted with CNA V about abuse, neglect and reporting. CNA V stated, As soon as you know about any abuse or neglect, you make sure the resident is safe and report to the administrator, if you can't, then the DON, and if you can't, then the charge nurse or nurse manager. CNA V also stated that she would report any incidence of a resident being hit. On 03/23/17 at 10:50 a.m. an interview was conducted with RN W. When asked why the 10/11/16 resident to resident altercation wasn't recorded as that, RN W stated she had been instructed to enter the incident as a potential for Bruising as it was a late entry, after the incident occurred. RN W stated, (the DON) does the follow up investigations. She'd be the one to have witness statements. On 03/23/17 at 8:13 a.m. an interview was conducted with CNA MM in which she stated, If you suspect any abuse, call the administrator and if not available the DON or house supervisor. They will investigate and they'd report to the state if they have to. On 03/23/17 at 11:13 a.m. an interview was conducted with CNA X in which she stated she was witness to the 10/11/16 altercation. CNA X stated Resident #S50 looked like she was just going to walk by Resident #18 and slapped her. She said she did give a statement over the phone but did not recall signing any statement or form or writing out a statement. CNA X stated, There's no specific form done. She went on to say she was the one to call the administrator and was told to monitor Resident #18's skin. Resident #10 A Review of the facility Incidents/Accidents reports, revealed on 10/7/16, on the 100 Hallway, Resident #10 was found lying on her right side in front of her recliner. The ordered exit alarm was not sounding, according to the incident report, dated 10/7/16. A review of the x-ray dated 10/8/16 revealed a significant injury, a right wrist fracture involving the distal metaphysis with impaction, and associated soft tissue swelling. The physician was contacted and Resident #10 was sent to the hospital, to set the fracture. Facility was asked for a full investigation. The facility did not provide documentation showing they had ruled out physical abuse. Per Resident #10's MDS assessment dated [DATE], her [DIAGNOSES REDACTED]. Resident #10's cognition was found to be mild/moderate with slight confusion. She required one assist for transfers, ambulation, hygiene, toileting, and bathing. On 3/22/17 at 3:20 p.m., the DON was asked to provide an investigation or witness statements for this unwitnessed event that occurred on 10/7/16. No investigation or witness statements were received from the facility. The Abuse Policy was not followed related to reporting unwitnessed falls with fracture and conducting investigations which included witness statements.

This Regulation will have two different Deficiency Statements. Findings include: A. Based on interview and record review, the facility failed to provide adequate supervision, and asistive devices, specifically a fall alarm were utilized in attempt to prevent falls resulting in significant injury and subsequent decline for three Residents (#3, #5, and #11) out of 14 residents reviewed for falls with significant injury from a total sample of 23 residents. This deficient practice resulted in increased pain, residents no longer ambulating, and decline in mood. Findings include: According to the electronic medical record and Minimum Data Set (MDS) assessment, dated 1/16/17, Resident #11 is a [AGE] year old female, admitted to the facility on [DATE], then re-admitted on [DATE] with the following Diagnoses: [REDACTED]. According to the accident report dated 9/21/16 at 6:50 p.m., Resident #11 sustained a fall out of her wheel chair and onto to her left hip. This incident was witnessed by staff, however Resident #11 was alone in her room and the wheel chair breaks were found to be unlocked. Resident #11 was sent to the hospital the next day after complaints of hip pain, and the x-rays confirmed a fractured hip. The MDS assessment dated [DATE] (prior assessment to the fall on 09/21/16) revealed Resident #11 was only mildly depressed with a PHQ-9 score (depression screening) of 3, a two person limited assist for ambulation in the hallway, she needed set up help and supervision for eating and was frequently incontinent of bowel and bladder. The comparison MDS assessment dated [DATE] (after the fall and hip fracture) revealed a decline in Resident #11's mood by a PHQ-9 score of 09, she was no longer ambulatory in the hallway, needed extensive assist with eating by one staff member and was