Every finding on record at Ingham County Medical Care Facility

Citation pertains to intake #3039609Based on interview and record review, the facility failed to protect and keep one resident (R70) of one resident safe from accidents that include elopement. Findings Include;Resident #70 (R70)Review of the medical records reflected that R70 was admitted to the facility on [DATE]. Diagnoses of Dementia, Anxiety and Depression. R70 was hospitalized and not on site at the facility during the survey. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2026 revealed R70 had a Brief Interview of Mental Status (BIMS) of 05 (Severe cognitive impact) out of 15. R70 wore a wander guard (security system used to protect residents who are prone to wandering).Record review revealed R70 verbalized an exit plan upon admission to the facility and a wander guard was placed on her right ankle. R70 was wandering in and out of other residents' rooms.Record review revealed the following:On 5/17/26- 9:29 AM- R70 attempting to exit the facility out the rear doors at the end of the hall. R70 asked maintenance staff to let her out so she could go home.On 05/17/26- 9:36 AM- R70 attempting to exit the facility out the rear doors at the end of the hall. R70 went up to nursing staff and said she needed to go home.On 05/17/26- 9:37 AM- R70 walked towards the atrium and was attempting to walk out the front doors to get out and get home, there were people waiting for her.On 05/17/26- 1:28 PM- R70 became agitated while pacing up and down the hallway asking about where her car was, where her son was and how to get out of there because she needed to get home.On 05/18/26- 11:37PM- R70 approached the [NAME] Ridge north exterior exit and attempted to exit out the automated door, in order to get outside, after pressing the blue handicap button. CNA was able to redirect R70 back to the nurse. R70 became agitated and needed to go home and get their car.On 05/18/26- 11:53 AM- R70 was outside briefly during an attempted escape, was observed by staff the entire time attempting to walk towards the exterior gate after getting through the interior door outside. R70 was then brought back inside by staff that could redirect her.On 05/18/26- 12:53 PM- R70 packing her belongings and attempting to leave the facility. R70 was able to be redirected to an activity.On 05/20/26- 10:16 PM- R70 was observed by CNA, walk up to courtyard door, press the handicap button to open the door and walk into the courtyard. Door alarm and wander guard alarm sounded. CNA followed R70 outside and redirected her back inside the building.On 05/20/26- 10:58 PM- R70 had room change due to exit seeking and elopement risk.On 05/20/26-4:03 PM- R70 attempting to go out fire door on unit. R70 trying to find a way out, re-educated on door safety and memory care unit.On 05/21/26- 10:14 AM- CNA reported to nurse, R70 exited the door. R70 re-entered the door to the hallway. Wander guard in place, not reported if it alarmed or not. R70 continued making statements about finding her car.On 05/21/26- 7:07 PM- R70 was restless and anxious and kept approaching exit door, attempted to go home, walk to her car reported by R70, hard to redirect.On 05/22/26- 11:33 AM- R70 noted old yellow bruising to side of abdomen. Root cause- Resident observed attempting to open exit doors and using her body. R70 walks up to the doors and uses her body to push the doors causing bruises. Immediate intervention; monitor for increase in size/swelling, staff to continue to redirect away from exit doors.On 05/22/26- 6:30 PM- R70 made multiple attempts to approach exit door, making statements about leaving, R70 stated She had to go home with her family, she had to go look for her boyfriend, she had too many things to do at home. R70 was able to be re-directed.On 05/28/26- 2:00 PM- R70 attempting to exit via locked door, adamite that she wanted to leave. Became upset and reported she would find a way out. R70's son was called, spoke to her for a few minutes. Approximately 10 minutes later R70 got up to walk to the exit door. R70 was redirected back from the door.On 05/30/26- 4:38 PM- R70 unable to fall asleep all night, in and out of bed, exit seeking, asking to go home, easy to redirect.On 05/30/26- 7:25 PM- R70 appeared anxious, attempting to approach doors to go home, redirection provided.On 06/09/26- 6:41 PM- R70 exit seeking and packing belongings.On 06/13/26- 8:12 PM- R70 wandering to the end doors stating I'm going home walking so fast she almost tripped over other residents several times. Prn Ativan given.On 06/15/26- 4:26 PM- R70 asking about how to get out and where her car was located.On 06/20/26- 12:01 PM- R70 wandering unit and asking for her car. Aide walked R70 outside in units gaited area for a few minutes. Came back in with staff fine.On 06/22/26- 6:48 PM- R70 did approach exit doors, but no attempts were made to open them.On 06/24/26- 1:52 PM- R70 was attempting to get another resident to go out the back door. R70 stated all you had to do is push on the door and hold it and it will open. R70 reported she needed to go get her car and go home.On 06/24/26-6:58 PM- R70 did approach the door multiple times, attempting to open the exit door.On 06/27/26- 4:54 PM- R70 asked staff can I get out that door pointing to the exit door in the lounge then the unit door. When redirected, stated I need to leave when reminded she stays here, R70 replied forget it, I am just going to leave.During an interview on 07/10/2026 at 9:17 AM, LPN/Unit Manager/Abuse coordinator C stated R70 exited out of the emergency exit door, looking for her car, took a right, couldn't find her car, and came back to the closest door, being front entrance, the receptionist assisted her in and back to her unit. LPN/Unit Manager/Abuse coordinator C also stated she was involved in updating the care plan for R70, updated immediately to prevent anything else from happening.Record review revealed additional elopements dated 05/18/2026 at 11:53 AM, 05/20/2026 at 10:16 AM and 05/21/2026 at 10:14 AM, that were not listed in the report. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included Element 1- The Elopement Assessment, Skin Assessment, Medical Director made a Tele-Health Visit, Nurse Practitioner follow up notes, Medication Administration Record reviewed. Element 2 included Elopement Risk Assessments on all residents, Audit of Wander Guard on Care Plans, Orders and Task. Element 3 included staff re-education, topic and information to be taught, and signatures of all staff attending. Element 4 included audits that were completed weekly to show compliance. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to Intake 3029138. Based on observation, interview, and record review, the facility failed to report a resident-to-resident sexual abuse allegation to the State Agency for two (R1 and R2) of three reviewed. Findings include: Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, dementia, anxiety, and depression. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/18/26 revealed R1 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). According to the medical record, R1 had been deemed unable to make his own medical and business decisions. The medical record did not include an assessment that R1 had the ability to consent to sexual activity/relationships or that his Durable Power of Attorney had the authority to make sexual activity/relationship decisions for him. Review of R1's care plan revealed Resident has a female friend on his unit and does not have the capacity to consent to friendly relationship. Spouse is aware of friendly relationship. Hx [history] of holding female friend/resident hand and providing hugs. Resident may comfort other residents and offer a hug if they are upset. The care plan was revised on 5/30/26 to reflect that R1 does have the capacity to consent to friendly relationship. There was no documentation in R1's medical record that he had consented to a sexual relationship with R2. Review of the medical record revealed R2 was admitted to the facility on [DATE]. The MDS with an ARD of 4/16/26 revealed R2 scored 15 out of 15 (cognitively intact) on the BIMS. R2 did not have a care plan regarding a relationship between her and R1. On 6/3/26 at 8:53 AM, R1 was observed sitting in a wheelchair outside his room. R1 then propelled himself back into his room and reported that R2 lives in the next room over and is his best friend. R1 reported he was married and R2 had a boyfriend, so they were only friends and the only physical contact between them has been a hug. On 6/3/26 at 2:04 PM, R2 was observed in his wheelchair in his room. R1 reported he did not recall any incidents where R2 was in his room or where staff had to separate them. When asked how he would feel if R2 touched him in is private area, R1 stated I would be appalled. An observation on 6/3/26 at 9:03 AM revealed R1 and R2's rooms were next door to each other. In a telephone interview on 6/3/26 at 9:22 AM, Certified Nursing Assistant (CNA) F reported they worked from 6:00 PM on 5/29/26 until 7:00 AM on 5/30/26 on R1 and R2's hallway. CNA F reported they heard from CNA E that CNA E witnessed R2 rubbing R1 inappropriately. In a telephone interview on 6/3/26 at 11:58 AM, CNA G reported on 5/29/26, herself and CNA E walked by R1's room and CNA G witnessed R2 rubbing R1 close to his private area. CNA G reported CNA E had a better view of the incident and then reported the incident to the nurse. Attempts were made to contact CNA E via telephone on 6/3/26 at 9:16 AM and 6/3/26 at 12:03 PM. CNA E did not return the calls prior to survey exit. Review of the facility's investigation revealed a statement from CNA E dated 5/29/26. The statement revealed the incident occurred on 5/29/26 at 9:00 PM. The statement was obtained by Unit Manager (UM)/Abuse Investigator (AI) I and revealed [CNA E] stated she was walking past [R1's] room and she observed [R2] sitting in her wheelchair next to [R1] and she had her hand down the front of his pants. She went up to tell the nurse about it. When she came back down the hall she stated [R2] had removed her hand and was now rubbing [R1] on the outside of his pants [on] his groin area. [CNA E] stated to [R2] that she shouldn't do that because [R1] has a roommate. She stated that [R2] got very upset and stated she wasn't leaving. In an interview on 6/3/26 at 10:58 AM, Social Services Supervisor (SSS) H reported R1 and R2 have had a friendly relationship which meant it was a non-physical, emotional friendship. SSS H reported on 5/29/26, it was reported staff observed R2 with her hand in R1's pants. SSS H reported she came into the facility the next morning to assess and see what happened. SSS H reported they were not aware of the facility having any type of assessment to determine if residents had the capacity to consent to sexual activity/relationships. In an interview on 6/3/26 at 11:42 AM, UM/AI I reported when there were allegations of abuse, staff called the abuse hotline which connected to the phone she carried. UM/AI I reported she then called the Nursing Home Administrator (NHA) A to discuss the information, and they decided what will be done. UM/AI I reported if she and NHA A decided to report to the State Agency, she then entered the information on the State Agency's reporting website and then an investigation was completed. UM/AI I reported she received a call the evening of 5/29/26 with a report that a CNA observed R2 with her hand down R1's pants. UM/AI I reported the information was discussed with NHA A and it was determined that since R1 and R2 had an ongoing relationship, could make their needs known, and could make their own decisions, the incident was not reportable to the State Agency. UM/AI I reported staff were instructed if something was going on between R1 and R2, to make sure it was private, so others were not uncomfortable with the situation. UM/AI I reported it wasn't until the next day (5/30/26), statements were obtained from R1 and R2. When asked to define friendly relationship according to R1's care plan, UM/AI I reported R1 and R2's relationship was a friendly, emotional, non-physical relationship. UM/AI I reported they do hold hands and hug. In an interview on 6/3/26 at 1:24 PM, NHA A reported on 5/29/26, staff called UM/AI I at the abuse hotline. UM/AI I then called NHA A and reported staff observed R1 and R2 together in R1's room and the CNA observed R2's hand down R1's pants. NHA A reported it was determined this was not an allegation of sexual abuse because R1 and R2 spend a lot of time together, were in a relationship, and could make their needs known. NHA A reported the physician saw R1 on 5/29/26 for other reasons so the facility reached out to the physician on 5/30/26 at which time the physician reported they felt R1 was cable of making their own medical and business decisions. When asked if there was any documentation prior to the alleged incident showing R1 and R2 had the ability to consent to sexual activity/relationship or that they have consented to a sexual relationship, NHA A reported she would have to check. No documentation was provided prior to the survey exit. In an interview on 6/3/202 at 6 9:14 AM, Licensed Practical Nurse (LPN) C stated Certified Nurse Aid (CNA) E had reported she had witnessed R2 touching R1 private area inappropriately to LPN C on 5/29/2026. LPN C said CNA E tried to separate R1 and R2 but they were unable to. LPN C said R1 and R2 were not care planned to have a relationship of the type. LPN C said R1's wife was ok with R1 and R2 being only friends. LPN C said she called the abuse hotline and LPN I answered the call. LPN C said LPN I told her not to document the incident but said she did anyway. LPN C said LPN E told her it was okay that the two residents do that (sexual acts), but they needed to do it in private. LPN E said she then contacted the Assistant Director of Nursing (ADON) J who told her that an investigation would be done regarding the incident. LPN C said her and CNA E both wrote a statement about the incident;

This citation pertains to intake number 3029138. Based on interview and record review the facility failed to ensure a comprehensive care plan was in place for one out of three residents (Resident #2). Findings Inlcuded:Per the facility face sheet Resident #2 (R2) was admitted to the facility on [DATE]. Review of a Brief Assessment for Mental Status (BIMS) dated 4/16/2026 revealed R2 had a BIMS score of 15 out of 15 which indicated full cognitive abilities. Review of a progress note dated 4/28/2026 revealed R2 became upset the night before when she was asked to leave another resident's (R1) room. Review of a social service progress note dated 5/19/2026 revealed R2 was met with in order to discuss R2 interfering with R1's care, to not wake R1 while sleeping, and to leave and return later if R1 was in the bathroom or receiving care. Another progress note dated 5/29/2026 revealed R2 was witnessed in R1's room inappropriately touching R1. R2 was asked to leave R1's room, however, would not comply. In an interview on 6/3/2026 at 9:14 AM Licensed Practical Nurse (LPN) C stated that on 5/9/2026, Certified Nurse Aid (CNA) E had reported to her R2 was in R1's room inappropriately touching R1. LPN C said CNA E reported to her that she was unable to separate the two residents. LPN C stated that R1's wife was ok with R1 and R2 being friends, and she had seen the two hug and hold hands.In an interview on 6/3/2026 at 10:59 AM Social Services (SS) H stated that R2 entering into R1's room was an issue. SS H said R2 would interfere with R`'s care. SS H stated there was no Interdisciplinary Team (IDT) meeting held to discuss R2's relationship with R1 and stated more should have been documented about their relationship. SS H said yes there should have been a care plan in place regarding R2 interfering with R1's care, and also regarding the relationship/friendship R2 had with R1. Review of R2's care plans revealed there was no care plan in place regarding R2's behaviors towards R1 nor a relationship with R1.

Based on observations, interviews, and record reviews, the facility to effectively clean and maintain food service equipment affecting 131 residents who consume food, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:On 12/09/2025 at 10:25 A.M., An initial tour of the food service was conducted with Dining Service Director F. The following items were noted: One 12-inch-wide by 12-inch-long return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits, adjacent to the mechanical dish machine. The 2022 FDA Model Food Code section 6-501.14 states: (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. (B) If vented to the outside, ventilation systems may not create a public health HAZARD or nuisance or unLAWful discharge. On 12/09/2025 at 11:10 A.M., An initial tour of the South Pantry Kitchenette was conducted with Dining Service Director F. The following items were noted: The [NAME] microwave oven interior was observed (etched, scored, particulate). The interior door frame and ceiling surface were also observed (etched, scored, corroded). Dining Service Director F stated: I will remove the microwave oven immediately. The 2022 FDA Model Food Code section 4-501.13 states: Microwave ovens shall meet the safety standards specified in 21 CFR 1030.10 Microwave ovens. The Manitowac ice machine undersplash and backsplash were observed soiled with accumulated and encrusted mineral (lime and calcium) deposits. The drip tray assembly was also observed soiled with accumulated and encrusted mineral (lime and calcium) deposits, dirt, and food residue. Dining Service Director F stated: I will have staff thoroughly clean and sanitize the ice machine as soon as possible. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The sole hand sink goose neck assembly was observed loose-to-mount. The interior vanity cabinetry was also observed severely (warped, particulate, discolored, and moist). The particle board was further observed separated from continuous moisture exposure. One red sanitization bucket was additionally observed stored directly beneath the polyvinyl chloride (PVC) wastewater plumbing. The red sanitization bucket was further observed completely full of water and overflowing onto the interior cabinetry flooring surface. Dining Service Director F stated: I will place a work order into the maintenance software system (ECHO). On 12/09/2025 at 12:40 P.M., An initial tour of the [NAME] Pantry Kitchenette was conducted with Dining Services Director F. The following items were noted: The Panasonic microwave oven interior was observed soiled with accumulated and encrusted food residue. Dining Service Director F stated: I will have staff thoroughly clean and sanitize the microwave oven as soon as possible. The [NAME] stainless steel commercial toaster interior was observed soiled with accumulated and encrusted food residue. Dining Service Director F stated: I will have staff thoroughly clean and sanitize the toaster as soon as possible. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 12/09/2025 at 2:59 P.M., A comprehensive tour of the South Pantry Kitchenette was conducted by this surveyor. The following item was noted: Dietary flatware (knives) was observed stored inverted, within a gray plastic caddy, with the food contact surface facing upward. The exposed food contact surface created a potential cross-contamination issue. The 2022 FDA Model Food Code section 4-903.11 states: (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. On 12/10/2025 at 11:38 A.M., A follow-up tour of the South Pantry Kitchenette was conducted by this surveyor. The following items were noted: The Manitowac ice machine undersplash and backsplash were observed soiled with accumulated and encrusted mineral (lime and calcium) deposits. Water was also observed dripping from the ice dispensing spout into the black drip tray. The drip tray assembly was also observed soiled with accumulated and encrusted mineral (lime and calcium) deposits, dirt, and food residue. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The flooring surface, located directly beneath the Manitowac ice machine was further observed severely soiled with dust, dirt, and debris (paper products, plastic lids, etc.). The 2022 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. On 12/11/2025 at 09:00 A.M, Record review of the Policy/Procedure entitled: Cleaning Schedule dated 9/7/22 revealed under Description: The health and safety of our associates and guests is of the utmost importance. Keeping clean and properly maintained cafe' and kitchens is critical to our success. On 12/11/2025 at 09:15 A.M., Record review of the Policy/Procedure entitled: Cleaning of Food and Non-Food Surfaces dated 9/7/22 revealed under Description: It is assumed that food contact surfaces within the facility/community are in good condition, made of non-toxic materials and are easily cleanable. It is assumed non-food contact surfaces of utensils and equipment within the facility/community must be made of materials that are safe, corrosion resistant, nonabsorbent, smooth, easily cleanable, and maintained in good condition.

