Every finding on record at Helia Healthcare of Newton

Based on interview and record review the facility failed to ensure wheelchair foot pedals were in place to prevent resident injury for 1 (R4) of 3 residents reviewed for accidents in the sample of 8.This past non-compliance occurred between 3/24/2026 and 3/26/2026.The findings include:R4's Face Sheet documented an admission date of 6/19/2024 with admitting diagnoses including chronic obstructive pulmonary disease, chronic cough, muscle weakness, history of multiple fractures, right patellar tendon rupture and age-related osteoporosis. R4's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R4 is cognitively intact. This same MDS documented R4 utilizes a wheelchair for locomotion and does not walk.The facility's Long Term Care Facility-Serious Injury, Incident and Communicable Disease report dated 3/25/2026 documents the following in part: Administrator notified of an x-ray report resulting in an acute non-displaced tibia fracture. According to CNA's (Certified Nursing Assistant) on shift, they were getting (R4) up for breakfast and unknowingly placed her in her roommate's wheelchair. CNA's could not find the foot pedals and R4 suggested they may be in the dining room. CNA's pushed (R4) to the dining room to get foot pedals and (R4) was unable to hold her right foot up. Resident's foot dropped to the floor and her toes bent backwards slightly.Result of xray showed acute non-displaced tibia fracture.On 4/9/2026 at 9:30am, R4 said before she came to the nursing home, she had injured tendons in her right knee that will never really heal up. R4 said due to the old injury, she often has pain in her right knee and takes medications for the pain. R4 said about two weeks ago, the staff (V7 and V8, both CNA's) were getting her up into her wheelchair for breakfast and accidentally put R4 into her roommate's wheelchair which did not have foot pedals. R4 said V8 asked her to hold her feet up off the floor so she could take R4 down to the dining room where staff thought the missing foot pedals were located. R4 said V8 realized R4 was in the wrong wheelchair and turned R4 around in the hallway and headed back to R4's room to get the correct wheelchair. R4 said she couldn't hold her feet up off the floor any longer and her right foot went down and twisted a small bit under the wheelchair. R4 said her right knee had already hurt that morning so she couldn't tell if the pain was from getting twisted or from her previous right knee issues. R4 said afterwards an x-ray of her knee showed a fracture, but she went to the bone doctor, and he said her leg was not broken and the previous x-ray was incorrectly read. R4 said her knee does not hurt anymore and is feeling better. On 4/9/2026 at 11:00am, V8 (CNA) clarified the incident with R4 occurred on the morning of 3/24/2026, and she and V7 (CNA) were getting R4 up for breakfast and accidentally put R4 into her roommate's wheelchair. V8 said R4 kept asking where her foot pedals were and R4 was supposed to have foot pedals on her wheelchair. V8 said she thought the foot pedals were in the dining room but then realized she had R4 in the wrong chair. V8 said when she turned R4 around in the wheelchair to go get the correct wheelchair, R4 dropped her feet and caused her right foot to go under the wheelchair and caused R4 discomfort. V8 said she had R4 evaluated by the nurse and R4 seemed ok.A statement in the facility's investigation file documents V7's account of what happened on 3/24/2026 at approximately 5:45am. The statement documents the following in part: (V7) had assisted R4 to the bathroom and afterwards grabbed the roommate's wheelchair by mistake and put R4 into the wrong wheelchair. (R4) has had many different chairs and I truly didn't notice. (V8) took R4 to the dining room and noticed R4 was in the wrong chair.On 4/9/2026 at 11:30am, V2 (Director of Nursing/DON) said she was the nurse who evaluated R4's right knee afterwards. V2 said R4's doctor and family were notified and an x-ray of R4's right knee/leg was ordered via mobile x-ray unit. V2 said the x-ray results showed R4 had a non-displaced tibia fracture. V2 said R4 went to an Orthopedic follow up appointment on 4/6/2026 and the Orthopedic doctor said R4 did not have a fracture and the mobile x-ray unit read the x-ray incorrectly. V2 said staff knew R4 was supposed to have foot pedals on her chair but didn't realize they were missing. V2 said it was her expectation for R4's wheelchair to have the foot pedals on before R4 uses it.On 4/9/2026 at 10:45am, V9 (Physical Therapist) said she has provided R4's physical therapy for several months and is very familiar with R4's care. V9 said R4 is supposed to have foot pedals when R4 is using the wheelchair. V9 said on 3/12/2026, she in-serviced the nursing staff concerning R4's wheelchair usage and included R4's foot pedals were to be on the chair and elevated.On 4/6/2026 at 10:30am, V10 (Family) said R4 has always been happy with the care at this facility. V10 said she was upset to learn R4 had a fractured right leg due to the staff not using foot pedals when they should have. V10 said she was very happy to hear R4 did not have a fracture, and her right knee was not severely injured during this event.Orthopedic office visit note dated 4/6/2026, documented the following in part: Chief complaint: Right knee tibia fracture. Leg got caught behind wheelchair. No pain reported. At the clinic today for further orthopedic management of tibia fracture, however I do not see any fracture on her most recent x-ray. She is not having any pain.Prior to the survey date, the facility took the following actions to correct the noncompliance:The facility held a QAPI (Quality Assurance and Performance Improvement) meeting on 3/26/2026 with V1 (Administrator) V2 (DON), V11 (Registered Nurse/RN), V12 (RN) and V13 (Regional Administrator). The QAPI Ad Hoc form notes under #1 Immediate corrective action for those affected by the deficient practice: (R4) x-ray showed fx (fracture) to tibia after incident in wheelchair. MD (medical doctor) and emergency contact notified of incident. Report sent to state (agency) Knee immobilizer in place until seen by ortho. Immediate education to staff involved with incident completed 3/26/26.Process/steps to identify others having the potential to be impacted by the same deficient practice: All residents have the potential to be affected.Measures put into place/systematic changes to ensure the deficient practice does not recur: Education to nurses and CNAs on transfers, wheelchair placement and pedals. Ensure all names are on wheelchairs. Ensure therapy communicates new wheelchair placement and pedals with DON/designee. DON/designee to audit (and) ensure proper transport of residents 3x (times)/week for 4 weeks. Consulted NP/MD (Nurse Practitioner/Medical Doctor) on vitamins for strengthen of bone density to prevent further decline.Plan to monitor performance to ensure solutions are sustained: Administrator to ensure programs are being followed. Report findings during QA meetings.

Based on observation, interview and record review, the facility failed to ensure food items were covered while stored in the refrigerator and scoops were removed from bulk food containers to decrease the risk of cross contamination. This failure has the potential to affect all 33 residents residing in the facility.Findings Include:On 8/18/25 at 10:00 AM during the initial tour of the kitchen, scoops with handles were found in a bulk container of brown sugar and in the food thickener. In addition during this same initial tour, a tray full of pitchers was observed in the refrigerator that were not labeled or covered with lids. V4 (Culinary Director) stated that he would have V3 (Culinary/Cook) find the lids to cover them. A food supply and storage policy with a revision date of January 2012, documents: Food and supply storage areas shall be maintained in a clean, safe and sanitary manner.4. Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date.On 8/20/25, at 2:30 PM, V1 (Administrator) stated that she did a walk through the kitchen and noticed the scoops in the brown sugar and thickening agent and had them removed, along with educating the staff not to leave the scoops in bulk food containers.The Long Term Care Facility Application for Medicare and Medicaid dated 8/19/25, documents that 33 residents reside in the facility.

Based on observation, interview and record review, the facility failed to ensure pureed food was prepared in accordance with the recipes and to preserve nutritional value for 6 (R4, R5, R10, R21, R26 and R27) of 6 residents reviewed for puree diets in a sample of 27.The Findings Include:R4's Face Sheet documented an admission date of 8/22/2024. R4's current physician orders for August of 2025 document R4 is to receive a regular diet/pureed consistency.R5's Face Sheet documented an admission date of 3/31/22 and a readmission date of 6/24/24. R5's current physician orders for August of 2025 document R5 is to receive a regular diet/pureed consistency.R10's Face Sheet documented an admission date of 8/3/19. R10's current August 2025 physician orders document R10 is to receive a regular diet/puree consistency.R21's Face Sheet documented an admission date of 12/1/23. R21's current August 2025 physician orders document R21 is to receive a regular diet/puree consistency.R26's Face Sheet documented an admission date of 6/29/25. R26's current August 2025 physician orders document R26 is to receive a regular diet/puree consistency.R27's Face Sheet documented an admission date of 8/8/23. R27's current August 2025 physician orders document R27 is to receive a puree diet with double portions.On 8/18/25 at 10:30 AM, V3 (Culinary/Cook) prepared the taco bake for the residents who are prescribed a puree diet. V3 stated there were 6 residents currently on a pureed diet. V3 was observed at this time scooping one non measured spoon full of taco bake into the blender. V3 proceeded to add water up to the twelve-cup line on the blender and blend the food with water. V3 then checked the thickness of the food product and stated that it needs to be the consistency of pudding, so she added 1 1/2 cups of thickening powder to get the food product thick enough. On 8/18/25 at 10:45 AM, surveyor made V4 (Culinary Director) aware of the above observation of V3 preparing the pureed food and questioned the process. V4 determined that V3 had not used a premeasured scoop to ensure the proper volume of food was added to meet the 6 residents' nutritional needs prior to the liquid to blend to proper consistency. V4 had V3 dispose of the food and start over.The taco bake recipe for pureed residents list the following steps: 1. Reserve the appropriate portions per the number of residents receiving a pureed diet. 2. Blend until smooth and add gravy until the desired thickness, add source cream and mild sauce for seasoning. Serving sizes: 6 ounces per resident, 9 ounces per resident ordered large portions, and 12 ounces per resident ordered double portions.

Based on interview and record review, the facility failed to ensure the referral and coordination of PASARR (Preadmission Screening and Resident Review) Level II Screening was completed for 1 (R4) of 1 resident reviewed for PASARR assessments in the sample of 27.Findings Include:R4's Resident Face Sheet documents an initial admission date to the facility of 08/22/2024 and included diagnoses of cerebral infarction, psychotic disorder, spastic hemiplegia affecting left non dominant side, essential hypertension, chronic obstructive pulmonary disease, major depressive disorder, gastro - esophageal reflux disease, anxiety disorder, hyperlipidemia, lymphedema, bipolar disorder, and pain in right knee.R4's Notice of PASRR Level 1 Screen Outcome was dated 07/21/2024, prior to admission, and documented Level 1 Negative, No Status Change. R4's admission Minimum Data Set (MDS) assessment dated [DATE] section A1500 - Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition - was Coded No. Section I5900. Bipolar Disorder has a check mark next to it indicating that it is an active diagnosis for R4.On 08/20/2025 at 12:00 PM, V1 (Administrator) stated that she could not find a PASARR level II in R4's chart. V1 stated that she was not aware that R4 had a new diagnosis of bipolar disorder in February of 2025. V1 stated that she will attempt to find out how R4 received the diagnosis. V1 stated that she has put in the request for a level II PASRR screening. On 08/21/2025 at 10:20 AM, V1 stated that there is someone coming today to complete the Level II screen on R4. A form titled R4's Notice of PASRR Level 1 Screen Outcome dated 08/20/2025, documented refer for Level II Onsite.On 08/21/2025 at 1:05 PM, V1 stated that Bipolar is not a new diagnosis for R4. V1 stated that the diagnosis is listed on R4's admission progress note from his primary physician. V1 stated that she is not sure how this was missed on admission, but it has been corrected. Facility Policy Titled Resident Assessment: Coordination with PASARR Program with a date of October 2017 documents All individuals with a mental disorder or intellectual disability who apply for admission to this facility will be screened in accordance with the State's Medicaid rules for screening.

