Every finding on record at Greentree of Hubbell Rehabilitation and Health

Based on interview and record review, the facility failed to administer covid vaccinations for six Residents (#49, #7, #14, #28, #43, and #45) of nine residents reviewed for covid vaccinations. This deficient practice resulted in death for Resident #49 (R49) from Covid-19 after the facility failed to administer the Covid-19 vaccine as requested.Findings include:Resident #49 (R49) Review of progress notes revealed the following: [DATE] at 2:57 a.m., read in part [R49] observed to be lethargic and not of one self from CNA (Certified Nurse Aide). Vitals revealed 80/49 (blood pressure) p (pulse) 61R (respirations) 18. [DATE] at 5:05 p.m., Patient is covid positive. Currently in isolation with precautions.Has s/s (signs and symptoms) and c/o (complained of) pain, body aches, and cough and congestion. [DATE] at 6:47 p.m., read in part Nurse entered into residents room for medication administration. Found [R49] in [recliner] sitting up right. [Resident] was found unresponsive in chair and did not wake up from sternum rub (a painful stimulus technique used by medical professionals to check if an unconscious or unresponsive person is conscious) CNA and Nurse picked up [resident] and moved to the floor. No pulse was present and not breathing. CNA and nurse started preforming .CPR (cardiopulmonary resuscitation) .EMS (emergency medical service) arrived and declared resident as expired (deceased ). R49's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with diagnoses that included Coronary Artery Disease (CAD) [a heart condition caused by plaque buildup in the hearts arteries reducing oxygen to the heart muscle] and Congestive Heart Failure [a condition where the heart muscle is too weak to pump blood efficiently, causing fluid to back up in the lungs, legs and body]. R49 scored a 10 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of moderate cognitive impairment. Progress note dated [DATE] at 3:16 p.m., read in part .call made to [family members name/POA (power of attorney) regarding vaccinations. She [POA] agrees to all vaccinations being given (to R49). Review of a document titled Universal Vaccination Consent Form read in part .Consent for Covid-19 vaccination. I give consent for [facility name] and its staff for me to be vaccinated.signature of resident representative.date [DATE]. Review of the progress notes did not indicate R49 declined the vaccination, that the vaccination was refused by R49, and there was no contraindication for R49 not to receive the vaccination. Review of a policy titled Covid-19 Vaccination date reviewed/revised [DATE], read in part .The residents medical record will include documentation of the following: a. education to the resident or resident representative.b. each dose of the vaccine administered to the resident, or c. if the resident did not receive the Covid-19 vaccine due to medical contraindication or refusal. R49's Michigan Care Improvement Registry (MCIR) [The MCIR provides a comprehensive official record of vaccinations, including dates and types. It highlights which vaccines a person had received, immunization status (up to date or overdue) and identifies vaccines based on age covering from 1994 onwards] dated [DATE], read in part .R49 was overdue for a Covid-19 vaccination.a vaccination was recommended on [DATE]. Review of Death Certificate dated [DATE] read in part .State of Michigan Department of Health and Human Services Certificate of Death.No. 36 Part I. Enter the chain of events-diseases, injuries, or complications that directly caused the death.a. Covid. Resident #14 R14's MDS assessment dated [DATE], revealed admission to the facility on [DATE], with diagnoses that included respiratory failure [a condition where the lungs cannot adequately supply oxygen to the blood or remove carbon dioxide, often causing shortness of breath and fatigue], asthma, Chronic Obstructive Pulmonary Disease (COPD) [a progressive lung disease that causes chronic inflammation, airway narrowing, and damage to the air sacs, leading to severe long-term breathing difficulties] or Chronic Lung Disease. [a progressive disorder that restricts airflow, reducing oxygen intake]. R14 scored a 15 of 15 on the BIMS assessment reflective of intact cognition. Review of a document titled Universal Vaccination Consent Form read in part .Consent for Covid-19 vaccination. I give consent for [facility name] and its staff for me to be vaccinated.signature of resident.date [DATE]. R14's MCIR dated [DATE] read in part .R14 was overdue for a Covid-19 vaccination.the vaccination was recommended [DATE]. Resident #28 (R28) R28's MDS assessment dated [DATE], revealed admission to the facility on [DATE], with diagnoses that included: Coronary Artery Disease (CAD) and hypertension. MDS Section C. cognitive patterns, revealed resident is rarely or never understood and is moderately impaired for making decisions. Review of a document titled Universal Vaccination Consent Form read in part .Consent for Covid-19 vaccination. I give consent for [facility name] and its staff for me to be vaccinated.consent via phone call from resident representative.date [DATE]. R28's MCIR dated [DATE] read in part .R28 was overdue for a Covid-19 vaccination.the vaccination was recommended [DATE]. Resident #43 (R43) R43's MDS dated [DATE], revealed admission to the facility on [DATE] with diagnoses that included: coronary artery disease and hypertension. R43 scored a 15 of 15 on the BIMS assessment reflective of intact cognition. Review of a document titled Universal Vaccination Consent Form read in part .Consent for Covid-19 vaccination. I give consent for [facility name] and its staff for me to be vaccinated.signature of resident.date [DATE]. R43's MCIR dated [DATE] read in part .R43 was overdue for a Covid-19 vaccination.the vaccination was recommended [DATE]. Resident #45 (R45) R45's MDS dated [DATE], revealed admission to the facility on [DATE] with diagnoses that included: diabetes and hypertension. MDS Section C. cognitive patterns, revealed resident is rarely/never understood and never or rarely made decisions. Review of a document titled Universal Vaccination Consent Form read in part .Consent for Covid-19 vaccination. I give consent for [facility name] and its staff for me to be vaccinated.signature of resident representative.date [DATE]. R45's MCIR dated [DATE] read in part .R45 was overdue for a Covid-19 vaccination.the vaccination was recommended [DATE]. During an interview on [DATE] at 2:32 p.m., the Director of Nursing (DON) reported the universal consent for the immunizations was offered upon admission, annually for the residents who reside at the facility, and when the recommendations for the vaccines were amended. If the resident/responsible party signed the consent and agreed to any vaccination, the DON would review the MCIR and the vaccinations would be ordered from the pharmacy. Vaccines had arrived at the facility in two days from when the vaccine was ordered. The resident could receive the vaccine in three days During an interview on [DATE] at 3:23 p.m., Director of Nursing (DON) reported, I did not recognize immunizations were not being completed after consents were signed.we found that at the end of February of 2026 the immunizations were not being given. During an interview on [DATE] at approximately 3:30 p.m., the Assistant Director of Nursing (ADON)/Infection Preventionist reported, I realized I was not keeping track of the immunizations or consents that were signed for the residents who wanted to receive vaccinations at the end of last month. Review of policy titled Covid-19 Vaccination date reviewed/revised [DATE], read in part .It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from Covid-19 by.offering our residents.the Covid-19 vaccine.Covid-19 vaccinations will be offered to residents.as per CDC (Centers for Disease Control).guidelines.Covid-19 vaccinations for residents may be administered in accordance with physician approved standing orders.Residents or their representative and staff will sign the consent form prior to administration of the Covid-19 vaccine.administration of the Covid-19 vaccination should not be delayed. Resident #7 (R7) Review of an admission Record revealed R7 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic obstructive pulmonary disease (COPD). Review of a Minimum Data Set (MDS) assessment for R7 dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6/15 indicating R7 was cognitively impaired. The immunization record documentation for R7 revealed their Covid-19 vaccination consent was signed via verbal consent by Responsible Party on [DATE] and the Electronic Medical Record (EMR) for R7 had no documentation of the Covid-19 vaccination being administered. Review of R7's current MICR (M-Care Improvement Registry (MICR-State Agency-Immunization Record) R7's read in part SARS-CoV-2 (Covid-19) read in part: Overdue [DATE]. Review of R7's Electronic Medical Record (EMR) read in part: General Progress Note [DATE] 23:53 . (R7) returned from the ED at 2030 via ambulance. Diagnosis: Collapse of lung tissue, heart failure and pneumonia. Review of R7's (EMR) progress notes read in part: [DATE] 13:00 General Progress.Called MD (Medical Doctor) about Sp02 (oxygen saturation level) at 88% on 2L of oxygen.MD agreed to send (R7) to ER (emergency room) for further evaluation. Review of R7's (EMR) read in part: General Progress Note [DATE] 09:54 . (Registered Nurse) RN entered Resident's room to give resident morning medications. Resident was sitting up in bed. RN called out Resident's name. Resident was slow to respond. Residents had a low O2 (oxygen) of 87%. RN initiated standing order of O2 2 liters/per minute. MD (Medical Doctor) notified. ADON (Assistant Director of Nursing) notified. In an interview on [DATE] at 4:10 PM., Assistant Director of Nursing (ADON) A reported she was unsure why R7 had not received his Covid-19 or Pneumococcal immunizations despite having consent for both vaccinations in [DATE] and R7 being at high risk for both viruses. ADON A reported she, the current Director of Nursing DON had noticed this a few weeks ago and began looking into it. ADON A reported R7 was recently sent to the hospital ([DATE]) and came back with a diagnosis of pneumonia, a collapsed lung and heart failure.

Based on interview and record review, the facility failed to ensure adequate staffing to promote the highest practicable level of physical, mental and psychosocial well-being with the potential to affect all 44 residents that reside in the facility.Findings include:Review of Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (quarterly submissions to CMS by nursing homes to report direct care staffing) for FY [fiscal year] Quarter 4 2025 (July 1 - September 30), read in part . [name of facility] triggered for excessively low weekend staffing.During an interview and record review on 3/3/26 at 1:15 p.m., Chief Operating Officer (COO) G reviewed the weekend schedules and payroll information which revealed low weekend staffing for Certified Nurse Aides (CNA) on the following dates and shifts:Saturday, August 2, 2025 3 CNAs day shift 3 CNAs afternoon shiftSaturday, August 9, 2025 3.5 CNAs day shift 3.5 CNAs afternoon shiftSaturday, September 6, 2025 3 CNAs day shiftCOO G acknowledged the facility had low weekend staffing on the above dates and shifts according to the Facility Assessment [(FA) An annual, documented, facility wide evaluation ensuring resources, staffing, and safety measures meet resident needs].Review of CMS final rule, effective August 8, 2024, mandates that nursing home facility assessments must directly inform and determine staffing requirements.Review of document titled Facility Assessment last updated 2/1/25, read in part .Certified Nurse Aides.minimum of 4-5 CNAs on day shift, Minimum of 4 CNAs on afternoon shift.

Based on interview and record review, the facility failed to complete a performance review for five out of five Certified Nurse's Aides (CNA's) at least every 12 months. This deficient practice resulted in the potential for inadequate care and unmet resident care needs for all 44 residents residing in the facility.Review of facility personnel records demonstrated the following:CNA E was hired on 11/10/21with no performance reviewCNA K was hired on 11/10/23 with no performance reviewCNA L was hired on 1/15/24 with no performance reviewCNA M was hired on 7/13/23 with no performance reviewCNA N was hired on 2/24/23 with no performance reviewDuring an interview on 3/3/26 at 8:34 a.m., Business Office Manager (BOM) reported I do not have any evaluations of any of the five staff members they are supposed to be done annually.The staff are supposed to have annual performance reviews.During an interview on 3/3/26 at 8:44 a.m., Director of Nursing (DON) acknowledged annual performance reviews were not completed.A request for a policy regarding performance reviews was not provided by the facility prior to exit from the facility.

This citation pertains to Intake# 2631101.Based on observation, interview and record review the facility failed to fully implement its policy for delivery and storage of controlled medications for one Resident (#51) of three residents reviewed for medication administration, storage and labeling resulting in the misappropriation of 120 narcotic pain medications for R51, the potential for an increase in drug diversion, misappropriation of medications, residents missing pain medication, and the potential for uncontrolled pain and discomfort.Findings include:Review of the Food and Drug Administration current labeling information https://www.fda.gov/drugsatfda read in part: NORCO contains hydrocodone, a Schedule II controlled substance.NORCO-Storage and Disposal-Because of the risks associated with accidental ingestion, misuse, and abuse, advise patients to store NORCO securely, out of sight and reach of children, and in a location not accessible by others, including visitors to the home [see WARNINGS, DRUG ABUSE AND DEPENDENCE]. Inform patients that leaving NORCO unsecured can pose a deadly risk to others in the home . Resident #51 (R51)Review of the admission Record for R51 revealed an original admission to the facility on 8/6/2024 with pertinent diagnoses which included: colon cancer. Review of a Minimum Data Set (MDS) assessment for R51 dated 10/24/2025 revealed a Brief Interview for Mental Status (BIMS) score of 99/15 indicating R51 was cognitively severely impaired.Review of a Physician's Order Summary read in part: (R51) Hydrocodone-Acetaminophen Oral Tablet 10-325MG (Hydrocodone-Acetaminophen) give 1 tablet three times daily.Review of a Facility Reported Incident (FRI) investigation presented to the State Agency (SA) read in part: Date/Time Incident Discovered: 9/19/2025 10:10AM Incident Summary: On the morning of September 19, 2025, during the routine medication pass, it was discovered that a narcotic was missing. The attending nurse contacted Pharmacy to inquire about retrieving the medication from our StatSafe (securely locked medication storage safe), as it was scheduled to be administered. The pharmacy advised that our facility should already have an adequate supply of the medication on hand. Physician notified and Investigation initiated. Investigation Summary/Actions Taken: Facility Reported Incident Investigation Incident Information Date of Incident: September 19, 2025, Resident Involved: (R51) Medication Involved: Hydrocodone 10-325mg (scheduled narcotic pain medication) Investigating Staff: (Previous) Registered Nurse (RN)/Director of Nursing (DON). Summary of Incident. On September 19, 2025, (Previous staff) notified DON that she had contacted the pharmacy to refill (R51's) Hydrocodone 10-325mg. The pharmacy indicated that the resident should have 120 tablets at the facility. The DON initiated a search for the medication and reviewed proof-of-use sheets and shift counts. It was determined that the medication was not administered, destroyed, or documented as wasted, and was unaccounted for. Chain of custody was reviewed for the medication in question, and a nurse was identified as potentially being involved in the missing medication. This nurse is no longer employed at the facility as of September 14, 2025. Notifications- Law enforcement was notified on September 19, with reports made to the State Police and subsequently to the County Sheriff's Office. The attending physician and residents responsible party were notified. Physician provided orders and replacement medications were obtained. Investigation Findings: Thirty-four residents were interviewed with no concerns identified related to medication management. All licensed nurses were interviewed and demonstrated understanding of narcotic control procedures. No concerns were raised regarding other nurses or medication management practices. Medication carts were reviewed, and excess or unnecessary narcotics were secured under double lock. Further audits were conducted to identify any other missing medications from residents, and no additional concerns were identified. Corrective Action- Education on narcotic control procedures has been reinforced. Ongoing audits of controlled substances have been implemented. Excess narcotics for hospitalized residents are secured under double lock. Continued monitoring for compliance with facility policy . Conclusion While the investigation did not definitively identify the individual responsible for diversion, the primary staff member of concern has separated employment.With the corrective action plan implemented and the separation of the staff members in question, residents are not at risk for further misappropriation.In an interview/observation on 3/02/2026 at 3:30 PM., RN B reported she was employed at the facility during the time (R51's) narcotic medication (Norco 10 mg- quantity 120 tablets) went missing. RN B reported the medication for the facility was delivered via UPS/FedEx. RN B reported resident medications come in a regular cardboard box with packaging tape and could easily be opened. RN B reported 2 nurses must now retrieve the pharmacy box, open it together and check all inventory, place all medications into the appropriate storage areas and then both nurses sign the packaging slip, stapled narcotic medications together and sign off on the narcotic count sheets indicating which nurses signed the medications in once delivered . In an observation/interview/record review on 3/2/2026 at 4:04 PM., with RN B's assistance the facility medication carts, medication storage room, Stat-safe and a pharmacy medication box delivered earlier along with narcotic medication count sheets were reviewed. RN B reported before (R51's) narcotic medications went missing the medication box from the pharmacy was often unattended once delivered and there were times nurses went the front office where packages were delivered and had to look through other boxes belonging to either the facility or residents to locate the box labeled with pharmacy. That nurse would open the box, check the inventory then fill their medication cart with the regular prescription medications. RN B reported when it came time to check in schedule/narcotics the nurse would call over another nurse and both nurses had to sign off on the inventory sheet from the pharmacy which came in the box. When this surveyor observed the pharmacy box in the medication room it was noted to be opened on the top with a pharmacy label, and regular packaging tape on the top portion of the box which was slit open, as well as the bottom of the box which was taped closed. The box contained no paperwork or medications as they had already been checked in for the day.In an interview on 3/3/2026 at 8:42 AM., RN C reported pharmacy medications delivered to the facility arrive via UPS/Fed/Ex. RN C reported a while back the process changed so that a nurse must sign in the pharmacy box as soon as it is delivered and the drivers/delivery person were supposed to wait for a nurse signature to retrieve the box. RN C reported the box was not locked as it was a regular cardboard box, which was taped with packaging tape. RN C reports despite the fact (R51's) narcotic medications went missing, at times the box was still retrieved from the front office amongst other boxes left for either the facility or residents. RN C reported this does not happen often, but it does continue to happen. RN C stated the fact the box could easily be opened and retaped, especially the bottom of the box because I don't know if or who is required to inspect for tampering. RN C reported he believes that most nurses at the facility do their best with the current procedure, it seems that if someone wanted to take medications from the box, it could potentially still be easy to do. RN C reported if that were to happen, it would probably be easier to catch because now 2 nurses not only sign the narcotic medication count sheets, but they are also both must sign the entire inventory sheet which includes all medications the pharmacy put in the box. RN C reported he is unsure why the medications are delivered from the pharmacy were not in a hard case locking tote or something like that with zip ties, or the ties with inventory numbers. RN C stated I think this would be something that would add another measure of safety, I am unsure of how the facility management and pharmacy used would accomplish this because the pharmacy is not local.In an observation/interview on 3/3/2026 at 10:54 AM, a UPS delivery staff (DS) entered the facility with approximately 4-6 packages including small and medium cardboard boxes and delivered them to the front office where the DON was seated. It was noted the UPS/DS had the DON sign a device for the packages. When asked, the UPS/DS stated, for the box with the pharmacy label I am required to ask for a nurse who shows identification then gives their signature when those are delivered UPS/DS reported he was newer to the route and was informed of this requirement when dropping off packages last week. UPS/DS reported there were no special delivery instructions on the pharmacy package from the sender. This surveyor inspected the box which was cardboard, taped with packaging tape, and a pharmacy label. The box did not appear to be locked or tamper proof. DON reported she was not employed at the facility during R51's FRI and Assistant Director of Nursing ADON A would know a little more if this surveyor had any further questions.In an interview on 3/3/26 at 3:50 PM., ADON A reported she was not employed at the facility at the time of R51's FRI investigation, but did start working shortly afterwards and worked on the follow up and auditing, as well as putting new measures in place for the policy and procedures of Medication/Pharmacy services, storage of narcotics to ensure compliance. ADON A reported the policies do not currently address the actual procedure in place or address how the facility currently receives resident medications. ADON A reported she was unsure if there was anything in the facility Policy and Procedures of Pharmacy Services and Medication Storage and Labeling nor is it written anywhere regarding who is responsible for checking in delivered medications and who is responsible for checking the medication box for tampering when it is delivered and signed for.Review of a facility Pharmacy Services Policy with a revision date of 4/1/2025 read in part: Policy- It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. Definitions: Pharmaceutical Services refers to: The process (including documentation, as applicable) of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, compounding, dispensing, packaging, labeling, distributing, administering, monitoring responses to, using and/or disposing of all medications, biologicals, chemicals Compliance Guidelines:1. The facility will provide pharmaceutical services to include procedures that assure the accurateacquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice.2. The facility will employ or obtain the services of a licensed pharmacist (in accordance with state requirements) who:a. Provides consultation on all aspects of the provision of pharmacy services in the facility.b. Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation; andc. Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.5. The facility in coordination with the licensed pharmacist will provide for:a. A system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications .b. Prompt identification of loss of or potential diversion of controlled medications; andc. Determination of the extent of loss or potential diversion of controlled medications.Further review of this policy revealed no new update or revision after R51's narcotic medications went missing to indicate any new practice, nor does it show the current procedure of pharmacy delivery methods including current pharmacy couriers.Review of a facility Medication Storage Policy with a revision date of 1/17/2025 read in part: Policy- It is the policy of this facility to ensure all medications housed on our premises will be stored in the medication room or medication carts according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines.2. Narcotics and Controlled Substances: a. Schedule II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key. b. Schedule II controlled medications are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area, such as in refrigerator. c. Any discrepancies which cannot be resolved must be reported immediately as follows: i. Notify the DON, charge nurse, or designee and the pharmacy; ii. Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted; iii. The DON, charge nurse, or designee must also report any loss of controlled substances where theft is suspected to the appropriate authorities such as local law enforcement, Drug Enforcement Agency, State Board of Nursing, State Board of Pharmacy, and possibly the State Licensure Board for Nursing Home Administrators. d. Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies.Further review of this policy revealed no new update or revision after R51's narcotic medications went missing to indicate any new practice, nor does it show the current procedure of pharmacy delivery methods including current pharmacy couriers.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for all 44 residents living in the facility. Findings include: On 3/1/2026 at 1:18 PM, the staff in the dietary department were observed doing tasks following the lunch service. Dietary Staff P was moving throughout the kitchen and was not wearing a restraint for his beard (a beard net).At 1:29 PM on 3/1/26, the Certified Foodservice Manager (CFM) T stated staff with beards should have a beard net in place. Staff P donned a beard restraint.According to the 2022 FDA Food Code section 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.On 3/1/26 at 1:12 PM, the reach-in refrigerators were observed and contained the following:Silk milk without an opened by (OB) date or a use by (UB) dateAn opened and partially empty 2-quart container of tomato juice without an OB date or UB dateA plastic baggie containing what appeared to be a breaded chicken patty. This item was not labeled and was without an OB date or UB date. Dietary Staff S said, Oh, I am taking that home. She explained it was left over from lunch service to the residents.Boost (a nutritional supplement) with a UB date of 2/24.Sandwiches wrapped in plastic with beige colored filling were stored in a pan marked egg salad sand UB 2/28/26. Dietary Staff R stated those are tuna salad, not egg salad (sandwiches). Staff R noted the UB date was yesterday.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specifiedunder S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded,based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use- by date based on FOOD safety .At 1:24 PM on 3/1/26, a bin was observed on the shelving across from the ovens. This bin housed partially used bags of gravy mixes, sauce mixes, and mashed potato flakes. The bottom interior of the bin had white flakes and other bits of food and powdery debris. The bin also contained three charger cords, instructions for use of a blender, and individual servings of peppermint candy. CFM T said, This should not be like this.At 1:30 PM on 3/1/26, the standing mixer was observed. The undercarriage was noted to have a buildup of dried on debris directly above the mixer arm and bowl and could contaminate the food being mixed when in use.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD- CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations.At 1:39 PM on 3/1/26, the lunch dishes were observed being washed in the dish room. Dietary Staff S was seen scraping partially eaten food from dirty dishes, loading the dirty dishes onto dish racks, and moving the racks into the dishwasher. Staff S would then move to the clean side of the dishwasher and without washing her hands, grabbed the clean dishes and stacked them or carried them into the kitchen for use. The CFM T also observed this process and when questioned said, She should be washing her hands between working the dirty and clean sides.According to the 2022 FDA Food Code section 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: . (E) After handling soiled EQUIPMENT or UTENSILS; . and (I) After engaging in other activities that contaminate the hands.