Based on observations, interviews, and record reviews, the facility failed to: (1) provide palatable food products, and (2) provide consistent dietary glassware and flatware affecting 131 residents who consume food, resulting in the increased likelihood for resident decreased food acceptance, nutritional decline, and undignified dining.Findings include:During an observation, interview and record review on 12/09/2025 at 12:10 PM several residents were sitting in Main Dining Room and staff were present appearing to be getting ready to serve lunch. Review of the posted menu located behind the silverware at the serving window reflected tomato Florentine soup, Korean BBQ chicken, moist fluffy rice, curried cauliflower, [NAME] gelatin, margarin, and 2% milk was on the menu for lunch. Continued observation with limited silverware noted in holder and several plastic silverware observed in room trays in carts located by the kitchenette. During an interview, Certified Nurse Aid DD reported staff must use plastic silverware when they run out when preparing room trays. Observed some trays with mix of metal and plastic with about half of trays (about 15 to 20 trays) with plastic silverware. CNA DD reported ran out of metal silverware about halfway through room tray prep. CNA DD reported had been issue for about one month and staff have reported to management that they run out of real silverware but continues to be an issue and residents' complaint because difficult to eat with flimsy plastic. CNA DD reported kitchen often runs out of food as well including that morning when several residents had ordered the pancakes, but kitchen ran out and served toast instead and times when they start to run low residents get smaller portions. CNA DD reported residents choose what they want when they arrive at the dining room from meal ticket that has only one choice on it for entrée and reported facility has alternative options, but kitchen staff often say they are not available at least daily. CNA K verified issues with not enough metal silverware and food and reported staff do not have enough blue handled cups with lids to pass water to resident or serve during meals and most don't have lids and have to use poor fitting disposable lids and observed use of thin clear plastic disposable lid used on several cups. CNA K reported if residents require two handled mugs and not available, they do the best they can and provide one handled mugs. Observed clear two handled mugs with lids that do not fit. CNA K reported food service has been a problem for months that frequently run out of food and often do not serve what is on the menu with at least four to five changes in kitchen management since contracted company change. CNA K reported residents complain about having to eat from plastic silverware and ask staff, are we in kindergarten? CNA K reported not homelike and alternative menu items not available except peanut butter and jelly or maybe tuna fish sandwich. CNA K and J reported often run out of 8-ounce glasses and must use two four-ounce glasses for residents that require 8 ounces of milk, with meal or give two four-ounce cups of juice if residents request more juice. CNA J and K reported facility had run out of milk in past as well and reported kitchen staff have had issues with staffing and not enough staff, and facility staff have had to assist in the kitchen over within past two months. CNA J reported one day cinnamon rolls were on the menus and the kitchen had run out and so they served Hawaiian rolls with cinnamon on the top and resident were disappointed. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R73 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included heart disease, congestive heart failure, diabetic, diverticulosis, irritable bowel, and depression. The MDS reflected R73 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required assist with meal set up and clean up. During an observation and interview on 12/09/2025 at 2:29 PM, R73 was in room sitting in a wheelchair and appeared calm, pleasant and able to answer questions without difficulty. R73 reported food at facility was bad and stated was served hot dogs 3 times last week. R73 stated, It is bad enough I have to be here, then I get bad food. R73 reported chooses to eat meals in room and two to three times a week has to eat meals with plastic silverware and stated, I pay a lot of money to be here and should not have to eat with plastic silverware. R73 reported was served corn last week and should not have been related to diagnosis and had lost weight recently. R73 stated, food is just not good, after starting to appear upset. R73 reported daughter was working on completing grievance form for food issues. During an observation, interview and record review on 12/10/2025 at 2:00 PM R73 was sitting in room with meal tray at side that had been delivered to room recently. There appeared to be wide egg noodles with ground white meat and pesto, with gravy. asparagus, puree cabbage soup, roll, and Strawberry Bavarian. R73 reported was finished stated, I ate something because I knew I had to eat something. R73 ate roll about 75% asparagus, and 25% entrée. The pureed cabbage soup was untouched as well as dessert. The strawberry dessert appeared to be pureed strawberry over pudding and pureed soup looked like dark mashed potatoes. R73 reported she really liked soup but not like that and did not care for looks of dessert and reported enjoyed sherbet but never offered. R73 meal ticket included entrée of 1 each S. Beef Hot Dog (turkey written in), garlic noodles, 6 ounces puree cabbage soup, roll, and Strawberry Bavarian with texture of regular ground. During an observation, interview and record review on 12/11/25 at 2:45 p.m., observed R73 meal tray at the bedside untouched with R73 in bed with eyes closed. The meal ticket reflected puree chicken noodle soup, stuffed pork chop, Brussel Sprouts, apple crisp. The tray included what appeared to be mashed potatoes, brown substance that looked like consistency of mashed potatoes, scoop of large grain multi color item, green beans and apple crisp with regular ground texture. R73 daughter entered room about 2:50 p.m. and reported R73 had ground meat because it was easier to chew not related to choking concerns and verified unsure why facility would puree pork chop or soup. R73 daughter reported R73 really likes soup. During an interview on 12/11/2025 at 3:10 PM, CNA GG reported alternative meals posted but told by kitchen staff not available at least daily including grilled cheese and mashed potatoes. CNA GG reported residents should have choices for meals and have basic options available. CNA GG reported facility has shortage of blue mugs and lids that fit properly for several weeks. During an interview on 12/11/2025 at 4:00 PM Kitchen Manager (KM) F reported had worked at the facility for about three months. KM F reported food modifications were ordered by Speech Therapy and kitchen staff are expected to follow meal tickets. KM F reported R73 had a hot dog on her meal ticket yesterday at lunch because maybe that is what she wanted and reported main entrée was pesto turkey and should have been R73 main entree on ticket with meat ground per order. KM F was unable to say why R73 had hot dog on ticket as main entrée and unable to say why R73's meal ticket had pureed chicken noodle soup today (12/11/25). KM F reported ground meal should look like ground meat and reported Brussel Sprouts were on the lunch menu today but kitchen staff had to substitute for green beans for quality reasons at the last minute. KM F reported couscous was served with lunch today (not on menu) but unable to say why it was served to R73 and verified was not on R73 meal ticket. KM F reported had ordered metal silverware three times since September and received more on 12/9/25 and reported was unsure where they go and may be issue with residents' hording silverware. During an interview on 12/15/2025 at 8:54 AM, Dietician H reported was familiar with R73. Dietician H reported R73 had several food eversions on admission and regular diet with ground meat was current texture order for meats only not related to swallowing issues. Dietician H reported if chunks of meat in soup would puree even if ground meat. Dietician H verified R73 had significant weight loss and was not on supplements currently. Dietician H reported alternate menu always available. During an observation on 12/15/2025 at 9:52 AM, R73 was observed in bed with eyes closed and untouched meal tray on bedside table. R73 meal ticket, dated 12/15/25 breakfast, included circled fresh grapes and corn flakes. Observed applesauce and corn flakes with no fresh grapes. Review of R73 Speech Therapy Evaluation, dated 10/23/25, reflected, Regular solids with ground meats, thin liquids. Inadequate mastication of tough meats .Pt's[patients] diet prior to ST[speech therapy] was regular solid, thin liquids. Pt's diet was downgraded to regular solids with ground meats due to pt's preference and inconsistency of cook on eat in the facility . Review of R73 Nutritional Assessment, dated 10/24/25, reflected grapes were on R73 list of liked foods. Continued review of the assessment reflected, Resident denies chewing or swallowing issues with current texture, Recent downgraded to ground meats r/t troubles with chewing some. Review of R73 Dietary Note, dated 11/18/25, reflected, Inadequate oral intakes r/t[related to] poor appetite AEB [as evidenced by] highly variable intakes and 10% weight loss x 6 mos. [times six months] . Review of the Grievance Log, dated 9/1/25 through 11/24/25, reflected over 25 kitchen/food complaints related to plastic silverware, food preferences not honored, no alternative choices available, lack of cups with lids, food temps and modifications. During a second interview on 12/15/25 at about 10:15 a.m. Dietician H reported was unsure why R73 was provided applesauce instead of requested fresh grapes and verified grapes were liked items. During an interview on 12/15/2025 at 11:03 AM, Speech Therapy (ST)HH reported R73 did not have swallowing issues but was started after request of resident on 10/24/25 visits with speech therapy because resident was tiring with chewing and was easier for resident. ST HH reported was unsure why soup was puree and stated that would be kitchen staff. On 12/10/2025 at 2:16 PM, a lunch test tray evaluation was conducted. The meal included cabbage soup, turkey with pesto, noodles, and asparagus. The cabbage soup was overcooked, resulting in the ingredients being excessively soft and mixed together. The noodles lacked flavor, and the turkey was notably dry. On 12/09/2025 at 12:49 P.M., An interview was conducted with Dietary Aide G regarding dietary service flatware inventory. Dietary Aide G stated: We don't have enough flatware (spoons, knives, forks). Dietary Aide G additionally stated: Management stated new flatware (knives, forks, spoons) is currently on order. On 12/09/2025 at 12:55 P.M., An interview was conducted with Registered Dietician (RD) H regarding dietary service flatware inventory. (RD) H stated: We order $400.00 worth of flatware a month. (RD) H also stated: We mainly order spoons and forks, rarely knives. On 12/09/2025 at 01:30 P.M., An interview was conducted with Dining Service Director F regarding dietary service flatware inventory. Dining Service Director F stated: We have been doing weekly room sweeps for flatware. Dining Service Director F also stated: Some residents are care planned for plastic spoons, knives, and forks. On 12/10/2025 at 11:52 P.M., Lunch meal food products were observed leaving the main food production kitchen, within an insulated stainless steel transport cart. On 12/10/2025 at 11:55 A.M., Lunch meal food products were observed arriving to the South Pantry Kitchenette, within an insulated stainless steel transport cart. On 12/10/2025 at 12:53 P.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident #92's lunch meal: Cabbage Soup - 143.7 Toasted Turkey Sandwich - 88.9 Strawberry Bavarian - 50.1* Beverage (Coffee) - 151.0 The 2022 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, and except as specified under ¶ (B) and in ¶ (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 degrees C (135 degrees F) or above, except that roasts cooked to a temperature and for a time specified in ¶ 3-401.11(B) or reheated as specified in ¶ 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5 degrees C (41 degrees F) or less. On 12/10/2025 at 01:35 P.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident #72's lunch meal: Cabbage Soup - 137.0 Mashed Potatoes - 137.1 Grilled Cheese - 141.8 Lemon Asparagus - 119.7* Strawberry Bavarian - 50.8* Beverage (Apple Juice) - 51.0* The 2022 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, and except as specified under ¶ (B) and in ¶ (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 degrees C (135 degrees F) or above, except that roasts cooked to a temperature and for a time specified in ¶ 3-401.11(B) or reheated as specified in ¶ 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5 degrees C (41 degrees F) or less. On 12/10/2025 at 03:01 P.M., An interview was conducted with Dining Service Director F regarding dietary service glass and flatware inventory. Dining Service Director F stated: I thought I only needed juice glasses. Dining Service Director F also stated: I will order new 8-ounce glasses for both dairy and water. On 12/11/2025 at 08:30 A.M, Record review of the Policy/Procedure entitled: Ordering, Assembling, and Presenting a Meal dated (no date) revealed under Assembling the Order: (1) Collect all the serving equipment needed for the course(s) you are picking up. This includes plates, glasses, dollies, and silverware. (2) Get all the food accompaniments and garnishes for this course. For instance, sour cream for baked potato or mint jelly for sliced lamb. (3) Pick up cold food first, taking care to keep it away from hot food on the tray or the steamtable. (4) Pick up hot foods next, covering all hot food with an insulated plate cover (banquet cover) to retain the heat. Use heated underliners for hot foods and chilled underliners for cold foods and salads. (5) Plan the assembling order of the entrees so you can pick up the items as soon as they are ready. (8) Remember that the appearance and temperature of food perfectly prepared when it leaves the kitchen can be spoiled by a server/aide who is thoughtless, slow, or careless. On 12/11/2025 at 08:45 A.M., Record review of the Policy/Procedure entitled: Meal Delivery dated 9/7/22 revealed under Description: Meals will be delivered to all residents/patients in a timely, organized, safe, and sanitary manner. Record review of the Policy/Procedure entitled: Meal Delivery dated 9/7/22 further revealed under Nursing: (1) Serves meals promptly upon delivery. (2) Clears, cleans, and sanitizes overbed tables in preparation for meal. (3) Positions resident/patient to ensure comfort and safety while eating and drinking. Aids with meal set-up as appropriate and assists residents/patients who require assistance. (4) Notifies Dining Services Department of any items missing or if a resident/patient requests a substitute. (5) Picks up the dishes after each meal and returns them to the designated area (Note: Used dishes will not be placed in carts containing unserved foods/beverages).

Based on observation, interview, and record review the facility failed to ensure that residents were treated with dignity and respect when residents were required to use plastic silverware for meals which diminished the homelike dining experience in two (Resident #33 and #73) and the potential to affect all residents that utilize utensils during meal service. Findings include:Review of the medical record reflected R33 was admitted to the facility on [DATE] and readmitted on [DATE]. The Minimum Data Set (MDS) reflected R33 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/09/2025 at 2:36 PM, R33 was observed in bed. R33 was dressed, however, multiple orange stains on R33's shirt were observed. R33 stated that she struggled feeding herself lunch that day. R33 explained that she utilized adaptive equipment and can feed herself when it is provided, except more recently, the facility had been utilizing plastic spoons instead of actual silverware, making it difficult to feed herself without spilling food all over herself. R33 explained that the difference in utensil weight and the spoon handle make a significant difference when self-feeding. R33 confirmed that the spots on her shirt were content of her lunch earlier that day. R33 stated that it made her feel humiliated. During an observation, interview and record review on 12/09/2025 at 12:10 PM several residents were sitting in Main Dining Room and staff were present appearing to be getting ready to serve lunch. Review of the posted menu located behind the silverware at the serving window reflected tomato Florentine soup, Korean BBQ chicken, moist fluffy rice, curried cauliflower, [NAME] gelatin, margarin, and 2% milk was on the menu for lunch. Continued observation with limited silverware noted in holder and several plastic silverware observed in room trays in carts located by the kitchenette. During an interview, Certified Nurse Aid DD reported staff must use plastic silverware when they run out when preparing room trays. Observed some trays with mix of metal and plastic with about half of trays (about 15 to 20 trays) with plastic silverware. CNA DD reported ran out of metal silverware about halfway through room tray prep. CNA DD reported had been issue for about one month and staff have reported to management that they run out of real silverware but continues to be an issue and residents' complaint because difficult to eat with flimsy plastic. CNA DD reported kitchen often runs out of food as well including that morning when several residents had ordered the pancakes, but kitchen ran out and served toast instead and times when they start to run low residents get smaller portions. CNA DD reported residents choose what they want when they arrive at the dining room from meal ticket that has only one choice on it for entrée and reported facility has alternative options, but kitchen staff often say they are not available at least daily. CNA K verified issues with not enough metal silverware and food and reported staff do not have enough blue handled cups with lids to pass water to resident or serve during meals and most don't have lids and have to use poor fitting disposable lids and observed use of thin clear plastic disposable lid used on several cups. CNA K reported if residents require two handled mugs and not available, they do the best they can and provide one handled mugs. Observed clear two handled mugs with lids that do not fit. CNA K reported food service has been a problem for months that frequently run out of food and often do not serve what is on the menu with at least four to five changes in kitchen management since contracted company change. CNA K reported residents complain about having to eat from plastic silverware and ask staff, are we in kindergarten? CNA K reported not homelike and alternative menu items not available except peanut butter and jelly or maybe tuna fish sandwich. CNA K and J reported often run out of 8-ounce glasses and must use two four-ounce glasses for residents that require 8 ounces of milk, with meal or give two four-ounce cups of juice if residents request more juice. CNA J and K reported facility had run out of milk in past as well and reported kitchen staff have had issues with staffing and not enough staff, and facility staff have had to assist in the kitchen over within past two months. CNA J reported one day cinnamon rolls were on the menus and the kitchen had run out and so they served Hawaiian rolls with cinnamon on the top and resident were disappointed. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R73 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included heart disease, congestive heart failure, diabetic, diverticulosis, irritable bowel, and depression. The MDS reflected R73 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required assist with meal set up and clean up. During an observation and interview on 12/09/2025 at 2:29 PM, R73 was in room sitting in a wheelchair and appeared calm, pleasant and able to answer questions without difficulty. R73 reported food at facility was bad and stated was served hot dogs 3 times last week. R73 stated, It is bad enough I have to be here, then I get bad food. R73 reported chooses to eat meals in room and two to three times a week has to eat meals with plastic silverware and stated, I pay a lot of money to be here and should not have to eat with plastic silverware. R73 reported was served corn last week and should not have been related to diagnosis and had lost weight recently. R73 stated, food is just not good, after starting to appear upset. R73 reported daughter was working on completing grievance form for food issues. During an observation, interview and record review on 12/10/2025 at 2:00 PM R73 was sitting in room with meal tray at side that had been delivered to room recently. There appeared to be wide egg noodles with ground white meat and pesto, with gravy. asparagus, puree cabbage soup, roll, and Strawberry Bavarian. R73 reported was finished stated, I ate something because I knew I had to eat something. R73 ate roll about 75% asparagus, and 25% entrée. The pureed cabbage soup was untouched as well as dessert. The strawberry dessert appeared to be pureed strawberry over pudding and pureed soup looked like dark mashed potatoes. R73 reported she really liked soup but not like that and did not care for looks of dessert and reported enjoyed sherbet but never offered. R73 meal ticket included entrée of 1 each S. Beef Hot Dog (turkey written in), garlic noodles, 6 ounces puree cabbage soup, roll, and Strawberry Bavarian with texture of regular ground. During an interview on 12/11/2025 at 11:15 am, Licensed Practical Nurse (LPN) NN reported shortage of cups, lids and silverware for about 2 weeks and residents complain and staff assist with grievance reports. During an interview on 12/11/2025 11:55 PM R73 observed in room drinking from broken blue mug with disposable lid. R73 demonstrated handle was broken and lid was leaking. R73 reported daughter had brought dinner it last evening and verified weight loss since facility admission because she does not always eat food because often does not like served food. During an observation on 12/11/2025 at 12:40 p.m., in main dining room residents observed eating with plastic silverware. During an observation, interview and record review on 12/11/25 at 2:45 p.m., observed R73 meal tray at the bedside untouched with R73 in bed with eyes closed. The meal ticket reflected puree chicken noodle soup, stuffed pork chop, Brussel Sprouts, apple crisp. The tray included what appeared to be mashed potatoes, brown substance that looked like consistency of mashed potatoes, scoop of large grain multi color item, green beans and apple crisp with regular ground texture. R73 daughter entered room about 2:50 p.m. and reported R73 had ground meat because it was easier to chew not related to choking concerns and verified unsure why facility would puree pork chop or soup. R73 daughter reported R73 really likes soup. During an interview on 12/11/2025 at 3:10 PM, CNA GG reported alternative meals posted but told by kitchen staff not available at least daily including grilled cheese and mashed potatoes. CNA GG reported residents should have choices for meals and have basic options available. CNA GG reported facility has shortage of blue mugs and lids that fit properly for several weeks. During an interview on 12/11/2025 at 4:00 PM Kitchen Manager (KM) F reported had worked at the facility for about three months. KM F reported food modifications were ordered by Speech Therapy and kitchen staff are expected to follow meal tickets. KM F reported R73 had a hot dog on her meal ticket yesterday at lunch because maybe that is what she wanted and reported main entrée was pesto turkey and should have been R73 main entree on ticket with meat ground per order. KM F was unable to say why R73 had hot dog on ticket as main entrée and unable to say why R73's meal ticket had pureed chicken noodle soup today (12/11/25). KM F reported ground meal should look like ground meat and reported Brussel Sprouts were on the lunch menu today but kitchen staff had to substitute for green beans for quality reasons at the last minute. KM F reported couscous was served with lunch today (not on menu) but unable to say why it was served to R73 and verified was not on R73 meal ticket. KM F reported had ordered metal silverware three times since September and received more on 12/9/25 and reported was unsure where they go and may be issue with residents' hording silverware. During an interview on 12/15/2025 at 8:54 AM, Dietician H reported was familiar with R73. Dietician H reported R73 had several food eversions on admission and regular diet with ground meat was current texture order for meats only not related to swallowing issues. Dietician H reported if chunks of meat in soup would puree even if ground meat. Dietician H verified R73 had significant weight loss and was not on supplements currently. Dietician H reported alternate menu always available. During an observation on 12/15/2025 at 9:52 AM, R73 was observed in bed with eyes closed and untouched meal tray on bedside table. R73 meal ticket, dated 12/15/25 breakfast, included circled fresh grapes and corn flakes. Observed applesauce and corn flakes with no fresh grapes. Review of R73 Speech Therapy Evaluation, dated 10/23/25, reflected, Regular solids with ground meats, thin liquids. Inadequate mastication of tough meats .Pt's[patients] diet prior to ST[speech therapy] was regular solid, thin liquids. Pt's diet was downgraded to regular solids with ground meats due to pt's preference and inconsistency of cook on eat in the facility . Review of R73 Nutritional Assessment, dated 10/24/25, reflected grapes were on R73 list of liked foods. Continued review of the assessment reflected, Resident denies chewing or swallowing issues with current texture, Recent downgraded to ground meats r/t troubles with chewing some. Review of R73 Dietary Note, dated 11/18/25, reflected, Inadequate oral intakes r/t[related to] poor appetite AEB [as evidenced by] highly variable intakes and 10% weight loss x 6 mos. [times six months] . Review of the Grievance Log, dated 9/1/25 through 11/24/25, reflected over 25 kitchen/food complaints related to plastic silverware, food preferences not being honored, available alternatives, lack of cups with lids, food temps and modifications. During a second interview on 12/15/25 at about 10:15 a.m. Dietician H reported was unsure why R73 was provided applesauce instead of requested fresh grapes and verified grapes were liked items. During an interview on 12/15/2025 at 11:03 AM, Speech Therapy (ST)HH reported R73 did not have swallowing issues but was started after request of resident on 10/24/25 visits with speech therapy because resident was tiring with chewing and was easier for resident. ST HH reported was unsure why soup was puree and stated that would be kitchen staff.

Based on interview and record review the facility failed to complete accurate Minimum Data Set (MDS) assessments for four resident (#7,#47,#72,#145) of 26 residents reviewed for MDS accuracy, resulting in inaccurate MDS assessments. Findings Include Resident #47 (R#47) Review of the medical record reflected that R47 was admitted to the facility on [DATE] and discharged on 12/10/2025. Diagnoses of displaced fracture of upper end of the left humerus, unspecified sequelae of cerebral infarction (a range of long-term effects and complications), Type 2 Diabetes Mellitus, heart failure and blindness in right eye. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/12/2025 revealed R47 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section GG0115, Functioning Limitations in Range of Motions reveals R47 is independent for all care, used a walker for safe ambulation. Record review of the Minimum Data Set (MDS) skin assessment with an ARD/Target Date of 11/12/2025, did not show accuracy for documentation on pressure ulcers on admission assessment. According to the section within the MDS 3.0 Section M- Skin Conditions under MO100. Determination of Pressure Ulcer/Injury Risk, did resident had a pressure ulcer/injury, a scar over boney prominence, or a non-removeable dressing/device, MDS RN EE marked no, that the resident did not have any pressure ulcers. Then under MO210. Unhealed Pressure Ulcers/Injuries, MDS RN EE marked yes, that R 47 had unhealed pressure ulcers. Then marked R47 as having 1 pressure ulcer stage 1, was not on a turning and repositioning program, had nutrition and hydration interventions to manage skin problems and marked yes for pressure ulcer care. Application of non-surgical dressing (with or without topical medication) other than feet was marked no to any dressing used for the pressure ulcer. 12/15/2025 10:32 AM Interview with Minimum Data Set (MDS) Coordinator RN S and MDS RN EE, writer asked both nurses about MDS admission skin assessment on R47. MDS Coordinator S stated MDS RN EE did the assessment on R47 and MDS RN EE was looking back through the residents' notes in the EMR. Writer asked what tools she used to complete her assessment. MDS RN EE stated she read the nursing /wound care notes upon admission. MDS RN EE stated that R47 had 2 pressure ulcers on the head-to-toe assessment. Wound Care Nurse Practitioner (NP) FF documented R47 had a stage 3 to left buttock, and a stage 2 to the right buttock. MDS RN EE stated she must have marked it wrong because she marked them further down on the MDS skin assessment. Further down revealed MDS RN EE only documented that R47 only had a stage 1 pressure ulcer, and no others, which R47 did not have a stage 1 pressure ulcer. Resident #145 (R145) Review of the medical record reflected that R145 was admitted to the facility on [DATE] and discharged on 12/13/2025. Diagnoses of Pneumonia, respiratory failure, pleural effusion, severe malnutrition, fracture of upper end of left tibia and fusion of the spine. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/2025 revealed R145 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Under section GG0115, Functional Limitation in Range of Motion, reveals R145 was impaired on one side of her upper extremity, uses a walker for ambulation and requires a set up or clean up assistance and supervision for oral care. R145 is dependent on toileting or showers. Record review of the MDS Skin Assessment documentation, R145 had Deep Tissue Injury (DTI) with open areas in the middle of the injury. MDS RN EE marked 3 DTIs, and the open areas that were measured and documented. R145 did not have 3 DTI's, she had 2 DTI's and a stage 3 pressure ulcer. During an interview on 12/15/2025 at10:45 AM, MDS RN EE stated she did not have Wound Care NP FF assessment note on R145, so she looked at the nursing notes for wound details. MDS RN EE stated wound care NP FF comes into the facility1 day a week, he makes rounds with Licensed Practical Nurse (LPN) L who completes the wound care the other 3 days a week. Stated wound care NP FF did not do his assessment until 12/04/25. Record review of hospital discharge report revealed that R145 came to the facility from the hospital with a stage 3 pressure ulcer of the sacral region. R145 also had a wound on the left ischium, right buttock and sacral region. The sacral region pressure ulcer was noted to have slough in the wound bed and area measured 11.3cm x 8.5cm scant drainage to area, wound base is 70% necrotic tissue, 10% slough and 10% granulating tissue, no malodor noted, wound edges attached. DTI noted on the right buttock, area measuring at 3.1cm x 8cm, wound base was 100% maroon in color. DTI noted on the left ischium measuring 3.6cm x 3.2cm with a bridge of good tissue, no drainage noted, no odor. Record review of a wound care assessment completed by wound care NP FF on 12/04/2025: Wound #1 Wound Assessment: Wound- Sacral unstageable pressure Measurements- 9 x 8.5 x unable to determine true depth Tissue type- slough/subcutaneous Peri Wound- fragile Drainage- moderate serous exudate Pain- moderate to severe Infection- increased drainage, non-viable tissue, recent hx of wound deterioration Overall Wound Condition- stable Wound Plan of Care- Cleanse sacral wound with anasept, pat dry. Apply nickel-thick layer of Santyl to wound bed followed by alginate (NO SILVER), secured with sacral silicone foam dressing daily and prn Wound Additional Orders- Frequent turning and repositioning to offload wounds Wound #2 Wound Assessment: Wound- Left ischium DTI Measurements- 1.5 x 2 x 0cm Tissue type- dark crusting Peri Wound- fragile Drainage- none Pain- none Infection- no observable signs Overall Wound Condition- stable Wound Plan of Care- skin prep daily and leave OTA Wound Additional Orders- Frequent turning and repositioning to offload wounds Wound #3 Wound Assessment: Wound- Right ischium DTI Measurements- 1.5 x 2 x 0cm Tissue type- dark epithelial Peri Wound- fragile Drainage- none Pain- none Infection- no observable signs Overall Wound Condition- stable Wound Plan of Care- skin prep daily and leave OTA Wound Additional Orders- Frequent turning and repositioning to offload wounds R145's pressure ulcers were not identified correctly, making the assessment inaccurate and could have affected treatment. Findings Included: Resident #7 (R7) Review of the medical record demonstrate that R7 was admitted to the facility 12/12/2024 with diagnoses that included cerebral infarction (stroke), dementia, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), type 2 diabetes, hypothyroidism (low thyroid hormone), anemia (low red blood cells), depression, psychosis (mental state where you lose touch with reality), hyperlipidemia (high fat content in blood), hypertension, anxiety, and insomnia. Review of R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed R7 had a Brief Interview for Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. During observation and attempted interview on 12/11/2025 at 09:31 a.m. R7 was observed lying down in her bed. A half length side rail was observed on the right side of the bed and on the left side of the bed. R7 did not respond to verbal questions. Review of the R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed section P-Restraints and Alarms A. Bed Rail was documented as 0.not used. Review of R7's plan of care did not demonstrate the use of bilateral side rails. Review of R7's physician orders did not include an order for the use of side rails. Review of R7's medical record did not demonstrate a side rail evaluation or that measurements of the bilateral side rails had been conducted. During an interview on 12/11/2025 at 10:32 a.m. Minimum Data Set (MDS) Coordinator S explained that she was responsible for the coordination of the facility MDS's. MDS Coordinator S was asked to review R7's MDS with an Assessment Reference Date (ARD) of 11/24/2025 and the review section P-Restraints and Alarms A. Bed Rail. MDS Coordinator S confirmed that it had been coded that R7 was not using side rails. MDS Coordinator S also confirmed that R7's plan of care did not include the use of bilateral side rails. MDS Coordinator S could not explain why R7's MDS was inaccurate regarding the use of side rails. During observation with MDS Coordinator S on 12/11/2025 at 10:41 a.m. R7 was observed lying in bed. MDS Coordinator S confirmed that R7's bed had two half rails position on the right and left sides of her bed. MDS Coordinator S explained that it was her opinion that R7 could not be using the observed side rails as positioning devices. Resident 72 (R72) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R72 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included cerebral vascular accident affecting left side, heart disease, anxiety and depression. The MDS reflected R72 had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact, and she required assist with dressing, hygiene, bathing, and transfers. During an observation and interview on 12/09/2025 at 10:28 AM R72 appeared calm, pleasant and able to answer questions without difficulty. R72 reported had history of stroke that effected left side with left arm contractures currently. R72 reported had worked with therapy in the past. Review of R72 MDS, dated [DATE], reflected no impairment for upper extremity Range of Motion. Continued review of all MDS, section GG0115, reflected impairment on one side. During an interview on 12/15/2025 at 1:43 PM, Therapy Manager LL reported R72 was currently receiving therapy including for left side impairment and verified had been same since admission and MDS range of motion documented as no impairment was incorrect on 2/24/25.