Based on interview and record review, the facility failed to ensure timely assessment and treatment was provided for a resident with a urinary tract infection for 1 (R29) of 1 resident reviewed for necessary care and services in the sample of 27. Findings Include:R29's Face Sheet documented an initial admission date to the facility on [DATE] and included diagnoses of pulmonary disease, essential hypertension, gastro - esophageal reflux disease, hyperlipidemia, osteoarthritis of knee, gout, depression, hypothyroidism, and adjustment disorder with mixed anxiety and depressed mood. R29's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 05, indicating R29 has severe cognitive impairment. R29's Progress Notes document the following: 8/10/25 at 3:30 AM - Res (resident) again has gross hematuria in urine or possibly pelvic cyst is causing vaginal bleeding; 8/13/25 at 8:24 AM - Call out to (name of V7/Physician) and reported resident having hematuria. Awaiting a call back; 8/13/25 at 3:25 PM - Received a call back from (V7's staff) at (V7's) office and received an order to obtain urinalysis and to send for culture and sensitivity; 8/15/25 at 10:46 AM - Urine collection obtained for specimen via straight cath (catheter). Res tolerated well. Urine sent to (local hospital) lab for processing. On 08/21/2025 at 12:30 PM, this surveyor asked V1 (Administrator) for the urine results for R29 as they were not available in R29's electronic medical record. On 08/21/2025 at 12:55 PM, V6 (Licensed Practical Nurse/LPN) stated she is waiting on the lab to fax the results. V6 stated she did not have them in the chart. On 08/21/2025 at 12:59 PM, V1 (Administrator) stated she has printed the labs from the hospital medical records and is sending them over to the physician for review. R29's Urine Bacteria Culture with a print date of 08/21/2025 and a result date of 08/18/2025 documented that R29's urine culture was growing proteus mirabilis.On 08/21/2025 at 1:57 PM, V1 stated that she called V2 (Director of Nursing/DON) who is off for a doctor's appointment to ask about the lab on R29. V1 said that V2 told V1 that she faxed it to V7 (Physician) on 08/18/2025 and she had forgotten to document that she faxed it. V1 stated that V2 forgot to follow up on 08/19/2025 because surveyors were in the building for the annual survey. V1 stated that the nurse working today is going to follow up with V7. On 08/21/2025 at 2:38 PM, V6 (LPN) stated that she has not heard back from V7's office yet. V6 stated when she receives lab results from the lab, she faxes them to the doctor's office and so does the lab. V6 stated that she follows up and calls the doctor's office to ensure that they received the lab. V6 stated that typically V7's office responds to labs very quickly and is not sure why this one was missed. On 08/21/2025, V2 (DON) was not available for questions regarding the urine lab result for R29. Facility policy titled Laboratory and Diagnostic Orders and Reporting dated December 2016 documented under section titled Procedure: 2. Licensed Nursing staff will notify the physician of lab results by fax or phone and document the notification on the lab report as to who was notified, the date and time of notification, and the method of notification and the nurses' signature. 3. If the lab results are abnormal, but not critical, a response from the physician should be expected within 24 hours.

Based on observation, interview, and record review, the facility failed to ensure restorative services were provided as ordered to maintain or improve range of motion for 1 (R4) of 1 resident reviewed for mobility in the sample of 27. The Findings Include: R4's Resident Face Sheet documented an initial admission date to the facility of 08/22/2024 and included diagnoses of cerebral infarction, psychotic disorder, spastic hemiplegia affecting left non dominant side, essential hypertension, chronic obstructive pulmonary disease, major depressive disorder, gastro - esophageal reflux disease, anxiety disorder, hyperlipidemia, lymphedema, bipolar disorder, and pain in right knee.R4's Physician Order Report with a date range of 07/21/2025-08/21/2025 documented an order for Restorative Therapy AROM (Active Range of Motion) 6-7 times a week on right side and PROM (Passive Range of Motion) 6-7 times a week to left side. R4's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, indicating R4 is cognitively intact. Section GG documents for functional limitation in range of motion that R4 has impairment on one side on upper and lower extremities. Section GG for self-care documents that R4 requires substantial / maximum assistance for toileting, shower/bathe self, upper body dressing, lower body dressing, putting on and taking off footwear and personal hygiene. R4's Care Plan dated 05/09/2025 with an edit date of 08/19/20025 documented a focus area of PROM (passive range of motion): potential for loss of range of motion due to decreased left knee function. Interventions listed include inform resident of task, do not range beyond point of resistance, observe for signs and symptoms of discomfort/pain if present stop, provide instruction during range of motion activities for both upper and lower extremities 5-10 reps each. Focus area of AROM (active range of motion): potential for diminished range of motion due to history of stroke and hemiplegia. Interventions listed included do not range beyond point of resistance, observe for signs and symptoms of pain/discomfort. If present stop, provide instruction for all range of motion activities for both upper and lower extremities 5-10 reps each, and provide physical assist to complete exercise as needed. On 08/20/2025 at 1:19 PM, V5 (Certified Nurse Assistant/CNA) started PROM on R4. V5 stated that she believes they only do PROM on R4's left leg and neck. V5 stated that they do not do it to R4's left arm or R4's right side. V5 stated she believes the order is for R4's leg and neck only and there is no order for his arm. V5 completed 10 reps to R4's left knee, left leg and neck. V5 did not provide PROM exercises to R4's left arm, nor did V5 complete AROM to the right side of R4's body. On 08/21/2025 at 1:54 P.M. V2 (Director of Nursing) stated that the order in the electronic chart does not specify what body part should be receiving range of motion. V2 stated that a resident should have passive range of motion to any part of upper and lower body parts that are not contracted. Facility Policy titled Range of Motion Exercises with a date of July 2014, documents under Preparation 1. Review residents guidelines for what joints are to receive Range of Motion.

Based on interview and record review, the facility failed to provide 8 hours of daily Registered Nurse (RN) coverage. This failure has the potential to affect all 36 residents residing in the facility. Findings include: On 02/20/2025 at 10:29 A.M. V1 (Administrator) stated she is aware there are a few shifts that did not have 8 hours with a Registered Nurse. V1 stated that V2 (Director of Nursing) has been working weekends to ensure that the facility has RN coverage every shift. V1 stated on 02/16/2025 that V2 was in the building and left for several hours before coming back. V1 stated she did not realize that registered nurse coverage hours had to be consecutive. On 02/21/2025 at 10:15 A.M. V1 stated that the facility uses several nurses from one shift who keep extending their contract to work for the facility. V1 stated that they have hired a new MDS (Minimum Date Set) nurse who will help cover RN hours when she gets trained. V1 verified the accuracy of the December 2024, January 2025, and February 2025 nursing schedules. Review of December 2024 Nursing Schedule documents four hours of RN coverage was provided at the facility on 12/07/2024. The same schedule documents two and a half hours of RN coverage was provided by the facility on 12/08/2024, and five hours of RN coverage was provided by the facility on 12/21/2024 and 12/22/2024. Review of Employee Timecard documented on 02/16/2025, V1 clocked in at 5:15 A.M. and out at 8:00 A.M. V1 then clocked in at 11:55 A.M. and out at 6:52 P.M. V1's hours were not consecutive. The facility provided a Matrix for Providers on 02/20/2025 which documented the facility currently has 36 residents residing at the facility. Facility policy titled Staffing with no date on it documented under section titled Policy: The Facility provides adequate staffing to meet needed care and services for our resident's population and according to regulatory staffing requirements (CMS, IDPH). Under the section titled Procedure: 2. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. The facility will schedule a registered nurse 8 consecutive hours each day.

Based on interview and record review, the facility failed to provide adequate direct care staffing to meet resident's needs. This has the potential to affect all 32 residents living at the facility. Findings include: 1. R7's Face Sheet documented an admitted [DATE] and listed diagnoses including History of Cerebral Infarction, Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure. R7's Minimum Data Set, dated dated dated [DATE] indicated R7 has moderate deficits in cognition and is totally dependent on staff for toileting, showering, and dressing. R7's Care Plan dated 8/27/24 documented a problem area, Resident's ability to perform activities of daily living requires assistance of staff. On 09/10/24 at 02:11PM, R7 was in his room sitting in his wheelchair watching TV. R7 was alert to person and place but not time. R7 stated he needed to use the bathroom and pushed his call light. After 15 minutes and 46 seconds, V8, Certified Nursing Assistant (CNA), responded and assisted R7 with toileting. 2. R15's Face Sheet documented an admitted [DATE] and listed diagnoses including polyneuropathy, Hypertension, and Dementia. R15's Minimum Data Set, dated dated dated [DATE] documented that R15 has severe deficits in cognition and requires substantial assistance from staff for toileting, showering, and dressing. R15's Care Plan dated 8/20/24 documented a problem area, Due to cognitive deficits, (R15) is dependent on staff for meeting his/her emotional, intellectual, physical and social needs. On 09/11/24 at 11:04 AM, V6, family member of R15, stated when she was visiting on 9/7/24 on day shift, it took an hour to get staff to take V6 to the bathroom. V6 stated on 9/8/24 on day shift, there was one CNA and one nurse to care for the whole building. On 09/11/24 at 1:13 PM, V7, Licensed Practical Nurse, stated there have been times where it has just been her and one CNA for the whole building on day shift on weekends. She stated there is also an issue at times with there being only one CNA and one nurse on night shift. On 09/12/24 at 1:16 PM, V9, CNA, stated there are times when there is only one CNA and one nurse for the whole building, and that it can happen on any shift both through the week and on the weekend. On 09/13/24 at 8:13am, V1, Administrator, stated she is the staff member responsible for scheduling nursing and CNA staff. V1 stated nurses work 12 hour shifts from 6am to 6pm and 6pm to 6am, and CNAs work 8 hour shifts. V1 stated one nurse and 2 CNAs are scheduled each shift. V1 stated there are times when CNA's call in, especially on the 2pm to 10pm shift and 10pm to 6am shift, but coverage can usually be obtained. V1 stated corporate staff have told her one CNA on the 10pm to 6am shift is enough for the current census, and that when the census gets up to 36 she can schedule a total of 3 CNAs either on day shift or evening shift, but not both. On 9/13/24 at 12:10 PM, V2, Interim Director of Nurses, stated it is her expectation that call lights should be answered within five minutes. Nursing and CNA Schedules for July, August, and September 2024 documented the following dates with one CNA and one nurse providing care for the entire facility: 7/1/24, 10pm to 6am shift. 7/4/24, 10pm to 6am shift. 7/12/24, 10pm to 6am shift. 7/13/24, 10pm to 6am shift. 7/18/24, 2pm to 10pm shift. 8/2/24, 2pm to 10pm shift. 8/10/24, 6am to 2pm and 2pm to 10pm shifts. 8/18/24, 6am to 2pm shift. 9/8/24, 6am to 2pm shift. 9/9/24, 2pm to 10pm shift. 9/10/24, 2pm to 10pm shift. The Long - Term Care Facility Application for Medicare and Medicaid provided by the facility with a date of 09/11/2024 documents that 32 residents reside at the facility.