now totally incontinent of bowel and bladder. Resident #11 was initially on Norco (narcotic pain medication) 5 milligrams/ acetaminophen 325 milligrams 1/2 tablet three times a day scheduled for pain. After her fractured hip, the pain medication was increased to 1 full tablet of Norco 5/325 mg scheduled three times a day, and Resident #11 could have an additional 1 tab Norco 5/325 mg every 4 hours as needed. Resident #11 did use her additional Norco for pain control. Resident #3 A review was conducted of Resident #3's INCIDENT NURSE CHARTING (electronic charting for incidents) which occurred between the dates of 12/15/16 through 2/06/17. The charting revealed, on 2/06/17 at 6:45 p.m., Certified Nurse Aide (CNA) JJ observed Resident #3 walking unassisted, from the couch she was laying on, down the 600 Hall corridor. Resident #3 fell and complained of pain. Following an assessment by Registered Nurse (RN) II, Resident #3 was transferred to the Emergency Department for evaluation and treatment. .TEACHING DONE: move alarms with resident when transferring from surface to surface .PHYSICAL STATUS PRIOR TO FALL: unsteady gait .weakness / fatigue . A review of Resident #3's x-rays dated 2/06/17, revealed, .non-displaced comminuted (right) intertrochanteric fracture . A review of Resident #3's medical record revealed she had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS assessment dated [DATE] revealed the Resident had scored 1/15 on the Brief Interview of Mental Status (BIMS) assessment, indicating severely impaired cognition. Resident #3 ambulated with the use of a wheelchair. A review was conducted of Resident #3's CARE NEED (Falls) revised 1/30/17. The CARE NEED for Falls read, need you to monitor me for safety .history of falls .I am using an audible EXIT ALARM when I am in my w/c (wheelchair) and other chairs in the neighborhood .this is to alert you if I attempt to rise without assistance, for my safety . On 3/23/17 at 10:25 a.m. an interview was conducted with CNA HH pertaining to the 2/06/17 incident. CNA HH confirmed she was Resident #3's caregiver on 2/06/17 and she stated Yes, she had forgotten to transfer the audible alarm back onto Resident #3 after she helped Resident #3 transfer to the couch in the 600 Hall corridor. CNA HH said she did receive 1:1 re-education on always transferring alarms when ever residents were transferred to any chairs or couches. Resident #5 A review of Resident #5's medical record revealed she had been admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS assessment dated [DATE] revealed the Resident had scored 4/15 on the BIMS assessment, indicating severely impaired cognition. This MDS assessment also showed Resident #5 had a PHQ9 (assessment indicating depressive symptoms) of 3, and she required limited assistance of one person for walking and limited assistance for wheelchair mobility. This MDS assessment indicated Resident #5 had been found with occasional, mild pain of a score of 6. A review of Resident #5's MDS assessment dated [DATE] revealed she had scored severely impaired for cognitive function per staff assessment, and had incurred a fall with fracture prior to readmission to the facility. This assessment showed she had scored a 5 on the PHQ9V (staff assessment of depressive symptoms), was scored as not having walked during the assessment period, and required extensive assistance of one staff for wheelchair mobility. This assessment showed Resident #5 was experiencing frequent, moderate pain. The resident had a decline in mood, walking, locomotion, and pain between 9/29/16 and 3/8/17. On 3/20/17 at 10:37 a.m. an interview was conducted with Unit Manager/RN W regarding Resident #5. When asked if there had been any falls, RN W stated, Yes, She had a fall with a hip fracture in February 2017. A review of the Incident Nurse Charting documentation for a fall dated 2/22/2017 revealed the following, . 