Every finding on record at Heritage House

Based on observation, resident interview, staff interview, document review and policy review the facility failed to provide food that was appetizing to eat and palatable to 4 of 16 residents reviewed (Resident #3, #5, #10 and #17). The facility reported a census of 55 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #3 documented a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment.On 9/8/25 at 12:19 PM Resident #3 stated the ham was dry and not enough for a child. Resident #3 stated the ham was cold. Resident #3 stated the ham is so dry he could not even eat it. Resident #3 stated look at this it just fell to little pieces. Observation on 9/8/25 at 12:17 PM revealed Resident #3's lunch meal room tray was brought into his room. Resident #3 picked up the ham and squeezed the ham in his hand. Ham fell to small pieces on Resident #3's plate. Ham appeared dark in color and very dry.2. The MDS dated [DATE] for Resident #5 documented a BIMS score of 15 indicating no cognitive impairment.On 9/9/25 at 9:48 AM Resident #5 stated there was only a postage size piece of ham served 9/8/25. Resident #5 explained the ham was so dry and over cooked it was barely able to be eaten. Resident #5 stated she did not ask for anything else but the ham was small and very dry. Resident #5 stated frequently the food was brought to her room cold. 3. The MDS dated [DATE] for Resident #10 documented a BIMS score of 15 indicating no cognitive impairment.On 9/8/25 at 12:51 PM Resident #10 stated the food was terrible. Resident #10 explained everything was over cooked. Resident #10 stated the ham was over cooked on 9/8/25 but not as bad as the last time when the ham was black. Resident #10 acknowledged the burnt black ham was served 2 weeks ago on the weekend. Resident #10 stated the ham on 9/8/25 was very dry. Resident #10 explained she asked for a side salad and was told it was too late to order the side salad. Resident #10 acknowledged she ate out in the dining room and the staff told her that she could not have a salad. On 9/8/25 at 1:06 PM Staff A, [NAME] stated she served Resident #10 today. Staff A stated at first Resident #10 did want what was for lunch and then changed her mind. Staff A stated Resident #10 asked for a side salad today during lunch service. Staff A explained lunch was from 11:30 AM - 12:30 PM. Staff A stated Resident #10 was present for lunch and requested a side salad. Staff A stated Resident #10 might not have heard that she was going to get her a side salad. Staff A acknowledged that she had been done with lunch service since before 12:30 PM and it was currently 1:10 PM. Staff A explained she lost track of time about getting the side salad for Resident #10. Staff A explained Resident #10 ended up eating everything for lunch that she was given. Staff A explained that when a resident asks for something else for lunch they must wait till about 12:15 PM - 12:30 PM if all the residents were present and the meal service was complete for the residents on the 1st floor. Staff A stated there are no other alternatives besides sandwiches and toast. Staff A explained she served the ham last time the facility had ham about 2 weeks ago on the weekend. Staff A explained a lot of the residents complained the ham was hard and burnt and a lot of the residents did not eat the ham. Staff A stated the ham looked a little too well done at lunch today. 4. The MDS dated [DATE] for Resident #17 documented a BIMS score of 15 indicating no cognitive impairment.On 9/8/25 at 2:27 PM Resident #17 stated there was not very much food for lunch and the small piece of ham that she had was way over done, almost inedible. Resident #17 stated she complained and the staff asked if she wanted a sandwich.Review of undated document titled, Diet Regular - Week 3 documented Monday at lunch meal baked glazed ham was served. On 9/11/25 at 8:49 AM Staff B, Chef stated he was not present over the weekend 2 weeks ago but was in the building on 9/8/25. Staff B stated he did not see the ham before it was served on 9/8/25. Staff B explained if the cooks have a question they will come and get him. Staff B stated the facility has stopped service before and will discard the meal and substitute as needed. Staff B acknowledged that the ham was bad 2 weeks ago on the weekend. Staff B explained a sample was saved for him and there was no way that ham should have been served to the residents. Staff B explained the ham in question was cooked the weekend of the 30th and 31st. Staff B stated the sample was saved and talked to Staff C, Director of Food and Beverage that both agreed the ham was horrible and should not have been served. Staff B explained he spoke with the cooks and the cooks told them that they were behind and the ham was left in too hot of a shaam. Staff B explained after cooking the ham would be placed in the shaam at 180. Staff B stated when the shaam was switched over it stayed at 350 for longer than expected. Staff B stated the cooks are new and receiving some training at that time. Staff B stated he spoke with the staff in person but no disciplinary actions were given. Staff B stated in that situation the cooks should have discarded and started again. Staff B acknowledged he did not see the ham prior to service on 8/9/25. Staff B stated it needs to look like a slice of ham on the plate, have substance, remain tender and palatable. On 9/10/25 at 2:19 PM Staff C, Director of Food and Beverage acknowledged the ham was over cooked when reported about 2 Sundays ago. Staff C explained depending on where staff were with the service the staff may call and have an item ran up. Staff C stated his expectation of ham was tender and at temperature. Staff C stated residents may order something off the menu. Staff C explained the cook should have made a note to come down right after lunch service and get Resident #10 a salad. Staff C stated there were 2 cooks that worked the weekend 2 weekends ago and the ham should have been quality checked prior to being sent to the residents. Staff C explained there was a chef present on 9/8/25. Staff C explained the chef was Staff B and he would have said the ham was acceptable for service or not. Staff C stated the previous ham was brought to the attention on the Monday after service 2 weeks ago by a staff member. Staff C stated the lead cook said he put the ham in shaam and became over cooked because the shaam was a higher temperature. Staff C stated he knew once he served it. Staff C acknowledged he did not see the ham that was served on 9/8/25. In an email sent on 9/11/25 by Staff C he explained that at the huddle staff go over the meal and had it plated for samples; it is covered in the manual as well as showtime huddle policy. Review of policy revised 6/25/25 titled, Showtime and Showtime Huddle Policy documented it was the expectation of the Executive Chef to be actively engaged in lunch and dinner, primarily leading Show-time huddles, providing tastings prior to service, touching tables, and rounding in health care. It was essential for the feedback and resident satisfaction increases when we are present and engaged. If a food preparation needs to be adjusted, staff could fix it. Our culinary leaders should not make it a practice to be in their office during meal service unless it was essential and another leader touched tables. Show-time huddle was to be performed prior to lunch and dinner service for all of culinary. Show-time huddle and binder would be used to capture information on team member recognition, sanitation and safety, actual tasting of the soup, entree and sides, noting garnishes, allergens and allowing for any adjustments to be made.

Based on observations, staff interviews and policy review, the facility failed to ensure open items were dated, covered and labeled. The facility further failed to maintain clean surfaces and flooring in the kitchen and food preparation areas and failed to ensure the thermometer used to test food temperatures was clean and sanitized to prevent cross contamination. The facility reported a census of 55 residents. Findings include:Observation 9/8/25 at 10:10 AM in the main kitchen with the Certified Dietary Manager (CDM) present revealed the following: a. Two open bags of breaded chicken breasts with no date, not sealedb. Two containers of chicken breasts, one without a lid and no date and one with a lid but no date. c. Food debris on the floor by the oven, grill and fryer and in the dry storage pantry. d. Grease build up on the surfaces and sides of the equipment. Observation 9/10/25 at 11:00 AM in the main kitchen with the CDM present revealed the following: a. Grease build up on the sides of the fryer, oven, stove top and grill. This was dried grease and spilled down the sides of the equipment. b. The floor under the equipment had food debris, dried up food. c. The refrigerator next to the fryer in the prep area had old food debris on the shelves and the shelves were dirty. d. In the freezer section of this refrigerator was an open plastic container with no lid, undated, of frozen chicken patties. d. There was food debris on the floor in the dry storage pantry, the same food debris observed during the initial kitchen tour. Observation 9/10/25 at 11:30 AM of lunch service on the PA unit with Staff F, kitchen staff, serving residents lunch. Staff F took the temperature of grapes located in the refrigerator, then without cleaning or sanitizing the thermometer, Staff F took the temperature of the chicken located in the steamer. Without cleaning or sanitizing the thermometer, Staff F then took the temperature of the asparagus in the steamer, then, without cleaning or sanitizing the thermometer, Staff F took the temperature of the rice in the steamer. Staff F then placed the thermometer, without a cover, onto the direct surface of the counter. Approximately 20 minutes later, Staff F used this same thermometer, without cleaning or sanitizing it, to take the temperature of a hamburger, then placed the thermometer back on the counter, without a cover. Approximately 15 minutes later, Staff F used this same thermometer, without cleaning or sanitizing it, to take the temperature of another hamburger, then placed the thermometer back on the counter, without a cover. During an interview 9/10/25 at 12:40 PM, Staff F acknowledged she did not clean or sanitize the thermometer in between taking the temperatures of the foods. She stated she was not trained to do this. During an interview 9/10/25 at 2:15 PM, the CDM stated an expectation the thermometer is cleaned/sanitized in between food items checked. The CDM stated an expectation the floors are clean in the kitchen, including the dry pantry storage. The CDM stated an expectation the equipment is clean, with no food debris or grease build up and acknowledged there was grease build up and food debris. The CDM stated an expectation food is labeled and sealed after it is opened and not stored in an open container, with no date. Review of the facility Food and Beverage Standard Manual, undated, documented all spills shall be cleaned up immediately and if needed the area shall be properly cleaned and sanitized. It is all team members responsibility to keep their environment clean. The Manual further documented sanitation expectations for food contact surfaces and utensils and food safety expectations for cross contamination and labeling for what, date, and discard date and storage standards.