Based on observation, record review, and interview, the facility failed to store food and maintain the kitchen in safe and sanitary manner to prevent potential contamination. This has the potential to all 32 residents residing in the facility. Findings Include: On 9/10/24 at 9:45 AM, the initial kitchen tour was completed and the following concerns were noted: the top of the dish machine had a layer of flaky dried matter on top covering the entire surface, a scoop with a handle was found inside the bulk thickener touching the food item, bottom shelves of stainless steel tables were dusty and had old/dried food debris on them, bulk food containers were found to be sticky to touch and dried spills going down the side and food debris on top, a container on the cooks table holding various utensils/seasonings was found to have crumbs and food debris in the bottom, the steam table had dried/black food substance burnt to the bottom of all inserts, the side of the stove was found to have old/dried food spills down the side, the floor under the stove and cooks stainless steel table had spilled food/food debris/paper products underneath them, the floor in the kitchen was upswept with food and paper products scattered everywhere, the stove top is full of old dried spilled food on the burners and under the burners near the flame. A sample cleaning schedule provided by V4 documents that the following items are to be cleaned after each use: can opener, coffee machine, counters, cutting boards, dining room chairs/tables, dishes, floors, food carts, food preparation appliances, kitchen/dining room floors, mixers, pots/pans, Range/Stove Top, and toaster. Items to be cleaned weekly are: dish machine, oven, garbage containers, garbage disposal, interior of dishwasher, refrigerator, sanitize dining room chairs, storeroom floor and windows. Monthly cleaning schedule includes; clean behind/under major appliances, freezer condenser boils/pans, shelves, stove hood/filters, and vacuum and dust back of appliances. Daily cleaning schedule lists: exterior of dishwasher and appliances, floors, kitchen sinks/faucets, kitchen towels/cloths, microwave and waster disposal. On 9/10/24 at 11:30 AM, V10 (Cook) was observed to be pureeing the lunch meal. V10 reached into the bulk food thickener and used the scoop without washing his hands or gloves. V10 then set the measuring cup on the table with no clean barrier and then placed the scoop back in the container when he was finished with the pureed pork. At this same time an observation of V10 stirring cherries on the stove with a spatula that he picked up off the stove top burner with no clean barrier between to stir the cherries. On 9/10/24 at 2:00 PM, V4 (Dietary Manager) stated that they have a cleaning list that is supposed to be completed weekly. V4 stated that for some reason it was not completed this week and she cannot say for sure how long it has been since the stove was cleaned. V4's expectation is that it is cleaned at least once a week. V4 stated that the she will remove the scoops out of the bulk containers and clean them. V4 stated that she will speak with her staff regarding placing food utensils on a clean barrier instead of on a table top and then used to cook the food. The Long Term Care Applications for Medicare and Medicaid provided by the facility on 9/11/24, documents 32 residents reside in the facility.

Based on interview and record review, the facility failed to provide 8 hours of daily Registered Nurse coverage. This failure has the potential to affect all 32 residents residing in the facility. Findings include: Review of June 2024 Nursing Schedule documents no RN coverage was provided at the facility on 06/19/2024 and 06/29/2024. Review of July 2024 Nursing Schedule documents no RN coverage was provided at the facility on 07/13/2024, 07/14/2024, 07/17/2024, 07/27/2024 and 07/28/2024. Review of August 2024 Nursing Schedule documents no RN coverage was provided at the facility on 08/03/2024, 08/04/2024, 08/17/2024 and 08/18/2024. On 09/10/24 at 02:01 PM, V1 (Administrator) stated that she is aware there are shifts that have no RN (Registered Nurse) coverage. V1 stated the facility utilizes agency nurses to fill in gaps. V1 stated that she has recently hired RN's and the September schedule has more RN coverage on it. On 09/13/2024 at 10:47 A.M., V1 stated the facility tries to have RN coverage for all days but it is hard to get RN's to apply. V1 stated that she recently hired more RN's so this should not be an issue moving forward. V1 verified the accuracy of the June 2024, July 2024, and August 2024 nursing schedules. The Long - Term Care Facility Application for Medicare and Medicaid provided by the facility with a date of 09/11/2024 documents that 32 residents reside at the facility.

Based on interview and record review, the facility failed to ensure assessments were successfully transmitted within 14 days of completion for 1 (R32) of 12 residents reviewed for assessments in the sample of 41. Findings Include: R32's Face Sheet documented an admitted [DATE]. Diagnoses include, but not limited to dementia, Alzheimer's disease, benign prostatic hyperplasia, and essential hypertension. On 09/11/2024 at 1:52 PM, V2 (Registered Nurse / Minimum Data Set Nurse) stated R32 had an admission assessment on 05/03/2024 and the discharge assessment was completed on 05/24/2024. V2 stated that she does not have to transmit the MDS because it was a private pay discharge. V2 stated that she did not transmit the assessment as it is not required to be. On 09/11/2024 at 2:55 PM, V1 (Administrator) stated that she is unfamiliar with the MDS not being transmitted. V1 stated that she will reach out to the corporate office and get the correct information on whether or not the MDS should have been transmitted. On 09/12/2024 9:45 AM, V2 stated she was inaccurate with what she said on 09/11/2024. V2 stated that she was confused about what type of assessment that it was. V2 stated that she got the private pay and the Medicare Advantage rules confused. V2 stated that she transmitted R32's assessment on 09/11/2024. On 09/12/2024 at 1:43 PM, V1 stated the facility does not have a policy about MDS. V1 stated the facility follows the RAI manual and the RAI manual is the policy. On 09/11/2024 at 12:52 PM, R32's MDS (Minimum Data Set) dated 05/24/2024 documented the assessment as complete. Review of CMS (Centers for Medicare & Medicaid Services) MDS 3.0 NH (Nursing Home) Final Validation Report documented completed submission of R32's 05/24/2024 assessment on 09/11/2024. RAI Manual Chapter 5, Submission and Correction of the MDS Assessments Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set (MDS) records for all residents in Medicare- or Medicaid-certified beds regardless of the pay source. Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements.

Based on interview and record review the facility has failed to update comprehensive care plans for 2 of 12 residents (R15 and R21) reviewed for care plans in a sample of 41. The Findings Include: 1. R15's Face sheet documents an admitted [DATE]. R15's Face sheet includes the following diagnosis: major depressive disorder, cognitive communication deficit, depression, unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, vascular dementia with agitation. R15's Current care plan documents a problem area of falls. The goal for this problem area is that resident will remain free from injury. The approach to this problem area include: therapy to evaluate and treat if POA (Power of Attorney) approves, provide proper well maintained footwear, staff assess pressure alarm is functioning when providing care, lock brakes of wheelchair when resident is not in it, non skid strips placed on the floor next to the bed, observe frequently and place in supervised area when out of bed, resident will be monitored when in the dining room and escorted back to her room when dining is complete, assure resident is wearing eyeglasses and are clean and in good repair, assure the floor is free of glare, liquids, and foreign objects, encourage resident to assume a standing position slowly, give resident verbal reminders not to ambulate/transfer without assistance, keep bed in lowest position with brakes locked, keep call light in reach at all times, keep personal items and frequently used items within reach, leave night light on in room, provide proper maintained footwear, provide environment free of clutter, and provide toileting assistance every 2 hours and as needed. On 9/11/24 at 2:30PM, V1 (Administrator) stated that R15 should have her call light within reach at all times to call for assistance. On 9/11/24 at 2:36 PM, V5 (Certified Nurse Assistant/CNA) stated that the family does not like R15 to have a call light due to the risk of her choking herself with the cord. V5 stated that they just check on her more often, that they do not have any other form of call light system for R15 to use. On 9/11/24 at 2:45 PM, V1 stated that the care plan is not updated to reflect the need for R15 to have an alternate type of call light/alert system to let the staff know assistance is needed, nor is the behavior/request of family in the care plan requesting to not use the standard call light. 2. R21's face sheet documents an admitted [DATE]. The following diagnosis are included on the face sheet: Parkinson's disease, anxiety disorder, depression, and major depressive disorder with psychotic features. R21's current month physician orders include an order for Seroquel 50 milligram tablet once daily at bedtime with a start date of 4/9/2024. R21's Current care plan has a problem area category of psychotropic drug use resident receives antidepressant medication. The goal for this problem area is that the resident will not exhibit signs of drug related sedation, hypotension, or anticholigenic symptoms. The approach to this problem area is that they will assess/record effectiveness of drug treatment, monitor signs and symptoms of sedation, hypotension, or anticholinergic symptoms and to monitor resident mood and response to medication. On 9/13/21 at 12:30 PM, V2 (Minimum Data Set Coordinator/Care Plan Coordinator) stated that the care plan had not been updated to include the anti-psychotic medication that was started on 4/9/24 or any individualized non pharmalogical interventions when behaviors are occurring. V1 did not provide a care plan policy and procedure on updating comprehensive care plans.

Based on observation, record review and interview the facility failed to implement fall precautions by placing the call light within reach for 1 of 2 (R15) residents reviewed for falls in a sample of 41. Findings Include: R15's face sheet documents an admitted [DATE]. This same document includes the following diagnosis: muscle weakness, other abnormalities of gait and mobility, and vascular dementia. R15's care plan has a problem area category of falls that has a start date of 8/18/22 and an edited date of 8/27/24. The goal for this problem area with a long term goal target date of 11/29/24 is that the resident will remain free from injury. An approach to this problem area with a start date of 8/18/22 is to keep the call light in reach at all times. R15's most recent recent quarterly MDS (Minimum Date Set) dated 5/20/24 documents in Section C a BIMS (Brief Interview of Mental Status) of 6, indicating R15 is severely impaired with cognition level. R15's same MDS Section J documents that R15 has had falls since admission/reentry. On 9/10/24 at 10:30 AM, R15 was observed to be in her recliner and no call light within reach. On 9/11/24 at 9:30 AM, 11:30 AM, 1:30 PM and 2:32 PM, R15 was observed sitting in her recliner with the call light sitting on top of her personal refrigerator in her room not within reach. On 9/11/23 at 2:35 PM, V5 (Certified Nurse Assistant) stated that the family does not want R15 to have a call light due to the possibility that she could strangle herself with it. V5 stated that they do not have an alternate source of a call light right now, they just check on her every two hours for sure and then when they are going up and down the hall.

