Every finding on record at Greenridge Post Acute

Based on observation, interview and record review, the facility failed to ensure pain was controlled, for one of three sampled residents (Resident 1), when the facility failed to timely administer pain relief medication to Resident 1.A review of Resident 1's admission record (AR), dated 4/11/26, indicated Resident 1 was admitted for HB-SS with acute chest syndrome (sickle cell disease with sickle-shaped red blood cells blocking blood flow in the lungs, leading to inflammation, low oxygen levels and pain, including severe pain).During a record review of Resident 1's minimum data set (MDS, an assessment tool to guide resident care), dated 4/1/26, the MDS indicated Resident 1 had a Brief Interview for Mental Status score of 14 (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) During a record review of Resident 1's physicians' orders set titled, Order Summary Report, (OSR) dated 03/26/26, OSR indicated Resident1 had an order for Hydromorphone HCL (a strong synthetic narcotic medication used to treat moderate to severe pain) 2 mg tablet give 1 tablet every 12 hours as needed for severe pain, an order for Hydromorphone HCL 2 mg tablet give 1 tablet by mouth every 4 hours as needed for moderate pain and an order for Hydromorphone HCL 2 mg tablet give 1 tablet by mouth every 4 hours as needed for pain. During a concurrent observation and interview on 6/18/26 at 10:55 a.m. with Registered Nurse 1 (RN 1), at medication cart, RN 1 unlocked the medication cart, then unlocked the controlled medication drawer and removed the emergency medication kit (E-kit). The E-kit was a plastic box, secured with two zip ties. The E-kit contained hydromorphone 2 mg tablets. RN 1 stated, the facility had two medication carts and each cart had an identical E-kit. RN 1 stated, the E-kits contained hydromorphone 2 mg tablets, the pain medication ordered for Resident 1. RN 1 stated, the facility had a procedure for giving a resident medication on an emergency basis. RN 1 stated, Resident 1 had recently been admitted and had not yet received his supply of medications from the pharmacy. The facility's procedure was as follows: when a resident had an order for a medication that the resident needed on an emergency basis and the facility did not have that medication in the resident's medications, the licensed nurse called the pharmacy to obtain a code and after obtaining the code, the licensed nurse removed the medication from the E-kit and gave the medication to the resident. RN 1 stated, the pharmacy must be able to see the doctor's order for the medication to give out the code. During a concurrent interview and record review on 6/18/26 at 11:05 a.m. with RN 1, Resident 1's Progress Notes Type: Nurses Notes (PN NN), dated 3/26/26 at 16:54, PN NN indicated, Resident 1 was admitted to the facility from another facility, the doctor was aware of the admission and all orders had been entered in the electronic chart. RN 1 stated, Resident 1was admitted on [DATE] at 16:54. During a concurrent interview and record review on 06/18/26, at 11:15 a.m., with RN 1, Resident 1's Progress Notes, Nursing Advanced Skilled Evaluation (PN [NAME]), dated 03/26/26, was reviewed. The PN [NAME] indicated, Resident 1 had a pain score of 10 at 21:19. RN 1 stated, nurses note indicated Resident 1's pain score was a 10 out of 10 at 21:19. During a record review of Resident 1's Progress Notes Type: MDS Notes (PN MDS), dated [DATE] at 23:50, was reviewed. The PN MDS indicated, pt was complaining of pain, due to rx issues pain medication got delayed. Hospital was contacted with no success. NP [NAME] was contacted no response, spherical NP on call was contacted, however there was a problem obtaining an rx for controlled meds. Coordinated with pharmacy to obtain vo order, finally got a code for ekit. But patient was in pain that oral medication wont help him, per patient he needs IV meds for pain and requested to call 911. Before pt's left he took dilaudid oral. Per patient he wants to go to ED for IV pain medication . 911 came and transport the pt. During a record review of Resident 1's Progress Notes Type: MDS Notes (PN MDS), dated [DATE] at 23:56, was reviewed. The PN MDS indicated, contacted spherical on call with no answer. During a record review of Resident 1's Medication Administration Record (MAR), dated 3/1/26 - 3/31/26, the MAR indicated, Resident 1 received Hydromorphone HCL Tablet 2 mg by mouth on 3/26/26 at 2345 for pain. During a concurrent interview and record review on 06/18/26, at 11:28 a.m., with RN 1, Resident 1's OSR was reviewed. OSR indicated, Resident1 had one order for Hydromorphone HCL oral tablet 2 mg give 1 tablet by mouth every 4 hours as needed for pain order date 3/26/26 and start date 3/26/26. OSR also indicated, Resident1 had three orders for Hydromorphone HCL oral tablet 2 mg give 1 tablet by mouth every 12 hours as needed for severed pain order date 3/26/26 and start date 3/26/26 with one order indicated as phone order, another order as prescriber entered and the third order as a verbal order. OSR further indicated, Resident 1 had four orders for Hydromorphone HCL oral tablet 2 mg give 1 tablet by mouth every 4 hours as needed for moderate pain order date 3/26/26 and start date 3/26/26 with two orders indicated as phone orders, another order as prescriber written and the fourth order as prescriber entered. RN 1 stated, the multiple orders for hydromorphone tablet 2 mg for pain showed the nurse's attempts to get an order to be able to get a code from the pharmacy so the licensed nurse could open the E-kit to give hydromorphone to Resident 1 for pain. During an interview on 6/18/26 at 1:00 p.m. with RN 1, RN 1 stated, based on RN 1's review of Resident 1's chart, it appeared the licensed nurse taking care of Resident 1 on 3/26/26, had difficulty getting an order for pain medication necessary to get a code to open the E-kit to get pain medication to give to Resident 1. RN 1 stated, nursing notes indicated Resident 1 complained of pain of 10 at 21:19. RN 1 stated, nursing notes indicated there was a delay in giving pain medication. RN 1 stated, MAR indicated the pain medication, hydromorphone 2 mg, was given by mouth at 23:45. RN 1 also stated, nurses notes indicated Resident 1 asked to be transferred to the acute care hospital emergency department in order to receive intravenous pain medication because Resident 1 felt oral pain medication would not be able to adequately treat his pain. During an interview 6/18/26 at 1:29 p.m. with Director of Nursing (DON), DON stated a resident with serious pain needed to be treated right away. DON stated, it was not acceptable for a resident with a pain score of 10, to be in pain and to wait almost 2 and 1/2 hours for pain medication to become available. During a review of the facility's policy and procedure titled, Pain Assessment and Management, dated Revised March 2015, the P&P indicated, . 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident . [emphasis in original]During a review of the facility's policy and procedure titled, admission Criteria, dated Revised December 2016, the P&P indicated, Our facility will admit only those residents whose medical and nursing needs can be met . 6. Residents will be admitted to this facility as long as their nursing and medical needs can be met adequately by the facility .

