Every finding on record at Hillside Manor

Based on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening or to promote healing of PIs for 1 (R9) of 2 residents reviewed for PIs out of a sample of 15 residents.R9 had a care plan intervention to use a Roho cushion in R9's wheelchair and recliner. The facility staff failed to ensure the Roho was properly inflated and functioned according to manufacturer's recommendations and failed to ensure weekly skin assessments were completed once R9 developed a full thickness. Findings include:The National Pressure Injury Advisory Panel (NPIAP) classifies a PI as follows: Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.Unstageable: Obscured full-thickness skin and tissue loss full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.The facility policy, Long Term Care Wound Care Prevention and Treatment Policy, dated 12/31/24, states, in part: . 3.2 Skin breakdown risk will be performed on admission and weekly for the first 4 weeks of admission to the facility, followed by quarterly or with significant change in resident condition. The Braden Skin Assessment tool will be used to determine skin breakdown risk.3.4 The Wound Care Certified (WCC) nurse or long-term care staff will collaborate with the practitioner to oversee management of skin impairments in Long Term Care .3.7 Documentation and Communication a. Skin assessments and interventions to prevent skin breakdown will be documented in the medical record. b. Abnormal skin findings will be reported to the practitioner. c. Handoff communication will include information related to skin assessments and interventions in place to prevent skin breakdown d. If there is no evidence of wound healing within 2 weeks of treatment, the plan of care should be reassessed and reviewed with the patient's practitioner3.8 Open Wounds a. Weekly wound healing assessment will include . -Pressure Injury -Anatomical location of wound -Wound dimensions including length, width, and depth -Undermining depth and location -Extent of tissue loss/staging -Tissue type including percentage of granulation, slough, and necrotic tissue -Amount, color, consistency, and odor of drainage -Presence of epithelialization at wound edges.R9 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (stroke causing weakness or paralysis to the left side of the body), other specified disorders of bone, unspecified site, chronic kidney disease, stage 3, and atherosclerotic heart disease of native coronary artery without angina pectoris (plaque buildup in arteries that provide blood to the heart without causing chest pain).R9's Significant Change Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/9/26 indicates R9 has a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating R9 is moderately cognitively impaired. The MDS indicates R9 has upper and lower extremity impairments on both sides, uses a wheelchair for mobility, requires substantial/maximal assistance for rolling left and right and has 1 stage 3 PI.On 12/4/23, R9's Comprehensive Care Plan is updated to include the intervention to turn R9 on the day, evening, and night shifts.On 12/3/23, R9's Comprehensive Care Plan is updated to include Rx (prescriptions) as ordered.On 12/23/23, R9's Comprehensive Care Plan is updated to include the problem I have the potential for impaired skin integrity.On 7/8/24, R9's Comprehensive Care Plan is updated to include Roho cushion to wheelchair and Roho cushion to recliner.On 11/13/25 at 8:43 AM, a Braden Scale (a measure of pressure injury risk) was completed for R9. This assessment scored 14, indicating moderate PI risk. Preventative measures are listed as: low pressure mattress, gel cushion, turn/repositioning schedule, and toileting schedule. On 12/2/25, an Occupational Therapy (OT) & Plan of Treatment document was completed. Plan of treatment includes patient will tolerate sitting in Broda chair (tilt-in-space positioning chairs) consistently for 2 hours with good trunk position to decrease risk for further contractures and skin impairment. Baseline for this goal is listed as increased left lean noted with insertable lateral support less effective. Another goal is listed as patient will demonstrate comfort and close to midline positioning with use of Broda chair or alternative seating system to decrease risk for contractures and skin impairment.The Initial Assessment section indicates the reason for referral due to a decline in wheelchair positioning impacting safety and skin integrity.The Results section indicate R9 was currently using a high back wheelchair reclining with mosaic Roho cushion. Per nurse, excoriation to buttock crease and skin between scrotum and rectum.On 12/3/25, R9's Comprehensive Care Plan was updated to include the intervention w/ (with) Sof-Care (pressure-relieving bed overlay).On 12/23/25, R9's Comprehensive Care Plan is updated to include the problem: I have a history of impairment to the right hip. I prefer to only sleep on my right side. I decline an air mattress as it limits my independence with bed mobility and impairs my comfort.On 12/26/25, an OT Treatment Encounter Note indicates OT assessed R9's position and comfort in Broda chair throughout the day. Good midline trunk position was noted as well as no forward migration of hips.During the month of December 2025, R9's repositioning documentation indicates he was repositioned 0-7 times a day. Per the facility policy, R9 should be repositioned every 2 hours while awake and to consider repositioning every 3-4 hours while sleeping.On 1/2/26 the facility completed R9's Skin Assessment. Two areas of skin impairment were noted on the left tuberosity. The first measures 0.5 cm (centimeters) x 0.5 cm with 100% slough tissue (dead or non-viable tissue). The second area is noted to be 0.1 cm x 0.1 cm with 100% slough tissue. No drainage or odor noted to either area. The surrounding skin was reddened, and the possible cause of impairment was documented as Pressure/shearing. The treatment was for mepilex lite (thin, flexible absorbent pad of foam) placed to the area for protection. Actions taken are listed as MD (Medical Doctor) notified, care plan updated, and OT screen sent. The assessment did not include a stage for the PIs however these areas per NPAIP would be consistent with an unstageable PI.On 1/2/26 at 3:48 PM, a Nurses Note is written that indicates NP R (Nurse Practitioner) ordered a Mepilex lite dressing to the left ischial tuberosity and change every 3 days and PRN (as needed).On 1/2/26, an OT Treatment Encounter Note indicates OT assessed R9's wheelchair positioning throughout the day. Midline trunk position achieved with use of padded lateral insert on left side. Patient reports comfort with high profile Roho cushion. No forward migration of hips noted.On 1/2/26, R9's Comprehensive Care Plan is updated to include the intervention pillow between knees/legs in bed.On 1/7/26, a Skin Assessment was completed. The assessment only indicated 1 PI on the left ischial tuberosity PI measures 5 cm x 3 cm x 0.1 cm. The initial wound stage is listed as Stage 3. Moderate, serosanguinous (combination of serious fluid and blood that appears thin, pink, and watery) drainage present. Granulation tissue (newly formed connective tissue that develops during healing) makes up 75%-100% of the wound. Epithelialization (regenerative process for skin following injury) present for 5% to less than 100% of the wound. Wound is currently stage 2. According to the NPIAP, wounds should not be backstaged. This wound should be considered a Stage 3. No undermining or necrotic tissue (dead, non-viable tissue that results from cell death) present. Interventions: wound consultant, turning and proper positioning, turning schedule, resident teaching to redistribute pressure & off-loading, risks and benefits of repositioning, monitor protein and calorie intake, vitamin and mineral supplements, minimize risk for shear and friction, air cushion for the wheelchair, pressure redistribution mattress, air fluidized surface mattress, and OT consult. The comments section states, .Appears to be trauma from adhesive of Mepilex border dressing in place. TAR (Treatment Administration Record) updated to reflect application of regular Mepilex with Medipore tape (soft, cloth surgical tape). OT screen resubmitted for further evaluation of skin impairment given development timeline in relation to recently issued Broda chair. Treatment: Foam Dressing. Treatment Change: No. On 1/8/26, an OT Treatment Encounter Note indicates education was provided to night shift nursing staff on bed positioning recommendations with bilateral offloading boots, turning side to side, and pillow between legs to ensure no contact between bony prominence and feet/ankles with bed. Additionally, OT assessed the inflation of the high profile Roho cushion and noted it to be low. OT inflated the cushion to the proper fill, however it continued to leak air. Roho cushion was replaced by OT.On 1/9/26 at 1:51 PM, a Skin Assessment was conducted. Type of Skin Impairment is listed as healing pressure stage 2 for both the right heel and left ischial tuberosity wounds. The possible cause is pressure/shearing over bony prominence. Resident medical diagnosis of presumed PVD (peripheral vascular disease) due to previous abnormal ABI (Ankle-Brachial Index-test to assess blood flow in peripheral arteries). Toileting schedule was revised 12/3/25. Wound healing potential listed as fair. Current protective devices in place include repositioning schedule, Roho cushion, specialty boots, air mattress, Broda chair issued 12/22, OT revaluation of chair and cushion on 1/8/26 reveals suspected air leak on Roho cushion and cushion replaced, further education to resident and staff.for need for repositioning throughout the day.On 1/9/26, an OT Treatment Encounter Note is written that indicates education was provided to nursing on bed positioning recommendations: change position side to side to offload buttocks and decrease risk for skin impairment to hip. OT also assessed position in Broda chair throughout the morning. Roho cushion properly inflated and patient reports comfort. Education to nursing on recommendations to ensure Roho cushion is flat and properly inflated prior to each transfer. Education to ensure cushion cover is not too small as this impairs cushion from lying flat. Education on frequently changing positions in Broda chair, standing in EZ stand (mechanical transfer device), lying down, and sitting in recliner to optimize pressure relief to buttocks to promote tissue healing. Education to not place means pad over Roho cushion as this decreases effectiveness for pressure relief.According to Roho Mosaic Cushion Operations Manual copyrighted 2017, Skin/soft tissue breakdown can occur due to a number of factors, which vary by individual. Check skin daily. Redness, bruising, or darker areas (when compared to normal skin) may indicate the beginning of soft tissue breakdown and needs to be addressed. If any discoloration does NOT disappear within 30 minutes of discovery, consult a healthcare professional immediately. Check inflation frequently, at least once a day! DO NOT use an under-inflated or an over-inflated product because the product benefits will be reduced or eliminated, resulting in an increased risk to skin and other soft tissue. If your product does not appear to be holding air, see TROUBLESHOOTING. If your product is still not holding air, contact your clinical caregiver, distributor, or ROHO, Inc. immediately. DO NOT use the product on top of, or in conjunction with, any other products or materials, unless otherwise indicated in this manual. Doing so may cause the individual to become unstable and vulnerable to falling. If your cushion feels unstable, see TROUBLESHOOTING or consult with a clinician for proper usage. DO NOT place any obstructions (except for a ROHO-provided cushion cover) between the individual and the cushion. Doing so will reduce product effectiveness. Consult with your clinician for proper usage. The cushion and the cover MUST be correctly oriented and sized. If they are NOT, the benefits provided by the cushion may be reduced or eliminated, increasing the risk to the skin or other soft tissue.An amendment to this note indicates nursing staff reported a new incidence of skin impairment on the left ischial tuberosity region from 1/2/26. Patient continues to prefer Broda chair over high-backed wheelchair. Broda chair offers more offloading options, R9 has improved upright posture which corresponds to improved unsupported sitting at EOB (edge of bed) and upright standing in EZ stand. Broda chair has improved patient comfort and has lessened risk for falls and contractures.On 1/9/26, an OT Discharge summary indicates a recommendation for frequent changes in angle of seating or changes of location of sitting to offload buttocks for optimal pressure relief.On 1/14/26, a Nursing Facility Routine Visit Note is written by NP R (Nurse Practitioner). This note indicates R9 was seen for a routine visit and follow up of multiple medical problems. The note also indicates staff deny any concerns for R9. Under the section titled, Assessment multiple conditions for R9 are listed; however, the pressure injury is not mentioned, nor is it mentioned throughout the rest of the note.On 1/16/26 at 12:25 PM, a Skin Assessment was completed. R9's left ischial tuberosity wound measured 3 cm x 2.5 cm x 0.1 cm. Moderate, serosanguineous drainage is present. Granulation tissue makes up 25% to 75% of the wound. Epithelialization is 5% to less than 100% of the wound. Necrotic tissue is present described as adherent, soft, black eschar (necrotic dried, dead tissue) and makes up less than 25% of the wound. PI is currently stage 3. No undermining present. Interventions added or changed: redistribution footboard for the Broda chair, dietician consult, and maintain/improve nutrition and hydration status.The last measurement recorded for this wound was 9 days prior on 1/7/26.On 1/22/26 at 2:19 PM, a Nurse Practitioner's Treatment Order is placed that states Apply narrow bordered Mepilex dressing to the buttock crease every three days PM (evening shift). First date: 1/24/26 (until resolved).On 1/23/26 at 11:11 AM, a Skin Assessment was completed. R9's left ischial tuberosity wound measured 3 cm x 3 cm x 0.1 cm. (Previous measurement was 3 cm x 2.5 cm x 0.1 cm). Moderate, serosanguinous drainage present. Granulation tissue makes up 75-100% of the wound. Epithelialization is present in 5% to less than 100% of the wound. No necrotic tissue is present. PI is currently a stage 3. No undermining is present. No interventions were added or changed.On 1/27/26 at 3:34 PM, a Braden Scale was completed for R9 and scored 13, indicating moderate PI risk.On 1/28/26, a Progress Note by NP R states NP R was updated by the dietitian regarding R9's significant weight loss. A new order was placed for mirtazapine (medication that helps increase appetite). The note does not address the PI.On 1/30/26 at 9:53 AM, a Skin Assessment documented R9's left ischial tuberosity wound measured 3 cm x 3 cm x 0.2 cm. (The wound is 0.1 cm deeper than previous measurements). Small, serosanguinous drainage present. Granulation tissue makes up 25% to 75% of the wound. No epithelialization is present. Necrotic tissue, described as adherent, soft, black eschar makes up 50% to 75% of the wound. PI is currently unstageable. No undermining present. No interventions were added or changed. The comments section states, in part: .Source of pressure appears internal - over bony prominence with known compromised nutritional and mobility status. Will change treatment to built up foam dressing to peri wound to further assist in offloading to area.During the month of January 2026, R9's repositioning documentation indicates he was repositioned between 4-7 times a day, every day.On 2/6/26 at 1:32 PM, a Skin Assessment is completed. R9's left ischial tuberosity wound now measures 3 cm x 3 cm x 0.5 cm. (0.3 cm deeper than on 1/28/26). Moderate, serosanguinous drainage present. Granulation tissue is now pink and/or dull, dusk red and/or fills 25% or less of the wound. No epithelialization is present. Necrotic tissue, described as adherent, soft, black eschar makes up 50% to 75% of the wound. PI is documented as Stage 3. Undermining is now present with 2-4 cm involving less than 50% of wound margins. Length of undermining is 0.8 cm at a direction of 0600-1000 (6:00 to 10:00). Intervention added: nutritional supplement. The comments section states: CURRENT STAGE: UNSTAGEABLE. [sic] Resident denies pain. Increase in wound size anticipated [sic] with breakdown of slough tissue. Provider updated completed 2/4- recommends POC (Plan of Care) discussion towards comfort at family meeting next week.On 2/11/26, a Nursing Facility Acute Visit Note is written by NP R and indicates R9 was seen for a chief complaint of continued decline in status, weight loss, and failure to thrive as reported by a facility nurse. This note does state, in part: . Now has wound to buttocks/hip. Additionally, regarding R9's goals of care, the note states, . Patient's goals of care include focus on comfort. Skin comfort. Low air loss mattress PRN (as needed). Moisture barrier cream: every shift to peri area as tolerated with cares. On 2/12/26 at 2:03 PM, a Skin Assessment is completed. R9's left ischial tuberosity wound now measures 3.5 cm x 3.5 cm, and depth is unable to be determined. Moderate, purulent drainage (thick, pus-like fluid) is present. Granulation tissue is pink and/or dull, dusk red and/or fills 25% or less of the wound. No epithelialization is present. Necrotic tissue, described as adherent, soft, black eschar makes up 75%-100% of the wound. PI is currently Unstageable. Undermining present with 2-4 cm involving less than 50% of the wound margins. Length of undermining is 1.0 cm at a direction of 0600-1000 (6:00 to 10:00). No interventions were added or changed. The comments section states, in part: . Wound presentation and POC discussed with provider and resident/family during family meeting 2/11- discussed poor healing potential and risks vs benefits of continuing with Broda chair for quality of life. Will continue with chair and transition to comfort with Hospice referral due to underlying cancer diagnosis. Goal is comfort and infection prevention with wound treatment. On 2/18/26, a Nursing Facility Routine Visit Note is written by NP R (Nurse Practitioner). This note indicates R9 was seen for a routine visit and medication review. The note also indicates staff deny any concerns for R9. Under the section titled, Assessment multiple conditions for R9 are listed, however the pressure injury is not mentioned, nor is it mentioned throughout the rest of the note.On 2/18/26, R9's Comprehensive Care Plan is updated to include the problem: I have a history of impaired skin integrity to my right heel and current impaired skin integrity to my left ischial tuberosity. I have transitioned to hospice due to overall decline and compromised nutritional status.On 2/19/26 at 2:26 PM, a Skin Assessment is completed. R9's left ischial tuberosity wound now measures 4.5 cm x 4.5 cm, and depth is unable to be determined. Moderate, purulent drainage is present. No granulation tissue or epithelialization is present. Necrotic tissue, described as adherent, soft, black eschar makes up 75%-100% of the wound. PI is currently Unstageable. Undermining present with 2-4 cm involving less than 50% of the wound margins. Length of undermining is 3.0 cm at a direction of 0600-1000 (6:00 to 10:00). No interventions were added or changed. The comments section states, . Hospice admit 2/18- new mattress provided. Large amount of slough tissue removed with dressing removal this date without trauma. Diet downgrade due to overall further decline. Wound healing potential is poor. Goal is comfort and infection prevention. No pain with today's assessment. On 2/27/26 at 12:59 PM, a Skin Assessment is completed. R9's left ischial tuberosity wound now measures 4.5 cm x 4.5 cm x 2 cm. Moderate, purulent drainage is present. Granulation tissue is pink and/or dull, dusk red and/or fills 25% or less of the wound. No epithelialization is present. Necrotic tissue, described as adherent, soft, black eschar makes up 25%-50% of the wound. PI is documented as Stage 3. Undermining present with 2-4 cm involving less than 50% of the wound margins. Length of undermining is 3.0 cm at a direction of 0600-1000 (6:00 to 10:00). Interventions added or changed: hospice consultation. On 2/28/26 at 2:51 PM, a Nurse Practitioner's Treatment Order is placed that states: [NAME] Mepilex Foam with hole cut in center (intent to offload pressure to area)- place over wound with hole exposing wound. Place second intact white foam over first foam and secure it with Medipore tape. Apply to the right greater trochanter (hip). Do not use Mepilex Border-only white thicker mepilex foam.On 3/2/26 at 10:34 AM, a Nurse Practitioner's Treatment Order is placed that states Flush wound using [NAME] syringe (syringe designed for precise irrigation), 30-60 cc (cubic centimeters) of Normal Saline (sterile mixture of sodium chloride and water). Dry gently with gauze. [NAME] Mepilex Foam with hole cut in center (intent to offload pressure to area)- place over wound with hole exposing wound. Place second intact white foam over first foam and secure it with Medipore tape. Apply to the left ischial tuberosity (hip). Do not use Mepilex Border-only white thicker mepilex foam. Once a day on the morning shift. On 3/6/26 at 12:16 PM, a Skin Assessment is completed. R9's left ischial tuberosity wound now measures 4.5 cm x 4.5 cm x 3.0 cm. Moderate, purulent drainage is present. Granulation tissue is pink and/or dull, dusk red and/or fills 25% or less of the wound. No epithelialization is present. Necrotic tissue, described as loosely adherent yellow slough, and makes up 25%-50% of the wound. PI is currently documented as Stage 3. Undermining present with 2-4 cm involving less than 50% of the wound margins. Length of undermining is 3.0 cm at a direction of 0600-1000 (6:00 to 10:00). No interventions were added or changed.On 3/10/26 at 10:31 AM, Surveyor interviewed R9. Surveyor asks R9 if he has any concerns with his skin. R9 indicates he has lots of skin wounds, and that he currently has one on his butt. During this interview, Surveyor observed R9's Hoyer sling to still be underneath him as he was sitting in his Broda chair.On 3/10/26 at 2:45 PM, Surveyor observed R9 sitting in his Broda chair with his hoyer sling underneath him.On 3/12/26 at 1:54 PM, Surveyor interviewed CNA P (Certified Nursing Assistant). CNA P indicated she has worked at the facility for 16 years, and she works on all the units. Surveyor asked CNA P how R9 transfers. CNA P indicates R9 transfers with a Medilift (Hoyer lift). Surveyor asked CNA P if R9's Hoyer sling should be removed from underneath him. CNA P stated, yes. Surveyor asks CNA P why it is important to remove the hoyer sling from underneath the resident. CNA P indicated the sling should be removed to reduce skin breakdown. CNA P indicated that R9 is repositioned at night every 2 hours, and he lays down after breakfast and lunch. Surveyor asked CNA P who is responsible for weekly skin checks. CNA P indicated the nurses complete the weekly skin checks.On 3/12/26 at 2:00 PM, Surveyor interviewed MT O (Medication Tech). Surveyor asked MT O if R9's Hoyer sling should be removed from underneath him. MT O indicated staff leave R9's Hoyer sling underneath him because they are full body slings and since R9 sits in a Broda chair, the slings are left in place because it is harder to get the sling back underneath the resident. Surveyor asks MT O if staff reposition or turn R9. MT O indicates R9 is repositioned every 2 hours night and day. Surveyor asked MT O who is responsible for weekly skin checks. MT O indicates the CNAs usually do the weekly skin checks during showers. There are forms to fill out and staff put the completed sheets in the binder.On 3/12/26 at 2:13 PM, Surveyor interviewed CNA L and asked if staff leave Hoyer slings underneath residents after transferring them. CNA L indicated staff do leave slings under residents if they are putting them in a Broda chair but not a bed. CNA L indicated when residents are in a Broda chair, staff can't get the sling back underneath the resident if they were to remove it. Surveyor asks CNA L which staff members are responsible for weekly skin checks. CNA L indicates CNAs fill out shower sheets and mark any new skin issues. These sheets are then given to the nurse.On 3/12/26 at 2:18 PM, Surveyor interviews CNA Q. Surveyor asks CNA Q how long she has been working at the facility. CNA Q indicates she is agency staff but has worked at the facility for around 4 years. Surveyor asks CNA Q if there is a floor or unit she usually works. CNA Q indicates she works on both floors. Surveyor asked CNA Q if R9's Hoyer sling is supposed to be left underneath him or be taken out. CNA Q indicates his Hoyer sling should be removed from underneath him. Surveyor asks CNA Q why it is important for staff to remove Hoyer slings from underneath residents. CNA Q indicates the sling is removed to relieve pressure. Surveyor asks CNA Q how often R9 is turned or repositioned. CNA Q states every 2 hours or as needed.On 3/12/26 at 3:00 PM, Surveyor interviewed IC F (Infection Control Nurse), who is also employed by the facility as the nurse educator, DON B (Director of Nursing), and CM S (Clinical Manager). Surveyor asks IC F if staff are expected to leave the Hoyer sling underneath the residents after transferring the resident. IC F states, yes. Surveyor asks IC F to help them understand the reasoning behind this practice. DON B indicated this is done for safety, because it is very difficult to get a Hoyer sling underneath someone sitting in a chair and use the lift safely. Surveyor asked DON B what the standard or policy is for turning and repositioning residents. DON B states every 2 hours unless it is individualized per the resident's care plan. Surveyor asks DON B how often R9 is turned or repositioned. Surveyor asked IC F, DON B, and CM S how often weekly skin checks are completed. DON B indicates through the completion of the shower sheets, which are a new practice. Surveyor asked DON B when this practice started. DON B stated since she started at the facility but before 1/1/26. Surveyor asked DON B if she was the one who discovered the pressure injury and DON B stated yes. Surveyor asks DON B if a root cause was determined for the pressure injury. DON B indicated she believes the pressure injury was internal prior to identification. Surveyor asked DON B how the pressure injury was discovered. DON B indicates CNAs found the wound while repositioning R9. Surveyor asks DON B if there is any documentation of the wound prior to 1/2/26. DON B and CM S review the electronic medical record and state, no. Surveyor asks CM S, who is a Wound Care Certified Nurse, if a provider was updated on 1/16/26 following the development of necrotic tissue within the wound bed. CM S indicated, no because the wound stagging was the same from the previous assessment and in her professional opinion, the change did not meet criteria that would require provider notification. Surveyor asks CM S if a provider was updated on 1/23/26 when the wound increased in size from 3 cm x 2.5 cm x 0.1 cm the previous week to 3 cm x 3 cm x 0.1. CM S indicates, no because the wound stagging was the same from the previous assessment and in her professional opinion, the change did not meet criteria that would require provider notification. CM S also indicates provider notification did occur on 1/14/26 per the provider's note. Surveyor asks CM S if there was an alternative note as the one Surveyor reviewed did not state anything regarding a pressure injury. CM S indicates the facility uses provider sheets which contain all information staff need to update the provider on that day. Surveyor requested to review copies of the provider sheets for the past 3 months. CM S indicates they do not retain those records. Surveyor asks CM S if OT evaluated the resident regarding the potential for the PI to be related to his Broda chair. CM S indicates OT evaluated R9 on 1/8/26 and found a potential air leak in the cushion, which was replaced, and a need for repositioning throughout the day. Surveyor asks IC F, DON B and CM S if they know when R9 received the Broda chair. CM S reviews the electronic medical record and indicates R9 received his Broda chair on 12/22/25. Surveyor asks CM S if she saw any signs or symptoms of infection on 2/12/26 with the drainage change from serosanguineous to purulent drainage. CM S indicates no, and she suspects the drainage change is related to the presence of slough tissue and not an infectious source.Surveyor requested to review a standard of practice or equipment manual that recommends leaving the Hoyer sling underneath residents after transfers; however, none was provided.