Based on record review and interview the facility failed to ensure residents were free from unnecessary medications for 1 of 5 (R2) residents reviewed for unnecessary medications in a sample of 41. The Findings Include: R2's Face sheet documents an admitted [DATE] and includes the following diagnosis: vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R2's current Physician Order Sheet documents an order for 1 mg (milligram) Risperadol with diagnosis: vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with a start date of 9/6/2023. A psychotropic and sedative/hypnotic utilization by resident report provided by V1 (Administrator) dated 9/6/24 documents that R2 started Risperidone 1 mg pm (as needed) on 9/6/23 and is due for a Gradual Dose Reduction (GDR) evaluation on 12/2024. The column labeled Last GDR is blank. On 9/13/24 at 1:30PM, V1 stated at this time there are no other pharmacy reports that show communication to recommend any medication reductions in the medical record. On 9/13/24 at 11:00 AM, V11 (Pharmacist) stated that he would check to see if there were any previous GDR attempts/recommendations for R2, but his routine is review the GDR's every 5 months to ensure that he catches all the medications to ensure they are reviewed per the Medicare guidelines. Review of R2's behavior tracking from 8/13/24-9/12/24 provided by V1 has no behaviors occurring. On 9/11/24 at 2:30 PM, V1 stated that all residents are tracked for the same behaviors because the new system does not allow them to individualize them. According to the tracking sheet R12 is tracked for verbal expression of distress, sleep cycle issues, apathetic/anxious/sad appearance, loss of interest, did the resident have any of the following problems or behaviors (PHQ-9-OV) (with no further explanation). On 9/13/24 at 12:30 PM, V9 (Certified Nurse Assistant) stated that R2 has not had any behaviors that he is aware of. On 9/13/24 at 1:00 PM, V2 (Minimum Data Set Coordinator) stated that R2 used to have behaviors of not having anxiety and eating and drinking all his snack and drinks that family brings in, but they have worked with him and this has all improved. V2 stated that since then he has not really had any behaviors. V2 stated that this is not tracked as a behavior nor is it on his care plan. V2 stated that she cannot find any further documentation regarding any recommendations or attempts at reduction of psychotropic medications. On 9/13/24 at 1:30 PM, V1 provided a document titled Gradual Dose Reduction Schedule that documented, Antipsychotics and Anxiolytics: During the first year of the use of these drugs in the facility, there should be one attempt to reduce the medication .

Based on interview and record review, the facility failed to provide adequate direct care staffing to meet resident's needs. This has the potential to affect all 37 residents living at the facility. Findings include: On 5/15/24 at 8:30am, V1 (Administrator) stated the current resident census is 37. V1 stated since the facility received a staffing citation from IDPH (The Illinois Department of Public Health) on 4/19/24, the facility signed a contract with a staffing agency. V1 stated the agency currently has nurses available which the facility is utilizing, but no CNAs (Certified Nursing Assistants) are available. On 5/15/24 at 9:15am, V3 (Power of Attorney/POA) of R1, stated on Tuesday 5/7/24 from about 3:30pm to about 6:00pm, the only CNA working was V11 (CNA). V3 stated during that time, she tried to find V11 for help transferring R1 into the wheelchair from the recliner and back again, but V11 was busy with other residents, and V3 stated she transferred R1 by herself although it takes two people to transfer R1. V3 stated the facility has an ongoing problem with being short staffed. V3 stated because of this, she has decided to have R1 discharged to home with in home care at the end of May 2024. On 5/15/24 at 10:45am, R4 was alert and oriented. R4 stated there are ongoing issues with staffing. R4 stated call lights can take up to an hour to be answered especially on overnight shift (10pm-6am), and there have been times in past month where only one CNA and one nurse were the only two staff in the building on overnight shift. R4 stated V7 (Registered Nurse [RN]/Minimum Data Set[MDS]/Care Plan Coordinator[CPC]) works as a floor nurse and sometimes as a CNA almost every weekend, in addition to her Monday through Friday job duties. On 5/15/24 at 11:00am, R2 was alert and oriented. R2 stated call lights take up to an hour especially on evening shift (2:00pm to 10:00pm) and overnight shift on weekends. R2 stated in the past month there have been times on the overnight shift when there is only one nurse and one CNA for the whole building, and she has noticed some of the CNAs working doubles due to the oncoming shift not relieving them. On 5/15/24 at 11:20am, R3 was alert and oriented. R3 stated she doesn't use the call light so she can't say how long it might take to get answered. R3 stated sometimes on night shift there are only two staff in the building, one CNA and one nurse, and sometimes the CNAs are working doubles because nobody is coming in to relieve them. On 5/15/24 at 2:20pm, V9 (CNA) stated in the past month, she has at times been the only CNA in the building, usually not for a whole shift but for a partial shift. V9 stated it is very difficult to meet all resident care needs under these circumstances. On 5/15/24 at 2:40pm, V11 (CNA) stated she has worked at the facility for about 3 weeks. V11 stated on 5/7/24 from 2:00pm to about 5:30pm, she worked alone with V5 (Registered Nurse/RN) because the 2pm to 10pm CNA called in sick. V11 stated it was very difficult to get residents fed, keep them clean and dry, and transfer them with only the help of V5. V11 stated on 5/3/24, she worked from 6:00am to 6:00pm because the evening shift CNA did not show up at 2:00pm. On 5/15/24 at 3:00pm, V5 (RN) confirmed in the past month, CNAs are occasionally working alone for part of a shift until coverage can be found. On 5/16/24 at 8:40am, V13 (Licensed Practical Nurse/LPN) stated within the past month, there have been overnight shifts with her and one CNA providing care for the whole building. On 5/16/24 at 8:50am, V14 (RN/Agency Nurse) stated she has only worked at the facility for a few weeks. V14 stated she works the 6:00am to 6:00pm shift. V14 stated there have been occasions on the weekends when she and one CNA were the only staff in the building. On 5/16/24 at 9:55am, V7 (RN/MDS/CPC) stated in the past month, there have been instances of one nurse and one CNA taking care of the whole building, Maybe not for a whole shift, but part of a shift. V7 confirmed she has also worked shifts as a CNA during that period because coverage could not be found, as well as working her 40 hour a week position as Minimum Data Set/Care Plan Coordinator and recently added duties of Interim Director of Nursing. On 5/16/24 at 12:55pm, V1 (Administrator) stated she is the staff member responsible for scheduling. V1 stated if residents were truly concerned about staffing they would be filing grievances, and they haven't. V1 stated she believes the facility is meeting minimum staffing requirements. V1 stated she,Tries to schedule 2 CNAs every 8 hour shift and one nurse every 12 hour shift. V1 stated CNAs working alone with one nurse on night shift is not uncommon. V1 stated, If staff call in, we do our best to get coverage. If I can't get coverage there is nothing I can do.We can't mandate staff to work. There is nothing I can do if the staffing agency doesn't have any CNAs. V1 stated she has just hired three new CNAs. On 5/16/24 at 1:25pm, V2 (Corporate Regional Director of Operations) stated she does not believe there is a problem with staffing at the facility, she Believes there is a problem with the staff and the residents' perception that they need to have more staff. V2 stated the staffing agency with which they have contracted, Have CNAs available but none are willing to come to the facility. On 5/17/24 at 7:50am, V4 (Ombudsman) stated in the past month, residents have complained about, Call lights taking too long, and the facility being short staffed, both of which are ongoing problems. V4 stated she intends to increase monitoring at the facility in relation to these issues. Nursing and CNA Schedules for April and May 2024 documented the following dates with one CNA and one nurse providing care for the entire facility: 5/1/24: 2:00pm to 10:00pm 5/3/24: 2:00pm to 10:00pm and 10:00pm to 6:00am 5/7/24: 2:00pm to 6:00pm 5/13/24: 2:00pm to 5:00pm and 10:00pm to 6:00am A Room Roster dated 5/15/24 documented a total of 37 residents living at the facility.

Based on interview and record review, the facility failed to provide adequate direct care staffing to meet resident's needs. This has the potential to affect all 36 residents living at the facility. Findings include: On 4/2/24 at 8:40am, V1, Administrator, stated she is the staff member responsible for scheduling nursing staff. V1 stated that for each 8-hour shift, one nurse and two CNA's (Certified Nursing Assistants) are scheduled. V1 stated on Easter Sunday, 3/31/24 the facility experienced, A staffing situation. V1 stated the two CNAs and one nurse scheduled for 6am to 2pm called in sick. V1 stated she called other CNA and nursing staff and everybody refused to come in except V9, Registered Nurse/Minimum Data Set Coordinator, V1 stated V1 worked as a CNA, although she is not certified, and she and V9 had to perform all resident care from 6:00am to 2:00pm until staff came in to relieve them. V1 denied there were any negative outcomes associated with this event. On 4/3/24 at 9:55am, R4 was alert and oriented. R4 stated on Easter morning only V1 and V9 were providing care as none of the other staff had showed up. R4 stated she had to have breakfast in bed, which she did not like, because they did not have time to get her up then, and V1 came in after 8:00am to get her dressed. R4 stated there have been Several times, that there has only been one CNA and one nurse in the building to provide care. On 4/4/24 at 3:00pm, V7, CNA, stated there have been several occasions where he was the only CNA on duty along with one nurse. V7 stated on 3/31/24 he had worked from 6pm on 3/30/24 to 6am 3/31/24. V7 stated staff called in that morning and V1 and V9 had to do all the resident care on day shift. V7 stated staff have problems getting all the showers done due to insufficient CNA staffing. On 4/10/24 at 3pm, V13, CNA, stated she has been in the facility's employ since 10/4/23 via her high school's vocational work program. V13 stated she works from about 3pm to 9pm. V13 stated there are normally two CNAs and one nurse on evening shift, but there have been times where it was just her and one nurse. V13 stated residents who are scheduled for showers on the 2:00pm to 10:00pm shift often do not get them due to being short staffed. On 4/11/24 at 9:50am, V1 stated she has been telling corporate staff that the facility needs more staff, and finally last night at 9pm they gave her the ok to start using a staffing agency again. V1 stated they used one in 2023 but as of January 2024 corporate said they couldn't use them anymore due to budget. On 4/11/24 at 10:25am, V6, Ombudsman, stated residents have complained about the facility being short staffed. On 4/11/24 at 12:20pm, R12 was alert and oriented. R12 stated she is not getting showers twice a week because the facility is short staffed. On 4/3/24 at 10:05am, R13 was alert and oriented. R13 stated she was admitted to the facility on [DATE] and has not had a shower, bath, or bed bath since her admission, nor had any staff asked her if she wanted one. On 4/11/24 at 12:50pm, R2 was alert and oriented. R2 stated there are times when the facility is shorthanded and as a result only one staff member is available to do her mechanical lift transfers. On 4/12/24 at 9:25am, V11, Housekeeping Supervisor, stated she has witnessed occasions where there has been one nurse and one CNA in the building to take care of all the residents. On 4/12/24 at 10:15am, V9 corroborated V1's account of 3/31/24. V9 stated that day was, Horrible. V9 stated thankfully with the holiday, several residents went out with their families and/or had family members come in who fed them. V9 stated there are always holes in the schedule as well as frequent call-ins. V9 stated she and V1 did the best they could and managed to get everything done. On 4/12/24 at 12:35pm, V10, Social Services Designee, stated there are times when one nurse and one CNA are working. V10 stated if corporate staff would let them start using agency staff again, it would not be a problem. The Staff Schedule for March 2024 documented that on the following dates on the 10pm to 6am shift, only one CNA was working with one nurse: 3/8/24, 3/18/24, 3/28/24, 3/30/24. The schedule further documented that 2 CNAs and one nurse called in for the 6am to 2pm shift on 3/31/24 and V1 and V9 worked the floor. A Room Roster dated 4/2/24 documented a total of 36 residents living at the facility.