Based on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of the residents, for one of three sampled residents (Resident 1), when the facility failed to obtain emergency medication to timely administer pain relief medication to Resident 1.A review of Resident 1's admission record (AR), dated 4/11/26, indicated Resident 1 was admitted for HB-SS with acute chest syndrome (sickle cell disease with sickle-shaped red blood cells blocking blood flow in the lungs, leading to inflammation, low oxygen levels and pain, including severe pain).During a record review of Resident 1's minimum data set (MDS, an assessment tool to guide resident care), dated 4/1/26, the MDS indicated Resident 1 had a Brief Interview for Mental Status score of 14 (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) During a record review of Resident 1's physicians' orders set titled, Order Summary Report, (OSR) dated 03/26/26, OSR indicated Resident1 had an order for Hydromorphone HCL (a strong synthetic narcotic medication used to treat moderate to severe pain) 2 mg tablet give 1 tablet every 12 hours as needed for severe pain, an order for Hydromorphone HCL 2 mg tablet give 1 tablet by mouth every 4 hours as needed for moderate pain and an order for Hydromorphone HCL 2 mg tablet give 1 tablet by mouth every 4 hours as needed for pain. During a concurrent observation and interview on 6/18/26 at 1055 a.m. with Registered Nurse 1 (RN 1) next to the medication cart, RN 1 unlocked the medication cart, then unlocked the controlled medication drawer and removed the emergency medication kit (E-kit). The E-kit was a plastic box, secured with two zip ties. The E-kit contained hydromorphone 2 mg tablets. RN 1 stated, the facility had two medication carts and each cart had an identical E-kit. RN 1 stated, the E-kits contained hydromorphone 2 mg tablets, the pain medication ordered for Resident 1. RN 1 stated, the facility had a procedure for giving a resident medication on an emergency basis. RN 1 stated, Resident 1 had recently been admitted and had not yet received his supply of medications from the pharmacy. The facility's procedure was as follows: when a resident had an order for a medication that the resident needed on an emergency basis and the facility did not have that medication in the resident's medications, the licensed nurse called the pharmacy to obtain a code and after obtaining the code, the licensed nurse removed the medication from the E-kit and gave the medication to the resident. RN 1 stated, the pharmacy must be able to see the doctor's order for the medication to give out the code. During a concurrent interview and record review on 6/18/26 at 1105 a.m. with RN 1, Resident 1's Progress Notes Type: Nurses Notes (PN NN) dated 3/26/26 at 1654, PN NN indicated, Resident 1 was admitted to the facility from another facility, the doctor was aware of the admission and all orders had been entered in the electronic chart. RN 1 stated, Resident 1was admitted on [DATE] at 1654. During a concurrent interview and record review on 06/18/26, at 11:15 a.m., with RN 1, Resident 1's Progress Notes, Nursing Advanced Skilled Evaluation (PN [NAME]), dated 03/26/26, was reviewed. The PN [NAME] indicated, Resident 1 had a pain score of 10 at 2119. RN 1 stated, nurses note indicated Resident 1's pain score was a 10 out of 10 at 2119. During a record review of Resident 1's Progress Notes Type: MDS Notes (PN MDS), dated [DATE] at 23:50, was reviewed. The PN MDS indicated, pt[patient] was complaining of pain, due to rx[treatment] issues pain medication got delayed. Hospital was contacted with no success. Nurse Practitioner (NP) was contacted, no response, spherical NP on call was contacted, however there was a problem obtaining an rx{order] for controlled meds. Coordinated with pharmacy to obtain vo{voice order], finally got a code for ekit[emergency kit]. But patient was in pain that oral medication wont help him, per patient he needs IV meds for pain and requested to call 911. Before pt[patient] left he took dilaudid (a potent synthetic opioid pain medication roughly 2 to 8 times stronger than morphine)oral. Per patient he wants to go to ED for IV pain medication . 911 came and transport the pt. During a record review of Resident 1's Progress Notes Type: MDS Notes (PN MDS) dated [DATE] at 2356, it indicated contacted spherical on call with no answer. During a record review of Resident 1's Medication Administration Record (MAR) dated 3/1/26 - 3/31/26, the MAR indicated: Resident 1 received Hydromorphone HCL Tablet 2 mg by mouth on 3/26/26 at 2345 for pain. During a concurrent interview and record review on 06/18/26, at 11:28 a.m., with RN 1, Resident 1's OSR was reviewed. OSR indicated, Resident1 had one order for Hydromorphone HCL oral tablet 2 mg give 1 tablet by mouth every 4 hours as needed for pain order date 3/26/26 and start date 3/26/26. OSR also indicated, Resident1 had three orders for Hydromorphone HCL oral tablet 2 mg give 1 tablet by mouth every 12 hours as needed for severe pain order date 3/26/26 and start date 3/26/26 with one order indicated as phone order, another order as prescriber entered and the third order as a verbal order. OSR further indicated, Resident 1 had four orders for Hydromorphone HCL oral tablet 2 mg give 1 tablet by mouth every 4 hours as needed for moderate pain order date 3/26/26 and start date 3/26/26 with two orders indicated as phone orders, another order as prescriber written and the fourth order as prescriber entered. RN 1 stated, the multiple orders for hydromorphone tablet 2 mg for pain showed the nurse's attempts to get an order to be able to get a code from the pharmacy so the licensed nurse could open the E-kit to give hydromorphone to Resident 1 for pain. During an interview on 6/18/26 at 1300 with RN 1, RN 1 stated, based on RN 1's review of Resident 1's chart, it appeared the licensed nurse taking care of Resident 1 on 3/26/26, had difficulty getting an order for pain medication necessary to get a code to open the E-kit to get pain medication to give to Resident 1. RN 1 stated nursing notes indicated Resident 1 complained of pain of 10 at 2119. RN 1 stated, nursing notes indicated there was a delay in giving pain medication. RN 1 stated, MAR indicated the pain medication, hydromorphone 2 mg, was given by mouth at 2345. RN 1 also stated, nurses notes indicated Resident 1 asked to be transferred to the acute care hospital emergency department in order to receive intravenous pain medication because Resident 1 felt oral pain medication would not be able to adequately treat his pain. During an interview 6/18/26 at 1329 with Director of Nursing (DON), DON stated a resident with serious pain needed to be treated right away. DON stated it was not acceptable for a resident with a pain score of 10, to be in pain and to wait almost 2 and 1/2 hours for pain medication to become available. During a review of the facility's policy and procedure titled, Pain Assessment and Management, dated Revised March 2015, the P&P indicated, . 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident . [emphasis in original]During a review of the facility's policy and procedure titled, admission Criteria, dated Revised December 2016, the P&P indicated, Our facility will admit only those residents whose medical and nursing needs can be met . 6. Residents will be admitted to this facility as long as their nursing and medical needs can be met adequately by the facility .

