Every finding on record at Heritage the

Based on medical record review, staff interviews, and facility policy review, the facility failed to notify the physician of a resident's change in condition. This affected one (#10) of three residents reviewed for change in condition. The facility census was 81.Findings include:Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] and expired on [DATE]. Diagnoses included Alzheimer's disease and memory deficit following cerebral infarction.Review of a Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #10 had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of nine (9). The resident was assessed to require supervision with toileting, bathing, and dressing, was frequently incontinent of bladder and bowel, and had no skin issues.Review of progress notes dated [DATE] at 1:20 P.M. revealed Registered Nurse (RN) #131 documented Resident #10 was not acting like herself, not eating, getting up, or using the restroom. RN #131 contacted Resident #10's daughter and offered to send her to the emergency room, and the daughter decline at that time. There was no evidence the facility notified the facility of the resident's change in condition. Further review revealed on [DATE] at 2:26 P.M., Resident #10 was transferred to emergency room without physician notification.Interview on [DATE] at 5:50 P.M. with Regional Nurse #128 verified the physician was not notified of change of condition for Resident #10.Review of facility policy titled, Notification of Change in Condition, dated [DATE], revealed a significant change in a resident's physical, mental, or psychosocial status results in reasons to notify the physician immediately.This deficiency represents non-compliance investigated under Complaint Number 2731910.

Based on observation, staff interview, and facility policy review, the facility failed to maintain a clean and home-like environment. This affected two (#13 and #18) of eight residents review for environment. The facility census was 81.Findings include:Observation on 02/23/26 at 9:07 A.M. revealed Resident #13's floor had a large amount of food crumb particles, small pieces of shredded paper, and mud-like substance throughout the entire carpet in the room. Interview on 02/23/26 at 9:09 A.M. with License Practice Nurse (LPN) #130 verified all findings in Resident #13's room.Observation on 02/23/26 at 9:50 A.M. revealed Resident #18's floor had a cover of shredded paper, shredded metallic paper, and food crumb particles from bed area to the door area. Interview on 02/23/26 at 9:52 A.M. with License Practice Nurse (LPN) #130 verified all findings in Resident #18's room. Interview on 02/23/26 at 11:18 A.M. Regional Nurse #128 revealed rooms should be cleaned daily including over the weekend. Review of the undated facility policy titled, Standard Operate Procedure (SOP)-Room Cleaning-Health Center, revealed daily cleaning include organize, trash pickup and dusting, spraying approved disinfectants, wipe surfaces clean, and vacuum room, and mop bathroom.This deficiency represents non-compliance investigated under Complaint Number 2731910.

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure timely drainage of urinary catheter bags. This affected one (#12) of four residents reviewed for urinary catheters.Findings include:Review of the medical record for Resident #12 revealed he was admitted on [DATE] with diagnoses including hereditary spastic paraplegia, chronic obstructive pulmonary disease, heart disease, cough, wheezing, shortness of breath, malignant neoplasm of bladder, and suprapubic urostomy.Review of a functional assessment dated [DATE] revealed Resident #12 required set-up to partial assistance with activities of daily living, utilized a motorized wheelchair, and was independent with mobility. Review an admission note dated 02/08/26 for Resident #12 revealed he was alert and oriented.Observation on 02/25/26 at 9:00 A.M. of Resident #12's urinary catheter bag revealed it was round, taut, and full of yellow liquid.Interview on 02/25/26 at 9:10 A.M. with Certified Nurse Aide (CNA) #138 confirmed Resident #12's urinary catheter bag was round, taut, and filled with urine. Subsequent observation of CNA #138 emptying the urinary catheter bag revealed 3,000 milliliters (mL) of urine was emptied from the bag.Review of the manufacturer's label for Resident #12's urinary catheter bag revealed the capacity of the bag was 2,000 mL.Review of facility policy dated 12/16/24 and titled, Emptying Urinary Bags, revealed the facility would empty urinary catheter bags each shift or more often if needed to prevent the bag from becoming full.This deficiency represents non-compliance investigated under Complaint Number 2752534.

Based on observation medical record review, resident and staff interview, and review of facility policies, the facility failed to ensure respiratory supplies were stored and dated in a safe manner and failed to ensure a resident's need for supplemental oxygen was provided in a timely and sufficient manner. This affected two (#13 and #57) of five residents reviewed for oxygen. The facility census was 81.Findings include:1. Record review for Resident #13 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease and chronic respiratory failure. Review of a Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #13 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to require oxygen therapy. Review of the current care plan revealed Resident #13 had potential for complications in functional and cognitive status related to respiratory disease related to obstructive pulmonary disease and oxygen use. Observation on 02/23/26 at 9:07 A.M. revealed Resident #13's oxygen concentrator was running at two liters of oxygen with undated tubing attached to nasal cannula laying on the floor in front of the concentrator. There was also undated tubing with an oxygen mask laying on the floor beside the concentrator. Interview on 02/23/26 at 9:09 A.M. with License Practice Nurse (LPN) #130 verified undated tubing, nasal cannula, and oxygen mask way laying on the floor. 2. Review of the medical record for Resident #57 revealed she was admitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia, stage five chronic kidney disease, chronic heart failure, and obstructive sleep apnea. Review of the quarterly MDS assessment dated [DATE] revealed Resident #57 was cognitively intact and did not display any behaviors at the time of the assessment. She utilized a wheelchair, was dependent for all transfers and mobility, and required partial to maximal assistance with activities of daily living. This assessment indicated she had cardiorespiratory diagnoses and utilized oxygen therapy. Review of physician orders for Resident #57 revealed an order dated 11/25/24 for continuous oxygen to be administered by nasal cannula at 2 liters per minute. Observation on 02/25/26 at 9:15 A.M. of Resident #57 sitting in the dining room revealed she was wearing an oxygen nasal cannula and had a portable oxygen tank on the back of her wheelchair set to two liters per minute. Further observation revealed the nasal cannula was not dated and two gauges on the portable oxygen tank indicated the tank was empty. Interview on 02/25/26 at 9:15 A.M. with Resident #57 revealed she had been feeling increased shortness of breath since she awakened that morning and was still experiencing increased shortness of breath at the time of the interview. Interview on 02/25/26 at 9:30 A.M. with Certified Nurse Aide (CNA) #140 confirmed Resident #57's nasal cannula was not dated and the gauges on the portable oxygen tank on the back of Resident #57's wheelchair indicated the tank was empty. Review of facility policy titled, Respiratory Equipment, dated 05/11/16, revealed to change the oxygen cannula and tubing monthly and as necessary, and keep the oxygen cannula and tubing in a plastic bag when not used. Review of facility policy dated 12/13/24 and titled, Administration of Oxygen, revealed the facility would date oxygen tubing and administer oxygen according to physician orders. This deficiency represents non-compliance investigated under Complaint Number 2752534 and Complaint Number 2731910.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure documentation in the electronic health record was complete and accurate. This affected two (#10 and #11) of eight residents reviewed for documentation. The facility census was 81.Findings include:1. Review of the medical record for Resident #11 revealed he was admitted on [DATE] with diagnoses including type two diabetes mellitus, metabolic encephalopathy, cardiomegaly, morbid obesity, and stage two chronic kidney disease. The resident died at the facility on [DATE]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively intact and did not display any behaviors at the time of the assessment. He utilized a walker with supervision and a manual wheelchair independently. He required supervision assistance with activities of daily living and touch assistance with shower transfers. The assessment indicated Resident #11 experienced shortness of breath with exertion, was diagnosed with medically complex conditions including the above noted diagnoses, and was not enrolled in hospice services. Review of physician orders for Resident #11 dated [DATE] revealed he was a full code (initiation of cardiopulmonary resuscitation in the event of cardiac or respiratory failure). Review of nursing progress notes from [DATE] revealed a note written by Licensed Practical Nurse #129 on [DATE] at 3:00 P.M. indicating a funeral home arrived at the facility to retrieve Resident #11's remains. Further review of progress notes and other areas of Resident #11's medical record revealed the absence of documentation of events that led up to the funeral home arrival at the facility. Interview on [DATE] at 9:10 A.M. with Regional Registered Nurse #128 confirmed the events leading up to the death of Resident #11 on [DATE] were not documented in the medical record. 2. Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] and died on [DATE]. The resident's diagnoses included Alzheimer's disease and memory deficit following cerebral infarction. Review of the MDS assessment dated [DATE] revealed Resident #10 had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of nine. The resident was assessed to require supervision with toileting, bathing, and dressing, and was frequently incontinent of bladder and bowel, and assessed with no skin issues. Review of nursing progress notes revealed Resident #10 was sent to the emergency room on [DATE] due to a change of condition. On [DATE] at 5:45 P.M., the hospital contacted the facility with an update regarding the resident having a wound on the coccyx. There was no previous notes for Resident #10 regarding any skin breakdown. Interview on [DATE] at 5:50 P.M. with Regional Nurse #130 revealed an internal investigation was completed on Resident #10. Regional Nurse #130 findings revealed on [DATE] at 6:00 A.M. during shift change, Resident #10 was found to have a bruised like area on the coccyx area. A foam pad was placed on area. Regional Nurse #130 stated there was no documentation of skin breakdown or placement of a foam pad placement entered in the resident's electronic health record. Regional Nurse #130 revealed the facility's policy was to open a wound event, assess the wound and document, notify the physician, notify the family, initiate treatment, enter order, and complete treatment. Review of facility policy dated [DATE] and titled, Guideline for Late Entry and Corrections to the Medical Record, revealed the facility would record information and events as soon as they occurred. Further review of this policy revealed the facility would maintain accurately documented clinical records. This deficiency represents non-compliance investigated under Complaint Number 2731910.