7:40 p.m. Bathroom. (Resident) sitting on the floor, in her bathroom, her back to the door frame . Resident crying out in pain with ROM (range of motion) to her left knee. Faint abrasion to her back . Transferred to emergency room . It appears resident was attempting to transfer herself to the toiled .Witnesses: None . A review of Resident #5's Physician Progress Assessment note dated 2/27/17 revealed, .1) status/post: surgical repair of fracture left hip . A review of an Interdisciplinary Team (IDT) note dated 3/6/17 revealed, .Discussed residents (#5's) current condition with IDT agreeing resident is at her baseline in comparison to last sig(nificant) change that was completed on 1/20/17. Care plan interventions for falls also reviewed with team agreeing they remain appropriate at this time. No care plan changes were made after Resident #5's 2/22/17 fall with hip fracture. A reivew of the Incident Nurse Charting dated 12/19/16 for Resident #5's fall that occured at 1:00 p.m. revealed, .possible bruising may exist. On 3/21/17 at 4:00 p.m. the DON was asked for the completed investigation of the unwitnessed fracture, including witness statements from staff who were interviewed. On 3/22/17 at 12:16 p.m., the DON was interviewed regarding the lack of investigation regarding the events of Resident #5's unwitnessed fall resulting in fracture. When asked where the interviews and investigations were, the DON reported that she only had the witness statement from RN Y dated for that morning. When asked if Resident #5 had a roommate at the time of her unwitnessed fall, the DON reported, Yes. When asked if the Roommate had been in the room at the time of the fall, the DON stated, I don't know. When asked if it would have been possible for the roommate to have pushed Resident #5, the DON stated, I don't know. When asked to confirm that the DON had not documented any investigation when the incident occured, the DON nodded and stated, I understand. The evidence indicated the facility failed to do a thorough investigation and implemented no new interventions to prevent a similar fall from happening again. On 3/23/17 at 10:44 a.m. a phone interview was conducted with Certified Nurse Aide (CNA) K was asked about the 3/22/17 fall, as she had been assigned to care for Resident #5 during the time of the fall. CNA K stated, By the time I got there she was sitting in the wheelchair. When asked if Resident #5 had been exhibiting pain, CNA K stated, Yes. When asked if it was normal behavior for Resident #5 to try to transfer herself to the bathroom, CNA K stated, No. She normally didn't do that. On 3/23/17 at 1:45 p.m. an interview was conducted with Registered Nurse (RN) Y who when asked about the unwitnessed fall stated, I observed her (Resident #5) on the floor in the doorway of the bathroom. I was pretty postive she had a fracture. When asked if Resident #5 had the behavior of trying to self transfer herself to the bathroom, RN Y stated, No, not recently. RN Y was asked if he had been questioned by the DON about the event and stated, The unit facilitator sent an email asking for clarification. When asked if he had been asked to provide a witness statement at the time of the event, RN Y stated, No. Not then. B. Based on observation, interview and record review, the facility failed to ensure proper safety in transporting residents in their wheelchairs, affecting four residents (#9, #16, #17, #20) out of 23 total sampled residents and four supplemental residents (S55, S56, S57, S58). This deficient practice has the potential to result in residents being injured during transport from one location to another, including feet catching on the floor and propelling the residents forward out of their wheelchair. Findings include: Resident #9 On 3/20/17 at 10:28 a.m., Resident #9 was observed being propelled in her wheelchair, by an unknown visitor and Resident #9's feet were observed bent backwards underneath the wheelchair, with the toes of her shoes dragging on the floor. Review of Resident #9's Electronic Medical Record (EMR) revealed she had [DIAGNOSES REDACTED]. A review of Resident #9's MDS assessment dated [DATE], indicated Resident #9 required one assist for transfers, ambulation, hygiene, bathing, toileting. A review of Resident #9's Falls Care Plan revealed the resident was at risk for falls and should have non-skid foot wear on at all times. The Fall Care Plan also indicated Resident #9 required extensive assist in all care areas, including transfers. Resident #20 On 3/20/17 at 2:53 p.m., Activities Aide N was observed propelling the wheelchair for Resident #20 without foot pedals and Resident #9 was holding her feet up. Resident #S56 On 3/20/17 at 2:55 p.m., CNA O was observed propelling Resident #S56 in her wheelchair out of the dining area without foot pedals on the wheelchair and Resident #9's feet were dragging on the floor. On 3/20/17 at 2:57 pm Activities Assistant Director M was observed shuffling three unknown residents out of the dining room in their wheelchairs into the hallways without foot pedals and the three unknown residen'ts feet were dragging on the floor. Resident #S57 On 3/20/17 at 3:27 p.m., CNA K was observed propelling Resident #S57 in