Based on observation, interview, and record review the facility did not store and prepare food in accordance with professional standards for food service safety. This has the potential to affect all 58 residents. Surveyor observed dried food drips on the outside of the oven doors. Surveyor observed personal, unmarked food in the beverage cooler. Surveyor observed a half loaf of bread undated and with visible freezer burn in the freezer. Surveyor observed burger patties improperly sealed in the freezer. Surveyor observed dessert bars not dated or marked and not properly closed in the bakery freezer. Surveyor observed trash cans in the food prep area to not have lids. Surveyor observed that the test strips to test the parts per million for the sanitizing buckets and three compartment sink were damaged and unusable. Surveyor observed dietary staff not cleaning the thermometer probe between each food during meal service. Surveyor observed a tray with uncovered food being taken down the hall. Evidenced by: The facility policy, titled Refrigerate Storage and Monitoring/Food Storage Procedures, dated 4/10/24, states, in part: . Purpose Statement: Establish guidelines for storage of. food and items necessitation cold storage. 3.6 Perishable employee food must be stored in a refrigerator designated especially for that purpose and clearly labeled Employee Use Only. On 3/10/26 at 8:39 AM, during initial tour of the kitchen with DM C (Dietary Manager), Surveyor observed dried food drips on the outside of the oven doors, personal, unmarked food in beverage cooler, a half loaf of bread undated and with visible freezer burn in freezer, burger patties not properly sealed in the freezer, dessert bars not dated or marked and not properly closed in the bakery freezer, trash cans in the food prep area to not have lids, and observed that the test strips to test the parts per million for the sanitizing buckets and three- compartment sink were damaged and unusable. DM C stated that the test strips must have gotten dropped in the water and been damaged. DM C stated that she checked in her office for more test strips, but the ones she had were expired. DM C indicated that there were no other test strips in the facility for testing parts per million of the sanitizing buckets. On 3/10/26 at 11:02 AM, Surveyor observed [NAME] D during meal tray service. Surveyor observed [NAME] D take a pan of garlic bread from the oven and test it, then set the thermometer temperature probe on the counter. A few minutes later, Surveyor observed [NAME] D take tomato sauce out of the microwave and test it using the same thermometer temperature probe. Surveyor asked [NAME] D when it is appropriate to clean the thermometer temperature probe. [NAME] D stated that normally he cleans it every time before inserting it into a new food but that a couple times he forgot to do that during the meal service. Surveyor asked [NAME] D what his process was for cleaning the thermometer temperature probe. [NAME] D stated that he would clean the thermometer temperature probe with an alcohol wipe for 3 seconds and then let it dry for 3 seconds before inserting the probe into the next food item. (Please note: the thermometer temperature probe should be allowed to dry at least 10 seconds before re-inserting the probe into the next food item to reduce the risk of cross-contamination). On 3/11/26 at 12:06 PM, Surveyor interviewed DM C who stated that she ordered new test strips for the parts per million sanitizer, but that she had not received them yet. DM C confirmed that she did not have any way of testing the chemical parts per million in the sanitizing bucket. On 3/12/26 at 9:23 AM, Surveyor observed a tray with uncovered food being taken down the hall and delivered to a resident's room. On 3/12/26 at 10:16 AM, Surveyor observed DA E (Dietary Aide) using the facility's industrial dishwasher. DA E indicated that they use a high temp dishwasher, and that they take the temperature off the readout and enter it on the temperature log sheet. Surveyor asked about testing the three-compartment sink. DA E stated that usually it was DW J (Dishwasher) that would do that. On 3/12/2026 at 10:48 AM, Surveyor interviewed IC F (Infection Control) nurse and shared the observation of food being carried down the hallway uncovered. IC F stated that the fruit and dessert cups are uncovered on the tray when they are received from the kitchen. Surveyor asked IC F if there could be a risk of airborne contamination if the trays are carried down the hallway with uncovered food. IC F stated that yes, perhaps they should be covered. IC F indicated that she covers her own food when she carries it down the hallway, so the resident's food should probably be covered as well. On 3/12/26 at 12:08 PM, Surveyor observed DW J (Dishwasher) using the facility's industrial dishwasher and three-compartment sink. DW J indicated that he washes the bigger items in the sink. Surveyor reviewed the dishwasher temperature logs with DW J, who stated that the dishwasher readout on the display should be double checked with the attached thermometer gauge on the dishwasher. Surveyor asked DW J how the parts per million (PPM) were tested in the three-compartment sink. DW J showed Surveyor the PPM log, which indicated blanks on 3/8/26 and 3/9/26, but a reading of 600 ppm on 3/10/26 with DA E's initials. On 3/12/26 at 12:17 PM, Surveyor interviewed DM C. Surveyor shared with DM C her observations of food that was open, not labeled, and improperly stored during the kitchen tour. DM C indicated that she had immediately discarded the personal food as well as the half loaf of bread and dessert bars. Surveyor asked DM C about the cleaning of the oven. DM C indicated that all the ovens get a monthly deep clean. Surveyor asked DM C about the test strips for the sanitizing buckets and three-compartment sink and reviewed the PPM log with her. DM C stated that DA E must have used the damaged test strips when he recorded 600 ppm on the log on 3/10/26. DM C stated that she should be receiving new test strips today. Surveyor asked DM C about the trash cans remaining uncovered in the food prep areas. DM C stated that she had the trash can lids ordered. Surveyor shared with DM C the observations of cross-contamination with food temping during meals service and the uncovered fruit and dessert cups observed being carried down the hall. DM C indicated that it was her expectation that the food be prepared, stored, and transferred in a safe and sanitary manner.

Number of residents sampled: 6Number of residents cited: 4Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 11 errors out of 37 opportunities that affected 4 (R3, R8, R15, & R4) out of 6 residents included in the medication pass task, which resulted in an error rate of 29.73%. RN N (Registered Nurse) did not follow facility policy or current standard of practice for the administration of R3's Daptomycin (Antibiotic) through a PICC (Peripherally Inserted Central Catheter) line. MT (Medication Tech) O did not administer the correct dose for R8's ipratropium bromide 0.06% inhalation solution (Nasal spray used to relieve runny nose). Instead of the ordered 2 sprays in each nostril, R8 was only administered 1 spray in each nostril. MT O did not follow facility policy or current standard of practice when administering R15's Artificial Tears eye drops. MT O did not hold R15's eyelids open when administering the eye drops. Surveyor observed LPN I (Licensed Practical Nurse) administer R4's medication late. This is evidenced by: The facility policy titled, Basic Medication Administration Policy, dated 12/18/24, states, in part: . 3.9. Eye Medication . d. Tilt head back slightly. e. Draw lower lid down gently by pressure on maxillary prominence and instruct patient to look upward. f. Drop medication into the mid lower eye area . (Of note: Surveyor requested a policy regarding intranasal medications, however none was provided). The facility policy, Basic Medication Administration, revised 12/18/24, states in part, as follows: Purpose: To provide for safe and appropriate administration of only medications to residents(s) at facility. General Medication Administration: All medications must be given within 1 hour before or 1 hour after scheduled time. If the medication is given before or after the 1-hour time allotment, a medication error will be noted per policy. Example 1 R3's Physician Orders: Daptomycin 100 MG (milligrams) injection to run over 30 minutes via PICC line. 0800 (8:00 AM). On 3/11/26 at 08:59 AM, Surveyor observes RN N (Registered Nurse) administer an injection of Daptomycin to run over 30 minutes. When assessing for patency of the PICC line, RN N failed to aspirate for blood return. Upon RN N programming the pump, Surveyor asked RN N to state her settings. RN N states she set the pump to 100 MG in 50 mL (milliliters) to run over 30 minutes, at a rate of 100 mL/hour (milliliters per hour). After RN N started the infusion, Surveyor reviewed the medication label on the 50 mL bag of IV fluid. Surveyor noted that the total volume of the bag is listed as 70 mL (milliliters). (Of note: This means that 20 mL would not be infused within the 30-minute timeframe for administration. The added bag volume is due to the addition of the antibiotic medication into the already existing 50 mL of IV solution). On 3/11/26 at 1:11 PM, Surveyor interviewed RN N. Surveyor asked RN N what the process is for administering intravenous medication through a PICC line. RN N indicates she starts by priming the line (allowing medication to flow through IV tubing to remove air before connecting the tubing to the patient), check the medication administration record for the dose, rate, and medication orders, review the 5 rights of medication administration, set up the pump, flush the PICC line, then administer the medication. Surveyor asked RN N if she should aspirate for blood return prior to administering the medication. RN N indicates she did not because she drew labs from the PICC line 30 minutes to 1 hour prior to administering the medication, but you should. Surveyor asked RN N what volume she set the pump. RN N states 50 mL. Surveyor asked RN N if she knows the total volume that was in the bag. RN N states 70 mL. Surveyor asked RN N if the total volume in the bag should have been administered. RN N indicates she sets the pump to 50 mL then goes back to check the bag to make sure all the medication was administered. Surveyor asked why is that important to set the pump for the total volume. RN N indicates because the medication needs to be given within 30 minutes. RN N also indicates she has never had the issue of medication left in the bag when setting the pump to the 50 mL volume. On 3/11/26 at 2:50 PM, Surveyor interviewed IC F (Infection Control Nurse), who also works as the facility's nurse educator. Surveyor asked IC F what education she provides to staff regarding PICC lines. IC F indicates she conducts in-person training with staff utilizing training arms that allow staff to practice accessing lines and setting pumps. IC F also indicates when a resident is admitted with a PICC line she does on the spot training with staff to refamiliarize them with the process and is available almost 24/7 for any staff who have questions. Surveyor asked IC F if competency checks are completed for staff. IC F states yes. Surveyor asked IC F if she would aspirate for blood return prior to administering medication through a PICC line. IC F indicates if it was her, she would have but does note RN N advised her she drew blood for labs 30 minutes before medication administration and has not had time to look up the standard of practice. On 3/11/26 at 1:44 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the process is for administering IV medications through a PICC line. DON B indicates to follow the SASH (Saline-flush with saline, A-administer medication, S-flush with saline again, H-heparin in the line to prevent clots) method, prepare the medication, check the medication administration record, prime the tubing, clean port with an alcohol wipe, connect tubing, set up pump, review the 5 rights of medication administration, administer the medication, flush the line and administer heparin to prevent clots. Surveyor asked DON B if staff should aspirate for blood return prior to administering medication. DON B states, yes. Surveyor asked DON B if the pump should be set to the bag volume or total volume. DON B indicates, initially it can be set to bag volume, then staff can go back to reset the pump to receive all the medication. Surveyor asked DON B if the pump should be set so the medication is administered according to order, as in over the 30-minute timeframe. DON B indicates, yes. Example 2 R15's Physician Orders: Artificial Tears Solution to eye(s) (both) 1 drop three times daily 0800 (8:00 AM) 1400 (2:00 PM) 2000 (8:00 PM) On 3/11/26 at 8:02 AM, Surveyor observes MT O (Medication technician) administer medications to R15. When administering the Artificial Tears, MT O held the dropper above R15's eyes and administered a drop without holding open R15's eyelids or requesting R15 to hold open his eyelids. Surveyor observed R15's eyes to be almost completely closed when the medication was administered. On 3/11/26 at 8:20 AM, Surveyor interviewed MT O. Surveyor asked MT O if she should hold open the resident's eyelids when administering eye drops. MT O indicates she should unless the resident can keep their eye open without someone holding the eyelids. On 3/11/26 at 1:44 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B to describe the process for administering eye drops. DON B indicates staff should perform hand hygiene, check the medication administration record, review the 5 rights of medication administration, don gloves, provide tissue to the resident, press on the inner part of the eye, and administer the medication. Surveyor asked DON B if staff should hold residents' eyelids open when administering eye drops. DON B states, yes. Surveyor asked DON B if it is acceptable to have residents hold their own eyelids open while receiving eyedrops. DON B indicates she would not as it is standard of practice to have the staff member hold the eyelids open. Surveyor asked DON B if medications should be administered according to physician order. DON B states yes. Example 3: R8's Physician Orders: Ipratropium Bromide 0.06% Solution. Nasal (both) (2 sprays) three times daily. 0800 (8:00 AM) 1100 (11:00 AM) 1700 (5:00 PM) On 3/11/26 at 8:13 AM, Surveyor observes MT O (Medication technician) administer medications to R8. When administering the ipratropium bromide nasal spray, MT O only administered 1 spray into each nostril, when the order states 2 sprays in each nostril. On 3/11/26 at 8:20 AM, Surveyor interviewed MT O. Surveyor asked MT O how many sprays of ipratropium bromide nasal spray she administered to R8. MT O indicates 1 in each nostril. Surveyor asked MT O how many sprays she should administer. MT O indicates she wants to wait until after R15 eats breakfast to administer the second spray. On 3/11/26 at 1:44 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if two nasal sprays per nostril are ordered, should they be administered at the same time. DON B states yes. Surveyor asked DON B if medications should be administered according to physician order. DON B states yes. Example 4: R4's Physician Orders, signed 3/3/26, include, in part, the following medications: 1. Ascorbic Acid 500mg (milligram) tablet by mouth two times daily 8:00 AM and 5:00 PM to prevent nutritional deficiency 2. MiraLAX (Polyethylene Glycol 3350 17g (grams)/scoop Powder by mouth daily 8:00 AM for constipation 3. Allopurinol 100mg (milligram) tablet by mouth (2) (tabs) daily 8:00 AM for gout 4. Aspirin 81mg (milligrams) tablet delayed release by mouth daily 8:00 AM 5. (Plavix) Clopidogrel Bisulfate 75mg (milligrams) by mouth daily at 8:00 AM 6. Acetaminophen 500mg (milligrams) by mouth (2) (tabs) three times daily with meals 8:00 AM, 12:00 (Noon) 5:00 PM 7. Lisinopril 20mg (milligrams) tablet by mouth by mouth daily 8:00 AM for hypertension (high blood pressure) 8. Sertraline 50mg (milligram) tablet by mouth ***75mg dose***daily 8:00 AM for depression On 3/10/26 at 9:30 AM, Surveyor observed LPN I (Licensed Practical Nurse) administer the eight (8) medications above to R4. R4's medication administration was outside the hour before and hour after window, this resulted in 8 medication timing errors. On 3/12/26 at 2:10 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor shared the medication error rate with DON B. Surveyor asked DON B, do you expect staff to follow physician orders. DON B stated, yes. Surveyor asked DON B, when a medication is ordered to be administered at 8:00 AM, what time would you expect the medication to be administered. DON B stated an hour before or an hour after the order time. Surveyor asked DON B, when a medication that is ordered for 8:00 AM is administered at 9:30 AM, is this considered a medication error. DON B stated, yes, correct. Surveyor shared the medication errors for R4 with DON B. Surveyor asked DON, would you expect staff to administer the R4's medications within an hour before or an hour after the ordered time of 8:00 AM. DON B stated, yes.