Based on observation, interview, and record review the facility failed to implement and document interventions designed to prevent further weight loss, including consistent monitoring and documentation of dietary intake, nutritional supplements, and snacks in two (Resident #10, Resident #116) out of 4 reviewed for nutrition. Findings include: Resident #10 (R10) Review of the medical record revealed R10 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, anxiety disorder, and insomnia. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/25 revealed R10 scored 00 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), ate a mechanically altered diet, and required setup or clean-up assistance with eating. On 12/15/25 at 9:58 AM. R10 was observed ambulating independently exiting the lounge and walking down the hallway. On 12/15/25 at 10:22 AM, R10 continued wandering the hallway while a group of residents were in the lounge eating applesauce and drinking coffee. A staff member approached R10, took her by the hand and walked briefly with her before redirecting her down another hall. The staff member did not attempt to redirect R10 into the lounge for a snack and coffee. Review of R10's weight history revealed on 11/5/25 R10 weighed 127.2 pounds and on 12/2/25, R10 weighed 119.2 pounds which was a 6.29% significant weight loss. Review of the Nutrition assessment dated [DATE] revealed R10's usual body weight was 130's and adding snacks TID [three times per day] & magic cup BID [twice per day] (290 kcal, 9g protein) r/t [related to] inconsistent intakes. The assessment revealed R10 disliked raisins, bacon, and pork. Review of the Physician's Orders revealed no orders for magic cup twice per day or snacks three times per day. Review of R10's Nutrition Care Plan revealed interventions that included: Provide and serve supplements and snacks as ordered see meal tickets for details (initiated 11/6/25) Provide, serve regular diet/mechanical soft texture/thin liquids as ordered. Monitor intake and record every meal (initiated 11/6/25. Food preferences to be reflected onto meal tickets (initiated 11/6/25) Review of the Nutrition/Dietary Note dated 12/11/25 revealed Resident with -6.3% weight loss x 1 month. Resident frequently walking around unit, increasing her nutritional needs. Currently receiving magic cup BID (290 kcal, 9g pro [grams of protein]). RD [Registered Dietitian] to add fortified smoothie qd [every day] (230 kcal, 6g pro). Will continue to monitor. Review of R10's meal tickets revealed 4-ounce magic cup with lunch and dinner. The lunch tray ticket dated 12/11/25 revealed the entree was 5-ounce ground stuffed pork chop. Pork was listed as one of R10's dislikes on the Nutrition assessment dated [DATE]. Review of Documentation Survey Report revealed the following missing Nutrition-Amount Eaten documentation: 11/7/25-dinner not documented 11/10/25-dinner not documented 11/13/25-lunch and dinner not documented 11/14/25-breakfast, lunch, and dinner all documented as not applicable 11/16/25-dinner not documented 11/18/25-lunch and dinner not documented 11/19/25-breakfast, lunch, and dinner not documented 11/21/25-lunch not documented 11/24/25-lunch and dinner not documented 11/25/25-dinner not documented 11/26/25-dinner not documented 11/27/25-dinner not documented 11/30/25-lunch and dinner not documented 12/1/25-lunch documented as not applicable 12/2/25-breafkast and dinner not documented 12/3/25-lunch and dinner not documented 12/4/25-dinner not documented 12/9/25-dinner not documented 12/10/25-dinner not documented 12/11/25-lunch and dinner not documented 12/14/25-lunch and dinner not documented Review of Documentation Survey Report revealed there were four opportunities to document supplement intake each day that included 12:00 PM day nurse, 12:00 PM day Certified Nursing Assistant (CNA), 5:30 PM day CNA and 5:30 PM evening nurse. The report revealed the following missing documentation for Nutrition: Supplements: 11/21/25 5:30 PM CNA and nurse documented as not applicable 11/22/35 12:00 PM CNA and nurse documented as not applicable 11/24/25-no documentation 11/25/25 12:00 CNA and nurse documented as not applicable and 5:30 PM CNA and nurse did not document 11/26/25 12:00 PM CNA and nurse documented as not applicable and 5:30 PM CNA and nurse did not document 11/27/25 5:30 PM CNA and nurse did not document 11/28/25-no documentation 11/29/25 12:00 PM CNA and nurse documented as not applicable 11/30/25-no documentation 12/1/25 12:00 PM and 5:30 PM CNA and Nurse documented as not applicable 12/2/25 5:30 PM CNA and nurse did not document 12/3/25-no documentation 12/4/25 12:00 PM CNA and nurse documented as not applicable and 5:30 PM CNA and nurse did not document. There was a PRN (as needed) documentation at 4:28 AM 12/5/25, 12/6/25, 12/7/25, 12/8/25-12:00 PM and 5:30 PM CNA and nurse documented as not applicable 12/9/25 5:30 PM CNA and nurse did not document 12/10/25 12:00PM CNA and nurse documented as not applicable and 5:30 PM nurse and CNA did not document 12/11/25-no documentation 12/12/25 12:00PM and 5:30 PM CNA and nurse all documented as not applicable 12/14/25-no documentation Review of the Nutrition-Snacks documentation revealed there was no documentation related to snacks in the last 30 days. In an interview on 12/15/2025 at 8:56 AM, RD H reported a resident's preferences and dislikes should be reflected on the meal ticket. When asked why R10 was served a pork on 12/11/25 when pork was listed as a dislike, RD H reported R10 may have requested it and that R10's dislike may have been pulled pork, but she would have to verify with R10's daughter. When asked what R10's intake was for that meal, RD H reported it appeared R10 did not eat that meal. When asked how a true intake was being monitored and evaluated when not all meal intakes, snacks, and supplements were documented, RD H agreed there was missing documentation and reported they would have to average the amounts that were documented and speak with staff. When asked what not applicable documentation meant, RD H reported she was unsure and that it could mean too many different things. In an interview on 12/15/25 at 2:02 PM, Director of Nursing (DON) B agreed there was missing documentation related to R10's meal, supplement, and snack intake. Review of the medical record reflected R116 was admitted to the facility on [DATE], with diagnoses that included dementia. R116 was interview able and answered questions appropriately. On 12/9/25 at 10:00 AM, R116 was observed in bed. R116 was conversant and discussing events when a staff member was observed delivering a small cup and spoon for R116. R116 explained that the cup contained a smoothie, and he does not eat the smoothies. On 12/09/2025 at 1:33 PM R116 was observed in his room. A staff member provided R116 with his lunch and assisted R116 with consuming his meal. On 12/11/2025 at 10:24 AM, R116 was observed in bed. A smoothie was observed on his bedside table, untouched. R116 and a family member confirmed that R116 does not touch the smoothies and they are better off in the trash. R116's family member confirmed that the smoothies are provided in an attempt to assist with R116's weight loss. Review of a Nutrition/Dietary Note dated 12/11/25 revealed Resident (116) with -12.4% (precent) weight loss [in] 6 mos. Resident with highly variable meal intakes. Currently receiving fortified smoothie . and pm (night) snack. Intakes encouraged. Review of R116's weight loss care plan revealed interventions including Provide and serve snacks per preference . Provide and serve supplement as ordered, and . Monitor and record meal intakes. Review of the task documentation revealed inconsistent data documentation completion for meal intake and supplement intake documentation, including multiple dates where not applicable was selected as an option for supplement intake and several dates where the amount consumed for meals was not completed. Further review of the task documentation revealed no evidence that R116 was being provided a nightly snack and no documentation for snack acceptance and/or consumption. In an interview on 12/15/2025 at 9:09 AM, Registered Dietician (RD) H states that the dieticians rely on meal consumption, including snacks, all three meals, and supplements, to determine the individual intake needs for the residents. RD H confirmed that R116 was on the significant weight loss list which is what prompted the intervention for smoothies and nightly snacks. RD 'H stated that the staff should be documenting the amounts consumed and should not be selecting not applicable as a response for consumption amounts.

Based on observation, interview, and record review, the facility failed to ensure appropriate monitoring of a resident prescribed an antipsychotic medication in one (Resident #93) out of 5 reviewed for medication review. Findings include: Review of the medical record reflected Resident #93 (R93) was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included nondisplaced bimalleolar fracture of right lower leg. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/23/25, reflected R93 scored 7 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/10/2025 4:01 PM, R93 was observed in her room watching television. Review of R93's Physician Orders revealed an active order for Seroquel Oral Tablet 50 MG (antipsychotic medication). Review of R93's Antipsychotic medication care plan revealed an intervention dated 1/16/23 which stated, orthostatic blood pressures as ordered. Review of R93's Physician orders revealed no order for orthostatic blood pressures. Review of R93's vital signs revealed no completed orthostatic blood pressures. In an interview on 12/15/2025 at 1:58 PM, Director of Nursing (DON) B stated that residents taking antipsychotic medications had specific monitoring requirements, including orthostatic blood pressure monitoring which is to be completed once a month. DON B reviewed R93's electronic medical record and confirmed the absence of orthostatic blood pressure monitoring.

This Citation Pertains to Intake #2649987 Based on interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act.Findings include: Review of the clinical record, including the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/25, revealed Resident 136 (R136) was admitted to the facility on [DATE] and was discharged home on [DATE], with diagnoses that include congestive heart failure and chronic kidney disease. R136 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 12/10/2025 09:57 am, during a phone interview with R136 she reported on October second, she was on a diuretic and had to void her bladder frequently, R136 stated used the call light frequently on the midnight shift due to the medication. R136 stated the Certified Nursing Assistant (CNA) was angry that R136 kept asking for help, R136 stated the more she asked for the bedpan, tension and anger from the CNA grew. R136 stated she asked for her name, but the CNA refused to tell R136. Of note, R136 was able to give this writer a physical description. R136 stated as the night progressed the final time, she turned her call light on, the same unknown CNA entered the room and at this time became physically rough with her care and shoved the bedpan hard into R136's hip. R136 reported this was very painful and caused a large bruise resulting her to be sent to the emergency room the next morning. R136 stated she reported to the midnight nurse (name unknown) that the assigned CNA was mad, provided rough care and intentionally shoved the bedpan into her hip causing pain. R136 stated she was dismissed by midnight nurse and told Licensed Practical Nurse (LPN) P when she came on duty that morning. Review of the Unusual Occurrence report dated 10/03/25 at 8:45am, revealed LPN P observed R136 being tearful and complaining of extreme right hip pain, the note reflected LPN P observed a large edematous area on R136's right hip, the physician and the abuse hotline called. On 12/11/25 at 10:30 am, during a phone interview with LPN P she reported that R136 told made an allegation of abuse on the morning on 10/03/25. LPN P reported R136 was tearful and said the midnight was angry she kept turning her call light on and the CNA was rough and shoved the bedpan into her right side/hip. LPN P stated R136 was very vocal and clear this was an intentional act which was why she reported it to the facility's abuse hotline per protocol. LPN P stated she spoke with LPN Q who handles the investigations of abuse allegations and was told that R136's x-ray came back negative and she was already aware and looking into it. R136 was insistent it was a deliberate act on behalf of the CNA, and the abuse hotline was called again to make sure LPN Q was aware of R136's insistence of being a deliberate act but LPN Q stated the root cause of the right hip hematoma was a positioning issue. On 12/11/25 at 10:45am, during an interview with LPN Q she reported she had no recollection of R136 but may have a soft file about the incident. LPN Q then stated was resident was care planned for and well known to change her story. Of note, there was no care plan in place that identified R136 as having behavior problems such as changing her story, embellishing or making false accusations. At 11:39 AM, LPN Q stated there was a soft file and it was determined that R136's right hip hematoma was determined to be a positioning issue. LPN Q elaborated it was not reported to the State Agency because she knew it was related to positioning. Review of the facility policy titled Resident-Abuse Neglect and Exploitation Prevention dated 09/01/21 Under the heading Reporting and Response 1. Alleged violations will be reported to the Administrator and designee per facility reporting process, state agency, adult protective services and all other required agencies (Law enforcement when applicable) within specified time frames.

This Citation Pertains To Intake #2649987 Based on interview and record review the facility failed to thoroughly investigate an allegation of abuse for one resident (Resident #136) of seven residents reviewed for abuse. Findings include Review of the clinical record, including the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/25, revealed Resident 136 (R136) was admitted to the facility on [DATE] and was discharged home on [DATE], with diagnoses that include congestive heart failure and chronic kidney disease. R136 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 12/10/2025 09:57 am, during a phone interview with R136 she reported on October second, she was on a diuretic and had to void her bladder frequently, R136 stated used the call light frequently on the midnight shift due to the medication. R136 stated the Certified Nursing Assistant (CNA) was angry that R136 kept asking for help, R136 stated the more she asked for the bedpan, tension and anger from the CNA grew. R136 stated she asked for her name, but the CNA refused to tell R136. Of note, R136 was able to give this writer a physical description. R136 stated as the night progressed the final time, she turned her call light on, the same unknown CNA entered the room and at this time became physically rough with her care and shoved the bedpan hard into R136's hip. R136 reported this was very painful and caused a large bruise resulting her to be sent to the emergency room the next morning. R136 stated she reported to the midnight nurse (name unknown) that the assigned CNA was mad, provided rough care and intentionally shoved the bedpan into her hip causing pain. R136 stated she was dismissed by midnight nurse and told Licensed Practical Nurse (LPN) P when she came on duty that morning. Review of the Unusual Occurrence report dated 10/03/25 at 8:45am, revealed LPN P observed R136 being tearful and complaining of extreme right hip pain, the note reflected LPN P observed a large edematous area on R136's right hip, the physician and the abuse hotline called. On 12/11/25 at 10:30 am, during a phone interview with LPN P she reported that R136 told made an allegation of abuse on the morning on 10/03/25. LPN P reported R136 was tearful and said the midnight was angry she kept turning her call light on and the CNA was rough and shoved the bedpan into her right side/hip. LPN P stated R136 was very vocal and clear this was an intentional act which was why she reported it to the facility's abuse hotline per protocol. LPN P stated she spoke with LPN Q who handles the investigations of abuse allegations and was told that R136's x-ray came back negative and she was already aware and looking into it. R136 was insistent it was a deliberate act on behalf of the CNA, and the abuse hotline was called again to make sure LPN Q was aware of R136's insistence of being a deliberate act but LPN Q stated the root cause of the right hip hematoma was a positioning issue. On 12/11/25 at 10:45am, during an interview with LPN Q she reported she had no recollection of R136 or LPN P reporting an allegation of abuse. When the unusual occurrence report was reviewed with LPN Q which stated the abuse hotline was contacted, LPN Q stated she had no recollection of being notified of the allegation. But will check to see if there was a soft file about the incident. LPN Q then stated was resident was care planned for and well known to change her story. Of note, there was no care plan in place that identified R136 as having behavior problems such as changing her story, embellishing or making false accusations. At 11:39 AM, LPN Q stated there was a soft file and it was determined that R136's right hip hematoma was determined to be more of a positioning issue opposed to an abuse concern. Review of LPN's Q soft file did not include an interview with R136, when queried why R136 was not interviewed, LPN Q stated R136 was at the hospital and not available. Of note, R136 was not admitted to the hospital. Review of the facility policy titled Resident-Abuse Neglect and Exploitation Prevention dated 09/01/21 Under the heading Investigating Alleged Abuse, Neglect and Exploitation1. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.2. Procedure to investigate include:a. Identifying staff responsible for the investigation;b. cautiously handling evidence that could be used in a criminal investigation;c. Investigating different types of alleged violations;d. Identifying and interviewing all persons i. Alleged victim ii. Victim roommates iii. Alleged perpetrators

Based on observation, interview, and record review the facility failed to develop and implement comprehensive care plan for one resident R7 of 26 reviewed. Findings Included:Resident #7 (R7)Review of the medical record demonstrate that R7 was admitted to the facility 12/12/2024 with diagnoses that included cerebral infarction (stroke), dementia, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), type 2 diabetes, hypothyroidism (low thyroid hormone), anemia (low red blood cells), depression, psychosis (mental state where you lose touch with reality), hyperlipidemia (high fat content in blood), hypertension, anxiety, and insomnia. Review of R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed R7 had a Brief Interview for Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. During observation and attempted interview on 12/11/2025 at 09:31 a.m. R7 was observed lying down in her bed. A half-length side rail was observed on the right side of the bed and on the left side of the bed. R7 did not respond to verbal questions. Review of the R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed section P-Restraints and Alarms A. Bed Rail was documented as 0.not used. Review of R7's plan of care did not demonstrate the use of bilateral side rails. Review of R7's physician orders did not include an order for the use of side rails. Review of R7's medical record did not demonstrate a side rail evaluation or that measurements of the bilateral side rails had been conducted. During an interview on 12/11/2025 at 10:22 a.m. Director of Nursing (DON) B explained that residents using side rails would have the following actions completed: - Assist Device/Bed Rail Assessment- Nursing 5 Day Assist Device/bed Rail Monitoring Form- A physician's order for the use of the assist device/bed rail. - The resident care plan would include the use of the assist device/bed railDON B was asked to review R7's medical record. DON B confirmed that R7 did not have any of the above documented actions completed in her medical record. DON B explained that the facility was currently conducting a Quality Improvement Project for the use of Assistive Device/ Bed Rails. DON B explained that currently R7 was not incompliance with the requirements of using assistive devices/bed rails at this time. During an interview on 12/11/2025 at 10:32 a.m. Minimum Data Set (MDS) Coordinator S explained that she was responsible for the coordination of the facility MDS's. MDS Coordinator S was asked to review R7's MDS with an Assessment Reference Date (ARD) of 11/24/2025 and the review section P-Restraints and Alarms A. Bed Rail. MDS Coordinator S confirmed that it had been coded that R7 was not using side rails. MDS Coordinator S also confirmed that R7's plan of care did not include the use of bilateral side rails. MDS Coordinator S could not explain why R7's MDS was inaccurate regarding the use of side rails. During observation with MDS Coordinator S on 12/11/2025 at 10:41 a.m. R7 was observed lying in bed. MDS Coordinator S confirmed that R7's bed had two half rails position on the right and left sides of her bed. MDS Coordinator S explained that it was her opinion that R7 could not be using the observed side rails as positioning devices. During an interview on 12/11/2025 at 11:07 a.m. Director of Nursing (DON) B re-confirmed that R7 did not have a physician's order for the use of side rails, did not have a plan of care for the use of side rails, and did have a Nursing 5 Day Assist Device/bed Rail Monitoring Form. DON B did provide a copy of Assist Device/bed Rail Assessment which had been completed 12/11/2025.

Based on observation, interview, and record review, the facility failed to provide bath/showers for one Residents (#13) of three Residents reviewed.Findings Included: Resident #13 (R13): Review of the medical record demonstrated that R13 was admitted to the facility 09/26/2023 with diagnoses that included cerebral infarction, schizoaffective disorder depressive, dementia, chronic obstructive pulmonary disease (COPD), atrial flutter, sleep disorder, hypertension, hyperlipidemia (high fat content in blood), and anxiety. Review of R13's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/2025, revealed R13 had a Brief Interview for Mental Status (BIMS) of 09 (severe cognitive impairment) out of 15. During observation and interview on 12/09/2025 at 01:39 p.m. R13 was observed sitting up wheelchair. R13 explained that she had not been receiving showers as frequently she wanted. She explained that she wanted to shower twice per week.Review of R13's MDS, with an ARD of 12/02/2025, section GG- Functional Abilities revealed that she was dependent for showers. Review of R13's Point of Care (computerized documentation of the medical record used by the certified nurse aides), task revealed shower Wednesday and Sunday PM. During an interview on 12/11/2025 at 09:37 a.m. Certified Nurse Aide (CNA) R explained that she is given a paper assignment, which identified which residents are to be bathed/showered during her shift. CNA R explained that showers are recorded on a shower sheet and are given to the nurses. During an interview on 12/11/2025 at 12:04 p.m. Director of Nursing (DON) B explained that residents are given baths/shower according to their plan of care. DON B confirmed that R13 was to receive 2 showers per week to be given on Wednesday and Sunday on the afternoon/night shift. DON explained that paper skin assessment sheets are how the facility demonstrated that a bath/shower was completed. DON B presented skin assessment sheets of R13 for the period of October 2025 to present. DON B explained that the following skin assessments sheets could not be located and therefore R13 had not received a shower on those dates. Review of skin sheets 10/08/25-no shower, 10/12/2025-no shower, 10/15/2025-no shower,10/27/2025-no shower, 11/02/2025- no shower, 11/05/2025- no shower, 11/09/2025- no shower, 11/23/2025-no shower, 12/03/2025- no shower, 12/10/2025-no shower. 11 showers were completed out of a possible 21 days during October until present date. DON B could not explain why showers had not been completed as directed per the plan of care for R13.