Based on interviews and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) received necessary care and services in accordance with professional standards of practice when Licensed Vocational Nurse (LVN) 1 did not re-assess and/or document Resident 1's vital signs (Vital signs reflect essential body functions, including heartbeat, breathing rate, temperature, and blood pressure and health care providers monitor vital signs to check patients' level of physical functioning) after a change in blood pressure (Blood pressure is the measurement of the pressure or force of blood inside your arteries. Each time heart beats, it pumps blood into arteries that carry blood throughout the body) and oxygen saturation (is the amount of oxygen you have circulating in your blood) values were noted significantly lower from Resident 1's baseline for more than 12 hours. This deficient practice placed Resident 1 at risk for delay in receiving higher level of care in a timely manner. Resident 1 was later transferred to the acute care hospital due to altered mental status and hyponatremia. Findings: 1.During a record review of Resident 1's Admission Record, printed on 4/13/23, the Admission Record indicated Resident 1 was admitted to the facility in November 2022. The Admission Record indicated that Resident 1 had medical diagnoses including multiple fractures of the pelvis, urinary tract infection, and atrial fibrillation (Atrial fibrillation is an irregular and often very rapid heart rhythm). During an interview on 6/13/24 at 4:00 p.m. with Resident Representative (RR), RR stated on 11/22/22, when he visited Resident 1 at 7:30 p.m., she was very confused. RR stated he notified the charge nurse to assess Resident 1 and to send Resident 1 out to the hospital. RR stated Resident 1 was not sent to the hospital until 11/23/22 around 2 p.m. During a concurrent interview and record review on 6/19/24 at 12:43 p.m. with Registered Nurse (RN) 1, Resident 1's Progress Notes were reviewed. RN 1 stated on 11/23/22 in the morning, RR called the facility to check if Resident 1 was sent to the hospital. RN 1 stated she assessed Resident 1 and noted Resident 1 to be confused. RN 1 notified Nurse Practitioner (NP) and got orders for stat labs. RN 1 stated around lunch time Certified Nursing Assistant (CNA) reported Resident 1 was not responding well and appeared more confused and Resident 1 was sent to the hospital around 2 pm. During a concurrent interview and record review on 6/19/24 at 1:10 p.m. with RN 1, Resident 1's Skilled services documentation and weights and vitals summary were reviewed. RN 1 stated on 11/22/22 Resident 1 ' s blood pressure (Normal range 120/80 mm hg- Systolic pressure reflects the force produced by the heart when it pumps blood out to the body, while diastolic blood pressure [the bottom number] is the pressure in your blood vessels when the heart is at rest) was documented as 97/58 mm Hg at 4:06 p.m. The document also indicated a triggered warning from the system that diastolic low of 60 exceeded. RN 1 stated Resident 1's blood pressure was lower than her baseline. RN 1 also stated the notes were documented by the morning shift, LVN 1. During a concurrent interview and record review on 6/19/24 at 1:15 p.m. with Registered Nurse 1, Resident 1's Skilled services documentation and weights and vitals Summary were reviewed. RN 1 stated on 11/22/22 Resident 1's oxygen saturation was documented as 90 % which is lower than her baseline. RN 1 stated Resident 1 did not have any underlying respiratory issue and an oxygen saturation reading of less than 93 % should be assessed. RN 1 stated a licensed nurse should have rechecked the vital signs and assessed the resident after a few minutes to ensure the vital sign numbers were correct and should have documented the findings. RN 1 also stated the next vital signs were documented on 11/23/22 at 7:55 a.m., which was more than 15 hours after noticing a change in Resident 1's vital signs from her baseline values. During a concurrent interview and record review on 6/19/24 at 3:35 p.m. with Director of Nursing (DON), Resident 1's diagnosis and progress notes were reviewed. DON stated Resident 1's systolic blood pressure is very low. DON also stated Resident 1 does not have any respiratory conditions and her oxygen saturation is 90%. DON stated the licensed nurse should have rechecked and compared the vital signs and documented the findings. DON also stated it is important to recheck because if the vital signs are persistently abnormal, they must notify the Physician. During an interview on 6/20/24 at 10:10 a.m. with NP, NP stated if there are changes to vital signs, staff should check if the vital signs are co-relating to resident's baseline. NP also stated staff should recheck and re-assess the resident and monitor every 30 minutes to ensure resident is stable. During an interview on 7/1/24 at 4:19 p.m. with LVN 1, LVN 1 stated she does not remember working with Resident 1. LVN 1 stated if there was a change in vital signs from a resident's baseline, she would recheck the whole set of vital signs again and document the rechecked vital signs. LVN 1 stated if any changes in condition or vitals are noted, it should be reported and followed up on. During a record review of Resident'1, Emergency Department Notes from the acute care hospital, dated 11/23/22, the Emergency Department Notes indicated Resident 1 was admitted to the Emergency Department with an altered mental status and hyponatremia (low sodium level in the blood and can cause mental confusion, seizures, coma, and death). Resident 1's sodium was 124 with normal range 136-144. During a review of the facility ' s policy and procedures (P&P) titled, Change in a Resident's Condition or Status, revised in May 2017, the P&P indicated, Procedure .3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR communication form 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food safely when the low-temperature dishwasher did not have sanitizer running through it on final rinse and when sanitization concentrations were not recorded on the sanitization log. This failure has the potential of placing 56 out of 57 residents at risk for food born illnesses. Findings During a concurrent observation and interview on 1/22/24 at 9:38 a.m., with Dietary Aide (DA1) and Certified Dietary Manager (CDM), in the kitchen, the bottle of chlorine sanitizer connected to the low-temperature dishwasher was empty. CDM stated the kitchen staff need to be checking sanitizer levels every day. CDM also stated that items that were previously washed need to be rewashed in order to prevent contamination. DA1 and CDM unable to state when the last time sanitizer level was checked. CDM stated that kitchen staff are to check the temperature and sanitizer concentrations before, during, and after shifts and record it in the log. During a record review of facility document titled Food and Nutrition: Dish Machine Temperature log - Low Temperature Machine (undated), indicated there were missing entries for 1/11/24, 1/20/24, 1/21/24, and 1/22/24. The temperature log also records sanitizer concentrations; for the dishwasher, the rinse concentration is 50-100 parts per million (ppm). The U.S Food and Drug Administration Food Code, dated 2022, indicted the presence of adequate detergents and sanitizers is necessary to effect clean and sanitized utensils and equipment .

Based on observation, interview and record review, the facility failed to ensure residents' rooms were safe, functional, sanitary and comfortable when, - Hot water in the bathrooms in rooms [ROOM NUMBERS] was too hot and - Air vent registers in rooms 29 A, 25 A, 21 A, 20 A, 18 A, 16 A, 10 A, 8 A, and 2 B were covered with thick brownish matter. These failures resulted in resident rooms 4,12, 29 A, 27 A, 25 A, 21 A, 20 A, 18 A, 16 A, 10 A, 8 A and 2 B not being safe, functional, sanitary and comfortable. Findings: 1. During an observation on 1/22/24 at 1:20 p.m., in the bathroom for room [ROOM NUMBER], the hot water felt too hot and measured 129.4 degrees Fahrenheit (F) (a measure of temperature used in the United States). 2. During an observation on 1/22/24 at 1:35 p.m., in the bathroom in room [ROOM NUMBER], the hot water felt too hot and measured 125.6 degrees F. 3. During a concurrent observation and interview on 1/22/24 at 1:58 p.m., with Administrator (ADM) and Maintenance Supervisor (MAINT) in the bathroom in room [ROOM NUMBER], the hot water felt too hot to the touch and measured 123.6 degrees F. ADM agreed the temperature was too hot at 123.6 degrees. 4. During a concurrent observation and interview on 1/22/24 at 2:03 p.m., with ADM and MAINT in the bathroom for room [ROOM NUMBER], the hot water felt too hot to the touch and measured 129.4 degrees F. ADM agreed the temperature was too hot at 129.4 degrees. 5. During an interview on 01/23/24 at 11:58 AM with ADM and Maintenance Supervisor from a sister facility (MAINT 1), both stated the hot water temperatures had been lowered, were no longer too hot and were below 120 degrees F in the resident bathrooms. 6. During an interview on 1/24/24 at 12:16 p.m. with MAINT, MAINT stated the hot water temperature should not be too hot because a resident could get burned. 7. During a review of the facility's policy and procedure (P&P) titled, Water Temperature, Safety of, dated Revised December 2009, indicated, 4. Maintenance staff shall conduct periodic tap water temperature checks . 5. If at any time water temperatures feel excessive to the touch.staff will report this finding to the immediate supervisor. 6. Direct-care staff shall be informed of risk factors for scalding/burns that are more common in the elderly. 8. During a concurrent observation and interview on 1/24/24 at 11:40 a.m., with Director of Nursing (DON) in rooms 16 A and 27 A, the air vents registers were covered with thick brownish matter. DON stated the air vent registers needed to be cleaned. 9. During an interview on 1/24/24 at 12:25 p.m. with Maintenance Supervisor (MAINT), MAINT stated he cleaned the registers monthly. 10. During an observation on 1/25/24 at 8:30 a.m. in rooms 2 B, 8 A, 10 A, 16 A, 18 A, 20 A, 21 A, 25 A, 27 A and 29 A the air vent registers were covered with thick brownish matter. 11. During a review of The Standard Practice for Inspection and Maintenance of Commercial Building HVAC Systems, dated 2018, page 8 indicated: b. Inspect grilles, registers, and diffusers for dirt accumulation .Clean as needed to remove dirt build up semiannually .replace if missing or damaged.