Based on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature for 1 of 15 sampled Residents (R19) R19 stated they were served cold food at meals. 1 of 1 test trays were observed to have food being served at undesirable temperatures. Evidenced by: The facility policy, titled Food and Nutrition - Tray Line Taste and Temperature Log Procedures, dated 10/15/24, includes in part: .3.1 Meals Served at Set Time. food is served at the appropriate temperature. to monitor taste and temperature on the service line for patient/resident food service. standard temperatures.Hot Entrees >= 140 degrees FahrenheitHot Vegetables >= 140 degrees FahrenheitHot Soup, Sauces, Gravies, Hot Beverage & Cereal >= 140 degreesCold Items <= 41 degrees Fahrenheit (or less)Frozen <= 0 degrees Fahrenheit (or less). Example 1: On 3/11/26 at 10:06 AM, Surveyor interviewed R19 who stated that the food at the facility tastes terrible. R19 indicated that she eats her meals in the dining room, and that the food is not served hot. R19 clarified that it is not every meal, but that a lot of the time the food is not served hot, and that lately the meals have been served very late. On 3/12/26 at 11:35 AM, Surveyor received a test tray after all the dining room and hall trays had been served. Surveyor took the temperatures of the food that was served, which included the following:Pork loin 118.9 degrees FahrenheitRice with tomatoes and spinach 148.8 degrees FahrenheitPeas 128.5 degrees FahrenheitMixed fruit cup 52 degrees FahrenheitPeach cobbler 53.8 degrees FahrenheitMilk 52 degrees FahrenheitCoffee 119.5 degrees FahrenheitSurveyor noted that many of the food items served were in the temperature danger zone, and that the hot foods were not served hot enough nor the cold foods cold enough. On 3/12/26 at 12:17 PM, Surveyor interviewed DM C (Dietary Manager) and asked what the safe temperature was for serving hot and cold foods. DM C stated that the serving temp of the pork should be at least 145 degrees Fahrenheit. Surveyor shared with DM C the temperatures taken of the test tray and asked if she would expect the food to be served at a safe and palatable temperature. DM C stated yes, that would be her expectation.

Based on observation, interview, and record review, the facility did not ensure nursing staff followed professional standards of practice when flushing a peripherally inserted central catheter (PICC) for 1 of 1 resident (R3) reviewed for intravenous medication administration.RN N (Registered Nurse) did not follow facility policy or current standard of practice for the administration of R3's Daptomycin (Antibiotic) through a PICC (Peripherally Inserted Central Catheter) line. RN N failed to check for blood return prior to administering the intravenous medication. RN N also failed to set the pump to administer the medication according to physician order. Evidenced By: The facility policy titled, Peripherally inserted central catheter (PICC) drug administration, dated 9/14/25, states, in part: . Implementation . While maintaining sterility of the syringe tip, attach a prefilled 10-mL syringe or a syringe specifically designed to generate lower injection pressure containing preservative-free normal saline solution to the needless connector. Unclamp the catheter and, if not contraindicated, aspirate slowly for a blood return that's the color and consistency of whole blood. If you don't obtain a blood return, take steps to locate an external cause of obstruction . According to the National Institutes of Health (NIH), before flushing the lumen with 0.9% sodium chloride, aspiration of blood should be attempted to ensure patency. The volume of fluid used for flushing should be twice the volume of the lumen.Source: https://www.ncbi.nlm.nih.gov/books/NBK594495/R3 was admitted to the facility on [DATE] with diagnoses including infection and inflammatory reaction due to internal right knee prosthesis (infection of his artificial right knee joint), urinary tract infection, and malignant neoplasm of prostate (prostate cancer).R3's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 2/18/26 indicates R3 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating he is cognitively intact. Section O indicates R3 is receiving IV (intravenous) medication and has Central access (example: PICC).R3's Physician Orders:Daptomycin 100 MG (milligrams) injection to run over 30 minutes via PICC line. 0800 (8:00 AM).On 3/11/26 at 8:59 AM, Surveyor observes RN N administer an injection of Daptomycin to run over 30 minutes. When assessing for patency of the PICC line, RN N failed to aspirate for blood return. Upon RN N programming the pump, Surveyor asked RN N to state her settings. RN N stated she set the pump to 100 MG in 50 mL (milliliters) to run over 30 minutes, at a rate of 100 mL/hour (milliliters per hour). After RN N starts the infusion, Surveyor reviewed the medication label on the 50 mL bag of IV fluid. Surveyor notes that the total volume of the bag is listed as 70 mL (milliliters).(Of note: This means that 20 mL would not be infused within the 30-minute timeframe for administration. The added bag volume is due to the addition of the antibiotic medication into the already existing 50 mL of IV solution). On 3/11/26 at 1:11 PM, Surveyor interviewed RN N. Surveyor asked RN N what the process is for administering intravenous medication through a PICC line. RN N indicates she starts by priming the line (allowing medication to flow through IV tubing to remove air before connecting the tubing to the patient), check the medication administration record for the dose, rate, and medication orders, review the 5 rights of medication administration, set up the pump, flush the PICC line, then administer the medication. Surveyor asked RN N if she should aspirate for blood return prior to administering the medication. RN N indicates she did not because she drew labs from the PICC line 30 minutes to 1 hour prior to administering the medication, but you should. Surveyor asked RN N what volume she set the pump. RN N stated 50 mL. Surveyor asked RN N if she knows the total volume that was in the bag. RN N stated 70 mL. Surveyor asked RN N if the total volume in the bag should have been administered. RN N indicates she sets the pump to 50 mL then goes back to check the bag to make sure all the medication was administered. Surveyor asked why is that important to set the pump for the total volume. RN N indicates because the medication needs to be given within 30 minutes. RN N also indicates she has never had the issue of medication left in the bag when setting the pump to the 50 mL volume. On 3/11/26 at 2:50 PM, Surveyor interviewed IC F (Infection Control Nurse), who also works as the facility's nurse educator. Surveyor asked IC F what education she provides to staff regarding PICC lines. IC F indicates she conducts in-person training with staff utilizing training arms that allow staff to practice accessing lines and setting pumps. IC F also indicates when a resident is admitted with a PICC line she does on the spot training with staff to refamiliarize them with the process and is available almost 24/7 for any staff who have questions. Surveyor asked IC F if competency checks are completed for staff. IC F stated yes. Surveyor asked IC F if she would aspirate for blood return prior to administering medication through a PICC line. IC F indicates if it was her, she would have but does note RN N advised her she drew blood for labs 30 minutes before medication administration and has not had time to look up the standard of practice. Surveyor requested RN F's most recent competency assessment.IC F provided Surveyor with a blank competency assessment she uses to assess all staff, including new hires and agency staff. This document is titled, Flushing of PICC and Medication Administration Competency Assessment and is dated 10/2022. This document stated, in part: . Flushing of Catheter with Normal Saline. 6. The RN demonstrates the steps in flushing PICC. Aspirate for blood flow/catheter patency. If no blood flow, reposition the arm. IC F indicates she is unable to locate RN N's competency assessment, however she is positive one was conducted when RN N was hired.On 3/11/26 at 1:44 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the process is for administering IV medications through a PICC line. DON B indicates to follow the SASH (Saline-flush with saline, A-administer medication, S-flush with saline again, H-heparin in the line to prevent clots) method, prepare the medication, check the medication administration record, prime the tubing, clean port with an alcohol wipe, connect tubing, set up pump, review the 5 rights of medication administration, administer the medication, flush the line and administer heparin to prevent clots. Surveyor asked DON B if staff should aspirate for blood return prior to administering medication. DON B stated, yes. Surveyor asked DON B if the pump should be set to the bag volume or total volume. DON B indicates, initially it can be set to bag volume, then staff can go back to reset the pump to receive all the medication. Surveyor asked DON B if the pump should be set so the medication is administered according to order, as in over the 30-minute timeframe. Surveyor asked DON B if medications should be administered according to physician order. DON B stated yes.RN N was observed not following the policy and procedure for IV medications.

Based on observation, interview, and record review, the facility did not ensure adequate interventions were in place for safety to prevent accidents from occurring for 1 of 3 residents (R4) reviewed for falls. R4 was admitted with a known history of falls. The facility did not ensure adequate fall interventions were in place upon admission, resulting in R4 having a fall with a distal fibular (lower end of the calf bone near the ankle) fracture.Evidenced by: The facility's policy titled, Fall Prevention and Management Procedure, dated 12/19/24, indicates, in part: Purpose Statement: To establish procedure for residents at risk for falls; to systemically assess fall risk factors; provide guidelines following a fall and resident specific fall preventive interventions. 3.1 Fall Risk - Individual Resident: a. Upon admission. a registered nurse will assess each resident for risk of falls using the Morse Fall Scale. b. If determined to be at risk for falling, the resident's interdisciplinary care plan will identify him/her as at risk, along with providing interventions to provide safety for the resident. 3.2 Prevention Interventions/Strategies: . d. Interdisciplinary care plans will provide interventions for each resident to assist with keeping resident safe.R4 admitted to the facility on [DATE] with diagnoses that include, in part: Vascular dementia, mild, with anxiety, adult failure to thrive, Pain in left hip, Other chronic pain, Strain of muscle, fascia and tendon of the posterior muscle group at thigh level left thigh, Depression unspecified, and Other Alzheimer's disease.R4's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/26 documents R4's Brief Interview of Mental Status (BIMS) score of 8 out of 15, indicating R4 has moderate cognitive impairment. R4's fall care plan upon admission, dated 2/4/26, states, in part: Problem: I have impaired physical mobility due to dementia. I have a history of falls.Goal: I will be free from falls.Intervention: Refer me to PT (physical therapy).Intervention: Administer my pain meds.Intervention: Praise my progress.R4's Comprehensive Care Plan, dated 2/4/26, states, in part: . Turn me AM shift. Turn me PM shift. Turn me NOC (overnight) shift.R4's Morse fall risk assessment score on 2/4/26 at admission was 90, indicating high fall risk.On 3/10/26 at 9:50 AM, Surveyor observed R4 in her room with a walking boot on left foot. R4 stated she fell and broke her foot a few weeks ago and went to the emergency room (ER).On 2/21/26 R4's fall summary report, provided by the facility, indicated the following: Fall Summary: .Resident was laying on her right side with her knees bent and her feet under the register. She was leaning on her right elbow with head elevated leaning on the side of the bed. She denies hitting head. States that she has no pain except to her left hip (chronic pain). Resident was assisted off the floor with 3 people and Medi-lift. No complaints of pain to the right side and ROM (range of motion) intact. C/o (complaints of) pain to left hip. Difficulties assessing pain as resident gives very non-specific answers regarding her pain to her left hip and she already has known limitations. Limited ROM to left hip/knee. With subsequent follow-ups resident complained of pain to left hip and then when asked to move her left leg could not move it and states it hurts.R4's ER note, dated 2/21/26, provided by the facility, states the following, in part: . female with history of dementia presenting. after a fall. Staff found her on the ground next to her bed. She does not appear to have any new injury. However, she is. unable to report what happened. She was reportedly complaining of left leg pain. However, staff state that it looked like she landed on her right side. She reportedly has been having left hip pain for weeks, and a recent MRI from a few days ago showed a possible left sacral insufficiency fracture. She also seems to have a lot of ankle pain. No prior ankle x-rays on file. reviewed the x-rays. She is a distal fibular fracture. short leg post mold splint. was applied.On 2/21/26 a progress noted entered into R4's electronic medical record states, in part: Received report from ER nurse stating that resident has a fibula fracture of the left foot and a splint was applied and is to be left in place until follow-up with ortho. Resident should be non-weight bearing on the left leg.R4's Morse fall risk assessment score on 2/21/26 at re-admission was 75, indicating high fall risk.On 2/21/26 R4's Comprehensive Care Plan was updated to include the following:Problem: I have impaired physical mobility due to dementia.Goal: I will be free from falls.Intervention: Posey alarm to bed.Intervention: Low bed.Intervention: Transfer me AM shift with 2 assist with Medi-lift.Intervention: Transfer me PM shift with 2 assist with Medi-lift. On 2/23/26 R4's Comprehensive Care Plan was updated to include the following: Problem: I need assistance due to progression of dementia - my husband was no longer able to care for me at home.Intervention: Last round toileting at 2 pm.Intervention: Last round toileting at 10 pm.Intervention: Last round toileting 5 am.Problem: Left distal fibula fracture.Intervention: Left ankle splint at all times.Problem: I have the potential for falls related to cognitive impairment, lack of safety awareness, history of falls.Intervention: TDWB (touch down weight bearing) left lower extremity. R4's Incident SBAR, provided by the facility, indicated the following, in part: Situation: [Resident Name] was noted to be laying in bed resting prior to fall. [Resident Name] started yelling for help. Resident said the pillow at her back made her feel stuck and tried to get up. She attempted to exit the bed, and slid down to the floor, landing on her right side with knees bent and feet were under the register. Pain was noted to the left hip. Resident complained of pain during ROM and stated it hurt.Background: Resident. admitted on [DATE], from hospital, following a fall at home. Husband was no longer able to care for her at home. admitted for rehabilitation and long-term care. [Resident Name] admitted with transfer status from bed to chair as non-weight bearing due to medical condition.Assessment: Review of resident BIMS indicates she has scored a 7 and 8 recently, indicating moderate memory impairment. Review of care plan indicates facility had a fall care plan in place and had identified that she was identified as a high fall risk and was undergoing physical therapy to help identify and mitigate her risks. Interview with resident indicates she remembers attempting to stand up, although could not recall details in depth. She did remember trying to get up on the bed after falling.Recommendation: Posey alarm added to bed and care plan to assist in notification of staff to resident's need of assistance. Low bed added to bed and care plan for safety.On 3/11/26 at 2:58 PM, Surveyor interviewed DON B (Director of Nursing) about R4's fall. DON B stated that she was working as a floor nurse at the time of the fall. DON B indicated that R4 had multiple things going on at home prior to her admission, including a lot of pain in her hips and thighs and inability to bear weight. DON B stated that R4 had multiple falls at home, and the husband would pick her up. Surveyor asked DON B what fall interventions had been in place prior to R4's fall on 2/21/26. DON B stated that prior to the fall R4 had turn and reposition schedule, so staff were checking on her often and last round toileting on the ends of the shifts to make sure that incontinence was not a factor in trying to get out of bed. DON B stated that R4 is very immobile, so they were surprised to see that she got out of bed on her own. Surveyor asked DON B if a full assessment including ROM (Range of Motion) had been completed on R4 after the fall. DON B stated that the issue with R4 is that she had no complaints of pain on the right side which was the side she landed on. DON B indicated that R4 had complained of pain on her left side which is the side that she has chronic pain. DON B stated that she asked R4 to move her leg and she would not move it for her. DON B stated that she always does a full assessment before getting any resident off the floor, and that she did ROM with R4 the best that she could with the position that R4 was in. DON B stated that R4 had complained of no ankle pain, in either leg, both prior to getting her off the floor and afterwards. DON B indicated that after R4 was in bed she continued to assess her, but that it was difficult to assess if there was anything new happening. DON B indicated that R4 returned from the ER with a splint, but that it was changed to a pneumatic boot (medical or recovery device that uses inflatable air chambers to provide support, compression, and adjustable stability to the lower leg and foot.) at her follow-up appointment with orthopedics on 3/2/26. DON B stated that R4 is non weight bearing to that leg, but that she can toe touch for transfers.On 3/12/26 at 1:14 PM, Surveyor interviewed CNA L (Certified Nursing Assistant) about R4's fall interventions before and after the fall. CNA L stated that R4 had just been transferred to her floor, so she wasn't sure about her fall interventions, but they would be on her care plan.On 3/12/26 at 2:51 PM, Surveyor interviewed DON B about R4's fall interventions before and after the fall. DON B stated that the admissions coordinator had indicated that R4's falls at home were due to weakness and transferring with her husband so there was no need for an alarm or anything upon admission. DON B stated that R4 doesn't get out of bed by herself, so they were surprised when that happened. DON B indicated that because R4 does not move by herself or try to climb out of bed, there had been no need for a low bed intervention. Both of these interventions were added to R4's care plan after the fall.The facility failed to ensure that adequate fall interventions were established upon admission for a resident with a known history of falls at home, thereby failing to keep R4 safe from a fall.

Based on observation, interview and record review, the facility did not provide nail care assistance for 1 of 1 (R19) dependent resident reviewed for Activities of Daily Living (ADLs) assistance.Staff did not assist R19 with nail care assistance even after Surveyor informed staff that the nails were digging into the palm of R19's contracted hand.Evidenced by:Facility policy, titled Foot and Nail Care for Long Term Care Residents, dated 11/28/22 with last review date of 12/31/24, states, . Purpose: To provide a consistent and safe method for the provision of foot and nail care for all adult residents. nail and foot care can be performed by Registered Nurses, Physicians, and appropriately trained assistive personnel .R19 was most recently admitted to the facility on [DATE] with diagnoses that include, Anxiety disorder, Depression unspecified, Ischemic Stroke (blood clot that blocks blood flow to the brain), and Contracture of muscle of right forearm. R19's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/30/25 documented that R19 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R19 has is cognitively intact. R19's Care Plan, includes, in part:Problem: I need assistance with my ADLs due to recent fall with fractures. Date Initiated:9/30/24.Intervention: Weekly nail care Wednesday AM. Date Initiated: 3/21/16.Problem: I have impaired physical mobility related to right sided weakness r/t (related to) previous CVA (cerebrovascular accident, i.e. stroke). Date Initiated: 3/21/16.On 3/11/26 at 10:06 AM, Surveyor interviewed R19 and observed moderately long fingernails on her right contracted hand, such that the thumb nail was poking up between the forefinger and middle finger on her right hand. R19 stated she needs staffs' assistance with clipping her fingernails. R19 stated staff tell her they will get to it when they have time; however, staff never seem to have the time. R19 stated the nails on her right hand are digging into her palm.On 3/11/26 at 3:42 PM, Surveyor accompanied CNA K (Certified Nursing Assistant) to R19's room to view R19's hand. With the assistance of CNA K, R19 was able to open her contracted right hand. Surveyor observed that the skin of R19's palm was intact. Surveyor and R19 pointed out to CNA K that R19 needed to have her nails trimmed. CNA K stated that a day shift nurse normally trims R19's nails.On 3/12/26 at 9:34 AM, Surveyor spoke with R19 in the hallway and asked if her nails had been trimmed. R19 indicated her nails still had not been trimmed. R19 stated that she was sure that the staff would get to it when they had time.On 3/12/26 at 1:16 PM, Surveyor interviewed CNA L and asked her how often R19 had her nails trimmed. CNA L stated that R19's nails were trimmed every week on her shower day.On 3/12/26 at 2:48 PM, Surveyor interviewed DON B (Director of Nursing) and asked how often R19 had her nails trimmed. DON B indicated that R19's nails were trimmed weekly by staff on her bath day or as needed. DON B stated R19 would let staff know. Surveyor shared with DON B that R19 had let staff know yesterday that her nails were digging into her palm and needed her nails trimmed; however, staff had still not trimmed R19's nails per her request. Surveyor asked DON B if staff should be assisting R19 with having her nails trimmed and per her need and/or request. DON B stated yes, staff should be assisting R19 with her nail care.

Based on interview and record review, the facility failed to immediately consult with 1 of 3 residents (R61) physicians when there was a significant change in the resident's physical status.The facility did not immediately contact a physician after R61 experienced decreased peripheral capillary oxygen saturation (SPO2) on two (2) consecutive days.This is evidenced by:The facility policy titled Resident Change in Condition Policy with a review date of 9/29/25 states in part; an Registered Nurse (RN) will assess residents exhibiting a change in condition and will inform resident, their physician, and responsible party. 3.1 The Nursing staff will update the residents attending physician or designee when: b. There is a significant change in the residents' physical, mental, or psychosocial status.R61 was admitted to the facility on [DATE] with diagnoses that include chronic diastolic heart failure (long term condition where the heart muscles become too stiff to relax and fill properly with blood between beats.) and atherosclerotic heart disease of native coronary artery (resident has plaque buildup narrowing the natural arteries supplying your heart.)R61's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/17/2025 states that R61 has a Brief Interview of Mental Status (BIMS) of 13 out of 15, indicating that R61 is cognitively intact.On 2/13/26 at 12:22, R61 had orders to administer oxygen via oxygen concentrator 1L-2L/min (liters per minute) continuous to keep O2 sat (oxygen saturation) greater than or equal to 90% or for clinical signs and symptoms (S/Sx) of shortness of breath (SOB)/dyspnea.On 2/18/26, R61 was seen by MD (Medical Doctor) with no new orders.On 2/18/26 AM (morning) charting in EMAR (electronic medication administration record) stated SPO2 83% on 3L. PM (evening) charting in EMAR stated 87% on 3L.No progress note with signs or symptoms was documented. No documentation that the physician had been notified.On 2/19/26 In AM R61's SPO2 was 87% on 2L, charted in EMAR. PM EMAR stated SPO2 at 87% on 2L. No other documentation in EMR regarding signs and symptoms or notification to the physician.On 2/20/26 a progress note was written as bed hold issued and appeal rights outlined.On 2/20/26 at 5:24 PM progress note states, CALL PLACED TO: Son and daughter in law REGARDING: Call placed shortly after resident was transferred to the ED (emergency department) to the family reporting resident condition and that transfer to the ED via 911 occurred. Questions answered, Support provided.CALL PLACED TO: FMP H (Family Medicine Physician) SPOKE WITH: nurse at the clinic. REGARDING: Resident transfer to the ED and updated on resident admission to [Hospital Name].On 3/12/26 at 2:45 PM, Surveyor asked RN G (Registered Nurse) when a resident has an SPO2 below the range in their O2 order, should the Provider be updated on the reading. RN G stated yes. Surveyor asked RN G Was R61's provider updated about her low readings on 2/18/26 and 2/19/26. RN G stated that it doesn't look like it. Surveyor asked RN G if R61 had any other signs or symptoms besides low SPO2. RN G stated nothing is documented in the chart about the incident.On 3/12/26 at 3:20 PM, Surveyor asked DON B (Director of Nursing) would you expect the resident's provider to be updated if SPO2 is below the range given in the oxygen order. DON B replied yes.On 3/12/26 at 4:10 PM, Surveyor asked FMP H would you expect the resident's provider to be undated when R61's SPO2 was below 90%. FMP H stated yes.The facility did not immediately contact a physician after R61 experienced decreased peripheral capillary oxygen saturation (SPO2) on two (2) consecutive days.