Based on observation, clinical record review, resident interview and staff interviews, the facility failed to provide food in a form to meet the resident needs for 1 of 14 residents reviewed (Resident #44). The facility reported a census of 55 residents. Findings Include:The Minimum Data Set (MDS) dated [DATE] documented Resident #44 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of stroke, anemia, renal insufficiency, malnutrition, unspecified mononeuropathy of left upper limb and hemiplegia affecting left nondominant side. The Care Plan for Resident #44, with a revision date of 4/15/25, included a focus area resident had an Activity of Daily Living (ADL) self-care performance deficit related to CVA (cerebrovascular accident, also known as a stroke) affecting the left side, with a goal of resident will improve current level of function through the review date and the interventions/tasks section indicated the resident was independent with eating and to assist as needed. During an observation on 9/8/25 at 1:52 PM, Resident #44 was in her room with her lunch tray on her bedside table in front of her. Observed the ham on her plate untouched, it was a slice of ham. Observed the resident use her right hand to pick up her fork and take a bite of corn casserole. The resident's left arm lay in her lap, unused. During an interview on 9/8/25 at 2:00 PM, Resident #44 stated she had a stroke years ago, this resulted in left sided paralysis. Resident #44 stated she eats her meals in her room, she prefers it this way. She said they used to cut her meat for her and now they do not, they had ham for lunch today and she was unable to cut it with just her one hand. She stated she is able to swallow her foods with no choking concerns, but due to her left sided paralysis she is unable to cut her meat. The resident stated she would like for them to cut up her meat so she can eat it, she stated it had been quite a while since they cut up her meat for her and she did not know why they stopped doing this. The resident demonstrated that she was unable to cut her meat with using just her right hand. Resident #44 stated she would have eaten her meat today for lunch if she had been able to cut it. During an interview on 9/8/25 at 2:15 PM, Staff G, kitchen staff working on the resident's unit today, stated he did not cut up Resident #44's meat as it did not say to do so on her diet plan or ticket. He stated he did not realize she could not cut up her meat. He did not cut up her ham today, and had not cut up other meat served to her on previous days. Review of the facility diet type report and diet ticket for Resident #44 revealed the resident had a regular diet type and regular diet texture with no additional directions provided. Review of the Electronic Health Record (EHR) for Resident #44 revealed a diet order of regular diet, with regular texture and consistency. Review of the EHR for Resident #44 revealed the resident was coded in the MDS section for eating as independent starting on the 3/11/24 MDS assessment, prior to this time the resident was coded as set-up or clean-up assistance for eating. During an interview on 9/10/25 at 1:00 PM, Staff H, kitchen staff working on this date on the resident's unit, stated she works routinely in this dining room and knows Resident #44 well. She stated the resident had difficulty in cutting up meat due to her left sided paralysis. Staff H stated when she works on this unit she will cut up the resident's meat. Staff H had observed the resident struggle with cutting up meat and unable to cut the meat fully. Staff H stated it is not on the resident's diet sheet to have her meat cut up, she has wondered why it had not been on her diet order and feels it should be. During an interview on 9/11/25 at 8:05 AM, Staff I, Dietician, stated Resident #44 is unable to cut her meat on her own and requires assistance with this. She stated it used to be in the diet order to cut the resident's meat, however for some reason this dropped off. Staff I stated it used to be in the care plan as well, to cut the resident's meat and the MDS used to code set up for the resident, now she is coded as independent, however she is not independent. Staff I stated she is not sure why it changed to independent because the resident is not independent with eating given that she is unable to cut her meat. During an interview on 9/11/25 at 8:59 AM, Staff E, Nurse Leader, acknowledged Resident #44 is unable to cut her meat and requires assistance with this, the resident is not independent with eating.

Based on observation, Electronic Health Records (EHR) review, policy review and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a catheter, that was on Enhanced Barrier Precautions (EBP) for 1 of 3 reviewed (Resident #3). The facility reported a census of 55 residents.Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #3 documented a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS also documented utilization of an indwelling catheter. Review of Resident #3's EHR titled, Orders documented a physician's order started 8/12/25 to change the indwelling catheter every month and PRN with 18 French with 10mL monthly and as needed. On 9/10/25 at 7:37 AM Staff D, Certified Nurse Assistant (CNA) completed catheter cares with Resident #3. Staff E present in the room during observation of Resident #3's care. Staff D applied a gown, completed hand hygiene, applied gloves, removed the brief, peri cloths were utilized for cleansing supra pubic area one wipe one swipe, gloves removed, hand hygiene completed, gloves applied, brief obtained and applied, applied sleeves to bilateral lower leg amputations, legs applied bilaterally, cream applied to buttocks, brief pulled up, gloves removed, assisted with gait belt in transfer to chair, removed trash bag, made the bed, removed gown grabbed the gait belt, obtained trash bag, walked down the hall to the dirty utility room walked down the hall to the next residents room. No hand hygiene completed after removal of gloves.On 9/10/25 at 7:53 AM Staff E, House Hold Coordinator stated she noticed she did not give him a wash cloth after he put the cream on his buttocks. Staff E stated she would have liked to see hand hygiene after each glove change and prior to leaving the room after the gown was removed. Staff E acknowledged she did not see hand hygiene completed after gloves were removed prior to Resident #3's transfer, after removal of gloves, or prior to leaving Resident #3's room.On 9/10/25 at 8:57 AM the DON stated she expected hand hygiene prior to and after glove application. Review of policy revised 8/24 titled, Hand Washing and Hand Hygiene documented Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn; immediately after gloves are removed; and when otherwise indicated to avoid transfer of microorganisms to other residents, personnel, equipment and/or the environment. Specific examples include but are not limited to: before and after providing personal care for a resident such as peri-care, after removing gloves and between contacts with different residents in high risk areas.

Based on observation, staff interviews, and facility policy review, the facility failed to maintain a clean environment throughout the length of resident room accessed hallways, when multiple stains were observed on 1 out of 3 that accessed resident rooms. The facility reported a census of 56 residents. Findings include: On 8/7/23 at 11:00 AM observation of the carpeted hallway A used by residents and visitors revealed excessive stains of various sizes and colors. On 8/7/23 at 1:40 PM in an interview with the Executive Director, he reported the Maintenance Department Supervisor was out of the facility. Facility policy for Floor care was requested but not provided for a review. During an interview on 8/8/23 at 9:50 AM Staff A confirmed carpets were stained and such conditions would have to be reported to the Maintenance Department who then would either shampoo the carpets or replace the stained areas with new carpet squares. On 8/10/23 at 9:00 AM in an interview with the Director of Nursing, she acknowledged that carpets were stained. In an interview on 8/10/23 at 10:30 AM, Staff B stated she was often assigned to work on hallway A but didn't realize the carpets were stained this bad. She further revealed housekeeping provides spot cleaning with shampooing and staff can call directly to the Maintenance department using the landline phone available to staff to report housekeeping issues.

Based on observation, staff interview, and document review and a facility policy review, the facility failed to provide a well balanced diet that meets nutritional and special dietary needs by use of incorrect serving size portions for meals for 4 of 56 residents reviewed. The facility reported a census of 56 residents. Findings include: During a continuous observation on 8/9/23 from 11:00 AM through 12:00 PM Staff C, Chef served lunch. Observed mechanical soft diets served to 4 out of 56 residents. While serving mechanical soft meat, portion scoop not utilized. Staff C tilted the meat container towards each plate and used a spoon to push off the meat onto each plate. Observed first 3 plates to have larger meat portions and the 4th plate received a smaller portion. A review of menu document provided by Staff C on 8/9/23 at 1:30 PM, signed by a Registered Dietician (RD), revealed scoop #8, 4-5 oz, was to be used for measuring mechanical soft meat. Staff C acknowledged he didn't follow the appropriate serving size portion for special diets during lunch service. A review of the facility provided document on 8/10/23 at 9:00 AM, titled Beverage Services Standard Manual, undated, included sections for Therapeutic Diets and Special Diets for staff to follow.