Based on interview and record review, the facility failed to provide the services of a trained, competent Certified Nursing Assistant (CNA) on 3/31/24. This has the potential to affect all 36 residents living at the facility. Findings include: On 4/2/24 at 8:40am, V1, Administrator, stated on Easter Sunday, 3/31/24 the facility experienced, A staffing situation. V1 stated the two CNAs and one nurse scheduled for 6am to 2pm called in sick. V1 stated she called other CNA and nursing staff and everybody refused to come in except V9, Registered Nurse/Minimum Data Set Coordinator. V1 stated V1 worked as a CNA, although she is not certified as a CAN. V1 stated she and V9 had to perform all resident care duties from 6:00am to 2:00pm. V1 denied there were any negative outcomes associated with this event. V1 acknowledged she performed transfers and incontinence care with no training or experience in personal care. V1 denied feeding residents or assisting with resident medications or treatments. On 4/3/24 at 9:55am, R4 was alert and oriented. R4 stated on Easter morning only V1 and V9 were providing care as none of the other staff had showed up. R4 stated she had to have breakfast in bed, which she did not like, because they did not have time to get her up then, and V1 came in after 8:00am to get her dressed. On 4/4/24 at 3:00pm, V7, CNA, stated on 3/31/24 he had worked from 6pm on 3/30/24 to 6am on 3/31/24. V7 stated CNA staff called in that morning and V1 and V9 had to do all the resident care on day shift. On 4/12/24 at 10:15am, V9 corroborated V1's account of 3/31/24. V9 stated that day was, Horrible. V9 stated thankfully with the holiday, several residents went out with their families and/or had family members come in who fed them. V9 stated she and V1 did the best they could and managed to get everything done and there were no negative outcomes. V9 denied that V1 fed residents or assisted with resident medications or treatments. An undated CNA Job Description stated, The overall purpose of the Certified Nursing Assistant position is to provide each of the assigned residents with routine daily nursing care and services in accordance with the residents' plan of care. Education and experience requirements: State certification as a Certified Nursing Assistant. A Room Roster dated 4/2/24 documented a total of 36 residents living at the facility.

Based on interview and record review, the facility failed to provide the services of a full time Director of Nurses/DON. This has the potential to affect all 36 residents living at the facility. Findings include: On 4/2/24 at 8:40am, V1, Administrator, stated V2, former DON, walked out 3/24/24, giving no notice of termination of employment. V1 stated V2 had stated she was tired of having to frequently work the floor as a nurse in addition to her DON duties. V1 stated there have since been no interested applicants. V1 stated the facility's other nurses, as well as corporate staff, have had to take over some of the DON duties. V1 stated V2 acted as the facility's Infection Control Preventionist and no staff has been assigned to take over those duties. V1 stated V2 is still employed by the facility as a PRN (as needed) staff nurse. On 4/11/24 at 3:30pm, V2 stated she left the position on 3/24/24 because she was tired of not being able to spend time with her family due to her DON duties as well as working the floor when there were call ins. V2 stated she is still employed by the facility PRN as a staff nurse. On 4/12/24 at 10:15a, V9, Registered Nurse/Minimum Data Set Coordinator, stated she is not sure who is performing the DON duties, but it is not her. V9 stated she is performing her own duties as well as having to work the floor at times, and she has no interest in applying for the DON position due to staffing issues. An undated DON Job Description documented, The Director of Nursing will recognize and respond to the nursing and health care of residents. This person will effectively manage the nursing department regarding residents, employees, families' visitors, and the public. The Director of Nursing will make prompt and accurate nursing assessment of care and management judgments. This individual will perform the essential functions of the job in a manner which benefits residents of the facility and complies with business necessity without causing undue hardship. The Director of Nursing position will require an individual who is dependable, self-sufficient, and can easily multi-task. Qualified candidates will plan, organize, develop, and direct the overall operation of the nursing department in accordance with local, state, and federal guidelines and regulations. The position is charged with responsibility to ensure the quality of care is delivered consistently to the resident population; and performs related work as required. A Room Roster dated 4/2/24 documented a total of 36 residents living at the facility.

Based on interview and record review, the facility failed to provide sufficient kitchen staff to carry out nutrition services on [DATE]. This has the ability to affect all 36 residents living at the facility. Findings include: On [DATE] at 9:25am, V1, Administrator, stated the facility's long term Dietary Manager died suddenly on [DATE]. V1 stated her replacement started on [DATE]. V1 stated in addition to the new Dietary Manager, there are two full time cooks, one morning and one afternoon. V1 stated the kitchen is fully staffed based on their census according to their corporation's guidelines. V1 stated on [DATE], Tuesday, one of the cooks called in and the other cook was scheduled to come in at 11:30 and could not come in early, so V1 cooked breakfast that morning. V1 stated she prepared scrambled eggs and provided a choice of cereal as well as donuts, which she stated were not on the menu that day but that combination had been on the menu previously as a Dietician approved meal. V1 stated for lunch she ordered pizza and breadsticks and served chocolate chip cookies which had been the resident choice meal to be served later in the month. V1 stated she checked temperatures of the food for safe holding and serving and documented them according to facility policy, prepared purees according to recipe, and portioned food according to the spreadsheet. V1 stated fluids were provided per resident preference, including thickened liquids following the instructions on the thickener container. V1 acknowledged she did not have certification in food sanitation. The Menu for [DATE] documented that the breakfast meal was to have been choice of cereal, pancakes, scrambled eggs, toast, jelly, margarine,, juice, milk, coffee, and tea. The lunch meal was to have been Mostaccioli, broccoli, garlic toast, and chocolate chip cookie. The Dietary Schedule dated [DATE] documented that the morning cook called out sick and was replaced by V1. An undated Culinary Associate Job Description stated, To be qualified for this position, you must maintain a current Food Services Sanitation certificate and have one (1) year job related experience including food preparation, full-line menu items and therapeutic diets. A Room Roster dated [DATE] documented a total of 36 residents living at the facility.

Based on observation, interview, and record review, the facility failed to check the dish machine and surface cleaning agent for the correct proportion of a sanitizing agent, failed to maintain equipment, food contact surfaces and storage areas in a clean and sanitary manner, and failed to store foods to prevent potential contamination. This has the potential to affect all 36 residents living in the facility. Findings include: On 4/2/24 at 11:15am, all cabinets in the kitchen were noted to be covered on the outside with a layer of grime. The floors throughout the area were sticky and had dried food debris around the and under the stove and under prep tables. The steam table held food debris and grime in its empty compartments. All drawers in the kitchen contained food debris. Shelves under prep tables had a thick layer of grime and also food debris. The cooler doors were dirty and grimy with food debris in the bottom. The microwave was dirty inside and out, the turntable had what appeared to be a layer of baked on oatmeal, and there was food debris under the turntable. There was a grimy open bin on one of the prep tables containing a bag of coating mix, a bag of coconut, and a bag of orange drink mix, all open to air. The coconut bag had food debris on it, the drink mix showed signs of having been wet, and there was food debris in the bottom of the bin. There was a layer of grime, grease, and dried food debris on the stove including rotini pasta pieces. There was a thick layer of grime and food debris on top of the dish machine. There was an open bin of plastic silverware under a prep table, and the shelf it was sitting on was grimy. On 4/2/24 at 11:18am, V3, Cook, was observed checking the temperature of ham and potato casserole. V3 picked up a thermometer which was sitting on the wooden prep table without its sheath, and without cleansing the thermometer, placed it in the casserole. Upon removing the thermometer, he wiped it clean using the oven mitt he was wearing and placed it back on the prep table. At 11:25am, he placed the thermometer back into the casserole without cleansing it, and again wiped the thermometer on the oven mitt. On 4/2/24 at 12:55pm, V5, Dietary Manager, was asked by the Surveyor to check the level of sanitizer in the sanitizing bucket which is used for cleaning surfaces. V5 placed a Ph (Potential of Hydrogen) test strip in the water and there was no change in color. The Surveyor asked what that indicated, and what type of chemical is being used for sanitizing surfaces and dishware, and V5 stated she was not sure. The Surveyor then asked for an observation of V5 testing the sanitizer in the dish machine, and V5 stated she was not sure how to do that. V5 stated if there is a kitchen cleaning schedule she does not know where it is. On 4/2/24 at 1:10pm, V3, Cook, stated he was not sure how to check the dish machine or the sanitizer bucket and stated this is not something he does, and nobody has ever trained him how to do it. V3 stated if there is a kitchen cleaning schedule, he is not aware of it. On 4/4/24 at 10:10am in the dry food storage area, shelving and floors were noted to be covered with a layer of grime. There was a box of powdered sugar, a bag of corn meal, a box of cornstarch, and box of lasagna noodles all being stored open to air. An undated Cleaning and Sanitation Policy stated,The kitchen will be maintained in a clean and sanitary condition. The state and/or federal food code will be maintained on file within the food service department, and will be the basis of all sanitation and food safety practices. An undated Machine Ware Washing Policy documented, Dishes, glassware, cups, utensils, and other dishware are washed, rinsed, and sanitized after each use. The machine for ware washing will be checked prior to each meal period to ensure it is functioning properly. Employees that use the ware washing machine will be responsible for knowing how to use the machine, document its use, and and properly maintain it after use. Steps include: Check that the wash cycle is maintaining proper temperature. Check sanitizer concentration using appropriate test strips. A Room Roster dated 4/2/24 documented a total of 36 residents living at the facility.