Based on observation, interview, and record review the facility did not provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 Residents (R41) reviewed for catheters.R41 has a history of bladder disorders and MRSA (methicillin-resistant Staphylococcus aureus, a bacteria that is resistant to many antibiotics) in the urine. CNA M (Certified Nursing Assistant) did not utilize aseptic technique to minimize the risk of cross contamination from microorganisms in the environment.Evidenced by:The facility's policy, Perineal Care/Catheter Care, dated 1/3/22 with last review date of 12/31/24, states, in part: Purpose:. Residents with indwelling catheters will receive catheter care with morning and evening cares, or as indicated in the plan of care. 3.1 Steps for Perineal Care:. b. Assemble equipment as needed for perineal care on bedside table providing barrier on table with paper/cloth towels. 3.4 Catheter Care: a. Complete perineal care prior to completing catheter care.R41 was admitted to the facility on [DATE] with diagnosis that include, in part: Other specified disorders of the bladder, unspecified dementia, Major depressive disorder, anxiety disorder, and repeated falls. R41's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/10/26 documents that R41 has a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating that R41 is severely cognitively impaired.R41's Comprehensive Care Plan states, in part: . Problem: I have indwelling catheter due to decreased mobility due to traumatic acetabular fracture. Imaging during fracture work up noted urinary retention. Catheter placed and provider indicates desire to continue due to obstructive uropathy and neurogenic component due to nature of fracture. Intervention: Catheter care with morning and evening care. Date Initiated: 11/19/25. Problem: I have a history of MRSA - urine. Goal: EBP (Enhanced Barrier Precautions) will reduce transmission of resistant organism to others. Date Initiated: 6/30/26.On 3/12/26 at 9:31 AM, Surveyor observed CNA M (Certified Nursing Assistant) and CNA L perform perineal and catheter care with R41. Surveyor observed CNA M place a basin of soapy water directly on R41's bedside table right next to several open drinks with straws in them. CNA M proceeded to use this basin on the bedside table to complete R41's perineal care. On 3/12/26 at 10:02 AM, Surveyor interviewed CNA M about R41's perineal and catheter cares. Surveyor asked CNA M if she should use a clean barrier on the bedside table when performing R41's cares. CNA M states yes, sometimes she puts a paper towel on the bedside table under the water basin to prevent water from splashing everywhere. Surveyor asked CNA M if placing a paper towel on the bedside table would also prevent contamination from microorganisms in the environment. CNA M stated yes, she could see where that would be beneficial.On 3/12/26 at 10:46 AM, Surveyor interviewed IC F (Infection Control Nurse) and shared with her the observation of R41's perineal and catheter care. Surveyor asked IC F if CNA M should have placed a barrier down on the bedside table before performing perineal cares. IC F states yes, it would not be a bad idea to do that, and she would have to check to see if it was part of the facility policy. On 3/12/26 at 2:55 PM, Surveyor interviewed DON B (Director of Nursing) and shared with her the observation of R41's perineal and catheter care. Surveyor asked DON B if CNA M should have placed a barrier down on the bedside table before performing perineal care. DON B stated yes, they have to put a barrier down for infection control purposes.

Based on interview and record review, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 out of 4 sampled residents (R1) by failing to serve R1 the correct diet and failing to administer first aid (Heimlich Maneuver) timely when R1 experienced a choking episode. R1 experienced a choking episode that required the Heimlich maneuver to clear R1's airway. The facility did not complete all assessments of Vital Signs (VS) and respirations over the next 24 hours. At supper the following day, the facility did not ensure that R1 received the proper downgraded diet of bite sized and soft food items. R1's meal card indicated R1 could be served a dinner roll, which was served. R1's new downgraded diet does not allow dinner rolls. R1 experienced another choking episode prior to leaving the dining room from supper. First aid (Heimlich maneuver) was not administered immediately and R1 expired. The facility's failure to complete frequent and thorough assessments, failure to provide the proper diet, and failure to administer first aid immediately created a finding of immediate jeopardy that began on 6/24/25. INHA A (Interim Nursing Home Administrator) and INHA B were notified of the immediate jeopardy on 7/9/25 at 3:35 PM. The immediate jeopardy was removed on 7/21/25, however, the deficient practice continues at a scope severity of a D (Potential for more than minimal harm/isolated) as the facility continues to implement its action plan.Findings include: According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.The International Dysphagia Diet Standardization Initiative (IDDSI) website's (https://www.iddsi.org/) IDDSI Framework and Detailed Level Definitions, dated July 2019, states, in part: 6 Soft and Bite-Sized Description/characteristics.soft, tender and moist throughout but with no separate thin liquid.Food Specific or Other Examples: .Bread No regular dry bread, sandwiches, or toast of any kind. The website's Frequently Asked Questions page, (USIRGFAQExceptionsBreadsMixedConsistencyJan2025.pdf), dated January 2025, states, in part: . Part 1: Bread.Soft and Bite-Size, Level 6 and Minced and Moist, Level 5 do not include regular dry bread, sandwiches, or toast of any kind, even if they are cut-up to the appropriate size indicated for each diet level. Use pre-gelled soaked breads that are very moist and gelled through the entire product. The facility's Life Support Certifications and Course Requirements policy, dated 2/17/25, states, in part: .The purpose of this document is to establish and outline standards for facility's American Heart Association (AHA) Training Center and facility life support requirement. This policy is complimentary to the AHA Center standards. 3.1 Managing Certifications a. Certifications in BLS (Basic Life Support) .are recognized solely from the AHA.The facility's first aid training, Basic Life Support Provider Manual eBook, undated, states, in part: Choking Relief in a Responsive Adult or Child: Abdominal Thrusts Use abdominal thrusts to relieve choking in a responsive adult or child.Choking Relief in an Unresponsive Adult or Child. A choking victim's condition may worsen, and the victim may become unresponsive. If you are aware that a foreign-body airway obstruction is causing the victim's condition, you will know to look for a foreign body in the throat. To relieve choking in an unresponsive adult or child, follow these steps: 1. Shout for help. If someone is available, send that person to activate the emergency response system. 2. Gently lower the victim to the ground if you see that they are becoming unresponsive. 3. Being CPR, starting with chest compressions. Do not check for a pulse. Each time you open the airway to give breaths, open the victim's mouth wide. Look for the object. A. if you see an object that looks easy to remove, remove it with your fingers. B. If you do not see an object, continue CPR. 4. After about 5 cycles or 2 minutes of CPR, activate the emergency response system if someone has not already done so.Heimlich Maneuver works by using the air in the lungs to push an object out of the airway, when performing abdominal thrusts, to restore normal breathing when an individual is choking. R1 was admitted to the facility on [DATE] with diagnoses that include, in part: unspecified dementia, severe, with mood disturbance (a condition with a decline in mental ability severe enough to interfere with daily life); unspecified dementia, severe, with anxiety; other persistent atrial fibrillation (a heart rhythm disorder which leads to the heart beating irregularly and rapidly); muscle weakness generalized.R1's admission Minimum Data Set (MDS), dated [DATE], indicates Self-Care Eating ability score of 5, indicating need for set up or clean up assist.R1's quarterly Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. R1's physician orders include:*DNR (Do Not Resuscitate)*General Level 7 foods-regular-easy to chewR1's care plan includes:*3/20/25.Problem: Cognition: I am alert and oriented to self and family. I am able to communicate some of my needs and wants to staff.*3/21/25.nurse aide.transfer me with 1 assist with EZ stand*3/31/25.nurse aide.monitor me for an increased difficulty with my chewing and/or swallowing abilityR1's progress notes include:*6/23/25 9:54am choking on whole fruit with Heimlich maneuver performed for removal.call received from hall indicating resident actively choking with Heimlich being performed. Upon arrival, writer confirmed code status and observed staff still actively and unsuccessfully attempting Heimlich maneuver. At that time, writer phoned 911 for assist and instructed staff to continue with firm Heimlich application. While on the phone with 911 operator, staff achieved successful removal of food item and resident breathing improved.*6/23/25 11:43 AM call received from ER (emergency room), ready for discharge; CXR (chest x-ray) completed and negative, VS (vital signs) have remained stable. Stay and work up unremarkable.*6/23/25 12:54 PM RN (Registered Nurse) was sitting at nurses' station helping another nurse when CNA (Certified Nursing Assistant) called out. Other nurse went to see what CNA needed in patient's room. CNA yelled that patient was choking. This nurse ran in room to assist. Nurse noted that patient was sitting in recliner, pallor was gray, lips and around eyes was turning blue and unable to speak. Patient was not breathing. When nurse asked CNA what happened CNA stated, her husband brought her fruit, and she was actively eating it when I walked into the room. She is choking on a piece of fruit. CNA was instructed to get behind patient to do the Heimlich maneuver. Instructed another nurse to call to upstairs unit to have other RN come down to assist. After approximately 10 thrusts, patient coughed out a piece of cantaloupe and was able to breathe. Patient started to respond and speak when EMS (Emergency Medical Services) arrived. Prepared transfer. Patient was sent to the ER for evaluation.R1's Emergency Department Provider Note, dated 6/23/25, states, in part: Patient presenting with complaints of choking episode that has since resolved after Heimlich. She does not have any signs of trauma. Nontender abdomen, lung sounds clear bilaterally. Plan for x-ray to rule out aspiration. Vitals normal. Low suspicion for rib fracture. Plan for DC (Discharge).Patient Instructions: You were seen in the ER after an aspiration event (the accidental inhalation of foreign material, like food, into the airway and lungs). You received an x-ray that did not show any signs of pneumonia or damage to the lung itself. Follow up with your primary care doctor within 1 week.On 7/7/25 at 10:33 AM, Surveyor interviewed FM Q (family member) and asked about events of 6/23/25. FM Q stated that while visiting R1, R1 was eating cantaloupe in R1's room and then R1 didn't talk. FM Q noted that R1 was digging in R1's mouth with R1's fingers and when FM Q asked what was wrong, R1 didn't say anything, but kept digging. FM Q stated FM Q went to alert staff as FM Q noted R1 was getting paler. FM Q stated 3 staff responded, they called 911 and were tapping resident on R1's back, but R1 didn't respond. FM Q stated that one of the aides crawled up in the resident's chair and got arms around R1 and performed thrusts. FM Q stated that one of the staff opened R1's mouth and pulled out a piece of cantaloupe. FM Q stated that when the EMTs arrived, R1 was breathing and had eyes open. FM Q stated they took R1 to the ER.On 7/7/25 at 11:11 AM, Surveyor interviewed CNA F regarding the incident on 6/23/25. CNA F stated that when walking down the hall, CNA F noted FM Q come into the hall and check the call light. CNA F indicated a feeling that something was needed by R1, and CNA F went into R1's room to ask. CNA F stated that FM Q stated, I think R1 is choking. CNA F stated that R1 was not breathing and was very gray in color. CNA F stated that CNA F started hitting R1 on the back with an open hand and yelled for the nurse. CNA F stated that LPN E (Licensed Practical Nurse) came to the door and LPN E yelled for RN R (Registered Nurse). CNA F stated that RN R arrived and instructed to start the Heimlich. CNA F stated that CNA F positioned self behind R1 in R1's recliner and started the Heimlich. CNA F stated that CNA F would do the Heimlich a couple times, then look to see if R1 would respond, then RN R would do back blows, then alternate. CNA F stated there were about 2 cycles of this alternation before RN U arrived and stated to just continue the Heimlich. Surveyor asked if R1 had a history of swallowing issues. CNA F stated no.On 7/7/25 at 12:56 PM, Surveyor interviewed RN U and asked about the 6/23/25 incident. RN U stated that LPN E called about a dire situation. RN U stated that on arrival, RN U noted R1 slumped over in recliner, color pale, with staff performing Heimlich. RN U indicated verifying R1's code status in the chart and calling 911. Surveyor asked about treatment for choking. RN U stated perform the Heimlich immediately. RN U stated that back blows are not typically performed on an adult.On 7/8/25 at 10:56 AM, Surveyor interviewed RN R. RN R indicated being at nurses' station with LPN E and hearing CNA F yell from R1's room. RN R stated that LPN E went to R1's room and RN R heard CNA F yell that R1 was choking. RN R stated that RN R ran to R1's room and saw R1 blue around lips, drooling, and R1's eyes were fixed. RN R stated R1 was choking and unresponsive. RN R indicated instructing CNA F to perform the Heimlich and RN R did alternating back blows. RN R indicated instructing LPN E to contact RN U to call EMS. RN R stated that R1 coughed up a piece of cantaloupe and her skin started to pink and R1 was coming back around. RN R stated that when R1 left for the ER, RN R requested that R1 be in a common room or with staff for eating until a swallowing evaluation was done. Surveyor asked RN R about treatment for choking. RN R indicated that if person is responsive the Heimlich is performed, if unresponsive back blows and Heimlich. R1's Therapy Screen notes include:*6/23/25 1:39 PM Therapy Screen request: please screen episode of choking on piece of fruit provided by family required Heimlich intervention. Currently on regular diet.*6/24/25 10:12 AM Therapy Screen response: 6/24/25-Requested orders. Thank you. Diet downgrade to IDDSI-Level 6. Soft and bite sized solids.R1's Physician Orders state:*6/23/25.Nutritional Problem.Diet Order: General Level 6 foods- soft and bite sized. An (International Dysphagia Diet Standardization Initiative) (IDDSI) framework provides a standardized system for describing food and drink consistencies for individuals with swallowing difficulties (dysphagia). (Soft Bite-sized level 6 - soft bite sized food which is a level 6 on IDDSI framework).*6/23/25.meal assist: Partial assistOn 7/8/25 at 9:19 AM, Surveyor interviewed SLP I (Speech Language Pathologist) who indicated R1 was independent with eating, ate meals in the dining room, and was on a general diet until R1's episode on 6/23/25. SLP I indicated after the first choking episode SLP I conducted a screen on R1. SLP I indicated R1's screen showed R1 needed to have a swallow study completed so SLP I contacted R1's Medical Doctor to obtain an order for a swallow study. While waiting for the swallow study, SLP I downgraded R1's diet to an IDDSI level 6 diet.R1's meal ticket, undated, is printed with the following:*Starter: 1 chocolate milk 240cc (cubic centimeters); 1 2% milk; 2 Skim Milk 240cc*Hot Prep: blank*Cold Prep: 1 Dinner Roll ea (each)*HSM (Hillside Manor) IDDSI SB6R1's progress notes include:6/23/25 3:14 PM spoke with POA (Power of Attorney) regarding patient's visit to ER. Informed POA that it would be preferred for patient to be in the common area/dining room for meals and snacks for precautions. POA also informed that patient was placed on 24-hour monitoring for VS (vital signs) and respirations.6/23/25 5:27 PM respirations normal lung sounds clear diminished.Important to note: there are no vital signs documented with 6/23/25 5:27 PM respiratory assessment.6/24/25 4:36 AM respirations: normal lung sounds: upon auscultation clear Blood Pressure 116/56 Pulse 71 temperature 95.9 respirations 16 O2 (oxygen) saturation 98% on room airImportant to note: there are no vital signs or respiratory assessment documented for 6/24/25 morning shift.6/24/25 6:51 PM This writer was paged to go to the 1st floor dining room to assist with resident. Upon arrival to dining room this writer observed several CNAs assisting resident, performing the Heimlich maneuver, resident pale, nonresponsive, without respirations, CNA G on phone with 911. Resident taken out of dining area, away from other residents, continuing Heimlich maneuver. Once in hallway this writer continued speaking with 911 operator, providing operator with pertinent resident information as CNAs transferred resident out of wheelchair onto floor as Heimlich maneuver not effective, chest compressions initiated at this time. NHA A (Nursing Home Administrator) and ADON D (Assistant Director of Nurse) arrived to assist, noted that resident had an active DNR (Do not Resuscitate) order, DNR bracelet on resident's left wrist, compressions stopped. ADON D and NHA A remained with resident and staff until EMTs (Emergency Medical Technicians) arrived.6/24/25 6:02 PM call placed to (POA) notified of resident passing due to witnessed choking episode-Heimlich unsuccessful and resident became unresponsive; resident is DNR (Do Not Resuscitate)-CPR (Cardiopulmonary Resuscitation) ceased per resident wishes. EMTs (Emergency Medical Technicians) arrived and verified DNR (Do Not Resuscitate) status and absence of VS (Vital Signs) at 1739 (5:30 PM) .On 7/7/25 at 1:29 PM, Surveyor interviewed CNA L about 6/24/25 incident. CNA L stated that CNA L was seated at the corner of the dining room table assisting residents to each side of CNA L to eat their supper. CNA L stated that R1 was next to one of those residents and R1 was self-feeding. CNA L stated that the resident between CNA L and R1 had finished with supper and left the dining room and that CNA L's partner, CNA J, was also gone from the dining room, leaving CNA L alone with the residents. CNA L indicated seeing little glimpses of R1 eating but concentrating attention on the resident that CNA L was feeding on the opposite side. CNA L indicated that R1 started to wheel away from the table, but CNA L wasn't observing her. CNA L stated that R1 wheeled behind CNA L. CNA L stated, I am only one person, and it is stressful in the dining room as there are quite a few feeders (residents that need to be assisted). CNA L stated that CNA J returned to the dining room and noted that R1 was blue. CNA L stated that the emergency was radioed (call for assistance), and other CNAs came to assist and one of them started the Heimlich. Surveyor asked if there was any intervention for R1 prior to the other CNAs arrival and starting the Heimlich. CNA L stated, I took the palm of my hand and patted her neck lightly, when we were waiting for help; it was just CNA J and me and R1 was bigger than us; we waited for help.On 7/7/25 at 1:50 PM, Surveyor interviewed RN M about 6/24/25 incident. RN M indicated hearing an alert regarding assist being needed in the dining room and went to assist. RN M stated R1 was slumped over and discolored, with a nurse checking pulse and a CNA on phone with 911. RN M stated an additional CNA was performing the Heimlich. RN M stated R1 was not breathing, and someone stated there was no pulse. RN M stated that RN M advised staff to move R1 into the hallway, away from the residents in the dining room. RN M stated that after moving R1 into hall, someone indicated to get ADON D and RN M went to do so. Surveyor asked about treatment for choking. RN M stated if they can talk/cough, call for help, no action; if they cannot talk/cough, call 911 and begin Heimlich and back blows. RN M stated continue until they clear, or they become unconscious. Surveyor asked what happens when they become unconscious. RN M stated check for pulse and make another decision; hopefully the RN is making the decision, it is not the CNAs call to make. I would keep doing the Heimlich until told by EMS not to.On 7/7/25 at 2:54 PM, Surveyor interviewed CNA G about 6/24/25 incident. CNA G indicated being on a resident unit when CNA J came to the unit and said R1 was purple and possibly choking. CNA G stated on arrival in the dining room, R1 was slumped over, purple, unresponsive and didn't appear to be breathing. CNA G stated, assuming R1 choked, CNA J got behind her, started doing the Heimlich, and said someone should call 911. CNA G stated CNA J dialed 911, then handed the phone to CNA G. CNA G stated CNA J said they should move R1 out of the dining room, away from the other residents. CNA G stated RN S arrived at some point while R1 was getting out of the dining room and took the phone from CNA G. When in the hall, R1 was transferred to the floor and CNA H started to do compressions. CNA G indicated being told to go downstairs to direct EMS to the correct location and on return with EMS, CPR had been stopped. Surveyor asked CNA G about treatment for choking. CNA G stated Heimlich maneuver, uncertain of any difference with unresponsive resident. Surveyor asked if R1 had previous concerns with swallowing. CNA G stated no problems until 6/23/25 when R1 choked on fruit.On 7/7/25 at 3:19 PM, Surveyor interviewed CNA H about 6/24/25 incident. CNA H stated the event was so traumatizing that only pieces are remembered. CNA H stated that someone radioed on the walkie talkie, but CNA H was unable to determine what was said. CNA H stated that CNA J came running to the unit and said that R1 was choking and turning blue. CNA H and CNA G ran to the dining room and attempted the Heimlich but didn't see anything come from her mouth. CNA H stated that someone said to remove R1 from the dining room and onto the floor and someone called 911. CNA H stated that 911 said to start CPR. CNA H stated that CNA H did one set of compressions, asked about a pulse, and was told that there was no pulse. Surveyor asked CNA H about treatment for choking. CNA H stated Heimlich maneuver, uncertain of any difference with unresponsive resident. On 7/8/25 at 9:30 AM, Surveyor interviewed CNA J about 6/24/25 incident. CNA J stated that CNA J had taken a resident away from the dining room and returned to the dining room in less than 5 minutes. Upon return to the dining room, CNA J noted R1 sitting behind CNA L with her head down further than normal and color appearing pale to purple. CNA J stated CNA J called R1's name and placed a hand on R1's shoulder to straighten R1 in the chair. CNA J stated there was mucous coming from R1's mouth and R1 was unresponsive. CNA J stated, I think R1 is choking. CNA J indicated leaving the dining room and running to the resident unit to find assist. CNA J indicated that CNA G and CNA H were at the nurses' station and the 2 CNAs started back to the dining room. CNA J stated that on the return to the dining room, CNA J used the walkie talkie to contact RN S to come assist with R1. CNA J stated that on return to the dining room, CNA L was standing next to R1, calling R1's name, CNA G started the Heimlich and said to call 911, and CNA J dialed the phone. Surveyor asked CNA J about length of time between finding R1 unresponsive and when CNA G started the Heimlich. CNA J said approximately 3 minutes. CNA J stated that CNA G did about 3 thrusts before CNA J gave CNA G the phone to speak with 911. CNA J reports starting to do the Heimlich. CNA J stated that RN M arrived and instructed to take R1 to the hallway. CNA J stated that in the hallway, R1 was moved to the floor and CNA H started compressions. CNA J stated that at some point RN S arrived and spoke with 911, then ADON D arrived and stated to stop compressions due to DNR status. On 7/8/25 at 1:27 PM during interview, CNA P (Certified Nursing Assistant) indicated CNA P was not sure what to do if CNA P suspected a resident had choked but is now unconscious. CNA P asked RN Educator M what to do. RN/Educator M indicated CNA P should keep trying to get more help while getting resident to the ground where she can begin abdominal thrusts and/or chest compressions on the unconscious person.On 7/8/25 at 2:27 PM, Surveyor interviewed ADON D (Assistant Director of Nursing) and asked if R1 had any swallowing concerns. ADON D indicated no recollection of R1 working with speech therapy prior to 6/24/25. Surveyor asked about care plan entry from 3/31/25 indicating need to monitor for difficulty with chewing and/or swallowing. ADON D stated this entry was made by the registered dietician (RD). Important to note: RD was out of office and unavailable for interview. Surveyor asked about interventions put into place for R1 following the choking incident on 6/23/25. ADON D stated that R1's diet was downgraded to IDDSI level 6, a speech screen was requested, R1 was changed to partial assist for meals (monitor from a distance-no need for 1 on 1), and respirations and vital signs were monitored for 24 hours. Surveyor asked how often vital signs and respirations were to be assessed. ADON D stated every shift. Surveyor reviewed documentation following 6/23/25 incident. ADON D indicated that there were no vital signs documented for the 6/23/25 5:27 PM assessment and there were no vital signs or respiratory assessment for 6/24/25 AM shift. ADON D stated that ADON D would have expected those assessments to be completed and documented. Surveyor asked ADON D about treatment for choking. ADON D stated all staff are trained in BLS (basic life support). The standard is to encourage coughing, summon assist, and if necessary, begin the Heimlich. Resident is removed from a common area for their dignity and to protect other residents from a traumatic event. Heimlich is performed until the object is expelled and the resident is breathing, or, if they become pulseless/non-breathing and they have a DNR, we stop; if they are a full code, we'd perform CPR. Surveyor asked if there was an investigation following the 6/24/25 incident. ADON D stated yes, all the CNAs and nurses were asked for statements. ADON D indicated that ADON D went to food/nutrition services to validate the meal served. Surveyor asked who served R1's meal. ADON D indicated no knowledge of who had served the meal. Surveyor asked how staff summon help in an emergency. ADON D stated via walkie talkie, phone, or voice/yelling. Surveyor asked when the CNA is expected to summons help. ADON stated immediately.On 7/8/25 at 3:21 PM during interview, SLP I indicated residents on a IDDSI level 6 diet cannot have a dinner roll. SLP I indicated there are exceptions made for certain residents on IDDSI level 6 diets. SLP I stated, I had not completed a formal evaluation for R1. Her order was for a level 6 diet with no exceptions. She could not eat bread.On 7/8/25 at 4:03 PM, Surveyor interviewed DME V (Deputy Medical Examiner) and asked about R1's autopsy. DME V stated there was evidence of choking; substance was hard to determine 100%, but it seemed to be a starchy substance, potentially mashed potato. Surveyor asked if DME V was aware that R1 had been served a dinner roll. DME V stated no, DME V had been told cod and mashed potatoes.On 7/8/25 at 4:34 PM, Surveyor interviewed ADON D and asked if residents receiving an IDDSI level 6 diet are to receive bread products. ADON D stated there is an allowance at times. Surveyor asked if R1 had an allowance and was to be served bread. ADON D stated no. On 7/8/25 at 5:10 PM, Surveyor interviewed NHA A and asked about the 6/23/25 incident. NHA A stated that all nursing staff present were asked to write a statement. Surveyor asked if CNA H, who performed compressions, was asked for a statement. NHA A indicated that NHA A did not realize that CNA H was present, and no statement had been requested. On 7/8/25 at 2:40 PM, DA K (Dietary Aide) stated to Surveyor, R1's meal ticket only had drinks and a dinner roll on it, but no food was ordered for her. It was blank. DA K also stated, I put butter on her roll and cut it into bite sized pieces. I had to go upstairs to get a tray that was mistakenly delivered up there. In the meantime, I don't know what happened. I came back and saw staff around R1 who looked pale. On 7/8/25 at 6:03 PM, Surveyor interviewed DA K (Dietary Aide) and asked if residents on IDDSI level 6 can have bread products. DA K indicated yes, they can with a waiver. Surveyor asked DA K if R1 had a waiver in place. DA K stated, No, I didn't make up the tray. I just served it. I was in dining room already when the trays came up. I gave R1 the tray. I cut cod up. I buttered the roll and cut it up. I only work there once a week and the week prior R1 was a general diet. I normally read the ticket and this time there was nothing on the meal ticket except for drinks and dinner roll. DA K indicated using the ticket to verify the food on the plate matches the food listed on the ticket, but DK A was unable to do that this time.On 7/9/25 at 9:16 AM, RN N (Registered Nurse) stated to Surveyor, When we get an order for a diet change, it gets changed in the care plan and in the orders. Then the system prints off a sheet that states the change. We fax this to dietary staff at the hospital. We are all responsible for making sure the cards are correct. We have diet sheets printed off in the dining room with all the diets on it and all staff, including dietary have access to these sheets.On 7/9/25 at 9:20 AM during interview, ADON D (Assistant Director of Nursing) indicated it is all staffs' responsibility to make sure the meal tickets and the meal are accurate prior to serving the resident.On 7/9/25 at 9:36 AM during interview, Nutrition Services District Manager O indicated hospital staff realized there was a mistake made and began putting together a response plan. Nutrition Services District Manager O stated, We needed to make immediate changes and acted right away. Nutrition Services District Manager O indicated the hospital staff received training on IDDSI levels for food and drinks. They ordered red placemats for all high-risk meal trays and began using them right away when they arrived. Nutrition Services District Manager O indicated she does not know why the Nursing Home Administration team was not made aware of the mistake and she now plans to include the nursing home staff in the education regarding IDDSI levels and on the new system for making sure residents are served the correct food items.On 7/9/25, Surveyor asked NHA A (Nursing Home Administrator) if dietary staff were asked to give statements. NHA A indicated being unaware that dietary staff were passing meal trays and therefore dietary staff were not asked about the incident and should have been. Surveyor asked NHA A if R1 should have received the correct diet. NHA A stated that the correct diet is expected to be served.During the partial extended survey conducted on 7/21/25, facility staff were not able to identify food items that are appropriate in accordance with the International Dysphagia Diet Standardization Initiative despite receiving education as part of the facility's initial removal plan. Additionally, staff in the facility were working with residents without knowledge of emergency procedures for choking despite recent education provided as part of the facility's initial removal plan.On 7/21/25 at 9:19 AM, CNA W (Certified Nursing Assistant) indicated to Surveyor residents on IDDSI level 5, 6, and 7 diets can have bread products.On 7/21/25 at 9:31 AM, CNA Y indicated to Surveyor residents on level 6 and 7 diets can have bread products.On 7/21/25 at 9:55 AM, CNA P indicated to Surveyor she was unsure which diet levels can have bread products and which ones cannot.On 7/21/25 at 10:28 AM, CNA X indicated to Surveyor if she saw a resident actively choking in the dining room she would run and go get the nurse. CNA X indicated she would leave the resident while she retrieved a nurse.On 7/21/25 at 10:41 AM, LPN E (Licensed Practical Nurse) indicated to Surveyor she would expect a CNA who observes a resident to be choking to call a nurse for help, then she expects the nurse to perform an RN assessment, to call 911, and then to start the Heimlich maneuver. LPN E indicated an RN has to assess before a CNA initiates the Heimlich maneuver.On 7/21/25 at 11:21 AM, INHA B (Interim Nursing Home Administrator) and RN M (Registered Nurse) indicated to Surveyor all staff were educated related to providing emergency care to a choking resident and how to identify foods within all levels of the International Dysphagia Diet Standardization Initiative. INHA B and RN M indicated all staff are basic life support certified and should know what to do in the event of a resident choking and they should know who can and who can't have bread products according to their ordered diet.The failure to serve the correct diet to a resident, failure to complete frequent and thorough assessments, and failure to administer first aid (Heimlich Maneuver) immediately created a reasonable likelihood for serious harm which created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 7/21/25, however the deficient practice continues at a scope severity of a D (Potential for more than minimal harm/isolated) as the facility continues to implement the following action plan.All nursing and dietary staff will be educated prior to start of their next shift regarding the facility policy and procedure on diet changes and location of diet lists. New staff to be educated regarding this process during orientation. The IDT and dietary staff are to ensure all new orders and dietary changes are communicated to the dietary department by the nurse entering the dietary order. Nursing staff to relay new dietary orders during huddle and changes to the diet are posted in each wing daily. This process and education began on 7/21/2025 and ongoing.Dietary cards were