Based on observation, interview, and record review the facility failed to maintain the outside grounds garbage storage area in a sanitary condition to prevent the harborage and feeding of pests potentially affecting all 44 residents of the facility.Findings include:During a tour of the grounds on 3/1/26 at 1:45 PM, Certified Foodservice Manager (CFM) T, Dietary Staff Q, and this Surveyor walked approximately 100 feet out to the garbage dumpster area. The area contained three mid-sized dumpsters. The first dumpster was filled with full black trash bags. The bags were stacked and were over the rim of the dumpster and as such, the lid could not be employed. The second dumpster, approximately one foot away from the first dumpster, was covered and upon inspection was half full of filled black garbage bags. The third dumpster, approximately one foot away from the second dumpster, was covered and upon inspection contained one filled black garbage bag.According to the 2022 FDA Food Code section 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be a possible source of contamination of food, equipment, and utensils. Storage areas for garbage and refuse containers must be constructed so that they can be thoroughly cleaned in order to avoid creating an attractant or harborage for insects or rodents. In addition, such storage areas must be large enough to accommodate all the containers necessitated by the operation in order to prevent scattering of the garbage and refuse. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.

Based on interview and record review, the facility failed to implement and maintain a comprehensive Quality Assurance Performance Improvement (QAPI) program that addressed the full range of services the facility provides. This deficient practice resulted in the potential for quality-of-care concerns for all 44 residents in the facility.Findings include:During an interview on 3/3/26 at 3:23 p.m., the Director of Nursing (DON) reported I oversee QAPI and I am unaware of any Performance Improvement Projects (PIP) we are working on. We are not working on any PIPs for sentinel events. We are not tracking or monitoring anything.We are not documenting on any action plans. QAPI is a program that needs to be worked on, it is a broken system.Review of policy titled 2026 Quality Assurance and Performance Improvement (QAPI) Plan dated 12/7/25, read in part .The QAPI plan of [facility name] is designed to establish and maintain and organized facility wide program that is data-driven and utilizes a proactive approach to improving quality of care and services throughout the facility.Our facility has a performance improvement programs which systematically monitors, analyzes, and improves it performance.our QAPI program focuses on systems an processes.

Based on interview and record review, the facility failed to establish priorities for its improvement activities, develop and implement action plans, and review or analyze data collected under the Quality Assurance Performance Improvement (QAPI) program. This deficient practice resulted in the potential for quality-of-care concerns for all 44 residents in the facility.Findings include:During an interview on 3/3/26 at 3:23 p.m., the Director of Nursing (DON) reported I oversee QAPI and I am unaware of any Performance Improvement Projects (PIP) we are working on. We are not working on any PIPs for sentinel events. We are not tracking or monitoring anything.We are not documenting on any action plans. QAPI is a program that needs to be worked on, it is a broken system.Review of policy titled 2026 Quality Assurance and Performance Improvement (QAPI) Plan dated 12/7/25, read in part .The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its sauces and implications of change The facility uses a thorough and highly organized structures approach to determine the root cause of identified problems.The committees overall responsibility is to develop and modify the plan, analyze information, and set priorities for PIP. The facility uses performance indicators to monitor a wide range of care processes and outcomes. Findings are reviewed against established benchmarks and/or targets for improvement. It also includes tracking, investigating and monitoring adverse events, to include developing action plans to prevent recurrences.

Based on observation, interview, and record review, the facility failed to provide a homelike environment free from foul odors and soiled environmental surfaces for all residents residing in the facility.Findings include:During initial entrance tour on 3/1/26 at 1:15 PM., it was noted there was a strong odor of urine when entering the facility. A foul smell of urine was noted on both the A & B units, the hallway to the units and throughout the nursing station areas.In an observation on 3/1/26 at 1:53 PM, room [ROOM NUMBER] both privacy curtains were noted to be heavily soiled with brown smudge marks in multiple areas. In an interview on 3/1/26 at 2:00 PM., Houskeeper (Hsk) I indicated the floors in resident rooms and bathrooms are not mopped daily. Hsk I indicated the strong smell of urine was most likely a combination of the floors not being mopped, soiled linen and soiled briefs that have not been taken out of the facility to the garbage and laundry building. Hsk I reported the laundry facility was in the building next door, and on the weekends sometimes the facility is short staffed, so the linens and garbage are not removed promptly. In an observation on 3/1/26 at 2:11 PM., the bathroom for room [ROOM NUMBER] was soiled with a dried build up urine around the toilet seat and the seat fasteners. Dried feces was smeared on the toilet tank, the rim of the toilet seat, and underneath the toilet seat on the tank bowl. The bathroom had a strong odor of urine.In an observation on 3/01/2026 3:48 PM., strong smell of urine noted on the back unit rooms 1-20 and near nurse's station. In an observation on 3/1/26 at 3:52 PM, room [ROOM NUMBER] both privacy curtains were noted to be heavily soiled. room [ROOM NUMBER] had a strong odor of urine when this surveyor toured the room. In an observation on 3/01/2026 3:50 PM., strong smell of urine noted on while this surveyor toured the unit with rooms 21-31. In an observation on 3/01/2026 3:52 PM., it was noted the bathroom for room [ROOM NUMBER] was soiled with a dried build up urine around the base, feces noted dried and smeared on the toilet tank, rim of the toilet seat, and underneath the toilet seat on the tank bowl. The bathroom had a strong odor of urine.In an observation on 3/02/2026 8:30 AM., strong urine smell on both A & B units upon observation of units for resident initial pool continuation.In an observation on 3/02/2026 2:31 PM it was noted on both A & B units a strong smell of urine while conducting environmental inspection. In an observation on 3/03/2026 at 10:00 AM., the bathroom door of room [ROOM NUMBER]-1 was noted to have a large (greater than 12 inch) circle of paint chipped. Review of the State Operations Manual revealed: Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas.A homelike environment is not achieved simply through enhancements to the physical environment. It concerns striving for person-centered care that emphasizes individualization, relationships and a psychosocial environment that welcomes each resident and makes her/him comfortable. It is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs.

Based on interview and record review, the facility failed to ensure Certified Nurse Aide (CNA) training of no less than 12 hours per year was completed for five of five CNAs reviewed for nurse aide training hours. Findings include:During an interview on 3/3/26 at 8:00a.m., Business Office Manager (BOM) revealed the annual 12-hour CNA training is based on the CNA hire date. Review of facility document provided by the BOM revealed the following: CNA E hire date 11/10/21 with 0 hours of training since 5/28/24. CNA K hire date of 11/10/23 with 0 hours of training since 11/10/23. CNA L hire date 1/15/24 with 0 hours of training since hire date. CNA M dire date 7/13/23 with 0 hours of training since hire date. CNA N hire date 2/24/23 with 0 hours of training since 11/15/23. During an interview on 3/3/26 at 8:44 a.m., Director of Nursing (DON) acknowledged five staff did not have 12 hours of annual training. Review of policy titled Nurse Aide Training Program date reviewed/revised 6/11/24, read in part .Each nurse aide shall be provided at least 12 hours of in-service training annually, based on his/her employment date.

Based on interview, and record review, the facility failed to Provide notification of transfer information to the hospital for one Resident (#5) of four reviewed for notification of transfer to the hospital Provide written notification of the bed hold policy and notify the local ombudsman upon transfer to the hospital in 4 of 4 Residents (#2, #5, #7, & #21) reviewed for transfer and discharge requirements.Findings include:Resident #2 (R2) Review of an admission Record revealed R2 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: acute respiratory failure. Review of a Minimum Data Set (MDS) assessment for R2 with a reference date of 12/26/25 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated R2 was cognitively impaired. Review of R2's Electronic Medical Record (EMR) read in part: 2/27/2026 22:42 Progress Note Text: Patient admitted to hospital . further review of R2's EMR revealed no Bed Hold policy or documentation of R2 or R2s representative being given a bed hold policy. In an interview on 3/2/2026 at 9:42 AM., Licensed Practical Nurse (LPN) D reported when a resident is transferred out via ambulance the documents that go with them include a face sheet, physicians orders, and current vital signs LPN D stated I am not aware of a bed hold policy, I am not sure if a resident gets the policy when being transferred out to the ED [emergency department]. During an interview on 3/3/26 at 8:51 AM., Registered Nurse (RN) C reported R2 had readmitted to the facility after about a week in the hospital. RN C reported when a resident gets sent out for an emergency transfer to the hospital, the nurse on duty puts a packet of documents together to give to the Emergency Medical Transport(EMT) personnel to give to the ED staff. RN C reported the packet included a face sheet, physicians orders and current vital signs taken before leaving the facility. RN C reported no bed hold was given when R2 transferred out to the ED on 2/27/26. RN C reported he did not know anything about a bed hold policy from the facility. Resident #21 (R21) Review of an admission Record revealed R21 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: type 2 diabetes. Review of a Minimum Data Set (MDS) assessment for R21 with a reference date of 1/29/2026 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated R21 was cognitively intact. Review of R21's EMR progress notes read in part: 2/10/2026 15:06 COMMUNICATION - with Physician was notified via phone.Resident unable to sit or stand without physical assist, leaning to the left and feeling off balance, blurred vision, and pupils not reacting equally. Speech fairly normal. Unable to state the day, month, or year and unable to focus and answer questions appropriately. Restless and complained I feel like I am going to pass out, as EMS arrived at 1445. Physically/manually lifted onto the EMS cot, due to inability to stand on his own. Report to ER, prior to transport. Review of R21's EMR revealed no bed hold policy documentation for R21's transfer to the hospital on 2/10/26. Resident #7 (R7) Review of an admission Record revealed R7 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic obstructive pulmonary disease (COPD) Review of the MDS assessment for R7 with a reference date of 2/17/2026 revealed a BIMS score of 6/15 which indicated R7 was cognitively impaired. Review of R7's EMR progress notes read in part: 2/25/2026 13:00 General Progress.Called MD (Medical Doctor) about Sp02 (oxygen saturation level) at 88% on 2L of oxygen.MD agreed to send (R7) to ER (emergency room) for further evaluation. Review of R21's EMR revealed no bed hold policy documentation for R7's transfer to the hospital on 2/25/26. Resident #5 (R5) Review of R5's MDS assessment dated [DATE], revealed admission to the facility on 5/22/23. The EMR revealed R5 was discharged from the facility and admitted to the hospital on [DATE] and 10/6/25. Review of the miscellaneous section of the EMR with the Director of Nursing (DON) revealed no evidence of a written notification of transfer and no bed hold policy being provided to the resident/representative. There was no evidence of notification to the Long-Term Care (LTC) Ombudsman provided by the facility. During an interview on 3/3/26 at 7:51 a.m., the DON reviewed the EMR and reported there was no written notification of transfer from the facility to the hospital, and indicated it should be in the EMR under the miscellaneous section. Review of policy titled Bed Hold Policy last reviewed/revised 7/14/25, read in part . The facility will provide the receiving provider [hospital] the following: a. contact information of the practitioner responsible for the care of the resident, b. Resident representative information including contact information, c. Advance Directive information, d. All special instructions or precautions for ongoing care, as appropriate, 3. Comprehensive care plan goals, f. All other necessary information, including a copy of the resident's discharge summary as applicable and any other documentation to ensure a safe and effective transition of care. During an interview on 3/3/26 at 9:15 a.m., Nursing Home Administrator (NHA) designee W reported, I am unable to find the ombudsman list for September or October and I cannot find any information regarding bed holds for the residents who were discharged from the facility and admitted to the hospital. Review of the facility 'Bed Hold' policy with a revision date of 7/14/2025 read in part: Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed -hold policy and addresses information explaining the return of the resident to the next available bed. Definitions: Bed-Hold, means holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. Policy Explanation and Compliance Guidelines: Bed Hold Notice Upon Transfer 1. Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies: a. (State) reimburses a nursing facility to hold a bed for up to ten days during temporary absence from the facility due to admission to the hospital only when the beneficiary leaves the facility. b. There is no limit to the number of hospital leave days per resident that may be billed to Medicaid annually as long as there are no more than 10 consecutive leave days per hospital stay. c. Private Pay residents may be given the option to pay the facility the per diem rate to hold their bed while absent from the facility. d. Residents will return to his or her previous room, if available. If that room is unavailable, the resident entitles to the next bed available in a semi-private room with a roommate of the same sex. Review of policy titled Transfer and Discharge last reviewed/revised 8/7/22, read in part .The Social Services Director or designee, will provide copies of notices for .transfers to the Ombudsman.such as in a list of residents on a monthly basis.

Based on observation, interview, and record review, the facility failed to ensure residents received diets as prescribed by a physician and in accordance with the plan of care for four Residents (#1, #17, #28 and #34) of five residents reviewed for therapeutic diets. Findings include:Resident #28 (R28)During breakfast meal rounds on 3/2/2026 at 8:05 AM, R28 was noted to have scrambled eggs and sausage with gravy served. R28's meal tray card indicated Diet: 2gm (gram) Na+ (Sodium).During an interview on 3/2/2026 at 8:35 AM, the Certified Food Service Manager (CFM) T was asked about the diet and she stated, We are out of low sodium gravy right now.The medical record for R28 indicated a physician diet order dated 9/4/2025 of No Added Salt (NAS), Low fat. Beneprotein (a protein supplement) BID (twice daily).Resident #17 (R17)During breakfast meal rounds on 3/3/2026 at 8:25 AM, R17 was observed to be eating in the dining room and received a cheese and egg croissant and oatmeal. R17's meal tray card indicated a Diet: 2gm Na+.The medical record for R17 indicated a physician diet order dated 8/11/2025 of No Added Salt (NAS) diet, Regular texture, Thin consistency.Resident #1 (R1)During breakfast meal rounds on 3/3/2026 at 8:30 AM, R1 received a cheese and egg croissant, oatmeal, and mandarin oranges. R1's meal tray card indicated Diet: Renal.The medical record for R1 indicated a physician diet order dated 2/11/2026 of Renal Diet Regular/IDDSI 7 texture, Thin consistency.Resident #34 (R34)The medical record for R34 was also identified with a physician diet order dated 10/20/2025 of Renal diet, Regular/IDDSI (International Dysphagia Diet Standardization Initiative) 7 texture, Thin consistency. This resident also had the potential to be affected by the staff's knowledge gap. During an interview on 3/3/2026 at 3:18 PM, CFM T stated there were differences in the 2-gram sodium diet and an NAS diet. The NAS diet was a regular diet with the only change of adding no additional salt. CFM T stated there were no residents on a 2 gram sodium diet in the facility. She was surprised when she printed the meal tray cards for R28 and R17 from her computer program and the tray cards read 2 gram sodium diet. The renal diets were also discussed. CFM T listed off several foods including mandarin oranges that should not be served to residents on a renal diet. She was unaware that mandarin oranges had been observed on R1's breakfast tray. The planned menu for the renal diet was reviewed and read, Hot cereal renal, scrambled eggs, cranberry orange muffin. This did not match the breakfast R1 had been served, a cheese and egg croissant, oatmeal, and mandarin oranges. CFM T stated that those on a renal diet could have salt. When the renal diet was discussed, CFM T asked this Surveyor, Where did you get that list of foods to be served and foods to be avoided on the renal diet? The answer was given that the list was taken from the facility's diet manual. CFM T stated there had been a list of foods to be avoided on a renal diet in the kitchen but it was not there to assist the staff when serving R1 and R34 who both had renal diets ordered by the physician. When CFM T was asked if her new Consultant Registered Dietitian (RD) had ever been in the building, to assist with the therapeutic diets, CFM T stated the RD had not been to the facility yet. The RD contract had started 1/1/2026 and they had been trying to set up a telehealth system, but it was not yet in place.The Diet Manual for the facility was presented (Long Term Care Diet Manual copyright 2022 Health Technologies, Inc) and Renal Precautions page 163 read in part, .If an individual is on dialysis, it is suggested that the Registered Dietitian or other member of the interdisciplinary team periodically contact the Dialysis Dietitian for co-ordination of care as needed. 7. The Registered Dietitian can provide further and more specific Renal Diet information and guidelines. Consider the following Renal Precautions when making meal selections that will help to manage your sodium, potassium and phosphorus intake. Avoid use of a salt packet and do not add salt at the table. Page 166 titled: Renal Diet Food Choice Lists for Meal Planning. 4. Using salt at the table is discouraged and salt packets are not added to meals sent to individuals that dine in their rooms.