her wheelchair without foot pedals from the resident's room to the Jordan River Room with Resident #S57's feet dragging on the floor. On 3/20/17 at 3:36 p.m., an interview was conducted with Assistant Activities Director P who stated residents should have foot pedals unless they are propelling themselves. This Surveyor asked if residents are dragging their feet on the floor is it appropriate to propel them without foot pedals, and she replied absolutely not. On 3/20/17 at 3:43 pm an interview was conducted with CNA Q. CNA Q stated foot pedals were on unless care planned not to be; or if a resident asked for foot pedals not to be put on, then the foot pedals would be stored in the back of their wheelchair. CNA Q also stated, If staff is propelling a resident without foot pedals they are to be in view of resident's feet in case their feet drop and staff can stop immediately. CNA Q was asked if it was appropriate practice to push resident from behind if the resident is dragging their feet on the ground. CNA Q responded, On a resident to resident basis. On 3/20/17 at 4:00 p.m., an interview was conducted with Restorative Aide R. Restorative Aide R stated use of foot pedals are dependent on resident need and some residents refuse foot pedals. This Surveyor asked, if when a resident is being propelled by staff, is it acceptable to push the resident with their feet dragging on the ground. Restorative Aide R said, Not usually, because that can be dangerous. Restorative Aide R also stated, We have had to go backwards (pull the resident instead of push) to keep a resident safe for residents refusing foot pedals. Resident #16 On 3/21/17 at 3:34 p.m. CNA S was observed propelling resident #16 down a hallway in her wheelchair without foot pedals. According to Resident #16's MDS assessment dated [DATE], she required one assist for transfers, dressing, hygiene, bathing, and toileting. The MDS assessment revealed Resident #16 was not walking at the time of the assessment. Resident #16 had sustained an unwitnessed fall that did not result in injury on 12/3/16, according to the EMR. According to Resident #16's care plan she needed a wheelchair with a gel cushion and bilateral foot pedals when not self-propelling her wheelchair. Resident #16's care plan also indicated Resident #16 had poor safety awareness. Resident #16 was observed with tennis shoes for foot wear at the time of this observation. Resident #S55 On 3/22/17 at 2:53 p.m., Support Services Staff U was observed propelling Resident #S55 without foot pedals in the hall and Resident #S55 was holding her legs in the air while the staff person was propelling her to her destination. Resident #S55's care plan was reviewed which showed for mobility the care partner was instructed to have foot pedals on if Resident #S55 was not self-propelling her wheelchair. Resident #17 On 3/20/17 at 10:30 a.m., an interview was conducted with Resident #17. She was sitting in her room, in her wheelchair with socks on her feet. She said she propels herself, in her wheelchair, using her arms, down the hallway. When asked, by this Surveyor if she is ever pushed by the staff to help her out, Resident #17 responded, .yes, I get pushed .(staff) do not use foot pedals .they (foot pedals) get in the way (after they are done pushing her and she is propelling herself). A review of Resident #17's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had minimal cognitive impairment. Resident #20 According to the electronic face sheet, Resident #20 is a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An interview took place with Resident #20 an her Family Member (FM) LL on 03/23/17 at 2:10 p.m. Resident #20 was sitting in her wheel chair, her upper body was observed to be jerking back and forth, causing her to slide forward in her seat, placing her at risk of falling out of the wheelchair. Resident #20 was asked how she gets to other activities outside her room and to other locations in the facility. The foot pedals for her wheel chair were observed to be in a bag on the back of her wheel chair during this conversation. FM LL replied, I don't put the wheel chair pedals on her wheel chair, she holds her feet up and I push her. FM LL was asked what could happen if his mother (Resident #20) should experience her jerking movements from her Parkinson's and should happen to drop her feet? FM LL replied, I guess she could fall. Resident #S58 On 3/23/17 at 11:30 a.m., Resident #S58 was being pushed down the 400 Hall corridor by Restorative Aide R. Restorative Aide R was walking next to him and talking with Resident #S58, while Resident #S58 kept his feet lifted up, doing none of the propelling. There were no foot/leg pedals being used to protect his feet/ankles from going under his wheelchair if he would get tired and put his feet down.