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure proper signage was in place for a resident on enhanced barrier precautions and failed to ensure urinary catheter bags were maintained in a manner to prevent infection. This affected two (#58 and #59) of four residents reviewed for infection control practices.Findings include:1. Record review for Resident #58 revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, bipolar, and cholecystectomy.Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of seven (07). The resident was assessed to have a surgical wound.Review of the care plan dated 02/05/26 revealed Resident #58 had a surgical incision with indication the resident required enhanced barrier precautions during high-contact care related to presence of surgical wounds.Observation on 02/25/26 at 9:41 A.M. revealed Resident #58 had bins containing personal protective equipment (PPE) for infection control precautions in Resident #58's room but there was no signage outside the door.Interview on 02/25/26 at time of finding with Resident #58 revealed the resident was unsure why the bins were in her room. Interview on 02/25/26 at 9:43 A.M. with Licensed Practical Nurse (LPN) #141 revealed the nurse was unaware Resident #58 was in isolation. LPN #141 reviewed the resident's orders and stated Resident #58 was not in any isolation. After reviewing the orders with the Surveyor, LPN #141 verified Resident #58 was in enhanced barrier precautions and confirmed there was no signage was in place to identify the isolation.Interview on 02/25/26 at 10:20 A.M. with Regional Nurse #128 verified enhanced barrier precaution orders were in place for Resident #58, however, no signage was in place.2. Review of the medical record for Resident #59 revealed she was admitted on [DATE] with diagnoses including type two diabetes mellitus, metabolic encephalopathy, urogenital implants, and hydronephrosis.Review of the quarterly MDS assessment dated [DATE] revealed Resident #59 was cognitively impaired and did not display any behaviors at the time of the assessment. She utilized a wheelchair independently, was dependent for transfers, and required substantial assistance with activities of daily living. The assessment indicated Resident #59 utilized a urinary catheter for management of neurogenic bladder.Observation on 02/23/26 at 3:00 P.M. of Resident #59 in her wheelchair in the dining room while participating in activities revealed her urinary catheter bag was on the floor lodged under the small front right wheel of her wheelchair.Interview on 02/23/26 at 3:02 P.M. with LPN #142 confirmed Resident #59's urinary catheter bag was on the floor lodged under the small front right wheel of her wheelchair. Subsequent observation revealed LPN #142 removed the urinary catheter bag from under the wheel and placed the urinary catheter bag under Resident #59's wheelchair, with half of the urinary catheter bag touching the floor. LPN #142 verbally confirmed Resident #59's wheelchair was low, the urinary catheter bag was on the floor, and there was currently no feasible option to hang the urinary catheter bag on the chair to provide placement both below the bladder and off the floor.Observation on 02/23/26 at 3:20 P.M. of Resident #59 in her wheelchair at the nurses' desk in the back of the facility revealed her urinary catheter bag was lying on the floor under her wheelchair.Review of the manufacturer's label for Resident #59's urinary catheter bag revealed the bag should not be on the floor.Review of facility policy dated 12/16/26 and titled, Emptying Urinary Bags, revealed the facility would keep urinary catheter bags off the floor to prevent damage and contamination.This deficiency represents an incidental finding discovered during the complaint survey.

Based on observation, record review, staff interview and policy review, the facility failed to ensure complete proper hand hygiene during a dressing change. This directly affected one (Resident #8) of three residents reviewed for wound care. The facility census was 83. Findings include:Review of the medical record of Resident #8 revealed an admission date of 07/18/22. Diagnoses include metabolic encephalopathy, acute osteomyelitis, paraplegia, and pressure ulcer injury of sacral region.Observation on 01/05/26 at 2:15 P.M. revealed Licensed Practical Nurse (LPN) #210 performed a dressing change on Resident #8. LPN #210 donned gloves, gown, and a mask and entered the room. LPN #210 assisted Resident #8 to roll to his right side exposing his bilateral ischium wounds. The wounds were covered with a bordered dressing and there was a small amount of brownish colored discharge on the protective pad beneath him. LPN #210 touched the drainage and removed the gloves, performed hand hygiene and donned new gloves. LPN #210 removed the soiled dressings, and without performing hand hygiene or changing gloves, cleaned the wounds with wound cleanser, applied skin prep to the surrounding tissue, and applied new dressings to both wounds. Interview directly after the procedure with LPN #210 provided confirmation she had not changed gloves nor performed hand hygiene between soiled and clean. Review of the policy titled Guidelines for General Wound and Skin Care, dated 05/10/17 with a review date of 12/16/14, revealed the facility will wash hands with soap and water after removing old dressings and apply new clean gloves for the continued care. This deficiency represents non-compliance investigated under Complaint Number 2670977.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure resident medications were prepared per professional standard. This affected on four Residents (#77, #78, #79, and #80) of four observed. The facility census was 82.Findings Include:Observation on 11/13/25 at 8:53 A.M. to 9:03 A.M. revealed Licensed Practical Nurse (LPN) #134 had three medication cups of unidentified pills on top of medication cart. LPN #134 picked up loose loose pills that were laying on top of medication cart using her bare hand, placed them in a clear sleeve and proceeded to crushed the pills. LPN #134 then was observed to placed the unidentified crushed pills in a fourth medication cup. LPN #134 placed three medication cups of unidentified pills into the medication cart. LPN #134 then placed pudding into the crushed medication cup and walked to Resident #79 in the common area, close to the nurse ' s station and administered the medication. LPN #134 removed one of the pre set medication cups with unidentified pills from medication cart, grabbed a pudding cup, walked to dining room and placed medications with pudding in front of Resident #78 to take medication.Interview on 11/13/25 at 8:57 A.M. with LPN #134 verified she prepared Resident ' s #77, #78, #79, and #80's medications at the same time. LPN #134 verified she had administered Resident #79 medication then administered Resident #78. LPN #134 stated she will be administering Resident #77 and #80's medications at a later time. LPN #134 verbalized preparing multiple residents medications at once is incorrect but it saves time.Review of facility policy, Preparation and General Guidelines, revised January 2018, revealed medication should be administered one resident at a time.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure medications were not left unattended. This affected one Resident (#87). The facility census was 82.Observation on 11/13/25 at 11:19 A.M. with Licensed Practical Nurse (LPN) #142 revealed Resident #87's medications (Albuterol Sulfate HFA (bronchodilator) aerosol inhaler, Astepro (antihistamine) nasal spray, Basaglar Kwikpen u-100 Insulin pen (long acting Insulin), Aspart Insulin pen u-100 (quick acting Insulin), and Symbicort HFA (corticosteroid) aerosol inhaler) were laying on top of medication cart unattended for four minutes. During the time the medications were on the medication cart unattended one family member, four residents and two staff members walked by medication cart. Interview on 11/13/25 at 11:23 A.M with LPN #143 verified medication were laying on top of medication cart unattended. LPN #143 stated, I am just trying to get done.Review of facility policy, Preparation and General Guidelines, revised January 2018 revealed no medications are kept on top of cart.