Based on observation, interview, and record review the facility failed to deliver mail/package unopened for one Resident (#20) of one resident reviewed for privacy related to receiving mail.Findings include:Resident #20 (R20)During an interview on 3/1/2026 at 2:28 PM, R20 voiced a concern about not receiving a package on the preceding Friday (2/27/2026). R20 had ordered a product and had been advised by a family member the order had been acknowledged as delivered. R20 stated they did not receive the package and had requested her Certified Nurse Aide (CNA) U look around the building for it. R20 said, I got it Saturday when I asked (CNA U) to look for me. R20 said CNA U found it opened in the conference room. R20 said, It had been opened and left there. I was very mad. I filled out a complaint and reported it to the administrator. The package was in R20's room and was observed to be clearly addressed to R20.During an interview on 3/1/2026 at approximately 2:35 PM, CNA U stated they did find the package on Saturday (2/28/2026) opened and in the conference room and they delivered it to R20.On 3/2/2026 at 3:10 PM, Social Service Designee (Staff V) stated she kept the grievance log and could not find the February log but offered to ask Nursing . Staff V stated she would present it when she found it.During an interview on 3/2/2026 at 4:15 PM, Assistant Director of Nursing (ADON) A stated she was investigating the opened package. ADON A said she knew several packages were delivered on Friday and she had placed the packages in the Business Office for safe keeping.During an interview on 3/2/2026 at 4:27 PM, Business Office Manager (Staff O) stated she had opened the package for R20 in error. Staff O said instead of delivering it to the resident, she put it on the conference room table around 3:00 or 4:00 PM. Staff O did not deliver it to the Resident on Friday.On 3/2/2026 at 4:50 PM, the grievance log was observed to have the concern of Package was opened by staff member for R20.During an interview on 3/2/2026 at approximately 5:00 PM, ADON A stated she was still investigating the concern but had not talked to R20 and did not know who found the package and delivered it to the resident.

Based on observation, interview, and record review, the facility failed to store oxygen equipment in a sanitary manner for two Residents (#18 and #37) of three residents reviewed for oxygen equipment and storage.Findings include:Resident #18 (R18) Review of R18's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 4/1/24 with diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD) [a progressive long term lung disease that causes obstructed airflow, making it hard to breathe] and anxiety disorder. During an observation on 3/2/26 at 7:38 a.m., R18's oxygen tubing was draped over an oxygen concentrator with the nasal cannula laying on the floor. During an interview on 3/2/26 at 8:23 a.m., Registered Nurse (RN) B reported, R18 on not on continuous oxygen but the oxygen cannula and tubing is supposed to be in a bag when not in use, not just lying on the floor. Resident #37 (R37) A review of R37's medical record revealed a most recent admission date of 1/29/2026 with diagnoses which included pulmonary fibrosis (chronic progressive disease where deep lung tissue becomes scarred, severely inhibiting oxygen absorption), COPD (Chronic Obstructive Pulmonary Disease a progressive lung disease that restricts airflow making it difficult to breathe) and chronic respiratory failure (a long term condition where lungs cannot properly oxygenate blood). The active Physician's Orders included: O2 (oxygen) at 1L per NC for sats 90% (to flow at one liter through a nasal cannula if the measured O2 in the blood was less than 90% saturation) dated 2/3/2026 and Change Oxygen Tubing weekly every night shift every Thu (Thursday) of oxygen use dated 1/29/2026. The Minimum Data Set assessment (MDS) dated [DATE] included documentation of oxygen therapy (Section O C1) both on admission' and while a Resident. On 3/1/2026 at 2:49 PM, R37 was observed in bed and wearing a nasal cannula with O2 flowing. The tubing extended from his face to the floor in coils and was connected to an oxygen concentrator and contained no labeling as to what date the tubing had been changed. R37 stated he was not sure, but it had been a while since the tubing had been changed. On 3/3/2026 at 10:01 AM, R37 was observed sleeping with O2. The O2 tubing was dated but long loops of coiled tubing were lying on the floor. The medical chart for R37 contained a care plan with a focus which included COPD with interventions of: Avoid extremes of hot and cold. Date Initiated: 01/30/2026 Give oxygen therapy as ordered by the physician. Date Initiated: 01/30/2026 Head of bed to be elevated . or out of bed upright in a chair during episodes of difficulty breathing (Dyspnea). Date Initiated: 01/30/2026 Monitor for difficulty breathing (Dyspnea) on exertion. Remind me not to push beyond endurance. Date Initiated: 01/30/2026 CNA Monitor for . acute respiratory insufficiency: Anxiety, Confusion, Restlessness, . Date Initiated: 01/30/2026 The oxygen saturation (O2 sats) was reviewed and noted to have been documented beginning on 1/29/26 and were recorded approximately once a day. There was no documentation from 1/31/26 through 2/3/26 or on 2/5/26, or on 2/10/26. During an interview on 3/3/2026 at 11:11 AM, the Director of Nursing (DON) discussed her expectations for O2 use. The DON said, I would not expect the tubing to be on the floor. It needs to be in a proper bag. She stated further the O2 tubing should be changed each week and dated. The DON also stated the O2 sats should be documented for each shift for those residents on O2 and the policy should be followed for care planning O2 use. The facility policy Oxygen Administration dated as reviewed/revised 8/2/25 read in part, Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. e. Keep delivery devices covered and in plastic bag when not in use. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. The type of oxygen delivery system. b. When to administer, such as continuous or intermittent and /or when to discontinue oxygen use. c. Equipment setting for the prescribed flow rates. d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. e. Monitoring complications associated with the use of oxygen.

Based on interview and record review, the facility failed to obtain consent for psychotropic medications for one Resident (#3) of five residents reviewed for unnecessary medications. Findings include: Resident #3 (R3)Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed admission to the facility on [DATE], with diagnoses including: anxiety disorder, depression, and post traumatic stress disorder [(PTSD) A mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or violent events].Review of R3's Electronic Medical Record (EMR) included active physician orders for the following medications:Chlorpromazine Oral Tablet 50 MG(milligram),Duloxetine Oral Capsule Delayed Release Sprinkle 60 MG- 1 capsule by mouth (psychotropic medication prescribed for depression), and;Mirtazapine Oral Tablet 30 MG Give 1 tablet by mouth at bedtime (psychotropic medication prescribed for depression).The EMR did not reveal any consent signed by the R3 or their responsible party.During an interview on 3/3/26 at 12:20 p.m., The Director of Nursing (DON) reported the consents for psychotropic medications are completed upon admission to the facility by the Social Services Designee (SSD) V. The DON was unable to locate a consent that had been signed by the responsible party in the EMR.During an interview on 3/3/26 at 12:36 a.m., the SSD V acknowledged signed consents were not in the EMR and she could not locate any signed consents not scanned into the EMR, in her office.Review of policy titled Use of Psychotropic Medication last reviewed/revised 7/15/25, read in part .Residents and/or representative shall be educated on the risks and benefits of psychotropic drug use.

Based on interview and record review, the facility failed to provide information to formulate an advance directive for two Residents (#3 and #49) of twelve residents reviewed for advance directives.Findings include:Resident #3 (R3)Review of R3's Minimum Data Set (MDS) assessment, dated 2/17/26, revealed admission to the facility on [DATE].Review of R3's Electronic Medical Record (EMR) did not reveal the resident/responsible party had received advance directive information or formulated an advance directive.Resident #49 (R49)Review of R49's MDS assessment, dated 11/18/25, revealed admission to the facility on 5/16/25.Review of R49's EMR did not reveal the resident/responsible party had received advance directive information or formulated an advance directive.During an interview on 3/2/26 at 2:45 p.m., Social Services Designee (SSD) V reported the advance directives had not been completed for these residents and were supposed to be done on admission and reviewed quarterly.Review of policy titled Communication of Code Status last reviewed/revised 2/21/24, read in part ( .It is the policy of this facility to adhere to resident rights to formulate advance directives.the facility will follow facility policy regarding a residents right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive.

Based on interview and record review, the facility failed to provide timely information of a change in coverage and subsequent changes in the amount billed for services for one Resident (#35) of three residents reviewed for receipt of Notice of Medicare Non-coverage. Findings include:Resident #35 (R35)The facility presented a list of residents whose Medicare Part A Service had ended and were eligible to receive a Notice of Medicare Non-coverage (a document to alert of payment changes). Three residents on this list were chosen, and their medical records were requested to ensure proper notification had been delivered two days prior to a change in billing.On 3/3/2026 at 2:37 PM, during this review, it was determined R35 was notified his Medicare coverage for current PT/OT/ST (Physical Therapy/Occupational Therapy/Speech Therapy) services would end on 10/8/2025. This form instructed the resident how to appeal this decision to end coverage and what would happen next. The signature line indicated R35 was notified that coverage of my services will end on the date on this notice, and that I can appeal this decision by contacting my QIO (Quality Improvement Office). The signature line was marked Verbal consent from DPOA (Durable Power of Attorney) and dated 10/9/25 (the day after change in charges had occurred).During an interview on 3/3/2026 at 2:45 PM, the Business Office Manager (Staff O) stated the form should have been given 48 hours before Medicare coverage ended. Staff O was asked for a policy for Notice of Medicare Non-coverage. The facility presented a policy titled Social Services dated as reviewed/revised on 6/29/2023, which read in part, 4. The social worker, or social service designee, will pursue the provision of any identified need for medically related social services of the resident. p. Notification to resident/responsible party of Notice of Medicare Non-coverage and Beneficiary Notice.

This citation pertains to Intake# 2631101 Based on observation, interview and record review, the facility failed to protect the resident's right to be free from misappropriation of property, by a staff member for one Resident (Resident #51) of three residents reviewed for misappropriation of property, resulting in 120 narcotic medication pills missing, increased potential for undetected controlled drug diversion and the potential for uncontrolled pain and discomfort with medication delivery delays from refill too soon notices flagged by the pharmacy provider.Findings include:Review of the Food and Drug Administration current labeling information https://www.fda.gov/drugsatfda read in part: NORCO. Abuse.NORCO contains hydrocodone, a substance with a high potential for abuse similar to other opioids including fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, and tapentadol, can be abused and is subject to misuse, addiction, and criminal diversion .Resident #51 (R51)Review of an admission Record revealed R51 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: colon cancer. Review of a Minimum Data Set (MDS) assessment for R51 with a reference date of 10/24/2025 revealed a Brief Interview for Mental Status (BIMS) score of 99/15 which indicated R51 was cognitively severely impaired.Review of a Physician's Order Summary read in part: (R51) Hydrocodone-Acetaminophen Oral Tablet 10-325MG (Hydrocodone-Acetaminophen) give 1 tablet three times daily.Review of a Facility Reported Incident (FRI) investigation presented to the State Agency (SA) read in part: Date/Time Incident Discovered: 9/19/2025 10:10AM Incident Summary: On the morning of September 19, 2025, during the routine medication pass, it was discovered that a narcotic was missing. The attending nurse contacted Pharmacy to inquire about retrieving the medication from our StatSafe (securely locked medication storage safe), as it was scheduled to be administered. The pharmacy advised that our facility should already have an adequate supply of the medication on hand. Physician notified and Investigation initiated. Investigation Summary/Actions Taken: Facility Reported Incident Investigation Incident Information Date of Incident: September 19, 2025, Resident Involved: (R51) Medication Involved: Hydrocodone 10-325mg (scheduled narcotic pain medication) Investigating Staff: (Previous) Registered Nurse (RN)/Director of Nursing (DON). Summary of Incident. On September 19, 2025, (Previous staff) notified the DON, she had contacted the pharmacy to refill (R51's) Hydrocodone 10-325mg. The pharmacy indicated the resident should have 120 tablets at the facility. The DON initiated a search for the medication, reviewed proof-of-use sheets and reviewed shift counts. It was determined the medication was not administered, destroyed, or documented as wasted, and was unaccounted for. Chain of custody was reviewed for the medication in question, and a nurse was identified as potentially being involved in the missing medication. This nurse is no longer employed at the facility as of September 14, 2025. Notifications-Law enforcement was notified on September 19, with reports made to the State Police and subsequently to the County Sheriff's Office. The attending physician and residents responsible party were notified. Physician provided orders and replacement medications were obtained. Investigation Findings: Thirty-four residents were interviewed with no concerns identified related to medication management. All licensed nurses were interviewed and demonstrated understanding of narcotic control procedures. No concerns were raised regarding other nurses or medication management practices. Medication carts were reviewed, and excess or unnecessary narcotics were secured under double lock. Further audits were conducted to identify any other missing medications from residents, and no additional concerns were identified. Corrective Action- Education on narcotic control procedures has been reinforced. Ongoing audits of controlled substances have been implemented. Excess narcotics for hospitalized residents are secured under double lock. Continued monitoring for compliance with facility policy. Conclusion While the investigation did not definitively identify the individual responsible for diversion, the primary staff member of concern has separated employment.With the corrective action plan implemented and the separation of the staff members in question, residents are not at risk for further misappropriation.In an interview on 3/2/2026 at 4:29 PM, at the time (R51's) narcotic medication (Norco 10mg-quanity 120 tablets) went missing, RN B indicated the medication was most likely taken from a staff member when it was delivered. RN B revealed the nurse identified was not signing for the pharmacy medication box when it was delivered and the box was mixed in with other boxes or packages that had been delivered. RN B stated if I remember correctly when the investigation was being completed it was noticed the entire inventory list that has all the medications in the box was missing, along with 4-narcotic count sheets totaling 120 pills and the 4 packages containing 30 pills each In an interview on 3/3/2026 at 8:42 AM., RN C reported at the time R51's narcotic medication went missing it would have been very easy for anyone including staff or a delivery personnel to have tampered with and/or opened the pharmacy medication box. RN C stated, I think it was probably a previous nurse, because most people would not know to take the entire inventory sheet, along with the narcotic count sheets with the narcotic medications that were missing. the box was not locked and was in a regular cardboard box, which was taped with packaging tape RN C reported at times the pharmacy box was still in front office amongst other delivered packages/boxes. RN C stated the fact the box could easily be opened and retaped, especially the bottom of the box because I don't know if or who is required to inspect for tampering. In an observation/interview on 3/03/2026 at 10:54 AM, a UPS delivery staff (DS) entered the facility with approximately 4-6 packages including small and medium cardboard boxes and delivered them to the front office. This surveyor inspected the box which was cardboard, taped with packaging tape, and a pharmacy label. The box did not appear to be locked or tamper proof. DON reported she was not employed at the facility during R51's FRI and Assistant Director of Nursing ADON A would know a little more if this surveyor had any further questions.In an interview on 3/3/26 at 3:50 PM., ADON A reported she was not employed at the facility at the time of R51's FRI investigation, but did start working shortly afterwards and worked on the follow up and auditing, as well as putting new measures in place for the policy and procedures of Medication/Pharmacy services, storage of narcotics to ensure compliance. ADON A reported it was her understanding from the previous DON and Nursing Home Administrator (NHA) working at the time that (R51's) medications along with the inventory list, and narcotic count sheets were taken out of the pharmacy medication box once delivered by a former staff member who previously had issues with substance abuse.Review of a facility Abuse, Neglect and Exploitation policy referenced by the State Operations Manual (SOM)- revision 2025, Appendix PP-F600/F607 read in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Further review of this policy did not address or reference the SOM or protocol for misappropriation (F602).

Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for psychotropic medications for one Resident (#20) of five residents reviewed for unnecessary medications.Findings include:Resident #20 (R20)A review of R20's electronic medical record (EMR) revealed an admission date of 5/1/2024 with diagnoses which included depression and anxiety disorder. The medical record included active Physician's Orders dated 3/1/22 including: Cymbalta (psychotropic medication prescribed for anxiety) Oral Capsule Delayed Release Particles 60 MG (milligrams) and busPIRone (psychotropic medication prescribed for depression) HCl (hydrochloride) Oral Capsule 10 MG.The Care Plan for R20 included focus plans for antidepressant medications and antianxiety medications.During an interview on 3/2/2026 at 3:40 PM, the Director of Nursing (DON) was asked if the facility had tried a gradual dose reduction (GDR). The DON stated, We rely on our pharmacist to let us know when GDRs are due.The EMR was reviewed and no evidence of a GDR attempt could be found. The facility staff was asked to determine when a GDR had been attempted for the prescribed psychotropic medications for R20.During an interview on 3/3/2026 at 1:50 PM, the DON stated, There is no GDR information for this resident. There are no GDR attempts for her (R20). There is no documentation to reflect the lack of GRDs.The facility policy titled, Use of Psychotropic Medication dated as reviewed/revised 7/15/2025 was reviewed. This policy read in part, 6. Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs.

Based on interview and record review the facility failed to obtain a PASARR (Preadmission Screening/Annual Resident Review) prior to admission for one Resident #3 (R3) of one resident reviewed for PASARR screening.Findings include:Resident #3 (R3)Review of Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE] with active diagnoses that included: Post Traumatic Stress Disorder (PTSD), anxiety disorder, depression, and Non-Alzheimer's dementia.During an interview on 3/2/26 at 3:33 p.m., Registered Nurse (RN) X reported we complete the PASSAR just prior to admission to the facility and then annually.the only one for R3 was completed on 10/2/24 and not one prior to her admission on [DATE]. R3 does need a new or updated PASSAR.Review of policy titled Resident Assessment-Coordination with PASARR Program date reviewed/revised 8/14/25 read in part .This facility coordinates assessments with the preadmission screening and resident review (PASARR) program.all applicants to this facility will be screened.PASSAR Level 1 initial pre-screening is completed prior to admission.