During interviews, observations and record review the facility failed to provide meaningful activities to one of one resident (R86) resulting in boredom, isolation and disengagement. Findings Include Resident #86 (R86)Review of the medical record reflected that R86 was admitted to the facility on [DATE]. Diagnoses of traumatic subdural hemorrhage without loss of consciousness, fracture of left great toe, emphysema, atrial fibrillation, heart failure, dyspnea with repeated falls. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/07/2025 revealed R86 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15.Under section GG0115, Functional Limitation in Range of Motion reveals R86 had impairment on both sides, used a walker and wheelchair for ambulation and required substantial/maximal assistance for all care. During an observation and interview on 12/09/2025 at 1:44 PM, R86 did not have any activities, magazines, books, or coloring materials for her to do while spending time in her room. R86 stated nobody had talked to her about bringing her activities in her room since it's so painful to go down to the activities off this floor. During an interview on 12/15/2025 at 11:10 AM, activity aide II stated they do check ins on residents and see how they are doing. Then stated not on the room visits or check ins today. Writer asked what a check in was about. Activity aide II stated they just stop in the room to see if they need anything, then stated on the days they make a 1 on 1 visit, they spend about 10-15 minutes with the residents. During an observation and interview on 12/15/2025 at 11:15 AM, R86 and her youngest daughter JJ were sitting in R86's new room. Writer asked both of them if anyone had been by this morning to include R86 in the activities, both stated no, they haven't seen anyone. R86 stated activities do not do anything with her in her room. Writer stated if she had a calendar for the month to let her know when things are going on. R86 stated no. No observation of an activity calendar on the resident's side to show her what activities are offered. Daughter JJ stated someone asked yesterday but R86 wasn't up to it. R86's daughter JJ that was the first time someone has asked her. R86's daughter JJ stated they stick their head in the room, but do not do anything but tell R86 what activity going on but doesn't stay to visit. R86 stated she needs help getting down to the area they are doing activities, that she can't get there herself. During an interview on 12/15/2025 at 12:31 PM, Activity Director KK stated she did not have access to her computer but would try to help. Activity Director KK stated activity staff could provide in room visits, 10-15 minutes per resident, check ins to see how they are doing. Activity Director KK stated she completed that with R86's daughter JJ, and her daughter stated she would not be interested in large groups, after she was admitted on [DATE]. Writer reminded Activity Director that preferences were reviewed with daughter LL and not resident directly. However, R86 is of sound body and mind, and she can make her own decisions regarding how she would like to spend her days. Activity Director KK stated she is unaware of anyone looking into that, also stated they look at that as an unserved activity. Activity Director KK stated the activity calendar would be posted on the magnetic white board at the end of R86's bed. Activity Director KK stated there was a recent room move from short term rehab to long term care, stated that housekeeping most likely threw it, referring to the activities calendar, away. Activity Director KK stated they would look at the calendar when they did a check in so the resident would know which activities they can attend on that day. R86 did not have a calendar posted on her magnetic whiteboard to observe what activates were being offered. R86 was not participating in the activity program.

Based on observation, interview and record review the facility failed to ensure resident safety during staff assisted mechanical lift transfer for 1 of 3 sampled residents (Resident #3) reviewed for accidents, resulting in Resident #3 right lower leg laceration that required hospital transfer and sutures. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R3 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included chronic osteomyelitis, heart failure, morbidly obese, diabetes, venous insufficiency, and depression. The MDS reflected R3 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required staff assist with dressing, hygiene, bathing and transfers.During an observation and interview on 12/09/2025 at 4:05 PM, R3 was sitting in wheelchair in resident room and appeared calm, pleasant and able to answer questions without difficulty. R3 reported an incident on 12/5/25, when staff were transferring her from the bed to the wheelchair and her right lower leg was cut when the lift tipped over during the transfer. R3 reported three staff were present including Certified Nurse Aid (CNA) MM, nurse and another CNA. R3 reported staff were unable to control the bleeding and had to emergency room for stitches. R3 had large dressing in place on right lower leg. R3 requested staff to get her back to bed and R3 granted this surveyor permission to observe. CNA DD reported planned to transfer R3 to bed after another CNA arrived.During an observation on 12/09/2025 at 4:15 PM, this surveyor entered R3's open door room and observe CNA DD hooking up R3 sling, placed under resident in wheelchair, to mechanical life. No other staff was present in the room. CNA DD transferred R3 from the wheelchair to the bed with the use of the mechanical life alone and resident tolerated well. This surveyor continued to observe from doorway area. Review of R3 Progress Notes, dated 12/5/2025, reflected, While transferring resident from bed to chair, staff was trying to reposition resident as she was upset that she was leaning to far to the left and while trying to reposition her the hoyer started to lift up and while we got the hoyer level again as resident was still up in the air nurse notice a large stream of dark red blood streaming from residents leg. Two CNA Staff unlocked wheel and pulled hoyer forward so nurse who was guiding from the back, could asses and apply press to the laceration on residents right calf. Quick assessment nurse assessed that there was an upside down J shaped laceration approximately seven cm from top to bottom. Nurse applied pressure, Cna alerted unit manager and nurse on green who brought ABD pads and colban to wrap leg tight. Once leg was wrapped tight we hoyered resident back onto bed. Resident was unaware that anything had happened to her leg until she realized nurse was concerned as she could not see what had happened. Resident has no feeling bilaterally from the Paramedics arrived and we call [named R3] sister for permission about going to hospital for stitches as resident did not want to go as she did not want to miss bingo. Both sisters were contacted and both stated she should go. Notified [named physician] that resident needed to be sent out for stitches and then called and left a message for PACE hospice on the general mail box. The only area we could think was she had hit with leg on top section of leg rest. So padding was added to her current wheelchair. It was discussed with unit manager and nurse that it might be reasonable to contact her hospice company about getting her a broda chair since she does not ambulated.Review of the Progress Noted, dated 12/5/2025, reflected, Resident returned just before dinner today. [named] hospital called and gave report that residents vitals were stable and that she received four stitches to the laceration on right lower from of shin. Resident returned and was very hungry so staff got her an early dinner. Resident is in bed , call light is within reach and resident can make her needs known. Follow up for an order for stitches removal on 12/12/2025.Review of R3 Care Plan, dated 9/4/24, reflected, TRANSFER: Dependent x 2 with mechanical lift and blue/XL trim sling.During an interview on 12/11/2025 at 11:15 am, Licensed Practical Nurse (LPN) NN reported was present on 12/5/25 and in room when R3s right lower leg was cut during mechanical lift transfer. LPN NN reported she was behind R3 guiding into wheelchair and CNA MM and OO were on each side of the lift. LPN NN reported the lift tipped when one leg of the lift came off the ground and one of the CNA staff stepped on lift leg quickly. LPN NN reported that is when they noticed R3 right lower leg was bleeding, and she applied pressure after R3 was lowered into wheelchair and lift was moved. LPN NN reported mechanical lift transfers require two staff and reported received re-education after incident to removed foot pedals prior to transfer.During an observation and interview on 12/11/2025 at 11:21 am, R3 was observed in room in bed, denied discomfort and reported there was usually two staff in the room when using mechanical lift for transfers.During an interview on 12/11/2025 at 12:15 PM, CNA OO reported was present on 12/5/25 when R3's leg was cut during transfer. CNA OO reported entered R3 room after R3 was in mechanical lift to assist and LPN NN was behind R3, and CNA MM was on the front left. CNA OO reported R3 was being transferred from the bed to the wheelchair positioned at the foot of the bed. CNA OO reported R3 was almost in the wheelchair when R3 was pushed to back of wheelchair the lift tipped, she grabbed lift and stood on it and it tipped back. CNA OO reported was unsure what caused bleeding, but right lower leg was bleeding and LPN NN was present and tended to that. CNA OO reported mechanical lift was positioned from side of wheelchair with leg of lift between front and back wheel of wheelchair toward the wall. CNA OO reported R3 was a two to three person assist with mechanical lift transfer and never one because requires at least 2 for safety. CNA OO reported received re-education after the incident of proper use of mechanical lift including positioning directly in front of the wheelchair.During an interview on 12/11/2025 at 11:50 AM, CNA MM reported was present when R3 had incident during staff assisted transfer with mechanical lift on 12/5/25. CNA MM reported LPN NN was positioned behind R3, and CNA OO had entered R3 room during the transfer. CNA MM reported the R3 was being transferred from the bed to the wheelchair at the foot of the bed and reported the legs of the mechanical lift were not in widest position because one leg of lift was position between front and back wheel of wheelchair and was not enough room between wall. CNA MM reported received re-education after incident on proper use of mechanical lift including using with legs positioned widest position and straight into wheelchair. CNA MM reported R3 requires two staff with use of mechanical lift transfers. During an observation and interview on 12/11/2025 at 1:55 pm, CNA GG demonstrated mechanical lift in Red Hall and verified exposed orange aluminum sharp areas about 16-18 inches up from floor on piston area of lift. CNA GG demonstrated use of lift and reported lift legs should be wide with transfer including lowering residents into wheelchair. CNA GG demonstrated use with wide legs positioned between front and back wheels of wheelchair indicated it was highly unlikely that lift legs were wide and more likely that legs were narrow on mechanical lift when staff attempted to position R3 to back of wheelchair (pushing R3 sideways in lift) when lift tipped sideways toward wheelchair.During an interview on 12/15/2025 at 2:05 PM, Director of Nursing (DON) B reported Unit Manager and Staff Educator PP completed investigation for R3 incident on 12/5/25. DON B reported would expect staff to use wide legs on lift during transfer and use of two person assist with mechanical lift transfer. During an interview on 12/15/2025 at 2:23 PM, Staff Educator (SE) PP reported was unsure who R3 cut the front of right leg when transfer from bed to wheelchair on 12/5/25 and was responsible for investigation. SE PP reported after speaking was everyone involved thought possibly R3's anterior right leg was cut on wheelchair pedal area but did not make sense. SE PP reported did not notice sharp area on mechanical lift. SE PP reported provided staff re-education related to proper mechanical lift use including proper positioning of lift legs in wide position and wheelchair positioning. SE PP reported would expect staff to always use two staff for all mechanical lift transfers. Review of the facility, MECHANICAL LIFT Policy, dated 12/28/22, reflected, OBJECTIVE: To transfer a Resident/Patient between two surfaces using a mechanical lift .PROCEDURE.Obtain assistance. The minimum number for a safe transfer is two people.Bring lift to the bed.Roll the base, spread wide open under the bed.Make sure there is room to maneuver the lift in the room.Make sure wheelchair is in position for transfer and brakes are locked.

Based on observation, interview, and record review the facility failed to ensure that bed rails were assessed and measured to prevent possible entrapment for one Resident (#7) of one resident reviewed for Residents using bed rails. Findings Included:Resident #7 (R7)Review of the medical record demonstrate that R7 was admitted to the facility 12/12/2024 with diagnoses that included cerebral infarction (stroke), dementia, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), type 2 diabetes, hypothyroidism (low thyroid hormone), anemia (low red blood cells), depression, psychosis (mental state where you lose touch with reality), hyperlipidemia (high fat content in blood), hypertension, anxiety, and insomnia. Review of R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed R7 had a Brief Interview for Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. During observation and attempted interview on 12/11/2025 at 09:31 a.m. R7 was observed lying down in her bed. A half-length side rail was observed on the right side of the bed and on the left side of the bed. R7 did not respond to verbal questions. Review of the R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed section P-Restraints and Alarms A. Bed Rail was documented as 0.not used. Review of R7's plan of care did not demonstrate the use of bilateral side rails. Review of R7's physician orders did not include an order for the use of side rails. Review of R7's medical record did not demonstrate a side rail evaluation or that measurements of the bilateral side rails had been conducted. During an interview on 12/11/2025 at 10:22 a.m. Director of Nursing (DON) B explained that residents using side rails would have the following actions completed: - Assist Device/Bed Rail Assessment- Nursing 5 Day Assist Device/bed Rail Monitoring Form- A physician's order for the use of the assist device/bed rail. - The resident care plan would include the use of the assist device/bed railDON B was asked to review R7's medical record. DON B confirmed that R7 did not have any of the above documented actions completed in her medical record. DON B explained that the facility was currently conducting a Quality Improvement Project for the use of Assistive Device/ Bed Rails. DON B explained that currently R7 was not incompliance with the requirements of using assistive devices/bed rails at this time. During an interview on 12/11/2025 at 10:32 a.m. Minimum Data Set (MDS) Coordinator S explained that she was responsible for the coordination of the facility MDS's. MDS Coordinator S was asked to review R7's MDS with an Assessment Reference Date (ARD) of 11/24/2025 and the review section P-Restraints and Alarms A. Bed Rail. MDS Coordinator S confirmed that it had been coded that R7 was not using side rails. MDS Coordinator S also confirmed that R7's plan of care did not include the use of bilateral side rails. MDS Coordinator S could not explain why R7's MDS was inaccurate regarding the use of side rails. During observation with MDS Coordinator S on 12/11/2025 at 10:41 a.m. R7 was observed lying in bed. MDS Coordinator S confirmed that R7's bed had two half rails position on the right and left sides of her bed. MDS Coordinator S explained that it was her opinion that R7 could not be using the observed side rails as positioning devices. During an interview on 12/11/2025 at 11:07 a.m. Director of Nursing (DON) B re-confirmed that R7 did not have a physician's order for the use of side rails, did not have a plan of care for the use of side rails, and did have a Nursing 5 Day Assist Device/bed Rail Monitoring Form. DON B did provide a copy of Assist Device/bed Rail Assessment which had been completed 12/11/2025.

Based on observation, interview, and record review the facility failed to ensure monitoring and inspection of resident bed frames and mattress for one resident (#7) of one resident reviewed for bed safety. Findings Included: Resident #7 (R7):Review of the medical record demonstrate that R7 was admitted to the facility 12/12/2024 with diagnoses that included cerebral infarction (stroke), dementia, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), type 2 diabetes, hypothyroidism (low thyroid hormone), anemia (low red blood cells), depression, psychosis (mental state where you lose touch with reality), hyperlipidemia (high fat content in blood), hypertension, anxiety, and insomnia. Review of R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed R7 had a Brief Interview for Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. During observation and attempted interview on 12/11/2025 at 09:31 a.m. R7 was observed lying down in her bed. A half-length side rail was observed on the right side of the bed and on the left side of the bed. R7 did not respond to verbal questions. Review of the R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed section P-Restraints and Alarms A. Bed Rail was documented as 0.not used. Review of R7's plan of care did not demonstrate the use of bilateral side rails. Review of R7's physician orders did not include an order for the use of side rails. Review of R7's medical record did not demonstrate a side rail evaluation or that measurements of the bilateral side rails had been conducted. During an interview on 12/11/2025 at 10:22 a.m. Director of Nursing (DON) B explained that residents using side rails would have the following actions completed: - Assist Device/Bed Rail Assessment- Nursing 5 Day Assist Device/bed Rail Monitoring Form- A physician's order for the use of the assist device/bed rail. - The resident care plan would include the use of the assist device/bed railDON B was asked to review R7's medical record. DON B confirmed that R7 did not have any of the above documented actions completed in her medical record. DON B explained that the facility was currently conducting a Quality Improvement Project for the use of Assistive Device/ Bed Rails. DON B explained that currently R7 was not incompliance with the requirements of using assistive devices/bed rails at this time. During an interview on 12/11/2025 at 10:32 a.m. Minimum Data Set (MDS) Coordinator S explained that she was responsible for the coordination of the facility MDS's. MDS Coordinator S was asked to review R7's MDS with an Assessment Reference Date (ARD) of 11/24/2025 and the review section P-Restraints and Alarms A. Bed Rail. MDS Coordinator S confirmed that it had been coded that R7 was not using side rails. MDS Coordinator S also confirmed that R7's plan of care did not include the use of bilateral side rails. MDS Coordinator S could not explain why R7's MDS was inaccurate regarding the use of side rails. During observation with MDS Coordinator S on 12/11/2025 at 10:41 a.m. R7 was observed lying in bed. MDS Coordinator S confirmed that R7's bed had two half rails position on the right and left sides of her bed. MDS Coordinator S explained that it was her opinion that R7 could not be using the observed side rails as positioning devices. During an interview on 12/11/2025 at 11:07 a.m. Director of Nursing (DON) B re-confirmed that R7 did not have a physician's order for the use of side rails, did not have a plan of care for the use of side rails, and did have a Nursing 5 Day Assist Device/bed Rail Monitoring Form. DON B did provide a copy of Assist Device/bed Rail Assessment which had been completed 12/11/2025.

This citation pertains to intake 2575199.Based on observation, interview and record review, the facility failed to protect R1's right to be free from sexual abuse by R2 and R4.Findings Include: R1:Review of the medical record reflected R1 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/19/25, reflected R1 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was independent for transfers and walking at least 150 feet.R2:Review of the medical record reflected R2 admitted to the facility on [DATE], with diagnoses that included dementia. The admission MDS, with an ARD of 6/2/25, reflected R2 scored eight out of 15 (moderate cognitive impairment) on the BIMS and was independent for transfers and walking at least 150 feet.R4:Review of the medical record reflected R4 admitted to the facility on [DATE], with diagnoses that included neurocognitive disorder with Lewy Bodies, Parksinson's and dementia. The Significant Change in Status MDS, with an ARD of 6/24/25, reflected R4 scored eight out of 15 (moderate cognitive impairment) on the BIMS. In an interview on 7/30/25 at 11:46 AM, Certified Nurse Aide (CNA) D stated they had previously received report that R2 had his hands in R1's pants, moving them around, and kissed her. CNA D stated R1 had just recently been touched by R4 as well. R1 and R4:On 7/30/25 at 11:14 AM, R1 was observed seated in a chair, attending an activity in the Lounge.In an interview on 7/30/25 at 3:58 PM, CNA E reported that R1 had two incidents with R4, on the same day, earlier in the month of July 2025 (7/9/25). CNA E reported R4 touched R1's buttocks from the outside of her pants. The same day, while in another resident's room, they observed R4 with his hand down R1's pants, inside her brief, touching her buttocks. CNA E reported they intervened and removed R4 from the room. An Incident Report, dated 7/9/25 at 3:15 PM, reflected R1 was in another resident's room, with R4, when R4 walked past R1 and touched her buttocks. A correlating Progress Note was not noted in R1's medical record. R1 and R2:A Progress Note for 7/24/25 at 10:33 PM reflected a CNA reported that while in the activity room, another resident was observed kissing R1's head and had one hand between R1's legs, rubbing her upper, inner thigh. According to the note, R1 was giggling, and the residents were separated. An Employee Statement Form, dated 7/24/25, reflected CNA F was walking by the Lounge area, looked in and observed R1 seated in a chair. R2 was seated on the arm of the same chair, with his left arm around R1 and his left hand on R1's shoulder. R2's right hand was observed between R1's upper thighs, making a rubbing motion, up and down. The form reflected CNA F also observed R2 kissing R1's forehead. An attempt was made to contact CNA F via phone on 7/31/25 at 8:27 AM. A return call was not received prior to the exit of the survey on 7/31/25. R1's Care Plan, initiated on 4/25/25, reflected she had a male friend on her unit and did not have the capacity to consent to a romantic relationship. Interventions dated 4/25/25 reflected to redirect male residents from entering or following R1 to her room and to redirect R1 to sit by other female residents during activities and meals. Interventions dated 7/25/25 reflected, separated the residents and wellness checks. On 7/30/25 at 11:21 AM, R2 was observed walking independently in the hallway, towards his room. On 7/30/25 at 11:25 AM, R2 was observed in his room. When asked about interactions with female residents, R2 reported being in the Lounge (on their unit) and rubbing R1's neck. R2 stated he was not supposed to do that and knew it at the time. R2 stated staff finally walked in on him. R2 denied touching any other part of R1's body. A Progress Note for 7/10/25 at 5:19 PM reflected R2 was seen holding hands with another resident and was successfully redirected. A Progress Note for 7/17/25 at 4:03 AM reflected R2 was attempting to wander into a female resident's room and was redirected. A Progress Note for 7/24/25 at 10:33 PM reflected R2 was observed kissing and rubbing the left upper, inner thigh of a female resident [R1]. According to the note, the residents were immediately separated.A Nurse Practitioner Progress Note for 7/29/25 reflected R2 was seen as follow-up to a recent resident to resident occurrence. According to the note, it was reported that R2 kissed another resident. The note reflected that R2 did not know why it happened and was remorseful. According to the note, R2 knew his behavior was inappropriate. Task documentation for behavior symptoms reflected R2 had sexually inappropriate behavior documented on 7/23/25 at 3:53 AM and on 7/25/25 at 6:29 AM. The documentation did not detail the behavior. In an interview on 7/31/25 at 8:34 AM, Social Worker (SW) H reported there was recently a kiss between R1 and R2. When something of that nature occurred, Care Plans were reviewed for any resident with direct involvement in the incident. SW H reported she had been in two meetings in which Care Plan changes were discussed, but she could not recall what the changes were. SW H acknowledged that a male resident wandering into a female resident room should have been addressed/documented on the Care Plan. Regarding CNA task documentation of sexually inappropriate behaviors for R2, SW H reported CNAs could only mark a box pertaining to the behavior. The CNAs were to notify the nurse, and the expectation was for a Progress Note of the behaviors to be documented. SW H reported they relied on a report for Progress Notes as notification of documented behaviors and did not typically review CNA task documentation for behaviors. In a phone interview on 7/31/25 at 9:03 AM, CNA I reported the Kardex (CNA Care Guide), which was part of the Care Plan, included information pertaining to resident care needs and behaviors. CNA I reported R2 had sexual behaviors, including touching females. According to CNA I, R2's task documentation pertaining to sexual behaviors on 7/23/25 included trying to touch the CNAs legs, as well as attempting to touch another CNA from the back. R2's Care Plan reflected he had a behavior problem of sundowning related to dementia. The Care Plan was updated on 7/25/25, with an intervention to offer movie night after dinner, with an iPad, in a supervised area. An intervention, dated 7/29/25, reflected R2 was noted to put his arm around staff and other residents as a sign of companionship.R2's Care Plan did not reflect a history of sexually inappropriate behavior.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety. Findings include: An observation of the main kitchen reach in cooler on [DATE] at 08:36 AM with Dining Services Manager (DSM) P revealed the following: - a container of chicken with a use by date of [DATE] - two containers of pureed vegetables with a use by date of [DATE] - a container of blue cheese dressing with a use by date of [DATE] - a container of pureed pasta with a use by date of [DATE] - an unlabeled/undated container of food. DSM P removed the expired/undated food items from the cooler and reported they believed the unlabeled container was pumpkin pie filling. On [DATE] at 08:50 AM, upon entrance into the rehab kitchen, a cloth hamper was observed overflowing with soiled rags and aprons. There were numerous fruit flies flying above the hamper. DSM P agreed there were fruit flies and reported the hamper should have been emptied the night before. An observation of the reach in cooler revealed the following: - a tub of coffee creamer with a use by date of [DATE] - ready care thickened water with a use by date of [DATE] - an unlabeled/undated bowl of unidentified food - an undated bowl of oatmeal - two pitchers of smoothies with a use by date of [DATE] - a jug of barbeque sauce with a use by date of [DATE] - ketchup with a use by date of [DATE] - tub of vanilla pudding with a use by date of [DATE] Dry storage included two containers of dry cereal with a use by date of [DATE]. An observation of the walk-in cooler revealed a tray of bedtime snacks which included three smoothies, four puddings, milk, a sandwich, and cottage cheese. The tray of items had a use by date of [DATE]. The walk-in cooler also contained a container of blue cheese with a use by date of [DATE], vanilla pudding with a use by date of [DATE], and an unlabeled/undated bottle of what appeared to be ranch dressing. DSM P removed all identified expired food items. DSM P reported the tray of bedtime snacks were likely snacks that were refused in which case they should have been disposed of and not placed back in the cooler. ,d+[DATE].17 of the 2017 Food and Drug Administration (FDA) Food Code, revealed (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. On [DATE] at 12:21 PM, the South Unit/[NAME] Ridge steam table service was observed. Dietary Aide (DA) Q was serving meals and reported they already took temperatures of the food items on the steam table. DA Q was asked to take temperatures again. The chicken breast had a temperature of 123 degrees Fahrenheit. DA Q reported the chicken was too cold and it would be sent back to the kitchen. On [DATE] at 1:25 PM a test tray was given to the surveyor. All other trays on the unit had been passed; this was the last tray in the cart and was immediately handed to the surveyor after the previous tray had been passed. The food temperatures were as follows: Chicken Breast: 128 degrees Fahrenheit; Potatoes: 124 degrees Fahrenheit; [NAME] Beans: 120 degrees Fahrenheit; Milk: 43 degrees Fahrenheit. ,d+[DATE].16 of the 2017 FDA Food code revealed Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S,d+[DATE].19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 [degrees Celsius] (135 [degrees Fahrenheit]) or above, except that roasts cooked to a temperature and for a time specified in ,d+[DATE].11(B) or reheated as specified in ,d+[DATE].11(E) may be held at a temperature of 54 [degrees Celsius] (130 [degrees Fahrenheit]) or above; P or (2) At 5 C (41 F) or less.