Based on observation and interview, the facility failed ensure proper handling of medication was used when preparing medication. This affected one Resident (#79) during medication pass. The facility census was 82.Observation on 11/13/25 at 8:53 A.M. with Licensed Practical Nurse (LPN) #134 the nurse was observed to picked up an unidentified number of pills for Resident #79 off of top medication cart with her bare hand, place the medications in a clear sleeve, and crush the medications to be administered for Resident #79. LPN #134 then placed pudding into the crushed medication cup and walked to Resident #79 in the common area, close to the nurse ' s station and administered the medication. Interview on 11/13/25 at 8:57 A.M. with LPN #134 it was verified she did not place Resident #79's pills in a medication cup but placed them on top of the medication cart on purpose. LPN #134 stated she was not aware she could not place pills on top of the medication cart and touch them with her bare hand.

Based on staff interview, observation, record review, and policy review, the facility failed to notify a resident representative of a new skin condition. This affected one (#15) of five residents reviewed for a change in condition. The facility census was 73.Review of the medical record for Resident #15 revealed an admission date of 01/11/22 with diagnoses of dementia, anxiety, anemia, and Type II diabetes mellitus.Review of the quarterly Minimum Data Set (MDS) assessment, completed 06/06/25, revealed Resident #15 had impaired cognition and required substantial/maximal assistance for bed mobility and was dependent for transfers.Review of Resident #15's electronic medical record (EMR) from 06/01/25 through 07/17/25 at 9:30 A.M. revealed no documentation regarding a bruise or new skin concern to Resident #15's face or neck. Additional review revealed no evidence Resident #15's representative was notified of a new skin condition on Resident #15's neck.Interview on 07/17/25 at 9:14 A.M. with Certified Nursing Assistant (CNA) #103 revealed she observed a change in condition to Resident #15 wherein bruising was noted to Resident #15's left neck and right jawline. CNA #103 stated she documented it in the CNA charting and it was also charted by the CNA on the previous shift.Observation on 07/17/25 at approximately 9:30 A.M., with Registered Nurse (RN) #202, of Resident #15 revealed a red area to Resident #15's neck on the left side of the front of her neck, halfway between the shoulder and jaw. Concurrent interview with RN #202 confirmed he did not document his assessment of the area on Resident #15's neck. RN #202 stated he was alerted to the new skin area on Resident #15 by the previous shift's nurse but could not clarify when he first became aware of the area. RN #202 confirmed he did not notify Resident #15's representative about the new skin area. Interview on 07/17/25 at 11:02 A.M. with the Administrator and RN Clinical Support (RNCS) #501 revealed the facility conducted an investigation into the new area on Resident #15's skin after the surveyor identified the lack of documentation in the EMR. RNCS #501 stated Resident #15's bruise was initially identified on 07/12/25 by Licensed Practical Nurse (LPN) #206 and reported to RN #202 to follow up on. RNCS #501 confirmed an assessment of the bruise was not documented and Resident #15's representative was not notified. RNCS #501 confirmed resident representatives should be notified when a new skin condition was identified. Review of the policy, Notification of Change in Condition, dated 05/10/16, revealed the resident's representative should be notified if there was an accident resulting in injury, a significant change in the resident's condition, or if there was a need to alter treatment significantly. Further review revealed documentation of notification should be recorded in the resident's electronic health record.This deficiency represents non-compliance investigated under Complaint Number 2561896.

Based on staff interview, record review, observation, and policy review, the facility failed to ensure timely assessments of a new skin condition. This affected one (#15) of five residents reviewed for change in condition. The facility census was 73.Findings include:Review of the medical record for Resident #15 revealed an admission date of 01/11/22 with diagnoses of dementia, anxiety, anemia, and type 2 diabetes mellitus.Review of the quarterly Minimum Data Set (MDS) assessment, completed 06/06/25, revealed Resident #15 had impaired cognition and required substantial/maximal assistance for bed mobility and was dependent for transfers.Review of Resident #15's Profile in the electronic medical record (EMR) revealed she required a mechanical lift for transfers since 06/10/22.Review of Resident #15's electronic medical record (EMR) dated 06/01/25 through 07/17/25 at 9:30 A.M. revealed no documentation regarding a bruise or new skin concern to Resident #15's face or neck.Review of the late entry Incident Report, initiated 07/17/25 at 11:08 A.M., revealed Resident #15 had a bruise to her left neck suspected to be caused by a mechanical lift sling.Interview on 07/17/25 at 9:14 A.M. with Certified Nursing Assistant (CNA) #103 revealed she observed a change in condition to Resident #15 wherein bruising was noted to Resident #15's left neck and right jawline. CNA #103 stated she documented it in the CNA charting and it was also charted by the CNA on the previous shift.Observation on 07/17/25 at approximately 9:30 A.M., with RN #202, of Resident #15 revealed a red area to Resident #15's neck on the left side of the front of her neck, halfway between the shoulder and jaw. Concurrent interview with RN #202 confirmed he did not document his assessment of the area on Resident #15's neck. Further, RN #202 denied any knowledge of a mark on Resident #15's jawline. RN #202 stated he was alerted to the new skin area on Resident #15 by the previous shift's nurse but could not clarify when he became aware of the area. RN #202 stated he did not create an Event in the EMR because he assumed the nurse on the previous shift would have initiated the Event. Additionally, RN #202 stated the Event in the EMR system created a prompt for staff to assess the area on each shift to monitor the new condition. RN #202 stated he was not prompted to complete and document an assessment of the area and confirmed he did not document any assessment of Resident #15's new skin condition.Interview on 07/17/25 at 11:02 A.M. with the Administrator and RN Clinical Support (RNCS) #501 revealed the facility conducted an investigation into the new area on Resident #15's skin after the surveyor identified the lack of documentation in the EMR. RNCS #501 stated Resident #15's bruise was initially identified on 07/12/25 by LPN #206 and reported to RN #202 to follow up on. RNCS #501 confirmed an assessment of the bruise was not documented. Concurrent review of a written statement obtained by RNCS #501 from RN #202 on 07/17/25 revealed RN #202 assessed Resident #15's bruise on 07/12/25 and RN #202 did not find the bruise suspicious as Resident #15 was transferred via mechanical lift and RN #202 had seen the lift sling rub against Resident #15's neck. Further review of the statement revealed RN #202 did not document an assessment of the bruise or suspected cause of the bruise.Observation on 07/17/25 at 11:55 A.M. revealed RN #202 measuring and assessing Resident #15's bruise. Concurrent interview with RN #202 confirmed it was left of center on her neck and halfway between her shoulder and jaw. RN #202 measured the area with a ruler, determining a width of two centimeters and a height of 0.7 centimeters. The coloring was brownish with yellowing around the edges. The edges were irregular and undefined. RN #202 stated the area had the appearance of an aging bruise. Further observation of Resident #15 revealed a scab on her left jaw. RN #202 stated it appeared to be an area Resident #15 picked. An attempted interview with Resident #15 at the time of the observation was unsuccessful.Follow-up interview on 07/17/25 at approximately 12:30 P.M. with the Administrator and RNCS #501 confirmed Resident #15's medical record contained no evidence of an assessment of a new bruise between 07/12/25 and 07/17/25 until a late entry Incident Report was initiated on 07/17/25 at 11:08 A.M. RNCS #501 stated the facility policy allowed for back-dating documentation up to two weeks. Review of the facility policy titled, Bruise, Rash, Lesion, Skin Tear, Laceration Assessment Guidelines, dated 05/10/16, revealed an identified skin alteration occurring after admission should be followed by completing a Bruise incident in the EMR along with a progress note. Continued monitoring of the wound should be completed.This was an incidental finding identified during the Complaint Survey completed 07/17/25.