This citation pertains to Intake# 2561427.Based on observation, interview, and record review, the facility failed to provide adequate supervision in 2 of 4 residents (Resident #4 and Resident #5), reviewed for accidents and hazards, resulting in R5 sustaining a 2nd-3rd degree burn when hot liquid hazards were left unattended.Findings include: Per the Bureau of Health Systems Burn Hazards Related to Heated Surfaces in Long Term Care Facilities ALERT dated 5/12/1999, Sustained skin contact with surfaces of equipment that have temperatures in excess of 107 degrees Fahrenheit can cause burns. Caution is required when exposing patients to warmed surfaces, particularly when they are helpless .Where the (heating) system is operating as designed .staff training and resident care policies to reduce the chance of exposure may also be appropriate .Resident #4Review of an admission Record revealed R4 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's disease.Review of a MDS assessment for R4, with a reference date of 7/28/25 revealed a BIMS score of 04/15 which indicated R4 was cognitively impaired.Further review of R4's MDS section GG-Functional Abilities revealed R4 was coded 04-Supervision.for: Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident.Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.In an observation of the main dining room on 9/16/25 at 12:10 PM, R4 self-propelled her wheelchair to an open 3-tiered cart loaded with 3 discarded resident lunch trays with various amounts of uneaten food on each tray. R4 took a large piece of chicken breast off this cart and began eating it as she moved through the dining room. R4 dropped approximately half of the chicken onto the floor after taking a few big bites. R4 then proceeded back to the 3-tiered cart helping herself to vegetables off another meal tray without any staff noticing. R4 then went over to the 3-tiered cart again and began to eat food from each of the meal trays left on the cart. At 12:17 PM, R4 went back over to the 3-tiered cart and started eating mashed potatoes using her fingers. During this time, only one staff member was present in the dining room and took no action. No staff noticed R4 self-propelling through the dining room making multiple trips to the 3-tiered cart and eating food which had been rejected by other residents.In an observation on 9/16/25 at 12:32 PM., CNA O noticed R4 at the meal cart and redirected her and asked if R4 wanted more food and if she (R4) was still hungry. R4 responded that she was still hungry. CNA O proceeded to go assist another resident and get R4 a cup of coffee.In an interview on 9/16/25 at 12:40 PM., CNA O reported R4 should have a mechanical soft diet, with no large, or dry pieces of meat because she has difficulty swallowing. CNA O reported there are not enough staff to keep eyes on all the residents, to keep them safe and properly groomed. CNA O reported she let the kitchen know that R4 was still hungry and they were going to make something for her.In an observation on 9/16/25 at 12:50 PM., the Maintenance Director/CNA G delivered a sandwich to R4 and walked away R4 began eating the sandwich, this surveyor noted sizable chunks of chicken breast falling from the sandwich, which was made of white bread, chicken chunks and very little substance that appeared to be mayonnaise. R4 appeared to be struggling to keep the sandwich together, much of it fell into pieces on the floor and then R4 proceeded to stuff the sandwich underneath a blanket while self-propelling out of the dining room. No staff were present in the dining room at this time.In an observation in the hallway on 9/16/25 at 1:00 PM., CNA J noticed R4 with the sandwich falling from her blanket, and hands. CNA J intervened and redirected R4 by asking R4 if she wanted to go to her room. R4 was agreeable and taken to her room. CNA J was noted coming back from R4's room with a handful of what was left of the chicken sandwich and then knocking on the kitchen door. CNA J was greeted by kitchen staff, and then CNA J reminded kitchen staff of R4's diet restrictions.In an interview on 9/16/25 at 1:05 PM., CNA J reported there are not enough staff in the facility to keep residents safe. CNA J reported she had just filed a grievance form for R4 regarding staff/dietary staff not following R4's diet order. CNA J reported R4 was on a mechanical soft diet, and could not meats, and anything dry or she would choke. CNA J reported R4 has difficulty swallowing. CNA J stated we are running around so much that things are getting missed, overlooked and we cannot keep going at this pace or something really bad is going happen, she could have choked to death. CNA J reported the grievance/concern form she filed was because R4's chicken patty was not prepared per her dietary restrictions, so the kitchen took the sandwich with the chicken patty back, then turned around cut up the patty into large chunks and gave it back to her (R4).Review of a facility Concern/Grievance form dated 9/9/25 revealed: Description of Grievance/Concern-Kitchen staff gave a resident (R4) a full chicken patty when she's mechanical soft and upon asking for a new sandwich for (R4) they cut up previous sandwich and gave it back .During an interview on 9/16/25 at 1:20 PM., CNA M reported there are a lot of staffing challenges for the nursing departments as well as all shifts. CNA M reported she has had to care for Residents that are 2 person assists by herself because there was no one available to assist because everyone is so busy, and the shift are always running short handed. CNA M reported it is difficult to care for the residents in the facility and not cut some corners because there is not enough time and staff. CNA M stated it breaks my heart; I feel the resident's deserve better care than we can provide.Review of R4s Care Plan dated 6/24/24 revealed: Resident Diet .IDDSI Level 6 -soft bite sized/Mechanical soft texture . (IDDSI- International Dysphagia Diet Standardization Initiative).Resident #5Review of an admission Record revealed R5 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Dementia. Review of a MDS previously defined just need MDS assessment for R5, with a reference date of 6/30/25 revealed a BIMS score of 00/15 which indicated R5 was severely cognitively impaired.Further review of R5's MDS section GG-Functional Abilities revealed R5 was coded as a #2. Eating- A. The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident.02-Substanital/maximal assistance- 02. - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.In an observation on 9/12/25 at 12:30 PM., R5 was seated in the dining room with no staff assistance. R5's lunch plate was 90% full, and she was asleep. Only one staff member was present assisting another resident.During an interview on 9/12/25 at 1:45 PM., Assistant Director of Nursing (ADON) A reported R5 sustained a burn to her stomach and to her upper thighs earlier in the day. ADON A reported she was waiting for a physician order to treat the burn, currently she had a standing order to put burn cream on the burn and cover it with a gauze. ADON A reported R5 spilled her coffee during breakfast.Review of R5's Progress Notes read in part: 9/12/25 at 8:52 AM., Note Text: Went to dining room to check for residents and observed this resident who indicated she was all wet. Brought resident to floor so she could be changed when CNA stated, Oh, she may have spilt her coffee. On inspection, residents spilled coffee and had some reddened areas to right abdomen and top of legs. top of left leg with some peeling skin and resident indicated painful. reddened areas to right breast, upper right abdomen, tops of both legs with left one peeling. resident dressed into loose clothes and cool compress applied.Review of R5's Skin Evaluation photos dated 9/12/25 in the facility Electronic Medical Record (EMR) revealed: photos of R5's upper thigh area/groin to have a substantial area of reddened with multiple large (quarter sized) blisters. This surveyor did not note any measurements at this time in the EMR.Review of R5's Care Plan read in part: I have a nutritional problem or potential nutritional problem. Date Initiated: 03/28/2025.I like coffee with all meals, like it black, ensure it is in a 2 handled cup with lid. Date Initiated: 03/28/2025.Review of R5's progress notes read in part: 9/12/2025 09:39 IDT (interdisciplinary team) Note Text: IDT reviewed resident's coffee burn incident. handled spout cup with lid for coffee has been implemented. Staff education provided. OT .Review of R5's progress notes read in part: 9/12/2025 12:10 Secure Conversations Messages: Subject: interventions for burns 9/12/2025 09:38 AM ADON -may we have an order for 2 handled spout cup with lid for coffee?In a phone interview on 9/16/25 at 5:10 PM., CNA J reported last week R5 was burned by hot coffee because she (CNA J) was running around trying to get everyone set up for breakfast and the facility was short staffed. CNA J reported R5 was seated at the dining room table, and she (CNA J) went to get coffee for her, the kitchen handed her a cup of coffee, and she knew it was too hot, so she went to get ice cubes and a lid because R5 was supposed to have a lid on her coffee. CNA J reported she added the ice cubes; while walking back to get a lid for the coffee she was distracted by another resident needing something and she (CNA J) just dropped off the cup of coffee to R5 without putting a lid on it. CNA J reported another staff noticed she (R5) was wet, and she shouldn't have been because she was just changed before breakfast. CNA J realized the cup of coffee was spilled and R5 was taken back to her room, and it was noticed initially there was red on her breast, and right stomach which then went all the way down to her upper legs which had some immediate blistering on her left thigh. CNA J stated I take full responsibility for that mistake, I have no problem admitting I made a mistake. I made the mistake because we don't have enough staff to manage that many residents on our daily assignments, and remember everything, it is impossible to do that under the conditions we are working. I am so sorry.I feel absolute horrible .

Based on observation, interview, and record review, the facility failed to provide treatment and services to prevent new pressure ulcers from developing for two Residents (#22 and #29) of three residents reviewed for pressure ulcer care. This deficient practice resulted in multiple newly facility acquired pressure injuries which subsequently required debridement, use of antibiotics and the use of a wound vac. Findings include: Resident #22 (R22) On 12/18/23 at 8:45 AM, an interview was conducted with R22 who was observed lying in her bed wearing a hospital gown and covered with a white bed sheet. R22 was observed with a wound vac on the left side of her bed on the floor which was connected to her lower abdominal area. R22 was asked how long she had the wound vac and if she came into the facility with it on her original admission and replied, No. I did not have this wound on my abdomen or the wound vac on admission and I have had it for a little over a month. I just hate this thing. I don't get up out of bed and in my chair because I must drag this thing around with me everywhere I go. Review of R22's admission record, date printed 12/17/23, revealed an original admission to the facility on [DATE], with diagnoses of diabetes mellitus, anemia, need for assistance with personal care, and absence of the right leg below the knee (amputation). The admission Minimum Data Set (MDS) assessment, dated 5/22/23, revealed her to be at risk for developing pressure ulcers and not having any existing pressure ulcers upon her original admission. A review of the quarterly MDS assessment, dated 11/22/23, revealed her to be at risk for developing pressure ulcers, to have one existing facility acquired stage three pressure ulcer, and to be cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. On 12/19/23 at 11:00 AM, an observation was made of R22 lying in her bed in her room. R22 was noted to have her wound vac at the left side of her bed. R22 was asked if she had any other wound and if she was able to turn and reposition by herself and replied, Yes. I will show you. I used to have a wound on my left back side, but I think it is healed now. R22 was observed to roll by herself on to her right side and was observed to have a dressing on her left upper hip/buttock area with a date on the dressing 12/12/23 with initials AS. R22 was asked when the dressing was to be changed and replied, Oh. I forgot all about that one. It is healed, but I like the dressing there for protection and it is changed every three days. On 12/29/23 at 11:20 AM, Registered Nurse (RN) N was asked to observe R22 in her room and the dressing. RN N stated she was not aware of a dressing in that area, and she was only aware of the wound vac. RN N was asked if the dressing should be changed and replied, I would have to look at the orders. Review of R22's skin wound evaluation, dated 9/20/23, revealed R22 was observed to have a stage one pressure ulcer develop on her left lateral thigh measuring 5.5 cm (centimeters) x 4.0 cm, and it developed in the facility. Review of R22's skin wound evaluations for wound of the left lateral thigh between 9/20/23 through 12/19/23, revealed missing evaluations on 11/1/23, 11/8/23, 11/15/23, 11/22/23, 11/29/23, and 12/6/23. Review of R22's treatment administration record (TAR), dated December 2023, revealed the lack of an order for current dressing observed to be dated for 12/12/23. Review of R22's skin and wound evaluation, dated 10/4/23, revealed a new stage two pressure ulcer of the left lower quadrant abdominal area and measured 6.2 cm x 2.1 cm and no depth recorded. Review of physician faxed communication, dated 10/4/23, read in part, .open area on underside (of abdominal area). Measuring 5 cm x 3 cm - area was cleansed with (name brand) wound cleaner - 3 x 3 opti-foam applied - please advise on tx (treatment) if you wish something else .(physician response) Continue care as above. Notify if, worsening - increased in size, tenderness or redness . Review of R22's care plan, dated 10/4/23, read in part, Focus: I have a stage 3 (pressure ulcer) to my left abdominal area .Goal: Interventions will be put in place to prevent decline in wound and maintain my comfort. Interventions/Tasks: Administer treatments as ordered and monitor for effectiveness. Assess me and attempt to determine underlying causes of wound .Assess/record/monitor wound healing per facility policy. Measure length, width, and depth .Assess and document status of wound perimeter, wound bed and healing progress .Wound vac per wound clinic to abdominal wound, change per wound clinic orders, monitor per facility protocol (11/6/23) . *Note: R22's care plan lacked any focus, goal, or intervention/tasks related to her being at risk for developing pressure ulcers as indicated on her MDS admission and quarterly assessments. Review of R22's progress note, dated 10/29/23, read in part, .No skin issues noted at this time, see wound nurse documentation for on going. Review of R22's treatment administration record (TAR), dated October 2023, revealed orders for: Open area underside of abdominal skirt: Cleanse area with (name brand) wound cleaner, apply opti-foam. Change every other day and prn (as needed). If soiled, until healed .In the morning on even days, start 10/6/23. Review of TAR for treatment sign out dressing changes for the above order revealed, treatments left blank and or not completed on days of 10/10/23, 10/18/23, 10/30/23. and 11/2/23. Review of R22's TAR, dated November 2023, revealed orders for: Perform wound care procedure to wound vac of left lower abdomen three times weekly as follows: remove drape and all foam from wound bed, cleanse wound bed and peri wound with normal saline and gauze. Cleanse skin around wound with chloraprep (if available) and apply skin prep, then cover skin around wound with drape. Reapply wound vac dressing set wound vac to 125 mm Hg. One time a day every Mon, Wed, Fri for Wound Care, start date 11/6/23. Review of TAR for treatment sign out dressing changes for the above order revealed, treatments 11/8/23, 11/10/23, 11/13/23, and 11/15/23 marked with a 9 indicating to other/see nurse note, and on 11/22/23, 11/24/23, and 12/4/23 left blank and or not completed. Review of R22's skin wound evaluations for wound of the left lower quadrant abdominal area between 10/4/23 through 12/19/23, revealed missing evaluations on 11/1/23, 11/8/23, 11/15/23, 11/22/23, 11/29/23, and 12/6/23. Incomplete evaluation on 11/27/23, revealed wound of the left lower quadrant abdominal area, stage three pressure ulcer, and measured 15.3 cm x 5.3 cm and n/a (not applicable) for depth. Review of R22's progress note, dated 10/31/23, read in part, .This RN spoke with scheduling services from (local hospital) regarding Resident's procedure tomorrow morning scheduled for 0830 arrival time . Review of R22's progress note, date 11/1/23, read in part, .left lower abdominal wound debridement were performed. Roll gauze wet to dry dressing placed and covered with ABD (abdominal) pad and tape. This RN instructed to replace dressing with wound vac tomorrow 11/2/2023. Resident stable and had left the hospital in route returning to facility. Review of R22's wound clinic note, dated 11/9/23, read in part, .(name) nurse to change the wound vac dressing on M-W-F until patient follow up appointment on 11/22/23 at 11:30am (11:30 a.m.) with (wound care physician name) in the wound clinic . Review of R22's progress note, date 11/9/23, read in part, .Resident upset with wound vac .resident in tears stating I never wanted this I can't do anything, can't move, can't get up on the commode . Review of R22's progress note, date 11/15/23, read in part, .Wound vac not changed due to functioning properly . Review of R22's wound clinic plan of care note, dated 11/29/23, read in part, .Patient missed her last wound clinic appointment and has been in ER (emergency room ) last week for the wound, she does not have the wound vac on upon arrival today and hasn't had it on since the ER visit last week .Old dressing removed from left lower abdominal wound with foul odor, large amount of foul, purulent drainage, patient states she hasn't been feeling well, has a low grade fever, pulse elevated and blood pressure lower than her normal. The wound bed is approximately 50% slough and necrotic tissue, the rest of the wound bed is pale pink, not healthy. (Wound care physician's name) is in to see and examine the patient, photos and measurements taken, a decision is made to have patient admitted for wound infection and possible sepsis .Progress/Lack of Progress: Lack of progress, there is a foul odor and foul, purulent drainage, patient is feeling ill, low grade fever upon arrival that did elevate later in the visit to 101.3 degrees Fahrenheit, patient complained of feeling cold, she is covered with blankets . Review of R22's weekly skin assessments between 11/1/23 through 12/11/23, revealed a lack of any weekly skin assessment during this time period. Review of R22's census, dated 5/16/23 through 12/4/23, revealed a hospitalization on [DATE] (stop billing) through 12/4/23 (activate billing) related to a wound infection. (Progress notes were reviewed during this time period and lacked any notes of R22 being transferred out or reason why R22 was transferred to the local hospital.) Review of R22's wound clinic plan of care, dated 12/13/23, read in part, .Progress/Lack of Progress: Lack of progress is seen today with pale wound bed and not much for granulation . Review of R22's wound care clinic progress note, dated 12/13/23, read in part, .Follow-up for incision and debridement of lower abdominal wound is area of Pannus. Patient had an abdominal wound measuring 9 x 6 x 5 cm with overlying eschar in need of debridement. Patient was last seen 11/29/23 .The patient had an abdominal wound measuring 4 x 2 cm in size with associated foul-smelling odor. There was a surrounding area of induration and erythema. Necrotic infected tissue was removed revealing a total wound size of 9 x 6 x 5 cm in size .Since I saw the patient last, she was brought back to the operating room for an additional incision and debridement due to significantly infected wound. Additional necrotic tissue was removed in the operating room, the patient's wound was cleaned and a wound vac was reapplied as an inpatient. She has subsequently been discharged back to the nursing home and has been following up with the wound care nursing every Monday-Wednesday-Friday .Today in the Wound Clinic, the patient's wound measures 5.1 x 15.4 x 2.8 cm .Patients 2nd incision and debridement . Review of physician nursing home progress note, dated 12/13/23, read in part, .Was in the hospital for further surgical treatment of abdominal wound. Initially hospitalized for this on November 1st (2023) and then hospitalized again due to further advancement of wound 11/29 through 12/4 . Review of R22's progress note, date 12/13/23, read in part, .during hospital stay to address infected wound . Review of R22's wound clinic plan of care, dated 12/13/23, read in part, .Spoke with (facility name) to see if the machine can be increased to 150 mm Hg (millimeters of mercury). Staff to check on this .Progress/Lack of Progress: Lack of progress is seen today with pale wound bed and not much for granulation - will see if we can increase suction . Resident #29 (R29) On 12/17/23 at 11:15 AM, an observation was made of R29 sitting up in his geri-chair in the B-Hall area near the nurses station. R29 was unable to be interviewed at the time due to his cognition. Review of R29's admission record, date printed 12/17/23, revealed an original admission to the facility on [DATE], with medical diagnoses of diabetes mellitus, anemia, dependence of devices, and dementia. A review of the annual MDS, dated [DATE], revealed him to be at risk for developing pressure ulcers and not having any existing pressure ulcers. MDS quarterly review, dated 11/7/23, revealed him to be at risk for developing pressure ulcers, to have one existing facility acquired stage two pressure ulcer, and to be cognitively impaired, unable to complete BIMS, and rarely or never understood. On 12/18/23 at 10:20 AM, an observation was made of R29 sitting up in his geri-chair near the B-Hall nurses' station. Several staff were noted to walk by and not acknowledge his presence. R29 appeared to be sleeping and his eyes were closed. On 12/18/23 at 2:42 PM, an observation was made of R29 sitting up in his geri-chair near the B-Hall nurses' station. R29 appeared to be resting with his eyes were closed. On 12/18/23 at 3:00 PM, a request was made of Licensed Practical Nurse (LPN) N to observe wound care on R29. LPN N stated that wound care was completed on night shift and was unsure if she would have time to accommodate this Surveyor. *Wound care was not observed at this time per request. On 12/19/23 at 11:13 AM, an observation was made of R29 sitting up in his geri-chair near the B-Hall nurses' station. On 12/19/23 at 1:25 PM, an observation was made of R29 sitting up in his geri-chair near the B-Hall nurses' station. On 12/19/23 at 1:31 PM, an observation was made of Certified Nurse Aide (CNA) I and CNA H removed R29 from B-Hall to his room and transferred him via Hoyer lift into his bed. CNA H was asked how often R29 was turned and repositioned and replied, We try and turn and reposition him every one to two hours. CNA H was asked how long R29 was to be up in his geri-chair during the day and replied, He is care planned to be up for meals and then returns to his bed after meals around 30 minutes to an hour and then we get him back up for the next meal. On 12/19/23 at 1:33 PM, a request was made of RN S to observe wound care for R29. RN S stated that night shift routinely completes this but would ensure an observation opportunity was provided for this Surveyor. RN S was asked which staff was responsible for skin and wound evaluations and measurements and replied, The wound care nurse but I feel like maybe I should be measuring and have not measured any wounds. On 12/19/23 at 1:40 PM, an observation was made of R29's wound care, which was performed by RN S. R29's dressing was removed, the wound was cleaned, and the wound was observed. R29's coccyx area was without any eschar or slough and had nice pink tissue on the wound bed. R29's wound was about the size of a large chicken egg (6 to 6.5 x 4 to 4.5 cm) and had a depth of what appeared to be 2 - 2.5 cm depth. R29's wound was through the epidermis and dermis layers of skin. RN S was asked how he felt the wound looked and what stage he would classify the wound at and replied, It looks better than it did. It no longer has eschar or slough. I would stage it as a stage three pressure ulcer. Review of R29's care plan, dated 10/17/23, read in part, Focus: I am at for skin alterations r/t (related to) decreased mobility, requiring increased staff assist, and some mixed incontinence of B/B (bowel and bladder) .I have an .pressure injury to coccyx area and pressure injuries to left heel and right lateral malleolus r/t limited mobility, incontinence .Coccyx wound infection .Goal: I will have no complication through review date. Coccyx wound infection will resolve by next review date. Interventions/Tasks: Administer antibiotics for coccyx wound infection per physician order (12/11/23) .Administer treatments as ordered and monitor for effectiveness (10/17/23). Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress .Bilateral heel protectors (11/8/23) .I need to turn/reposition at least every 2 hours, more often as needed (10/17/23) .I will have a skin assessment by nurse weekly and prn (as needed) (12/15/23) .Wound care consult order received (11/21/23). Review of R29's weekly skin assessments, dated 7/1/23 through 12/17/23, revealed missing weekly skin assessments on 7/3/23, 7/10/23, 7/31/23, 8/7/23, 8/14/23, 8/21/23, 8/28/23, 9/4/23, 9/11/23, 9/18/23, 10/2/23, 10/9/23, 10/23/23, 10/30/23, 11/6/23, 11/13/23, 11/20/23, 11/27/23, 12/4/23, and 12/11/23. Review of physician fax communication, dated 10/14/23, read in part, Resident has an open area on bottom of scrotum. The area is about 0.6 inches in diameter, has a scab, is red and looks irritated. Another open area on bottom of left glute does not have a defined border, looks purple and red in color, area is about 1 inch in diameter, area is irritated as well. Powder was put on areas, no opti-foam though. What would you like to do? Please advise. (Physician response) Please have the wound nurse see him and advise appropriate dressing. In the meantime, he needs to be rotated every 1/2 hour to avoid the gluteal pressure sore being worse. *Note: Care plan was not updated to reflect new turning and repositioning physician recommendations. Review of R29's skin and wound evaluation, date 10/16/23, revealed the development of a facility acquired pressure ulcer stage II on his coccyx, measured 2.4 x 2.0 cm and no depth recorded, no drainage, edges attached, and goal of care: healable. Review of physician fax communication, dated 10/23/23, read in part, Resident wound to coccyx is now black with eschar. Could we get an order to try aquacell AG covered with opti-foam. Change daily and prn? (Physician response) Yes. As above. Review of R29's skin and wound evaluation, date 11/7/23, revealed the developed facility acquired pressure ulcer stage II on his coccyx was now unstageable per facility documentation, measured 4.2 x 2.9 cm and no depth recorded, light exudate with serous drainage, slough (no percentage recorded), and eschar (no percentage recorded). Review of R29's skin and wound evaluation, date 11/21/23, revealed the developed facility acquired pressure ulcer stage II on his coccyx now unstageable per facility documentation, measured 3.7 x 2.4 cm and 1.0 cm depth recorded, moderate exudate with sanguineous drainage, slough (no percentage recorded), and eschar (no percentage recorded). Review of R29's skin and wound evaluation, date 11/27/23, revealed the developed facility acquired pressure ulcer stage II on his coccyx now unstageable per facility documentation, measured 7.0 x 4.6 cm and no depth recorded, moderate exudate with sanguineous drainage, slough (no percentage recorded), and eschar (no percentage recorded). *In review of the photo of the wound there is clearly a depth to the wound that was not measured and worsened from the prior depth measurement. Review of R29's physician orders, dated October 2023, revealed, Opti-foam to coccyx. Change every other day and prn. Every day shift every other day for wound care. Start date 10/18/23. *Note: no as needed sign out and R29 known to be incontinent of bowel and bladder. Review of R29's physician orders, dated November 2023, revealed, To coccyx daily and prn: Clean area, apply aquacell AG, cover with opti-foam. One time a day for wound care. Start date 10/24/23. Review of the TAR for November 2023, revealed missing dressing changes on 11/22, 11/27/23 and 11/29/23. *Note: no new or changed wound care orders after this order. No as needed dressing changes signed out in addition to regular dressing changes. Review of R29's census, date printed 12/19/23, revealed a stop billing on 11/20/23 and activate billing on 11/22/23 and then another stop billing on 12/13/23 and activate billing on 12/15/23. In review of the TAR for November 2023, dressing changes were being marked as completed on 11/21/23 and for December 2023, revealed dressing changes were being marked as completed on 12/14/23 when R29 was absent from the facility. Review of physician fax communication, dated 12/3/23, read in part, Resident coccyx ulcer smells odorous .(Physician response) 1.) If possible please culture the wound. 2.) Start Augmentin 400mg/5ml - 2 tsp. po, BID x 10 days (10 ml [800 mg] by mouth, twice daily for ten days). Review of R29's skin and wound evaluation, date 11/7/23, revealed the development of a second facility acquired pressure ulcer stage II on his right lateral malleolus, measured 1.1 x 0.8 cm and no depth recorded, no drainage, edges attached, and goal of care: healable. No further skin and wound evaluations were recorded for the coccyx wound after the date of 11/27/23 and no further skin and wound evaluations for the right lateral malleolus after 11/29/23. No wound measurements for the month of December 2023 were recorded in EMR at the time of the survey date exit on 12/19/23. On 12/19/23 at 8:30 AM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA was asked what her expectations were for wound care documentation, dressing changes, and skin assessments and replied, I would expect all dressing changes to be completed and signed out in the treatment record, skin wound measurements and skin assessments are completed weekly and recorded, and any missing documentation should have a nurses note for the reason why it was incomplete. The NHA was asked how long wound care treatment changes are made and referred this Surveyor to the wound care nurse who was not in today but would be in tomorrow. On 12/19/23 at 9:45 AM, the Survey team was made aware that the Director of Nursing wound is not available today and wound not be in the facility and if we needed anything to reach out to the NHA. On 12/19/23 at 11:10 AM, an interview was conducted with CNA E regarding showers and skin assessments. CNA E is the supervisor for all facility CNA's. CNA E CNA E was asked when skin assessments are scheduled for and replied, They are done on shower days each week by the nurses. CNA E further stated that the assessments had been discontinued in March 2023 and a new one was implemented but could not describe the process. CNA E replied, The CNA's takes the resident to the shower room and then calls the nurse to observe the skin and then documents the findings. On 12/19/23 at 11:40 AM, an interview was conducted with Wound Care Nurse / RN T who was asked how often wounds get measured and how often skin assessments are to be completed and by whom and replied, Residents with wounds get weekly measurements and skin sweep assessments are completed weekly with showers by nurses. RN T was asked if there was any reason a Resident would miss wound measurements, dressing changes, or skin assessments and replied, Well, I guess only if they refuse or are absent from the facility. Lately, it has been hit or miss. RN T was asked why wound measurements and skin assessments were not performed weekly for R22 and R29 and replied, A few weeks ago I had to work the floor so they did not get done. RN T was asked if she was a full-time employee or a part-time employee and replied, I work part-time. RN T was asked how long R22 has had the wound on her abdominal area and replied, She acquired it at the facility. RN T was asked how long R22 has had her wound vac and when the last time she observed R22's wound and replied, It has been awhile since I observed her wound. She has the dressing changed every Monday, Wednesday, and Friday. RN T was asked if she was the nurse who applied the dressing to R22's left lateral thigh area and replied, I am not sure I did work last week. I guess it could have been me. RN T was asked about the initials on the dressing and if the dressing for wound cares should have physician orders and replied, Yes, all dressings should have physician orders. RN T was asked if she could provide orders for R22's dressing change to that area and replied, I would have to check. RN T returned and stated that R22 did not have orders for the dressing. RN T was asked how long the dressing should be left on and when it should be changed and replied, I think is was to be changed every three days. RN T was reminded that the original date on the dressing was 12/12/23 and should have been replaced but lacked an order to be changed. RN T stated that last week another facility nurse took over wound care. RN T was asked if she was trained by her and if this nurse knew how to take pictures of the wounds and fill out the appropriate assessments and replied, She knows how to take pictures. I do not know if she has done any evaluations yet. She knows where the evaluations are in the computer charting system. I did not train her yet. Review of facility policy titled, Wound Treatment Management, dated 10/27/22, read in part, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 3. Dressing changes may be provided outside the frequency parameters in certain situations: a. Feces has seeped underneath the dressing. b. The dressing has dislodged. c. The dressing is soiled otherwise or is wet . 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound (see above) . Review of facility policy titled, Skin Assessment, dated 10/7/2022, read in part, Policy: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury .7. Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. b. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). e. Document if resident refused assessment and why. F. Document other information as indicated or appropriate. Review of facility policy titled, Skin Audits by Nursing Assistance, dated 10/27/22, read in part, Policy: It is our policy to communicate changes in skin condition to appropriate personnel as part of our systematic approach for pressure injury prevention and management. This policy establishes responsibilities of nursing assistants in communicating changes in skin condition. Policy Explanation and Compliance Guidelines: 1. Nursing assistants shall inspect all skin surfaces during bath/shower and report any concerns to the resident's nurse immediately after the task. 2. Nursing assistants shall also report changes in skin condition that are noted during any care procedure .