Based on interview and record review, the facility did not ensure residents were seen by a physician every 30 days for the first 90 days after admission and every 60 days thereafter for 1 of 1 residents (R1) reviewed for physician visits. R1 was not seen by a provider at least once every 30 days for the first 90 days after admission.This is evidenced by:Facility policy, titled Physician Visits Policy, reviewed 12/31/24, includes: The physician needs to see a newly admitted resident at a minimum of once every 30 days for the first 90 days and then at least every 60 days thereafter.R1 was admitted to the facility on [DATE] with diagnoses that include, in part: unspecified dementia, severe, with mood disturbance (a condition with a decline in mental ability severe enough to interfere with daily life); unspecified dementia, severe, with anxiety; other persistent atrial fibrillation (a heart rhythm disorder which leads to the heart beating irregularly and rapidly); muscle weakness-generalized.R1 was seen by his physician on 3/12/25.There is no evidence of R1 being seen by a physician in April, therefore missing a 60-day visit after admission.On 7/21/25 at 10:00 AM, ADON D (Assistant Director of Nursing) stated, There should be a physician's visit and signed orders for April, but they were missed.On 7/21/25 at 11:21 AM, INHA B (Interim Nursing Home Administrator) indicated R1 should have had a physician visit at 30 days, 60 days, and 90 days from her admission, but the 60 days visit was missed.

Based on observation, interview, and record review, the facility did not ensure that each resident receives adequate supervision to prevent accidents for 1 of 2 Residents (R3) reviewed for dining supervision.R3 is care planned for feeding assistance and direct supervision with meals and was observed eating in dining room with no staff seated at table.Evidenced by:Surveyor requested dining / meal supervision policy. NHA A (Nursing Home Administrator) indicated that the facility does not have a separate policy, but follows state and federal regulations for adequate supervision for residents as denoted on the individual care plan.R3 was admitted to the facility on [DATE] and has diagnoses that include Parkinson's disease with dyskinesia (a progressive neurological disorder that primarily affects movement, causing symptoms like tremors); dementia in other diseases classified elsewhere, unspecified severity, with mood disturbance (a decline in mental ability severe enough to interfere with daily life); dysphagia, unspecified (difficulty swallowing foods or liquids, ranging from mild difficulty to complete and painful blockage); essential tremor (a neurological condition causing involuntary rhythmic shaking, most commonly in the hands).R3's most recent quarterly Minimum Data Set (MDS) indicates a Brief Interview of Mental Status (BIMS) score of 4, indicating moderate to severe cognitive impairment.R3's care plan states, in part; *4/10/25 Nutritional Problem: I have a significant tremor which is now worsening which places limitations on my ability to feed myself independently. I now require feeding assistance by staff.general set up assistance as well as direct supervision and cuing and feeding assistance.*4/20/25 Nurse aide-monitor me for any increase difficulty with my chewing and/or swallowing abilityR3's Speech Therapy Discharge summary, dated [DATE], states, in part: Pt (patient) and care staff will utilize safety of swallow guidelines including upright positioning, slow rate, small bites, alternating liquids and solids, clearing mouth before next bite, cues to remain on task, continue with meal; assistance in drinking and eating if patient demonstrates weakness or difficulty. Discharge 1/30/25.with support from care staff for safety of swallow guidelines.On 7/8/25 at 8:48 PM, Surveyor observed R3, seated at dining room table alone, feeding himself mandarin oranges and drinking Glucerna (liquid supplement). CNA J (Certified Nursing Assistant) was seated with her back towards R3, at another table, assisting 2 residents with their meals. CNA T entered the dining room at 9:03 AM with another resident and served that resident their meal.On 7/8/25 at 9:03 AM, Surveyor interviewed CNA T and asked if R3 needed assistance with meals. CNA T stated, I don't think so. CNA T then left the dining room.On 7/8/25 at 9:12 AM, CNA J approach Surveyor indicating her departure from the dining room. Surveyor asked CNA J if CNA J was allowed to leave the dining room as no staff members would be in the room and 2 residents were still eating. CNA J stated that the residents in the dining room were from another hall and that hall's staff should be returning to the dining room. Surveyor asked CNA J to remain in dining room. Surveyor asked CNA J if any residents in the dining room needed assistance with meals. CNA J stated that R3 needed assistance when his blood sugar was low. CNA J stated that CNA J would assist R3 if working on his hall. Surveyor asked CNA J how a CNA is aware that someone needs assistance with meals. CNA J stated when a resident is sluggish or not awake/not feeding themselves; a CNA can see that they need help. Surveyor asked if there is any documentation that tells the CNA that a resident needs assist. CNA J stated that in the computer charting it would say assistance with meals. Surveyor asked if there was anything in R3's charting stating that R3 needed assistance. CNA J stated not in the CNA charting, as far as I know.On 7/8/25 at 4:34 PM, Surveyor reviewed R3's care plan with ADON D (Assistant Director of Nursing) and asked about the meaning of direct supervision, cuing, and feeding assistance. ADON D stated that it meant that someone should be sitting at the table with R3 and assisting R3 with eating.

Based on observation, interview and record review, the facility did not ensure prompt resolution of all grievances for 2 of 3 residents (R1 and R2) reviewed for grievances. R1's Representative voiced concerns related to R1 sitting wrong in a shower and rushing R1 with meals not allowing her to finish. The facility failed to follow up on these concerns using their grievance policy and procedure. R2's Resident Representatives voiced concerns during a meeting and these concerns were documented in R2's medical record. The facility failed to follow up on concerns using the facility's policy and procedure for grievances. Evidenced by: Facility policy, titled Resident Rights/Organizational Ethics Policy, reviewed 12/31/24, includes: A grievance is a formal or informal written or verbal complaint that is made by a resident or the resident's representative about care and treatment furnished as well as that which has not been furnished, the behavior of staff and other residents and other concerns regarding the stay. Grievances include but are not limited to complaints about treatment furnished as well as that which has not been furnished, care, management of funds, any suspected violation of state or federal nursing facility regulations ., lost clothing, violation of resident rights, and complaints related to behavior of other residents . It is the policy of the facility that each resident and/or resident representative has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal . the facility will designate a Grievance Official who is responsible for oversight of the grievance process . the grievance process includes receiving and tracking grievances through to their conclusions, leading any necessary investigations by the facility, work with facility staff utilizing root cause analysis process for resolution of the grievance or concern . The grievance official, administrator and his or her designee will be forwarded all . grievances electronically within one working day of receiving the grievance. The grievance official, administrator, and his or her designee will acknowledge receipt of the grievance to the resident or resident representative that submitted the grievance . the grievance official, administrator, or his or her designee will thoroughly investigate the grievance . Some grievances may require more extensive investigation. If the grievance cannot be resolved . the grievance official, administrator, or his or her designee will inform the resident or resident representative that the facility is still working to resolve the grievance . All documentation and evidence demonstrating the result of all grievances shall be retained for a period of no less than 18 months from the issuance of the grievance decision. All residents and our resident representative will provide a notice of rights at the time of admission both orally and in writing in a format and a language he or she understands and that includes how to file grievance. This will include . the right to obtain a conclusion regarding his or her grievance . grievances may be submitted verbally or in writing as well as anonymously . Example 1 R2 admitted to the facility on [DATE]. R2's most recent MDS (Minimum Data Set), with ARD (Assessment Reference Date) of 6/12/25, indicates R2's cognition is severely impaired with a BIMS (Brief Interview for Mental Status) score of 6 out of 15. R2's Hospice Note, dated 6/19/25, includes: Resident Representative . did share some concerns including late breakfast, patient needing help completing menus, using a different lift . Facility grievance log, from 5/1/25 to 6/23/25, does not contain any grievances related to R2's representatives concerns. On 6/23/25 at 11:27 AM during an interview RN E (Registered Nurse) indicated there are no grievances recorded for R2. On 6/23/25 at 2:36 PM, SW F (Social Worker) indicated NHA A (Nursing Home Administrator) is the facility's Grievance Official. SW F indicated she was unaware of R2's concerns and if she had been she would have looked into them. SW F indicated all concerns voiced should be followed up on using the facility's grievance process unless they meet the definition of abuse. SW F indicated the facility can not track and trend concerns if they are not recorded on one log. On 6/23/25 at 3:23 PM, SW F indicated Hospice workers should report all grievances, concerns, complaints to the facility and/or fill out a grievance form for the resident and turn it in. SW F indicated she is unsure which facility staff member is responsible for following up on grievances recording in hospice notes. On 6/24/25 at 9:45 AM Hospice Services Interim Manager G indicated concerns related to a resident's meals being late, needing a different lift, or needing assistance with a task are grievances and she was not familiar with the facility's grievance process. Hospice Services Interim Manager G indicated she was not sure who from the facility is responsible for following up on grievances recorded by hospice staff. On 6/24/25 at 10:00 AM Hospice Services RN H (Registered Nurse) indicated she has never filled out a grievance for a resident who voiced concerns to her and she is unfamiliar with the facility's grievance process. On 6/24/25 at 10:37 AM, NHA A indicated she is the facility's Grievance Official. NHA A indicated she was unaware of concerns recorded in R2's hospice notes, but they are grievances and the facility should follow their grievance process. NHA A indicated hospice staff who receive concerns should tell the floor nurse and fill out a grievance form for/with the resident. NHA A indicated all grievances should be recorded in one spot, on the grievance log and there is no grievance for R2 on the log. On 6/24/25 at 2:45 PM RN I indicated she has never filled out a grievance form and she just tells one of the social workers concerns that are voiced to her. RN I indicated a family member voicing concerns related to a late meal is a grievance. RN I indicated a family member voicing concerns about needing a different lift is a grievance. RN I indicated a family member voicing concerns related to a patient needing additional help is a grievance. On 6/24/25 at 4:33 PM during a phone interview, DON B (Director of Nursing) indicated she expects when a resident or a resident representative voices a grievance to staff and hospice staff, they go directly to the floor nurse to report it. DON B indicated they can record it in (Electronic Charting System), but they should also follow the facility's grievance process. Example RR D voiced concern for R1 which was not added to the facility grievance log to be investigated. R1 admitted to the facility on [DATE] and had diagnoses that include: age related osteoporosis (a disease that weakens bones, making them more susceptible to fracture); hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness following a stroke); vascular dementia (a type of dementia caused by reduced blood flow to the brain, which damages brain tissue and impairs cognitive function). R1's Minimum Data Set (MDS) dated [DATE], indicates a Brief Interview of Mental Status (BIMS) score of 99, meaning R1 was unable to complete the interview due to not being able to respond to the questions and/or R1 was unable to understand the questions. A facility self-report indicates that on 5/31/25, RR D expressed concerns to the facility, including; * .RR D was a little frustrated with CNA C because RR D was trying to feed R1 and RR D felt like the CNA was in a rush. This happened on 2 occasions. * .RR D felt like the CNA had not positioned R1 correctly on the shower chair On 6/23/25 at 1:40 PM, Surveyor interviewed RR D, who stated CNA C had come to give R1 a bath, but the meal had come late, so RR D was still feeding R1. RR D stated CNA C threw hands in the air and stated, oh no, what am I going to do and was upset. RR D stated CNA C left the room to take care of another resident and came back a bit later. RR D stated that when CNA C returned, RR D pushed R1's meal aside and told CNA C to give the bath, as CNA C was upset. RR D stated feeling rushed. RR D stated that when CNA C returned to the room following the bath, R1 was not sitting properly on the bath chair. On 6/24/25 at 3:44 PM, Surveyor interviewed DON B and asked RR D concerns. DON B stated that CNA C had come to give R1 a bath while RR D was feeding R1 breakfast and that RR D felt rushed by the CNA's attitude. DON B stated that RR D told CNA C to go ahead with the bath, but that RR D felt uncomfortable with CNA C. DON B stated that RR D said RR D felt it was possible that CNA C transferred R1 solo with the mechanical lift. Important to note: RR D's concern regarding CNA C was not entered onto the facility grievance log. Facility grievance log, from 5/1/25 to 6/23/25, does not contain any grievances related to R2. On 6/23/25 at 11:27 AM during an interview RN E (Registered Nurse) indicated there are no grievances recorded for R2 or R1. On 6/23/25 at 2:36 PM SW F (Social Worker) indicate NHA A (Nursing Home Administrator) is the facility's Grievance Official. On 6/24/25 at 10:00 AM Hospice Services RN H indicated she has never filled out a grievance for a resident who voiced concerns to her and she is unfamiliar with the facility's grievance process. On 6/24/25 at 10:37 AM NHA A (Nursing Home Administrator) indicated she is the facility's Grievance Official. NHA A indicated all grievances should be recorded in one spot, on the grievance log and there is no grievance for R1 or R2 on the log. NHA A indicated the facility does not have follow up or an investigation on the grievances voiced by RR D related to her positioning in the shower chair or of hospice staff rushing her with her meals. NHA A indicated she has ideas on how to improve the facility's grievance process and she will start today educating on the process, where to find forms, and how to fill out the forms. NHA A indicated the facility retains all information related to grievances for 18 months and they use the grievance log to track grievances and identify trends throughout the home. On 6/24/25 at 2:45 PM RN I indicated she has never filled out a grievance form and she just tells one of the social workers concerns that are voiced to her. RN I indicated a family member voicing concerns related to staff rushing a resident during meal time could be a grievance and concerns related to a resident's positioning in the shower chair could be a grievance. On 6/24/25 at 4:33 PM during a phone interview, DON B (Director of Nursing) indicated she expects when a resident or a resident representative voices a grievance to staff and hospice staff, they go directly to the floor nurse to report it. DON B indicated other concerns that are voiced while conducting interviews for a facility self report should be recorded and followed up on using the facility's grievance process.