Based on observation, interview and record review, the facility failed to develop, revise and/or implement care plan interventions and to follow facility policy to maintain acceptable parameters of nutritional status for 3 of 13 residents (R9, R10, R12) reviewed for weight loss in the sample of 27. This failure resulted in and R9 experiencing an 11.1 percent weight loss in 3 months. Findings include: 1. R9's Care Plan documents an admitted [DATE] and lists diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Minimum Data Set (MDS) dated [DATE], in Section C, documents R9 has a Brief Interview for Mental Status (BIMS) score of 7, indicating R9 can communicate but has impaired cognition and impaired short term and long-term memory. R9's MDS documents in Section G, Eating; R9 is extensive assist of 1 person for eating. R9's Care Plan also documents a problem category of Nutritional Status with a start date of 8/18/22 and states Resident has experienced weight loss R/T (related to) decreased appetite and dementia. Currently on regular diet with supplements BID (twice per day). Relies on staff for feeding and fluid intake. Other diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Approaches dated 8/18/22 include to encourage oral intake of food and fluids, to provide physical assistance for meals and provide supplements as ordered. There was no reproducible evidence presented from the facility that weight loss had been addressed in R9's care plan as an issue prior to 8/18/22. R9's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/16/22 between 9:30 AM and 3:00 PM, continuous observation of the cart with R9's dietary supplement was noted by the nurse's station as not being distributed, and R9 was not observed to receive her 10AM dietary supplement. On 8/16/22 at 12:15 PM, R9 was waiting on her noon tray. At 1:10 PM, R9 received her tray. At this time, R9 was asleep in her recliner and no staff were observed to make sure R9 was awake to eat her noon meal. At 1:20 PM, V9 (Certified Nurse Aide/CNA) came in to assist R9 with her meal. R9 stated the meal was cold and she didn't feel like eating. R9 was not encouraged to eat, offered a different tray, nor offered to reheat the cold food. R9's Weight Record documents the following weights: 131.2lbs (pounds) on 6/1/22, 127.4lbs on 7/1/22, and 116.6lbs on 8/11/22. This documents a 14.6 pound weight loss since June 2022, which calculates to an 11.1% weight loss in 3 months. R9's Registered Dietician Note dated 8/18/22 documents: Current weight of 117# (pounds) is down 10#-1 mo, down 18#-3 mo, down 8#-5 mo. Res is within weight standards per BMI (Body Mass Index) of 21.32. No recent labs. No open skin areas per report. Resident is on regular diet and meal intake average varies. Receives supplement 2x daily. Recently went hospice care. Related to weight loss and varied intakes, receives super cereal at breakfast. Continue to monitor. 2. R10's Care Plan documents an admitted [DATE] and lists diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] unspecified, Other specified abnormalities of plasma proteins, Nontoxic single [CONDITION(S)] nodule, Mixed [CONDITION(S)], Gastro-[CONDITION(S)] reflux disease without esophagitis. R10's MDS dated [DATE] documents in Section C that R10 has a BIMS score of 5, indicating R10's cognition is severely impaired, and she has short term and long-term memory impairment. This same MDS documents in Section G, Eating, that R10 requires supervision and setup assistance from the staff. R10's Care Plan also documents a problem category of Nutritional Status with a start date of 7/26/22 and states Resident has experienced weight loss R/T (related to) fair/poor food and fluid intake. Currently on mechanical soft diet. Receives supplements. Has own teeth. Relies on staff for set up and cueing during meals. Other factors include dementia, [CONDITION(S)], GERD, age. Approaches dated 7/26/22 include to Provide setup help and cueing assistance for meals encourage oral intake of food and fluids, and provide supplements as ordered. On both 8/15/22 and 8/16/22 at 12:30 PM, R10 was observed sitting in her recliner asleep, with her noon meal tray on the bedside table that had been placed in front of her. R10's meal tray sat in front of R10 for over 40 minutes during continuous observation and no staff went into R10's room to wake her up and encourage R10 to eat her lunch. R10's tray went back to the kitchen untouched both days on 8/15/22 and 8/16/22. R10's Weight Record documents the following weights: 125lbs in February 2022, 121lbs on 4/1/22, 118lbs on 5/1/22, 118.6lbs on 6/1/22, and 115lbs on 7/1/22. These records document that R10 had a 6lb weight loss in 4 months and a 10lb weight loss since February 2022 (8% loss in 6 months). 3. R12's Care plan documents an admitted [DATE] and lists diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's MDS dated [DATE] documents in Section C that R12 has a BIMS score of 8, indicating R12 can communicate, but has impaired short term and long term memory. This same MDS documents in Section G, Eating, that R12 is extensive assist of 1 person with her meals. R12's Care Plan also documents a problem category of Nutritional Status with a start date of 8/18/22 and states Resident has experienced weight loss. Currently on mechanical soft diet with supplements. Has dentures. Relies on staff for food and fluid intake. Other factors may include poor intake, [CONDITION(S)], dementia, [CONDITION(S)], [CONDITION(S)], depression, hallucinations, [CONDITION(S)], [CONDITION(S)]. Approaches dated 8/18/22 include to encourage oral intake of food and fluids, to provide physical assistance for meals and provide supplements as ordered. There was no reproducible evidence presented from the facility that Nutritional Status had been addressed in R12's care plan as an issue prior to 8/18/22. On 8/16/22 at 1:00pm, R12 received her noon (lunch) tray. V9 (Certified Nurse Aide/CNA) was assisting R12 to eat, but R12 stated she didn't like the food because it was cold. R12's food was not offered to be re-heated, and she didn't receive another tray. R12 only ate 35% her noon meal. On 8/16/22 at 1:25 PM, V9 and V10 (CNAs) both stated they try to pass out the trays as soon as they come out, and it takes a long time to assist residents who need to be fed or encouraged to eat their meal. V10 stated when there are only 2 people passing out trays and assisting with the meals, it's hard to get everyone fed before their food is cold, and it takes time to go to the kitchen for another tray. On 8/18/22 at 2:30 PM, V1 (Administrator) stated she was wanting to get staff members who weren't Certified Nurse Aides or Nurses trained so they could assist with the meals. V1 stated it's hard for just 2 or 3 Certified Nurse Aides to get all of the feeding assistance done. V1 stated if other staff members could assist with the mealtimes, the residents who need help with their meals would receive that service efficiently, and the meals wouldn't be cold. The facility's undated policy on Assistance with Meals documents in line #3. Residents Requiring Full Assistance: a. Nursing staff will remove food trays from the food cart and deliver the trays to each resident's room. b. Nursing staff will feed those residents needing full assistance. c. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. Line #5. For all residents, hot foods shall be held at a temperature of 136 degrees or above until served. Cold foods shall be held at 40 degrees or below until served. Nursing and Dietary Services will establish procedures such that delivery of food to serving areas accommodates this requirement. The facility's policy on Weight Management Program dated 7/2014 documents under Policy; It is the policy of the facility to manage resident weight through prevention, assessment, and implementation and evaluation of interventions. Line #2; On the first through the fifth days of the month the Certified Nurses Aide will take the weights for all monthly weights. Weekly weights will be obtained for any resident determined by the Weekly committee. Line #10; The Director of Nursing or his/her designee will list all residents who have had a weight loss or gain greater than five pounds, poor intake, pressure ulcers, chewing or swallowing problems, receive tube feedings, all new admissions, all readmissions, or abnormal lab results will be given to the registered dietician for assessment and recommendations.