Based on observation, staff interview, and review of facility policies, the facility failed to ensure food was labeled and properly refrigerated, the kitchen was maintained in a sanitary manner, and food was not handled with contaminated gloves. This had the potential to affect all residents who consume food from the kitchen. The facility census was 81. Findings include: 1. Observation of the walk-in cooler on 03/10/25 at 8:54 A.M. revealed four quart sized containers of strawberries not dated. Three of the four quarts had a gray fuzzy substance on the strawberries. Interview with [NAME] #596 on 03/10/25 at 8:58 A.M. confirmed the observed strawberries were moldy and not dated. Observation of the deep fryer on 03/10/25 at 8:59 A.M. revealed three overcooked and oil-saturated French fries along the edge of the deep fryer and overcooked crumbs floating in the oil. Interview with Director of Food Services (DFS) #583 on 03/10/25 at 9:02 A.M. confirmed the observations of the deep fryer. Additionally, she stated the fryer was typically cleaned every Thursday, but it had been heavily used the previous day and should have been cleaned. Observation of the walk-in freezer on 03/10/25 at 9:05 A.M. revealed one bag of chicken strips and one bag of onion rings were opened without being dated and the bags were not tied closed. Interview with DFS #583 on 03/10/25 at 9:07 A.M. confirmed the observed chicken strips and onion rings in the walk-in freezer were opened, untied, and undated. Observation of the shelving unit next to the meat reach-in refrigerator on 03/10/25 at 9:08 A.M. revealed one 2/3 full gallon sized container of syrup placed on the shelf. The syrup labeling indicated it should have been refrigerated after opening. Interview with DFS #583 on 03/10/25 at 9:09 A.M. confirmed the observed syrup was on the shelf and the label indicated it should have been refrigerated after opening. Review of facility policy titled Storage Procedures, dated January 2025, indicated food shall be properly stored to keep foods safe and preserve flavor, nutritive value, and appearance. Additionally, frozen foods would dated and wrapped in moisture proof wrapping or placed in suitable containers to prevent freezer burn. 2. Observation on 03/10/25 at 12:09 P.M. of meal service in the House Dining Room revealed [NAME] #596 plating food for residents. She touched the top shelf of the steam table and meal tickets with her gloved hand then touched a handful of chips and unwrapped sandwiches with the same contaminated gloved hand. She placed the contaminated food on a plate that was served to residents. Interview on 03/10/25 at 12:12 P.M. with [NAME] #596 confirmed she touched food that was served to residents with her contaminated gloved hand. Observation on 03/11/25 at 12:15 P.M. of meal service in the Manor Dining Room revealed Dining Services Assistant (DSA) #536 plating food for residents. He touched the top shelf of the steam table and meal tickets with his gloved hand then touched sandwich buns with the same contaminated gloved hand. He placed the contaminated food on a plate that was served to residents. Interview on 03/11/25 at 12:21 P.M. with DSA #536 confirmed he touched food that was served to residents with his contaminated gloved hand. Review of facility policy titled Guideline for Handwashing/Hand Hygiene, dated 12/17/24, indicated hand hygiene would be used frequently and appropriately.

Based on observations, staff interview, and policy review, the facility failed to ensure medications were not prepared and stored in medication cart prior administration. This affected four (#05, #19, #42, #65) out of the fourteen residents that resided on Legacy Hall. Additionally, the facility failed to ensure an opened insulin pen was dated upon first use and was not expired. This affected one (#09) out of three resident insulin pens observed in the Legacy Hall medication cart. The facility census was 81. The findings include: Observation on 03/12/25 at 8:15 A.M. of the Legacy Hall medication cart revealed four separate clear, plastic medication cups with unidentified medications sitting in the second drawer. The observation revealed two letters were written on each plastic medication cup. The observation of the medication cart also noted Resident #09's Lantus Solostar 100 units per milliliter (ml) Insulin pen injector, opened, without an open date and with expiration date of 02/13/25. Interview with Registered Nurse (RN) #620 at 8:20 A.M. confirmed the Legacy Hall medication cart contained four medication cups with unidentified mediations. RN# 620 stated she prepared the medications for Residents #05, #19, #42, #65 and when she went to administer the medications the residents they were sleeping therefore she placed the medication cups back into the Legacy Hall cart to administer at a later time. RN #620 confirmed the two letters written on the medication cups were the initials for Residents #05, #19, #42, #65. RN #620 confirmed the Lantus Solostar insulin pen injector was opened, not dated, and expired on 02/23/25. Review of facility policy titled Specific Medication Administration Procedures, revised 11/2018, stated the policy was to administer medications in a safe and effective manner. The policy stated prior to removing medication package/container from the cart/drawer to prepare the resident for medication administration and to check for vital signs, other tests to be done during/prior to medication administration. Review of facility policy titled Medication Storage in the Facility, revised 10/2019, stated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The policy stated outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secures closures are immediately removed from the inventory and disposed of according to procedures for medication disposal and reordered from the pharmacy , if a current order exists. The policy stated all expired medications would be removed from the active supply and destroyed in the facility.

Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure call lights were in reach of residents. This affected four residents (#15, #14, #57 and #4) of nine residents reviewed for call lights. The facility census was 81. Findings include: 1. Observation on 03/10/25 at 4:28 P.M. of Resident #15 in her room revealed she was sitting in a chair crying and her call light cord was tied to the bed handle out of her reach. Interview on 03/10/25 at 4:28 P.M. with Resident #15 confirmed she was crying due to pain and she could not reach her call light cord to alert staff she needed assistance. Interview on 03/10/25 at 4:28 P.M. with Licensed Practical Nurse (LPN) #518 confirmed Resident #15 could not reach the call light cord to alert staff that she needed assistance. 2. Review of Resident #14's medical record revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, morbid obesity, anxiety disorder, aphasia and dysphagia following a stroke. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #14 was cognitively intact. Resident #14 was dependent on staff for toilet use, parts of dressing, and transfer. Resident #14 required maximal assistance with bathing. Observation on 03/10/25 at 11:18 A.M. of Resident #14 found her up in her wheelchair and her call light was observed on the bed. Coinciding interview with Resident #14 revealed she was not able to get to the call light independently and the staff attempted to get the call light close to her. Interview on 03/10/25 at 11:30 A.M. with Certified Nursing Assistant (CNA) #641 verified Resident #14's call light was not in reach of Resident #14. CNA #641 was observed moving the call light within reach of Resident #14. 3. Review of the medical record for Resident #57's medical record revealed an admitted [DATE]. Diagnoses included dementia, cognitive communication deficit, symbolic dysfunctions, muscle weakness, and depressive episodes. Observation on 03/10/24 at 10:59 A.M. of Resident #57 found her lying in bed. Resident #57's call light was observed on the night stand and not in reach of Resident #57 while she was in bed. Interview on 03/10/25 at 11:30 A.M. with CNA #641 verified Resident #57's call light was not in reach. CNA #641 moved the call light and placed it next to Resident #57 in her bed. CNA #641 verified Resident #57 was able to use her call light. 4. Review of Resident #4's medical record revealed an admitted [DATE]. Diagnoses included dehydration, Alzheimer's disease, osteoarthritis, major depressive disorder, anxiety disorder, scoliosis, chronic pain, and altered mental status. Review of the MDS assessment, dated 12/20/24, revealed Resident #4 was cognitively intact. Resident #4 required moderate assistance with toilet use, bathing, parts of dressing, bed mobility and transfer. Observation on 03/10/25 at 11:23 A.M. of Resident #4 found Resident #4 lying in bed with a neck pillow in place around her neck. Resident #4's call light were observed out of reach on the bedside table approximately a foot from the side of the bed. Interview on 03/10/25 at 11:30 A.M. with CNA #641 verified Resident #4 utilized her call light and the call light was not in reach of Resident #4. Review of the facility policy titled Guidelines for Answering Call Lights, revised 12/17/24, revealed the facility was to ensure the call light was plugged in securely to the outlet and in reach of the resident.

Based on observation and staff interview, the facility failed to ensure resident beds were maintained in a safe condition. This affected one resident (#53) of nine reviewed for physical environment concerns. The facility census was 81. Findings include: Review of Resident #53's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, stroke, type II diabetes, psychosis, altered mental status, major depressive disorder, anxiety disorder, and muscle weakness. Review of Resident #53's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and rarely or never understood. Resident #53 was dependent on staff for toilet use, bed mobility and transfer. Observation on 03/10/25 at 11:27 A.M. of Resident #53's room found the headboard of the bed leaning to the left when facing the bed. When the headboard was touched it was found to have been broken free from the bed frame on the left side and was attached only by the right side to the frame of the bed. Interview on 03/10/25 at 11:29 A.M. with Certified Nursing Assistant (CNA) #641 verified Resident #53's bed was broken. She was unsure how long it had been that way since she does not regularly work on Resident #53's hallway.