Based on observation, interview, and record review, facility failed to ensure kitchen staff were competent in job duties related to testing the sanitization solution concentration in the low temperature dishwasher. This failure has the potential for improper cleaning and sanitization which could lead to increase in risk for food-borne illness for 57 out of 57 residents. Findings: During a concurrent observation and interview on 1/22/24 at 9:30 a.m., in the kitchen, with Certified Dietary Manager (CDM) and Dietary Aide (DA1), DA1 was observed testing the sanitizer solution concentration of the low-temperature dishwasher. DA1 was observed letting the dishwasher run for two cycles, then taking the litmus test strip and dipping the strip on the residual water left on the plate covers for 5 seconds. CDM reminded DA1 that litmus paper should be dipped in the water at the bottom of the dishwasher. DA1 then dipped the litmus paper into the rinse water reservoir. CDM stated that DA1 should not test the rinse water reservoir since it is contaminated and the litmus paper needed to be dipped into the water at the bottom of the dishwasher. During the same observation and interview, DA1 stated sanitizer concentration in the dishwasher needs to be 120 ppm (parts per million). A review of facility's Dietary Aid job description, dated 2003, indicated the Dietary Aide performs a number of kitchen duties including Perform dishwashing/cleaning procedures . A review of facility's policy and procedure, titled Sanitization, dated 2008, indicated low-temperature dishwasher b. final rinse with 50 parts per million (ppm) hypochlorite (chlorine) .

Based on observation, interview, and record review, the facility failed to ensure the food quality and integrity of stored food items when: 1. In the kitchen's dry storage room, there were eight bags of marshmallows dated 8/25/21, three months past the recommended storage guideline of two months. 2. In the kitchen's dry storage room, there were two bags of hotdog buns dated 10/20/21, 14 weeks past the recommended storage guideline of seven days. This failure had the potential to result in the residents being offered less palatable food, which could result in less food intake and weight loss, or potentially developing food-borne illness. Findings: During a concurrent observation and interview in the kitchen on 2/7/22, at 11:30 a.m., with the Director of Food and Nutrition Services/Dietary Manager (DM), the DM confirmed the dry storage room contained the following items: 1. There were eight bags of marshmallows with a handwritten date of 8/25/21. Three of the eight packages had marshmallows stuck together along the inside of the bags with a texture not as soft as the rest of the contents. 2. There were two bags of hotdog buns with a handwritten date of 10/20/21. Parts of some of the hotdog buns were not as soft and tender as the other hotdog buns. The DM stated the dates on the bags of marshmallows and hotdog buns indicated the items should have already been discarded. During a concurrent interview and record review on 2/7/22, at 11:45 a.m., with DM, the facility food storage policies and procedures were reviewed. The DM stated the facility policy and procedure (PNP), RDs [registered dieticians] for Healthcare, Inc. 2018, Dry Goods Storage Guidelines, dated 2018, indicated the storage length guidelines for dry good storage. The DM confirmed the PNP indicated the recommend shelf storage time for unopened bread was 5-7 days; the recommended shelf storage time for unopened bags of marshmallows was two months.

Based on observation, interview, and record review, the facility failed to ensure three nursing staff performed required hand hygiene (handwashing or use of an alcohol-based hand sanitizer) for four of 12 sampled residents (Residents 39, 2, 8, and 25) when: 1. The Director of Nursing (DON) failed to perform hand hygiene between doffing soiled gloves and donning new gloves during Resident 39's wound dressing changes for two separate wounds. 2. Licensed Vocational Nurse 1 (LVN 1) failed to perform hand hygiene between doffing soiled gloves and donning new gloves during Resident 2's wound dressing change. 3. Licensed Vocation Nurse 2 (LVN 2) failed to perform hand hygiene before and after direct contact with Resident 8 to administer medication. 4. Licensed Vocation Nurse 2 (LVN 2) failed to perform hand hygiene before preparing medication for Resident 25, and before and after direct contact with Resident 25 to administer medication. These failures had the potential to cause infection or spread infection which could result in hospitalization for Resident 2, Resident 39, Resident 8, and Resident 25. Findings: 1. During a concurrent observation and interview on 2/8/2022, at 10:00 a.m., with the Director of Nursing (DON), in Resident 39's room, Resident 39 lay on her left side with one dressing on her mid-back, and one dressing on her coccyx (commonly called the tailbone). The DON performed a dressing change on Resident 39's mid-back wound: the DON removed the soiled dressing from Resident 39's wound, changed gloves, cleaned the wound, changed gloves, measured the wound, changed gloves, applied ointment to the wound bed, changed gloves, and placed a new dressing over the wound. The DON did not perform hand hygiene between any glove change during the dressing change procedure. The DON changed her gloves and repeated the process on Resident 39's coccyx wound, without any intervening hand hygiene between the mid-back and coccyx wound dressing changes. The DON stated hand hygiene was not necessary between glove changes during a procedure on the same resident. 2. During a concurrent observation and interview on 2/10/2022, at 12:11 p.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 2's room, Resident 2 lay on her right side with a dressing on her coccyx. LVN 1 performed a dressing change on Resident 2's coccyx wound: LVN 1 removed the soiled dressing, applied powder to the wound edges, changed gloves, and placed a new dressing over the wound. LVN 1 did not perform hand hygiene when she changed gloves during the dressing change. LVN 1 stated hand hygiene was not necessarily done with the glove change since she had worked between two areas she considered clean. 3. During a continuous observation on 2/8/22, from 4:30 p.m. to 4:45 p.m., Licensed Vocational Nurse 2 (LVN 2) stood at the medication cart in the doorway to Resident 25's room and prepared medications for Resident 25. LVN 2 carried the prepared medications in a cup into Resident 25's room and handed Resident 25 the medication cup. Resident 25 took the medications and returned the empty cup to LVN 2, who threw the cup in a trash can, and exited the room without performing any hand hygiene. 4. During a continuous observation from 4:45 p.m. to 5 p.m., LVN 2 left Resident 25's room and went directly to the medication cart, without performing hand hygiene. LVN 2 moved the medication cart down the hall to the doorway of Resident 8's room, and without performing hand hygiene, LVN 2 crushed pills and mixed them into applesauce in a small cup. LVN 2 took the applesauce cup into Resident 8's room and fed Resident 8 the applesauce-medication mixture. LVN 2 discarded the empty applesauce cup and exited Resident 8's room without performing any hand hygiene during the observation. During a telephone interview on 2/10/22, at 11:30 a.m., with LVN 2, LVN 2 stated the residents were not on any special isolation precautions and she believed she had followed all infection control measures when passing medications to Resident 25 and Resident 8. During an interview on 2/9/2022, at 1:44 p.m., with DSD/IP, DSD/IP stated staff were to wash their hands or use hand sanitizer each time they changed gloves and before and after resident care. A review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, dated 8/2015, indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . Before and after direct contact with residents; Before preparing or handling medications; . Before handling clean or soiled dressings, gauze pads, etc.; .After handling used dressings, contaminated equipment, etc. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observation, interview, and record review, the facility failed to ensure staff indicated the opened-on date for one of one multidose vial (vial of liquid medication intended for injection/infusion that contains more than one dose) of influenza vaccine. The failure to label the vaccine vial had the potential to result in facility residents receiving an expired, ineffective dose of influenza vaccine which would not provide adequate protection against influenza. Findings: During a concurrent observation and interview on [DATE], at 12:10 p.m., with the Director of Nursing (DON), in the medication refrigerator, in the medication storage room, there was an open box which contained a multidose vial of influenza vaccine. The DON confirmed the outside of the box had a handwritten date and initials, but the multidose influenza vaccine vial inside the box was uncapped and undated. The DON stated she was unable to be certain of the date the multidose vial was opened since the vial itself was not dated. A review of the facility's policy and procedure titled, Vials and Ampules of Injectable Medications, dated ,d+[DATE], indicated, The date opened and the initials of the first person to use the vial are recorded on multidose vials (on the vial label or an accessory label affixed for that purpose). A review of the Centers for Disease Control (CDC), Injection Safety, Information for Providers, Questions about Multidose Vials, dated [DATE], indicated, If a multi-dose (vial) has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