Based on observation, interview and record review, the facility failed to implement skin care interventions to prevent a decubitus ulcer from developing for one Resident (#11) of five sampled residents reviewed with pressure ulcers, from a total of 22 sampled residents. This deficient practice resulted in Resident #11 developing an avoidable stage III decubitus ulcer. Findings include: A review of Resident #11's Minimum Data Set (MDS) assessment dated [DATE] revealed a [AGE] year old woman was readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS also revealed Resident #11 was coded as having severe cognitive impairment and was at risk for developing decubitus ulcers. A review of Resident #11's skin care plan for skin integrity dated 1/28/14, read, "...Skin Care: ...my skin is fragile... I will remain free of areas of pressure and other skin breakdown..." A review of Resident #11's Braden Scale scoring tool revealed: 2/01/14 - scored "low risk" for developing decubitus ulcers, 5/02/14 - scored "high risk" for developing decubitus ulcers, 7/29/14 - scored "high risk" for developing decubitus ulcers. There were no revised "Skin Care" plans written on 5/02/14 or 7/29/14, once Resident #11 was assessed at high risk and continued to be high risk for skin breakdown. There were no added interventions such as, allow regular position changes and the use of pressure relieving interventions, float feet with pillows, or monitor feet with cares. A review of Registered Nurse (RN) Supervisor "G"'s initial skin assessment progress note (for the decubitus ulcer) dated 8/01/14 read, "(Resident #11) (found) with open area to bottom of foot distal to 5th digit, scant amount of blood observed on sheets by (unknown Certified Nurse Aide (CNA)) during am cares, foot assessed and nurse notified... (ulcer) 1.7 centimeters (cm) X (by) 1.9 cm round area with smaller 0.9 cm X 1.0 cm round area within, smaller area is open, wound base is deep red/black, unable to measure depth however, tissue loss is noted... larger area appears calloused, skin is hard and white turning boggy and pink to red closer to open area... scant amt (amount) of sanguineous drainage noted... area cleansed and dried, [MEDICATION NAME] and allevyn dressing applied, rook boot placed, physician noted... orders for monitoring, dressing change, wound healing supplement written, (care plan) updated..." A review of "Skin Care" plan for Resident #11 updated 8/01/14 read, "...have pressure sore on bottom of left foot... make sure I am wearing my Rock Boot at all times except during transfers... need to float my feet with pillows when I am in bed and resting in recliner... Monitor my feet with cares and report new findings to nurse immediately..." A review was conducted of Resident #11's physician progress notes [REDACTED]. 8/07/14 - PAC "J" wrote, "(Resident #11) has developed... (decubitus) ulcer stage 2 with small central area unable to stage... recheck in one week..." 8/13/14 - PAC "J" wrote, Resident #11 left foot assessment "stage III (decubitus) ulceration, central area has unroofed... still with copious exudate..." On 1/22/15 at 9:15 a.m., this surveyor observed Resident #11's stage III left foot decubitus ulcer dressing change. Resident #11 was laying on her right side and Physician "K" redressed the decubitus ulcer with the help of RN Supervisor "G" and Licensed Practical Nurse (LPN) "X". The decubitus ulcer was observed tender to the touch for Resident #11 and the size was measured by Physician "K" as 0.9 millimeters (mm) X 0.6 mm with minimal depth. There was no drainage and the ulcer appeared to be healing with pink tissue around the center dot and the surrounding tissue blanched. This sore was identified by RN Supervisor "G" as the same stage III decubitus ulcer which began on 8/01/14. An interview was conducted with Supervisor (RN) "G" on 1/23/15 at 10:00 a.m., pertaining to Resident #11's stage III decubitus ulcer. This surveyor asked her for any documentation which would demonstrate Resident #11's decubitus ulcer was unavoidable. Supervisor RN "G" stated, "...If I had it, I would have brought it to you..." On 1/23/15 at 1:00 p.m., an interview was conducted with the Administrator pertaining to Resident #11's left foot stage III decubitus ulcer. The Administrator stated she was aware of the situation and confirmed Resident #11 had developed the stage III foot ulcer at the facility. ( ) --