Based medical record review, observation, staff interview, and policy review, the facility failed to ensure residents were free from any physical restraints. This affected two (#28 and #73) out of two residents reviewed for restraints. The facility census was 81. Findings include: 1. Review of Resident #28's medical record revealed diagnose of Alzheimer's, dementia, right hand contractures, reduced mobility, glaucoma, and cognitive communication deficit. Review of physician orders, dated 12/18/24, revealed no physician order for a standard pillow to be placed under a fitted sheet on the left side of resident when in bed. Review of Resident #28's care plan, dated 01/17/25, revealed the right side of the bed was to be against the wall. Review of the Minimum Data Set (MDS) assessment, dated 12/27/24, revealed Resident #28 required maximal assistance with bed mobility. Observation on 03/10/25 at 03:54 PM revealed Resident #28 laying in bed on her right side facing the wall. Bilateral mobility bars were in place and pulled up. A standard size pillow was placed length wise under the fitted sheet and pressed tightly up against resident's back and buttocks area. Coinciding interview with Certified Nursing Aide (CNA) #646 at the time of the finding verified the pillow was in place to keep Resident #28 in the bed. Review of the facility policy titled Guidelines for Restraint/Enabler Use, dated 12/17/24, revealed use for safety devices to be evaluated by interdisciplinary team before use with risk and benefits of restraint use. A device can not restrict a resident from what they could previously could do this would be considered a restraint. 2. Review of Resident #73's medical record revealed an admitted [DATE]. Diagnoses included traumatic subdural hemorrhage without loss of consciousness, atrial fibrillation, Alzheimer's disease, dementia, restlessness, and agitation. Review of physician orders, dated 01/15/25, revealed no physician order was written for a standard pillow to be placed under a fitted sheet on the left side of resident when the resident was in bed. Review of the care plan revealed Resident #73 had reduced safety awareness due to Alzheimer's and dementia Review of the MDS assessment, dated 01/29/25, revealed the resident required moderate assistance with mobility and maximal assistance with sit and stand. Observation on 03/10/25 at 2:19 P.M. revealed Resident #73 was laying in her bed. The right side of the bed was against the wall. A standard pillow was placed length wise under the fitted sheet and pressed securely against Resident #73's back and hip. A high backed wheelchair was placed sideways beside Resident #73's bed by at her hip and legs area. Interview on 03/10/25 at 2:28 P.M. with CNA #628 verified the pillow was placed to keep Resident #73 in bed so Resident #73 could not swing her legs over the side of the bed. CNA #628 moved the wheelchair to the other side of the room.

Based on medical record review and staff interview, the facility failed to ensure the care plan was updated timely to include the development of a pressure ulcer for one (#4) out two residents reviewed for pressure ulcers. The facility census was 81. Findings include: Review of Resident #04's medical recorded revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, osteoarthritis of right hip, major depressive disorder, and scoliosis. Resident #4 enrolled in hospice care 03/04/25. Review of Resident #04's Minimum Data Set (MDS) assessment, dated 12/20/24, identified Resident #4 was at risk for pressure ulcer development but no pressure ulcer noted. Review of Resident #04 nurse's notes revealed on 02/23/25 at 10:11 P.M. an open area was found on the sacrum during care. Certified Registered Medication Aide (CRMA) #622 notified Licensed Practice Nurse (LPN) #643 at the time of the finding. Further reviewed of nurses note dated 02/27/25 at 3:27 A.M. revealed the resident's daughter was notified of the wound and a treatment was established. Review of Resident #04's comprehensive care plan revealed the pressure ulcer was not addressed on the plan of care until 03/11/25. Interview on 03/13/15 at 12:10 P.M. with Regional Director of MDS Nurse #659 confirmed Resident #04's care plan for pressure ulcer was not initiated until 03/11/25.

Based on observation, medical record review, and staff interview, the facility failed to follow physician orders to apply washcloths to the hands of one (#53) of four residents reviewed for skin conditions. The facility census was 81. Findings include: Review of Resident #53's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, stroke, type II diabetes, psychosis, major depressive disorder, anxiety disorder, muscle weakness, abnormal posture, contusion of part of the head (12/09/24), and dementia with behavioral disturbance. Review of Resident #53's Minimum Data Set (MDS) assessment, dated 11/21/24, revealed Resident #53 was severely cognitively impaired. Resident #53 was dependent on staff for eating, toilet use, bathing, dressing and mobility. Review of Resident #53's physician orders revealed an order dated 01/21/25 for wash cloths to hands change daily and as needed. Review of Resident #53's care plan, revised 03/10/25, revealed supports and interventions for risk for skin breakdown. Interventions for risk for skin breakdown included keeping Resident #53's skin as clean and dry and possible, minimize skin exposure to moisture and apply treatments as ordered. Observation on 03/10/25 at 1:46 P.M. found Resident #53 lying in bed. Resident #53's arms were bent at the elbows and her hands were clenched in fists. No washcloths were observed in her hands protecting her palms. Interview on 03/10/25 at 1:52 P.M. with Certified Nurse Assistant (CNA) #646 verified Resident #53 was to have washcloths placed in her hands and they had not been placed as ordered.