This Deficient Practice Statement (DPS) has two parts: A and B. A This deficiency is related to Intake #MI 574. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an elopement from the facility resulting in Immediate Jeopardy (IJ) for one Resident (R54), of one resident reviewed for elopement. This deficient practice resulted in Immediate Jeopardy (IJ), with the likelihood of serious harm, injury, or death when R54's location was identified and reported being on a State Highway by an unidentified passing motorist. Findings include: During interviews conducted on 10/25/22 with Certified Nurse Aide (CNA) N, CNA P, CNA Q, Maintenance Director (Staff) B, and CNA P at 11:17 a.m., 11:26 a.m., 12:08 p.m., 12:09 p.m., and 12:26 p.m. respectively, all confirmed R54 had eloped, unwitnessed and unsupervised from the facility. Staff could not identify the date and/or time of the elopement, the staff who returned the resident, nor the motorist who reported the resident near the State Highway. CNA P stated, [R54] made it to the road (State Highway) . traffic was actually stopped for her . It was summer, right after we got the brand new (exit) doors . It was a mess. We had to call [Staff B] in town, and told him we believed the doors were not working (alarming) .The two girls (staff) that brought [R54] back said they found [R54] in the road with traffic stopped to prevent hitting her . Staff Q confirmed she was working the day R54 eloped from the facility. Staff Q stated, [R54] was found in the road with traffic stopped. Staff B stated, [R54] got out (eloped) door 5, where smokers generally go out. Staff B said there was a mechanism in the door that failed, resulting in no alarm sounding. Staff B said nobody (no staff) knew R54 was gone from the building and confirmed he had also heard that traffic was stopped on the State Highway to prevent hitting [R54] in the road. Review of R54's Minimum Data Set (MDS) assessment, dated 6/27/22, revealed R54 was admitted to the facility on [DATE] with diagnoses that included: anxiety disorder, weakness, [CONDITION(S)], arthritis, and [CONDITION(S)]. R54 scored 8 of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderate cognitive impairment. Wandering - Presence and Frequency was documented as 1. Behavior of this type occurred 1 to 3 days during the assessment period. R54 required limited one -person assistance with locomotion in and off the unit and used a walker or wheelchair for locomotion. During an interview on 10/25/22 at 2:10 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) were asked for a copy of the incident report for R54's elopement from the building to determine the exact date of R54's unsupervised exit. Witness statements from all parties involved and the staff list for people working on the date of the elopement were requested. The DON confirmed the elopement had not been reported to the State Agency and said there was no information the facility could provide, as no witness statements were obtained, no incident report was completed, and no date was documented in the medical record. This Surveyor requested any, and all documentation of R54's elopement. During an interview on 10/25/22 at 2:20 p.m., the NHA, DON, and Staff B entered the Survey team meeting room. The NHA stated, That (elopement) was not my understanding of what happened. [R54] was found on the facility property. The NHA confirmed the incident had not been reported nor investigated, and noted she was not in the building at the time of the elopement and did not speak directly to any staff. The DON confirmed there was no report to the State Agency, no incident report, no investigation, no witness statements, and no progress notes in the electronic medical record (EMR) to indicate that R54 had eloped from the building. During a telephone interview on 10/25/22 at 2:48 p.m., R54's Durable Power of Attorney (DPOA) R was asked if notification of an elopement from the building had been reported to DPOA R. DPOA R stated, [R54] did get out once, but they did let us know about that . It was someone who lived nearby that brought her back. During an interview on 10/26/22 at 10:36 a.m., the NHA was asked for the date of the elopement. The NHA stated, I don't know, but I may be able to find out. When asked how she would be able to find the date of the elopement, the NHA stated, When it happened [the DON] and I talked (and perhaps texted) about it on the phone. During an interview on 10/26/22 at 11:00 a.m., the DON confirmed she had spoken with the NHA on the day of the elopement, identified as 7/19/22 per the DON. When asked about an Elopement care plan, the DON stated, [R54] should have had an elopement care plan. The DON reviewed the 6/22/22 (Admission) Wander Guard Evaluation Assessment and confirmed no care plan interventions related to wandering were added for R54. The DON also reviewed R54's Care Plans and found no care plan for wandering. The DON stated, [R54] doesn't have a care plan for wandering. When asked why no progress notes, incident report, investigation, or witness statements were completed, the DON said the former NHA, the current NHA, and the DON had talked about it and decided not to report the incident because she was found on facility property (Important to note that the facility also owns a building on the corner of the roads that R54 was found). The DON confirmed that staff did not see her leave the building, and no documentation of the event occurring. The DON expressed understanding of this Surveyor's concern with the elopement and the lack of documentation and investigation of the incident. The DON confirmed a family member (of the DON), Activity Aide (AA) S, had been one of the staff members to find R54. The DON said she did not want the family member contacted for an interview. During an interview on 10/26/22 at 11:03 a.m., Staff B confirmed the courtyard gates were to be closed during the summer. Staff B stated, The gates were to be closed in July (of 2022), but they were broken because staff pushed them outward the wrong way and broke the gates. They should have been closed when [R54] went out (eloped). During an interview on 10/26/22 at 1:29 p.m., the NHA said the elopement happened on 7/24/22 instead of the 19th. The NHA said she had reviewed her phone and the DON had provided the wrong date The NHA provided the Facility Staffing Sheet for 7/24/22 at this same time. Review of R54's complete EMR found no written documentation to show evidence that R54 eloped from the building on 7/24/22, prior to identification and facility notification of Immediate Jeopardy related to R54's unsupervised elopement from the facility. Facility administration repeatedly denied any documentation was available for review, related to R54's elopement until 10/27/22, and the Immediate Jeopardy Template had been received (on 10/26/22). Documents never provided by the facility included the incident report, progress notes, and the facility investigation identifying date of elopement, time of elopement, name of motorist reporting elopement, and names of staff who returned R54 to the facility. Typed Witness Statements were received on 10/27/22. During an interview on 10/27/22 at 9:10 a.m., the DON provided nine (9) typed Witness Statements signed by both the individual staff member and the DON, all dated 7/24/22. All statements said no door alarm was heard prior to R54's elopement from the building on 7/24/22. When asked why the DON had not provided the Witness Statements with this Surveyors' multiple requests for documentation regarding this elopement, the DON stated, I forgot that I had gotten the statements - I forgot all about it. During an observation on 10/27/22 at 10:15 a.m., the elopement path was walked by survey team members. Exit was through door five and through the gait to the alleyway. The gate was found closed with a latch and bungee cords. The gate was manually opened, and survey team members walked westward up the alleyway toward the State Highway until the sidewalk was reached. Looking south, the break in the fence between the dining room exit door and the sidewalk was observed, where staff had exited to find R54. Staff would have not been able to see the resident on the road from inside of the dining room, as the dining room was at a lower elevation than the sidewalk, and partially blocked by the apartment building. Review of Activity Aide (AA) T's Witness Statement, that was documented as obtained as soon as [R54] was back in the building (on 7/24/22) by [the DON] . revealed the following, in part: AA T was in the dining room working on a puzzle with a resident when AA S came into the dining room and said 'A gentleman just came to the door and asked if we had an escapee as there is a confused woman in a w/c (wheelchair) near the road' . AAs T and S exited using the dining room door and when they got to the sidewalk, they looked toward the apartment buildings (north) and noted [R54] to be sitting in her w/c on the edge of the road, right up to the sidewalk . and cars had pulled over to the side of the road . No Witness Statement was available from AA S. During the interview on 10/27/22 at approximately 9:15 a.m., the NHA and DON confirmed no root cause analysis was completed as part of a facility investigation to prevent further elopements. The DON said nursing staff performed a post-elopement assessment, but it was not documented in the medical record. The DON agreed any physical assessment completed should be documented in the EMR. No post-elopement physical assessment was found in the EMR. The NHA and DON confirmed door five was not latching properly and acknowledged there was a problem with the exit door alarm. The DON and NHA confirmed facility staff went out through door three, through the dining room, which was a different exit than door five used by R54. The NHA stated, She was a moderate elopement risk (score of 4), but one or two days before, she had started with more exit seeking. [R54] hadn't attempted to leave, had never attempted to exit seek prior to the [new medication] starting. The DON agreed that R54 had NO exit seeking before the start of the [new medication] on 7/22/22. Review of a Nursing: Wander Risk Evaluation, dated 6/29/2022, with a Lock Date of 7/19/22, revealed R54 was a High Risk for wandering, with a Score of 19. This 6/29/22 Wander Risk Evaluation completed seven days after the 6/22/22 Wander Risk Evaluation documented R54 Has attempted to leave OR has successfully eloped; OR demonstrates exit seeking behaviors, with Additional Risk Factors of Number of reported elopement attempts in the past 12 months of 15. Remarkably different from the Admission Wander Assessment that documented R54 had zero elopement attempts in the past 12 months. Review of R54's Care Plans, found no Wandering/Elopement Risk care plans in effect until 7/19/22, although a high-risk score for wandering of 19 on 6/29/22, Lock Date of 7/19/22. No Wandering Care Plans were identified in the EMR by the DON on 11/26/22 at 11:00 a.m., when R54's EMR was reviewed in the presence of this Surveyor. During a follow up interview on 10/31/22 at 7:56 a.m., Maintenance Director B confirmed an electrical company had changed out the panic bar on door 5 on 7/20/22. Maintenance Director B stated, There was a screw inside the strike (plate) that came loose. I don't know when it came loose (between 7/20/22 and 7/24/22) . There was a spring on the screw and the screw or latch failed . The gate (blocking exit from the courtyard) should have been closed but the gate was broken . Review of the Elopements and Wandering Residents, policy, revised 6/2022, revealed the following, in part: .'Elopement' occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so .1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner . Adequate supervision will be provided to help prevent accidents or elopements . If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The administrator or designee should also notify the company's corporate office . Appropriate reporting requirements to the State survey agency shall be conducted. 6. Procedure Post-Elopement: a. A nurse will perform a physical assessment, document, and report findings to physician . c. A social service designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults . g. Documentation in the medical record will include findings from nursing and social service assessments, physician/family notification, care plan discussions, and consultant notes as applicable. The IJ was identified during the Recertification Survey on 10/26/22 at 12:20 p.m. It began on 7/24/22 at 11:00 a.m., when R54 exited Door 5, unwitnessed and unsupervised. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified of the Immediate Jeopardy on 10/26/22 at 1:45 p.m. A verbal request was made of the Facility for a written immediacy abatement plan at this same time. The Facility Removal Plan, read, 1.) A headcount of all residents was conducted to ensure all residents are accounted for. 2.) All exterior doors have been tested to ensure proper working function of door alarms. 3.) Elopement policy and procedure was reviewed, and no changes were made. 4.) Education with all staff will be conducted today 10/26/22 by on elopement policy and procedure. This will be conducted in person and over the phone for staff who are not working today. Administrator and DON will be educated by Director of Clinical Operations, Administrator and DON will educate management team and Management team will educate their department's staff. 5.) Education with all staff will be conducted today 10/26/2022 to ensure courtyard gate remains closed at all times. This will be conducted in person and over the phone for staff who are not working today. 6.) Resident #54 was successfully discharged from the facility on 8/15/22 to her home. 7.) Resident #54's physician and family were updated. 8.) Resident #54's medical record was reviewed and no injury or change in baseline is noted. 9.) Complete investigation into Resident #54's elopement will be conducted. 10.) Reviewed current binder of elopement risk residents to ensure assessments, care plans, and pictures are up to date. 11.) Audits of the alarm functionality of all exterior doors will be conducted daily for 1 week and 3 times a week for 3 weeks. 12.) Quarterly Elopement drills will be conducted as scheduled. 13.) Resident Elopement assessments will continue to be conducted upon admission, quarterly, annually, upon significant change and as needed. Completion Date: 10/26/22 On 10/27/22 an onsite verification of immediacy removal revealed the above interventions had been implemented. This was confirmed through observations and interviews. Although the Immediate Jeopardy was removed on 10/26/22, the facility remained out of compliance at a scope and severity of no actual harm with potential for more than minimal harm that had the potential to affect all residents with wandering behaviors due to the inability to verify staff education, all policy review/updates, system changes, and sustained compliance. B. Based on observation and interview the facility failed to ensure a safe resident environment as evidenced by hot water temperatures at resident room sink fixtures exceeding 120 F. This deficient practice has the potential to result in scalding injury to any of the 52 residents due to exposure of hot water. Findings include: On 10/24/22 between 3:30 PM and 4:30 PM the temperature of the water being supplied to faucets in resident room sinks was measured with a digital metal stem probe thermometer. Hot Water supplied from the faucets was measured to be 126 F in resident rooms on the B side hall and included rooms: 22, 23, 24, 25, 26, 27, 28, 29, & 30. Not all resident rooms were available to be observed due to privacy concerns. Rooms on the A side hall included 1, 6, 9, 10, 12, 14, with hot water temperatures ranging between 123 F and 126 F. On 10/24/22 at 4:35 PM, an interview was conducted with Maintenance Supervisor MS B , while in resident room 10. The temperature of the hot water was measured by this surveyor using the metal probe thermometer, and MS B using the facility's infrared hand held thermometer. The water temperature was measured to be 124 F by the metal probe thermometer and 114 F using the infrared device. At 4:45 PM observations were made with MS B at the water heaters used to supply the hot water to each of the halls. Side A's water heater was observed with a thermometer mounted on the exit line and read a temperature of 124 F. The B side water heater was also equipped with a thermometer on the exit pipe and read a temperature of 127 F. MS B stated he had not looked at the water heater mounted thermometers, rather had only used the infrared device to measure the water temperature in the stream from the faucet.