Based on observations, staff interviews, and document review, the facility failed to store and prepare food in accordance with professional standards for 56 of 56 residents. Resident food had not been prepared under sanitary conditions and with clean sanitary equipment. The facility reported a census of 56 residents. Findings include: On [DATE] from 10:00 AM-11:00 AM continuous observation during the initial primary kitchen tour revealed the following: 1. The upright stainless steel refrigerator/freezer unit located near cooking equipment revealed the refrigerator unit had a soaked hand towel inside on the bottom portion to absorb excess water leaking on the left side of the unit. Debris noted on the bottom of the fridge. Container #1 with a gravy-like substance, labeled but the label was unreadable. In the freezer unit, Containers #2, #3, #4, #5 not labeled, overfilled with frozen food items, lids not sealed tight. Container #6, #7 not labeled, missing lids, food exposed to air. A buildup of debris noted on the bottom of the freezer. The 2-compartment industrial oil deep fryer Vulcan brand had a buildup of brown substance across the entire surface above the oil levels, including the front and sides of the stainless steel stand. Oil inside of both compartments had a deep brown color appearance and several dark brown french fries floated at the surface along with other hard to identify food pieces. To the right of the deep fryers, a countertop griddle had a buildup of brown substance throughout the entire surface, including the backsplash and the sides. Sides of the griddle were covered in yellow-brown substance with accumulation of debris. To the right of the griddle, a countertop charbroiler had a buildup of black substance between the grates along with other debris, covering the entire surface. The backsplash was covered with brown substance. Lids used for griddle cooking were placed directly on top of the grates along with other food storage containers. To the right of the charbroiler, a gas range grates had a buildup of dark brown substance, including debris. Individual control knobs on all these pieces of equipment had visible buildup of unknown substances. The stainless steel wall behind all 4 pieces of equipment had multiple brown and gray colored splashes. Some areas on hood vents above 4 pieces of equipment displayed an extensive amount of yellow to dark brown buildup substance. The tile floor underneath the equipment was covered with layers of debris, including 1 visibly wet puddle of unknown substance about 3 inches in diameter between the gas range and the charbroiler. Opposite of the equipment, the food preparation counter had a plastic brown tray sitting with an eclectic toaster on it with a buildup of visible dry crumb like substance around the entire tray. A shelf below the counter stored 2 containers with dry breakfast cereal. Container #1 had no label and had a plastic cup/scooper inside directly resting on the cereal. Container #2 labeled [DATE] and had a plastic cup/scooper inside directly resting on the cereal. Tile floor underneath the food preparation counter had a buildup of debris. Tile floor underneath the ice machine near the food preparation counter had a buildup of debris, drain underneath the ice machine had a visible accumulation of debris. An exit door by the ice machine displayed a buildup of black substance around high-use areas: above, below and at the door handle sites. Five waste bins located throughout the kitchen were not covered with lids. 2. Observation of the dry food storage area revealed the following: a. Debris on the floor that had not been swept up. b. Partially used prune juice box stored on the floor and Honey graham crackers box stored on the floor in front of the door, to keep it open. c. Natural Cocoa Powder box labeled opened ,d+[DATE], unsealed bag, open to the air. d. Tortillas bag unopened, expired on [DATE]. 3. Observation of the main freezer storage revealed several boxes stacked and stored on the floor surface, including the following: a. 1 box of ready-to-eat dinner rolls unsealed, unlabeled, exposed to air. b. 1 box of breaded mozzarella sticks unsealed, unlabeled, open to air. c. 1 bag loosely packed, with dinner rolls, opened, unlabeled. d. 1 box of ground beef patties, unlabeled, exposed to air. e. 1 box of choc. chunks frozen cookies, unlabeled, exposed to air. f. 1 box of chicken crispy filets, unsealed, unlabeled, exposed to air. g. 1 box of chicken breast strips, unsealed, unlabeled. h. 1 box of sweet desserts, unsealed, undated, open to air. 4. Observation of the main refrigerator storage revealed a couple of butter packets, several onion peels and other debris scattered throughout the floor surface. 5. During a continuous observation on [DATE] from 11:00 AM through 12:00 PM Staff C, Chef served a lunch meal to 56 residents. Staff C put on a pair of gloves. He proceeded to check the temperature of the cold salad, he picked up a pen and documented in the temperature log, he dipped his gloved hands in the sanitizing bucket and wiped the thermometer with the towel located inside the bucket. He repeated the same steps while obtaining hot food temperatures, without changing his gloves or/and washing his hands. He touched the meat with the same pair of gloves while removing bones from ribs for 14 plates out of 56. He wiped his gloved hands midway through the service on a towel from a sanitizing bucket, located nearby. Moments prior, another staff member used the same towel to clean the counter top where Staff C was dishing up lunch plates. Staff C did not have a hair net on or a cover. Three other staff members in the kitchen did not have a hair net, only a hat. In an interview with the Food and Beverage Supervisor on [DATE] at 10:30 AM, she acknowledged food was not stored properly and cleaning schedules had not been followed. In an interview with Staff C on [DATE] at 1:30 PM, he acknowledged that he didn't prepare food in accordance with professional standards. He further stated he didn't realize he needed to have a head cover since he kept his hair shaved. In an interview with the Food and Beverage Supervisor on [DATE] at 1:35 PM, she stated that an alcohol wipe to be used for cleaning the food thermometer between each food item checked and a baseball cap was acceptable to be worn by staff if hair does not extend past ears. She reported in an interview on [DATE] at 3:40 PM the Executive Director stated his expectation was for everyone to wear a hair net prior to entering the kitchen area. A review of the facility provided document on [DATE] at 9:00 AM, titled Food and Beverage Services Standard Manual, undated, documented Sanitation Expectations, including hand washing and general cleaning, and Food Safety Expectations, including food labeling, glove use, and storage handling for staff to follow. A review of the facility provided document on [DATE] at 9:00 AM, titled Hair Net Policy, last approved ,d+[DATE], documented hair nets must be on prior to entering the kitchen areas and those with shaved heads and if in the kitchen, may wear an approved hat.

Based on clinical record review and staff interview, the facility failed to notify a resident of charges for services provided for 1 of 3 residents reviewed (Resident #49). The facility reported a census of 56 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] documented an admitted [DATE] for Resident #49. The MDS further documented a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition for decision making. Review of Resident #49's clinical record revealed the facility did not provide a documented advance notice for Medicare coverage end of stay. During an interview on 8/09/23 at 1:20pm, the Social Services Director acknowledged documentation regarding the cost of stay at the facility had not been completed on Resident 49's paperwork as expected.

Based on clinical record review, resident interview and staff interviews the facility failed to represent an accurate assessment of the resident's status during the observation period of the Minimum Data Set (MDS) by not accurately recording diagnosis to 1 of 8 residents reviewed (Resident #26). The facility reported a census of 56 residents. Finding include: The MDS dated [DATE] documented Resident #26 had a Brief Interview of Mental Status (BIMS) of 15 out of 15 indicating no cognitive impairment. The MDS revealed documentation that dialysis was performed while a resident of the facility in the last 14 days. On 8/8/23 at 10:16 AM Resident #26 stated that he is not and never has been on dialysis. Record review of the Care Plan's dated 5/12/23 and 6/27/23 revealed no Care Plan for dialysis. Review of the Progress Notes for the months of May and June 2023 revealed no documentation of dialysis treatment. Review of electronic records titled Assessments for the months of May and June 2023 revealed no documentation of dialysis treatment. On 8/9/23 at 12:03 PM Staff D Registered Nurse (RN) / MDS Coordinator, stated Resident #26 was on hospice and not dialysis. Staff D stated she entered the wrong check box and the resident had never been on dialysis. Staff D stated the facility currently did not have anyone on dialysis at the facility. Staff D stated the facility's expectation was that MDS would have been correctly filled out to reflect an accurate picture of Resident #26's health status. Staff D stated Resident #26 was a hospice patient and that should have been the box that was filled in on MDS. On 8/10/23 at 4:00 PM the DON stated the facility's expectation is the comprehensive assessment would have been correctly completed on the MDS. The DON stated the facility has no policy on completing a comprehensive assessment for the MDS. The DON stated the facility follows the Resident Assessment Instrument (RAI) manual for MDS documentation.

Based on observations, clinical record review and staff interviews the facility failed to implement the care plan for transfers for 1 of 8 residents reviewed (Resident #20). The facility reported a census of 56 residents. Finding include: The Minimum Data Set (MDS) dated [DATE] for Resident #20 documented the resident as severely impaired for cognitive skills. The MDS documented the resident required extensive assist of one person for bed mobility, transfers, dressing, and toileting. The Care Plan dated 6/8/23 for Resident #20 documented the resident as assist of one for pivot transfers to/from wheelchair. On 8/9/23 at 9:10 AM observed Staff E Certified Nursing Assistant (CNA) transfer Resident #20 without a gait belt. Staff E completed the transfer to the recliner while Resident #20's bedroom door was open. Staff F entered Resident #20 room and told Staff E of gait belt expectations with transfers. On 8/9/23 at 9:15 AM Staff F RN, stated the Staff E is a CNA with hospice. Staff F stated it was her expectation that all residents that are an assistance of one with transfers require a gait belt to be utilized. Staff F stated Resident #20 is an assist of one. On 8/9/23 at 9:42 AM Staff E stated that she had a gait belt in her car and that application of the gait belt slipped her mind. Staff E stated she knew Resident #20 required a gait belt for transfers. She stated she transferred Resident #20 by hugging the body and didn't think it caused Resident #20 any pain. Staff E stated Resident #20 would have let her know if she was in pain and the resident is vocal and did not vocalize any pain. On 8/9/23 at 4:43 PM the DON stated the facility's expectation is to follow the care plan for transfers and that all transfers with one assist require a gait belt be utilized. Review of policy titled Transfer Techniques with copyright date of 2023 provided by DON revealed: a. The purpose was to transfer the resident from bed to chair, toilet or tub safely. b. Have the resident sit on the edge of bed with feet uncrossed and resting on the floor. He/She may use this opportunity to practice sitting balance. Put on a gait belt and shoes. c. The procedure is reversed for transferring the resident from the wheelchair back to bed.

Based on document review and staff interview the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service by not having a certified dietary manager for 56 of 56 residents. The facility reported a census of 56 residents. Findings include: On 8/7/23 at 1:30 PM, a request for documentation from the Executive Director of qualifications for dietary manager revealed no certification or documentation. On 8/9/23 at 4:00 PM the Executive Director stated they are actively recruiting a candidate for the Certified Dietary Manager. She stated the current Dietary Supervisor has been in the management role for one year but is not a certified food service manager, does not have a national certification for food service management and safety from a national certifying body, does not have an associate's or higher degree in food service management or in hospitality, and does not have 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting.

Based on interviews with staff and residents and record review, the facility failed to report allegations of abuse to the Department of Inspections and Appeals (DIA) to determine if further investigation was needed as required for 2 of 15 residents reviewed (Resident #222 and Resident #333). The facility reported a census of 53 residents. Findings include: 1. According to Minimum Data Set (MDS) dated [DATE] Resident #222 had a Brief Interview for Mental Status (BIMS) test score of 15/15 points (intact cognitive abilities) and required extensive assist of one staff for bed mobility, transfers, toilet use, and personal hygiene. A facility investigation report showed that on 5/15/21, Resident #222 told a certified nursing assistant (CNA) she didn't want the big guy to take care of her. She added that she received a skin tear when he was taking care of her. The facility's investigation revealed Staff B, CNA cared for the resident on 5/8/21 and she had also sustained a skin tear on that date. Staff B stated that the resident's call light sounded repeatedly all evening long because she held it in her hand. As a result, he told the Director of Nursing (DON) he attached the call light to the side rail. He reported the resident later got her arm tangled in the cord reaching for the light and she sustained a skin tear injury. The resident reported to the DON that she didn't want Staff B to take care of her because he was so big and scared her. The DON recommended that Staff B bring another staff member into the room with him when caring for Resident #222 in the future. 2. According the MDS dated [DATE], Resident #333 scored 12 of 15 possible points on the BIMS test, which meant the resident displayed moderate cognitive deficits. The MDS documented the resident required extensive assist of 1 staff with transfers, walking, toilet use, and personal hygiene. The care plan updated on 7/2/21 identified Resident #333 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility investigation report documented on 5/15/21 Resident #333 made a comment that the big guy pushed her face into a pillow to go back to sleep. The administrator interviewed the resident and nurse on duty that evening. The nurse reported the resident did not have any abnormal behaviors that night, but did display more confusion than her usual. The resident told the administrator that she felt safe at the nursing home, so the administrator determined the situation was not abuse and did not need to be reported to DIA. On 5/12/22 at 9:39 AM, the DON said that the allegations against Staff B were not reported to DIA because they thought if they investigated and did not think abuse had occurred, they did not need to submit a report.