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION AND ENCOURAGE ASSISTIVE DEVICES TO PREVENT ACCIDENTS FOR ONE RESIDENT (#1), IDENTIFIED IN A FACILITY REPORTED INCIDENT FOLLOWING A FALL OUT OF TOTAL FACILITY POPULATION OF 113. THIS FACILITY DEFICIENT PRACTICE RESULTED IN HARM TO RESIDENT #1 WHEN HE fell AND SUSTAINED A FRACTURE TO RIGHT LEG WITH LOSS IN PHYSICAL MOBILITY. FINDINGS INCLUDE: ON 6/13/12 AT APPROXIMATELY 9:30 A.M., AN INVESTIGATION WAS INITIATED INTO A FACILITY REPORTED INCIDENT INVOLVING RESIDENT #1 IN WHICH RESIDENT #1 fell IN HIS ROOM SUSTAINING A FRACTURED RIGHT HIP. A REVIEW OF THE FACILITY'S INVESTIGATIVE REPORT OF THIS INCIDENT, DATED 6/4/12, REVEALED THAT EARLY ON THE MORNING OF 6/1/12 AT APPROXIMATELY 5:50 A.M., RESIDENT #1 SUSTAINED AN UNWITNESSED FALL IN HIS ROOM IMMEDIATELY AFTER HAVING INCONTINENCE CARE PROVIDED TO HIM BY CERTIFIED NURSE AIDE (CNA) "E". CNA "E" WAS IN THE ROOM WITH RESIDENT #1 AT THE TIME OF THE INCIDENT. A REVIEW OF RESIDENT #1'S ADMISSION FACE SHEET REVEALS THIS [AGE] year OLD MAN WAS admitted to the facility on [DATE]. THE FACILITY INVESTIGATIVE REPORT INCLUDED THE FOLLOWING CURRENT [DIAGNOSES REDACTED]. THE FACILITY'S INVESTIGATIVE SUMMARY REVEALED RESIDENT #1 WAS RESIDING ON THE HORIZONVUE SPECIAL NEEDS UNIT (SNU) OF THE FACILITY AT THE TIME OF THE INCIDENT. THE SUMMARY REPORT ALSO IDENTIFIED THAT RESIDENT #1 HAD BEEN INDEPENDENTLY AMBULATORY AND WAS ABLE TO TRANSFER HIMSELF AT THE TIME OF THE INCIDENT. A REVIEW OF RESIDENT #1'S FALL HISTORY AT THE FACILITY REVEALED THAT HE STUMBLED (WITHOUT FALLING) IN HIS BATHROOM AND WAS INTERCEPTED BY A CERTIFIED NURSE AIDE (CNA) ON 10/23/11. THERE WAS NO INJURY. RESIDENT #1 ALSO HAD A FALL ON 1/31/12, WHICH RESULTED IN AN ABRASION TO HIS RIGHT KNEE. STAFF HAD RESPONDED TO THE PRESSURE ALARM ON HIS BED IN THAT INSTANCE. THERE HAD BEEN NO OTHER HISTORY OF FALLS UNTIL THE FALL REPORTED ON 6/1/12. A REVIEW OF THE CARE PLAN FOR RESIDENT #1 AT THE TIME OF HIS 6/1/12 FALL REVEALED A CARE PLAN ENTRY DATED 5/1/12, UNDER THE CATEGORY OF MOBILITY. THE INTERVENTION READ, "I HAVE A SLOW GAIT WHEN I AMBULATE BUT PLEASE WATCH ME FROM AFAR FOR INDICATIONS OF DECLINE AND UNSTEADINESS. MY WIFE HAS REQUESTED A FWW (FRONT WHEELED WALKER) BE AVAILABLE IN CASE I GET TIRED." UNDER THE SAME MOBILITY HEADING IS LISTED THE FOLLOWING INTERVENTION UNDER THE HEADING OF "DEVICES". THE ENTRY LISTS "FRONT WHEELED WALKER. I WANT TO MAINTAIN MY ABILITY TO AMBULATE TO ALL AREAS AS LONG AS MY DISEASE PROCESS ALLOWS." UNDER THE HEADING OF "PERSONAL CARE" EFFECTIVE 5/1/12, THE FOLLOWING CARE DIRECTIVE IS IDENTIFIED, "VISION: I WEAR GLASSES WHEN I DESIRE." A CARE PLAN UPDATE, EFFECTIVE 5/10/12, AND LISTED UNDER THE HEADING "SAFETY NOTES" IDENTIFIES THE FOLLOWING INTERVENTION, "I HAVE A FRONT WHEELED WALKER TO USE AS I DESIRE. I AM SAFER AND MORE STEADY WHEN I AM USING MY WALKER, SO PLEASE REMIND AND ENCOURAGE ME TO USE IT AND PROVIDE IT TO ME IF I FORGET." ON 6/13/12 AT APPROXIMATELY 10:00 A.M., AN INTERVIEW WAS CONDUCTED WITH RESIDENT #1 IN HIS ROOM. RESIDENT #1 DID NOT RESPOND TO QUESTIONS REGARDING HIS FALL AND FRACTURE IN A MANNER THAT COULD EXPLAIN THE CIRCUMSTANCES SURROUNDING HIS FALL (TALKING ABOUT FISHING. SPEAKING TO HIS BROTHER WHO WAS NOT IN THE ROOM). ON 6/13/12 AT APPROXIMATELY 11:00 A.M., A TELEPHONE INTERVIEW WAS CONDUCTED WITH CNA "E" WHO HAD, BY HIS REPORT, BEEN THE ASSIGNED CAREGIVER FOR RESIDENT #1 ON THE MORNING OF THE INCIDENT. CNA "E" INDICATED THAT RESIDENT #1 HAD BEEN AMBULATING IN THE HALLWAY AT AROUND 5 A.M. CNA "E" IDENTIFIED THAT AROUND 5:45 A.M., HE PROVIDED INCONTINENCE CARE FOR RESIDENT #1 AND HELPED CHANGE HIS CLOTHING IN RESIDENT #1'S BATHROOM. CNA "E" STATED THAT WHEN HE WAS FINISHED , HE ASKED RESIDENT #1 IF HE WOULD LIKE TO SIT IN HIS CHAIR OR ON THE EDGE OF HIS BED AND RESIDENT #1 DECLINED BOTH OFFERS. CNA "E" STATED RESIDENT #1 BEGAN TO WALK AWAY TOWARDS THE DOOR. CNA "E" STATED HE LAST SAW RESIDENT #1 STANDING BY THE OPEN PRIVACY CURTAIN IN HIS ROOM AND HE SEEMED TO BE HANDLING THE CURTAIN. CNA "E" STATED THAT AS HE TURNED TOWARDS RESIDENT #1'S BED TO GATHER THE SOILED CLOTHING, HE HEARD A LOUD NOISE AND TURNED TO FIND RESIDENT #1 LYING ON THE FLOOR." CNA "E" STATED HE CONTACTED HIS CO-WORKER, CNA "F", TO GO AND GET HELP FROM THE NURSE, REGISTERED NURSE (RN) "D". RN "D" CAME ON THE SCENE IMMEDIATELY AND PROVIDED EMERGENCY MEDICAL CARE AS RESIDENT #1 WAS REPORTING PAIN IN HIS RIGHT SIDE. THE FACILITY INVESTIGATIVE