Based on interview and record review, the facility failed to timely notify the physician of signs and symptoms indicative of an injury/[CONDITION(S)], and to immediately obtain orders for an x-ray for one (R2) of three residents reviewed for quality of care in the sample of three. This failure resulted in R2 experiencing a delay in medical treatment including surgical intervention for a right [CONDITION(S)] for at least three days or more from the time symptoms were noted. Findings include: On 4/22/22 at 10:20 am, V2 (Hospital Social Worker) stated the facility sent R2 to the emergency room (ER) on the evening of 04/19/22. V2 stated the facility staff stated that R2 fell on [DATE] and was experiencing hip pain and swelling of the right leg. V2 stated the facility staff said they did not send R2 to the ER sooner because R2 had not previously complained of pain. V2 stated an x-ray done in the ER showed that R2 had sustained a broken right hip. V2 expressed concern regarding the length of time between the fall and the facility sending R2 to the ER for evaluation and treatment. R2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Care Plan with a review date of 01/26/22 documented, (R2) has a history of falls, with the last one being 03/31/22. R2's 02/07/22 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 7, indicating R2 has severe deficits in cognitive functioning. This BIMS indicated R2 was alert, could repeat three words without difficulty, could repeat one of them without prompting after five minutes, and could state the current month, The same MDS indicated R2 displayed clear speech, usually understood others, and was usually understood by others. The MDS also indicated R2 ambulated with the assistance of one staff member and had no difficulty with range of motion to the upper or lower extremities. R2's 04/06/22 Fall Risk Assessment documented a score of 20, indicating R2 is at risk of falls due to being disoriented to person, place, and time at all times, and a history of three or more falls in the past three months. R2's 03/31/22 Fall Investigation, completed by V8 (Registered Nurse/RN) documented, Resident on floor in hallway. Resident denies any pain or injury. Resident taken to hospital-no. Resident assessed, small skin tear to right elbow noted. Predisposing situation factors: Ambulating without assistance, (and) not using wheelchair. On 04/22/22 at 10:50am, V3 (Family Member of R2) stated she is a nurse. V3 said R2 has a history of falls, mostly due to self-transfer and lack of recognition of safety issues due to advanced Dementia. V3 stated R2's most recent fall was on 03/31/22. V3 stated R2 had chronic back pain due to spinal curvature. V3 stated staff gave R2 prn (as needed) pain medication when she complained of pain and it was effective. V3 stated beginning 04/02/22, she and V6 (Family Member) began observing that R2 would grab her right hip and yell out in pain. V3 stated she and V6 asked various staff numerous times to call V5 (R2's Physician/Facility Medical Director) and get an order to x-ray R2's right hip. V3 stated staff always said R2 did not need an x-ray, and they were monitoring R2 and keeping V5 informed of her condition. V3 stated she cannot recall which staff they asked about the x-ray, because the facility has several agency staff working there now. V3 stated when she visited R2 on 4/16/22, R2 was soiled, so V3 removed R2's clothing to change her, and V3 saw that R2's right leg was swollen from the thigh down, R2's right hip was bruised, and R2's right foot was externally rotated. V3 stated she informed V9 (Licensed Practical Nurse/LPN) and V9 examined R2. V3 stated V9 said she would contact V5 about getting an x-ray but it probably wouldn't be x-rayed that day as it was a holiday weekend and V9 didn't think the contracted portable x-ray provider was available. V3 said she heard nothing further until 4/19/22, when she was notified by V6 that R2 had been sent to the ER. On 4/22/22 at 11:40am V4 (Certified Nursing Assistant/CNA), stated that after R2 fell on [DATE], V4 did not recall seeing a bruise on her right hip, nor range of motion abnormalities, swelling, or external rotation. V4 stated she did recall that R2 would complain of right leg pain at times but R2 also would at times complain about pain all over and couldn't really tell you what was wrong due to her Dementia. V4 stated she believed nursing staff were giving R2 prn pain medications. On 4/22/22 at 11:45am, V6 (Family Member) stated when she visited R2 on 4/2/22, R2 seemed to be in pain, grabbing her right hip and saying her leg hurt. V6 stated on that date (4/2/22) she saw R2's right leg out of her clothing and noticed a bruise on the right hip, but V6 did not notice if there was any swelling or external rotation at that time. V6 stated R2 seemed to be less able to move the right leg like usual. V6 stated on 4/2/22 she started asking the nurses to get the right leg x-rayed, and staff would always say they would Check with (V5) and let us know. V6 stated They just kept saying that anytime we asked. V6 stated she didn't know which staff she talked to as the facility has a lot of agency staff working at present. V6 stated when R2 was in pain, nursing staff would give her a pain pill, and R2 was also getting a scheduled pain pill. V6 stated everything came to a head when V3 (Family Member) visited on 4/16/22, and V3 told V6 that R2's right leg was swollen. V6 stated V3 said she had the nurse come in and look at it, and the nurse said they would get it x-rayed. V6 stated she never heard any more about it until the evening of 4/19/22, when the facility called and said they were sending R2 to the ER because the right hip was fractured. On 4/22/22 at 1:00pm, V7 (RN) stated her first day at the facility was on 04/07/22. V7 stated she had very little interaction with R2. V7 stated she did not recall doing any physical assessments on R2. V7 stated she didn't recall hearing anything from the CNA's or in report about R2's right hip. V7 stated she didn't think R2 ever complained of pain or needed PRN (as needed) pain medication. V7 stated when she worked on 04/19/22, she recalls seeing a faxed x-ray result which documented that R2 had a fracture of the right femur. V7 stated she immediately notified V6 (Family) and V5 (Physician), and V5 ordered R2 to be sent to ER. V7 stated she called the ambulance immediately and R2 was sent to the ER. On 04/22/22 at 1:10pm, V8 (RN) stated she was on duty when R2 fell on [DATE]. V8 stated she immediately assessed R2's vital signs and did a head-to-toe physical evaluation and a neurological check, and there were no findings of physical injuries, except a small skin tear to right elbow. V8 stated V5 (Physician) was in the facility rounding at that time, so he also assessed R2, and gave no new treatment orders. V8 stated in the days that followed, R2 exhibited no issues with the right leg or hip. V8 stated she recalled R2 had her usual complaints of back pain, but no complaints of hip/leg pain. V8 stated R2's family approached her one time, of which she does not remember the date, and asked V8 if she felt R2's hip needed an x-ray. V8 stated she assessed R2's right hip, and there were no bruises, swelling, external rotation, pain, or shortening of the leg, so she didn't contact V5. V8 stated she does not recall if she documented this assessment. V8 stated this was the only formal assessment she did for R2 in April 2022, but she remembered helping the CNA's dress R2 one morning, and R2 didn't have any bruises, swelling, external rotation, or shortening. V8 stated R2's range of motion was the same as it always was, and at times R2, as usual would stand up unassisted while seated in her wheelchair and would require redirection. V8 stated she came in to work at 6:00am on 4/19/22 and there was a 4/18/22 order on the desk for R2 to get an x-ray of the right hip. V8 stated she called the facility's contracted portable x-ray provider. V8 stated their staff came out within a couple of hours, and she recalls it was before lunch. V8 stated the results had not come in when she left at 2:00pm that day. A fax communication from V5's office, dated 04/18/22, documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An illegible signature and Done, 04/19/22 were handwritten in the lower right corner. A 04/19/22 Right Radiological Examination, Femur, for R2 documented, Question Femoral Neck Fracture. On 4/22/22 at 1:45pm, V5 (Physician) stated R2 fell on [DATE] while he was rounding at the facility. V5 stated he assessed R2, and noted R2's face was bruised, but there were no injuries to the right hip or leg. V5 stated nobody from the facility contacted him about R2 until V9 (LPN) called his office on 4/18/22 at 11:44am saying the right leg was swollen, and V5 stated he then ordered an x-ray of the right hip. V5 stated his next contact with the facility was on 4/19/22 when V7 called and stated the x-ray showed a right [CONDITION(S)], and V5 ordered R2 to be sent to ER. V5 stated R2 subsequently required surgery to repair the hip. V5 stated he was unaware the leg had been swollen and R2 had been complaining of pain on 04/16/22. V5 stated he would have ordered an x-ray immediately. V5 further stated when he ordered the x-ray on 04/18/22, it should have been done stat (immediately), and if the portable x-ray provider was unavailable, staff should have called him for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V5 additionally stated that if staff had notified him on 04/02/22 of the family's request for an x-ray because of R2's complaints of hip pain, he would have ordered the x-ray immediately. V5 stated he is available by phone 24 hours a day for his patients and the facility knows how to contact him. V5 stated the facility's lack of action meant that R2 went without intervention for the [CONDITION(S)] for three extra days. V5 stated complications from the untreated fracture could have included bleeding into the fracture with resulting [CONDITION(S)], since R2 is taking [NAME] stated other complications could include a blood clot from the fracture, and the development of a pressure ulcer from the lack of normal mobility. V5 stated he doubted it took from 03/31/22 until 04/16/22 for R2 to develop leg swelling and external rotation of the leg. V5 stated he expected staff to do a physical assessment of R2 at least daily for several days after the fall in case new symptoms developed or something was missed during the initial assessment. V5 stated he doubted nursing staff were adequately assessing R2 in the days after the fall. A 04/19/22 ED (Emergency Department) Hospital Admission Evaluation documented, History of Present Illness: (R2) is an [AGE] year-old female presenting via EMS (Emergency Medical Services) from the nursing home for evaluation after a fall. (R2) was complaining of more right hip pain today so they did (an) x-ray which showed right [CONDITION(S)] so (they) sent patient to ED . Assessment and Plan: Closed right [CONDITION(S)]. Patient is admitted to (hospital) .Orthopedic surgery will be consulted regarding her care .She will be given [MEDICATION(S)] for pain every 4 hours as needed. On 4/22/22 at 2:15pm, V9 (LPN) stated that on 4/16/22, V3 (Family) asked her to assess R2's right leg, which was swollen and painful. V9 stated she does not recall if it was bruised. V9 stated that V3 said she, V6 (Family), and V11 (R2's Power of Attorney), did not want R2 sent to the emergency room . V9 stated she told V3 she did not think the portable x-ray provider would come out on a holiday weekend. V9 stated she did not try to contact the x-ray provider. V9 stated she did fax V5's office about R2's status, but then realized as it was the weekend, his office would be closed. V9 stated she did not call V5. V9 stated she told the oncoming nurse, V10 (RN) about the hip, and that R2 would need to be monitored. When asked, if in her professional opinion, R2 should have been sent to theER on [DATE], or if she should have contacted V5, V9 stated she is agency staff and is not very familiar with R2, so she couldn't say for sure. V9 stated she did not recall ever performing a physical assessment for R2 except for 04/16/22. V9 stated she did not recall discussing R2 with any of R2's family prior to 4/16/22. On 4/22/22 at 1:35pm, V3 (Family) stated she told V9 (LPN) that it is always difficult for R2 to go to the ER because she gets upset and confused due to her Dementia, and V3 felt it was preferable if R2 didn't have to go but did not state that the family didn't want R2 to go out. V3 stated she had assumed V9 called V5 (Physician). V3 stated V9 did not say one way or other if she thought R2 should be sent out. On 4/22/22 at 2:45pm, V10 (RN) stated when she came on duty on 4/16/22, V9 stated V3 did not want R2 sent to the ER. V10 stated that V9 stated she called V5, and that R2 was to be monitored, and there was no order for an x-ray. V10 stated she did not talk to any of R2's family. V10 stated she did not contact V5 as she believed V9 already had. V10 stated she did not recall any of the family ever asking for R2 to get an x-ray. V10 stated she recalled working with R2 on 04/16/22 and 04/17/22, and R2 was her usual self, she fed herself with a good appetite, and had no complaints of pain that V10 recalled. V10 stated she thought she had done a physical assessment on R2 on both days but was not sure if she had documented it. V10 stated she did not contact V5 about R2. V10 stated she recalled observing CNA staff roll R2 from side to side when they changed her, and she did not appear to be in pain. V10 stated she did not recall seeing any bruises, and the right leg did not look swollen. R2's April 2022 Nursing Progress Notes contained no documentation about R2's post 03/31/22 fall status, R2's family reports of R2 complaining of pain, R2's family requesting an x-ray, nor any nursing assessments related to physical assessment or range of motion, until a 04/16/22 note at 3:40pm. This Nursing Progress Note was authored by V9 and documented the following: (R2) (is) noted to have swelling to the right hip and RLE (Right Lower Extremity) with complaints pain at times to RLE. Family here and requesting x-ray orders from MD (Medical Doctor). Family notified by this nurse that x-ray may not be possible today here at the facility due to it being a holiday weekend. (Easter). This nurse informed the family that we would monitor for changes and pass the info(rmation) on to (V5/Physician). The family states understanding. Oncoming nurse (V10/RN) notified. A Change in a Resident's Condition or Status Policy dated November 2016 documented, A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there (are) changes in level of care, resident rights, etcetera.