Based on record review and staff interview the facility failed to update residents' care plans to reflect changes in their status for 3 of 15 residents reviewed (Residents #15, #23, and #26). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated [DATE], Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident scored 3 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant the resident demonstrated severely impaired cognitive abilities. A Code Status Request form dated [DATE] documented Resident #15 requested Full Code Status, which indicated staff WOULD provide cardiopulmonary resuscitation in the event the resident's respirations and pulse were to cease. Resident #15's IPOST (Iowa Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan revised [DATE] documented Resident #15's CPR wishes as Full Code. During an interview on ,d+[DATE] at 4:00 PM, the Director of Nursing (DON) reported she expected staff to keep care plans current including revisions to residents' code statuses as needed. 2. An MDS dated [DATE] documented Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also documented Resident #1 scored 15 of 15 possible points on the BIMS test (intact cognitive abilities). The MDS identified Resident #1 required extensive assistance for bed mobility and toilet use. The care plan revised on [DATE] documented Resident #1 had a potential for functional bladder incontinence related to weakness from [CONDITION(S)], [CONDITION(S)] arthritis, and history of urinary tract infections. The care plan included a goal to minimize/prevent [CONDITION(S)], but failed to address the resident's bed pan use. During an interview on [DATE] at 1:30 PM, Resident #1 reported she used the bed pan during the night per her choice as it is easier for her than getting out of bed and walking to the bathroom During an interview [DATE] at 12:10 PM, Staff A, MDS Coordinator verified the care plan lacked information regarding the resident's choice to use a bed pan during the night. 3) According to the MDS dated [DATE], Resident #26 had a Brief Interview for Mental Status (BIMS) score of 14, which meant that the resident demonstrated intact cognitive abilities. The care plan dated [DATE], documented the resident's advanced directive wishes included a Do Not Resuscitate (DNR) order in the event of [CONDITION(S)]. According to a Code Status Request from signed by the physician on [DATE] at 8:37 AM, Resident #26 wanted staff to provide cardiopulmonary resuscitation (CPR) in case she went into [CONDITION(S)] (no respirations and no pulse). The face page in the electronic chart identified Resident #26's CPR wishes as FULL CODE. During an interview on [DATE] at 5:34 PM, the director of nursing reported the facility's standard of practice is that the appropriately trained clinical staff follow the current plan of care, which is driven by MDS assessment process facilitated by the interdisciplinary team.

Based on resident interviews and record review, the facility failed to ensure staff responded to and answered residents' call lights in a timely manner (within 15 minutes) to meet each resident's needs for 2 of 9 resident's reviewed (Residents #1 and #23). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 3/3/22 documented Resident #23 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed Resident #1 scored 15 of 15 possible points on the Brief Interview for Mental Status (BIMS) test which meant the resident demonstrated intact memory and cognitive abilities. The MDS indicated Resident #1 required extensive assistance with transfers, dressing, toilet use, and personal hygiene. Resident #1's care plan revised on 3/16/22 identified she demonstrated a self-care performance deficit and admitted to hospice on 12/10/21. The care plan revealed the resident would allow staff assist with activities of daily living to increase her comfort. During an interview on 05/09/22 at 1:20 PM, Resident #23 stated she woke up this morning at 8:30 a.m. and activated her call light, which staff did not come to assist her until 9:30 a.m. Resident #23 reported staff told her it took so long because there was only 1 person that could help her. A Device Activity Report (call light record) dated 4/1/22 - 5/12/22 revealed the following call light response times for Resident #23: a. 15-20 minutes = 20 b. 21-25 minutes = 7 c. 26-34 minutes= 9 d. 35-45 minutes = 3 2. The MDS dated [DATE] documented Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented Resident #1 had a BIMS of 15 and required extensive assistance for bed mobility and toilet use. The care plan revised 6/2/21 documented Resident #1 had a potential for functional bladder incontinence related to weakness from [CONDITION(S)], [CONDITION(S)] arthritis, and history of urinary tract infections. The care plan included a goal: the risk for [CONDITION(S)] will be minimized/prevented. During an interview 5/11/22 at 1:30 PM, Resident #1 reported she had to wait 45 minutes during the night for staff to answer her call light when she needed to use the bed pan and commented she was surprised she didn't have an accident. Resident #1 stated a new staff member reported it took so long for her to answer Resident #1's call light because she did not have a pager alerting her when the residents activated their call lights. Resident #1 revealed she had to increase her fluids because she had been having symptoms of a urinary tract infection and added she timed call lights using the clock located on her nightstand. A Device Activity Report (call light record) dated 4/1/22 - 5/12/22 revealed the following call light response times for Resident #1 and their roommate: a. 15-20 minutes = 9 b. 21-25 minutes = 4 c. 26-34 minutes= 2 d. 35-45 minutes = 2 e. 46-55 minutes =1 During an interview 5/12/22 at 1:15 PM the Director of Nursing revealed she expected staff to answer call lights in a timely manner, but was unable to give a specific time frame.

Based record review and interview, the facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II into Resident #6's care plan. The facility reported a census of 55 residents. Findings include: According to the Minimum Data Set (MDS) with an assessment reference date of 1/30/20, Resident #6 had [DIAGNOSES REDACTED]. The MDS documented the resident scored 13 on the Brief Interview for Mental Status (BIMS), which meant the resident displayed intact cognition. During record review on 2/12/20 at 10:35 PM, the PASARR revealed a recommendation of psychiatric services by a psychiatrist to evaluate response to [MEDICAL CONDITION] medications, modify medication orders and evaluate response to need for ancillary therapy services. During record review on 2/12/20 at 10:40 PM, the care plan directed staff to follow level II recommendations but does not state what the recommendations are. During an interview on 2/12/20 at 10:50 PM, the Director of Nursing (DON) reported Resident #6 used to see the VA for the recommended services and added that the VA oversees all of the resident' medications, although the resident #6 refused to see psychiatric services. When asked if the staff documented the refusal, the DON stated perhaps, it was a long time ago. The facility's comprehensive care plan process policy directed the comprehensive care plan must describe the following: any specialized services or specialized rehabilitative services that the community will provide as a result of the PASARR recommendations. If a community disagrees with the PASARR, documentation must be in the residents record indicating its rationale.

Based on observation, interview and record review, the facility failed to review and revise the care plan for 1 of 14 residents reviewed (Resident #24). The facility reported a census of 55 residents. Findings include: The Minimum Data Set ((MDS) dated [DATE] documented Resident #24 exhibited intact cognitive functioning as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 points possible. The MDS also documented she required extensive assist of 1 staff for toilet use, transfers, and dressing. The care plan dated 12/4/19 identified the resident had an order for [REDACTED]. In an observation on 2/10/20 at 12:11 PM Resident #24 was eating a lettuce salad and spaghetti and she started to cough and choke on her food. Another resident sitting at the table next to her became concerned and started to pat her on the back. Eventually, the coughing stopped and she continued eating. A review of the clinical record revealed that the resident had a 6 pound weight loss in the last three months. The clinical record contained a faxed communication to the physician from a registered nurses stated that the residents weight was down. October 166.7, November 165.5, December 167.1 and January 160.4. The RN stated that the resident cut carbs out of diet and snacking weight loss intentional by resident In an interview on 2/12/20 at 8:05 AM with Resident #24, she discussed her food choices and recent weight loss. She said she's been trying to lose weight. She acknowledged she did choke on her food at times, but didn't like the ground meats and chose to take the risk of aspiration in order to enjoy her food. The resident's care plan last updated on 12/4/19, lacked information regarding the resident's wish to lose weight and did not contain any reference to a dietician consult. The care plan indicated that one of the goals was that the resident would have no significant weight change in the next quarter, and also a goal for the resident to follow speech therapy recommendations. The chart lacked any information regarding a speech therapy consult. A interview with the Registered Dietician (RD) and Director of Nursing (DON) on 2/12/2020 at 10:05 a.m., verified Resident #24 could have benefited from a consult with the dietician if she was interested in a healthy weight loss program.