REPORT REVEALED THAT RESIDENT #1 WAS SENT TO A LOCAL HOSPITAL WHERE X-RAY RESULTS DATED 6/1/12, REVEALED AN "IMPACTED RIGHT FEMORAL NECK FRACTURE", THE UPPER END OF THE THIGH BONE EXTENDING FROM THE HIP TO THE KNEE.. THE INTERVIEW WITH CNA "E" REVEALED THAT HE HAD NOT OFFERED OR SUGGESTED TO RESIDENT #1 THAT HE USE HIS FRONT WHEELED WALKER AS HE WALKED AWAY FROM CNA "E" AFTER CARES. CNA "E" STATED THAT RESIDENT #1 USUALLY REFUSED TO USE HIS WALKER AND IN THE INSTANCES IN WHICH HE DID, DID NOT SEEM TO RECOGNIZE WHAT THE WALKER WAS FOR (STATED THAT RESIDENT #1 WOULD FREQUENTLY STEP BACKWARDS WHEN GIVEN THE WALKER). CNA "E" STATED WHEN RESIDENT #1 FIRST ENTERED THE FACILITY IN 10/11, HE SEEMED TO USE THE WALKER MORE APPROPRIATELY, BUT ONLY SEEMED CONFUSED BY IT NOW. CNA "E" ALSO INDICATED HE DID NOT OFFER RESIDENT #1 HIS EYEGLASSES AS HE HAD ALWAYS REFUSED TO PUT THEM ON IN THE PAST. THE RIGHT HIP FRACTURE INCURRED BY RESIDENT #1 RESULTED IN A CHANGE IN HIS CONDITION AND DECLINE IN THE OVERALL LEVEL OF HIS FUNCTIONING. ACCORDING TO THE FACILITY INVESTIGATION REPORT DATED 6/04/11, RESIDENT #1 IS CURRENTLY NOT AMBULATING ON HIS OWN AND REQUIRES A FULL MECHANICAL LIFT FOR TRANSFERS. RESIDENT #1 HAD BEEN INDEPENDENT FOR AMBULATION AND SELF-TRANSFER PRIOR TO THE INCIDENT, AND FOLLOWING THE ACCIDENT HAS NOT BEEN ABLE TO BEAR WEIGHT SECONDARY TO HIS INJURY. ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THE USE OF SAFETY DEVICES (ALARMS) IDENTIFIED AND ORDERED TO PREVENT FALLS FOR 3 RESIDENTS (#51, #52 AND #53) OF 4 RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL FACILITY POPULATION OF 113 RESIDENTS. THIS FAILURE CONTRIBUTED TO FALLS FOR THESE VULNERABLE RESIDENTS WITH THE POTENTIAL FOR ADDITIONAL FALLS WITH INJURY. FINDINGS INCLUDE: THE FACE SHEET OF RESIDENT #51 REVEALED HE IS AN [AGE] year OLD MAN admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE "FALL RISK ASSESSMENT" DATED 7/17/12, SCORED RESIDENT #51 AT 13, WHICH INDICATED HE WAS AT HIGH RISK FOR FALLS. THE "SAFETY" CARE PLAN DATED 6/28/12 READ, "I HAVE A SILENT INFRARED ALARM IN PLACE TO BE USED WHEN I AM IN BED TO ALERT YOU TO MY GETTING UP." A REVIEW OF A "FALL REPORT" DATED 7/17/12 AT 11:15 P.M. READ, "DESCRIBE WHAT HAPPENED: STAFF OBSERVED RESIDENT SITTING ON THE FLOOR WITH BACK TO BED, FEET EXTENDED OUT." THERE WAS NO EVIDENCE OF AN INFRARED ALARM IN USE. THIS FALL REPORT'S "FALL SUMMARY" READ, "...HE (RESIDENT #51) HAS HISTORY OF FALLS ....HE HAS NO SAFETY AWARENESS...HE DOES NOT USE CALL LIGHT, NOR DOES HE CALL OUT FOR HELP...". THE PHYSICIAN'S REVIEW FOR THIS INCIDENT READ, "RESIDENT (#51) GAIT/BALANCE VERY POOR. INJURY TO LEFT FOREARM, SKIN TEAR. SITTING BALANCE ALSO VERY POOR." DURING AN INTERVIEW ON 8/9/12 AT 1:40 P.M., UNIT FACILITATOR - REGISTERED NURSE (RN) "F" STATED, "...YES, THE INFRARED ALARM DOES NOT APPEAR TO HAVE BEEN IN PLACE...ITS NOT ADDRESSED AT ALL IN THE INCIDENT REPORT....YES, THE ALARM WAS A SAFETY DEVICE TO ALERT STAFF HE (RESIDENT #51) WAS PUTTING HIMSELF IN AN UNSAFE SITUATION....SO THEY COULD RESPOND TIMELY TO PREVENT THIS (A FALL)." THE FACE SHEET OF RESIDENT #52 REVEALED SHE IS AN [AGE] year OLD WOMAN admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE "FALL RISK ASSESSMENT" DATED 7/21/12, SCORED RESIDENT #52 AT A 19 INDICATING RESIDENT #52 WAS A VERY HIGH FALL RISK. THE "FALL REPORT" FOR RESIDENT #52 DATED 7/21/12 READ, "FALL INTERVENTIONS ADDED: EXIT ALARM (PERSONAL TAB ALARM) ATTACHED TO RESIDENT WHEN SHE IS SITTING IN A CHAIR TO ALERT STAFF WHEN RESIDENT TRIES TO STAND SO THEY CAN ASSIST HER." A "FALL REPORT" DATED 7/25/12 READ, "RESIDENT WAS SITTING IN THE RECLINER IN THE ALCOVE ON (UNIT), SHE STOOD UP, WHEN SHE WENT TO SIT BACK DOWN SHE SAT ON THE EDGE OF THE CHAIR AND SLID OFF THE CHAIR." THERE WAS NO INDICATION AN EXIT (PERSONAL TAB) ALARM WAS IN USE FOR RESIDENT #52 AT THE TIME OF THE FALL. IN AN INTERVIEW ON 8/9/12 AT 1:50 P.M., WITH UNIT FACILITATOR RN "F", SHE STATED "HONESTLY, ...