Based on record review, observation, and staff interview, the facility failed to accurately assess a pressure ulcer, failed to complete an assessment of a pressure ulcer when identified, and failed to obtain a treatment for a pressure ulcer. This affected two (#38 and #4) out of three residents reviewed for pressure ulcers. The current census is 81. Findings include: 1. Record review for Resident #38 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #38 include dementia, urinary tract infection, respiratory failure, and chronic kidney disease. Review of Resident #38's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had impaired cognition and was incontinent of bowel and bladder. Review of Resident #38's wound management revealed on 02/13/25 the resident was noted to have an open wound measuring 7 centimeters (cm) by 2 cm by 0.1 cm depth. Per the wound assessment the wound had a 'foul' odor with necrotic tissue, irregular edges with a dark purple/rusty discoloration. In the comment section of the assessment the nurse documented the Director of Health Services (DHS) observed with the nurse and identified the ulcer as a Kennedy ulcer. The wound assessment was signed by Licensed Practical Nurse (LPN) #580. No further documentation or confirmation was noted in the record from the DHS. Review of the document titled The Pressure Ulcer Letter of Unavoidability dated 02/19/25, revealed LPN #580 documented Resident #38's pressure ulcer was unavoidable due to being a [NAME] Ulcer. Per the document the resident was referred to hospice and the Certified Nurse Practioner (CNP) signed the document on 02/20/25. Review of Resident #38's wound management revealed on 02/19/25 the wound was measured at 7 cm by 3 cm with no depth, moderate serous exudate, foul odor, necrotic tissue and the skin around the wound was dark purple. Review of Resident #38's wound management revealed on 02/25/25 the wound measured 6.4 cm by 2.5 cm with no depth, moderate exudate with seropurulent drainage, odor, with slough, and well defined wound edges with pink and normal skin surrounding the wound. The wound was documented as 'stable'. Review of Resident #38's wound management revealed on 03/04/25 the wound measured 6 cm by 2.5 cm with no depth, exudate present with slough, and skin blanchable around wound. Interview on 03/12/25 at 3:30 P.M. with LPN #580 revealed she does all wound assessments, measuring, and dressing changes for wounds, however she was certified in wound care LPN #580 verified she had identified Resident #38's coccyx wound as a Kennedy ulcer and had notified the physician of this. The physician then consulted hospice on 02/20/25. LPN #580 stated to her knowledge the CNP, the current DHS, and the physician had not visibly assessed Resident #38's wound. LPN #580 verified she had documented the wound was an unavoidable pressure ulcer and assessed it to be a [NAME] wound. LPN #580 stated the previous DHS had observed Resident #38's ulcer but had not commented or documented on the stage of the ulcer in the records. Interview on 03/12/25 at 3:15 P.M. with CNP #459 stated she was told by staff Resident #38 had a Kennedy ulcer and she had signed orders for the care. CNP #459 stated she had not visibly assessed the wound herself but was told by LPN #580 what the wound was. CNP #459 stated she had not measured or provided care for the wound and relied on the nursing staff to update her on the status of the wounds. Interview and observation of wound care for Resident #38 on 03/13/25 at 7:55 A.M. with current DHS #515 and LPN #580 revealed Resident #38 had a wound on his coccyx. The wound appeared to be an unstageable wound. DHS #515 stated per her opinion the wound was a typical unstageable pressure ulcer. DHS #515 verified the wound appeared to be well defined and the skin around the wound appeared pink and blanchable. The edges had small traces of red blood noted and the wound had no odor. DHS #515 stated the bed of the wound was obstructed by what appeared to be slough and verified there were no defined shapes related to a Kennedy ulcer. DHS #515 verified it was an unstageable ulcer and did not appear to be a Kennedy ulcer. 2. Review of Resident #04's medical recorded revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, osteoarthritis of right hip, major depressive, and scoliosis. Resident #4 enrolled in hospice care 03/04/25. Review of the quarterly MDS assessment, dated 12/20/24, revealed the resident was cognitively intact, required moderate assistance with bed mobility, transfers, and toileting. Resident #04 was at risk for pressure ulcer development and did not have a pressure ulcer at the time of the assessment. Review of Resident #04's nurse's note, dated 02/23/25 at 10:11 P.M., revealed an open area was found on the sacrum during care. The note stated Certified Registered Medication Aide (CRMA) #622 notified the nurse. The nurse's note stated the area on the sacrum was observed to be bloody. The resident complained of pain to the area and severe back pain. There were no orders for treatment to the area. There was no assessment of the area. Review of a nurses' note, dated 02/26/25 at 4:25 A.M., stated the dressing to the sacral area was clean, dry, and intact. The resident had no signs and symptoms of pain. Review of the nurse's note dated 02/27/25 at 3:27 P.M., written by Licensed Practical Nurse (LPN) #560, stated Resident #04 was noted to have an open are to the coccyx and a treatment had been established. There were no orders for treatment to the area. Review of Resident #04 weekly wound management evaluation dated 02/27/25 revealed a ulcer to the coccyx. The facility identified the ulcer to be a Kennedy ulcer due to sudden onset and resident decline. The evaluation revealed the wound measurement to be 3.5 cm by 3.5 cm, with no depth noted. Review of Resident #04's physician order dated 02/27/2025 revealed a treatment to the coccyx wound to cleanse wound with wound cleanser or normal saline, apply skin prep to peri-wound, apply Medihoney, and cover with foam dressing as needed. Review of physician order dated 2/28/25 revealed a treatment for Medihoney 80% to be applied topically daily with no location for application identified. Review of physician order dated 03/03/25 revealed to cleanse the coccyx wound with wound cleanser, pat dry with gauze, apply Medihoney gel to wound bed, and to cover wound with boarder gauze. The order stated to change dressing every three days and hold one day. Review of Resident #04's February 2025 Treatment Administration Record (TAR) revealed no wound care was ordered from 02/23/25 to 02/28/25. Review of the wound management evaluation dated 03/11/25 revealed the ulcer to the coccyx had moderate serous to purulent drainage. The wound bed was noted to have 50% slough with 50% granulation. The peri area was red and blanchable. The evaluation revealed the wound measurement to be 3 cm by 1.5 cm with no depth noted. Interview on 03/12/25 at 3:17 P.M. CRMA #622 stated the wound was found on 02/23/25 during personal care and she notified Registered Nurse #563 at time of finding. CRMA #622 described the wound as bloody with no black areas noted. It was about the size of a quarter, round in shape, and was superficial. Interview on 03/13/25 at 10:05 A.M. Regional Director of Nursing (DON) #658 confirmed the medical record for Resident #4 did not contained documentation to support the facility evaluated Resident #4 coccyx wound when first observed on 02/23/25 nor was a treatment initiated at that time. Review of facility policy titled Guidelines for General Wound and skin Care, dated 12/17/24, revealed the facility will document type of wound, location, stage (if applicable), length, width, depth in centimeters, base, drainage, per wound tissue, and treatment of the wound weekly.

Based on medical record review, resident interview, staff interview, interview with pain management nurse, and policy review, the facility failed to ensure a resident was given the pain management's recommendation for pain medication to more effectively control her pain. Actual harm occurred to Resident #81 when the resident had continued with uncontrolled pain and was not being treated with the pain management's recommendation to change the pain medications to a different opioid [MEDICATION NAME] (Tylenol-[MEDICATION NAME] #3) to more effectively control her pain. This affected one (#81) of one residents reviewed for pain. The facility identified 55 residents on a pain management program. The facility census was 88. Findings include: Review of Resident #81's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 14-day Minimum Data Set (MDS) assessment, dated 06/11/18, identified the resident as being cognitively intact and the resident was receiving scheduled and as needed pain medications, identified the resident as frequently having pain, and revealed the pain has made it hard for the resident to sleep at night or having to limit day-to-day activities because of pain. Review of the pain care plan, last revised on 05/10/18, revealed the resident has complaints of pain related to diabetic [MEDICAL CONDITION], lumbar spinal stenosis with chronic back pain and past left foot fracture. Interventions included to refer to pain management as ordered, administer medications as ordered/needed and return to assess effectiveness, allow sufficient uninterrupted rest periods, assess effects of pain, evaluate effectiveness of pain management interventions, and monitor and record any complaints of pain. Review of the pain management notes, dated 06/20/18, revealed the recommendations were to discontinue [MEDICATION NAME] (narcotic to treat moderate to severe pain) as patient has no alleviation of pain. The pain medication was given for her very poor sleep and inhibiting her function during the day. The notes stated they would trial Tylenol-[MEDICATION NAME] #3 (narcotic to treat mild to moderately severe pain) one tablet nightly as needed for two weeks and the patient states understanding after reviewing the risk first benefits. Review of the physician's orders revealed an order for [REDACTED].#3 or discontinuation of [MEDICATION NAME] per the pain management notes dated 06/20/18. Review of the nurse's notes from 06/01/18 until 06/27/18 revealed a note on 06/01/18 at 10:53 P.M. The noted mentioned the resident stated the as needed [MEDICATION NAME] was ineffective for pain. A note on 06/16/18 at 1:26 P.M. revealed as needed [MEDICATION NAME] was given at 9:05 A.M. with no effect. A note on 06/19/18 at 5:59 A.M. revealed the resident continued to complain of pain throughout the night, stated the [MEDICATION NAME] was ineffective for the most part, the physician was updated and the resident was to see pain management the same morning. Review of the nurse's note, dated 06/22/18 at 12:24 A.M., revealed the as needed [MEDICATION NAME] given per request for complaints of pain in her back and bilateral lower extremities and the resident stated the medications was somewhat effective for pain relief at the time. Review of the copy of the script, dated 06/20/18, revealed it was faxed over by pain management on 06/27/18 and it was a script for Tylenol-[MEDICATION NAME] #3 one tablet by mouth at bedtime for 14 days. Review of the (MONTH) Medication Administration Record [REDACTED]. ten times: on 06/20/18 at 2:04 A.M. for back pain level of seven out of ten (a pain scale to measure a person's pain intensity, zero was no pain and a ten was worst pain possible) and it was not effective; on 06/21/18 at 11:21 P.M. for back and leg pain and was slightly effective; 06/22/18 at 9:16 A.M. for a pain level of eight and was slightly effective; on 06/22/18 at 8:08 P.M. for leg pain level of eight and was effective; on 06/23/18 at 8:15 P.M. for a pain level of seven and was effective; on 06/24/18 at 10:08 A.M. for a pain level of seven and was slightly effective; on 06/24/18 at 8:14 P.M. for back pain level of eight and was effective; on 06/26/18 at 12:05 P.M. for back and neck pain level of five and was slightly effective; on 06/27/18 at 11:36 A.M. for back pain of seven and was slightly effective; and on 06/27/18 at 7:46 P.M. for leg pain level of seven, and was effective. Interview with Resident #81 on 06/25/18 at 11:56 A.M. revealed she has pain in her back and her legs. She voiced she also has restless leg syndrome. Resident #81 voiced she had went to the pain clinic three days ago and the pain clinic doctor told her they were going to order Tylenol-[MEDICATION NAME] #3. She voiced she was having pain and asked the nurse for it and she was told there wasn't a physician order. Additional interview with Resident #81 on 06/27/18 at 12:07 P.M. revealed she was still receiving the [MEDICATION NAME]. Resident #81 again voiced when she had seen pain management they voiced they were going to discontinue the [MEDICATION NAME] and order Tylenol-[MEDICATION NAME] #3. Resident #81 voiced with the [MEDICATION NAME] she was still having pain. She voiced her pain was constant in her back and in her right leg. Resident #81 described her pain level was a nine and stated she probably would not go to activities that day because of her pain. Interview with Licensed Practical Nurse (LPN) #244 on 06/27/18 at 12:10 P.M. stated Resident #81 has pain in her back and legs, but mostly in her back and the resident has stated the [MEDICATION NAME] doesn't help her pain. Interview with Pain Management Nurse (PMN) #201 on 06/27/18 at 4:38 P.M. revealed Resident #81 was seen on 06/20/18 and was given a script for Tylenol-[MEDICATION NAME] #3. PMN #201 voiced there was a phone call received earlier today from the facility regarding this same issue. PMN #201 voiced prior to today there was no phone call received regarding Resident #81 and her pain medications. Interview with the Director of Nursing (DON) on 06/27/18 at 4:45 P.M. verified prior to today nobody had called pain management regarding Resident #81's pain medications. She stated she was not aware they didn't have the script until surveyor intervention. The DON stated the medical records nurse seen on the paperwork the Tylenol-[MEDICATION NAME] #3 was a recommendation, however, thought there was a script that was coming over. The DON confirmed the resident was not receiving the correct pain medication that pain management had prescribed and confirmed Resident #81 does complain of pain 'off and on'. Review of the facility policy titled Guidelines for Pain Observation and Management, dated 05/23/17, revealed to ensure each residents pain including its origin, location, severity, alleviating and exacerbating factors, current treatment and response to treatment will be observed and documented according to the needs of each individual. It identified to implement the care plan approaches to assist with pain management and evaluate the effectiveness of pain management intervention modify as indicated.