Based on observation, clinical record review, staff and resident interview, the facility failed to complete accurate and timely nutritional assessments for 3 of 14 residents reviewed (Resident #24, #55, and #33). The facility reported a census of 55 residents. Findings include: 1) The Minimum Data Set (MDS) for Resident #24 dated 12/5/19 indicated that the resident had intact cognitive functioning as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS indicated that she required extensive assistance with the help of one staff for toileting, transferring and dressing. The care plan dated 12/4/19 documented Resident #24 had a potential for altered nutritional status and ate a regular diet with a mechanical soft, cut meat texture. In an observation on 2/10/20 at 12:11 PM, Resident #24 was eating a lettuce salad and spaghetti and she started to cough and choke on her food. Another resident sitting at the table next to her became concerned and started to pat her on the back. Eventually, the coughing stopped and she continued to eat. In an interview on 2/12/20 at 8:05 AM, the resident discussed her food choices and recent weight loss. She said she's been trying to lose weight. She acknowledged that she does choke on her food at times, but doesn't like the ground meats and I know I could aspirate. She added she chose to take that chance so she could enjoy her food. A review of the clinical record reveled a faxed communication to the physician from a Registered Nurse (RN) stating that the residents weight was down; October 166.7 pounds, November 165.5 pounds December 167.1 pounds and January 160.4 pounds. The RN stated that the resident cut carbs out of diet and snacking, weight loss intentional by resident. The chart lacked any dietician assessments or consultations. 2) The MDS dated [DATE] for Resident #55 indicated that she required extensive assistance with the help of one staff for toilet use, bed mobility, transferring and dressing. The resident had impaired cognitive functioning as evidenced by a BIMS score of 6 out of 15. The MDS indicated that the resident was admitted on [DATE] and her weight was recorded as 140 pounds upon admission. A review of the clinical chart showed that the only dietary assessment for the resident was dated 1/22/20 and read as follows: (Resident #55) is a new resident recovering from [MEDICAL CONDITION] and surgery. She also has a [DIAGNOSES REDACTED]. She feeds herself in the dining room. A review of the clinical record revealed the residents weights were documented as follows: 1/30/20, 143.6 pounds 2/2/20, 139.8 pounds 2/6/20, 138.7 pound. The record showed that on 1/30/2020 the doctor wrote an order to begin supplemental shakes twice a day. A nursing note dated 2/4/10 stated that the doctor had been made aware of the weight loss with no new orders, on that date the resident was also referred to Hospice services. In an interview with the Registered Dietician (RD) and Director of Nursing (DON) on 2/12/2020 at 10:05 AM in was revealed that the dietician started her position at the facility on January 1,2020 and the transition had been challenging. The RD stated that she gathers her resident information from their history, at care conferences, doctor's notes and nursing notes. She stated that she completes quarterly assessment or more often if there were specific nutritional or weight concerns with a resident. The RD stated that she expects that the resident's weights were taken at least monthly and that she should be contacted if there are concerns. The dietician acknowledged that the weight losses for resident's #33 and #55 were concerning. She also acknowledged that Resident #24 could have benefited from a consult with the dietician if she was interested in a weight loss program. The DON acknowledged that the facility needed to develop a better process for accurate and timely nutrition assessments. She stated that she was concerned about the weight losses and she planned to contact their corporate office to see what they recommend for a more detailed dietary assessment form. 3. The MDS dated [DATE] recorded Resident #33 had a Brief Interview for Mental Status (BIMS) score of 8/15, which meant the resident displayed moderate cognitive impairment. The MDS documented the resident had [DIAGNOSES REDACTED]. Record review on 2/11/20 at 10:37 AM, revealed the resident ate a regular diet with mechanical soft, ground meat texture and honey-thickened liquid. Records also show the resident weighed 118.8 on 2/10/20, 116.9 on 1/10/20, 125.0 on 12/9/19, and 127.1 on 11/16/19, which was a weight loss of -6.53% in 90 days. Record review of the care plan on 2/11/20 at 10:42 AM, revealed Resident #33 required sit by assist for meals for verbal cues and took a long time to eat. The care plan directed staff to offer to reheat food as needed. During record review on 2/12/20 at 9:33 AM, documentation showed an order for [REDACTED]. There record also sowed the resident ate 50 percent or more of her meals 29 times during the 14 day look back for February. Review of the progress notes on 2/12/20 at 9:25 AM, revealed a registered nurse notified the physician of weight loss as follows: Resident's weight has gone from 127.1 pounds to 115.2 pounds in the last 90 days. Recommendations: Please Advise. An entry in the progress notes dated 1/3/20 at 2:38 pm, documented nursing observations, evaluation, and recommendations: Weight assessment: Loss 7.1% in 30 days. Average meal intake: 55 percent. Diet: mechanical soft diet with ground meat and honey thickened liquids. Mighty Shakes 3 times a day. Resident #33 able to chew her food and swallow, although at times, the resident pocketed her food and started to cough. Staff assist (feed) when she allowed it. Sometimes she refused to eat or drink Mighty Shakes. Lung sounds clear, breathing unlabored and even, and the resident denies shortness of breath. Resident #33 had moderate swelling noted in her lower extremities, and plan to continue with mighty shakes and weights as ordered. Review of records show the only dietary note scanned into chart dated 12/16/19 documented an initial which described Resident #33 rested in the room in bed, seems happy and very pleasant, but difficult to understand. Resident #33 will be followed on a regular basis. During an interview with the Registered Dietician (RD) and Director of Nursing (DON) on 2/12/2020 at 10:05 AM, the RD stated she gathered her resident information from history in the resident's record, care conferences, and doctor and nursing notes. She stated she completed quarterly MDS assessments or makes a note under the dietary note in the electronic health care record (EHR) as her documentation of dietary assessment. When asked, the RD stated that there was no other documentation other than one note in the EHR dated 12/16/19. The RD stated that she expected nursing staff to weigh the resident at least monthly and notify the physician, request supplements, and contact the RD with concerns. The dietician verified weight loss was an issue for Resident #33.

Based on staff interviews, the facility failed to employ a qualified person to serve as the director of food and nutrition services in the absence of a full-time dietitian. The facility identified a census of 51 residents. Findings include: During an interview on 1/7/19 at 1045 AM, Staff A, acting dietary supervisor/chef reported the facility currently does not have a Certified Dietary Manager (CDM), and has not employed a CDM since 9/12/18. Staff A reported he is not certified and acknowledged the dietitian does not meet the criteria to be the CDM as the dietitian is part time. During an interview on 1/08/19 @ 3:37 PM, the Nursing Home Administrator stated the facility has not employed a CDM since 9/12/18. The Nursing Home Administrator acknowledged the part time dietitian does not mee the requirment of a CDM. The Administrator acknowledged the facility was out of compliance by failing to employ a qualified CDM.

Based on observation and staff interview, the facility failed to dispose of contaminated items and wash hands during meal service in accordance with professional standards for food service safety for 1 of 3 household observed. The facility reported a census of 51 residents. Findings include: During observation of the lunch meal service on 1/8/19 starting at 12:25 PM, in the Country Grove Household, Staff B, Dietary Cook, checked the food temperatures. At 12:32 PM, Staff B picked paper up from the household kitchen floor and threw the paper in the trashcan. Staff B then used a thermometer and checked the temperature of an enchilada microwavable meal, and placed the pan on the stovetop. Staff B then washed her hands. At 1:07 PM, Staff B removed two individual containers of Dole peaches from the refrigerator and dropped one of the containers of dole peaches on the floor. Staff B picked the container up off the floor and placed the container on the counter, Staff B walked to the opposite side of the counter, opened a drawer, obtained utensils from the drawer, placed the utensils on a tray, then opened one of the containers of peaches and placed the peaches and a container of yogurt onto a divided plate. Staff B then used the handwashing sink and filled a handled mug with ice and water for Resident # 6, and placed a lid on the mug. At 1:10 PM, Staff B proceeded to place cake in individual bowls for the residents. Staff B failed to wash her hands in-between dirty to clean tasks. During an interview 1/10/19 at 8:29 AM, Staff C, Cook, reported hands needed washed after touched contaminated items and went between dirty to clean tasks. Staff C confirmed they had two sinks in the Country Grove household. One sink used for handwashing only, and the other sink used for washing dishes/pans and when obtained water for drinking. During an interview 1/10/19 at 8:45 AM, Staff A, Cook/Chef reported he expected staff discard items when dropped on the floor or contaminated and washed their hands. Staff A stated the handwashing sink only used for washing hands, and should not be used when obtained water for drinking.

Based on observation, staff interview and facility policy the facility failed to maintain sanitary conditions during meal service. The facility reported a census of 54 residents. Findings include: 1. During initial during on 9/25/17 at 9:00 a.m. observation revealed the Food and Beverage Director walked down the middle of the kitchen, where cinnamon rolls sat uncovered, with no hair net on. Observation on 9/26/17 at 10:50 a.m. revealed the Food and Beverage Director walked down the middle of the kitchen, where cinnamon rolls sat uncovered, without wearing a hair net. At 11:00 a.m. the Food and Beverage Director informed staff that a hair net, head bands, or caps needed to be worn at all times. 2. Observation on 9/26/17 at 12:15 p.m. revealed Staff A Cook/Chef prepared 4 room trays and these were delivered to resident's rooms without covers on the plates and cups. At 12:19 p.m. Staff A put a glove on his left hand, opened the refrigerator with his right hand, then removed a bag of lettuce with his left hand and placed it on the counter. Staff A then obtained a bowl and with the same gloved left hand, took the tie off of the lettuce bag. Staff A then reached in to the bag of lettuce with the same gloved left hand, put lettuce in a bowl and served the salad to a resident. Staff A failed to serve the lettuce out of the bag under sanitary conditions. During interview on 9/27/17 at 10:10 a.m. the Food and Beverage Director stated when anyone enters the kitchen they should always have a hair net on. He stated that if he is just working in his office, he does not wear a hair net. He also stated the staff serving the lettuce should have used tongs to get the lettuce out of the bag. He also expected all food and drink items to be covered before being deliver to resident rooms. Review of the facility's undated Hair Net Policy revealed hair nets/hats must be worn when prepping, cooking, or serving food from behind the line. Hair nets must be on prior to coming into food prep areas where uncovered food is being prepared. 3. Observations on 9/26/17 at 8:30 a.m. and 11:25 a.m. revealed Staff E, Cook/Chef served food to all the residents on the Dementia care unit without a beard net. An observation on 9/26/17 at 12:13 p.m. revealed the Food and Beverage Director placed two glasses of chocolate milk in the fridge with gloved hands. With the same gloved hands, he began breaking up the rolls, opening up the jelly packets and then served food to residents. An interview with the Food and Beverage Director on 9/27/17 at 10:16 a.m. revealed acknowledgement of concern with touching the fridge handle and food with the same gloved hands. The Director was unsure of the cleanliness of the fridge handle and who touched this area. The Food and Beverage Director also indicated that Staff E's beard was a little long and he needed to trim the beard. The Food and Beverage Director stated that hair nets can also be used for the beard, but he has ordered beard nets. Review of the Disposable Glove Usage policy revealed food handlers must change gloves when moving from one task to another.