Intake# MI 185 Based on observation, interview, and record review, the facility failed to provide adequate supervision, physician ordered assistive devices, and properly maintained medical equipment (anti-rollback wheelchair) to prevent two falls with major injuries involving Residents #2 and Resident #3 of three residents reviewed for falls. This deficient practice resulted in harm for Resident #2 with fracture, hospitalization , increased pain, and decreased mobility. Findings include: Resident #2 Review of Resident #2's Minimum Data Set (MDS) assessment, 11/13/21, reflected the following diagnoses: diabetes, chronic [CONDITION(S)] (low sodium), dementia, and alcoholic [CONDITION(S)]. Resident #2 showed independence with bed mobility and toilet use but staff supervision was required for transfers. Resident #2 required staff supervision and one staff physical assist with ambulation. Resident #2 was continent for both bladder and bowels. The Brief Interview for Mental Status (BIMS) reflected intact cognition with a score of 14 out of 15. Review of Facility Reported Incident, 1/18/22, showed Resident #2 sustained an unwitnessed fall on 1/17/22 at 12:45 a.m. from bed to floor. On 1/17/22, Resident #2 was evaluated at an emergency room and diagnosed with a left hip contusion and pain and returned to the nursing home. On 1/18/22, Resident #2 was reluctant to bear weight on their lower extremities, bilateral lowered extremities were red and warm to touch, was unable to lift legs up in bed, and now needed extensive assistance of two staff. Resident #2's was transferred to a different emergency room were the comminuted distal left femur fracture with intra-articular extension (left hip fracture) was identified. Resident #2 was then transferred to a third hospital where surgery was performed (ORIF-open reduction internal fixation of the left femur). Resident #2 remained hospitalized as of the date of exit from the facility (2/9/22). Review of Resident #2's Care Plan, last reviewed 3/2/20, read in part, (Resident #2) has an ADL (Activities of Daily Living) self-care performance deficit .has bilateral assist rails for positioning. During an observation on 2/9/22 at 10:22 a.m., Resident #2's bed showed no bed rails were on either side of the bed. On top of the bed showed an Army green colored comforter, a collapsed two-wheeled walker, clothing, and a folded crochet blanket colored blue, black, and white. During a follow-up interview on 2/9/22 at 10:37 a.m., the Director of Nursing (DON) confirmed Resident #2's bed had not been changed since their transfer to the hospital. The DON said Resident #2 had a physician order for bilateral bed rails. When asked about the Assist Rail Screening dated 9/27/21, which showed Resident used one bed rail for positioning and support, the DON said it was not accurate. The DON said Resident #2 did not have either one or two bed rail(s) installed on the bed. The DON confirmed Resident #2's fall Care Plan and Physician Order (2/5/20) for bilateral assist bars were not followed. Resident #3 Review of Resident #3's MDS assessment, 12/7/21, reflected the following diagnoses: [CONDITION(S)] (stroke), non-Alzheimer's dementia, [CONDITION(S)]/[CONDITION(S)], muscle weakness, hypertension, and left hand contracture. Resident #3 required two staff assistance for bed mobility, transfers, and toilet use. The BIMS assessment reflected a score of nine which indicated moderately impaired cognition. During an observation/interview on 2/9/22 at 10:22 a.m., Resident #3 was lying in bed with the left arm contained in a black sling (no hand splint noted to left hand). Resident #3 said, I have a broken bone. Resident #3 said he fell in the bathroom (2/8/22) while being toileted with the assistance of two certified nurse aides. Resident #3 said, . the young lad helping me in the bathroom tripped over big, rubber boots in the bathroom and lost his balance . Resident #3 said, Ouch, that hurts! Resident #3 attempted to reposition themselves. An observation of Resident #3's bedside for fall risk showed the following: two long, folded black strings and food debris on the floor to the right side of the bed, a bedpan covered in clear plastic bag on the floor directly in front of the nightstand, wheelchair foot pedals lying on the floor next to the bedpan. Licensed Practical Nurse (LPN) X was notified of Resident #3's complaint of increased pain. LPN X stated, OK. On 2/9/22 at 10:58 a.m., the NHA confirmed Resident #3 had fallen in the shower room on 2/8/22 while being toileted by CNA U and Nurse Assistant (Staff) M. During an observation of the shower room, in the presence of NHA and CNA S, CNA S said the shower boots were stored to the right side of the toilet, but they had been removed since they were currently in use in the second shower room. The NHA said CNA U and Staff M had performed an improper transfer. Review of Staff M's post fall witness statement, dated 2/9/22, read in part, didn't have the easiest transfer. The chair got caught on my leg; and made us loosen our grip as we tried to transfer the resident. Review of CNA U post fall witness statement, dated 2/9/22, read in part, (Resident #3's) chair (wheelchair) doesn't lock well and I believed the chair slipped back, it wasn't the easiest transfer because (Resident #3's) legs were tired and our positioning. I also noticed (Resident #3's) chair was not locking right on the wheels, about an hour before the transfer. Review of (Resident #3's) Incident on February 8, 2022 read in part, Upon inspection of (Resident #3's) wheelchair immediately following the incident, we observed that the anti-rollback mechanism on the back of the wheelchair was loose. On attempt to roll the wheelchair backwards, both with weight in the chair and without, the wheelchair rolled back despite the anti-rollback mechanism . During an interview on 2/9/22 at 1:52 p.m., Maintenance (Staff) J confirmed Resident #3's wheelchair had loose bolts which caused the wheelchair anti-rollback misfunction. Review of Resident #3's Progress Notes, dated 2/8/22, written by LPN Y read in part, was heard screaming in the A side shower room. Upon observation resident was laying on the floor on his back. Resident denies hitting his head, resident stated he fell off the toilet. LUE (left upper extremity) noted with discoloration and swelling. 911 called and resident transferred to (hospital) for further evaluation. LPN Y's next Progress Note, 2/8/22, read Call received from ED (emergency department) (Resident #3's) fall resulted in humeral head facture of the LUE. Resident will need to follow up with Ortho ASAP (as soon as possible). Review of the facility's policy Falls and Fall Risk, Managing revised March 2018, read in part, 'Fall Risk Factors .d. obstacles in the footpath; e. improperly fitted or maintained wheelchairs .