Based on interview and record review, the facility did not complete a thorough investigation in response to a potential allegation of abuse for 1 of 3 residents (R1) reviewed for abuse. On 5/31/25, the facility became aware of an alleged injury of unknown origin due to discolored (yellow) areas on R1's right knee and left ankle. The facility did not interview other like residents as part of the investigation. Evidenced by: The facility's Reporting of Caregiver Misconduct in the Skilled Nursing Facility policy, dated 12/31/24, states, in part: .c. Investigation of injuries of Unknown Origin or Suspicious injuries: must be immediately investigated to rule out potential abuse . e. The investigation will consist of at least the following: a review of the completed complaint report an interview with the person or persons reporting the incident interviews with any witnesses to the incident a review of the resident medical record if indicated a search of the resident room (with resident permission) an interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident interviews with the resident's roommate, family members, and visitors a root-cause analysis of all circumstances surrounding the incident R1 admitted to the facility on [DATE] and had diagnoses that include: age related osteoporosis (a disease that weakens bones, making them more susceptible to fracture); hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness following a stroke); vascular dementia (a type of dementia caused by reduced blood flow to the brain, which damages brain tissue and impairs cognitive function). R1's Minimum Data Set (MDS) dated [DATE], indicates a Brief Interview of Mental Status (BIMS) score of 99, meaning R1 was unable to complete the interview due to not being able to respond to the questions and/or R1 was unable to understand the questions. A facility self-report indicates that on 5/31/25, RR D (Resident Representative) expressed concerns about discolored (yellow) areas on R1's right knee and left ankle; felt like a Certified Nursing Assistant (CNA) had not positioned R1 correctly in the shower chair recently .R1's legs seemed to be in different directions and positioned differently than usual . On 6/23/25 at 1:40 PM, Surveyor interviewed RR D about yellow discoloration on R1. RR D stated there was bruising to R1's right foot, side of right calf, and toward the right hip. RR D stated, unsure of date, CNA C had given R1 a bath and upon return R1 was sitting on the bath chair, on her right hip, with leg stretched way out. RR D stated that R1 looked uncomfortable. RR D stated the positioning may have caused R1's bruises. On 6/24/25 at 3:44 PM, Surveyor interviewed DON B and asked about the investigation for R1. DON B stated that upon learning of R1's bruising, DON B spoke with RR D, who indicated that CNA C had given R1 a shower and that R1 was positioned differently in the shower chair. DON B stated that RR D voiced feeling uncomfortable with CNA C and thought it was possible that CNA C had transferred R1 solo with the mechanical lift. Surveyor asked if CNA C took care of other residents in the facility. DON B stated yes. Surveyor asked if other residents were interviewed about transfers and interactions with CNA C. DON B stated no. Surveyor asked if like-residents should be interviewed in an investigation. DON B stated yes. The facility became aware of an alleged injury of unknown origin due to discolored (yellow) areas on R1's right knee and left ankle. The facility did not interview other residents who CNA C took care of as part of their investigation.

Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 3 of 4 residents reviewed (R37, R12, and R36) for accidents. R37 and R12 are being cited at severity level 3 (actual harm) R36 is being cited at severity level 2 (potential for more than minimal harm). R37 has a history of multiple falls, primarily from her lift chair. Facility staff did not implement fall interventions. R37 had one fall that resulted in a fracture of her right elbow and a laceration to forehead requiring staples, and another fall that resulted in fracture of her clavicle and a laceration to her head requiring staples. R12 had a history of falls, 26 falls in the past year, one of which resulted in a laceration and fracture of maxillary sinus. The facility did not complete a thorough root cause analysis on several of the falls or ensure that appropriate interventions were in place and included in R12's care plan. R12 had a fall with laceration and fracture. R36 is edentulous and wears an upper denture. R36 has not had a lower denture since admission to the facility. On 11/10/24 R36's upper denture was missing. On 11/11/24 ST C (Speech Therapist) recommended R36's diet order be changed (from Level 6) to International Dysphagia Diet Standardisation Initiative (IDDSI) Level 4 (pureed). On 11/13/24 Surveyor observed R36 eating a whole banana at breakfast that was slightly green and firm. Surveyor observed R36 coughing while eating the banana. PSM G (Patient Services Manager) stated R36 should not be served banana on a Level 4 diet. PSM G stated, it is important for R36 to receive the correct Level 4 to avoid a health hazard, safety hazard, and choking hazard. PSM G stated, the Dietary Department has not received R36's updated diet recommendation from the facility or from ST C. Subsequently, R36's meal ticket and IDDSI level was not updated. Evidenced by: The facility's policy titled Fall Prevention and Management Procedure last reviewed on 5/6/24 states in part .3.2 Prevention Interventions/ Strategies: a. Environment Safety: All staff will work together to create a safe environment. b. Medications will be reviewed by Pharmacists as necessary. c. Recommendations will be provided as appropriate. d. Interdisciplinary care plans will provide interventions for each resident to assist with keeping resident safe. e. Therapy screens will be sent with potential for therapy and review of interventions .f. All residents will have: Nonslip footwear during transfers and ambulation .Assess elimination need, assist as needed .3.5 Fall Prevention and Management Interventions: a. Low bed b. Restorative program for ambulation c. Reminder signs in room d. Toileting schedule .i. Activities j. Hip protectors k. Elbow/ knee pads .m. Dycem . Example 1 R37 was admitted to the facility on [DATE] with diagnoses that include dysphasia (difficulty swallowing) following a cerebral infarction (stroke), congestive heart failure (chronic condition where the heart doesn't pump blood as well as it should), major depressive disorder, history of falls, and vascular dementia. R37's most recent Minimum Data Set (MDS) dated [DATE] states that R37 has a Brief Interview of Mental Status (BIMS) of 14 out of 15, indicating that R37 is cognitively intact. R37's Minimum Data Set (MDS) also stated that she is dependent on staff for bed mobility and all transfers. R37's care plan states in part: .3/26/24: Problem: I am independent with the use of remote for recliner to assist in adjusting my position due to chronic phlegm/emesis. I have been observed raising my chair too high my family is aware of this activity and potential for injury associate with this, but I request I continue to have control of remote .9/23/24: Problem: I have suspected clavical [sic] fracture s/p (status post) fall. I have ortho consult pending for further evaluation .Interventions: 9/28/23: posey alarm to wheelchair, recliner, bed. 8/9/24: wedge to right side under right body pillow . Documentation is as follows: 9/27/23 at 5:15 PM: .At 17:15 (5:15 PM) writer called to unit due to unwitnessed fall. Resident laying on the floor on right side in front of lounge chair (remote controlled lift recliner). Small amount of blood noted on the floor next to resident. Upon assessment, resident with scrape/ skin tear to right temple, quarter sized bump. Hematoma open and bleeding above right eye, golf- ball sized bump to forehead. Complaints of pain to head. Right elbow skin tear approx. (approximately) 0.5 in (inches). Resident had several stories regarding how she fell including picking up a watch, something about witch craft and other nonsensical sentences .Orders received to send to ER (emergency room ) .Footwear worn: Barefoot/socks .To prevent future falls: Discussed with POA (Power of Attorney), will think about further and will decide if posey alarms would be effective and to discuss resident using lounge chair while having increased confusion .PT (Physical Therapy) screen placed, OT (Occupational Therapy) screen placed .Morse Fall Risk Assessment: Risk Score 90 . emergency room documentation dated 9/27/23 at 8:43 PM states in part: .No acute intracranial hemorrhage .Skin tears are not able to be closed with suture. Bacitracin and steri- strips applied by the nurse . 9/29/23 at 7:47 AM: Measures to reduce reoccurrence: Posey alarm to chairs and bed. 10/20/23 at 6:05 PM: .Alarm activated- staff at nurses [sic] station responded to find resident lying face down on floor perpendicular to lounge chair with head towards the window and feet towards bed; pillow under right leg (as was on footrest of recliner). Recliner in semi raised position. Writer summoned- writer observed moderate active bleeding from head. Writer directed another RN (Registered Nurse) to call 911 due to bleeding and body placement limiting ability to assess extent of injury. Appears resident hit head on floor .While awaiting EMS (Emergency Medical Services) arrival, blood pool tripled in size with blood clots noted .Writer observed skin tear to right elbow medial to previously noted skin tear- also moderately bleeding at time of incident .Footwear worn by resident: Barefoot/ socks- barefoot at time of incident .To prevent future falls: to be assessed upon return from ER . emergency room documentation dated 10/21/23 at 1:19 PM states in part: .XR (X-ray) Elbow Complete Right Findings: Mildly displaced fracture of the proximal ulna, involving the olecranon process (pointed tip of the elbow) .Procedure: Laceration repair .Location: Side of forehead at the scalp line. Total length of repair: 1 cm (centimeter). Anesthesia: 2 ml (milliliters) of 1% lidocaine with epinephrine. Description: Was thoroughly cleaned and irrigated. The wound was closed with 2 staples with good wound approximation. Emergency Department Splint Procedure Note: Injury: Olecranon fracture on the right .Splint was placed to ensure immobilization and adequate pain control. Adequate gauze padding was placed, and the splint was secured with ACE bandage . 10/23/23 at 8:14 AM: Measures to reduce reoccurrence: pending PT eval given new elbow fracture . 1/30/24 at 7:00 AM: .Resident with confusion and was acting on belief that she needed to ready for a trip. Resident was observed sitting on her legs on right side of bed. Back resting on bed .Interventions in place: low bed, posey alarm, body pillow bilaterally .To prevent future falls: Resident has posey alarm in place. She has increased confusion with disease progression and goal is to prevent injuries from fall . It is important to note that the facility did not implement a new fall intervention. 3/25/24 at 8:15 PM: .CNA (Certified Nursing Assistant) staff members assisting other residents in their bathrooms. Resident must have elevated chair. Another alert resident going past room, heard alarm going off and seen that the resident was on the floor. She told another resident and other resident yelled for help. CNA staff heard yelling of resident and immediately went to room of fallen resident. Alerted charge RN. Writer also noted at that time. Entered room. Lounge chair in complete upright position. Resident lying on her right-side facing chair with her head towards entry door. Charge RN already assessing, Resident noted to have right side head injury. Moderate amount of blood noted to shirt and floor. Noted to have a small bump with skin tear to right side of forehead. Skin tear measures 3cm x 3cm .No external rotation or shortening. Resident placed back in lounge chair via med-lift per agency protocol. Area to forehead cleansed by writer and 4 large steri- strips applied to area .Footwear worn by resident: barefoot/ socks .To prevent future falls: family continues to want resident to have lounge chair controller . It is important to note that the facility did not implement a new fall intervention. 9/6/24 at 6:18 PM: .Resident was in her recliner and was walking/ standing when she fell .Posey alarm was sounding but was very soft and this writer could not hear it until almost in the room .Resident was found on the floor by CNA and alerted this writer that she was on the floor, and she was bleeding. Resident laying on her right side with her head almost underneath the bed. Noted she has a large laceration to the right side of her head with bruising already appearing. Held pressure to area. Resident laying on right side almost in a perpendicular position from her bed. Laying on her right shoulder and right hip. Denies pain, however, does state that right shoulder is sore' with attempts to move. 911 called to transport resident to ER for further evaluation . emergency room documentation dated 9/6/24 at 7:05 PM states in part: .Procedure: laceration repair note. Location: right temple. Anesthesia: 1% lidocaine with epinephrine. Laceration length/ type: 2.5cm. Suture type/ size: Surgical staples. Number of sutures: 3 . After repeated complaints of pain by R37, the facility obtained an order for an x-ray to R37's right shoulder on 9/16/24. The x-ray results states in part: .Impression: 1. Probable distal clavicle fracture . It is important to note that the facility did not implement a new fall intervention. On 11/13/24 at 2:34 PM, Surveyor interviewed CNA R (Certified Nursing Assistant). Surveyor asked CNA R how she knows what fall interventions are in place for each resident, CNA R reported that they have a binder with each resident's care plan and interventions. Surveyor asked CNA R what interventions are in place for R37, CNA R stated that she did not know. Surveyor asked CNA R how she would find out what interventions are in place, CNA R stated that she would ask the nurse and other CNAs. On 11/14/24 at 1:30 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what fall interventions were put in place for each of R37's falls, DON B reported that for 9/27/24 the posey alarms were implemented. Surveyor asked if R37 should have been wearing gripper socks at the time of the fall, DON B stated that there is no way to know what she was wearing. Surveyor asked about the interventions for the fall on 10/27/23 and if the PT screen was for R37's fractured elbow or falls, DON B reported that it was potentially for both. Surveyor asked about the intervention related to R37's fall on 1/30/24, DON B stated the intervention was to reinforce the previous interventions. Surveyor asked DON B about the intervention related to the fall on 3/25/24, DON B reported that there was no new intervention. Surveyor asked DON B what the intervention implemented after R37's fall on 9/6/24, DON B reported that they reiterated the family's preference to allow R37 to have the remote to the recliner. Surveyor asked DON B with the facility's documented increased confusion with R37, did they increase supervision, DON B stated that she could not find that they did. Surveyor asked DON B if she would have expected that staff check on R37 more often, DON B stated yes. Surveyor asked DON B if the facility has completed a safety assessment for R37's ability to use a remote-controlled recliner, DON B reported that they have been looking for evidenced based practice related to screening for recliner safety. Surveyor asked DON B if R37 was ever placed on a toileting schedule, DON B reported that on 10/16/24, she was placed on last round toileting. Surveyor asked DON B if they have documentation regarding the risks vs. benefits related to R37's recliner use indicating the potential poor outcomes that was signed by the family, DON B stated no. It is important to note that R37 has been on warfarin (blood thinner) since admission to the facility. 50285 Example 2 R12 was admitted to the facility on [DATE] with diagnoses that include, in part: repeated falls, pain in left hip, age-related osteoporosis, overactive bladder, chronic pain syndrome, depression unspecified, mild cognitive impairment of uncertain or unknow etiology, age related cataract, sensorineural hearing loss, and nausea. R12's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 11/5/24, indicates R12 has a BIMS (Brief Interview of Mental Status) of 5 out of 15, indicating R12 has severe cognitive impairment. R12's fall care plan, includes, in part: --Problem: I have a history of falls due to my choice to transfer/ambulate without staff assistance. I am aware that I require assistance to maintain my safety, but often do not ask for help. I have weakness and impaired judgement. My son has requested Posey alarm placement due to continued self-transfer attempts. We do not see eye to eye on this subject, and I frequently turn off my alarms prior to self-transfers. My son has been educated on the risk of falls, along with potential for major injury . January 2023: frequent falls, resident failing to call and await staff assistance. Resident fall and behavior pattern does not demonstrate a patter of effectiveness of alarms - does not halt nor stop her attempts at independent ability. POA (Power of Attorney) has been educated on multiple occasions as to the risk of injury with resident behaviors and circumstances regarding falls and resident refusal to participate in therapy services. Recommendations continue to require assistance with all mobility. POA agrees with removal of alarms at this time as they are not altering resident pattern of behaviors and falls . Date: 1/30/24. --Goal: I will maintain the ability to transfer and the ability to ambulate with 1 assist. Date 8/11/21. --Goal: I will be free of injury from falls. Date 2/28/25. --Interventions include, in part: Low bed (Date 3/15/22). Right body pillow (Date 1/31/24). Do not leave alone in bathroom when using toilet (Date: 1/23/22). Keep wheelchair placed on bathroom side of bed when resident is in bed (Date 6/5/24). On 9/10/23 at 9:40 AM, R12 had an unwitnessed fall in her room. Root cause of fall: resident states walked from chair to nightstand across room to adjust radio. Measures to prevent reoccurrence: continue interventions as per comprehensive CP (care plan). No injuries. On 9/22/23 at 7:50 PM, R12 had a witnessed fall in her room. Root cause of fall: poor decision making. Measures to prevent reoccurrence: Continue with reminders and reinforcement of the need for staff to assist with needs. No injuries. Of note, R12 has severe cognitive impairment. On 10/9/23 at 1:15 AM, R12 had an unwitnessed fall in her bathroom. Root cause of fall: Resident reports transferring self from toilet to wheelchair in front of toilet that was placed there and locked by staff who had to exit room to attend another resident in safety situation. Measures to prevent reoccurrence: none listed. Injuries: hit head, neurological checks initiated per protocol. On 11/6/23 at 5:15 PM, R12 had an unwitnessed fall in her room. Root cause of fall: Resident reports was walking self with walker and reported feeling dizzy. Measures to prevent reoccurrence: none listed. Noted no ongoing safety concerns, resident choosing to not call nor wait for staff assistance with mobility needs. No injuries. On 11/10/23 at 10:15 PM, R12 had an unwitnessed fall in her room. Root cause of fall: Resident slid out of wheelchair while attempting to self-transfer back to bed. Staff had not previously assisted resident into wheelchair, so resident had transferred self into wheelchair prior (which is parked in bathroom). Measures to prevent reoccurrence: none listed. No injuries. On 11/16/23 at 2:15 PM, R12 had an unwitnessed fall in her room. Root cause of fall: Resident reports taking self from bathroom with walker and bent over to reach for slippers on floor. Resident had taken self from recliner to bathroom. Measures to prevent reoccurrence: Refer to mobility CP for full list of interventions. No injuries. On 12/1/23 at (no time listed), R12 had an unwitnessed fall in her bathroom. Root cause of fall: Poor safety awareness. Measures to prevent reoccurrence: none listed. No injuries. On 12/5/23 at (no time listed), R12 had an unwitnessed fall in her room. Root cause of fall: Poor decision making - consistently is getting up without asking for assistance and losing her balance. Measures to prevent reoccurrence: Multiple attempts at education along with therapy and restorative programs are in place in an attempt to keep the resident safe. No injuries. On 12/12/23 at 11:10 PM, R12 had an unwitnessed fall in her room. Root cause of fall: Resident self-transferred from bed to wheelchair - transferring without staff assistance or assistive device. Measures to prevent reoccurrence: Multiple attempts at education along with therapy and restorative programs are in place in an attempt to keep the resident safe. No injuries. On 12/14/24 at 7:00 PM, R12 had a witnessed fall in her room. Root cause of fall: Resident was sitting at edge of bed looking for TV remote leaning back and forth and slid off bed. Measures to prevent reoccurrence: none listed. No injuries. On 12/19/24 at 10:00 AM, R12 had an unwitnessed fall in her room. Root cause of fall: Resident self-transferred from bed to wheelchair - transferring without staff assistance or assistive device. Measures to prevent reoccurrence: none listed. No injuries. On 12/20/23 at 3:30 PM, R12 had an unwitnessed fall in her room. Root cause of fall: Resident ambulating in room without assist or assistive device. Measures to prevent reoccurrence: none listed. No injuries. Noted no ongoing safety concerns with poor judgement and disregard for need for staff assistance. On 12/21/23 at 8:30 PM, R12 had an unwitnessed fall in her room. Root cause of fall: Resident attempted to get out of low bed independently resulting in slide out of bed onto floor. Measures to prevent reoccurrence: none listed. No injuries. On 1/31/24 at 7:30 PM, R12 had an unwitnessed fall in her room. Root cause of fall: Resident attempted to crawl over body pillow to attempt to get out of low bed to either turn light off or get bed control (resident inconsistent with reports). Measures to prevent reoccurrence: Removed body pillow from bathroom side of bed as resident continues to climb over this which may increase risk of fall trying to overcome obstacle. Injuries: bump on head, neurological checks initiated. On 2/6/24 at 9:30 AM, resident had an unwitnessed fall in her room. Root cause of fall: Resident was reaching for TV remote while sitting on walker resulting in fall. Measures to prevent reoccurrence: none listed. No injuries. On 2/6/24 at 7:30 PM, R12 had a witnessed fall in her room. Root cause of fall: Resident had taken self from bed to the bathroom, using wheelchair upon completion of using bathroom, left wheelchair in bathroom and walked back into room using furniture as a support. Staff walked by room to find resident using bed and recliner as support as knees appeared to be buckling and staff assisted resident to be lowered to floor. Measures to prevent reoccurrence: Continue with toileting schedule, anticipating resident needs, rounding, keep items within reach. Resident continues to get up by self even after these interventions without staff assistance and/or appropriate AD (Assistive Device). No injuries. On 2/20/24 at 1:00 PM, R12 an unwitnessed fall in her room. Root cause of fall: Resident was reaching from wheelchair/slide off wheelchair. Measures to prevent reoccurrence: Refer to prior investigations/current mobility/ADL (Activities of Daily Living)/urinary CP. Injuries: Bruise to elbow. On 2/22/24 at 5:00 AM, R12 had an unwitnessed fall in her bathroom. Root cause of fall: Poor decision making related to safety needs. Measures to prevent reoccurrence: All measures have been attempted without success. No injuries. On 3/26/24 at 1:35 AM, R12 had an unwitnessed fall in her room. Root cause of fall: Resident attempted to transfer self from low bed to w/c (wheelchair). Measures to prevent reoccurrence: Reinforcement of need for assistance with ADL's/toileting. No injuries. On 3/31/24 at 8:15 AM, R12 had an unwitnessed fall in her room. Root cause of fall: Resident was in bed reaching for bed controller causing resident to roll OOB (out of bed). Measures to prevent reoccurrence: Please refer to comprehensive mobility, ADL, and toileting CP for all interventions. Injuries: bruising (location not listed). On 4/11/24 at 11:00 AM, R12 had an unwitnessed fall in her room. Root cause of fall: Resident was reaching from chair for oxygen. Measures to prevent reoccurrence: As per comprehensive care plan. No injuries. On 6/8/24 at 2:00 PM, resident had an unwitnessed fall in her room. Root cause of fall: Resident was standing to close bathroom door and stepped back for clearance and foot caught on walker wheel causing fall. Measures to prevent reoccurrence: Continue interventions as per comprehensive care plan. Resident is now in single occupancy room which allows her more space - this may be contributing to decreased number of falls recently. No injuries. On 7/11/24 at (time not listed), R12 had an unwitnessed fall in her room. Root cause of fall: Poor safety awareness. Resident and family member have been educated on the potential for injury with continued poor decision making related to safety. Measures to prevent reoccurrence: Continue with reminders, rounding. No injuries. On 7/22/24 at 11:02 AM, R12 had an unwitnessed fall in her room. Root cause of fall: Poor safety decision. Measures to prevent reoccurrence: Multiple interventions attempted in the past. PT (physical therapy) evaluation placed. No injuries. On 7/24/24 at (no time listed), R12 had an unwitnessed fall in her room. Description of event: Resident was pulling her bathroom door open and lost her balance. Resident was transferred to the hospital for further evaluation. Result of ER (emergency room ) visit noted to be laceration of face and fracture of maxillary sinus. Root cause of fall: Poor safety decisions and awareness. Resident continues to put self at risk of injury with independent transfers and ambulation. Measures to prevent reoccurrence: Continue with reminders and interventions per care plan. Injuries: laceration and fracture of maxillary sinus. Son/POA was updated with the transfer and is aware of resident's poor safety awareness and risk for injury. R12's ER notes on 7/24/24 state in part: Patient presents to ER for unwitnessed fall earlier today. Patient has laceration to left lateral forehead. Four sutures placed. CT (computed tomography) scan completed of head and neck. Diagnostic details: Left inferior anterior maxillary wall fracture with hematoma in the left maxillary sinus. On 8/23/24 at 1:00 PM, Resident had an unwitnessed fall in her room. Root cause of fall: Resident standing on own and used overbed table for assistance which is on wheels and it rolled away. Measures to prevent reoccurrence: Reminders to resident combined with all previous interventions - refer to fall CP and previous fall assessments. No injuries. On 11/13/24 at 9:02 AM, Surveyor observed R12 sitting in her recliner with a sign placed on the wall in front of her hanging under the TV that states, Please call for assistance. No other fall interventions observed in room. On 11/13/24 at 4:30 PM, Surveyor interviewed DON B (Director of Nursing) regarding R12's multiple falls. DON B indicated that prior to the fall with fracture on 7/24/24, the facility had been encouraging R12 to undergo a therapy evaluation for recommendations on preventing falls, but both R12 and her son/POA Power of Attorney) did not want to have therapy. DON B stated that they had also tried alarms, but they were ineffective. DON B stated the staff have put items closer within reach for R12, ensure she is wearing appropriate footwear while awake, anticipate her needs, offer her snacks and a sweater, and put her on a toileting schedule. DON B acknowledged that many of R12's falls revolved around her desire to maintain her independence and self-transfer. DON B stated that it was her expectation that staff follow the care planned interventions to prevent R12 from having repeated falls and injuries. DON B indicated that the care plan interventions would be on the CNA (Certified Nursing Assistant) Kardex/Group List. Of note: the only fall interventions listed on R12's Kardex/Group List are: Low bed, Transfer with 1 assist and walker, and right body pillow. Toileting schedule is listed every two hours. On 11/14/24 at 12:38 PM, Surveyor asked CNA M, (Certified Nursing Assistant) who stated that she was a new employee. CNA M showed Surveyor the Kardex/Group List. Surveyor asked CNA M if she knew anything about keeping items within reach, anticipating needs, offering snacks or a sweater, or appropriate footwear, as these are not listed on the CNA Kardex/Group List. CNA M stated she was not aware of these interventions. On 11/14/24 at 12:41 PM, Surveyor interviewed RN N (Registered Nurse) what fall interventions were in place for R12. RN N replied that R12 has a low bed, body pillows, wearing shoes or slippers while awake, and to keep her walker or wheelchair close by. RN N stated that R12 still self-transfers at least daily. On 11/14/24 at 12:47 PM, Surveyor interviewed LPN K (Licensed Practical Nurse) who stated that R12 transfers without assistance multiple times per day. LPN K stated that fall interventions for R12 included anticipating her needs. On 11/14/24 at 12:55 PM, Surveyor interviewed CNA O who stated that R12 self-transfers daily, and that she will see her walking unassisted in her room when she walks by. CNA O stated that the sign to call for assistance in R12's room was a fall intervention, as well as repeatedly reminding R12 verbally to wait for assistance. The facility failed to create a robust fall care plan that included appropriate fall interventions and to ensure that the fall interventions were adequately communicated to the frontline care staff. R12 had multiple falls, one which resulted in a fracture and head laceration requiring sutures. 30992 Example 3 The facility follows IDDSI (International Dysphagia Diet Standardisation Initiative). IDDSI Level 4 Pureed Food for Adults: What is this food texture level. Level 4 - Pureed Foods - Area usually eaten with a spoon - Do not require chewing - Have a smooth texture with no lumps - Hold shape on a spoon - Fall off a spoon in a single spoonful when tilted - Are not sticky - Liquid (like sauces) must not separate from solids Why is this food texture level used for adults: Level 4 - Pureed Food may be used if you are not able to bite or chew food or if your tongue control is reduced. Pureed foods need the tongue to be able to move forward and back to bring the food to the back of the mouth for swallowing. It is important that puree foods are not too sticky because this can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat. Pureed foods are best eaten using a spoon. How do I test my food to make sure it is Level 4 Pureed: It is safest to test Pureed Food using the IDDSI Fork Drip Test and the IDDSI Spoon Tilt Test. IDDSI Fork Drip Test: Liquid dos does not dollop, or drip continuously through the fork prongs. A small amount may flow through and form a tail below the fork. IDDSI Spoon Tilt Test: Sample holds its shape on the spoon and falls of fairly easily if the spoon is tilted or lightly flicked. Sample should not be firm or sticky. R36 was admitted to the facility on [DATE] with diagnoses including, but not limited to, dysphagia, cerebral infarction (stroke), diabetes mellitus type 2, and vascular dementia. R36 has an APOAHC (Activated Power of Attorney for Health Care). R36's comprehensive care plan, dated 5/24/21, indicates, in part, as follows: Monitor me for any increased difficulty with my chewing and/or swallowing ability. R36 care plan documents he receives a Level 6 Diet. On 11/8/24 R36's Dietary Assessment documents the following: Resident is currently on a General with IDDSI Diet: Level 6 foods - Soft & bite sized with bread products allowed, and Level 0 liquids-Thin. Divided plate with Dycem mat and No straws. Supplements: 240 ml Ensure Plus High Protein BID (Twice Daily) Involuntary weight loss of 10% in 6 months. Nutrition Interventions: Medical food supplements added Ensure Plus BID at 1000 and 1900 to help stop weight loss. Writer is also monitoring food intake, fluid intake, weights, skin integrity, tolerance to mechanically altered diet, tolerance of nutritional supplement (Ensure Plus). Will proceed. The plan is to revise/update care plan long term placement so we will Continue with current nutritional interventions, with the addition of Scheduled nutritional supplement. Ensure Plus at 1000 and 1900 to help stop weight loss, and we will Encourage fluids with each encounter, and MDS (Minimum Data Set) completed. On 11/10/24 R36's top denture went missing. Of note, R36 is edentulous and does not have a bottom denture. On 11/10/24 at 4:29 PM, staff entered the following note: Therapy Screen Request: Please Screen: Upper denture is missing, please screen for safety with chewing swallowing with current diet. On 11/11/24 at 10:30 AM, Surveyor spoke to R36 and his APOAHC (Activated Power of Attorney). R36 and his APOAHC stated that R36's denture was lost on 11/10/24. On 11/11/24 at 12:07 PM, Surveyor observed R36 eating ranch chicken (bite size pieces), mashed sweet potatoes, and milk. R36 started coughing while eating the chicken and then vomited. Staff took him out of the dining room and back to his room. On 11/11/24 at 12:09 PM, Surveyor observed R36 with no signs of coughing or watering eyes. R36 stated he was not having any difficulty breathing and was feeling fine. On 11/11/24 at 12:16 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor relayed that while R36 was eating lunch that he coughed on ranch chicken and vomited the chicken back up. Surveyor shared with DON B possible concern for aspiration. The facility assessed and monitored R36 for the next 24 hours. On 11/11/24 at 12:31 PM, Surveyor spoke with LPN K (Licensed Practical Nurse). LPN K stated that R36 has occasional nausea induced by coughing, and swallowing problems. LPN K stated, R36 takes Reglan (to treat gastroesophageal reflux disease) and omeprazole (to treat heartburn and damaged esophagus). LPN K stated, it doesn't happen all the time but if he eats really fast food will come back up. Surveyor asked LPN K, has this been worse over the last day. LPN K stated, no. LPN K stated, we completed an incident report for R36's missing dentures and SW J (Social Worker) is working on it. LPN K added, she updated R36's APOAHC on 11/10/24. LPN K stated, R36's APOAHC will talk with SW J about getting the dentures replaced. Surveyor asked LPN K was R36's diet modified. LPN K stated, we put in for a ST (Speech Therapy) consult yesterday but i [TRUNCATED]

Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS). This has the potential to affect all 52 residents residing within the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting and triggered for one fiscal year quarter for one star staffing rating, excessively low weekend staffing, no RN hours, and failure to have licensed nursing coverage 24 hours a day. Evidenced by: The facility's Payroll Based Journal Entry Procedure policy, dated 11/15/24, states, in part: . 3.6 Data submission will be verified for accuracy prior to the reporting deadline by the designated HSM (Hillside Manor) scheduler/employee. a. Prior to the deadline for quarterly submission, the administrator will verify the data uploaded into the PBJ is accurate and complete. The CMS PBJ Staffing Data Report for fiscal year quarter 3 2024 (April 1-June 30), includes: No RN Hours. Infraction dates: 4/6, 4/7, 4/17, 5/4, 5/5, 5/16, 5/18, 5/19, 5/25, 5/26, 5/27. The CMS PBJ Staffing Data Report for fiscal year quarter 3 2024 (April 1-June 30), includes: Failed to have Licensed Nursing Coverage 24 Hours/Day. Infraction dates: 4/1, 4/2, 4/3, 4/4, 4/5, 4/6, 4/7, 4/8, 4/9, 4/10, 4/11, 4/12, 4/13, 4/14, 4/15, 4/16, 4/17, 4/18, 4/19, 4/20, 4/21, 4/22, 4/23, 4/24, 4/25, 4/26, 4/27, 4/28, 4/29, 4/30, 5/1, 5/2, 5/3, 5/4, 5/5, 5/6, 5/7, 5/8, 5/9, 5/10, 5/11, 5/12, 5/13, 5/14, 5/15, 5/16, 5/17, 5/18, 5/19, 5/20, 5/21, 5/22, 5/23, 5/24, 5/25, 5/26, 5/27, 5/28, 5/29, 5/30, 5/31. On 11/14/24 at 11:59 AM, Surveyor observed the facility staffing postings and nursing schedules for April and May 2024. Each day had at least 8 hours of RN coverage and 24 hours/day licensed nursing coverage. On 11/14/24 at 12:34 PM, Surveyor interviewed NS L (Nurse Scheduler) and DON B (Director of Nursing). NS L indicated she is responsible for completing the PBJ reporting. NS L indicated that the process for gathering and transmitting data had not been changed for April and May. NS L indicated that CMS was contacted when the error was noted, and facility was told that CMS had received a file, but the data was invalid. DON B indicated the data may have been encrypted or sent with the wrong file type. DON B indicated that the cause of the issue was still unknown to the facility, but facility was working on processes to ensure proper reporting. DON B stated she did expect facility to submit accurate data.

Based on observation, interview and record review, the facility did not store and prepare food in accordance with professional standards for food service safety. This has the potential to affect all 52 residents. Surveyor observed items opened and undated in the refrigerators and coolers. Surveyor observed food items unsealed and/or unmarked in the freezers. Surveyor observed boxes stored on the floor of the freezer. Surveyor observed the facility's meat slicer to be stored uncovered and mixer to be unclean. Surveyor observed a scoop in the powdered sugar container in the food preparation area. Surveyor observed dietary staff touch dirty dishes and then ready to eat food items without performing hand hygiene. Evidenced by: Example: Opened and undated items Facility policy, entitled Food and Nutrition - Food Handling Guidelines dated 6/20/22 states in part, . Food is handled using Hazard Analysis and Critical Control Point (HACCP) process in accordance with regulatory guidelines. Proper handling procedures and techniques are visually monitored on an ongoing basis . On 11/11/24 at 9:03 AM, during initial tour of the kitchen, Surveyor observed items opened and not dated in the facility's refrigerators and coolers, including lettuce, breadcrumbs, grapes, cucumbers, blueberries, and cartons of milk. Surveyor interviewed ADFN E (Associate Director of Food and Nutrition) who indicated that the produce was undated because it would be used next. Surveyor asked ADFN E if those items would be used within the next 24 hours. ADFN E stated that she wasn't sure. Surveyor asked ADFN E how long milk was good for after it was opened. ADFN E replied that milk was good until the expiration date on the carton. Example: Unsealed and unmarked items On 11/11/24 during initial tour of the kitchen, Surveyor observed items opened and not sealed in the facility's freezer, including pound cake, angel food cake, green beans, peas, hamburger patties, chicken strips and chicken patties. Surveyor interviewed ADFN E and asked if items should be properly sealed or tied closed once they are opened in the freezer. ADFN E agreed that they should be closed properly to prevent freezer burn. Example: Food improperly stored On 11/11/24 during initial tour of the kitchen, Surveyor observed several boxes of food sitting on the freezer floor. Surveyor interviewed ADFN E who stated they were not supposed to be sitting on the floor but that they were working with a skeleton crew over the weekend. Example: Meat slicer and mixer On 11/11/24 during initial tour of the kitchen, Surveyor observed the facility's meat slicer stored uncovered in the kitchen, with the blades and other parts stored on a rolling cart, also uncovered. Surveyor interviewed ADFN E who stated she was unaware that it needed to be covered. On 11/11/24 during initial tour of the kitchen, Surveyor observed the facility's mixer to have dried food on various parts of the mixer. ADFN E stated she had not noticed that and thanked Surveyor for helping her see areas of the kitchen that needed improvement. Example: Scoop in the food On 11/11/24 during initial tour of the kitchen, Surveyor observed a scoop in the powdered sugar bin in the food preparation area. ADFN E indicated that the scoop should not be stored in the food. Example: Unclean hands/Hand hygiene Facility policy, entitled Hand Hygiene Policy, dated 9/23/24, includes in part: . The purpose of this policy is to ensure . staff is aware of the principles and practice of good hand hygiene. Transmission of microorganisms can easily occur via the contaminated hands of HCWs (Healthcare Workers) . On 11/12/24 at 9:05 AM, Surveyor observed CNA T (Certified Nursing Assistant) bring a resident into the dining room and begin feeding him without putting on gloves or performing hand hygiene. On 11/12/24 at 9:39 AM, Surveyor interviewed CNA T and asked her if she would have done anything differently regarding hand hygiene during dining service. CNA T replied that she should have performed hand hygiene, using the wipes provided on the table, before starting to assist the resident with feeding. On 11/12/24 at 9:13 AM, Surveyor observed DA P (Dietary Aide) picking up dirty trays and dishes in the dining room. Surveyor observed DA P then go to the kitchenette and touch the bread to make a resident some toast without washing hands or performing hand hygiene. On 11/12/24 at 9:17 AM, Surveyor interviewed DA P and asked him if he would have done anything differently regarding hand hygiene during dining service. DA P stated that he would not. Surveyor asked DA P if he performed hand hygiene after he touched the dirty plates and before he touched the bread. DA P replied that he had done hand hygiene and that he always does hand hygiene. (Of note, two Surveyors observed DA P picking up dirty dishes and then touching the bread without performing hand hygiene.)