Based on interview and record review, the facility failed to ensure witnesses observed the signing of a Do-Not-Resuscitate (DNR) document by one (Resident #78) of one reviewed. Findings include: Review of the medical record reflected Resident #78 (R78) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included encephalopathy and left side hemiplegia and hemiparesis following cerebral infarction (stroke). R78's DNR form reflected the resident signed the form on 3/1/24, the Physician signed the form on 3/5/24, and two witnesses signed the form on 3/6/24. The Attestation of Witnesses section of the DNR document reflected, The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence . In an interview on 10/09/24 at 12:40 PM, Social Services Supervisor (SS) K reported two witnesses had to sign the DNR document, indicating the person signing on behalf of the resident was of sound mind at the time of signing. SS K reported they would sign as a witness if they talked to the person (resident or responsible party) that signed the DNR document but may not have actually witnessed them sign it. SS K stated they would confirm the person signing the document was of sound mind to make the decision for DNR and that the resident's wishes were DNR before signing as a witness.

Based on observation, interview and record review facility failed to: 1) accurately assess, monitor and prevent the development of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for one Resident (R21) of four reviewed for pressure ulcers, resulting in R21 facility acquired stage 4 pressure wound(Full thickness tissue loss with exposed bone, tendon or muscle) that developed infection requiring antibiotic treatment, pain, and the increased likelihood for delayed wound healing and/or worsening of wounds and overall deterioration in health status. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R21 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included anemia, hypertension (high blood pressure), heart failure, heart disease, renal disease, peripheral vascular disease, facility acquired pressure ulcer stage IV, anxiety, and depression. The MDS reflected R21 had a BIM (assessment tool) which indicated her ability to make daily decisions was severely impaired, and she required two person physical assist with bed mobility, transfers, dressing, toileting, hygiene, bathing and one person physical assist with eating. During an observation on 8/28/23 at 9:45 AM, R21 was laying flat on back on air mattress with heels resting directly on mattress. R21 hair appeared un-groomed and greasy and was wearing a hospital gown. Observed a sign by the head of the bed, taped to the wall, with wound care instructions. Review of the facility Matrix, dated 8/28/23, reflected R21 had a stage 4 pressure ulcer. Review of R21 Physician Orders, dated 6/28/23, reflected, Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for Coccyx wound until 07/08/2023 05:59 x 10 days. 20 administrations. LD 07/08/2023 @ 0600. First dose taken 06/28/2023 @ 0600. During an interview and observation on 8/29/23 at 1:45 PM, PACE(community assistance program) aid AI and R21 family member AJ were in R21 room. R21 was laying flat in bed with heels directly on bed and bilateral compression socks not in place. R21 appeared in pleasant mood and to be able to answer simple questions and appeared well groomed. R21's family AJ reported R21 was having a good day and reported visited R21 almost every day to assist with grooming and feeding during meals and reported PACE staff come three times daily to assist R21 with meals. PACE aid AI verified aid visits 3 times daily to assist with meals and personal care and position changes and reported R21 was compliant with position changes. R21 family AJ reported R21 care started to decline when rehab staff moved from Wing C(R21 hall) back to Wing B and reported several agency staff who were not familiar with R21 needs that included frequent repositioning, incontinence care, two person assist with all care and staff assist with eating. R21's family AJ reported facility staff were not repositioning R21 and R21 developed a large pressure ulcer on her buttock area and staff were not following physician orders and communicating with PACE staff related to treatments. R21's family AJ reported R21 has PACE services that assist with wound care as well and that is why there is a sign on R21 wall with current wound care orders because they were not being completed as ordered. R21's family AJ reported did wash R21 hair since surveyor observation yesterday because it was greasy. R21's family AJ reported had to encourage staff all the time to assist R21 with drinks and frequently offer because R21 could not on own and today observed no beverage at the bedside. PACE aid AI reported after meals facility staff remove the tray including beverages and PACE AI reported she removes drinks from tray to keep in room. R21's family reported has had to ask staff to provide personal care to R21's backside occasionally and change sheets at least weekly after R21 observed soiled and sheets soiled within past 2 months and stated R21 does not like to smell. R21's family AI reported was not aware R21 received antibiotics for pressure wound and reported communication had been an issues for at least 2 months. During an interview on 8/29/23 at 2:20 PM, Unit Manager(UM) AC reported had worked at the facility for about one month and reported prior wound nurse left in June and Assistant Director of Nursing (ADON) C currently follows resident wounds. UM AC reported ADON C performs weekly wound rounds including wound assessments and documentation can be located on Progress Notes. UM AC reported nursing staff are expected to complete weekly skin assessments. UM AC reported was unsure when R21 pressure ulcer developed. UM AC verified was unable to located R21 wound monitoring between 6/4/23 to 7/6/23 and verified should be weekly. Review of the facility, Skin Assessment, dated 5/10/23, reflected an area to right buttock described as, suspected pressure injury noted(like open blister). Approximate: 3cmx 4cm. Blanchable redness around area noted. TX initiated: wash with soap a&water, pat dry, apply venelex ointment & cover with (4x4) Silicone DRSG. Review of the facility, Skin & Wound Evaluation, dated 5/11/23, provided by facility ADON C, reflected R21 had wound measurements of 6.1 cm long by 1.2 cm in width. The document appeared incomplete as evidenced by no other sections of evaluation were answered. Review of the Provider Progress Note, dated 5/11/2023 at 4:47 PM, for R21, reflected, seen for wound assessment and treatment - perianal/ buttock skin denudation Objective: Assessment: peri anal skin appears denuded from friction and shear, has sm amt of maceration from urine area measures 2.0x 1.0 w 0 depth, no drainage, skin slightly erythemic, no s/s infection Plan: d/c the Venalex and use Chamoa zinc oxide base cream will provide better skin protection, apply prn . Review of R21's Provider consult, dated 5/11/23, reflected plan included, At this point we are going to discontinue the Venelex. I do not feel that is benefiting her wound healing. We will start using Chamo, it is a zinc oxide base cream that will provide a better skin protection and apply that p.r.n. and will need to continue to monitor her clinically as she does have quite a bit of urine sitting on her skin and the skin irritation and denudation is due to some shearing and son maceration and will need to be monitored. Review of R21 Physician Orders, dated 3/4/22 to 5/11/23, reflected, apply zinc oxide ointment to bilateral buttocks and coccyx every day and evening shift for prevention. Review of R21 Physician Orders, dated 5/11/23 to 6/8/23, reflected, Use chamo to buttocks for skin protection for friction and sheer every shift. Review of the Electronic Medical Record, dated 5/11/23 through 6/4/23, with no evidence of wound monitoring including, progress notes, wound and skin assessments, or provider notes. Review of R21 Skin and Wound Progress note, dated 6/4/23 at 3:07 p.m., reflected, resident has open area to coccyx approx. 1.0 x 0.5, venelex applied with 3 x 3 dressing placed. will monitor. Review of Physician orders with no evidence of treatment changes. Review of the facility, Skin Assessment, dated 6/5/23, reflected R21 had a new suspected pressure ulcer on coccyx area with description that included, Stage 3 to coccyx, slough, dark central core, beefy red wound base, no drainage, no s/s of infection, no drainage, 3.5 x1.5, no depth; Lateral stage 2 ulcer 1.0x 0.5, no depth, clean, beefy red wound base, no s/s of infection. Review of R21 Unusual Occurrence Progress Note, dated 6/5/2023 4:00 p.m., reflected, Dependent for all care, does not ambulate, incontinent of stool ,observed with 2 new open areas to coccyx. Tx currently in place. Interventions. Turn / reposition perprotocol, staff to off -load pressure away from coccyx with use positioning device. Currently on low air loss mattress. Care plan and kardex updated. Review of R21 Physician Progress Note, 6/19/2023 at 12:58 p.m., seen for wound care assessment and treatment, stage 4 coccyx ulcer .coccyx ulcer measures 4.0 x 3.7 w 2cm depth in deepest area and 1.5 cm rest of wound, clean beefy red wound base, almost friable, periwound tissue slightly macerated, intact, no s/s infection .Plan: stage 4 coccyx ulcer VAC dres, change M-W-F. Review of R21 Progress Note, dated 6/21/2023 at 2:05 p.m., reflected, Wound vac dressing changed to stage 4 coccyx ulcer. Resident medicated for pain prior to procedure. L= 4.5cm x W=4.0cm x D= 1.8cm, tunneling at 7'0 clock 4.5cm. Wound has slough,and some eschar tissue; Peri wound is beefy red, no odor, no s/s of infection . Review of R21 Progress Note, dated 6/24/2023 at 4:01 a.m., reflected, res temp was 101.5@1953 @2300 temp was 102.3 Review of R21 Health Status Progress Note, dated 6/26/2023 at 4:33 p.m., reflected, Coccyx wound vac dressing changed by nursing; wound measures 6.0cm L X 5.0 CM W X 3.5CM D. Wound bed with yellowish/ greenish slough, peri wound with reddish excoriation, slight drainage, some odor present . Review of R21 Health Status Progress Note, dated 6/28/2023 at 4:52 p.m., reflected, Wound nurse from Pace here to evaluate resident's coccyx wound. Physician contacted, treatment changed from wound vac to topical wound treatment with specific directions. Resident started on oral antibiotic for wound infection. Coccyx wound measures 4.5cm L x 6.6cm W X4.6CM D, yellowish/ greenish slough present, periwound with reddish appearance. Note completed by prior wound nurse AK. Review of R21 Health Status Progress Note, dated 6/29/23, reflected, Late Note .Seen by wound nurse; Coccyx ulcer tx consists of gently packing the wound. Ulcer measures 6cm x 7.0 cmx 6.0cm deepest area. Resident currently on antibiotic for wound infection. Wound has odor, Wound bed presents with greenish/yellow slough. Resident continues on palliative care, due to overall medical decline . Note completed by prior wound nurse AK. (One day between wound measurements with significant difference in measurements noted. No evidence of Physician ordered wound treatments were noted in R21 EMR.) Review of the Health Status Progress Note, dated 7/2/2023 at 6:32 a.m., reflected, Continues on ABT therapy for wound on coccxy's. Resident remains afebrile, some discomfort to perform the wound care per doctor orders. Continues on scheduled pain medication for pain. Review of R21 Skin/Wound Progress Note, dated 7/6/2023 at 1:19 p.m., reflected, Seen for Wound assessment and treatment of stage 4 coccyx pressure ulcer. Ulcer measures 5.0 x 6.0 w 3.5cm depth, clean beefy wound base w spotting area of slough, no increase in drainage, no foul odor, peri wound tissue intact. Remains on ATB, also has a foley to divert the urine . Review of R21 Skin/Wound Progress Note, dated 7/10/23, created 7/19/23, reflected, LATE ENTRY: Assisted with dressing change per orders. PACE NP [named] present with this writer. Wound bed granulated and beefy red. Some slough present on right lateral edge of wound. Measurements are: 4cm tunneling @ 11 O'clock, 4cm tunneling @ 5 O'clock and 2cm tunneling @ 12 O'clock, 5cm deep x 6.25cm wide. Resident tolerated well. Daughter was given an update on progress of wound when visiting. Review of R21 EMR including the Treatment Administration Record(TAR), dated 6/1/23 through 6/30/23, reflected no evidence of treatment changes noted on 6/5/23 through 6/9/23 when new stage 3 and stage 2 pressure ulcers were identified. Continued review of R21 TAR, dated 6/9/23 through 6/13/23, reflected wound treatment orders, Stage 3 ulcer to coccyx, with lateral open area, NS cleanse, blot dry, apply santyl ointment, cover with large silicone bordered dressing, change daily, and prn, due to incontinence of stool one time a day for wound treatment. Continued review of the TAR reflected no evidence wound treatment was performed on 6/14/23. The TAR reflected treatment order changes on 6/16/23 through 6/19/23 that included, Stage 4 pressure ulcer to coccyx, lateral open area has merged into coccyx wound , NS cleanse, blot dry, apply santyl ointment to wound bed, gently pack with iodaform guaze cover with large silicone bordered dressing, change daily, and prn, due to incontinence of stool one time a day for wound treatment. The TAR reflected negative pressure Wound Vac treatment was started 6/19/23 through 6/28/23. The June and July TAR reflected no evidence R21 received stage 4 coccyx wound treatments 6/29/23 through 7/6/23(eight days) and 7/8/23, 7/9/23, 7/24/23, 7/26/23 and 7/29/23. Review of R21 Skin/Wound Progress Note, dated 8/9/2023 at 2:10 p.m., reflected, Resident was assessed r/t stage 4 coccyx wound. Wound is 6cmX7cmX1.5cm, 90% granulationtissue to wound bed, 10% slough,wound edges are rolled, pink and surrounding skin is blanchable. Moderate amount of yellow drainage on old bandage. Review of R21 Skin/Wound Progress Note, dated 8/28/2023 at 9:46 a.m., reflected, Late entry from 8/25/23 Resident was assessed During wound rounds. Coccyx pressure ulcer measures 5.5cmX6.8cmX1.3cm. 95%granulation tissue, 5% slough towound bed. Tolerated treatment well. Surrounding skin is blanchable. Edges are rolled. Review of the TAR, dated 8/1/23 through 8/30/23, reflected R21 did not received Physician ordered dressing changes for the facility acquired stage 4 pressure ulcer to R21's coccyx as evidence by not being documented as complete on the following dates: 8/3, 8/6, 8/9, 8/11, 8/16, 8/18, 8/21, and 8/23/23. (Eight missed dressing changes). Review of the Skin Care Plans, dated 1/12/23, reflected R21 had potential impairment to skin integrity r/t fragile skin, morbid obesity, impaired mobility. Continued review reflected revisions, dated 6/5/23, that reflected, The resident has impairment to skin integrity, stage 3 pressure injury to the coccyx , and a stage 2 pressure injury laterally r/t fragile skin, morbid obesity, impaired mobility .The resident has Stage 4 pressure ulcer to Lateral Coccyx r/t mechanical destruction of tissue secondary to pressure from refusing to get OOB and/or repositioning, other causative factors: decreased mobility, obesity, CHF w/edema, lymphedema, PVD, loose stools. Date Initiated: 06/13/2023 .Interventions included, BED MOBILITY: The resident requires extensive assist of (2) staff for repositioning and turning in bed routinely and as necessary. Date Initiated: 01/12/2023 .BEDFAST: The resident is bedfast all or most of the time. Date Initiated: 01/12/2023 .Monitor/document/report PRN any s/sx of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. Date Initiated: 01/12/2023 .Administer treatments as ordered and monitor for effectiveness. Date Initiated: 06/15/2023 .Assess/record/monitor wound healing at least every 7 days, Measure length, width and depth where possible, type of tissue, and exudate. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 06/15/2023 .Encourage and assist to a position of comfort at least with every care round as resident will allow/tolerate, more often as needed or requested. Date Initiated: 06/15/2023 .If The resident refuses treatment, confer with the resident , IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. Date Initiated: 06/15/2023 .Use pillows and such to maintain postural alignments, as resident will allow/tolerate. Date Initiated: 06/15/2023 .Weekly skin assessment with shower per facility policy. Report any changes in skin condition to MD prn Date Initiated: 06/15/2023 . Continued review of the Care Plans reflected no updates between 5/10/23 and 6/13/23 when pressure ulcer was identified. Review of the Progress Notes, including behavior notes and tasks, dated 5/1/23 through 8/30/23, reflected no evidence R21 refused position changes every care round. During an interview on 8/29/23 at 5:03 PM, ADON C reported had worked at the facility since June 2023 and was responsible for wound rounds since 7/21/23. ADON C reported wound rounds are completed weekly for all residents with pressure ulcers or extensive wounds. The facility also meets for weekly wound meetings that include, MDS coordinators, Unit Managers, Dietary, Therapy, Director of Nursing (DON) B to discuss healing progress, change in treatments, dietary supplements, eating intake, therapy changes, changes in surface changes, showers, skin assessments completed, treatment orders up to date, an needed and scheduled treatments, Care Plans updated and verified was ADON C responsiblility to keeps records. ADON C reported was responsible for weekly wound monitoring including measurements, treatments, communication with provider, description of wound and documents in the Skin/Wound Progress Notes. ADON C reported prior to starting wound rounds 7/21/23 prior Wound Nurse AK was responsible for monitoring facility wounds. ADON C reported found wound monitoring in several locations including assessments, provider notes, Progress Notes without pattern and reported weekly wound rounds were not being completed and things were missed. ADON C reported facility completed skin sweep of entire facility in June 2023 and identified all wounds at that time and was unable to provide date. ADON C reported expected staff to complete weekly skin assessments under assessment tab of EMR. ADON C reported staff expected to complete Unusual Occurrence Note if a new skin irregularity is identified on a non-scheduled day for weekly skin assessment then report to Unit Managers and meet as team. ADON C reported nurse are expected to measure wounds including length, width and depth and describe wound bed and peri wound and include if tunneling present. ADON C reported facility has Nurse Practitioner who often is part of team for weekly wound rounds. ADON C reported had provided documentation to this surveyor related to R21 stage 4 coccyx pressure ulcer and verified was facility acquired and reported was unable to determine the date of onset. ADON C reported did not assess R21 stage 4 pressure ulcer the week of 8/13/23 to 8/19/23 because she was on vacation and was unable to report why weekly wound monitoring was not completed. ADON C reported documentation to be completed same day with occasional next day documentation notes. ADON C reported wound expect physician orders to be followed and R21 to be repositioned frequently and documentation of refusal. During an interview on 8/30/23 at 11:13 AM, Certified Nurse Aid (CNA) P reported was familiar with R21 and required full assist with care. CNA P reported rehab staff moved back to B Wing 3/23/23 and reported several agency staff used to work on C Wing(R21 hall) who often can not be dependable.