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance devices to prevent falls resulting in harm to four Residents (#4, #5, #6, and #7) out of six residents reviewed for falls. This deficient practice resulted in fractured ribs, contusions, head hematoma, spinal fractures, pain, and fearfulness during provision of care following the falls. Findings include: Between 10/18/20 and 10/27/20 an abbreviated survey was conducted to investigate Facility Reported Incidents (FRIs) and an anonymous complaint related to resident falls within the facility. Resident #6 Review of Resident #6's Minimum Data Set (MDS) assessment, dated 7/25/20, revealed Resident #6 had the following diagnoses: heart failure, [CONDITION(S)] (PVD), diabetes mellitus, obesity, depression, absence of bilateral legs above the knee, and other complications of amputation stump. Resident #6 scored 13 of 15 on the Brief Interview for Mental Status (BIMS), reflective of intact cognition. Resident #6 required extensive, two-person assistance with transfers, dressing, toilet use, personal hygiene, and physical help with bathing activity with the assistance of one staff. Resident #6 used a wheelchair for locomotion. Review of Resident #6's Incident Report: 9/9/20 10:30 (a.m.), CNAs (Certified Nurse Aides) were assisting resident into the shower, as CNA was pulling resident into shower stall over the 'lip in to (sic) floor' the wheel to the shower chair broke off. Resident started to fall backwards in the shower chair .Resident stated the wheel broke and I fell backwards on the nurse .Predisposing Environmental Factors: Equipment malfunction. Injuries documented on Incident Report: Skin Tear - 33) Right thigh (front). Review of the Facility Investigation Report revealed: .at 5:30 p.m. resident (Resident #6) requested . transfer to hospital to be evaluated .returned with diagnosis of fractured ribs x (times) 2 .A new shower chair was ordered, and maintenance will continue with checking of equipment; including shower chairs to ensure safety of equipment. During an interview on 10/18/20 at 11:36 a.m., Resident #6 was asked about the fall in the shower on 9/9/20. Resident #6 stated, The back, left wheel fell right off. Me and the shower chair was on the floor . I had three fractured ribs. When I fell , I had pain (immediately). I had pain for three weeks with fractured ribs .I missed a couple showers. I am afraid to go back in there (shower) after what happened (fall with fractured ribs) . Review of Resident #6's Physician Orders revealed the following orders implemented after the fall from the broken shower chair on 9/9/2020: Order Date/Start Date 9/9/2020: [MEDICATION(S)] (pain medication), Give 1 tablet by mouth every 6 hours as needed for rib area pain. Order Date/Start Date 9/9/20: Acetaminophen Tablet 324 MG Give 2 tablet by mouth every 4 hours as needed for general discomfort per standing orders. Order Date: 9/10/20, Start Date 9/11/20: Wash skin tear to right stump with normal saline, apply triple antibiotic and apply band-aid daily until healed one time a day. Review of Resident #6's Electronic Medical Record (EMAR) for September 2020, revealed skin assessments were to be completed after showers every Wednesday and Saturday. There was no documentation (nurses initials) on 9/5, 9/9, 9/12, and 9/16 to show completed skin assessments. Administration of [MEDICATION(S)] for pain was documented for 11 non-consecutive days following the fall on 9/9/2020. Observation of the shower room Resident #6 used for showers, found a gap of approximately 1.5 to 2 inches between the linoleum used in the main shower room floor, and the tiles in the shower itself. There was an increase in height, going up from the linoleum into the shower, of approximately 1/8 - 1/4 inch. During a telephone interview on 10/21/20 at 5:10 p.m. regarding Resident #6's fall, Staff G stated, .The tile in the shower area is slightly higher than the rest of the floor. As I pulled him into the shower the wheel snapped off . I think it (shower chair) has been here since I started [AGE] years ago .I know it is older. The PVC pipe snapped right above the wheel . it was scary . He [Resident #6] started complaining of chest pain. I know it scared the daylights out of him . Staff G confirmed they did not send Resident #6 out to the hospital immediately following his complaints of chest pain. Review of the undated Investigation Summary, completed by the facility, revealed the following, in part: On 9/9/20 at 9:45 a.m., [Resident #6] was being wheeled into the shower, over the lip to get into the shower space, the shower chair leg broke off tipping resident backwards and onto his back in the shower chair on the floor . Resident refused to go to hospital at time of fall .Approximately at 5:30 pm, resident requested to get out of bed for dinner, resident c/o pain and was having a hard time moving and requested transfer to the hospital to be evaluated. Resident returned with a diagnosis of fractured ribs x 2 and old pleural effusion. During an interview on 10/19/20 at 8:37 a.m., Staff BB said there was no documentation (logs) to show the length of time the shower chairs were in use by the facility or to verify the facility had performed preventive maintenance to ensure the shower chairs were functional and safe for resident use. Staff BB stated, A lot of this stuff is old - they (shower chairs) have been here for a while. Staff BB said he was unaware of any weight limit on the chair, and the shower chair had been discarded in the trash. Resident #4 Review of Resident #4's MDS assessment, dated 8/15/20, revealed Resident #4 had the following diagnoses, in part: diabetes mellitus, other fracture (right shoulder), [CONDITION(S)], and Non-Alzheimer's dementia. Resident #4 required supervision with setup help only with bathing and was independent with setup help only for bed mobility, transfers, eating, and toilet use. Resident #4 had Upper Extremity Impairment on one side (shoulder, elbow, wrist, hand) and normally used a walker and wheelchair for mobility. Resident #4 scored 11 out of 14 on the BIMS), reflective of moderately impaired cognition. Review of a previous 6/16/20 Facility Reported Incident (FRI) investigation report revealed Resident #4 had a witness fall on 6/16/20. X-rays performed on 6/17/20 had the following Impression Right Shoulder: Avulsion fracture of the greater tuberosity and slightly impacted [MEDICATION(S)] fracture right humeral neck (right shoulder fracture). Review of Resident #4's Incident Report, dated 9/11/20 at 10:44 a.m., revealed the following, in part: Resident description: Resident reported the shower chair tipped over while he (was) in the shower, resident stated multiple times that the wheels were 'locked'. Resident stated he hit the back, right side of his head on the shower wall, and landed on his right shoulder and right hip. Rated pain 6-7/10 .Resident did report pain in his right shoulder, right hip, tailbone, and occipital area of head .Injuries Observed at Time of Incident .Right trochanter (hip) .Sacrum .Back of head .Right shoulder (front) . No Witnesses were listed on this facility report, and documentation to show the resident was transferred to the hospital was N for no. Review of the electronic Neuro Checks form, dated 9/11/20, revealed Resident #4 verbally complained of pain at a level of six (on a 1-10 scale), involving his right shoulder, right hip, tail bone, and back of head during four assessments completed following his fall. The Comments section at the 1-hour assessment revealed, Resident out to the ER (emergency room ) via EMS (Emergency Medical Services) at 1140 (11:40 a.m.). Review of Resident #4's 9/11/2020 Emergency Department record revealed: You were seen today for: Fall; R (right) shoulder/hip contusion (bruise) . Review of Resident #4's Fall Care Plan, revealed the following, in part: Education provided to CNA regarding resident safety while in shower room on day of fall, Date Initiated: 09/16/2020 . New shower chairs ordered, Date Initiated: 9/11/2020. Resident #4's ADL (Activities of Daily Living) Care Plan revealed, Bathing: extensive assist x 1 staff member on Sunday and Thursdays, Date Initiated: 11/21/2019, and Provide support during transfers to RUE (right upper extremity), please encourage [Resident #4] to wear his sling, Date Initiated: 06/30/2020. Resident #4 was noted to be NWB (non-weight bearing). Review of a letter drafted by Staff R, to Resident #4's Responsible Party on 10/14/20, revealed the following: On 9/11/20 [Resident #4] was transferred to the Emergency Department . following a witnessed fall. He was given a CT scan of his head and C-Spine, as well as X-Rays of his right hip and shoulder .He was diagnosed with right shoulder and hip bruising and was instructed to use his already prescribed [MEDICATION(S)] for pain control. Review of Resident #4's Progress Notes revealed the following reported pain levels and use of prescribed pain medication ([MEDICATION(S)]) following the fall from the shower chair: 9/14/20 16:20 (4:20 p.m.) - Give 1 tablet by mouth every 6 hours as needed for pain 1-5 on pain scale coccyx pain. 9/15/20 23:08 (11:08 p.m.) - . back pain at tail bone . 9/19/20 12:22 (12:22 p.m.) - . 8/10 pain in his tail bone not alleviated by offloading or repositioning. Resident is demonstrating discomfort on his face and in his tone of voice. 9/20/20 00:22 (12:22 a.m.) - . pain in left hip pain, right shoulder and 'tailbone'. 9/21/20 18:02 (6:02 p.m.) - .pain in his tailbone, and right shoulder . 9/22/20 19:31 (7:31 p.m.) - .c/o (complained of) tailbone pain . 9/25/20 08:45 (8:45 a.m.) - .pain in his coccyx area, pain was not relieved by repositioning. 9/25/20 21:16 (9:16 p.m.) - . complaining of right shoulder pain . 9/26/20 19:54 (7:54 p.m.) - . pain in right shoulder and tailbone . 9/28/20 10:56 (10:56 a.m.) - . pain all over, even his tail bone . 9/30/20 11:45 (11:45 a.m.) - .pain in tail bone radiating down to his hip rated at a 10. 10/2/20 9:32 (9:32 a.m.) - .coccyx pain . 10/4/20 23:33 (11:33 p.m.) - . Pain level 9/10 per pt (patient) in R shoulder and R hip. 10/7/20 08:34 (8:34 a.m.) - .back and hip pain . Documentation of a Skin Assessments on the September 2020 EMAR skin assessment every evening shift every Sun for skin assessment, Start Date 10/20/19, revealed Resident #4 received two documented skin assessment during the month: following the fall on 9/11/20: one on 9/20/20 and one on 9/27/20. Documentation for 9/13/20 was blank, absent any nursing staff initials. During an interview on 10/19/20 at 8:37 a.m., Staff BB said there was no documentation to show the length of time the shower chairs were in use by the facility or to verify the facility had performed preventive maintenance to ensure the shower chairs were functional and safe for resident use. Staff BB stated, A lot of this stuff is old - they (shower chairs) have been here for a while. During a telephone interview on 10/21/20 at 5:10 p.m., when asked about the age of the shower chair, Staff G stated, In all honesty, I think it (shower chair) has been here since I started [AGE] years ago . I know it is older . During a telephone interview on 10/23/20 at 2:44 p.m., in regard to Resident #4's fall in the shower room, Staff F, who was present in the shower with Resident #4 stated, .The shower chair was all locked (wheels were locked) .on that style of shower chair only the two back wheels locked - the front wheels did not lock . Staff F said the shower chair moved down the hall (with the wheels locked) following the incident. Staff F stated, The Nursing Home Administrator (NHA) is aware the locks did not work properly . All those chairs were there (in facility) from when I was there eight years ago. During a telephone interview on 12/21/20 at 4:05 p.m., when asked about shower chair warranties, [NAME] Vice President of [Company Name] confirmed there was a five-year warranty on the shower chair frame. Review of a Policy for Preventative Maintenance of Equipment in a Skilled Nursing Facility, dated 9/11/2020 (following Resident #4's and Resident #6's fall), revealed the following, in part: In order to provide a safe environment for residents, employees, and visitors, a preventative maintenance program has been implemented to promote the maintenance of equipment in a state of good repair and condition. Routine inspections promote safety throughout the facility and aid in keeping equipment in good working order and operating in accordance with manufacturer's guidelines .Assessed equipment includes items owned by the facility, supplied by a vendor, leased, or rented . During a telephone interview on 10/23/20 at 3:19 p.m., with the facility Nurse Consultant Q, Director of Nursing (DON), and Staff A present on the call, the NHA confirmed she had personally sat in the shower chair used by Resident #4 on the day of his fall and confirmed when the shower chair locks were engaged, the wheelchair did move. The NHA stated, When you leaned on the arms it tipped forward. The DON confirmed Resident #4's Incident Report was not filled out properly. When asked if there was a Skin Assessment completed, the DON stated, No formal skin assessment was completed for [Resident #4] on 9/11/20. When asked what the cause of Resident #4's fall with resulting transfer to the ER, contusions to his right hip and previously fractured right shoulder, and prolonged pain, the DON stated, The shower chair. Resident #5 Review of the anonymous complaint received 5/20/20, revealed the complainant heard a loud crack, and a yell/moan from a resident who fell from a wheelchair, without foot pedals, while being pushed by facility staff. The complainant was concerned with lack the of emergent medical evaluation due to potential head injury and bruised and swollen face and neck. Review of Resident #5's MDS assessment, dated 3/10/20, revealed the following active diagnoses: Alzheimer's disease, [CONDITION(S)], non-Alzheimer's dementia, anxiety, depression, and borderline personality disorder. Resident #5 had unclear speech, moderately impaired vision, and was rarely able to be understood, or understand others. Resident #5 scored a 99 on the BIMS because he was unable to complete the interview and had severe cognitive impairment. Resident #5 required extensive two-person assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and was totally dependent upon staff for bathing. Resident #5 used a wheelchair for mobility and was able to self-propel throughout the building. Resident #5's communication was assessed as rarely/never understood). Review of the facility Incident Report, dated 5/18/20 at 11:30 a.m., revealed the following: .resident (#5) laying face first on the floor in front of the kitchen entry door with [Staff F] kneeling at his side and [Staff T] standing in front of the kitchen entry door Injuries Observed at Time of Incident: Hematoma, Injury Location 64) Other .Notes: hematoma to right side of forehead . Resident Taken to Hospital? N (no) . During a telephone interview on 10/21/20 at 12:47 p.m., former Staff T, who witnessed Resident #5's fall on 5/18/20, was asked to describe the incident. Staff T stated, . [Staff F] was pushing [Resident #5] in his wheelchair. I don't think he had foot pedals (rests) on the wheelchair .He (Resident #5) fell (on his head) and he didn't put out his arms or anything (to lessen the fall) .[Staff P] took his vitals and looked at him and then they got him up .He had a red mark on his head and it got progressively worse over the day .By the time I left around 4 to 5 (p.m.) he was looking worse and his red mark was getting bigger .It came out like a goose egg on his head .the following day he had one black eye. Review of the Wheelchair Transport Policy, signed 7/24/20 by Staff F, the NHA, and Staff D, revealed the following, in part: When a resident ambulates the wheelchair with his/her feet and the leg rests and foot pedals are not in place then a care giver may push the wheelchair from the side. Caregivers should always speak or appropriately communicate to the resident and inform him/her prior to pushing the wheelchair that he/she is about to commence pushing the wheelchair. Review of two Employee Corrective Action Forms for Staff F, dated 5/19/20 and 5/22/20, revealed the following: 5/19/20, 1st Written Warning, Infraction Date: 5/18/20, Description of Violation: Moved resident behind him by pulling w/c (wheelchair) and resident fell forward, Supervisor Corrective Plan of Action: Approach from front/side. Always use leg rest unless able to self-proper (with) you, move slowly, .from armrest/hand . 5/22/20, Description of Violation: Fall investigation - action could have resulted in major injury. As [Staff F] started to wheel him towards his room he fell forward, landing on his head and chest. Supervisor Corrective Plan of Action: Termination. Signed 5/22/20 by the former DON UU, Staff D, and former Staff VV. Review of the facility Assessing Falls and Their Causes policy, dated 2001, revealed the following: If a resident has just fallen, or is found on the floor .evaluate for possible injuries to the head, neck, spine, and extremities .If there is evidence of injury, provide appropriate first aide and/or obtain medical treatment immediately .If the assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details . Review of Resident #5's Progress Note, dated 5/18/20, revealed the following, in part: .Resident with hematoma noted to be appearing on right side of forehead. Ice pack was applied while taking his vitals and waiting for [mechanical] lift .Placed [mechanical lift] sling under left side of resident with help from [multiple staff]. Rolled resident onto his back and was able to pull the right side of [mechanical lift] sling out and attach to [mechanical] lift .Resident was placed in his wheelchair and then brought to room to assess further in his bed. Staff transferred him to his bed from wheelchair via [mechanical] lift . Review of Resident #5's Progress Notes, revealed the following, in part: 5/18/20 17:52 (5:52 p.m.) On further assessment, res (resident) noted to have hard swelling in right side of neck . Had DON assess neck swelling. Call to on call Dr. 5/18/20 18:23 (6:23 p.m.) Spoke with PA (physician assistant) . PA orders to ice area and monitor, call with worsening changes of any kind. Progress notes reviewed revealed Resident #5's hard swelling in the right side of his neck continued to be documented through 5/24/20, nearly closed right eye due to swelling/bruising continued through 5/25/20, and facial bruises, including bilateral eyes, forehead, and face were documented through 6/15/20. During a telephone interview on 10/21/20 at 6:06 p.m., Staff P stated, I assessed [Resident #5 on 5/18/20] once he got back into bed. When asked why Resident #5 was not transferred to the ER for evaluation after a fall with a head injury, Staff P stated, His son did not want [Resident #5] to get transferred out. During a telephone interview on 10/22/20 at 11:10 a.m., Resident #5's Family Member (FM) AA was asked if he had ever declined a request to transfer Resident #5 following a fall with a head injury. FM AA stated, I don't decline him being sent out, and I have put a standing order in his chart that I pre-authorize them to seek treatment if they need to act. Review of an Employee Corrective Action Form completed for [Staff P], dated 5/19/20, revealed the following, in part: Description of Violation: Didn't follow policy when assisting a resident up from a fall per clinical documentation . Supervisor Corrective Plan of Action: Will only use [mechanical] lift when assisting a resident up from the floor after a fall. Going forward alert DON of any falls while in building immediately. When not in facility, call DON. Review of Resident #5's Fall Care Plan, revealed the following 5/18/20 intervention: Do not push or pull [Resident #5] from the back of his wheelchair. When approaching him, do it from the side/front, so he can hear/see you. Tell him to move his feet in his wheelchair so he can self-propel with you holding his hand or arm rest of his chair. Be sure to give him time to process what has been said. If he is unable to follow the task, his leg rests must be placed before assisting [Resident #5] with wheelchair mobility. During an interviews on 10/22/20 at 11:31, p.m. and 12:30 p.m., the NHA confirmed there was an investigation file for Resident #5's fall in May of 2020, but it was not reported to the State Agency because it was a witnessed fall. When asked about post-fall policy regarding residents with potential head and/or neck injuries, the NHA stated, They (facility staff) should have left him (Resident #5) on the floor and called EMS. I would have sent him out immediately because of the nature of the incident. I would have instructed them (facility staff) not to move him . The NHA acknowledged [Staff P] was given a write up (corrective action) for moving the resident prior to assessment. No evidence was provided to show Resident #5 was assessed for internal head or neck injury due to the fall on 5/18/2020. Resident #7 Review of a Facility Reported Incident (FRI) was conducting during an abbreviated survey conducted 10/18/20 - 10/27/20. The Date of Alleged Event was 9/13/20 at 7:35 a.m., when Resident #7 .was observed on the floor next to his bed .Resident c/o back pain to back, physician and ambulance called, and resident sent to hospital. Resident later returned to facility with diagnosis of T10 compression fraction. Review of Resident #7's Face Sheet, printed 10/21/20, revealed resident #7 was his own responsible party, although completion of the BIMS on 10/5/2020, scored a 10 of 15, reflective of moderately impaired cognition. Resident #7 had the following diagnoses, in part: severe protein-calorie malnutrition, cachexia, chronic obstructive pulmonary disease (COPD), and anxiety disorder. Review of Physician Orders as of 9/20/20, revealed the implementation of following safety intervention: Bed alarm and chair alarm for safety, Order Day 09/01/20. Review of Resident #7's Progress Notes revealed the following: 9/1/20 8:15 a.m. - .resident was leaning up against the wall to the right of the door (bathroom doorway). Feet out in front of him towards the toilet .Physician office called and note sent as well to notify her of his fall. Requesting bed and chair alarm for safety . 9/1/20 10:14 p.m. - res with generalized pain 7/10, had [MEDICATION(S)], now states the pain is in his back and hurts terribly. Asked if it hurts worse sinse (sic) his fall this morning, res states yes, and in my ribs . 9/13/20 11:16 a.m. - Resident was on floor on his back .he was c/o of intense back pain and ambulance was called at 0740 (7:40 a.m.) to send to ER for evaluation of the back .Bed alarm was noted to be shut off . 9/13/20 1:59 p.m. - Received call from the ER nurse with report that resident is ready to come back. He has a right rib contusion a new since 8/22/2020 compression fracture of the T10 Vertebrae . 9/20/20 3:30 p.m. - .Resident was on the floor. It was an unwitnessed fall .He had been experiencing pain and this nurse gave him a [MEDICATION(S)] and after that he had been experiencing hallucinations .His bed alarm had been unplugged, the resident had done this before. A new bed alarm was applied and a note to check for functionality every shift put in his orders on the MAR . 9/21/20 4:20 p.m. - [Resident #7] returned to [facility] at 1600 following a following (sic) with [Physician] at the local hospital. [MEDICATION(S)]-lumbar sacral brace ordered, and patient is to return 6 weeks for follow up. Patient is to wear brace whenever out of bed . Review of Resident #7's Fall Care Plan, Initiated 07/02/20, revealed the following interventions: Bed alarm and chair alarm for safety, Date Initiated: 09/01/2020 Sent out to the ER for evaluation and treatment post fall, Date Initiated: 9/13/2020. Resident has history of unplugging bed alarm, now using different bed alarm and placed it lower in bed, so that if he unplugs this one, the alarm will sound. Date Initiated: 09/20/2020. Review of the facility 9/13/20 Incident Report for Resident #7 confirmed the Resident was taken to the hospital for evaluation of intense back pain. Predisposing Environmental Factors included 'Fall Alarm in Place', and 'Other'. Other Info: Bed alarm was not on. During an interview on 10/22/20 at 9:36 a.m., when asked about Resident #7's fall on 9/13/20, Staff Y stated, I found [Resident #7] (on the floor). He was in excruciating back pain and we (facility staff) sent him out (to the ER) .The bed alarm was not working . He would often unplug the bed alarm. So, when the bed alarm was not working . it was no surprise. We had an older bed alarm. He had a white one (bed alarm) with a button that you press . they got another kind after the last fall (on 9/20/20) . Review of Resident #7's 9/20/20 Fall Incident Report, included the following, in part: Other info: Resident had unplugged his bed alarm . Review of the Preliminary Radiology Report, dated 9/13/2020, revealed the following: Clinical Indications: Injury or trauma; Initial encounter; Generalized; [MEDICATION(S)] trauma (contusions or hematomas); Patient HX: Fall at nursing home . Impression: 1. New T10 vertebral body moderate to moderately severe compression fracture with minimal posterior extrusion . During an interview on 10/22/20 at 11:45 a.m., the DON was asked for documentation of skin assessments completed for Resident #7 related to his falls. The DON stated, There were no Skin Assessments completed for [Resident #7] The DON confirmed Resident #7 was scheduled for showers on Monday and Fridays, and skin assessments were completed on shower days. The DON stated, There is probably not skin assessments in there (EMAR) - I can look . The DON stated she did not believe there was a policy on skin assessments because she had never seen one.

Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcer for two Residents (R #2 and R #5) of two residents reviewed for pressure ulcers. This deficient practice resulted in the development of four, facility acquired, unstageable pressure ulcers. This deficient practice had the potential for pain, infection, increased nutritional needs, and the deterioration of condition. Findings include: A review of R #2's Minimum Data Set (MDS) assessment, reference date 1/24/19, shows the following major Diagnoses: [REDACTED]. The Brief Interview for Mental Status (BIMS) reflected intact cognition. R #2 required at least two staff for bed mobility, transfers and toilet use. Review of R #2's Progress Notes, 1/18/19, indicated three blisters (two on bottom of right foot 45 mm x 25 mm and 36 mm x 16 mm (millimeters) and one on the bottom of left foot (40 x 21 mm). Review of R #2's Progress Notes revealed documentation of pain with pressure ulcers on 1/28/19 .states feet are somewhat sore . and on 1/31/19 .states feet are somewhat sore . During an interview on 2/13/19 at 2:45 p.m., R #2 confirmed knowledge of blisters to bilateral soles but relayed he's blind and unable to see them. R #2 stated, .they've told me they're pretty much healed . Review of 2/7/19 Skin/Wound Note reads, .Blister located Sole Left Foot. The Blister measures the following: 4.8 cm 2 (centimeter square) by 2.6 cm by 2.1 cm .90% of wound filled Eschar (dead skin) .Blister located Sole Right Foot. The blister measures the following: 8.9 cm 2 by 4.1 cm by 3.5 cm .and 90% of wound filled with Eschar tissue . An interview on 2/14/19 at 8:35 a.m., Wound Care, Registered Nurse (RN) C and RN Supervisor D confirmed R #2's three pressure ulcers were facility acquired and unstageable. RN C stated the pressure ulcers were thought to be caused by R #2's footboard coming in contact with the soles of his feet. RN C was asked what care plan interventions were in place to address the footboard and care for the pressure ulcers. RN C did not verbally respond. R #2's Care Plan was reviewed together which confirmed no footboard interventions to prevent sole pressure to footboard were found. An interview on 2/20/19 at 9:43 a.m., Maintenance Director H confirmed no knowledge of R #2's multiple pressure ulcers caused by residents' footboard. Staff H said he felt residents' sole wounds were caused by him sliding down to the lower half of his bed after using the trapeze bar. Review of facility's, Prevention of Pressure Ulcers (revised 9/2013) read, .1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time .5. Once a pressure ulcer develops, it can be extremely difficult to heal .6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in conditions are recognized, evaluated, reported .and addressed . Review of R #5 MDS assessment, reference date 12/6/18 , shows an admission date of [DATE] with the following major Diagnoses: [REDACTED].>non-Alzheimer's dementia, depression, pubis fracture, weakness and pain. R #5 required assistance of two staff for bed mobility, transfers and toilet use. During an interview on 2/14/19 at 10:12 a.m., the Director of Nursing (DON) said that the nurse who performed R #5's readmission assessment (11/29/18), did not remove TED (compression stockings covering feet and legs) to fully visualize the skin. The wound was noted within the Progress Notes on 12/3/19, Resident with fluid filled blister on right heel that measures 4.2 cm by 5 cm Review of facility's, Pressure Ulcers/Skin Breakdown-Clinical Protocol revised 3/2014, read, .3. The staff will examine the skin of a new admission for ulcerations or alterations in skin .

Based on interview and record review, the facility failed to administer narcotic pain medication for one Resident (R #6) of three residents reviewed for pain relief. This deficient practice resulted in R #6's unrelenting, excruciating pain and hospital transfer. Findings include: Review of R# 6's Minimum Data Set (MDS) assessment, 12/21/19 reference date, shows the following major Diagnoses: [REDACTED]. The Activities of Daily Living (ADL) reflected two plus person assistance required for bed mobility, transfers, dressing and toilet use. The Brief Interview for Mental Status (BIMS) indicated moderate impaired cognition. Review of R #6's Progress Notes: 12/17/19 at 8:11 (a.m.) read, Resident in significant pain, 10/10 pain ad scale. Res. appears confused but oriented. Res having difficulty swallowing meds, her prn (as needed) [MEDICATION NAME] (narcotic pain medication) is not in stock . This RN (registered nurse) attempting to get authorization to pull med from e-kit (emergency backup medications) to get pain under control . 12/17/19 at 8:33 (a.m.) -[MEDICATION NAME] 500 mg (milligram-one pill) administered for .Pain 8/10 pain ad (administered) . 12/17/19 at 11:15 (a.m.) read, Res condition did not improve from earlier note. Order received . to transfer res to (hospital) ED (emergency department) for evaluation for uncontrolled pain. Res left by (ambulance) at 1130 (11:30 a.m.). Review of facility's, Administering Medications (revised (MONTH) 2012) reads, .4. Medications must be administered in within one (1) hour of their prescribed time . On 12/13/19 at 4:11 p.m., the Director of Nursing (DON) was asked why R #6's had not received the physician ordered narcotic for pain. The DON explained the contracted pharmacy had not received the necessary paperwork from the facility to allow nurses to access the emergency backup supply (which contained [MEDICATION NAME]). When asked, the DON stated the medication orders were received via facsimile to the facility on [DATE] at 11:12 a.m. This Surveyor stated R #6 had experienced excruciating pain on 12/17/19 beginning around 8 a.m. and continued until her emergency transfer for the pain at 11:30 a.m. without ever receiving any narcotic pain medication [MEDICATION NAME] 3 1/2 hours. The DON responded, I would have gotten the medication from the backup stock and worried about the paperwork later .