Based on clinical record review, observation and staff and resident interviews, the facility failed to provide adequate supervision, safe equipment and sufficient transfer assistance for 1 of 13 current residents reviewed (Resident #5). The facility identified a census of 58 residents. Findings include: Resident #5 had a MDS (Minimum Data Set) assessment with a reference date of 5/23/13. The MDS reflected Resident #5 had [DIAGNOSES REDACTED]. The MDS identified Resident #5 had a BIMS (Brief Interview of Mental Status) score of 15 which reflected intact memory and cognition. The assessment documented the resident required limited assistance of 1 with transfers and that s/he used a walker for mobility. The MDS documented Resident #5 required physical help with transfers only during bathing. The Care Plan dated 5/29/13 reflected an intervention that the resident required 1 person assistance for bathing due to chronic low back pain and arthritis of the spine. The Care Plan also documented the resident ambulated independently in his/her room with a walker and directed staff to assist the resident with one staff and a walker, when outside of their room. The Incident Report dated 8/10/13 at 8:45 PM documented after Resident #5's bath he/she stood up from the bath chair (brakes locked) and the chair slid back a few to 2 inches. Resident #5 became scared, sat back down and bumped his/her arm on the chair column area below the forearm to wrist. The report documented a possible injury and the resident went to the hospital for an x-ray. Review of a Diagnostic Imaging Report dated 8/10/13 at 9:23 PM identified Resident #5 had a displaced impaction fracture of the distal radius and a possible non-displaced fracture of the distal ulna. Review of a follow-up Diagnostic Imaging Report dated 8/16/13 documented stable alignment of an angulated right distal radius (wrist) fracture compared to 8/10/13 and an unchanged distal ulna fracture apparent. Nurse's Notes dated 8/22/13 at 10 AM documented Resident #5 went to surgery via a personal vehicle. The resident returned to the facility at 6:15 PM with an ACE (elastized bandage) wrap and sling to the right arm. Review of a Diagnostic Imaging Report dated 9/6/13 noted a plate and screw fixation of the right distal radius with markedly improved alignment compared to 8/16/13 and a healing distal ulna fracture. During an interview with the DON (Director of Nursing) and observation on 9/18/13 at 8:50 AM, the surveyor and DON went to the whirlpool tub room to observe the chair and column where Resident #5 had obtained the fractures. The surveyor sat in the chair and when she started to get up the chair slid back. Observation revealed the brakes as on but that they were under the column support and allowed the chair to push back and turn to the left. The DON stated the Arjo representative had been in another part of the facility and he came over and checked the tub. He reported the tub to be fully operational. The DON stated after the incident she directed staff to move the tub chair to the wall so that the chair would not slide. During an interview with Resident #5 on 9/18/13 at 9:15 AM, the resident stated when she/he stood up from the bath chair, the walker was not in front of the resident. The resident looked down and all she/he could see was the floor. The resident went to grab for the bath chair and sat down hard. The CNA (Certified Nursing Assistant) told the resident to go ahead and stand up; the resident did not know the location of the CNA. Normally, the resident had staff beside him/her, but the staff member was not there and no one had hold of the resident. During a telephone interview with Staff D, CNA on 9/19/13 at 11:00 AM, she stated the walker had been in front of Resident #5 and she stood beside the resident. Staff D stated she had told the resident to stand up and did not give the resident any physical assistance until the resident started to fall.

Based on clinical record review and interviews, the facility failed to plan for and direct nursing services to ensure Resident #1 received adequate supervision with equipment to protect against hazards in the environment. Unannounced to the nursing home staff, Resident #1 accompanied his/her spouse to a doctor's appointment without facility staff knowing Resident #1's whereabouts for approximately ,[DATE] minutes. The driver that transported Resident #1 and his/her spouse to the appointment had no knowledge of Resident #1's safety needs including that he/she used a walker for ambulation. When they arrived to the destination, Resident #1 remained standing near the front of the van as the driver assisted the resident's spouse. Resident #1 fell to the ground hitting his/her head and sustained three (3) brain bleeds and died the evening of the fall. The findings constitute an immediate jeopardy to the resident's health and safety. The facility identified a census of 59 of which 14 resided on the Chronic Confusion and Dementing Illness (CCDI) unit. Findings include: The clinical record for Resident #1 identified the resident admitted from the hospital to the facility's Chronic Confusion and Dementing Illness (CCDI) unit on [DATE]. The Safety Risk Data Collection form dated [DATE] revealed Resident #1 had balance problems, impaired vision, impaired judgment and a decline in decision making skills. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 with the following Diagnoses: [REDACTED]. The assessment determined Resident #1 scored 7 on the Brief Interview of Mental Status (BIMS) test. A score of 7 associated the resident's daily cognitive patters as moderately impaired. The assessment revealed Resident #1 exhibited continuous, non-fluctuating disorganized thinking, expressed delusional ideas, and wandered ,[DATE] days of the assessment period. The assessment determined Resident #1 required limited assistance from staff to complete transfers and ambulation. The assessment determined the resident ' s balance during transition and walking as not steady but able to stabilize without staff assistance when moving from a seated to standing position; when walking (with assistive device if used); when turning around and facing the opposite direction while walking; when moving on and during surface-to-surface transfers. The assessment identified Resident #1 used a walker for mobility. The Care Plan dated [DATE] identified goals to address Resident #1's memory loss, impaired communication related to dementia, impaired vision, inattention, poor decision, potential to wander and fall risks. Resident #1 had been identified as a fall risk due to his/her history of hypertensive crisis, cardiac disease and use of pacemaker. The falls risk goal directed staff to give the resident time to process and follow cues. The goal indicated for staff to monitor Resident #1 for adverse side effects that could increase his/her risk for falls from antianxiety medication, dizziness, unsteadiness or hypotension. The goal indicated Resident #1 required a walker to ambulate independently. Resident #1's behavior Care Plan identified a goal for the resident to remain within the facility unless supervised. The resident's psychosocial Care Plan revealed on [DATE] Resident #1 liked to do everything with his/her spouse and had increase anxiety if separated (from spouse.) On [DATE], the Care Plan noted Resident #1 would not sleep unless together. Resident #1 moved to a different room to be closer to his/her spouse. On [DATE] the Care Plan identified Resident #1 and his/her spouse liked to do all things together to decrease stress. The activities Care Plan also revealed Resident #1's stress would be reduced by including him/her in all activities with spouse. The Nurse's Notes dated [DATE] at 2:50 p.m., documented Resident #1 left the facility with Wesley Community Services staff (WCS) to accompany his/her spouse to an appointment. During interview on [DATE] at 3:30 p.m. Staff E, licensed practical nurse (LPN) stated she made an entry in the Nurse's Notes for Resident #1 dated [DATE] at 2:50 p.m. that indicted the resident left the facility to accompany his/her spouse to a doctor's appointment. Staff E stated she did not know Resident #1 had left the CCDI unit until the DON came and told her the resident had fallen and had been taken to the emergency room . Staff E stated she then made the entry in the resident's clinical record before the DON made her entry and estimated the time of departure as 2:50 p.m., Staff E stated she had provided paperwork needed for the spouse's doctor's appointment to Staff B (the driver) and then left the unit to admit a resident to another area of the facility. The Sign Out Sheet dated [DATE] did not identified that Resident #1 or his/her spouse had been signed out of the facility. The form included a section for the date, resident name, time left, time returned, and accompanied by for staff/family/beauty operator or others to sign out if a resident left the area. During interview on [DATE] at 3:00 p.m. The DON stated she had been in the CCDI unit just prior to the time Resident #1 and his/her spouse left and had not been aware both were going to the appointment and at this time residents were not routinely signed out of the facility at the time of departure. During interview on [DATE] at 2:20 p.m. Staff C, CNA, stated she had also been on duty for the 2:00 p.m.