This citation pertains to MI00132943 and MI00132547 Based on observation, interview and record review the facility failed to prevent falls and/or accidents for three (Resident #113, #114 and R111) of five reviewed, resulting in fall from mechanical lift with injuries and fracture and skin tear during care. Findings include: Resident #113(R113) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R113 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), dementia, arthritis, diabetes, seizure disorder, and anxiety. The MDS reflected R113 had a BIM (assessment tool) score which indicated her ability to make daily decisions was severely impaired and she required one-person physical assist with bed mobility, eating, dressing, toileting, and two-person assist for transfers, hygiene and showering. The MDS reflected no functional limitations in range of motion on both upper and lower body. According to a complaint intake, dated 11/17/22, indicated R113 had a fall from a mechanical lift during a staff transfer. Review of the Incident Report, dated 11/12/22 at 1:35 p.m., reflected under incident description, Two CENAs were transferring resident from her w/c to her bed via hoyer lift, resident was leaning forward in the sling, as one of the CENA attempted to pull her back the strap holding the bottom portion of the sling came off and she fell forward out of the sling from about chest level hitting her Lt. lower face (mouth area) on the base of the hoyer lift. She then landed on the floor, staff rolled her to her side when they saw bleeding. The incident report reflected notes, dated 11/17/22, that included, Resident was alert and oriented, trembling from the fall and unable to verbalize pain. Her upper dentures broke in multiple pieces, causing several teeth to fall out of the dentures. Blood noted on her left side, upper gums .physician was notified and gave orders to send the resident out to ER for further evaluation . Continued review of notes, dated 11/17/22, reflected, Interventions: Resident was set to [named hospital for further evaluation. Plan of correction completed with CENA's, re-education on mechanical lift policy usage was conducted. All Romedic Hoyer lifts removed off LTC [long term care] units immediately until fully inspected. Replacement mechanical lifts are now being utilized. Manufacture rep called in to inspect lifts. Lift #27, which was being utilized in this situation, was observed to have excess tension in the screw, that holds the red flap in place, causing it to not fully close automatically when sling was placed in loops. Care Plan and Kardex reviewed and updated accordingly. During a telephone all on 2/22/23 at 4:19 p.m., R113 Durable Power of Attorney (DPOA) Y reported she was R113 responsible party and daughter and reported visits R113 frequently at the facility. R113 DPOA Y reported R113 required total assist with transfers and reported fell from a mechanical lift on 11/12/22 and was dropped on head resulting in moderate facial trauma, cut on lip, broken dentures, glasses and sent to the emergency room . DPOA Y reported had requested copy of incident report and to speak with management related to incident and had not yet heard back from the facility. DPOA Y reported Direct of Nursing (DON) B told DPOA Y that R113 fell out of mechanical lift because R113 leaned forward in sling during staff transfer. DPOA Y reported was upset because she did not feel R113 was able to move in that way and reported staff should have kept R113 positioned in safe manor to prevent fall. DPOA Y reported the fall was traumatic for both the R113 and herself and should not have happened. DPOA Y reported R113's nose is not the same as prior to facial trauma and developed abscess on lip in same location a lip laceration that require antibiotic treatment about one month ago. DPOA Y reported was upset that facility did not notify DPOA Y prior to ordering a narcotic pain medication for R113 after incident. DPOA Y reported staffing appear to be a challenge at times because difficult to get timely assistance. Review of the Nursing Progress Note, dated 11/12/2022 at 2:23 p.m., NP notified of resident fall out of the hoyer sling has laceration to top upper left lip r/t upper denture broke due to hitting hoyer lift leg region. n.o received to send to ER for evaluation. POA updated and agreed to send to ER for evaluation .On call abuse and DON notified via telephone to report occurrence. Review of R113 Nursing Progress notes, dated 11/13/2022 7:15 p.m., reflected, Resident returned to facility at 1915 via stretcher transported by 2 EMS personnel. Resident has Bruising around eyes and swelling around eyes and jaws. Resident has a scratch to Left upper arm . Review of R113 Physician visit note, date 11/14/22, reflected, Staff were transferring her this weekend in the lift when resident leaned forward in the sling and the strap came off of the lift and the resident fell forward and hit her face on the base of the Hoyer lift. She had a lot of bleeding rom her oral cavity. Her upper dentures were broken into three spots from the fall .She was noted to have a lot of bruising and swelling around her eyes and jaw as well as small laceration to her lip. Nurse today stated that she is on the scheduled Tylenol and feels that pain is well controlled .This resident does have dementia and does have some difficulty making her needs known .She is noted to have bruising to the periorbital areas with swelling to her nose and lips . Review of R113 Social Service Progress note, dated 11/14/2022 at 12:22 p.m., reflected, Included in phone to daughter r/t denture and questions pertaining to return to facility was discussed. Daughter thanked this writer for follow up call. Daughter request a follow up call from management. Management notified of request. Review of R113 Nursing Progress Notes, dated 11/14/2022 at 5:10 p.m., reflected, Resident kept in bed resting per request of DPOA. Repositioned frequently .Resident with two black eyes and edema to let side of face. Neuro checks WNL. Denies pain. NP gave order to start Roxanol 0.25 ml (5mg) q8h PRN for pain. BP elevated at 178/90 . Review of R113 Physician Progress Note, dated 1/4/2023 at 3:55 p.m., reflected, seen for Rt upper lip nodule/abscess/ bradycardia .Assessment: dtr requested us to assess her lip nodule, area is just above the lip on Rt firm movable nodule, somewhat erythemic on the mucous side in the mouth, no erythema noted on the outer lip side. no c/o pain upon palpation, no facial grimacing. eating well w no difficulty swallowing .Keflex 500mg tid 9-3-9 x 7 days for lip abscess . Review of R113 Physician visit note, dated 1/4/23, reflected, As far as the right lip nodule, could be an abscess in tat area. It is mobile mass and it may be related to the recent fall that has caused it to form. We will put her on some Keflex 500mg one p.o. tid .for seven days and we will continue to monitor this area clinically . During a telephone interview on 2/21/23 at 11:12 a.m., Certified Nurse Aid (CNA) Z reported was caring for R113 on 11/12/22 when R113 fell out of the mechanical lift. CNA Z reported her and CNA N were using the newer style mechanical lift with wrong sling that was older style slings for older style lifts and attempted transfer R113 from the wheelchair to the bed. CNA Z reported hooked four sling straps and began to lift R113 out of wheelchair and R113 leaned forward, sling strap snapped out of hook and R113 fell headfirst on the floor. CNA Z reported they tried to catch R113 but were unable to before R113 face hit on mechanical lift floor legs and floor. CNA Z reported saw blood from R113 mouth while R113 on side and had to slide R113 off base because face appeared to make contact with bolt on lift base. CNA Z reported CNA N left room to get nurse and reported R113 seemed calm but had tears running down her face after fall and reported R113 was unable to express needs. CNA Z reported was provided education on mechanical lifts after incident and newer style mechanical lifts were removed from the floors. CNA Z reported R113 had facial bruising and knot on head and reported was sent to hospital and return to facility the next day. Resident #114(R114) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R114 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), dementia, diabetes, depression, psychotic disorder, and anxiety. The MDS reflected R114 had a BIM (assessment tool) score of 7 which indicated her ability to make daily decisions was severely impaired and she required two-person physical assist with bed mobility, transfers, dressing and one person assist with toileting, hygiene and showering. The MDS did not reflect R114 had history of osteoporosis. According to a complaint intake, dated 11/17/22, indicated R114 developed a fracture during care. Review of an Incident Report, dated 8/15/22 at 7:31 a.m., for R114, reflected, Writer was notified by CNA that she was trying to open patient's legs to change brief and she heard something pop in patients Lt hip. The report indicated resident response was patient moaned and stated that left hip hurt with pain level of 6. The report indicated, Injury Type major Injury-Fracture. The report notes reflected, per Xray results of right femur 2 views has an acute moderately displaced fracture involving the distal shaft and metaphysis of the right femur. Additional AP and lateral images of the right knee indicates to rule out extension of the fracture into the femoral component of the prosthesis. Continued review of the report notes, dated 10/18/22, reflected, During AM care, staff was opening legs for care when she heard a pop of the left hip. Patient complained of pain and right leg was found at an awkward angle and unable to move. X-ray was completed and fracture positive. Was not sent to hospital, but a appt. was schedule with an orthopedic surgeon to evaluate. Resident has a history of uncooperative with care and being combative. Resident was kicking out at staff and being combative during care that morning . Review of R114 Nurse Practitioner visit note, dated 8/15/23, reflected, I am seeing this resident today to follow up on report of the hip pain. Nursing staff contacted the on-call provider this morning after resident was being assisted with changing her brief early this morning. The staff heard a popping sound and thought it was her left hip. The nurse contacted on-call provider and requested a x-ray. X-ray has not been completed yet. This resident was seen this morning lying in bed. She was alert. She does have end stage dementia. She was able to answer yes, no questions at times. She was able to report that heparin was a 5/10. When attempting to asses the legs, the resident would state, do not hurt me. Blankets were removed from her lower extremities and she was noted to have a deformity to the right lower extremity, light palpation of the lower extremities indicated that she had much more tenderness of the right side At this time we will add a right hip and femur x-ray stat due to the deformity and pain. We will start Norco .q. 6 hours p.r.n pain . Review of the Electronic Medical Record, dated 7/1/22 through 8/15/22, reflected no evidence of R114 history osteoporosis diagnosis. During an interview on 2/21/22 at 2:15 a.m., Abuse Coordinator (AC) L R114 incident on 8/15/22 was not reported to the State of Michigan and believed she had investigation in her office and was unsure why it was not provided to surveyor when all incidents report with complete investigations for R114 were requested on 2/14/23. During a follow up interview on 2/21/23 at 2:54 p.m., AC L CNA N was providing care to R114 on 8/15/22 at the time of the incident. AC L reported incident was not report because CNA was following care plan at the time of the incident. AC L was unable to answer how she knew CNA N was following R114 care plan at the time and unable to provide evidence During an interview and record review on 2/21/23 at 3:54 p.m. Director of Nursing (DON) B reported R114 incident on 8/15/22 was not reported to the State of Michigan (SOM) because there was no new injury and R114 or family did not reported abuse. DON B reviewed radiology reported again and reported she must have read it incorrectly. DON B reported R114 had history of bilateral knee replacements so at high risk for fractures. DON B reported care plans indicated history of osteoporosis and DON B verified osteoporosis added to care plans after 8/15/22 incident. DON B reported was not reported to the SOM because there was no evidence of abuse because the CNA who provided the care was questioned and was alone and they can not assume it was abuse. DON B verified no other interviews with staff or other residents on hall. Requested evidence that abuse was ruled out. During an interview on 2/21/23 at 5:30 p.m., CNA N reported was caring for R113 on 11/12/22 when R113 fell out of mechanical lift. CNA N reported was assisting another CNA transfer R113 from a wheelchair to bed and reported older sling did not fit good into new mechanical lift and hook slipped off of lift and R113 fell out of sling and hit head and face on base of lift and ground. CNA N reported received training after incident and new lifts removed from halls. CNA N reported was also R114 nurse on 8/15/22 when R114 fractured left leg during care. CNA N reported performed care for R114 alone and was attempting change R114's brief and put pants on when she heard a pop on R114's left side. CNA N reported R114 moaned and complained of pain after resident kicked left leg outward while attempting to put R114's pants on. CNA N informed nurse immediately. CNA N reported R114 was a one person assist at that time and was non-ambulatory. During a telephone interview on 2/22/23 at 1:43 p.m., previous DON D reported thought both R113 incident on 11/12/22 related to fall from staff assisted mechanical lift and R114 incidents 8/15/22 related to fracture during care had been reported to the SOM. Previous DON D reported at the time of the incidents they were discussed with Abuse Coordinator L, Chief Operating Officer C, DON B, and Nursing Home Administrator A. Prior DON D reported mechanical lift slings did not properly work with newer mechanical lifts and verified was determined during investigation completed after R113 incident. Prior DON D reported R114 incident should have been reported to SOM related to possible allegation of abuse related to injury of unknown origin. Prior DON D reported CNA staff are expected to follow resident care plans and had fired CNA staff in past for not following care plans related to a fall with injury during staff assisted transfer. Resident #116(R116) Review of the Face Sheet 2/23/23, reflected R116 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), dementia, diabetes, anxiety and depression. Review of the Facility Reported Incident, dated 11/29/22, reflected R116 had a witnessed fall during one person assist transfer resulting in a laceration to the R116's head. The investigation reflected the care plan indicated R116 required a two person assist with transfers and the care plan had not been followed. During a telephone interview on 2/22/23 at 5:20 p.m., Registered Nurse (RN) P reported was familiar with both R113 and R114 and reported both events should have been reported to SOM because both events should not have happened and could have been prevented. RN P reported staffing is not safe for residents with examples of R113 and R114 events along with R116 who had a fall during a staff assisted transfer that should have been two person assist and CNA staff transferred R116 alone and R116 fell and was injured. RN P reported frequently 1 CNA on each hall on nights which requires them to make tough decisions because not enough staff to provide residents required care. RN P reported R113 incident management placed blame on equipment but should have been more focus on safe staff assistance because of the sling loops were place on the mechanical lifts correctly it would be impossible for resident who weighted over 120 lbs. to slip out of loops related to gravity. RN P reported R114 incident should not have occurred while providing care no matter what and should have been reported as allegation of abuse within 2 hours. RN P reported management was more concerned that R116 fall during staff transfer was related to equipment opposed to staff not following the plan of care. RN P reported nurses do not have time to give residents showers and reported had to take the word of the CNA staff that they completed them but knows showers were being missed related to no enough staff. Resident #111(R111) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R111 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), heart failure, kidney disease, obstructive uropathy, paraplegic, diabetes, and depression. The MDS reflected R111 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact and he required two-person physical assist with bed mobility, transfers, and toileting, and one person assist with dressing, locomotion, hygiene and showering. The MDS reflected no behaviors including refusal of care. Review of compliant intake, dated 11/14 22, reflected concerns related to staff providing safe transfers with use of mechanical lift that cause skin tear. Review of R111 facility incident report, dated 9/28/22 at 10:17 p.m., reflected, Nurse Description: Resident was in the Hoyer Lift when a thin layer of skin was observed that had peeled back from the upper (L) abdomen. Resident Description: Resident stated that the Hoyer strap rubbed against his abdomen . The report reflected R111 had minor skin tear to abdomen at time of incident. The report included notes that reflected, On 09/28/22 at approximately 22:17 the CENA?s were finishing the residents shower. They observed a thin layer of skin that had peeled back on the resident's upper abdomen, on the left side. The original skin hear was 3 in x 3 in. Resident stated that the hoyer strap rubbed against his abdomen .non-ambulatory and 2x EA with mechanical lift for toileting on the commode and showers. His BIMS is 15/15, indicating he is cognitively intact . Review of R111 Resident Feedback Form, dated 9/9/22, reflected R111 reported concerns staff used incorrect mechanical lift sling. Results of the investigation included R111 had order for blue trimmed sling to be used and staff educated and R111 was satisfied with results on 9/15/22 per staff documentation with no documented follow up with R111 or evidence R111 was agreed to resolution or agreed with plan. Review of R111 Nurse Progress Note, dated 9/30/2022 at 3:48 p.m., reflected (L) abdominal assessed with possible burn, blistering fluids filed. On call physician assessed area via emailed. No other recommendation required, we'll continue with current treatment pr physician. Review of R111 Nurse Progress Note, dated 10/1/2022 at 3:39 p.m., reflected, Wound care to LUQ/LLQ, no dressing to remove,there is an open area that is draining with serous drainage on the LUQ, blisters (+) with fluid filled, wound bed is red, crust (+),surrounding tissue intact, no redness, no s/s of infection. Are a was cleansed with NS, air dry,applied silver sulfadiazene cream to affected area including LUQ/LLQ, left thigh, bil ankles(inner). Tolerated the procedure very well . Review of the Treatment Administration Record(TAR), dated 9/28/22 through 10/31/22, reflected R111 had an order for cleans left abdomen skin tear with normal saline and cover with silicone border dressing every 72 hours and TAR indicated R111 received treatment 8/28/22. Continued review of the TAR reflected R111 did not receive wound treatments to abdomen wounds between 9/28/22 and 10/15/22. Review of R111 Progress Notes, dated 10/13/2022 at 7:56 p.m.Returned from the wound clinic at approximately 16:45 via stretcher. No new orders returned to facility. Abdomen covered with ABD pads after debridement. New dressing on coccyx. Nurse will follow up with wound clinic in the morning to update any new orders. Next appointment 1o/20/22 . Wound clinic orders started on 10/15/22 according to TAR for daily dressing changes with no evidence R111 received physician ordered daily dressing change on 10/14/22. Review of the Physician orders, reflected no evidence R111 had treatment orders in place between 9/30/22 and 10/15/22 for wound that required detriment on 10/13/22 at wound clinic appointment. Review of the Skin Assessment, dated 10/19/22 and 10/31/22, reflected R111 had an existing abnormal skin areas including non-pressure wound to left abdomen that measured 28 cm by 14 cm. Review of R111 Nurse progress note, dated 10/20/2022 at 4:22 p.m., reflected, Abdominal wound TX preorder. Wound covers with greenish slough. No drainage noted. Sign of improvement, with dressing dry and intact. Resident will re-assess by wound clinic 10/27/22. During a telephone interview on 2/23/23 at 2:07 p.m., Confidential Staff (CS)AA reported staffing had been concern for at least three months. CS AA reported staff report unsafe staffing and allegations of abuse to management on several occasions that they do not report to the SOM. CS AA reported if sling was hooked on mechanical lift correctly not possible for body over 100 pounds to slip off hooks related to gravity alone if equipment was being used properly. CS AA reported familiar with R110 and reported night staff refuse to care for R110 and staff have informed Licensed Practical Nurse (LPN) X on several occasions about care concerns with no changes and no investigations. CP AA reported same 2 CNA staff that worked night shift on 2/20/23. (Prior to 2/21/23 morning care observed for R110, with witness reported care concerns to LPN X). CP AA reported staff report care concern because allegations of potential neglect. CS AA reported often cared for R111 and reported R111 had reported staff caused abdominal skin tear/burn from removing mechanical lift sling roughly that caused shearing skin tear. CS AA reported another example of not enough staff to provide needed care because everyone had to be in a rush.

This citation pertains to intake MI 4505. Based on interview and record review, the facility failed to provide one resident (Resident #12) of 3 residents reviewed for accidents with adequate supervision and assistive devices to prevent Resident #12's recent hip replacement from dislocating. Findings include: Review of the medical record and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was a [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #12 had clear speech, was understood, understands, was cognitively intact and required extensive assistance of two staff members for bed mobility. Resident #12 was not available for interview and was discharged from the facility on 7/5/2019. Review of the nurses note written by (Licensed Practical Nurse (LPN) I, dated 6/2/2019 at 11:43 p.m. revealed, Staff (Certified Nursing Assistant (CNA) G) reported pt (Patient) needs pain medication. This writer went to the room and pt had c/o (complained of) right hip pain, 5/10. PRN (as needed) medication given. Pt stated, When I wanted to be reposition (sic), I think something went wrong. Assess pt and observed right leg was shorter than the other leg. (Resident #12's physician) notified. Received order to send pt to ER (emergency room ) for further evaluation. Pt is her own decision maker and stated she is going to call her family. Review of the hospital emergency room Documentation dated 6/3/19 at 1:49 a.m. revealed, (Resident #12) comes from rehab for (Right) hip replacement rehab, (Resident #12) was being repositioned when she felt a pop and now has (right) posterior hip deformity .(Resident #12) is a [AGE] year-old female coming with right hip pain after rolling from her left side to her right side in bed. (Resident #12) states she supposed to be using a binder pillow to keep her legs separated but she did not use it last night .Assessment/Plan: Right hip dislocation .Performed procedural sedation .and reduce patient's right hip (put her hip back into place) . Review of the indident report dated 6/2/19 at 11:43 p.m. revealed, It is our conclusion that patient was being repositioned when her hip dislocated. (Resident #12) is a recovering from a recent hip surgery, and it is believed that hip precautions were not in effect when repositioning patient. During a telephone interview on 7/11/19 at 12:50 p.m., when asked about Resident #12 dislocating her hip, LPN I stated, I did an incident report .I think two aides helped her to go to the bathroom and then helped her go to the bed. I think then somebody tried to move her position. And then she called me and told me that she had pain and said that something went wrong. When asked if there was an abductor pillow available? LPN I stated, Yes, usually we put a pillow between the legs. I never was a witness to her removing the pillow .We would have to educate the resident (on using the pillow between the legs. When asked if there was a foam pillow in the room at the time of the dislocating, LPN I stated, One of the staff said that she did not have a pillow between her legs. During a telephone interview on 7/12/19 at 12:35 p.m., when asked about repositioning Resident #12 on 6/2/19, CNA G stated, She had called me into the room and said that she needed to be positioned. She was laying on her side towards the window and I turned her to her back, and she said something went wrong. There was nothing placed between her knees. When asked if there something supposed to be between her knees, CNA G stated, Usually when they lay on her side, we put a pillow between her legs. When asked why there was not a pillow between her legs when she repositioned Resident #12, CNA G stated, I have no idea, I helped the aide before put her in bed and turned her to her side, but then I left. When asked if when Resident #12 is in bed is there supposed to be an abductor pillow between her legs to keep her legs apart CNA G stated, The whole time I dealt with her she never had anything between her legs. She was complaining of pain being on her side, and then when I turned her, she said, 'oh something is wrong'. I did let the nurse know and she went in. When asked if she was aware that per the care plan, Resident #12 was supposed to have an abductor pad in place when in bed, CNA G stated, No I did not, I didn't even look at her data sheet (guide that CNAs use to understand resident cares). When asked if there was a reason she didn't look at the data sheet. CNA G stated, No I was just turning her. When asked when you are supposed to look at the data sheet, CNA G stated, Anytime we are going to give them care to see if they need anything .There was a pillow between her feet but nothing between her legs. CNA G continued, I don't really deal with her much, they (other staff) say that she likes to take the pillow off between her legs, and throw it on the floor, but that night I did not see any pillows on the floor and I never seen her do that (remove the pillow from her legs). During a telephone interview on 7/12/19 at 2:00 p.m., when asked about Resident #12 being put to bed without a pillow on 6/2/19, CNA H stated, I answered (Resident #12's) bathroom light and (CNA G) was in there. We got her back into bed and I did not put a pillow in between her legs, she is supposed to have an abductor pillow .I tried before, and she said she doesn't use that (the pillow). When asked if she let the nurse know that Resident #12 refused to use the pillow, CNA H stated, Yes, they knew about this before, but that night I did not even try to put the abductor pillow in place and I did not put a pillow in place. When asked if there was any reason why she did not attempt to put the pillow in place prior to repositioning Resident #12, CNA H stated, No, I just totally forgot. Review of the medical record, to include physician orders [REDACTED].#12's hip dislocating, that Resident #12 was educated on the risk of not using the pillow, there was no documentation of Resident #12 refusing to have a pillow put between her legs or removing a pillow, nor were there any alternative interventions in place to reduce the risk of hip dislocation, besides the pillow between the legs. Review of the physician order [REDACTED]. Review of Resident #12's Baseline Care Plan, with an admission date of [DATE] revealed the intervention of, Foam abductor between legs when in bed. During an interview on 7/11/19 at 12:04 p.m., when asked about the incident with Resident #12, Unit Manager J stated, On (5/30/19) there was an order for [REDACTED].>