Based on interview and record review, the facility failed to ensure adequate assessment of a Resident following a fall, for one Resident (#100) out of three reviewed for abuse and neglect, from a total sample of three Residents. This deficient practice resulted in Resident #100's delayed treatment for [REDACTED]. Findings include: According to the Minimum Data Set (MDS) Assessment, dated 10/16/17, Resident #100 was a severely cognitively impaired man, who required extensive assistance from staff for all activities of daily living (ADLs), and was rarely or never understood, and who could rarely understand others, whose [DIAGNOSES REDACTED]. According to the facility investigation summary, dated 12/14/17, on 12/14/17 at 1:30 a.m., Resident #100 independently ambulated from the bed to the bathroom when he fell to the floor carrying his blankets and pillow. Registered Nurse (RN) D assessed Resident #100 and documented no evidence of pain or injury, and together with Certified Nurse Aide (CNA) F, transferred Resident #100 into a wheel chair for supervision at the nursing station. During a phone interview on 1/24/18 at 4:20 p.m., CNA C recalled Resident #100's fall (on 12/14/17): I came in at 2:00 a.m., so I wasn't there for the fall. CNA C said she was updated regarding the fall and observed Resident #100 sitting in a wheelchair at the nursing station in a hospital gown. CNA C stated she noted Resident #100 needed his brief changed on her 4:00 a.m. rounds, so she took Resident #100 to his room, where Resident #100 hollered in pain and grabbed his left leg when she attempted to transfer him to the bed. CNA C got CNA E to assist her, and again, when they attempted to stand Resident #100, he hollered out in pain and grabbed the left leg, not bearing weight on it. CNA C stated, Something's wrong and said she immediately told RN D about Resident #100's crying in pain and grabbing his left leg, unwilling to bear weight on it. When asked what RN D's response was, CNA C stated, (RN D) said, 'We'll worry about that later'. CNA C stated, I can't believe he's (RN D) not going to do anything. CNA C confirmed RN D did not visit Resident #100 again before the shift ended at 7:00 a.m. CNA C said CNA E also agreed something was very wrong. CNA C said she waited for the dayshift nurse, RN B, to come in (around 7 a.m.) and told RN B what happened. RN B then assessed Resident #100 with CNA C and Resident #100 hollered out again with barely a touch. CNA C said the Director of Nursing (DON) then arrived and CNA C left the room. CNA C said the next thing she knew Resident #100 was being transferred to the hospital. During a phone interview on 1/24/18 at 4:31 p.m., CNA E confirmed what CNA C reported about Resident #100's condition on 12/14/17, saying, Yes, we both thought something was wrong. CNA E said CNA C went to tell RN D about Resident #100's pain, but RN D did not assess Resident #100. When asked if CNA E told anyone, CNA E said she did not because CNA C said she would tell the dayshift nurse. During a phone interview on 1/24/18 at 4:36 p.m., RN B was asked about the event. RN B said she arrived on shift about 6:45 a.m. on 12/14/17 and (CNA C) just about bowled me over at the door, and told me about Resident #100's fall and hollering in pain and RN D not addressing this. RN B said she received report from the night nurse and went to assess Resident #100. RN B said Resident #100 did grimace with touch, so she got the DON to assess as well. The DON then told RN B to send Resident #100 to the hospital for an X-ray. RN B said she could not remember if she reported CNA C's report of RN D's failure to assess Resident #100, to the DON, but said, I probably did, I tell her (DON) everything. A progress note for Resident #100 dated 12/14/17 at 8:55 a.m. revealed, Dr (physician) .return phone call and would like sent to ER (emergency room ) for evaluation. Family notified .0927 (9:27 a.m.). Ambulance arrived around 0930 (9:30 a.m.). The Discharge Summary from the hospital, dated 12/16/17, which included the radiology report, revealed, Surgical Indication .He fell about 1:00 in the morning, and was found to have a left intertrochanteric [MEDICAL CONDITION]. After discussions with his daughter and family, it was felt that open reduction and internal fixation for pain management and mobility was appropriate .Impression Acute angulated and displaced intertrochanteric [MEDICAL CONDITION] femur. ([MEDICAL CONDITION]) The Medication Administration Record [REDACTED]. During a phone interview on 1/25/18 at 8:05 a.m., RN D was asked about the event on 12/14/17. RN D said Resident #100 fell in the room, was assessed and found to have no injury or pain. When asked if he re-assessed at any point in his shift, RN D stated, I did the normal neuros (routine periodic neurologic assessment). When asked if CNA C or E reported any pain or other symptoms by Resident #100, later in the shift or specifically around 4:00 a.m., RN D stated, I don't remember that at all. RN D was asked if he called the DON to report the fall. RN D said he did not because there was no major injury. When asked if he had ever been counseled or disciplined regarding not helping with residents at night, RN D stated, Not individually, there were emails to all nurses about helping out. During an interview on 1/24/18 at 8:15 a.m., the DON was asked if she expected to be called for any fall. The DON responded, Yes, all falls should be reported to me immediately. I would've expected (RN D) to call me. He should have. During an interview on 1/25/18 at 8:15 a.m., the DON was asked if RN D had any disciplinary action or was ever spoken to about helping CNAs on shift. The DON stated CNAs had complained to her about RN D not helping answer call lights and that she talked with RN D about that in phone conversations and through emails. The DON stated, (RN D) was spoken to regarding helping CNAs more recently. A concern form dated 12/28/17-1/2/18, revealed a concern initiated by staff, night shift CNAs, reported to the Administrator (NHA) and the DON. Further, the form revealed, .Area of concern .night shift nurses not answering call lights .Follow up .all nurses instructed in (software communication) to answer call lights 1/2/18. Note sent to night shift in (software communication) to help answer call lights. Nurses responded OK .Resolution of concern .(No indicated by checkmark in box) .(RN D) not answering call lights. Private message in (software communication) 1/15/18 that he is not helping answer call lights per staff. (RN D) responded I am helping answer call lights .One-to-one discussion (box checked on form) .see above ., signed by DON, dated 1/15/18. The facility policy, Abuse Program, not dated, revealed, .This facility affirms the right of our residents to be free from verbal, sexual, physical, emotional, mental abuse, self-abuse/self-neglect, neglect, medical neglect, .Residents must not be abused by anyone, including, but not limited to, facility staff .other caregivers who provide care .This facility therefore prohibits mistreatment, neglect or abuse of its residents . During the exit conference on 1/25/18 at 11:00 a.m., the Nursing Home Administrator (NHA) expressed worry about this Surveyor's concern regarding RN D's neglecting to assess Resident #100 after CNA C reported to him that Resident #100 was in pain and not bearing weight on the left. The NHA stated, I agree with you it's neglect. That's (expletive). The NHA then stated RN D would no longer be working in the facility and that the event would be reported to the State Board of Nursing.

Based on observation, interview and record review, the facility failed to provide necessary treatment to prevent development of multiple pressure sores for one Resident (#6) assessed at increased risk for skin breakdown of four residents reviewed for pressure sores from a total sample of 14 residents. This deficient practice resulted in the development of two avoidable Stage II pressure sores with the potential for increased pain and risk of infection for this resident. Findings include: A review of Resident #6's admission Minimum Data Set (MDS) assessment dated [DATE] shows a [AGE] year old with a Brief Interview of Mental Status (BIMS) score of 14/15 reflective of intact cognition with the following major Diagnoses: [REDACTED]. The same MDS reflected Resident #6 was at risk for development of pressure ulcers, but no ulcers were present on admission. Resident #6's functional status reflected need for extensive assistance with bed mobility, transfer, locomotion, dressing, toilet use, bathing and hygiene. Occasional urinary incontinence and frequent bowel incontinence were also reflected in the same MDS. A CAA (Care Area Assessment) Summary Report dated 4/28/16 read, Resident (#6) triggered the pressure ulcer CAA because requires extensive assistance with bed mobility .at risk for pressure ulcer also because he is frequently incontinent of bowel and occasionally incontinent of bladder .Care plan will be developed. An IDT (interdisciplinary team) progress note dated 5/20/16 read in part, .resident (#6) has excoriated area 1 cm (centimeter) x 0.5 cm to coccyx . The IDT progress note on 5/21/16 read in part, .Stage II pressure sore on coccyx . An IDT progress note for Resident #6 dated 7/22/16 read, During skin assessment two open blisters were noted on the R (right) and L (left) buttocks .L buttock measures 3 x 3 cm and the R buttock measures 3 x 2.7 cm. Resident #6's Wound Care Plan was initiated 8/1/16, over four months after the CAA (Care Area Assessment) Summary Report dated 4/28/16 revealed a care plan would be developed to prevent skin breakdown. One intervention on the Wound Care Plan for Resident #6 indicated the use of an air mattress, which was not observed on Resident #6's bed during the entire standard survey from 8/30/16 through 9/02/16. During an interview with Resident #6 on 8/30/16 at 1:40 p.m., when asked why he felt pressure sores developed to his buttocks replied, They (staff)don't check me when I sleep. I lay in piss . A telephone interview with Resident #6's Friend M was conducted on 8/31/16 at 2:07 p.m. Friend M stated she visited with Resident #6 on 8/26/16, 8/27/16 and 8/29/16. Friend M described strong urine odor in Resident #6's room each day. During an interview on 8/30/16 at 3:00 p.m.,with Activity Director in Training G, Social Worker H and the Director of Nursing (DON). The DON was asked about Resident #6's pressure sore development. In response, the DON opened Resident #6's medical chart and reviewed the admission skin assessment and confirmed the pressure sores were not present on admission. The Activity Director in Training G then stated, He (Resident #6) sits in his chair all day. This Surveyor asked for documentation showing the Resident #6 received staff education for off-loading (repositioning) and any refusals for repositioning prior to the development of the pressure sores. The DON stated, I don't know if the nurses and Certified Nursing Assistants (CNAs) have charted when they offered repositioning or resident refusals. Resident #6's pressure sores to coccyx were observed on 8/31/16 at 10:25 a.m. in the presence of Licensed Practical Nurse (LPN) EE and CNA D while using a mechanical standing lift. The irregular shaped wound to the resident's left coccyx was open with a red base and the right, open wound had a silver/blue base. ( )

Based on interviews and record reviews, the facility failed to determine on admission whether the resident had an advance directive, failed to assess the resident's decision-making capacity, failed to determine whether the resident wished to formulate an advance directive, failed to have a system in place to ensure staff knew where to access documented information on residents' treatment choices and advance directives, and failed to incorporate into the medical record the resident's treatment choices regarding life sustaining measures in emergent situations for one (Resident #100) of six residents reviewed for advance directives from a total facility population of 47 residents. Resident #100 was found on the floor, breathless and without a heartbeat, by facility licensed nursing staff on [DATE] at approximately 7:45 a.m. Prior to Resident #100's planned admission into the facility, he was living at home and was assigned a temporary legal guardian. Resident #100 functioned in the facility for four days before he was found not able to breathe and without a heartbeat. The facility staff who responded to Resident #100's emergent situation did not know if Resident #100 had an advance directive or if Resident #100 was to be provided cardiopulmonary resuscitation (CPR) measures. Despite not knowing, the facility failed to initiate CPR and failed to activate emergency medical services (EMS) placing Resident #100 in immediate jeopardy to his life and safety. On [DATE] at 3:03 p.m., the facility was notified of the immediate jeopardy which began on [DATE] at approximately 7:45 a.m. when the facility failed to assess Resident #100's competency for making decisions and failed to adequately assist with determining Resident #100's choices concerning emergent medical care; failed to ensure documentation of Resident #100's life-sustaining treatment choices was readily accessible in the medical record; and failed to provide CPR measures for Resident #100 whose code status was to be determined. A written plan for removal of the immediate jeopardy was requested. During the completion of the extended survey on [DATE] thru [DATE], the immediate jeopardy was removed on [DATE] when this surveyor verified the following facility actions: 1. All current residents' medical files were audited to ensure residents' code status was present. 2. Made sure that an orange code status sticker for all full code and undetermined code status residents was in place on each resident's medical file. 3. Implemented new process where resident's code status is indicated on the resident's care guide inside their room closet. 4. Implement new process for licensed nurses to be provided with a roster of all residents' current code status to be carried with the nurses at all times. 5. Educated staff on new procedures and reviewed with them the CPR policy, code cart, its location and contents. 6. Revised their "Admission Procedure" and "BLS-Basic Life Support/CPR-Cardiopulmonary Resuscitation" policy and procedures. 7. Updated their "Advance Directives Notice" for their admission packets and their "Advance Directives & Care Planning" policy and procedure with the approval of their Medical Director. 8. Verified that all licensed nursing staff's CPR certification is current. Although the immediate jeopardy was removed, the facility deficient practice was not corrected and remained at an isolated deficiency for more than minimal harm until: Validation by the State Agency of the facility's ability to maintain substantial compliance with identifying each resident's advance directive upon admission and implementing appropriate measures in accordance with the advance directives. Findings include: A review of Resident #100's closed medical file revealed on his Admission Record (undated), he was a [AGE] year old man admitted to the facility on [DATE]. His "[DIAGNOSES REDACTED]. A nurse progress note written by Registered Nurse (RN) "D" on [DATE] at 10:45 a.m., read in part, "Resident (#100) found by CNA (Certified Nurse Aide) at 0745 (7:45 a.m.) face down on floor for unknown length of time.....Resident completely blue and cool to touch....no breath sounds, no pulse...no blood pressure, no respirations present...Order obtained at 0820 (8:20 a.m.) to release body to funeral home....Body released to...funeral home at 0915 (9:15 a.m.)." The Assistant Director of Nursing (ADON) was interviewed on [DATE] at 4:25 p.m. The Assistant Director of Nursing stated, "I was working the floor with (RN "D") that day ([DATE]). One of the CNAs had seen (Resident #100) lying in bed, sleeping, at 7:20 a.m. At about 7:45 a.m., another CNA found him lying on the floor, face down. She got (RN "D") and me. (RN "D") observed no breathing, no radial pulse. We got him onto his back. He was blue in color. He had no vital signs (pulse, respirations, blood pressure, and/or temperature)...No, we didn't do CPR. There was no sticker on his chart which meant he was a "no code". If a resident is a "full code", an orange sticker is put on their chart. One of the CNAs checked his chart because (RN "D") said, 'I don't know his code status.'" Registered Nurse (RN) "D" was interviewed on [DATE] at 11:20 a.m. RN "D" stated she did not see an advance directive or any indication of Resident #100's code status in his medical chart prior to the incident on [DATE]. She stated, "No, we didn't do CPR since he had no respirations ... I had one of the aides call (the Director of Nursing). I didn't know what his code status was when I entered his room. That was the first thing I asked. What was his code status? I can't remember if it was the other nurse or a CNA who checked the chart." Certified Nurse Aide (CNA) "E" was interviewed on [DATE] at 12:50 p.m. CNA "E" stated, "I can't remember who asked me to check (Resident #100's) code status....It was approximately seven minutes after they found him (Resident #100)...I didn't even know where to look (for his code status); we (CNAs) don't usually go in their charts at all. I never did find it. I don't know who did." The ADON was interviewed a second time, on [DATE] at approximately 2:00 p.m. The ADON stated, " ...I remember telling the CNA, while we were in (Resident #100's) room, to go check his code status. She came back and said there was nothing in the chart." A form titled "Letters of Guardianship" signed by a judge on [DATE] and expiring on [DATE], appointed temporary guardianship of Resident #100 to Guardian "A". This letter gave Guardian "A" powers and responsibilities for emergency medical and placement decisions for Resident #100. A "Notice of Hearing" signed by the Probate Register on [DATE], revealed a hearing was to be held on [DATE], to appoint a guardian and conservator for Resident #100. Guardian "A" was interviewed by telephone on [DATE] at 10:50 a.m. Guardian "A" stated, "Yes, I was present during (Resident #100's) admission to the facility. Yes, the facility provided me information on advance directives. I can't remember if advanced directives were formulated. No, (Resident #100) did not discuss his choices regarding CPR with me." During an interview with the Director of Nursing (DON) on [DATE] at 9:20 a.m., she stated, "An orange sticker on the side of a resident's chart, says either 'Full' code or 'TBD'--to be determined. In either case, CPR is to be done in the event of an emergency if an orange sticker is on the side of the resident's chart. No, there was no orange sticker on the side of (Resident #100's) chart on [DATE]...." Licensed Practical Nurse (LPN) "F" was interviewed on [DATE] at 1:00 p.m. Licensed Practical Nurse "F" stated, "I did the initial physical assessment--vital signs, lung sounds--of (Resident #100's) admission. I did not address his code status. (Guardian "A") was here when he got here, then she left. It was at change of shift. I did the front of the 'Admitting Nurses Notes'. Afternoon shift (nurse) did the skin assessment on the back. We were questioning (Resident #100's) code status because all we had was an H&P (History & Physical). I don't know who's responsibility it would have been to put an orange sticker on the chart; any one of us three--me, the other nurse (Registered Nurse (RN) "G"), or the social worker. Home admissions are tricky--there's no report or anything." Registered Nurse "G" was interviewed on [DATE] at 1:11 p.m. Registered Nurse "G" stated, "Yes, I finished (Resident #100's) initial assessment when he was admitted . No, I did not address his code status. I believe the social workers do that." Social Services (SS) "C" was interviewed on [DATE] at 1:25 p.m. Social Services "C" stated, "(Guardian 'A') was in such a hurry that day. She basically came in and signed the papers (for Resident #100) and left. She took the 'Medical Treatment Preference Sheet' with her. We thought we had time to get it back but we never got it back." Social Services "C" was asked what code or CPR status Resident #100 should have been until his Medical Treatment Preference sheet was completed/returned. Social Services "C" replied, "I don't know; that's as clear as mud." When asked which facility staff is responsible for putting an orange "Full" or "TBD" sticker on a resident's chart, if appropriate? Social Services "C" replied, "The nurses, I guess. We all work on these admissions as a team." A facility form titled "Medical Treatment Preference Sheet" read in part, "In the absence of this form being completed or an advance directive stating otherwise, understand that any and all life sustaining measures may be used unless ordered differently by your physician." During the survey, the facility was unable to provide a "Medical Treatment Preference Sheet" for Resident #100. Resident #100's "Admitting Orders" signed by the physician on [DATE], showed that Resident #100's "code status, indicating whether or not Resident #100 was to receive CPR during an emergent situation, was left blank. A hospital discharge summary dictated by Physician "B" on [DATE], revealed Resident #100 was hospitalized three months prior to his admission into the facility. Within the body of this two-page document, are [DIAGNOSES REDACTED]. History of pneumonia with scar tissue in his lungs. He has been on the ventilator previously and is a NO CODE because of this" and "History of Present Illness:...the [MEDICAL CONDITION] is bad enough that he is now a NO CODE." Resident #100's "Admitting Nurse's Notes" dated [DATE], showed that he was admitted to the facility from home. Throughout the survey, the facility was unable to provide written documentation or verbal validation that staff had spoken with Resident #100 regarding his advanced directives during his length of stay at the facility from [DATE]-[DATE]. The facility was also unable to provide a current physician's orders [REDACTED].#100. ( )