Based on review of a closed medical record, review of an emergency squad report, review of hospital records, review of a death certificate, staff interviews, review of the facility's alarm policy and review of manufacturer instructions of a pressure pad alarm, the facility failed to ensure the nursing staff visually checked Resident #10's fall prevention alarm to ensure the device was activated in the ON position to assure proper functioning as Resident #10 had a history of [REDACTED]. This resulted in Immediate Jeopardy and actual harm when Resident #10 was found moaning on the floor in his room, the resident was bleeding from the head, the fall prevention alarm was not activated, and Resident #10 sustained a cervical spine fracture of the second vertebra (C-2) with a spinal cord lesion and subsequently passed away. This affected one (#10) of four residents reviewed for falls with fall prevention alarms as an intervention. The facility identified seven residents at risk for falls with orders for fall prevention alarms. The facility census was 94. On 03/15/17 at 11:05 A.M., Regional Nurse #170 and the Director of Nursing (DON) were notified Immediate Jeopardy began on 02/24/17 at 4:40 A.M. when Licensed Practical Nurse (LPN) #120 discovered Resident #10 moaning face down on the floor bleeding from the head and diaphoretic. Resident #10's fall prevention alarm was found not to be activated and the operational switch was set to the OFF position. Resident #10 was sent to the emergency room for evaluation and treated for [REDACTED]. Resident #10 was not a surgical candidate and he was hospitalized , was placed on Hospice care and subsequently passed away while in the hospital four days later on 02/28/17. During the surveyor's investigation, information was obtained related to Resident #10 having a history of turning off the ordered fall prevention alarm; however, the resident's history of turning off the fall prevention alarm was not documented and the resident was not re-evaluated for appropriateness of an alternative intervention. The Immediate Jeopardy was removed on 02/27/17 when the facility completed the following corrective actions: · On 02/24/17 at 4:40 A.M., Resident #10 was assessed by LPN #120 after the resident was found on the floor. LPN #120 provided first aide to a laceration to Resident #10's head and the nurse initiated Emergency Medical Services. At 5:08 A.M. Resident #10 was sent to the hospital for evaluation and treatment. · On 02/24/17 at 5:10 A.M., Registered Nurse (RN) #110 examined Resident #10's fall prevention alarm and discovered the power switch was turned off. The nurse turned on the alarm and it was in functional order. RN #110 notified the DON of the incident and that the alarm was not on. · On 02/24/17 at 10:30 A.M., the DON interviewed all staff members present during the time of the fall and discovered no staff member admitted to turning Resident #10's alarm off prior to the incident. · On 02/24/17, the DON audited the medical records of all current residents who were identified as high fall risks and who utilized a fall prevention alarm for appropriateness of fall interventions and to ensure interventions were in place. There were no other concerns identified with fall interventions and alarms not being implemented. · On 02/24/17, the DON and Assistant Director of Nursing (ADON) began education with nursing staff to ensure fall prevention alarms were functional, activated in the ON position and to ensure the appropriate use of the alarm for each resident with a current alarm. The education was completed on 02/27/17 at 11:35 A.M. · On 02/25/17 at 9:00 A.M., the Administrator and DON conducted an audit of all residents with fall prevention alarms to ensure the alarms were in place and functioning. There were no concerns identified. On 02/25/17 the DON and ADON implemented on-going monitoring to ensure fall interventions were in place. The monitoring was planned daily for two weeks, three times a week for two weeks then randomly twice monthly for three months to ensure fall interventions were implemented. Additionally, all new admissions will be evaluated for fall risk and appropriate fall interventions. · On 03/14/17, the DON and Regional Nurse #170 evaluated all residents with fall prevention alarms to ensure appropriateness for each resident. The DON evaluated the residents with fall prevention alarms regarding their ability to disengage the alarm and/ or remove the alarm. If the resident was evaluated to have the ability to remove or disengage the alarm, the alarm was discontinued and other interventions were implemented as appropriate. There were no other concerns identified. · On 03/14/17 at 7:30 P.M., the DON provided follow-up education to all nursing staff that if a resident with a fall prevention alarm is able to disengage or remove the alarm, this needs documented and reported to the DON or designee. · On 03/14/17 and 03/15/17, staff interviews with LPN #181, State tested Nursing Assistant (STNA) #181, STNA #140, LPN #120, STNA #130 and STNA #150 revealed the staff were knowledgeable on fall interventions including the use of alarms and the need to visually check that alarms were on. There were no concerns identified. · On 03/14/17 and 03/15/17, the medical records of Residents #11, #12 and #13 were reviewed. These residents were identified as being at risk for falls and were ordered to use a fall prevention alarm. There were no concerns identified. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] and was discharged to an acute care hospital on [DATE] status [REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10's Brief Interview of Mental Status (BIMS) score was a four out of 15, indicating severe cognitive impairment. The MDS documented Resident #10 was an extensive assist of two staff for bed mobility, transfers, walking in the room and personal hygiene. The MDS also documented Resident #10 was an extensive assist of one for toilet use and was not steady, only able to stabilize with human assistance moving from a seated to standing position and uses a walker or wheelchair. Resident #10 was not on a urinary toileting program as he was always continent of urine and bowel and had no falls since the prior assessment dated [DATE]. Review of Resident #10's care plan dated 10/03/16 revealed a focus for the risk of falling related to weakness and poor safety awareness. Interventions for the focus included keeping items frequently used within reach, bed in low position, proper footwear at all times, one assist with all transfers, call light within reach and staff to utilize a pressure pad alarm at all times. Review of Resident #10's physician's orders revealed an order dated 10/17/16 instructing staff to utilize a pressure pad alarm at all times and to check every shift. An Event/Incident Report including a Fall Risk assessment dated [DATE] was reviewed which identified Resident #10 as being at high risk for falls and having a history of falling. Review of the February 2017 Treatment Administration Record (TAR) revealed Resident #10's alarm was checked to ensure it was functional on 02/23/17 for the 6:00 P.M. to 6:00 A.M. shift. The entry was initialed by the DON. Further review of Resident #10's medical record revealed there was no documentation regarding the resident disengaging or turning off his fall prevention alarm. Review of LPN #120's progress notes for Resident #10 dated 02/24/17 at 5:08 A.M. revealed the resident was found on the floor by the nurse. The nurse heard moaning from the resident's room, checked on the resident, and found him on the floor face down, bleeding from the head and diaphoretic at 4:40 A.M. LPN #120 applied pressure to the resident's head and told him not to move. The resident was not moved due to possible injury and was alert and able to express where pain was located. Resident #10 stated he was trying to stand and use the urinal. LPN #120 called out for the other nurse on the unit to call emergency services and the resident was sent to the emergency room . Resident #10's pressure alarm was on the bed and was not activated at the time of the fall. The emergency squad report dated 02/24/17 was reviewed. According to the report, the squad was called to the facility as Resident #10 had fallen. Upon arrival, Resident #10 was found lying prone on the floor and staff stated he fell from a standing position. A C-Spine was placed on Resident #10's neck and the resident was log rolled to his back. Resident #10 had a laceration above the left eye with heavy bleeding and a dressing was placed to control the bleeding. There was approximately 150 to 200 milliliters (ml) of blood on the floor from the resident's laceration with swelling around the