This citation pertains to Complaint intake number MI 945. Based on interview and record review, the facility failed to provide adequate supervision (Resident #221) and implement interventions (Resident #164) to prevent falls, in 2 of 7 residents reviewed for falls, resulting in fractures and other injuries. Findings include: Resident #221 (R221) R221's Minimum Data Set (MDS) assessment dated [DATE], introduced the Brief Interview for Mental Status (BIMS), a short performance based cognitive screener for nursing home (NH) residents score was 06 (scale: 00-07 Severe Impairment). The same MDS assessment revealed R221 was an [AGE] year-old admitted to the facility on [DATE] and had the [DIAGNOSES REDACTED]. The same MDS indicated R221 revealed a Patient health Questionnaire (PHQ-9), a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression, score was 09 (Score 5-9 indicated minimal depression). The same MDS assessment indicated R221 required extensive assistance for bed mobility, transfers, and walking; R221 required supervision and one person physical assistance with eating. Incident Report titled Un-witnessed and dated 11/8/18 at 6:20 PM, revealed R221 was observed on the floor in the dining room near assigned table, lying face down with extremities sprawled out, wheelchair at side, sensor alarm sounding. R221 reported after the fall that he slipped. A hematoma was noted on R221's forehead (localized collection of blood outside of blood vessels), and C-1, C-2 and C-3 vertebrae (spine) fractures were noted on the same report. The same incident report revealed R221 had had multiple falls in the last 60 days and 2 housekeepers were in the dining room at the time of the fall, but did not witness the fall. In the attached housekeeper's Vv statement dated 11/8/18, I heard the chair alarm go off as soon as I turned my heard (resident name) was on the ground. In the report titled Investigation for (resident name), not dated, regarding fall from 11/8/18, R221's fall was not observed on surveillance footage, as it was not in camera view. Attached to the same report was a signed statement from one of the housekeepers Vv in the dining room at the time of R221's fall, indicating she had noticed that R221 was leaning to the right while sitting at the table eating ice cream, and appeared to be lacking energy when she was cleaning near his table prior to the fall. On 12/14/18 at 4:10 PM, Housekeeper Ww stated on 11/8/18 she was cleaning the dining room and did not see R221 until after he fell . R221 was in the back of the dining room near the corner. Housekeeper Ww stated at the time of R221's fall there were no nursing staff in the dining room. On 12/18/18 at 12:07 PM, Assistant Director of Nursing (ADON) Gg stated during an interview that nursing staff were supposed to be in the dining room while residents were eating. ADON Gg stated she reviewed the video of the dining room from 11/8/18, R221's fall was not in view or any the nursing staff. On 12/18/18 at 12:46 PM Social Worker (SW) LL was interviewed and stated she investigated R221's fall on 11/8/18 at 6:20 PM, and there were 2 nurses at the nurses station at the time of his fall. SW LL stated she did not obtain any statements from Certified Nurse Assistants (CNA's) that were working at the time of R221's fall or the CNA that was assigned to monitor residents in the dining room during the evening meal. SW LL stated she did not know if Housekeeper Vv reported R221 leaning to the right and lacking energy to the nurse prior to his fall. On 12/18/18 at 2:20 PM, CNA Xx was interviewed and stated she was assigned to R221 on 11/8/18 at the time of his fall. CNA Xx stated she was not in the dining room at the time of the fall, she was down another hallway as she was assigned to resident room trays. CNA Xx stated in the same interview, that because of the pillars in the dining room, R221 could not be seen from the nurses station. In review of progress note dated 11/8/2018 at 6:50 PM, while waiting for an ambulance, R221's speech was slurred and low toned, appeared lethargic, and non-sensical statements were made. R221's Neurological assessment checks were abnormal, R221 raised right leg when asked to raise right arm. Hospital Discharge Summary dated 1/9/18, indicated R221 was to wear a Miami J Collar when he was up and moving, otherwise soft collar when in bed, for conservative management of his neck fractures. R221's Minimum Data Set MDS dated [DATE], revealed he was readmitted to the facility. MDS dated [DATE], revealed R221 was discharged due to Death in facility. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.16, (MONTH) (YEAR), instructed A previous fall, especially a recent fall, recurrent falls and falls with significant injury are the most important predictors of risk for future falls and injurious falls and to evaluate the physical environment as well as staffing needs for residents who are at risk for falls. Resident #164 (R164) Review of the Admission Record and Minimum Data Set ((MDS) dated [DATE], revealed R164 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], revealed R164 scored 7 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), required extensive assistance of one staff for toilet use, was frequently incontinent of urine, occasionally incontinent of bowel, and was not on a toileting program. The MDS dated [DATE], revealed R164 scored 10 out of 15 (moderate cognitive impairment) on the BIMS and required extensive assistance of two staff members for toilet use. On 12/13/18 at 04:18 PM, R164 was observed asleep in bed. Review of R164's Falls Care Plan reviewed on 6/7/18, 7/28/18, 8/27/18, 9/19/18, 10/4/18, 10/29/18, and 10/31/18, revealed undated, but typed (indicating it was in place when the care plan was first typed on 6/7/18; interventions added after that date were handwritten) interventions including toilet more frequently, dicem (nonslip material) to above and below w/c (wheelchair) cushion, remove foot rests when not transporting resident Review of the Incident Details dated 7/28/18 at 7:05 AM, revealed R164 was found on the floor in her room and the incident was unwitnessed. The Details of the Incident revealed Per witness statement from the aid-I saw (R164 name) laying on the floor, on her stomach as I walked by her room. She said she was trying to get to the bathroom. this nurse and pm nurse ran to room to find resident lying on stomach by bathroom. Resident stated she was trying to walk to the bathroom but her briefs fell down and made her trip. Resident denied any pain. Resident fully conscious. Resident has full ROM (range of motion). Residents VSS (vital signs stable). Resident was not wearing gripper socks when incident happened. Review of the Details of Corrective Measures Taken by Facility revealed on 7/28/18, neuro checks were initiated along with gripper socks at bed time. On 7/30/18 the corrective measures listed were gripper socks at night and will also initiate a bowel and bladder x 3 days to determine if a pattern is noted. On 12/18/18 at 04:20 PM, Assistant Director of Nursing (ADON) In Training FF, reported R164 did not have any record of bowel and bladder tracking during the last six months. When asked about the tracking that was done as a corrective action following R164's fall on 7/28/18, ADON In Training FF reported she would look into it. On 12/18/18 at 04:42 PM, ADON In Training FF reported R164 did not have bowel and bladder tracking completed after her fall on 7/28/18. Review of the Incident Detail dated 10/4/18 at 5:20 PM, revealed R164 fell out of her wheelchair. The facility's corrective measures included adding dicem to above and below wheelchair cushion for additional safety. However, dicem was already a care planned intervention. Review of the Incident Details dated 10/27/18 at 9:45 AM, revealed R164 sustained an unwitnessed fall from her wheelchair in the corridor and sustained a major injury. Review of the Details of the Incident written by Registered Nurse (RN) D on 10/27/18, revealed Resident was observed on the floor by Green Gables Hallway. Resident was lying on the left side: resident c-o (complained of) left should pain. PRN Tylenol was given, and x-ray to left shoulder ordered. Bruising and redness observed to left face and around the left eye: might have been caused by resident's eye glasses pressing on her face. Resident also has redness to left shoulder and bil. (bilateral/both) knees. Resident said I was trying to go to my room and use the restroom. The fall might have occurred when the resident was trying to maneuver through the small bump between the bare floor, and carpeting leading to Green Gables hallway. Review of the Details of the Incident written by Licensed Practical Nurse (LPN)/Restorative Supervisor OO on 10/31/18, revealed It is our conclusion that the resident was propelling herself in her wheelchair from the nursing station to her room to use the restroom when she fell out of the chair. Resident was observed on the floor lying on her right side. Bruising and redness was observed on the left side of her face, around her left eye, that may have been caused by her eye glasses pressing on her face. Redness was also observed on her left shoulder and bilateral knees. Resident did complain of left shoulder pain and PRN Tylenol was given. It appears that while (R164 name) was propelling herself on the vinyl flooring, her wheelchair was rolling along smoothly, however, the change in the flooring and friction of the carpet stopped her. Review of the facility's investigation included one statement from a staff member, whom was not assigned to care for R164 at the time of the fall. The investigation did not reveal whether or not dicem was in place on the wheelchair or if R164 was continent or incontinent at the time of the fall. It was unclear what interventions were in place at the time of the fall. Review of the POS [REDACTED]. There were no staff names listed on the Post Fall Huddle. The Post Fall Huddle revealed the incident occurred at 9:45 AM and R164's last toileting attempt was at 8:00 am. There was no indication if R164 was toileted at 8:00 AM or if this was an attempt. The Post Fall Huddle revealed toileting, CNA educational (sic) to toilet residents before and after meals. Review of the only staff statement, written by Certified Nursing Assistant (CNA) BB revealed Resident was trying to find the bathroom and she started wheeling herself down her hall, and next thing you know, she fell out of her chair at the carpet at the beginning of the hall. Review of the Investigation revealed Surveillance footage was reviewed and at 9:45am, (R164) is observed sitting on the edge of her wheelchair and leaning forward, using her feet to propel herself. (R164's) fall was not observed on camera as when she crosses over the threshold, exiting the nursing station area (vinyl flooring) and entering Green Gables Hallway (carpet flooring), she physically exits the camera view; however, the back end of her wheelchair is still in view and is observed coming to a halt on lip of where the vinyl flooring ends and carpet flooring begins. When the wheelchair stops, a staff member who is sitting at the nurses' station immediately stands up and walks over to (R164) .Conclusion: (R164) fractured by falling out of her wheelchair onto the floor, landing on her left side. It appears that while (R164) was propelling herself on the vinyl flooring, her wheelchair was rolling along smoothly; however, the change in flooring and friction of the carpet stopped her. It is likely that the combination of change in flooring along with her forward seating position, caused her to fall forward out of the wheelchair. There was not abuse or neglect in this case, and the injury is not suspicious. Staff were following her care plan, and all interventions were in place. (R164's) care plans have been reviewed and updated. The conclusion did not mention R164's need to use the bathroom at the time of the incident. On 12/14/18 at 10:13 AM, the surveyor attempted to contact Registered Nurse (RN) D via telephone and left a voicemail requesting a return call that day. RN D was the nurse assigned to care for R164 on 10/27/18. On 12/18/18 at 01:55 PM, Nursing Secretary HH reported RN D was out of the country until 12/23/18 and the facility also tried to contact RN D without success. In a telephone interview on 12/18/18 at 02:22 PM, Certified Nursing Assistant (CNA) BB reported on 10/27/18, she and CNA Tt were sitting at the North Unit Nurse's station between green and red hallways when R164 came up to the nurses' station. CNA BB stated R164 was confused. When she gets to pushing herself around, she is confused. CNA BB reported R164 was looking for the bathroom and stated she asked where the bathroom was that she could use. I told her to go down her hall and her aide would help her. She said ok and started to head that way. Right as soon as she got to the carpet, that's where she fell .we heard a loud bang. We looked up and she was on the floor. When asked why she nor CNA Tt assisted R164 to the bathroom, CNA BB stated I was in the middle of charting. I didn't know she doesn't propel herself until she gets confused. It was really busy on our hall. I charted when I had a minute. She came to us asking questions and where the bathroom was. CNA BB reported she did not receive any education regarding this incident. When asked if there was anything that could have prevented R164 from sustaining the fall, CNA BB stated If she would have been toileted right after she ate, that would have worked. When I work green hall, I would toilet all of them right after they are done eating and lay them down if they want to lay down. CNA BB reported green hall usually finished breakfast by 9:00 AM. In a telephone interview on 12/18/18 at 04:48 PM, CNA Tt reported on 10/27/18, she and CNA BB were sitting at the nurses' station. CNA Tt reported R164 said something to CNA BB, but she was not sure what because CNA Tt was on the computer. CNA Tt reported CNA BB' said yup head down that way, that's where your room is. CNA Tt reported R164 headed down that way and fell out of her wheelchair. CNA Tt reported she did not witness the fall. In an interview on 12/14/18 at 11:26 AM, Licensed Practical Nurse (LPN)/Restorative Supervisor OO reported the standard of care at the facility was to toilet residents before and after meals and as needed and stated everyone here should be toileted before and after meals. When asked what the toilet more frequently intervention on R164's care plan meant, LPN/Restorative Supervisor OO stated standard is before and after meals and PRN. If we do more frequently, those are for the residents who use the bathroom more often so each time the staff is with them, they should be asking about toileting. Any time a staff member interacts with that resident. On 12/18/18 at 2:48 PM, LPN/Restorative Supervisor OO reported before and after meals toileting is an every two hour toileting timeframe. LPN/Restorative Supervisor OO reported she was not aware R164 asked to use the bathroom and was told to head down the hallway on 10/37/18. In an interview on 12/18/18 at 03:01 PM, Assistant Director of Nursing (ADON) Gg and ADON In Training FF reported the facility concluded R164 fell because of the change in flooring and the friction in the carpet. When asked what more frequent toileting meant, ADON FF stated more frequently than just before and after meals, more frequently than every two hours, check in on them when walking down the hallway. ADON FF reported R164 must have said she needed to use the restroom because she was at the nurses' station propelling to her room to go to the bathroom. ADON Gg reported it was not okay for staff to tell R164 to head down the hallway to the bathroom. On 12/18/18 at 03:15 PM, facility surveillance footage was reviewed with Director of Operations (DOO) X and the following was revealed: On 10/27/18 at 9:15 AM, RN D transported R164 from the dining room table and set R164 in front of the television on North Unit. There were multiple staff walking by R164 and in and out of the dining room. At 9:39 AM, R164 began looking around and at 9:40 AM, R164 backed up her wheelchair and looked around. At 9:41:30, another staff member walked by R164. At 9:41:42 R164 began self propelling her wheelchair (with footrests in place, even though care planned to not have in place unless transporting). At 9:42:50 R164 was visible from another camera angle, approaching the front of the North Unit nurses' station. Staff was visible behind the nurses' station. R164 was observed grabbing along the ledge of the nurses' station an looking around. At 9:44 AM, R164 propelled her wheelchair to the green and red hall side of the North Unit nurses' station, where she stopped in front of staff, and appeared to talk to the two staff members sitting at the nurses' station. R164 then propelled to the handrail along the wall between red and green hall, sat for a moment, then began propelling along the handrail, past a wet floor sign, and down green hallway. R164 was then out of camera sight. The two staff members at the nurses' station stood up and walked green hall. DOO X identified the staff members at the nurses' station as CNA BB and CNA Tt. ADON In Training FF reported CNA Uu was assigned to care for R164 on 10/27/18. On 12/18/18 at 03:45 PM, the surveyor was unsuccessful at contacting CNA Uu via telephone. The surveyor left a voicemail requesting a return call, which was not received prior the survey exit. Review of the Radiology Report dated 10/27/18, revealed R164 sustained a scapula fracture. Review of the Progress Notes dated 10/27/18 at 11:30 PM, revealed .Resident has a fracture involving upper lateral scapula (left) .Resident c/o (complained) of pain and scheduled [MEDICATION NAME] (narcotic pain medication) was given). The Progress Notes dated 10/28/18 at 8:17 AM, revealed This morning Res. c/o (resident complained of) pain so tylenol 650 mg was given as ordered . The Progress Note dated 10/39/18 at 4:23 PM, revealed Resident c/o left shoulder pain during lunch hour. Scheduled pain medication given .NP (Nurse Practioner) visited and is aware of resident's fracture to scapula on left shoulder. New order; NP scheduled [MEDICATION NAME] 5-355 mg to Q6H (every 6 hours) for 1 week & also referred resident to an orthopedic surgeon.

Based on observation, interview, and record review, the facility failed to prevent the occurrence, reoccurrence, and worsening of a pressure ulcer for 1 of 6 reviewed for pressure injuries/ulcers (Resident #2), from a total of 30 sampled residents, resulting in pain and physical decline. Findings include: According to the MDS/Minimum Data Set, dated dated [DATE], Resident #2 was an [AGE] year old with severe cognitive impairment who was admitted to the facility on [DATE], weighed 203 pounds, had impairment movement on both upper and lower extremities on one side of her body, needed extensive assistance with bed mobility, had a urinary catheter, was incontinent of bowels, and had [DIAGNOSES REDACTED]. On 8/28/17 at 1:00 PM, Resident #2 was observed laying in bed at an approximate 75 degree angle with her eyes closed, and gurgling noises were audible. A blue wedge was behind Resident #2's right side, but her torso and buttocks were flat on the bed. A tube feeding was running, and Daughter/guardian #1 WW and Daughter #2 XX were sitting in chairs near the end of the bed. Daughter #1 WW reported Resident #2 had sore on her butt and said, it's less than 1 inch, never been any larger, and healing .she's getting an air mattress today. (1 inch = 2.54 cm) According to Resident #2's Braden Scale for Predicting Pressure Sore Risk, dated 4/06/17, Resident #2 was at High Risk for developing pressure ulcers. Review of Resident #2's Care Plans her plan of care for relating to being at risk of pressure ulcers was not initiated until 4/14/17. According to Resident #2's Skin Condition Reports, dated 4/17/17 at 11:47 AM (10 days after she was admitted to the facility), New (1st recording) .Present on the Coccyx is a Pressure Ulcer. The following findings were documented. Staging. Stage 2, Length in cm - 0.5, Width in cm - 1.0. Skin is not blanchable, no odor is apparent, no drainage is apparent. This wound was not present on admission. Wound base is visible, Pink wound base = 100%, surrounding tissue is reddened . According to a document entitled Unavoidable Pressure Ulcer Evaluation, date/signed 4/17/17, UM V documented, .pressure ulcer was unavoidable. In an interview, on 8/30/17 at 8:22 AM, UM V was asked if the information she documented on the Unavoidable Pressure Ulcer Evaluation proved the pressure ulcer was unavoidable, UM V said, No. When asked if the facility had a form for Avoidable Pressure Ulcer Evaluation, UM V said, No. When interviewed why she documented that the pressure ulcer was unavoidable, she said, I don't know .(Resident #2) couldn't move at all. (Resident #2) is totally dependent on staff, that's why (the pressure ulcer) was unavoidable. Resident #2's Skin Condition Report, dated 4/27/17 at 11:31 AM, revealed Coccyx .Skin site is healed . According to an untitled document, dated 5/03/17, (2 weeks later) Re: THREE DAY SUSPENSION - VIOLATION OF FACILITY WORK RULE #1 - CONTINUED OR GROSS NEGLECT OF DUTY. (CNA T) .on April 16, 2017 you had (Resident #2) in the chair for more than 8 hours even though the resident was paralyzed completely on the right side. Another aide assisted you to get the resident in a Wheelchair at 8 am on 4/16/17 and another aide helped you put her to bed at 5 pm that day (9 hours). (Resident #2's) catheter was full of urine so that it exploded all over including (Resident #2). On 4/17/17 (Resident #2) had a stage 2 pressure ulcer. This pressure ulcer was directly related to the lack of pressure relief on 4/16/17 .You will serve the three day suspension on .May 04, 2017 .May 8, 2017, and .May 9, 2017. Your return to work day is May 11, 2017 . Stapled to the back of the THREE DAY SUSPENSION notice was document entitled (Facility) CONCERNS, dated/signed by UM/Unit Manager V on 4/19/17. The document revealed: (LPN/Licensed Practical Nurse O) reported to (UMV) that she had asked (CNA/Nurse Aide T) to lay (Resident #2) down at 12 N (noon), and again at 1 pm .(LPN O) also reported to (UM V) that (CNA T) told her that (Resident #2) said she was not ready, so she repositioned her. (LPN O) reported that at 4:30 PM (Resident #2's daughter/name not documented) came to her and said she would like her mother laid down because she has been up a long time .(Resident #2) up in w/c (wheelchair) for 8 hours (actually 9+ hours - see below) .(Resident #2's daughter/name not documented) insisted and (Resident #2) was laid down after dinner after 5 pm. Resident #2's Skin Condition Report, dated 7/07/17 at 10:53 AM, revealed, New (2nd recording) for Site .Present on the Coccyx is a Pressure Ulcer 0.5 cm x 2 cm. pink granulation tissue .Wound dressed with silicone bordered dressing. Resident #2's Skin Condition Report, dated 7/10/17 at 2:23 PM, revealed .shearing/friction wound to coccyx .(Resident #2's) bottom gets sore, [MEDICATION NAME] (sic) dressing applied, roho cushion (pressure reduction device) placed for pressure relief in chair. Resident #2's Skin Condition Report, dated 7/17/17, revealed: President on the Coccyx is a Pressure Ulcer. Stage 3, Length in cm = 2.0, Width in cm = 0.5, Depth in cm = 0.5 .Area is non blanchable . On 8/29/17 at 11:40 AM, an observation was made of a dressing change done by Education Coordinator/RN/Registered Nurse N who was assisted by RN O. Resident #2 was observed to have labored breathing, was perspiring, her eyes were closed and she was not responding when spoken to; her bed was at an approximate 50 degree angle during the procedure. After the dressing was removed, a crater like (Stage III) pressure ulcer was observed on Resident #2's coccyx; one area of the wound was beefy red and other areas were covered with slough. According to RN N's measurements, it was 3 cm x 2.5 cm x 0.2 cm. The tissue surrounding the crater, approximately 2 cm around the circumference was dark. A second (Stage II) tissue injury/pressure ulcer beneath the first one measured 0.6 cm x 0.3 cm (depth was surface). After cleansing the ulcer, RN N applied [MEDICATION NAME] ointment to her gloved finger and attempted to smear it into the wound bed, but it did not adhere, (a small amount of the ointment adhered on one side of the skin outside of the wound, but none was visible in the open area). Rather than apply [MEDICATION NAME] directly onto the dressing and then apply it over the wound so it would make contact with the wound, RN N applied the dry dressing to the unmedicated wound. RN N told RN O it was ok for her to leave the room, that she could reposition Resident #2 herself. RN Oleft the room, and RN N took the blue incontinence pad under Resident #2 and gave it a tug to pull Resident #2 closer to the middle of the bed. In an interview, on 8/29/17 at 3:20 PM, WN/Nurse G was interviewed about Resident #2's skin condition and why she acquired a re-opened pressure ulcer on her coccyx on 7/07/17. WN G said he really didn't know why. In an interview, on 8/30/17 at 10:05 AM, CNA P, reported he worked full time, day shift, and had been assigned to Resident #2 ever since she moved from the Rehab Unit to the(NAME)Pond Unit (5/16/17) where she now resided. CNA P said he was the staff member who reported Resident #2 had a pressure ulcer on 7/07/17. CNA P reported Resident #2 did not refuse care, and said, I always made sure she was turned and/or repositioned in her wheelchair every 2 hours. I found the pressure ulcer the day I came back after having 2 days off. When interviewed about how he turned Resident #2 in bed he said he used to turn Resident #2 by himself, until she got sick a couple of days ago. CNA P demonstrated how he used the blue pad to turn Resident #2 by himself. He jerked his clenched hands inward and upward, and said, I would give the blue pad a quick tug. Then, roll her. Now that she's sick, the past couple of days, we use 2 staff to gently lift, then turn with the blue pad. In an interview, on 8/30/17 at 10:05 AM, Education Coordinator RN N reported, The blue pads are incontinence barriers, we use them to lift, not pull; not supposed to pull on them because it can cause shearing. RN N stated it was necessary for 2 staff to reposition Resident #2 with a blue pad, but 2 staff for bed mobility/repositioning was not care planned or on the Kardex/Nurse Aide Care guide because: 1.) she had recently educated staff on the appropriate use of the blue pad for positioning, 2.) Resident #2 was a large woman and could not assist with repositioning, and 3.) it was common knowledge staff were to use the blue pad appropriately. Review of Resident #2's Kardex/Nurse Aide Care Guide, updated 8/28/17, revealed no instruction how many staff were required for bed and/or wheelchair repositioning, or for how long Resident #2 was to be up in her wheelchair. In an interview, on 8/30/17 at 2:30 PM, Registered Dietitian reported Resident #2's nutritional status was adequate and poor nutrition was not a contributing factor in her obtaining pressure ulcers at any time since her admission. Review of all Resident #2's physician progress notes [REDACTED]. Review of the facility Skin Ulcer Protocol, dated 12/15/09, revealed, .Prevention of Pressure Ulcers - Refer to Preventative Skin Care Policy and Braden Scale Policy .Repositioning - Refer to Preventative Skin Care Policy . However, review of the Preventative Skin Care Policy, dated 11/04/15, and Braden Scale Policy, dated 6/03/15 revealed no instructions on the use of Blue Pads and the 3 above policies did not address the assessment of residents' skin tolerance to pressure or whether their skin needed more frequent that every 2 hour turns, or how long her skin could tolerate being in a chair.