Based on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect the total census of 52 residents. Residents (R) voiced concerns of food not being served at a desirable temperature (R32, R41, R46, and R28). 2 of 2 test trays were observed to not be served at desirable temperatures. Evidenced by: The facility policy, titled Food and Nutrition - Trayline Taste and Temperature Log Procedure, dated 10/15/24, includes in part: . The purpose of Menu Works Daily Service Patient/Resident Taste and Temperature Log is to monitor taste and temperatures on the service line for Patient/Resident food service . Standard Temperatures . Hot Entrees >= 140 degrees Fahrenheit . Hot Vegetables >= 140 degrees Fahrenheit . Hot soup, sauces, gravies, hot beverage and cereal >= 140 degrees Fahrenheit . Cold items <= 41 degrees Fahrenheit or less . Example 1 R32 admitted to the facility on [DATE]. Her most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/17/24 indicates R32 has a moderate cognitive impairment with a BIMS (Brief Interview of Mental Status) score of 11 out of 15. On 11/11/24 at 10:40 AM, Surveyor interviewed R32 who indicated that she usually eats in her room, and that the food is not hot enough. R32 stated that this morning breakfast was practically cold. Example 2 R41 admitted to the facility on [DATE]. His most recent MDS with an ARD of 10/8/24 indicates his cognition is intact with a BIMS score of 15 out of 15. On 11/11/24 at 2:16 PM, Surveyor interviewed R41 who indicated that he usually eats in his room and that the food is often not hot and needs to be warmed up by staff. Example 3 R46 admitted to the facility on [DATE]. Her most recent MDS with an ARD of 10/30/24 indicates her cognition is intact with a BIMS score of 13 out of 15. On 11/11/24 at 2:33 PM, Surveyor interviewed R46 who indicated that she usually eats in the dining room. R46 stated that this morning the eggs were cold, and the bacon was so hard she couldn't bite into it. R46 stated that the food comes with covers on, but it doesn't keep the food warm. Example 4 R28 admitted to the facility on [DATE]. Her most recent MDS with an ARD of 10/1/24 indicates her cognition is intact with a BIMS score of 15 out of 15. On 11/11/24 at 2:47 PM, Surveyor interviewed R28 who indicated that she usually eats in her room. R28 indicated that the food is not always hot, especially breakfast, which is typically not as hot as it should be. R28 stated that breakfast is the first meal of the day and it's important to have something hot to give you the energy you need to get going. Example 5 On 11/12/24 at 9:29 AM, Surveyor received a test tray most of the dining room trays had been served, (there were 6 trays remaining on the dining room cart). Of note, the plates for the room trays and dining room are set on plate warmers and are covered by either a thin plastic cover that has a hole in the top center of it, or a solid plastic cover. Surveyor took the temperatures of the food that was served, including a breakfast sandwich with poached egg, ham slice and provolone cheese on a croissant, oatmeal, hashbrowns, diced peaches, and orange juice. Surveyor noted that all the items were in the temperature danger zone. The temperatures were as follows: poached egg 107.8 degrees Fahrenheit (F), ham slice 107.4 degrees F, hashbrowns 100.9 degrees F, oatmeal 114.6 degrees F, diced peaches 60.8 degrees F, orange juice 61.9 degrees F. The provolone cheese on the breakfast sandwich appeared to have melted and then hardened again, the croissant was soggy in the middle and hard on the outside, the oatmeal was congealed in the center with a ring of water around it in the bowl and the orange juice appeared to have separated in the glass. This test tray was not palatable. Example 6 On 11/14/24 at 11:40 AM, Surveyor received a test tray after all the hall trays had been delivered. Surveyor took the temperatures of the food that was served, including rice with tomatoes and spinach, peas, roast pork with gravy, mixed fruit, milk, coffee, and peach crisp. Surveyor noted that many of the items were not at the appropriate temperatures, including rice with tomatoes and spinach at 130.6 degrees F, peas at 112.3 degrees F, roast pork with gravy at 117.5 degrees F, mixed fruit at 58.6 degrees F and milk at 43.3 degrees F. This test tray was not palatable. On 11/14/24 at 11:48 AM, Surveyor interviewed ADFN E (Associate Director of Food and Nutrition). ADFN E stated that the inpatient rooms at the hospital are served first, then the residents in the community. ADFN E stated that she has noticed that the trays will sit on the carts waiting for the residents to come into the dining room, which can sometimes be a long time. Surveyor asked ADFN E if she would expect the food that is served, even at the end of meal service, to be at the desired temperatures. ADFN E replied yes, that would be her expectation. ADFN stated that she knew that cold food was a concern.

Based on observation, interview, and record review, the facility did not ensure 3 of 3 residents (R16, R26, R41) with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections and provide dignity for residents. R16, R26, and R41 were observed with their catheter drainage bag uncovered. Evidenced by: The facility's policy titled Resident Rights Policy last reviewed on 2/28/24, states in part .Dignity and Respect: a. This facility will care for each of its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. b. We will promote their right to receive care and treatment in a manner and in an environment that maintains or enhances their dignity and respect in full recognition of their individuality . Example 1 R16 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease, benign prostatic hyperplasia with lower urinary tract symptoms (a prostate gland enlargement that can cause problems with urination), depression, anxiety, and type 2 diabetes mellitus. R16 has a urinary catheter drainage system. On 11/11/24 at 9:29 AM, Surveyor observed R16 sitting in his wheelchair, in his room with his catheter bag uncovered and the door open. On 11/11/24 at 11:48 AM, Surveyor observed R16 sitting in his wheelchair in the hallway with his catheter bag uncovered. On 11/14/24 at 4:13 PM, Surveyor interviewed R16 and FM W (Family Member). Surveyor asked R16 if he would prefer to have his catheter bag covered, R16 stated yes. FM W reported that R16's catheter bag is uncovered most of the time and that they would prefer for it to be covered when R16 is taken out of the facility. On 11/12/14 at 2:29 PM, Surveyor interviewed CNA U (Certified Nursing Assistant). Surveyor asked CNA U if they typically put a dignity bag over catheter bags, CNA U stated that if they have them available and that sometimes they don't have them. On 11/12/24 at 2:33 PM, Surveyor interviewed CNA V. Surveyor asked CNA V if she got R16 up for the day, CNA V reported that she did get R16 up. Surveyor asked CNA V if she put a dignity bag over his catheter bag, CNA V reported that they never put them on and that she was unaware that the facility had them. 50228 Example 2 R26 was observed with urinary drainage bag uncovered. R26 was admitted to facility on 8/30/24 with foley catheter for assist in wound healing. On 11/12/24 at 7:52 AM, Surveyor observed R26's urinary drainage bag hanging from the side of the bed nearest the door. The drainage bag was not covered and was visible from the hallway. 50285 Example 3 R41 was observed with urinary drainage bag uncovered. R41 was admitted to facility on 2/16/22 with foley catheter for urinary retention. On 11/11/24 at 2:14 PM, Surveyor observed R41's urinary drainage bag hanging from the side of his garbage can, uncovered. On 11/14/24 at 4:22 PM, Surveyor observed R41's urinary drainage bag hanging from the side of his garbage can. At this time, the urinary drainage bag was covered by a dignity bag. Surveyor asked R41 if his urinary drainage bag was normally covered. R41 replied no, it was not normally covered. On 11/14/24 at 1:30 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she would expect residents with catheter bags to have the bags covered, DON B reported that the facility's policy is that if a resident is out of their room, the bag should be covered. Surveyor asked DON B if a resident is sitting in their room with the door open, should their catheter bag be covered, DON B stated that it is general practice that they should be covered.

Based on interview and record review the facility failed to immediately consult with physician when needing to alter treatment for 1 (R37) of 3 residents reviewed for physician notification. R37 had an unwitnessed fall on 9/6/24. The facility did not call the on-call physician when R37 reported increased complaints of pain. R37 was found to have a distal clavicle fracture. Evidenced by: The facility's policy titled Resident Change in Condition Policy last reviewed on 12/12/23, states in part .The Nursing Staff will update the resident's attending physician when: .c. There is a need to alter the resident's treatment .f. Deemed necessary or appropriate in the best interest of the resident . R37 was admitted to the facility on [DATE] with diagnoses that include dysphasia (difficulty swallowing) following a cerebral infarction (stroke), congestive heart failure (chronic condition where the heart doesn't pump blood as well as it should), major depressive disorder, history of falls, and vascular dementia. R37's most recent Minimum Data Set (MDS) dated [DATE] states that R37 has a Brief Interview of Mental Status (BIMS) of 14 out of 15, indicating that R37 is cognitively intact. R37's Minimum Data Set (MDS) also stated that she is dependent on staff for bed mobility and all transfers. Fall documentation states: 9/6/24 at 6:18 PM: .Resident was in her recliner and was walking/ standing when she fell .Posey alarm was sounding but was very soft and this writer could not hear it until almost in the room .Resident was found on the floor by CNA (Certified Nursing Assistant) and alerted this writer that she was on the floor, and she was bleeding. Resident laying on her right side with her head almost underneath the bed. Noted she has a large laceration to the right side of her head with bruising already appearing. Held pressure to area. Resident laying on right side almost in a perpendicular position from her bed. Laying on her right shoulder and right hip. Denies pain, however, does state that right shoulder is sore' with attempts to move. 911 called to transport resident to ER (emergency room ) for further evaluation . emergency room documentation dated 9/6/24 at 7:05 PM states in part: .Procedure: laceration repair note. Location: right temple. Anesthesia: 1% lidocaine with epinephrine. Laceration length/ type: 2.5cm. Suture type/ size: Surgical staples. Number of sutures: 3 . It is important to note that the emergency room did not x-ray R37's shoulder. Nurse's notes state the following: 9/7/24 at 2:02 AM: PRN (as needed) Med Given: Acetaminophen 325mg tablet given for pain/ discomfort. Pain level before med: 5. Location: head. 9/7/24 at 3:49 PM: PRN Med Given: Acetaminophen 325mg tablet given for pain/ discomfort. Pain level before med: 3. Location: head. 9/9/24 at 5:38 PM: PRN Med Given: Acetaminophen 325mg tablet given for pain/ discomfort. Pain level before med: 6. Location: right shoulder, right hip. 9/13/24 at 9:39 PM: Resident complained of right shoulder pain, ice applied and scheduled Tylenol given. Bruising noted from most recent fall. Winces with movement of arm toward midline. Action: Continue to observe. Fax sent to: [Nurse Practitioner] regarding continued complaints of pain to right shoulder since fall. It is important to note that 9/13/24 was a Friday. 9/14/24 at 6:14 AM: Complaints of right shoulder pain when asked. 9/15/24 at 4:54 AM: Complaints of pain to right shoulder, ice pack applied. NP (Nurse Practitioner) updated via fax. 9/15/24 at 5:55 AM: Fax sent to: 9/15/24 [Nurse Practitioner] regarding update on right shoulder pain. 9/15/24 at 7:39 AM: Right shoulder discomfort after returning from outing with family. Action: Continue to observe. 9/16/24 at 7:24 AM: Orders received: Obtain x-ray of right shoulder (3 views): dx (diagnosis): recent fall; right shoulder pain. 9/17/24 at 8:19 AM: X-ray impression showed probable distal clavicle fracture. On 11/14/24 at 1:30 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if a resident is experiencing an increase in pain, would she expect nurses to call the on-call physician, DON B stated yes. Surveyor discussed with DON B that nurses sent 2 faxes during the weekend of 9/13/24- 9/15/24 regarding R37's pain. Surveyor asked DON B if she would expect staff to call the on-call physician when a resident has an increase in pain over a weekend after a recent fall; DON B stated yes, they should be calling.

Based on observations and staff interviews, the facility had not ensured that the resident environment remained as free as accident hazards as is possible, and that each resident received adequate supervision to prevent accidents in 21 ( #19, and #23 through #41) of 108 residents. The facility utilized four compartment Duke steam tables located in unsupervised dining rooms on the first and second floor resident care units. The steam tables were accessible to touch. The facility's practice was to turn the steam tables on the high setting at 6:30 a.m., and leave the steam tables activated at the same temperatures until after the supper meal (approximately 12 hours). The steam tables were only supervised during meal service. The metal steam tables were very hot to touch and temperature readings of both the stainless steel surfaces of the steam tables and the boiling water housed in the wells were extremely high. The facility housed a total of 21 independently mobile, cognitively impaired residents between the two units. Facility's failure to supervise the extremely hot steam tables created a finding of immediate jeopardy situation (has caused or is likely to cause serious harm and there is a reasonable degree of predictability of a similar situation occurring in the future) that began on 7/25/12. The facility was notified of the immediate jeopardy on 7/25/12. At survey exit on 7/26/12, the immediate jeopardy was removed. Findings include: At 156 degrees, hot-water scalding can occur in less than a second. The assumption is that these temperatures apply also to heat (non-water) burns. According to an article found at http://list.uvm.edu/cgi-bin/wa?A2=ind0308C&L=SAFETY&P=3519, ASTM C 1055-99 notes in its publication, "Standard Guide for System Heated Surface Conditions That Produce Contact Burn Injuries," "no surface should cause more than a first degree burn on 5 seconds exposure. (For consumer exposures, no surface should cause first degree burns on less than 60 seconds exposure.) This suggests that no contactable surface should ever exceed 140 degrees F (Fahrenheit). The ASTM standard classifies damage from short-term burns at this temperature as only "possibly reversible"; i.e., permanent scar tissue and/or skin grafts may result. This source notes, "Liquids or solids at 162 degrees F. will cause third degree burns almost instantly." The risk for harm is magnified in the elderly, who may have conditions that prevent instant recoil from hot surfaces. Third-degree burns are the most serious of all burns, involve all layers of the skin and cause permanent tissue damage. Fat, muscle and even bone may be affected. According to www.burnsurgery.org <http://www.burnsurgery.org>, " A deep dermal burn will require 4-10 weeks or longer to heal. Since the new epidermis is very thin and not adhered well to dermis, wound breakdown is common. Excision and grafting is the preferred treatment. Dense scarring is usually seen if the wound is allowed to heal primarily. " The manufactures operation manual for the Duke food warmer (steam table) dated 5/14/04 indicates, "Do not allow your customers to come in contact with any surface labeled "CAUTION HOT". WARNING: Steam can cause serious burns. Always wear some type of protective covering on your hands and arms when removing lids or pans from the unit. Lift the lid or pan in a way that will direct escaping steam away from your face and body. Fill food wells with two quarts of water. Turn the control to "HIGH" and preheat the warmer for 30 minutes. After preheating, set the control to your desired serving temperature. The facility's dining room hostess time work schedule dated 2/13/12 indicates that the staff turn on the steam wells of the steam tables at 6:30 a.m. At 7:15 a.m., take temperatures of hot and cold food and beverages. At 7:30 a.m., serve residents. At 9:30 a.m., clean steam well, add two tablespoons of tartar to wells. At 10:00 a.m., take temperatures of hot and cold food and beverages. At 12:55 p.m., turn off steam table well drain, wipe out. Add water to steam table for p.m.'s On 7/25/12 at 11:10 a.m., surveyor # entered the first floor resident dining room. Resident #23, #35 and #27 were seated at tables in the dining room. The room was unsupervised by staff. The surveyor walked up to an accessible four compartment Duke steam table. There was no notable indication on the steam table that the table was extremely hot to touch. There was hot food in the wells of the steam table covered by a thin plastic lid each containing a handle. The surveyor leaned her left hand on the stainless steel counter located on the front of the steam table and due to excessive temperatures, immediately retracted her hand. The surveyor then utilized a digital thermometer whose probe came in full contact with the stainless steel surface of the steam table. The temperature reading was 207.1 degrees F. It was also noted that water was bubbling from under the plastic covers onto the surface of the steam table. The surveyor stood by the steam table for approximately 5 minutes. During that time, no staff was visible in the dining room and none of the residents attempted to touch the steam table. On 7/25/12 at 11:15 a.m., CNA (Certified Nursing Assistant)-K entered the first floor resident dining room and verified to the surveyor that meal service began at 11:30 a.m. and that between meal service, the steam table was always left unsupervised by nursing or dietary staff. CNA-K touched the metal on the steam table and verified to the surveyor that the metal was extremely hot to touch and was only able to leave her hand on the metal for approximately 2 seconds before having to retract it due to intense heat. The surveyor had CNA-K contact a dietary staff to the unit and the surveyor notified NHA (Nursing Home Administrator)-J regarding her findings. NHA-J verified the steam table metal surfaces were hot to touch. NHA-J was instructed to supervise the first floor steam table while the surveyor went to the second floor dining room. On 7/25/12 at 11:20 a.m., surveyor # entered the second floor resident dining room and noted a four compartment steam table. The room was unsupervised by staff. The surveyor walked up to an accessible four compartment Duke steam table. There was no notable indication on the steam table that the table was extremely hot to touch. There was hot food in the wells of the steam table covered by a thin plastic lid each containing a handle. The surveyor touched the stainless steel counter located on the front of the steam table and due to excessive temperatures, immediately retracted her hand. The surveyor then utilized a digital thermometer whose probe came in full contact with the stainless steel surface of the steam table. The temperature reading was 172 degrees F. Surveyor also noted that water was bubbling from under the plastic covers onto the surface of the steam table. There were 4 residents seated in the dining room at the time of the observation. All of the residents were cognitively intact. On 7/25/12 at approximately 11:22 a.m., surveyor # re-entered the facility's first floor dining room. NHA-J was supervising the room. A few moments later, TSW (Tray Service Worker)-L entered the dining room and verified to the surveyor that the steam tables remain on high all day and that food had been placed in the wells at approximately 10:30 a.m. that morning for an 11:30 a.m. meal service. TSW-L also verified that kitchen staff do not supervise the steam table once the gauges are turned onto the high position. TSW-L touched the metal surfaces of the steam table and stated, "...it is very hot to touch and I can only keep my hand on it for a few seconds". The surveyor instructed TSW-L to notified her manager of the surveyors findings. On 7/25/12 at 1:15 p.m., NHA-J verified to surveyor # that no resident burns had occurred during the last year due to extremely hot steam table surfaces. NHA-J further verified to the surveyor that resident #23 through #35, who resided on the facility's first floor and residents #19 and #36 though #41 who resided on the facility's second floor were independently mobile and cognitively impaired. On 7/25/12 at 2:15 p.m., surveyor # again entered the first floor resident dining room with surveyor # . Both surveyors noted that the steam table gauges were on high and all four wells contained water covered by thin plastic lids with handles on them. Surveyor # then utilized a digital thermometer whose probe came in full contact with the stainless steel surface of the steam table. The temperature reading was 155 to 159 degrees F. It was also noted that water was bubbling from under the plastic covers onto the surface of the steam table. The surveyor then removed a plastic lid and had to stand back as a large amount of hot steam was expelled from the well which contained bubbling water. The temperature of the water in the well was obtained using a digital thermometer and a reading of 209.3 degrees F was noted. Surveyor # immediately informed NHA-J. NHA-J entered the first floor dining room and touched the metal surface of the steam table. NHA-J verified that he could only "touch it for a couple of seconds because it was hot". NHA-J also stated, "...I don't think there is a problem because it hasn't been a problem before". NHA-J also stated, "...I will shut it off now". On 7/26/12 at 7:45 a.m., surveyor # interviewed FSM (Food Service Manager)-O. FSM-O verified to the surveyor that it was the facility's practice to fill the wells of the steam table at 6:30 a.m., turn the gauges to high, place the foods into the wells, exit the dining rooms and return to service meals from 7:00 a.m. until 9:30 a.m. The wells are left on until the meal service begins at 11:30 a.m. until approximately 1:00 p.m. Dietary staff then dump the water from the wells, clean the wells, refill the wells with water, turn the steam table gauges on high, exit the room and return to place food in the wells at approximately 4:30 p.m. for dinner service which began at approximately 5:00 p.m. until 6:30 p.m. After supper, the wells were emptied and the gauges were turned off on the steam table until the following morning at 6:30 a.m. FSM-O verified that the steam tables, which the gauges are on high from 6:30 a.m. until approximately 6:30 p.m. were only supervised during plating of the meals and that the steam tables are always housed in the dining rooms in the same area as observed by the surveyor. FSM-O verified that the manufacturer of the steam table suggests a 30 minute warm up time for proper food holding temperatures. On 7/26/12 at 7:50 a.m., surveyor # interviewed DFS (Director of Food Services)-P. DFS-P stated, "It has been our practice forever to leave the steam tables on all day. It has been that way ever since we purchased the steam tables sometime in 2006. None of my staff had ever mentioned that the metal on the steam table was hot. Neither my staff or the Nursing Home Administrator had told me yesterday that there was a concern regarding the high steam table surface and water temperatures. We had not supervised the steam tables except for meal plating when they were on all day".