Based on interview and record review, the facility failed to timely recognize/identify reported signs and symptoms indicative of an injury/[CONDITION(S)], and to immediately obtain orders for an x-ray for one (R2) of three residents reviewed for quality of care in the sample of three. This failure resulted in R2 experiencing a delay in medical treatment including surgical intervention for a right [CONDITION(S)] for at least three days or more from the time symptoms were noted. Findings include: On 4/22/22 at 10:20 am, V2 (Hospital Social Worker) stated the facility sent R2 to the emergency room (ER) on the evening of 04/19/22. V2 stated the facility staff stated that R2 fell on [DATE] and was experiencing hip pain and swelling of the right leg. V2 stated the facility staff said they did not send R2 to the ER sooner because R2 had not previously complained of pain. V2 stated an x-ray done in the ER showed that R2 had sustained a broken right hip. V2 expressed concern regarding the length of time between the fall and the facility sending R2 to the ER for evaluation and treatment. R2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Care Plan with a review date of 01/26/22 documented, (R2) has a history of falls, with the last one being 03/31/22. R2's 02/07/22 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 7, indicating R2 has severe deficits in cognitive functioning. This BIMS indicated R2 was alert, could repeat three words without difficulty, could repeat one of them without prompting after five minutes, and could state the current month, The same MDS indicated R2 displayed clear speech, usually understood others, and was usually understood by others. The MDS also indicated R2 ambulated with the assistance of one staff member and had no difficulty with range of motion to the upper or lower extremities. R2's 04/06/22 Fall Risk Assessment documented a score of 20, indicating R2 is at risk of falls due to being disoriented to person, place, and time at all times, and a history of three or more falls in the past three months. A Fall Investigation dated 03/28/22 documented,Resident was in bed and tried to transfer herself to her chair. Resident fell and hit right side of face .Resident complains of right sided leg, rib, and head pain. Resident is on blood thinners and was sent out to ER for further evaluation and treatment. Doctor and family aware. A 03/28/22 ER History and Physical stated, (Hip) X-ray showed no acute fracture. R2's 03/31/22 Fall Investigation, completed by V8 (Registered Nurse/RN) documented, Resident on floor in hallway. Resident denies any pain or injury. Resident taken to hospital-no. Resident assessed, small skin tear to right elbow noted. Predisposing situation factors: Ambulating without assistance, (and) not using wheelchair. On 04/22/22 at 10:50am, V3 (Family Member of R2) stated she is a nurse. V3 said R2 has a history of falls, mostly due to self-transfer and lack of recognition of safety issues due to advanced Dementia. V3 stated R2's most recent fall was on 03/31/22. V3 stated beginning 04/02/22, she and V6 (Family Member) began observing that R2 would grab her right hip and yell out in pain. V3 stated she and V6 asked various staff numerous times to call V5 (R2's Physician/Facility Medical Director) and get an order to x-ray R2's right hip. V3 stated staff always said R2 did not need an x-ray, and they were monitoring R2 and keeping V5 informed of her condition. V3 stated she cannot recall which staff they asked about the x-ray, because the facility has several agency staff working there now. V3 stated when she visited R2 on 4/16/22, R2 was soiled, so V3 removed R2's clothing to change her, and V3 saw that R2's right leg was swollen from the thigh down, R2's right hip was bruised, and R2's right foot was externally rotated. V3 stated she informed V9 (Licensed Practical Nurse/LPN) and V9 examined R2. V3 stated V9 said she would contact V5 about getting an x-ray but it probably wouldn't be x-rayed that day as it was a holiday weekend and V9 didn't think the contracted portable x-ray provider was available. V3 said she heard nothing further until 4/19/22, when she was notified by V6 that R2 had been sent to the ER. On 4/22/22 at 11:40am V4 (Certified Nursing Assistant/CNA), stated that after R2 fell on [DATE], V4 did not recall seeing a bruise on her right hip, nor range of motion abnormalities, swelling, or external rotation. V4 stated she did recall that R2 would complain of right leg pain at times but R2 also would at times complain about pain all over and couldn't really tell you what was wrong due to her Dementia. On 4/22/22 at 11:45am, V6 (Family Member) stated when she visited R2 on 4/2/22, R2 seemed to be in pain, grabbing her right hip and saying her leg hurt. V6 stated on that date (4/2/22) she saw R2's right leg out of her clothing and noticed a bruise on the right hip, but V6 did not notice if there was any swelling or external rotation at that time. V6 stated R2 seemed to be less able to move the right leg like usual. V6 stated on 4/2/22 she started asking the nurses to get the right leg x-rayed, and staff would always say they would Check with (V5) and let us know. V6 stated They just kept saying that anytime we asked. V6 stated she didn't know which staff she talked to as the facility has a lot of agency staff working at present. V6 stated everything came to a head when V3 (Family Member) visited on 4/16/22, and V3 told V6 that R2's right leg was swollen. V6 stated V3 said she had the nurse come in and look at it, and the nurse said they would get it x-rayed. V6 stated she never heard any more about it until the evening of 4/19/22, when the facility called and said they were sending R2 to the ER because the right hip was fractured. On 4/22/22 at 1:00pm, V7 (RN) stated her first day at the facility was on 04/07/22. V7 stated she had very little interaction with R2. V7 stated she did not recall doing any physical assessments on R2. V7 stated she didn't recall hearing anything from the CNA's or in report about R2's right hip. V7 stated she didn't think R2 ever complained of pain or needed PRN (as needed) pain medication. V7 stated when she worked on 04/19/22, she recalls seeing a faxed x-ray result which documented that R2 had a fracture of the right femur. V7 stated she immediately notified V6 (Family) and V5 (Physician), and V5 ordered R2 to be sent to ER. V7 stated she called the ambulance immediately and R2 was sent to the ER. On 04/22/22 at 1:10pm, V8 (RN) stated she was on duty when R2 fell on [DATE]. V8 stated she immediately assessed R2's vital signs and did a head-to-toe physical evaluation and a neurological check, and there were no findings of physical injuries, except a small skin tear to right elbow. V8 stated V5 (Physician) was in the facility rounding at that time, so he also assessed R2, and gave no new treatment orders. V8 stated in the days that followed, R2 exhibited no issues with the right leg or hip. V8 stated she recalled R2 had her usual complaints of back pain, but no complaints of hip/leg pain. V8 stated R2's family approached her one time, of which she does not remember the date, and asked V8 if she felt R2's hip needed an x-ray. V8 stated she assessed R2's right hip, and there were no bruises, swelling, external rotation, pain, or shortening of the leg, so she didn't contact V5. V8 stated she does not recall if she documented this assessment. V8 stated this was the only formal assessment she did for R2 in April 2022, but she remembered helping the CNA's dress R2 one morning, and R2 didn't have any bruises, swelling, external rotation, or shortening. V8 stated R2's range of motion was the same as it always was, and at times R2, as usual would stand up unassisted while seated in her wheelchair and would require redirection. V8 stated she came in to work at 6:00am on 4/19/22 and there was a 4/18/22 order on the desk for R2 to get an x-ray of the right hip. V8 stated she called the facility's contracted portable x-ray provider. V8 stated their staff came out within a couple of hours, and she recalls it was before lunch. V8 stated the results had not come in when she left at 2:00pm that day. A fax communication from V5's office, dated 04/18/22, documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An illegible signature and Done, 04/19/22 were handwritten in the lower right corner. A 04/19/22 Right Radiological Examination, Femur, for R2 documented, Question Femoral Neck Fracture. On 4/22/22 at 1:45pm, V5 (Physician) stated R2 fell on [DATE] while he was rounding at the facility. V5 stated he assessed R2, and noted R2's face was bruised, but there were no injuries to the right hip or leg. V5 stated nobody from the facility contacted him about R2 until V9 (LPN) called his office on 4/18/22 at 11:44am saying the right leg was swollen, and V5 stated he then ordered an x-ray of the right hip. V5 stated his next contact with the facility was on 4/19/22 when V7 called and stated the x-ray showed a right [CONDITION(S)], and V5 ordered R2 to be sent to ER. V5 stated R2 subsequently required surgery to repair the hip. V5 stated he was unaware the leg had been swollen and R2 had been complaining of pain on 04/16/22. V5 stated he would have ordered an x-ray immediately. V5 further stated when he ordered the x-ray on 04/18/22, it should have been done stat (immediately), and if the portable x-ray provider was unavailable, staff should have called him for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V5 additionally stated that if staff had notified him on 04/02/22 of the family's request for an x-ray because of R2's complaints of hip pain, he would have ordered the x-ray immediately. V5 stated he is available by phone 24 hours a day for his patients and the facility knows how to contact him. V5 stated the facility's lack of action meant that R2 went without intervention for the [CONDITION(S)] for three extra days. V5 stated complications from the untreated fracture could have included bleeding into the fracture with resulting [CONDITION(S)], since R2 is taking [NAME] stated other complications could include a blood clot from the fracture, and the development of a pressure ulcer from the lack of normal mobility. V5 stated he doubted it took from 03/31/22 until 04/16/22 for R2 to develop leg swelling and external rotation of the leg. V5 stated he expected staff to do a physical assessment of R2 at least daily for several days after the fall in case new symptoms developed or something was missed during the initial assessment. V5 stated he doubted nursing staff were adequately assessing R2 in the days after the fall. A 04/19/22 ED (Emergency Department) Hospital Admission Evaluation documented, History of Present Illness: (R2) is an [AGE] year-old female presenting via EMS (Emergency Medical Services) from the nursing home for evaluation after a fall. (R2) was complaining of more right hip pain today so they did (an) x-ray which showed right [CONDITION(S)] so (they) sent patient to ED . Assessment and Plan: Closed right [CONDITION(S)]. Patient is admitted to (hospital) .Orthopedic surgery will be consulted regarding her care .She will be given [MEDICATION(S)] for pain every 4 hours as needed. On 4/22/22 at 2:15pm, V9 (LPN) stated that on 4/16/22, V3 (Family) asked her to assess R2's right leg, which was swollen and painful. V9 stated she does not recall if it was bruised. V9 stated that V3 said she, V6 (Family), and V11 (R2's Power of Attorney), did not want R2 sent to the emergency room . V9 stated she told V3 she did not think the portable x-ray provider would come out on a holiday weekend. V9 stated she did not try to contact the x-ray provider. V9 stated she did fax V5's office about R2's status, but then realized as it was the weekend, his office would be closed. V9 stated she did not call V5. V9 stated she told the oncoming nurse, V10 (RN) about the hip, and that R2 would need to be monitored. When asked, if in her professional opinion, R2 should have been sent to theER on [DATE], or if she should have contacted V5, V9 stated she is agency staff and is not very familiar with R2, so she couldn't say for sure. V9 stated she did not recall ever performing a physical assessment for R2 except for 04/16/22. V9 stated she did not recall discussing R2 with any of R2's family prior to 4/16/22. On 4/22/22 at 1:35pm, V3 (Family) stated she told V9 (LPN) that it is always difficult for R2 to go to the ER because she gets upset and confused due to her Dementia, and V3 felt it was preferable if R2 didn't have to go but did not state that the family didn't want R2 to go out. V3 stated she had assumed V9 called V5 (Physician). V3 stated V9 did not say one way or other if she thought R2 should be sent out. On 4/22/22 at 2:45pm, V10 (RN) stated when she came on duty on 4/16/22, V9 stated V3 did not want R2 sent to the ER. V10 stated that V9 stated she called V5, and that R2 was to be monitored, and there was no order for an x-ray. V10 stated she did not talk to any of R2's family. V10 stated she did not contact V5 as she believed V9 already had. V10 stated she did not recall any of the family ever asking for R2 to get an x-ray. V10 stated she recalled working with R2 on 04/16/22 and 04/17/22, and R2 was her usual self, she fed herself with a good appetite, and had no complaints of pain that V10 recalled. V10 stated she thought she had done a physical assessment on R2 on both days but was not sure if she had documented it. V10 stated she did not contact V5 about R2. V10 stated she recalled observing CNA staff roll R2 from side to side when they changed her, and she did not appear to be in pain. V10 stated she did not recall seeing any bruises, and the right leg did not look swollen. On 4/22/22 at 3:15pm, V1 (Administrator) was asked for any Nursing Assessments done for R2 for April 2022. V1 produced three printed half slips of paper titled, Shower Sheets, all with handwritten notes showing the following: 4/6/22: Skin Issues-0 (zero, none). The sheet had illegible signatures in the CNA and Nurse signature lines; 4/9/22: Skin Issues: 0. There were no CNA or Nurse signatures on this sheet; and 4/16/22: Skin Issues: None. (V3/Family) helped with bed bath. The CNA signature line was signed by V4, but there was no nurse signature on this form. On 04/26/22 at 2:35pm,V12, RN, stated there are times on occasion when R2 cannot rate her pain on a ten scale nor state the location of the pain. V12 stated when this happens, staff utilize a pain scale for cognitively impaired residents. V12 stated this method has been very effective in ensuring R2's pain is well controlled. R2's April 2022 Nursing Progress Notes contained no documentation about R2's post 03/31/22 fall status, R2's family reports of R2 complaining of pain, R2's family requesting an x-ray, nor any nursing assessments related to physical assessment or range of motion, until a note on 04/16/22 at 3:40pm. This Nursing Progress Note was authored by V9 and documented the following: (R2) (is) noted to have swelling to the right hip and RLE (Right Lower Extremity) with complaints pain at times to RLE. Family here and requesting x-ray orders from MD (Medical Doctor). Family notified by this nurse that x-ray may not be possible today here at the facility due to it being a holiday weekend. (Easter). This nurse informed the family that we would monitor for changes and pass the info(rmation) on to (V5/Physician). The family states understanding. Oncoming nurse (V10/RN) notified. A Change in a Resident's Condition or Status Policy dated November 2016 documented, A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there (are) changes in level of care, resident rights, etcetera.