Based on interview and record review, the facility failed to ensure that the conservator (CV 1, a person who has health care/financial decision making capabilities) for one (Resident 1) of three sampled residents was notified when Resident 1 fell and sustained a nose fracture (a breaking of a nasal bone). This deficient practice resulted in Resident 1's conservator being unaware of Resident 1's fall and pending x-rays for two days, and unaware of the nose fracture for 15 days, and so was unable to assist with healthcare decision-making. Findings: Review of Resident 1's Admission Record, indicated Resident 1 was admitted to the facility in 2019 with an included diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's nurse's note dated 5/12/21, indicated Resident 1 had a witnessed fall and swelling noticed on bridge of nose. Review of Resident 1's X-ray report dated 5/12/21, indicated Resident 1 had a nasal bone fracture. Review of CV 1's notes for Resident 1 dated 5/14/21 at 4:25 p.m., indicated, Phone call .re: change of condition. Client fell today, had x-rays, has regular neuro checks. During an interview with the Director of Nursing (DON) and the Facility Manager (FM) on 5/26/21 at 12:46 p.m., DON and FM stated they could not find documentation that Resident 1's conservator was notified regarding the nose fracture. DON and FM stated Resident 1's conservator should have been notified regarding the nose fracture. Review of CV 1's notes for Resident 1 dated 5/27/21 at 5:32 p.m. indicated, Client is being monitored still for the nose fracture back on 14th, x-rays were completed post fall. Review of the facility's policy and procedure titled Communication with Residents and Family Members revised April 2011, indicated, Staff members are briefed on the following elements to share with residents and family members as assigned: b. Any Injuries or any X-ray Results.

Based on interview and record review, for one of three residents (Resident 1), the facility failed to provide Restorative Nurse Assistant (RNA) Program (after therapy, restorative activities to assist residents in restorative techniques such as range of motion, exercise activities and the use of assistive devices such as splints). This failure had the potential to result in further decrease in range of motion (measurement of the amount of movement around a specific joint or body, such as the shoulder, elbow, wrist, knee or ankle), and development of contracture (permanent shortening of a muscle or joint). Findings: Review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident 1's Joint Range of Motion assessment, dated 4/16/19, indicated Resident 1 had moderate limitation (50 to 75 percent (%) available range of motion) of range of motion on right hip, right knee and right ankle. During a telephone interview with Physical Therapy (PT) 1 on 1/16/20, at 2:35 p.m., PT 1 stated Resident 1's physical therapy was discontinued and was referred for RNA program. Review of Resident 1's Restorative Nursing Program Referral Form, dated 6/12/19, indicated Resident 1 was to receive the following RNA services: 1. Ambulation (walking) 25 to 50 feet with bilateral platform front wheel walker (a medical tool designed for those who are recuperating from leg or back injuries, or for the elderly and disabled people who may need additional support for stability to maintain balance while walking, walker with padded forearm rests) and with right ankle foot orthosis, and; 2. Right ankle range of motion exercises. The referral form indicated the program's goal was to maintain or increase current function and right ankle range of motion. Review of Resident 1's physician's orders [REDACTED]. During an interview with Restorative Nursing Assistant (RNA) 1 on 7/1/19, at 11:16 a.m., RNA 1 stated the RNA program order written on 6/14/19 was not entered into the electronic medical record until 6/20/19. RNA stated the next day, 6/21/19, RNA program was supposed to be done but RNA 1 stated she had to work on the floor as a Certified Nursing Assistant (CNA) because the facility was short of staff. RNA 1 also stated she also had to work on the floor as a CNA on 6/24/19 so there was no staff to do RNA program that day. RNA 1 also stated CNAs did not apply splint to Resident 1's hand because it had to be taken off after two hours and that CNAs placed the hand rolls instead. Review of Resident 1's Restorative Task, dated (MONTH) 2019, indicated orders for walking and range of motion for right ankle was not administered until 6/26/19 and missed RNA program on 6/21/19 and 6/24/19. The Restorative task also indicated there was an order for [REDACTED]. Review of the Daily Group Assignment, dated 6/21/19, indicated RNA 1 was assigned to care for residents on the floor. On 6/24/19, RNA 1 also worked on the floor as a CN[NAME] Further review of the group assignments indicated RNA 1 worked on the floor as a CNA on the following dates: 6/10/19, 6/13/19 and 6/18/19. During an interview with CNA 1 on 7/1/19 at 12:08 p.m., CNA 1 stated RNA 1 did RNA program for residents. CNA 1 stated if RNA worked on the floor because of staffing shortage, there was no RNA program exercises for Resident 1. CNA 1 stated she did not do ambulation and range of motion exercises to residents when RNA 1 got pulled to work on the floor as a CN[NAME] Further review of Resident 1's Restorative Task record for (MONTH) 2019 indicated Resident 1 did not receive splinting of left hand and left hand passive stretch five out of 23 times (5/7/19, 5/16/19, 5/20/19, 5/21/19 and 5/23/19). Review of the facility's Daily Group Assignments indicated on 5/7/19, 5/16/19, 5/20/19, 5/21/19 and 5/23/19, RNA 1 was pulled to work on the floor as a CN[NAME]

Based on observation, interview, and record review, the facility failed to exercise reasonable care for the protection of one of three sampled residents (Resident 1) property from loss or theft when Resident 1 clothing inventory sheet was not signed by Resident 1, Resident 1's representative, or a staff member upon Resident 1's admission to the facility. This failure had the potential to result in Resident 1's belongings not being documented in the event of an alleged loss or theft. Findings: Review of Resident 1's Clothing Inventory sheet, dated 5/20/15, indicated there was no signature of Resident 1, Resident 1's representative, or a staff member acknowledging the items brought in by Resident 1 upon her admission to the facility. During an interview on 6/12/19 at 10:59 a.m., DON stated Resident 1 had no other inventory list in her chart and she was not sure why Resident 1 had not signed it. DON also stated there was documentation on why the Resident 1 did not sign her inventory sheet. Review of Resident 1's records indicated there was no documentation of why Resident 1's clothing inventory sheet was not signed by Resident 1, Resident 1's representative, or a staff member. Review of facility's policy and procedure titled, Personal Property, undated, indicated .4. The resident's personal belongings and clothing shall be inventoried, labeled and documented upon admission on the inventory sheet and as items are brought in after admission. Inventory sheet should be printed and signed (by) facility staff and resident/responsible party if available

Based on observation, interview, and record review, the facility failed to ensure accurate dispensing and accounting of emergency medications when the intravenous (IV - administered through vein) emergency kit (IV E-Kit) was not replaced after it was opened and used items was not accounted. This deficient practice placed residents at risk for not receiving the necessary IV supplies in an emergency. Findings: During an observation on 5/28/19, at 10:59 a.m., the IV E-kit in the medication room was open, but was not resealed. During interview with Registered Nurse (RN) 1 on 5/28/19, at 10:59 a.m., RN 1 stated somebody opened the IV e-kit but he did not know who. During interview with RN 2 on 5/30/19, at 11:52 a.m., RN 2 stated the facility's process for using the E-kit included filling out the form that was inside the E-kit, leaving the white copy inside the e-kit, and the yellow copy was to be attached to the e-kit log; then fill out the Emergency Medication Administration Log, then reseal the e-kit with red colored tie. Review of facility records did not show any documentation or log of when the IV E-kit was opened and what was used. Review of the facility policy and procedure Emergency Pharmacy Service and Emergency kits (E-kits) dated 09/10 indicated, upon removal of any items from the emergency kit, the nurse documents the medication or item used on an emergency kit log Items to be documented on the log include: Residents name, medication name, strength and quality, date and time of medication removal .signature of nurse removing and administering dose .faxed log sheet will inform the pharmacy of items used form the emergency kit, this will notify the pharmacy to replace the kit