This citation has two deficient practice statements: DPS#1 and DPS#2. DPS #1) Based on observation, interview and record review the facility failed to prevent an accident for 1 of 12 residents reviewed for falls (Resident #17) from a total of 30 sampled residents, resulting in Resident #17's fracture of the right lateral malleolus on 3/12/17 while being transported in a wheelchair without foot pedals by facility staff. Findings Include: According to Mosby's Textbook for Long-Term Care Nursing Assistants 7th edition, in the Wheelchair Safety Section, Make sure the person's feet are on the foot plates (wheelchair foot pedals) before moving the chair. The person's feet must not touch or drag on the floor when the chair is moving. Never push a person in a wheelchair without feet resting on the footplates (foot pedals). Review of the facility, Transporting Residents in Wheelchairs policy and procedure, dated 8/31/16, reflected, Objective: To maintain resident's safety while transporting residents in wheelchairs .Without Footrest .3. Ask the resident to lift up his/her feet and with one hand hold the resident's shoulder to maintain control of the resident's upper body, never losing control of the resident's upper body. 4. Proceed slowly, looking over the resident's shoulder to monitor position of feet and hands during movement to ensure proper placement . Review of the facility, Transforming Residents in Wheelchairs policy and procedure, dated 3/29/17, reflected, Objective: To maintain Resident's/Patient's safety while transporting residents/patients in wheelchairs. No Resident/Patient's will be pushed or propelled by staff without footrest on their wheelchairs .Without Footrest 1. Let the Resident/Patient know transportation assistance cannot occur without footrest on the wheelchair . Resident #17 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #17 was a [AGE] year of female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #17's had a BIM (assessment tool) score which indicated her ability to make daily decisions was cognitively intact, and she required two person physical assist with transfers and one person physical assist with dressing, hygiene, bathing and supervision with locomotion one the unit. In an observation and interview during the facility initial tour on 8/28/17 at 9:05 a.m., Registered Nurse (RN) Aa reported Resident #17 was not in the room at that time. RN Aa reported Resident #17 was admitted to the facility as a long term resident related to a history of cerebral vascular accident(CVA) with right side weakness, expressive aphasia and seizure disorder. RN Aa reported Resident #17 used a left hand pump to self propel the wheelchair. RN Aa reported Resident #17 had a history of [REDACTED]. RN Aa reported Resident #17 was not interviewable related to expressive aphasia and reported Resident #17 repeatedly says, BaBaBa. In an observation on 8/28/17 at 12:03 p.m. Resident #17 was noted to be exiting her room in the wheelchair with a right arm rest present and a right padded foot pedal in place. Resident #17 was self propelling wheelchair with her left arm pump on the wheelchair. Review of the, Personal Profile, dated 8/3/17, reflected Resident #17 used a one arm drive wheelchair to self propel with no assistance needed. Review of the facility Incident Report, dated 3/12/17 at 7:50 a.m., reflected Resident #17 was being transferred in a wheelchair, with no foot pedals in place, down the hall by Certified Nurse Assistant (CNA) X when Resident #17's right foot dropped and caught underneath the wheelchair. The report reflected Resident #17 refused to use the foot pedal prior to transfer. The Report reflected Resident #17 indicated she was in pain. The report reflected Resident #17 had a fracture involving the distal fibula. Review of the attached witness statement, dated 3/12/17, completed by CNA X reflected, I was pushing the resident in her wheelchair down the hall when the resident right foot suddenly dropped and the resident foot got caught underneath her chair . Review of the Investigation for Resident #17 on 3/12/17 reflected, Conclusion: (Resident #17) fractured due to dropping her right foot onto the floor while being assisted down the hallway in her wheelchair. There was not abuse or neglect in this case, and the injury is not suspicious. Although the CNA did not have his hand on (Resident #17's) shoulder at all times per policy, this would not have prevented (Resident #17) from propping her foot . Review of the facility Incident Report, dated 7/15/17 at 7:00 p.m., reflected Resident #17 was being transferred in a wheelchair, with no foot pedals in place, by Resident #17's daughter when Resident #17's right foot got caught under the wheelchair. The report indicated the family member verified the incident by phone. The report indicated no injury and a negative x-ray report was included. Review of the Physician Orders, dated 4/23/17, reflected Resident #17 had an order the reflected, R foot cradle on w/c, Special Instructions: for positioning and comfort. Review of Progress Notes, dated 2/15/17 through 3/11/17, reflected no documentation of Resident #17's refusal to use right foot pedal. Review of the ADL Care Plans, dated 2/7/17, reflected Resident #17 had interventions that included, Right foot cradle on wheelchair. The Care Plan indicated no mention of refusal to use right foot cradle/foot pedal. Review of the Psychosocial Care Plan , dated 2/8/17, reflected Resident #17 had no mention of refusal to use ordered right foot pedal. In an interview on 8/30/17 at 10:20 a.m., RN QQ reported Resident #17 had a right elevated foot pedal since admission several years ago. RN QQ reported Resident #17 was compliant with the right elevated foot pedal except on occasion when she was in room and not moving. RN QQ reported Resident #17 had the right foot pedal related to a history of a CVA with right side weakness and no fine motor movements on the right side. RN QQ reported he had worked with Resident for over a year and had no known Resident #17 refuse to use the right foot pedal during transfers. In an interview on 8/30/17 at 10:30 a.m., Certified Nurse Aide (CNA) X reported he had worked for the facility for over a year and was familiar with Resident #17. CNA X reported on 3/12/17 prior to breakfast he assisted Resident #17 from room 248 to the Dining Room in her wheelchair. CNA X reported Resident #17 refused to use the right foot pedal prior to the transfer. CNA X reported Resident #17 was able to rest her weak right foot over the raised left foot during the wheelchair transfer and keep her feet elevated. CNA X reported after passing the nursing station Resident #17's right foot dropped and got caught under the wheelchair. CNA X reported he placed his hand immediately on Resident #17's shoulder to prevent her from falling out of wheelchair and called the nurse to assess the Resident #17. CNA X demonstrated the distance from room 248 to the location when Resident #17's foot got caught under the wheelchair and it appeared to be about the half way point between from room 248 to the Red Dining Room which was about 250 feet. CNA X reported the facility policy and procedure prior to the incident was if the resident could hold their feet up staff could push the wheelchairs without foot pedals. CNA X reported after the 3/12/17 incident the facility policy and procedure changed and staff are now no longer able to transfer residents without foot pedals. CNA X verified his written witness statement from 3/12/17. In an interview on 8/30/17 at 11:14 a.m., Complaint Investigator Social Worker (CISW) HH reported Resident #17 was seen by the orthopedic doctor on 3/20/17, who verified the non displaced fracture of the right lateral malleolus. Unit Manager BB was present at the interview as well who reported she was not involved with that incident related to be on vacation at the time. Restorative Supervisor (RS) EE reported she was involved in the investigation and was familiar with Resident #17. RS EE reported Resident #17 was not able to verbally communicate with staff, however, would refuse to allow staff to put right foot rest on the wheelchair by waving hands and shaking head. RS EE reported often would refuse the right foot pedal prior to the 3/12/17 incident. RS EE reported if Resident #17 refused the staff should document in the progress notes of the electronic medical record. RS EE reported she was unsure if Resident #17's Care Plan reflected the refusal of right foot rest. In a telephone interview on 8/30/17 at 11:47 a.m., Resident #17's family PP reported she did not recall being told by the facility that Resident #17's right ankle fracture was related to the 3/12/17 incident of a staff member transferring Resident #17 in a wheelchair without foot pedals. Resident #17's family PP reported she was under the impression Resident #17 fell from the wheelchair. Resident #17's family PP stated, they have a way of sugar coating things. Resident #17's family PP did verify that while pushing Resident #17's wheelchair, without the right foot pedal on 7/15/17, Resident #17's right foot got caught under the wheelchair. In an interview on 8/30/17 at 1:10 p.m., Therapy Director OO reported it was his expectation that staff should never push a resident in a wheelchair without foot pedals in place. In a second interview on 8/30/17 at 1:25 p.m. RS EE reported she was unable to locate documentation of Resident #17's refusal to use foot pedals during transfers. RS EE reported she had worked with the facility for [AGE] years. In an interview on 8/30/17 at 3:10 p.m., Assistant Director of Nursing (ADON) TT reported the she was unable to locate any documented refusal of foot pedals for Resident #17 prior to 3/12/17 in the medical record. ADON TT reported the facility did a past non compliance. In an interview on 8/30/17 at 3:20 a.m. Director of Nursing (DON) B reported after Resident #17's incident on 3/12/17, that resulted in Resident #17's right ankle fracture after a staff member was pushing Resident #17's wheelchair without foot pedals, the facility policy and procedure had changed to include staff are no longer able to transport residents in wheelchairs without foot pedals in place. DON B reported the facility completed a past non-compliance on 3/24/17, after Resident #17's orthopedic physician confirmed non-displaced fracture of the right lateral malleolus. DPS #2) Based on observation, interview and record review the facility failed to monitor 1 of 12 residents reviewed for falls (Resident #4) from a total of 30 sampled residents for compliance of alarm device usage, provide rounds and/or Activity of Daily Living (ADL) assistance, failed to follow the plan of care and failed to maintain a functioning call light device, resulting in the disconnection of alarm devices a total of 5 times from 5/6/17 to 7/30/17, delay in response for ADL, and falls with and without injuries. Findings Include: Resident #4 According to the Electronic Medical Record (EMR) Resident (R) #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Significant Change Minimum Data Set (resident assessment tool) completed on 6/9/17 R4 had a Brief Interview for Mental Status score of 5 out of 15 (0-7: severely cognitively impaired), required extensive assistance of 2 persons for transfers, ambulating in room and toileting. During the initial tour on 8/28/17 at around 9:20 AM with Unit Manager Registered Nurse (RN L), R4 was observed to not be in his room. A foot cradle was noted at the foot of his bed, bilateral padded grab bars were noted on his bed, 4 floor strips were noted on the right/left side of his bed, a front wheeled walker was noted next to his bed, a soft touch call light was noted on top of his bed, and 4 floor strips were noted in front of a recliner chair with a dycem (anti-slip device) pad in the seat. RN L revealed that R4 had recently had a fall with a fracture, had a history of [REDACTED]. On 8/29/17 R4 was observed in TV area in the large dining room at around 10:00 AM sitting up in his wheelchair with his eyes closed. A tab alarm was observed to be attached to the back of his pullover sweater, he had glasses on, was cleanly dressed/groomed, skin protectant sleeves were observed under his pullover sweater, and he shoes and gripper socks on. On 8/29/16 at around 4:06 PM R4 was interviewed in his room. R4 was asked if he had ever fallen, and replied yes. When asked when was the last time he had fallen R4 replied, I fell next to the bed on the floor. It's been more than once of course. R4 was asked what was he was trying to do when he had fallen. He replied, I don't always know, I don't know why I fell . Maybe carelessness. The last fall was on the arm, and yes it hurt. R4's skin was observed to be thin, skin protectant sleeves were noted under his long sleeve shirt, his bed had padded side rails, a foot cradle, a perimeter mattress, his wheelchair had a padded seat cushion with a dycem pad on top of it, 4 floor strips were observed in front of his recliner, a cushioned floor mat folded against wall on the right side of bed (where he was located), a mat was observed on the left side of the bed on the floor, and a stop sign device was noted at the entry door. Requested incidents related to falls, reflected R4 had total of 16 falls from 3/28/17 to 8/13/17 some with and without injuries. Fall #1) occurred on 3/28/17 at 1:15 AM. R4 was found on the floor with no injury. R4 revealed he was trying to go the bathroom. The call light was in reach but not functioning. The time R4 was last toiled was not listed on the form. In the morning of 8/30/17 at around 8:15 AM, the Director Of Nursing (DON) had provided documentation requested on 8/29/17, that reflected the last time R4 was toileted was around 12:00 AM, according to rounds policy. Yet, the facility's ROUNDS policy effective 6/3/15 reflected CNA's/Rehab Specialist will complete rounds throughout the shift with last rounds at 2 p.m., 10 p.m., and 4 a.m. The policy did not reflect rounds occurred at 12 a.m. In addition, the call light had a faulty wire and had to be replaced. Fall #3) occurred on 5/6/17 at 9:00 PM. R4 was found on the floor, with a skin tear injury to his lower forearm. It was determined R4 Chair Sensor Alarm had been removed from the chair, and that R4 frequently turned off his chair sensor and moved it. Fall #7) occurred on 6/21/17 at 8:30 PM R4 was found on the floor with no injury. Certified Nursing Assistant (CNA VV) reported the Bed Sensor Alarm was not sounding when he entered the room. It was determined that R4 turned the alarm off. Fall #8) occurred on 6/22/17 at 7:00 PM R4 was found on floor, with an abrasion to his left scapula. It was determined the alarm was not sounding, and that the Bed Sensor Alarm had been turned off by R4 for the second time. Fall #11) occurred on 7/1/17 at 1:00 AM R4 was found on floor with no injury. The Bed Sensor Alarm cord had been pulled out. The bed alarm was not sounding. It was determined R4 disengaged the device, and that R4 had a history of [REDACTED]. R4 stated he moved out of bed because he was uncomfortable, his gown twisted and he fell . The plan was to place the bed sensor on R4's bed side table hidden out of reach, leave door open at all times, and that they will place pajamas rather than a gown on R4. Fall #13) occurred on 7/30/17 at 4:20 AM R4 was found on floor with no injury. The report reflected R4 had been taking his gown and body alarm on and off all night, stated that he was hot, and his alarm was not sounding. The Falls Care Plan with a review date of 6/22/17 reflected on 6/22/17 the intervention: 1:1 education with safety alarms. Yet, according the comprehensive MDS April 2017 and the significant change MDS June 2017, R4 was considered to be severely cognitively impaired. The Falls Care Plan with a review date of 8/13/17 reflected on 7/1/17 the intervention: Place in pajamas no gowns, and on 8/13/17 to monitor frequently at night and offer assistance if awake.

THIS CITATION PERTAINS TO INTAKE NUMBER MI 877. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT FALLS IN 1 OF 4 SAMPLED RESIDENTS (#101), IN A TOTAL OF 4 SAMPLED RESIDENTS, RESULTING IN RESIDENT #101 EXPERIENCING A LEFT HIP FRACTURE, hospitalization , AND SURGICAL INTERVENTION (PLACEMENT OF A FIXATION DEVICE). FINDINGS INCLUDE: REVIEW OF THE FACE SHEET REVEALED RESIDENT #101 WAS A [AGE] year OLD WOMAN WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED RESIDENT #101 WAS MODERATELY COGNITIVELY IMPAIRED, AND REQUIRED MINIMAL TO MODERATE ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL'S). REVIEW OF THE FALL RISK ASSESSMENTS COMPLETED ON ADMISSION TO THE FACILITY (4/13/2011), AND ON 1/9/2012, IDENTIFIED RESIDENT #101 AT HIGH RISK FOR FALLS. THE FALLS CARE PLAN INITIATED 5/9/2011, AND REVISED 6/15/2011, SPECIFIED RESIDENT #101 WAS TO WEAR PROPER FOOTWEAR, IDENTIFIED AS "GRIPPER SOCKS FOR THOSE WHO DO NOT WEAR SHOES AND/OR AT HS (BEDTIME)" AND USE OF A BED SENSOR WHILE IN BED. THE RESIDENT DATA SHEET (UTILIZED BY NURSE AIDES TO PROVIDE CARE) SPECIFIED RESIDENT #101 WAS TO WEAR GRIPPER SOCKS, AND TO USE A BED SENSOR WHILE IN BED. ACCORDING TO THE FACILITY INCIDENT REPORT DATED 2/6/2012, AND THE FACILITY INVESTIGATION REPORT DATED 2/9/2012, RESIDENT #101 WAS OBSERVED BY A NURSE ON THE FLOOR OF HER ROOM ON 2/5/2012 AT 3:40 P.M. THE NURSE REPORTED RESIDENT #101 WORE SLIPPERS WITHOUT GRIPPER BOTTOMS, AND THAT A FUNCTIONING BED SENSOR WAS PRESENT, BUT NOT ALARMING AS SHE OBSERVED RESIDENT #101 ON THE FLOOR. RESIDENT #101 WAS REPORTED TO HAVE RECEIVED X-RAYS, AS ORDERED BY HER PHYSICIAN, WHICH REVEALED PRESENCE OF A LEFT HIP FRACTURE. RESIDENT #101 WAS SENT TO A LOCAL HOSPITAL FOR EVALUATION. THE OPERATIVE REPORT FROM THE HOSPITAL DATED 2/8/2012 AT 8:09 P.M., REVEALED RESIDENT #101 UNDERWENT SURGICAL PLACEMENT OF A FIXATION DEVICE, ON 2/8/2012, TO REPAIR HER LEFT HIP FRACTURE. DURING AN INTERVIEW ON 2/27/2012 AT 2:15 P.M., RESIDENT #101 SAID, "I fell . I WENT TO GET SOMETHING. I BROKE MY LEFT LEG. THEY SENT ME TO ANOTHER PLACE TO TREAT ME, THEN I CAME BACK HERE. I DON'T REMEMBER TOO MUCH. I'M [AGE] years OLD, AND MY MINDS NOT TOO HOT." DURING THE INTERVIEW, RESIDENT #101 WAS OBSERVED RESTING IN HER BED, WHICH WAS IN THE LOW POSITION. SHE WAS LYING ON A PERIMETER MATTRESS (MATTRESS WITH RAISED EDGES), AND A FUNCTIONING PAD SENSOR ALARM WAS OBSERVED BENEATH THE AREA OF HER HIPS. DURING AN INTERVIEW ON 2/27/2012 AT 2:45 P.M., CERTIFIED NURSE AIDE (CNA) #3 SAID SHE HAD BEEN ASSIGNED TO RESIDENT #101 ON 2/5/2012 ON THE SECOND SHIFT (IDENTIFIED AS 2:30 P.M. TO 11:00 P.M.). THE CNA SAID THAT PRIOR TO RESIDENT #101'S FALL AT 3:40 P.M., SHE HAD BEEN ALERTED TO ROOM BY HER BED ALARM SOUNDING 15 MINUTES EARLIER, AS RESIDENT #101 SELF TRANSFERRED FROM HER BED TO THE STANDING POSITION. THE CNA SAID SHE PLACED RESIDENT #101 BACK IN HER BED, IN THE SITTING POSITION, AT THE FOOT OF BED. THE CNA SAID THE PAD SENSOR FOR THE BED WAS POSITIONED AT THE HEAD OF THE BED; THE UPPER THIRD OF THE BED. "I SAT THE RESIDENT AT THE FOOT OF THE BED, AND THE ALARM SENSOR WAS AT THE HEAD OF THE BED, SO SHE WASN'T SEATED ON THE ALARM. I EXPLAINED TO THE RESIDENT I WOULD CHECK WITH A NURSE TO FIND OUT HER QUARANTINE STATUS (RESIDENT #101 HAD BEEN QUARANTINED TO HER ROOM DUE TO FLU-LIKE SYMPTOMS). I LEFT THE ROOM TO FIND THE NURSE. THE NURSE FOUND THE RESIDENT ON THE FLOOR ABOUT 15 MINUTES AFTER I LEFT THE RESIDENT. " DURING AN INTERVIEW ON 2/28/2012 AT 10:25 A.M., LICENSED PRACTICAL NURSE (LPN) #8 SAID, "ON COMPLETION OF SHIFT TO SHIFT REPORT, I WENT TO RESIDENT #101'S ROOM FIRST. I SAW HER ON THE FLOOR IN HER ROOM FROM THE DOORWAY. THERE WERE NO ALARMS SOUNDING. SHE WAS AT THE FOOT OF THE BED, ON THE FLOOR, SITTING UPRIGHT. SHE DIDN'T HAVE GRIPPER SOCKS, OR RUBBER SOLED SHOES, ON; JUST SLIPPERS THAT WERE NON-GRIPPER. THE RESIDENT DID HAVE A FUNCTIONING BED SENSOR ON HER BED, BUT IT WAS AT THE UPPER THIRD OF THE BED. I CHECKED THIS SENSOR AFTER I ASSESSED THE RESIDENT AND BEFORE I PUT HER BACK IN BED. THE BATTERY AND EVERYTHING WAS WORKING." DURING AN INTERVIEW ON 2/27/2012 AT 3:05 P.M., PHYSICAL THERAPIST (PT) #4 SAID, " SHE (RESIDENT #101) WAS AT RISK FOR FALLS; SHE had a history of [REDACTED]. THIS RESIDENT SHOULD'VE BEEN SEATED ON HER BED SENSOR ALARM 'CAUSE FOR HER TO STAND AND WALK WAS UNSAFE FOR HER. SHE SHOULDN'T HAVE BEEN LEFT UNATTENDED AT THE FOOT OF THE BED, IT WAS UNSAFE." DURING AN INTERVIEW ON 2/28/2012 AT 11:10 A.M., THE DIRECTOR OF NURSING #1 SAID A RESIDENT HAD TO BE SITTING ON THE BED SENSOR ALARM, OR THE ALARM WOULD NOT ACTIVATE. DURING AN INTERVIEW ON 2/28/2012 AT 2:15 P.M., THE ADMINISTRATOR SAID HE EXPECTED FACILITY STAFF TO MEET THE NEEDS, BASED ON ASSESSMENTS OF RESIDENTS, TO MAINTAIN SAFETY.