left eye. Resident #10 was then transported to the emergency room for treatment. Review of Resident #10's hospital notes dated 02/24/17 revealed the resident was admitted to the hospital post fall. The chief complaint was a closed head injury and laceration to the head. Review of the results of Resident #10's Computed Tomography (CT) scan dated 02/24/17 revealed there was a cervical fracture of the spine with a spinal cord lesion. Review of the hospital's orthopedic physician notes dated 02/24/17 revealed Resident #10's case was discussed with the surgeon and the family. surgery for [REDACTED]. Resident #10's death certificate dated 02/28/17 was reviewed. The death certificate identified the resident's immediate cause of death was a C-2 fracture and subsequently listed conditions were related to a fall. Interview on 03/14/17 at 12:02 P.M. with the DON and Regional Nurse #170 revealed the DON was working the evening/night shift of 02/23/17 into 02/24/17 and worked until 4:00 A.M. on 02/24/17. Per the DON, Resident #10 had refused a medication after midnight on 02/24/17 and the resident appeared to be in no distress during the interaction; however, the DON stated she did not check to see if Resident #10's fall prevention alarm was activated and the switch was in the ON position during the interaction with the resident. The DON stated the last time she checked on the resident was 02/24/17 at 3:00 A.M. and she found the resident in bed asleep with the call light within reach and no distress noted. The DON stated she did not check to see if the resident's fall prevention alarm was activated during that observation. The DON stated she left the facility, after reporting off to the oncoming nurse, around 4:00 A.M. in the morning on 02/24/17. According to the DON, on 02/23/17 at 9:00 P.M., STNA #140, a second shift aide, told her the aide had activated Resident #10's alarm and checked its functionality at 6:30 P.M. when the aide assisted Resident #10 to bed. The DON stated she documented the alarm was on in the TAR; however, she did not visually check the functionality of the alarm during her shift. The DON stated she was unaware if the resident had the capability to turn off the pressure alarm himself. Interview on 03/14/17 at 12:50 P.M. with RN #110 revealed she was working from 10:00 P.M. to 6:00 A.M. on 02/24/17, the day Resident #10 had fallen. RN #110 stated the resident was found by the other nurse (LPN #120) who called out for her to call nine-one-one (911) around 4:40 A.M. RN #110 stated she called for the emergency squad and went into Resident #10's room to assist LPN #120 with the resident. RN #110 stated while she was assisting the other nurse with the resident she did not hear the bed alarm sound. RN #110 stated after the emergency squad transported the resident out of the facility she examined the bed alarm and noted the switch was in the OFF position and the light wasn't blinking. RN #110 asked LPN #120 if she had turned off the alarm and she said no. RN #110 stated she asked all the staff that was present at the time of the fall and in the location of the fall, which included LPN #120, STNA #130 and STNA #150 if they had turned off the alarm and all staff members told her they did not turn off the alarm. Interview on 03/14/17 at 4:35 P.M. with STNA #130 revealed she was the aide working Resident #10's hall on 02/24/17 from 6:00 P.M. to 6:00 A.M. STNA #130 stated the resident would use his urinal both sitting and standing. STNA #130 stated the resident would go to bed around 6:30 P.M. to 7:00 P.M. and he would not have any incontinent episodes and wake early to use the bathroom usually around 5:00 A.M. to 6:00 A.M. STNA#130 stated the resident was capable of turning off the alarm as he would turn off the alarm by himself if he wanted to stand up and use the urinal but he didn't always do this on a regular basis and she reported this to the nurse after the fall. STNA #130 stated the resident was lying in bed at 4:30 A.M. when she checked on him. STNA #130 stated Resident #10 was not on a toileting program or on a check and change every two hours program, but every resident would get a visual check every two hours by the aides. STNA #130 stated she did not visually check Resident #10's personal alarm to see if it was activated on her shift. Interview on 03/14/17 at 4:59 P.M. with LPN #120 revealed she was the nurse who found the resident on the floor on 02/24/17 at 4:40 A.M. LPN #120 stated she received report between 4:00 A.M. and 4:15 A.M. that morning and was in the hall preparing medications when she heard moaning coming from Resident #10's room. LPN #120 stated she went into the room and found the resident lying on the floor with a laceration to his forehead and she called for the other nurse to call 911 while she started to assess the resident. According to LPN #120, the resident had told her he was standing up to pee and fell to the floor, the urinal was lying near the resident and his briefs were pulled down to his thighs. LPN #120 stated she did not see any urine on the floor or on the resident while she was sitting with him awaiting the emergency squad. LPN #120 stated she did not move the resident because she knew he had hit his head. LPN #120 stated she stayed with the resident until the emergency squad arrived and took him to the hospital. LPN #120 stated the resident's alarm was not sounding when she entered the room and found the resident. After the squad took Resident #10 out of the facility, she and another nurse examined the alarm and found the pressure pad was on the bed but the power switch was in the OFF position. LPN #120 stated she did not know if the resident or a staff member had switched off the alarm, but she stated the resident had been known to switch off the alarm in the past. Interview on 03/14/17 at 5:25 P.M. with STNA #150 revealed she was a float aide for the facility on 02/24/17. STNA #150 stated she had worked with Resident #10 in the past and he was not on a toileting program and was frequently continent throughout the night. STNA #150 stated Resident #10 was capable of turning off his alarm but did not turn it off on a regular basis. STNA #150 stated she did not check on the resident or ensure the alarm was in the ON position on the morning of 02/24/17. Interview on 03/15/17 at 9:00 A.M. with STNA #140 revealed she was the aide who assisted Resident #10 to bed on 02/23/17 around 6:30 P.M. STNA #140 stated she turned on his alarm after he was in bed. STNA #140 stated she reported to the DON the alarm was on and functional prior to her leaving at the end of her shift at 10:00 P.M. STNA #140 stated on 02/23/17 at around 8:30 P.M. she was on the unit assisting another resident to bed when she heard what she thought was an alarm near Resident #10's room. STNA #140 stated she could not immediately leave the other resident's room because she was physically assisting the resident to bed. When the other resident was in bed, she went to find the source of the alarm but it was no longer sounding when she got to the hallway. STNA #140 stated she thought another staff member had responded to the alarm and reset the alarm. STNA #140 stated she did look into Resident #10's room and he was in bed and he waved at her when she asked if he was okay. STNA #140 stated this was around 8:40 P.M.; however, STNA #140 stated she did not look at the alarm itself to see if it was turned on during this observation. STNA #140 stated the resident she was assisting with bedtime care, and Resident #10, were the only two residents on the hall with a fall prevention alarm. Review of the facility policy titled Alarm Checks dated 05/11/16 revealed the purpose of the policy is to ensure resident and door alarms are properly functioning to protect the safety of campus residents. According to the policy, all personal alarms should be checked for proper functioning and evaluated for continued appropriateness. Frequency of individual alarm checks should be daily for function and every shift for placement or based on the resident's individual plan of care. Alarm checks should be part of routine daily care; with daily dressing, bathing, toileting, at meals, etc. Review of the undated manufacturer's instructions for the Pressure Pad for Direct Supply Attendant Resident Monitors indicated the device was not to prevent falls; however, the device is used within close proximity to caregivers as part of a comprehensive resident mobility management program. According to the instructions, staff should always test the system before every use. According to the instructions, the in use light will blink as a visual indication that the alarm is in use and functional. This deficiency substantiates Complaint Number OH 104.