Based on observation and interview, the facility failed to prepare, store, and serve food under sanitary conditions when dirty ladles, plates, tong and drawer were stored in the same drawer with clean utensils. These failures placed residents at risk for contracting food borne illness. Findings: During an observation of the dietary department on 5/29/19 at 12:06 p.m., with the Certified Dietary Manager (CDM) and Dietary Staff (DS), the following items were noted: a. One six ounce ladle had small black particles inside the scoop. b. One eight ounce ladle had black debris and water pooled inside the scoop. c. Two eight ounce ladles had black debris and dust. d. One twelve inch tong had white substance on the handle. e. Three plates with caked-on yellow matter, and black debris, were stored on the plate warmer with clean plates. f. The drawer where the cook's clean utensils were stored had substance and black debris. During an interview with the CDM on 5/29/19 at 12:06 p.m., she stated the person assigned to wash dishes was responsible for ensuring the dishes were clean and dry before storing the items. During an interview and observation with the DS on 5/29/19 12:10 p.m., she acknowledged the drawer where the cook's clean utensils were stored was dirty. DS touched the black debris inside the drawer and it created a black smear. During a second interview with the DS on 5/30/19 at 12:08 p.m., she stated every kitchen staff including cooks were responsible for ensuring the drawers for utensils were kept clean.

Based on interview, and record review, for one of three (Resident 1) sampled residents, the facility failed to ensure safety when Certified Nursing Assistant (CNA) 1 assisted Resident 1 to the bathroom without the physical assistance of a second staff member. This failure resulted in Resident 1 falling on the bathroom floor and sustaining femoral neck (part of the hip joint) fracture. Findings: Review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to guide care), dated 1/29/19, indicated Resident 1 required two persons physical assist when using the toilet room and with transfers on/off toilet. The MDS also indicated Resident 1 had short term memory loss and required the extensive help from staff with two persons assist when transferring to and from the toilet. During a telephone interview with CNA 1 on 4/30/19, at 2:13 p.m., CNA 1 stated, on 4/7/19 in the afternoon, she took Resident 1 to the bathroom. CNA 1 stated Resident 1 held the grab bar with one hand. CNA 1 stated while Resident 1 was in a standing position and about to transfer from the shower chair to the wheelchair, Resident 1 became stiff, her hand lost grip of the grab bar and she began to fall. CNA 1 stated she could not hold Resident 1's weight and could not stop her from falling. CNA 1 stated Resident 1 fell on the bathroom floor and landing on her right hip. CNA 1 stated she knew Resident 1 required two persons assist with toilet transfers but at the time, no one was available to help as everybody was busy. During an interview with Registered Nurse (RN) 1 on 4/26/19, at 2:24 p.m., RN 1 stated that on 4/8/19 (the day after Resident 1's fall incident), a staff member reported that Resident 1 appeared to be in severe pain on the right leg. RN 1 stated X-rays were done and found that Resident 1 had fractured right hip. RN 1 stated Resident 1 needed assist from two staff for transfers (movement from one surface to another like wheelchair to shower chair or bed). RN 1 stated Resident 1's care plan also indicated two person transfers because, although sometimes Resident 1 was able to help when moving from bed to wheelchair or back, one would never know when Resident 1 was able to help or not. Review of Resident 1's Nurses Notes, dated 4/8/19, indicated Resident 1 complained of pain (rated as 7 out of 10, with 0 being no pain and 10 being the worst pain) when her right leg was touched or moved. The notes indicated X-rays were done. Review of Resident 1's Radiology Report, dated 4/9/19, indicated right femoral neck fracture. Review of Resident 1's Progress Notes, dated and signed 4/12/19, by Resident 1's attending physician at the facility indicated Patient had a fall in the (facility) after toileting and was sent to (acute hospital) after X-ray result showed femoral neck fracture. On 4/9/19, (Resident 1) underwent right hip hemiarthroplasty (surgical procedure that involves replacing half of the hip joint).

Based on observation, interview and record review, for one of four sampled residents (Resident 4), the facility failed to ensure treatment and services were provided in accordance with the comprehensive person-centered plan of care when Certified Nursing Assistant (CNA) 2 provided incontinent care for Resident 4 one time during the morning shift. This failure resulted in Resident 4 being left in wet incontinence briefs until the afternoon shift. Findings: Review of the clinical record indicated Resident 4 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident 4's Minimum Data Set (MDS - an assessment tool used to direct resident care), dated 8/2/18 and 10/31/18, indicated Resident 4 was always incontinent of bladder (loss of bladder control, a person urinates when they do not want to). Review of Resident 4's Bladder and Bowel Incontinence care plan, dated 8/3/18, indicated instructions for staff to provide Prompt good incontinent and skin care every two hours and prn (as needed). During an observation on 10/18/18, at 3:30 p.m., CNA 1 wheeled Resident 4 to the bathroom from the Activity Room to Resident 4's room and provided incontinent care. During an observation and concurrent interview with CNA 1 on 10/18/18, at 3:40 p.m., CNA 1 wheeled Resident 4 out of the bathroom. CNA 1 was in Resident 4's bathroom and there was a pair of wet pants placed on top of a wet incontinent brief on the sink. CNA 1 stated Resident 4's brief was soaking wet (with urine) and had leaked through Resident 4's pants. CNA 1 stated she also had to change Resident 4's pants because they were also wet (with urine). During an interview with Activity Director (AD) on 10/18/18, at 3:42 p.m., the AD stated she had counseled CNA 2 (morning shift CNA) in the past about the need to take Resident 4 to the bathroom in the morning because of past incidents of Resident 4 being soaking wet with urine (when the afternoon shift started). During an interview with Director of Nursing (DON) and concurrent review of Resident 4's voiding and incontinent supplies log on 10/18/18, at 3:55 p.m., the DON stated residents received incontinent care depending on what time they got up in the morning. The DON stated that if they (CNAs) get (Resident 4) up late, (Resident 4) would get incontinent care when (Resident 4) got up. The DON stated CNAs logged the number of briefs used for a resident for a particular shift along with the number of times incontinent or continent care was provided. Review Resident 4's voiding and incontinent supplies log, dated 10/18/18 at 1:59 p.m., indicated Resident 4 received incontinent care one time during the morning shift. The log did not indicate any other incontinent care done in the morning shift or if Resident 4 had refused incontinent care. During a telephone interview with CNA 2 on 11/29/18, at 3:48 p.m., CNA 2 stated Resident 4 was totally incontinent of urine. CNA 2 also stated she wrote down notes on Resident 4's incontinent care once every shift and that if the log indicated only one brief and one incontinence for the shift, it meant the resident's brief was changed once. CNA 2 stated if Resident 4 refused to go to the bathroom, refusal would be documented in the incontinence log or the voiding log. Review of the facility's policy and procedure titled Urinary Incontinence-Clinical Protocol, last revised (MONTH) 2013, indicated .based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to improve resident's continence status