-10:00 p.m. shift in the CCDI unit on [DATE]. She stated she had seen Resident #1 and his/her spouse in their room as she reminded the spouse of his/her doctor's appointment. Staff C then stated she then became busy with two other residents and did not know Resident #1 left the CCDI unit with his/her spouse. She stated she thought it unusual the resident did not come out for coffee at 3:00 p.m. but did not check the resident's room to see if s/he were there. Staff C stated Resident #1 used a walker for ambulation, but required reminders to use it as the resident often forgot it. During interview on [DATE] at 4:20 p.m. Staff F, certified nursing assistant (CNA), stated she had been assigned to the CCDI until on the 2:00 PM-10:00 p.m. shift on [DATE]. She stated she had visualized Resident #1 when she came on duty that afternoon and did not realize the resident gone from the unit until she had been told that by Staff E. Staff F stated the resident did use a walker for ambulation, but would often forget it and staff would present it and the resident would use it. Review of the resident's clinical record revealed a Nurse's Notes entry by the facility's Director of Nursing (DON) on [DATE] at 3:30 p.m. which documented she received a phone call from Wesley Community Services that Resident #1 had fallen. The DON documented the resident now at the emergency room . The DON faxed the resident's face sheet, medication records and resuscitation status to the hospital and left a message with the resident's family member to go to the emergency room . The Emergency Department Physician Documentation dated [DATE] documented the resident examined by a physician at 15:34 (3:34 p.m.) and documented the resident sustained [REDACTED]. A computerized axial tomography (CAT) scan of the resident's head completed on [DATE] at 3:34 p.m. revealed an acute extra-axial hemorrhage (bleeding that occurs within the skull but outside of the brain tissue) with a 3.5 centimeter (cm) lentiform hemorrhage in the right posterior parietal region which could represent an acute epidural or atypical subdural hematoma. Additionally, the CAT scan showed a right temporal parietal subdural hemorrhage 6 millimeters (mm) in thickness with multifocal post-traumatic subarachnoid hemorrhage bilaterally (both sides) and an 8 mm leftward subfalcine shift. Resident #1 transferred from the Emergency department to the hospital at 4:57 p.m. at which time the physician documented the resident's condition had declined, became less responsive and started to note some difficulty in maintaining the resident's oxygen saturation level. The Physician's Documentation also stated the physician identified the resident's injuries as quite significant to the resident's family and the decided to admit the resident to the hospital for comfort care. The physician documented due to the resident's age and other medical problems, an urgent neurosurgical intervention would not provide any improvement in the resident's quality of life. The discharge problems were documented as epidural, subdural and subarachnoid hemorrhages. The Nurse's Notes dated [DATE] at 12:30 p.m. documented the hospital called and related Resident #1 expired on [DATE] at 11:40 p.m. The Director of Nursing (DON) written narrative dated [DATE] included the following: Today ([DATE]) Resident #1's spouse had a doctor appointment at 2:45 p.m. At 2:40 p.m., Wesley Community Services (WSC) would provide transportation for the spouse. The nurse gave the WSC driver a packet of papers and the aides were assisting Resident #1's spouse to get ready for the appointment. Resident #1 had also been in the room. The driver took Resident #1 and his/her spouse for the appointment. The DON documented Resident #1 is independent with ambulation and transfers, and staff encourage Resident #1 to use his/her walker, but Resident #1 does not always use it. The DON documented Resident #1's gait was steady without. The DON identified Resident #1 didn't take his/her walker with him/her. The DON identified Home Care contacted her to report Resident #1 had fallen and hit his/her head and was getting X-rays. At 5 p.m. the DON called the ER and learned Resident #1 had three (3) separate bleeds in his/her brain. The DON documented Resident #1 was barely responsive and moaning. The DON documented she visited with the driver (WCS) aid (Staff B) who reported Resident #1 followed his/her spouse out of the room and she got them into the van. When they arrived to the appointment, the driver got Resident #1 out first and left him/her at the hood of the van. When the driver came around the van with the spouse, Resident #1 was on the ground face up. A nurse from the clinic came out to assist. The driver for Wesley Community Services (which is owned and operated by the same corporation as the nursing facility) was interviewed regarding Resident #1's fall on [DATE]. During interview on [DATE] at 11:20 a.m. Staff B, stated she had been scheduled to transport Resident #1's spouse to a doctor's appointment on [DATE]. Staff B stated she had never transported Resident #1 or his/her spouse before. When she arrived in the CCDI unit the resident's spouse informed her Resident #1 would be going to the appointment with them. Staff B stated she had not been made aware of this prior to this time. Staff B had already received the paperwork for the spouse's doctor appointment from the charge nurse. Staff B stated she then left the CCDI unit with Resident #1 and his/her spouse. Staff B stated she did not sign out either resident and did not inform any staff members she took Resident #1 off the unit and out of the facility. Resident #1 did not have a walker. Staff B reported Resident #1 seemed ok and did not know if either resident needed a walker, etc. Staff B reported no staff told her anything about either resident and Staff B did not ask staff if Resident #1 required a walker for ambulation. Staff B stated she had never transported two residents at the same time. Staff B reported she assisted the resident's spouse in the front passenger seat of the van and Resident #1 had been in the seat behind her. When she arrived at the doctor's office/clinic Staff B stated she assisted Resident #1 out of the van and had the resident stand at the front driver's side corner of the van with his/her hands placed on the hood and then went around to the passenger side to assist the spouse. When Staff B and the resident's spouse walked around the front of the van they saw Resident #1 lying on the ground on his/her back. Staff B stated neither she nor the resident's spouse heard the Resident #1's fall. Staff B called out for help to a person coming out of the clinic for assistance. During interview on [DATE] at 10:30 a.m., a physician's assistant-certified (PA-C) stated she responded to the parking lot because a Code White had been announced over the paging system of the hospital which attached to the clinic. (A Code White is a signal to personnel that a person, who currently does not have an appointment at the hospital or clinic, has fallen or has been injured.) The PA-C stated she had been the first medical person to respond and found Resident #1 alert and sitting on the ground being held up with the assistance of bystanders. Emergency personnel and other hospital staff arrived, assessed the resident and lifted him/her into a wheelchair and transported the short distance to the emergency room . During interview on [DATE] at 2:30 p.m., Staff D, RN, stated nurses arrange for resident transpiration through Wesley Community Services if a family member is unable to do it. Prior to [DATE] the only information required to set up transportation had been to let Wesley Community Services know if the resident required a wheelchair van or a standard van and did not usually provide any information about the resident to the driver at the time of pick-up. Staff D stated this policy had changed (since this incident). During interview on [DATE] at 11:50 a.m. Staff C, registered nurse (RN) stated Resident #1 used a walker because the therapist recommended it but the resident would sometimes forget it so staff would bring it to his/her and she would then use it. Staff C stated when residents leave the unit and/or the facility the resident or responsible party are to sign them out. During interview on [DATE] at 9:10 a.m., Staff G, contract physical therapy assistant stated the resident has Tinetti score in the midrange of ,[DATE] which is a good balance range for residents such as Resident #1. The Therapy Communication Tool dated [DATE] directed Resident #1 could ambulate independently with the use of a wheeled walker. Staff G stated he realized the resident had the potential to forget to use the walker, but felt s/he would still be safe with ambulation but the walker would provide additional balance support. During interview on [DATE] at 10:00 a.m. the facility's DON stated that prior to the incident of [DATE] Wesley Community Services staff or family members did not consistently sign resident's out of the building. She also stated that facility staff did not provide resident education to Wesley Community Services staff on the needs of the residents they would transport and does not send CNAs with residents on transports to appointments. The DON stated that information is now documented on a form that both the nurse and the Home Care Staff must sign before a resident leaves the building. She also related Home Care Staff received transfer training by Staff G on [DATE]. The facility abated the IJ on [DATE] when they in-services staff on the following policy: On [DATE] the facility implemented a new policy in order to educate Wesley Community Services staff on the needs of the residents they transport. The undated Home Care Escort from Heritage House policy directed the following: Care Coordinator (Wesley Community Services) will receive the following information from the nursing home staff requesting resident escort and will give this information to Home Care (WCS) staff upon assignment: a. Resident's name b. mode of transportation that will be used c. date and time and exact location of appointment d. pick up time e. physical or cognitive impairments of the resident f. any other pertinent information The policy indicated drivers providing transportation would do the following: 1. Upon arrive at Heritage House a. Home Care staff will contact the nurse at the front desk b. Nurse will bring resident to the front lobby c. nurse will supply the necessary paperwork to staff d. resident will be equipped with necessary assistive devices e. Nurse will confirm with Home Care staff: 1. appropriate method of transportation 2. Family who will meet resident at the appointment 3. Destination and appointment type 4. Physical/mental impairments of the resident 5. other pertinent information f. Home Care staff will sign out the resident in the log book 2. Upon return to Heritage House, Home Care Staff will: a. sign in resident in log book b. return appropriate paperwork to the nurse c. leave resident with nurse at the front desk 3. No guests will be riding with the home care aide. During interview on [DATE] at 10:10 a.m. the DON stated as of today all staff members, with the exception of 5 seasonal PRN (as needed) CNA's who work in summer while on break from college and a CNA and a nurse who are currently on maternity leaves have received education on the new policy. The DON stated the 7 remaining staff members will be educated prior to their first scheduled shift upon return to work. These actions lowered the deficiency from a scope and severity of J to D, with the need for ongoing monitoring of the current policy to ensure residents received adequate supervision and necessary safety equipment during transfers.