(RN "G") WROTE THIS (THE INTERVENTION OF THE EXIT ALARM ON 7/21/12 FOR RESIDENT #52) AND DIDN'T TELL ANYONE...THE INTERVENTION...EXIT ALARM (FOR RESIDENT #52) WAS ADDED TO THE WHEELCHAIR BY (RN "G") BUT SHE DIDN'T ADD IT TO THE CARE PLAN, SO ON 7/25/12 (LICENSED PRACTICAL NURSE (LPN) "H") REMOVED IT (THE ALARM) AND THE RESIDENT fell ....YES, THIS WAS POOR COMMUNICATION...I AGREE THIS WAS A HUGE PROBLEM AND MAY HAVE BEEN PREVENTED IF THE ALARM WAS IN USE." THE FACE SHEET OF RESIDENT #53 REVEALED SHE IS A [AGE] year OLD WOMAN admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE "FALL RISK ASSESSMENT" DATED 6/14/12, SCORED RESIDENT #53 AT 15 INDICATING RESIDENT #53 WAS A HIGH RISK FOR FALLS. THE CARE PLAN FOR RESIDENT #53 TITLED, "SAFETY" DATED 6/20/12 READ, "I HAVE NO SAFETY AWARENESS DUE TO MY DISEASE PROCESS...I HAVE AN EXIT (PERSONAL/TAB) ALARM ON WHEN IN W/C (WHEELCHAIR) AND A PRESSURE ALARM AT ALL TIMES. PLEASE MAKE SURE MY ALARMS ARE PRESENT AND FUNCTIONING AT THE START OF YOUR SHIFT." A REVIEW OF A "FALL REPORT" DATED 7/17/12, SHOWED RESIDENT #53 WAS SITTING IN HER WHEELCHAIR OUTSIDE THE (UNIT'S) DINING ROOM HOLDING ONTO THE HANDRAIL. STAFF PERSON "I" WALKED OUT OF THE DINING ROOM AND NOTED RESIDENT #53 LAYING ON THE FLOOR ON HER RIGHT SIDE WITH HER LEGS EXTENDED OUT PARALLEL WITH HER BODY. THERE WAS NO DOCUMENTED EVIDENCE OF AN EXIT (PERSONAL/TAB) ALARM OR A PRESSURE ALARM IN USE AT THE TIME OF THIS INCIDENT FOR RESIDENT #53. DURING AN INTERVIEW ON 8/8/12 AT 2:15 P.M. WITH UNIT FACILITATOR RN "F", SHE WAS ASKED FOR EVIDENCE OF ALARMS IN USE AT TIME OF RESIDENT #53'S FALL. REGISTERED NURSE "F" STATED, "I SURE CAN'T FIND IT. IT LOOKS LIKE, FROM READING THE INCIDENT REPORT, THAT INDEED THE PRESSURE ALARM TO (RESIDENT #53'S)WHEELCHAIR WAS NOT IN USE..OR THE EXIT ALARM....IF THE ALARMS WERE ON AND FUNCTIONING (STAFF PERSON "I") MAY HAVE BEEN ABLE TO RESPOND AND PREVENT HER FROM FALLING" DURING AN INTERVIEW ON 8/9/12 AT 2:25 P.M.WITH THE ADMINISTRATOR, SHE STATED, "I UNDERSTAND WE HAVE A PROBLEM...THE POC (PLAN OF CORRECTION) CAN BE GREAT BUT, IF ITS NOT IMPLEMENTED IT DOESN'T WORK. IF THE SAFETY INTERVENTIONS WERE NOT IN PLACE...THESE WERE AVOIDABLE (FALLS)... WE CAN'T SHOW ANYTHING DIFFERENT... I UNDERSTAND." IN AN INTERVIEW ON 8/9/12 AT 2:50 P.M. WITH UNIT FACILITATOR RN "F", SHE STATED, "MY UNIT HAS THE HIGHEST NUMBER OF FALLS IN THE FACILITY BECAUSE ALL MY RESIDENTS HAVE SEVERE DEMENTIA AND ARE STILL AMBULATING WITH POOR SAFETY AWARENESS RELATED TO THEIR DEMENTIA...ALL SAFETY INTERVENTIONS ARE IMPORTANT TO BE IMPLEMENTED SO WE CAN HELP PREVENT A FALL." ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE ONE (#1) OF NINE RESIDENTS REVIEWED FOR ADMINISTRATION OF MEDICATIONS WAS FREE OF ANY SIGNIFICANT MEDICATION ERRORS, RESULTING IN THE RESIDENT FALLING AND SUSTAINING A HEAD INJURY THAT REQUIRED hospitalization . FINDINGS INCLUDE: RESIDENT #1 WAS AN [AGE] year-old FEMALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO A FACILITY REPORTED INCIDENT/INVESTIGATION (FRI) DATED 4/29/2011, RESIDENT #1 RECEIVED MEDICATIONS INTENDED FOR RESIDENT #9. THE FOLLOWING EVENTS OCCURRED. ON THE MEDICATION OCCURRENCE REPORT DATED 4/28/2011 AT 9:16 A.M., STAFF "B" SELF-REPORTED A MEDICATION ERROR INVOLVING RESIDENT #1. STAFF "B" REPORTED GIVING RESIDENT #1 [MEDICATION NAME] 50 MILLIGRAMS (MG), [MEDICATION NAME] XL 100MG, [MEDICATION NAME] 150MG, AND [MEDICATION NAME] 10MG WHICH WERE ORDERED FOR RESIDENT #9. A REVIEW OF THE ACTIVE PHYSICIAN ORDERS [REDACTED].#1. IN ADDITION, THE MEDICATION OCCURRENCE REPORT READ "SOMEONE TO SBA (STAND BY ASSIST) FOR NEXT COUPLE HOURS DURING AMBULATION". THE CURRENT FALL RISK assessment dated [DATE], IDENTIFIED RESIDENT #1 AS NOT AT RISK FOR FALLS. RESIDENT #1 WAS FOUND ON THE FLOOR FROM AN UNWITNESSED FALL ON 4/28/2011 AT APPROXIMATELY 12:15 P.M. IN THE HORIZONVUE "A" CORRIDOR JUST PAST room [ROOM NUMBER]. THE FALL REPORT DATED 4/28/2011, INDICATED THAT RESIDENT #1 HAD A HEMATOMA ON THE BACK SIDE OF HER HEAD, WAS SPITTING UP BLOOD AND NOT SPEAKING. EMERGENCY SERVICES (EMS) WAS CALLED AND THE RESIDENT WAS TRANSFERRED TO THE HOSPITAL. A physician progress notes [REDACTED].M. ON 4/28/2011 READ, "PATIENT fell AFTER I LEFT THE DEMENTIA UNIT. FALL NOT WITNESSED. PATIENT VOMITED BLOOD AND HAD LARGE CONTUSION ON THE BACK OF HEAD. 911 CALLED AND PATIENT SENT TO emergency room BY AMBULANCE". ACCORDING TO THE FACILITY'S NURSING 2011 DRUG HANDBOOK, ALL ABOVE NAMED MEDICATIONS HAVE THE COMMON CENTRAL NERVOUS SYSTEM ADVERSE REACTION OF DIZZINESS, WHICH COULD LEAD TO A FALL. IN ADDITION, A BLACK BOX WARNING ISSUED READ "BECAUSE OF ITS PROARRHYTHMIC EFFECTS, [MEDICATION NAME] ([MEDICATION NAME]) SHOULD BE RESERVED FOR PATIENTS WITH LIFE-THREATENING VENTRICULAR ARRHYTHMIAS." DURING AN INTERVIEW WITH THE CONSULTANT PHARMACIST STAFF "G" VIA PHONE ON 6/2/2011 AT APPROXIMATELY 12:30 P.M, HE INDICATED THE FOUR MEDICATIONS OF [MEDICATION NAME] XL, [MEDICATION NAME], AND [MEDICATION NAME] COULD ALL CAUSE THE CENTRAL NERVOUS SYSTEM EFFECT OF DIZZINESS, AS STATED IN THE NURSING 2011 DRUG HANDBOOK. RESIDENT #1 RETURNED FROM THE HOSPITAL to the facility on [DATE] AT 10:15 A.M. ( )