Based on interview and record review, facility failed to ensure one (Resident 1) of three sampled residents was allowed to return to the facility after admission to Acute Care Hospital (ACH). This failure resulted in Resident 1 to be in psychosocial distress. Findings: According to an undated Face Sheet, Resident 1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. the heart and brain to narrow, block, or spasm). In a phone interview with Case Manager (CM 1) from an ACH, on 8/28/18, at 2:55 p.m., CM 1 stated that the facility was refusing to take Resident 1 back due to her behavior problems. Review of Nurses Notes dated 8/27/18 indicated Resident 1 was sent to ACH on the same date for Shortness of Breath and prior to that Resident 1 was verbally abusive towards another resident. In an interview with facility's Administrator (ADM), on 8/29/18, at 3:15 p.m., ADM stated it was not a good idea to readmit Resident 1 back to the facility because of her behaviors towards others. Review of ACH's Emergency Department (ED) Notes dated 8/28/18, showed Resident 1 was medically cleared for discharge back to the facility. It further indicated Resident 1 was not suffering from a psychiatric disorder. In an interview on 9/4/18, at 10:12 a.m., Director of Nursing Services (DON) at the facility stated, We are not going to offer an assessment for her (Resident 1) to readmit her back to the facility. In an interview on 9/4/18, at 10:55 a.m., Social Services Manager (SSM) at ACH stated Resident 1 was still there and the facility had not attempted to reassess Resident 1 even after Resident 1 was medically cleared to go back to the Facility. In a phone interview on 9/5/18, at 2:19 p.m., Resident 1 stated that she felt abandoned by the facility. The facility's policy and procedure Readmission to the Facility revised 04/2013 indicated, Residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility.

Based on interview and record review, for one (Resident 1) of 3 sampled residents, the facility failed to implement its abuse policy and procedure when Resident 2 told Resident 1 to shut up, Resident 1 cried, and Registered Nurse (RN 1) did not report the incident. For Resident 1, this failure had the potential to result in further abuse from Resident 2. Findings: Review of Resident 1's Admission Record, undated, indicated Resident 1 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to guide care), dated 5/4/18, indicated Resident 1 had slurred speech and sometimes understood what others said to her. In an interview on 5/15/18, at 1:54 p.m., Certified Nursing Assistant (CNA) 1 stated, just recently, Resident 1 got upset and cried when Resident 2 told her to shut up. CNA 1 stated she reported the incident to the nurse on duty. In an interview on 5/15/18, at 1:34 p.m., RN 1 stated one time recently Resident 2 was talking on the phone and Resident 1 wanted to talk with her. Resident 2 stayed on the phone for a long time and, after the call, she shouted at Resident 1 and Resident 1 cried. RN 1 stated she did not report the incident to the Director of Nursing (DON) or the Administrator. In an interview on 5/15/18, at 2 p.m., the Facility Manager (FM) stated she was not aware that Resident 2 told Resident 1 to shut up. Review of facility's policy and procedure titled, Abuse Prevention and Reporting, undated, indicated .G. Reporting .1) All mandated reporters are required by law to report incidents of known or suspected abuse .2. It is this facilities policy that any known or suspected abuse will be reported by completing an Incident and Injury Report .First responder or first staff member informed will be responsible for informing immediate supervisor and initiating incident report .Definition .Verbal Abuse .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

Based on interview and record review, the facility failed to implement their Resident Council policy and procedure to allow residents to vote and elect a President for the Resident Council when facility staff choose the Resident Council President and presented the President to the Residents at a Resident Council meeting This failure resulted in a Resident expressing concern about her right to vote and elect a President for the facility's Resident Council. Findings: During a confidential group interview on 4/2/18, at 11:28 a.m., one Resident stated the Activities Director (AD) informed her the facility staff voted and selected the current Residents' Council President and she was not happy about it. The Resident stated each resident had the right to vote who should be the Residents' Council President. In an interview on 4/2/18, at 12:05 p.m., the Activities Director, stated the facility's department supervisors and other facility staff choose the Resident Council President and presented the President to the Residents at a Resident Council meeting. Record review of the facility's policy and procedure, titled Resident Council, revised (MONTH) 2011, indicated .The council is encouraged to elect a President or Chair to act as a liaison and facilitate communication between the council and facility management .The position is voluntary .Resident may be appointed to record the minutes, otherwise minutes will be recorded and maintained by the designated staff member .

Based on interview and record review, the facility failed to inform and provide information for one of 13 sampled residents (Resident 169) regarding the option to prepare an advance directive (a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). This deficient practice had the potential to result in Resident 169's wishes regarding medical treatment not being followed. Findings: Review of the Resident 169's undated Face Sheet indicated Resident 169 was admitted to the facility on 3/26/18 with multiple [DIAGNOSES REDACTED]. During an interview with Resident 169 on 4/4/18, at 7:58 a.m., Resident 169 stated no one from the facility talked to him about an Advance Directive, but he would be interested in having one. Review of Resident 169's medical chart, indicated Resident 169 did not have an advance directive. During an interview with the Director of Nurses (DON) on 4/2/18, at 9:08 a.m., DON stated Resident 169 did not have an Advance Directive. During an interview with the Social Services (SS) on 4/2/18 at 9:21 a.m., SS stated she did not give information regarding Advance Directives to residents or discuss Advance Directives with residents or their responsible parties. Review of the facility's policy and procedure titled Advance Directives, revised (MONTH) 2013, indicated .Prior to or upon admission of a resident to our facility, the Admission Nurse or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives

Based on observation, interview and record review, the facility to ensure that staff supervised one (Resident 1) of three sampled residents who was walking in the hallway, resulting in Resident 1 falling and sustaining a laceration on her forehead and fracturing her arm. Resident 1, who has poor short term memory, poor balance and was assessed to be a high risk for falls, was left alone in hallway on 7/19/14 while the CNA went to find a chair. Resident 1 attempted to follow the CNA and fell over a Hoyer lift (mechanical aide for transferring residents) sustaining a laceration and fracture of her arm. Findings: On 8/6/14, review of the medical record showed that Resident 1 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. There were fall risk assessments documented every three months that showed that she was at high risk for falls. Review of the complete resident assessment, dated 7/14/14, showed that Resident 1 had short and long term memory problems, was moderately impaired for decision making, required the extensive assistance of one staff for bed mobility, transfers, dressing, eating, toiletting and bathing. She required moderate assistance of one staff for walking. Her ability to communicate was impaired with understanding others "sometimes" and "does not express her needs." Review of nurses notes, dated 7/19/14 at 2:15 p.m., showed, "Patient fell in hallway near bathrooms around 12:00 p.m. Patient walking in hallway and tripped on hoyer lift that was in the hallway. Patient then fell and hit head. Neurological assessment done on patient. Patient had cut on left frontal lobe that was bleeding, measuring 6 x 1.55 x 0.5cm. (centimeters). Second cut on left nostril, measuring 2 x 1.2 x 0.2 cm. Both were bleeding. 911 called and patient was kept on floor in lying position until ambulance arrived." Review of the hospital emergency department physician's history and physical, dated 7/19/14 at 4:44 p.m., showed, "[AGE] year old female with chief complaint of head injury with laceration diagnosed as closed head injury, forehead laceration, and face laceration. Patient has history of dementia (baseline confused speech, transfers with assistance). TIA (transient ischemic attack which is a momentary lack of oxygen to the brain) with no residual who presents with head laceration. Witnessed mechanical fall. fell forward and hit head and face into mechanical lift device. Patient answers 'yes' indiscriminately to all questions which is typical behavior for her. Exam: +6 cm (centimeter) gaping left forehead laceration with small area of bone exposed; no skull depression...+2.5 cm laceration directly below left nostril. No bone exposed. Do not leave unattended- Fall risk." Review of nurses notes, dated 7/19/14 at 11:06 p.m., showed, "Resident came back to facility...at 10 p.m. ...Noted left side forehead laceration 5.7. cm. with 11 sutures and upper lip 2.6 cm. with 6 sutures intact." Review of care plans showed, "Potential for trauma, falls," dated 7/24/14 due to history of a fall on 7/19/14, mental status and unsteady gait. Under the heading "Interventions" showed "Equipment should be placed out of hallway area when not in use. Transfer with assistance." During review of the Director of Nurses' (DON) investigative summaries, dated 7/30/14, showed, "Resident requires extensive to total assistance with activities of daily living due to impaired cognition and impaired mobility. When ambulating she can walk independently but is hand-held due to gait and balance...Resident 1 was left standing in the hall while her staff member went to look for a chair for her. The resident followed her and tripped on her shoe. When the staff turned to try and catch her from falling, the patient fell toward the mechanical lift parked in the hallway. Patient's face hit leg of mechanical lift on which she sustained a laceration. Patient noted to have swollen left arm during morning care on 7/26/14. Patient exhibited facial grimacing and moaning on movement...On 7/27/14, nurse practitioner assessed patient and ordered x-ray to left arm. X-ray results received on 7/29/14 and it noted that patient has a fracture to left proximal (nearest to shoulder) humerus (upper arm bone). Results also showed degenerative changes and osteopenia (lack of hard bone formation). Physician was notified and ordered for acute hospital transfer.... Patient returned around 6:15 p.m. with splint to left arm..." During interview on 8/7/14 at 9:45 a.m., RN 1 (registered nurse) stated, "She ambulates independently but you have to take her hand and guide her." During observation of Resident 1 and interview with RN 1 on 8/7/14 at 10:15 a.m., two CNA's were assisting Resident 1 from bed to wheelchair. Resident 1 was dressed in street clothes and had a splint on her left arm. She smiled and responded to my questions with, "Right. Yes." RN 1 stated, "She requires more assistance since the fall. She wasn't using a wheelchair before the fall. Now she has a sling and pain." During phone interview on 8/20/14, the DON reviewed the medical record and stated, "There is no care plan in the record to prevent falls before she fell on [DATE]." During phone interview on 8/20/14 at 2:55 p.m., CNA 1 stated, "I was walking with Resident 1 to the dining room and saw there were no chairs. I left her standing by the door and went around the corner to get a chair. Someone said she was following me. I turned around and saw her fall to the side- not towards me. I tried to catch her but she fell on top of the hoyer lift which was left in the hallway. We store hoyers in alcoves on each station but we leave them in the hall if we're going to use it soon." __________________________________________________________ Class "B" Citation #02-2352- -F The facility violated the aforementioned regulation by failing to ensure that staff supervised Resident 1 while she was walking in the hallway, resulting in Resident 1 falling and sustaining a laceration on her forehead and fracturing her arm. Resident 1, who has poor short term memory, poor balance and was assessed to be a high risk for falls, was left alone in hallway on 7/19/14 while the CNA went to find a chair. Resident 1 attempted to follow the CNA and fell over a Hoyer lift (mechanical aide for transferring residents) sustaining a laceration and fracture of her arm.On 8/6/14, review of the medical record showed that Resident 1 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The facility did "Fall risk" assessments every three months that showed that she was at high risk for falls. Review of the complete resident assessment, dated 7/14/14, showed that Resident 1 had short and long term memory problems, was moderately impaired for decision making, required the extensive assistance of one staff for bed mobility, transfers, dressing, eating, toileting and bathing. She required moderate assistance of one staff for walking. Her ability to communicate was impaired with understanding others "sometimes" and "does not express her needs."Review of nurses notes, dated 7/19/14 at 2:15 p.m., showed, "Patient fell in hallway near bathrooms around 12:00 p.m. Patient walking in hallway and tripped on Hoyer lift that was in the hallway. Patient then fell and hit head. Neurological assessment done on patient. Patient had cut on left frontal lobe that was bleeding, measuring 6 x 1.55 x 0.5 cm(Centimeters). Second cut on left nostril, measuring 2 x 1.2 x 0.2 cm. Both were bleeding. 911 called and patient was kept on floor in lying position until ambulance arrived."Review of the hospital emergency department physician's history and physical, dated 7/19/14 at 4:44 p.m., showed, "[AGE] year old female with chief complaint of head injury with laceration diagnosed as closed head injury, forehead laceration, and face laceration. Patient has history of dementia (baseline confused speech, transfers with assistance). TIA (transient ischemic attack which is a momentary lack of oxygen to the brain) with no residual who presents with head laceration. Witnessed mechanical fall. fell forward and hit head and face into mechanical lift device. Patient answers 'yes' indiscriminately to all questions which is typical behavior for her. Exam: +6 cm (centimeter) gaping left forehead laceration with small area of bone exposed; no skull depression...+2.5 cm laceration directly below left nostril. No bone exposed. Do not leave unattended- Fall risk."Review of nurses notes, dated 7/19/14 at 11:06 p.m., revealed "Resident came back to facility...at 10 p.m. ...Noted left side forehead laceration 5.7. cm. with 11 sutures and upper lip 2.6 cm. with 6 sutures intact."Review of care plans showed, "Potential for trauma, falls," dated 7/24/14 due to history of a fall on 7/19/14, mental status and unsteady gait. Under the heading "Interventions" showed "Equipment should be placed out of hallway area when not in use. Transfer with assistance."During review of the Director of Nurses' (DON) investigative summaries, dated 7/30/14, showed, "Resident requires extensive to total assistance with activities of daily living due to impaired cognition and impaired mobility. When ambulating she can walk independently but is hand-held due to gait and balance...Resident 1 was left standing in the hall while her staff member went to look for a chair for her. The resident followed her and tripped on her shoe. When the staff turned to try and catch her from falling, the patient fell toward the mechanical lift (Hoyer) parked in the hallway. Patient's face hit leg of mechanical lift on which she sustained a laceration. Patient noted to have swollen left arm during morning care on 7/26/14. Patient exhibited facial grimacing and moaning on movement...On 7/27/14, nurse practitioner assessed patient and ordered x-ray to left arm. X-ray results received on 7/29/14 and it noted that patient has a fracture to left proximal (nearest to shoulder) humerus (upper arm bone). Results also showed degenerative changes and osteopenia (lack of hard bone formation). Physician was notified and ordered for acute hospital transfer.... Patient returned around 6:15 p.m. with splint to left arm..."During interview on 8/7/14 at 9:45 a.m., RN 1 (registered nurse) stated, "She ambulates independently but you have to take her hand and guide her."During observation of Resident 1 and interview with RN 1 on 8/7/14 at 10:15 a.m., two CNA's were assisting Resident 1 from bed to wheelchair. Resident 1 was dressed in street clothes and had a splint on her left arm. She smiled and responded to my questions with, "Right. Yes." RN 1 stated, "She requires more assistance since the fall. She wasn't using a wheelchair before the fall. Now she has a sling and pain."During phone interview on 8/20/14, the DON reviewed the medical record and stated, "There is no care plan in the record to prevent falls before she fell on [DATE]."During phone interview on 8/20/14 at 2:55 p.m., CNA 1 stated, "I was walking with Resident 1 to the dining room and saw there were no chairs. I left her standing by the door and went around the corner to get a chair. Someone said she was following me. I turned around and saw her fall to the side- not towards me. I tried to catch her but she fell on top of the Hoyer lift which was left in the hallway. We store Hoyers in alcoves on each station but we leave them in the hall if we're going to use it soon."Therefore the facility failed to supervise Resident 1, who was ambulating in the hallway, resulting in Resident 1 falling and sustaining a laceration on her forehead and fracturing her arm.