Based on observation, record review and staff interviews, the facility failed to have an adequately functional nurse call system so staff can promptly respond to resident's requests for help. The sample consisted of 3 of 13 residing at the facility and 3 closed records (Residents #1, #4 & #10). The facility reported a census of 61 residents. Findings include: 1. The quarterly MDS (Minimum Data Set) assessment with a reference date of 3/10/11 identified Resident # 10 had [DIAGNOSES REDACTED]. According to the MDS the resident required extensive assistance of one staff person with bed mobility, transfers and toilet use. Review of the care plan updated 6/8/11 revealed the resident at risk for falls related to a history of fall with fracture and directed staff to keep call light in reach and remind the resident to use. The care plan also directed staff provide assist of 1 staff with transfers. Review of the Post Fall assessment dated [DATE] at 2:15 PM revealed the Certified Nursing Assistant entered and found the resident sitting on the floor in his/her bathroom with his/her back against the wall and legs out to the right. The resident complained of a soreness ache in the right upper outer leg. Review of the Nurse's Notes dated 6/6/11 at 2:15 PM revealed the resident found on the floor and complained of right outer upper leg pain/ache. The resident could move all extremities with no extra amount of pain. Rechecked for any injury. The resident did not hit his/her head and said nothing broken, just sore. Review of the Nurse's Notes dated 6/7/11 at 9:00 AM revealed the resident complained of right leg, hip and knee pain. A call was placed to the physician for orders to transport to the emergency room and for an x-ray. At 9:10 AM the Medivac arrived to the facility and transported the resident to the hospital emergency room . Review of the Patient Transfer Form dated 6/7/11 revealed the resident experienced a fall yesterday afternoon and seemed OK with right leg ache but ambulated this AM and right leg to knee continue to hurt. The pain was rated on a scale of 1 to 10 with 10 the worst. The pain was rated as a 10. Review of the History and Physical dated 6/7/11 revealed the x-ray report with findings of a right valgus-impacted neck fracture. Review of the Facility Visit Report dated 6/8/11 revealed a repair receipt for the call light system. Interview with a representative reported the same case visit occurred in March 2009. Several visits for the Wandergaurd system occurred in June 2010 and October 2010 but unable to tell the exact work completed on these dates. Review of the document identified the call light report dated 6/6/11 at 1:45:34 PM revealed the resident's bath call light on for 39.4 minutes. On 6/8/11 at 3:30 PM, Staff Q (Certified Nursing Assistant) was interviewed and stated she passed by the resident's room and heard screaming. Staff Q stated she did not know the resident was in the bathroom. Staff Q also stated the call light was on but did not show on the pagers. Staff Q stated the pagers do not always show the call light if the Wanderguard activates. On 6/8/11 at 3:37 PM Staff U (Licensed Practical Nurse) was interviewed and identified the resident as alert and oriented. Staff U stated the resident always used the call light for assistance. The day the resident fell the bathroom call light was on. Staff U also stated that they did not know exactly when the resident was put on the toilet but had looked on the computer and the call light had been on for 39 minutes. Staff U stated the facility had checked the pagers and the pages failed to have the notification of the resident ' s light turned on. Staff U stated had seen the pagers not work before-when the Wanderguard is on but unsure how long this had been occurring. During an interview with Staff O, CNA on 6/9/11 at 9:00 AM, Staff O stated she could not remember assisting the resident to the bathroom but must have done so. Staff O also stated if the Wandergaurd would sound then it would block out the light paging system. This occurrence happened to some lights but not all the lights. Staff O stated when the Wanderguard sounded then the staff knew to go back and check on the resident which had been taken to the bathroom. During an interview with the Director of Nursing on 6/9/11 at 8:30 AM, the Director stated she had caught the call light problem on Tuesday and then put people in front of the computer. It seems to be the Wandergaurd system which affected the system when the Wanderguard would sound. The Director of Nursing stated unsure how long the pagers had not worked correctly but every time the technicians came to the facility, the technicians could not replicate the problem. The staff could not replicate the problem. We always told the residents the old call system is there and had always been up and running. During an interview with a family member on 6/9/11 at 9:30 AM, he/she identified the resident as " reasonably sharp " . He/she also stated that the resident stated had dinner and taken to the bathroom then pulled the string. He/she waited and waited and pulled the string again and it felt like 20 to 30 minutes at least. He/she then stated stood up, pulled the pad and underwear up while hanging on to the bear. Then he/she reached for the other bar and went down. He/she then hollered for help. 2. The MDS (minimum data set) assessment dated [DATE] documented Resident # 1 had [DIAGNOSES REDACTED]. The MDS identified the resident required total assistance of 2 or more persons with transferring and bed mobility. The assessment documented walking in the room or corridor did not occur during the 7 day assessment period. The MDS further documented the resident was not steady without human assistance during moving from a seated to standing position, moving on and off the toilet and surface to surface transfers. The assessment identified the resident normally used a walker or wheelchair as mobility devices. An updated care plan dated 5/11/11 identified that the resident was at risk for falls due to [MEDICAL CONDITION], memory loss, poor safety awareness, [DIAGNOSES REDACTED], diuretic use and a history of falls. The care plan instructed the staff to place a personal alarm on the resident at all times and a pressure alarm to the bed. The care plan also documented the resident required the assistance of one person for transfers and ambulation. A temporary care plan dated 5/18/11 documented a fall without injury on 5/18/11. The care plan instructed the staff to check alarms, increase monitoring and monitor for nonverbal and verbal signs of pain. The nurse's notes dated 5/18/11 at 8:50 a.m. indicated another resident summoned the aide and then the aide found the resident on the floor beside the bed. The resident sat on the right hip, holding the hand rail. The resident voiced pain. The nurse inquired. The resident said like a bump and 2 on a pain scale. The note indicated there to be no sign or symptoms of pain (non-verbal) with the use of the EZ stand (sit/stand mechanical lift). The resident performed full range of motion as usual ability. The resident had no bruising or swelling. The care plan was updated and the alarm checked. Family and doctor notified. Review of a safety risk data collection tool dated 11/15/10 identified a fall on 11/20/11. The tool indicated a history of multiple falls on 8/16/10 and 8/20/11. The form also documented the use of both a bed and chair alarm since 5/28/10. Review of a Post Fall Assessment identified a fall on 5/18/11 at 8:50 AM. The form documented the personal alarm failed to sound. The form also documented in a handwritten notation that the staff did not have the alarm plugged in to alert staff if the resident is " antsy " . 3. The MDS assessment dated [DATE] documented Resident # 4 had [DIAGNOSES REDACTED]. The MDS identified the resident with short term memory loss and severely impaired cognitive skills for daily decision making. The assessment also documented the resident required extensive assistance of 2 or more persons with bed mobility and transfers A safety risk data collection form dated 12/17/11 documented the resident had a history of [REDACTED]. A temporary care plan dated 6/3/11 documented a fall with complaints of lower back pain. The staff interventions included: a. Monitor for pain b. Monitor often c. Encourage use of the call light d. Encourage to wait for help The updated care plan dated 3/23/11 identified the resident at risk for falls related to dementia, frequent infections, use of an antidepressant, antihypertensive and diuretic as well as the use of oxygen and breathing equipment. The care plan documented on 6/3/11 to utilize a tab alarm and chair sensor alarm. The care plan also instructed : - one staff assist the resident with transfers and ambulation. - keep call light in reach and remind resident to use it -toilet routinely before and after meals, upon arising and before bed. -monitor side effects that could increase risk for falls from medication, dizziness and unsteadiness. Review of the Nurses ' Notes dated 6/3/11 at 10:20 AM documented the resident was trying to get up out of the wheelchair by self. The resident stated he/she was trying to walk and fell to the floor at the breakfast table. The resident complained of lower back pain and was sent to the emergency room for evaluation. Observation on 6/7/11 at 9:16 AM revealed the resident sitting in a recliner. Observation also revealed the wheelchair sat beside the resident with the alarm attached to the wheelchair. Observation revealed no alarm on or in the recliner. Observation on 6/7/11 at 10:30 AM revealed the resident sitting in the same recliner. The Director of Nursing (DON) came to the resident's room and stated the resident's alarm was sounding at the nurse's station. No alarm sounded in the unit. The DON took the alarm and changed the battery. Staff F (License Practical Nurse) (LPN) stated the alarm was used in the wheelchair only. The DON returned to the resident's room and attached the alarm to the resident sitting in the recliner. Review of the document identified the call light/pager system dated 6/7/11 at 9:50:06 AM revealed the system activated 45.5 minutes. Observation on 6/8/11 at 7:15 AM revealed Staff G, CNA assisted the resident with morning cares. The CNA assisted the resident with ambulation from the bed to the toilet. The staff performed pericare as the resident sat on the toilet. The staff then assisted the resident with dressing. The staff placed the soiled linen saver, brief and soiled wipes in the garbage can. The staff washed her hands and then decided to perform oral cares. The CNA discovered the resident needed mouthwash and left the room. The staff left the resident unattended on the toilet with the door closed. Observation on 6/8/11 at 11:10 AM revealed the resident seated in a recliner in the bedroom. Staff G confirmed there was no alarm on the recliner. Observation on 6/8/11 at 1:35 PM revealed the resident seated in a recliner with an alarm on the wheelchair. No alarm was observed on the resident in the recliner. Observation on 6/8/11 at 3:25 PM revealed the resident seated in a recliner with the alarm on a wheelchair sitting nearby. No alarm was observed on the resident in the recliner. Interviews related to the call light system: On 6/9/2011 at 8:01 A.M. Staff K, Certified Nursing Assistant (CNA) was interviewed and stated when a resident uses the call light, it notifies the staff via the staff's beeper. Staff K stated there to be no light over the resident's door. Staff K stated this system was used to make the environment more home like and less intrusive. Staff K stated the Wanderguard system would kick out the call lights if a Wanderguard sounds. Staff K stated the resident's call light won't show on the beepers if the fire alarm or Wanderguard system would be activated. Staff K stated at 5 minutes, if the call light had not been answered, it would show again on the pager. Staff K stated this would be the way it had been since she began employment 3 years ago. Staff K stated the call lights come back on as long as the Wanderguard system not still activated. As off 6/8/11 in the evening, the old call light system had been put back into service, however, the fire alarm and Wanderguard system still came across the staff pagers. Staff K explained the computerized call light system and the call lights register on a computer screen. Staff K stated if the Wanderguard system is activated, the call lights will not show on the computer and this would upset the nurses, families and residents. Staff K stated has found residents walking about in their rooms because the staff couldn't hear the chair or bed alarms sounding. Staff K stated the alarms were blocked. On 6/9/11 at 8:25 AM, Staff G (CNA) was interviewed and stated the facility has had the computerized call system for the past 2 years. Staff G stated when a resident pushes their call light box, the pager alerts the staff. Staff G stated that in the past, a Wanderguard system would overpower the call light system and in the small area where she works, the resident's call out for help. Staff G stated the Wanderguard does not kick out the call light system every time and glad to go back to the old call light system. On 6/9/2011 at 8:35 a.m., Staff V (CNA) was interviewed. Staff V stated she had worked at this facility for 7 years. and believed the new call light system had been in for about 2 years. Staff V stated the facility has taken the system down. Staff V explained several call lights can come across the pager and the staff have to scroll down through the list of call lights. If a Wanderguard sounds and comes across, the staff can cancel the Wanderguard and then the staff can scroll down through the call lights. The pager holds up to 20 call lights messages. Staff V stated she was glad to go back to the old call light system. The call light messages don't get removed from the pager until the staff remove them. Staff V stated the only time a call light wasn't answered was when she forgot to cancel the light on her pager after she had already answered the light. Interviews with residents: Resident #13 was interviewed on 6/9/11 at 8:59 AM and stated her/his call light doesn't work. The resident laid in bed. The resident demonstrated by pushing a grey bulb. The surveyor observed the light over the door fail to illuminate as did the light on the call system in the room. The surveyor pushed the grey bulb and pushed in on the cord.. The call light again failed to illuminate or sound. The surveyor called Staff G , CNA to the room and she pushed hard on the cord. The light then lit and sounded. Staff G stated this resident needed a button to push rather than a bulb. The resident stated this type of call light was used for the previous resident who lived in this room. During an interview with Resident #19 on 6/9/11 at 9:07 AM, the resident stated the facility was using the old call light system now. Resident #19 stated the residents had never had both call systems to use at the same time. During an interview on 6/9/11 at 9:15 AM with Resident #20, the resident stated the residents ever had access to both call light systems at the same time. Observation revealed this resident had a double call light cord. The resident stated once you push your call light button, you can't push it again until someone answers it. Observation on 6/9/11 at 12:55 PM during a call light re-enactment with Staff P, Registered Nurse (RN) revealed when the aerial call light system was activated at the same time the Wanderguard was activated, both were displayed on the pager. Observation revealed that by testing the aerial system by pushing the button and resetting it up to 20 times, only 12 pages could be displayed on the pager. Observation also revealed the pager wouldn't reset each time and the time on the pager was incorrect. Note: At the time of the complaint investigation, the violation was coded as "J" Immediate and Serious Jeopardy Level. By 6/8/2011, the facility implemented measures that adequately addressed the jeopardy by removal of the newer light system and went to using the older wire call light system. The scope and severity was lowered to "D" after the situation was abated on 6/8/2011. As of 6/9/2011 the facility continued to need to: ? Inservice staff of call light system in use, ? Simplify pager alerts ? Continue to monitor and ensure the operational function of the alarm system and call light system.