Every finding on record at Iron River Care Center

This deficiency pertains to Complaint 2724132All times are in Eastern Daylight Time (EDT) unless otherwise notedBased on observation, interview, and record review, the facility failed to provide physician ordered treatment and physician ordered pain medication for one Resident #1 (R1) of three residents reviewed for pain, resulting in prolonged pain not adequately relieved by medications and a decline in urinary continence.Findings include:Resident #1 (R1)Review of the Incident report titled Fall with Injury dated 1/5/26 at 3:00 a.m., read in part .Resident.announced to staff at the nurse's station, Help I've fallen. This nurse and CNA immediately went to resident's room. Resident was now on her bed, resting on her bent legs, head down, back showing. On the resident's middle/lower back is a large hematoma [a localized collection of clotted or partially clotted blood that pools outside of blood vessels, typically within tissue, an organ, or a body space. Often caused by trauma] /abrasion one inch in height and three inches in length with areas of skin missing, slightly bleeding.resident stated a pain [level] of 6 on a 0-10 scale.During a phone interview on 2/2/26 at 12:35 p.m., Family Member (FM) B reported, The facility called me to tell me that my mom fell on 1/5/26.A couple days later my mom called me and told me that she was in excruciating pain because she fell and hurt her back.she sent me a picture of her back and I could see a huge bump on her lower back.I called the facility because I was concerned and they told me they did not send her to the hospital.they didn't even do an x-ray until many days later.I am worried about my mom because she tells me all she did was lay in bed after the fall.During an interview and observation on 2/2/26 at 3:11 p.m., when queried about the fall, R1 reported I was standing near the bed and I don't know what happened, suddenly my legs gave out and my back hit the frame of the bed.the pain was unbearable, it hurt so bad I could barely stand it.For the next few days all I did was stay in bed, I didn't even get up to use the bathroom and wet myself in the bed.I was to afraid to get up.I didn't want to hurt myself again.I have been on pain medication for quite some time and I have a high pain tolerance, but the pain medication didn't touch the pain I had. I did tell the staff but they didn't talk to me about my pain.I just want to be comfortable and enjoy my life instead of just lying in bed which is what I did.I have cancer and I want more than just to lie here.I am so depressed, I have nothing to look forward to.please come here and look at my back (resident pulled up the back of her shirt and a large raised area was noted on her lower back) it isn't as bad as it used to be, it finally went down a little when they put the heating pad on it, but it still hurts.A review of R1's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 2/4/25 with active diagnoses that included: cancer, Chronic Obstructive Pulmonary Disease (COPD) [a lung disease that causes airflow obstruction, making it hard to breathe], and anxiety disorder. R1 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of intact cognition. Section J of the MDS revealed R1 had frequent pain the last five days often making it difficult to sleep at night and limited participation in rehabilitation along limited day to day activity.Review of R1's face sheet revealed an admission diagnosis of chronic pain syndrome [a condition where pain lasts for months or years after an injury or illness has healed, causing physical, mental and emotional symptoms that interfere with daily life].During an interview on 2/3/26 at 9:50 a.m., Registered Nurse (RN) C reported R1 did complain of pain after her fall.her pain medication was not increased.we did not start the warm compresses until a week or so later.During an interview on 2/3/26 at 10:03 a.m., Certified Nurse Aide (CNA) D reported After the fall she did complain of pain, and I told whatever nurse was working.R1 was concerned about the hematoma on her back and how bad it looked.she did not get out of bed due to the pain and she was incontinent for a couple of days.she just wouldn't get up because her back hurt.Review of physician progress note dated 1/5/26 revealed Resident.had a fall earlier today against her bed that left a large hematoma on her lower back that is very tender.contusion to lower back.can use ice to area for next two days then heat. If pain uncontrolled may need to increase oxycodone (a strong opioid pain medication).Review of progress note dated 1/5/26 at 9:17 a.m., revealed Pain assessment interview should be conducted. Resident has had pain or hurting at sometime during the last 5 days.over the past five days how much of the time has pain mad e it hard for you to sleep at night: frequently.pain intensity 8. Please rate the intensity of your worst pain over the last five days: very severe, horrible.Review of document titled NSG [Nursing]: Skin Evaluation dated 1/7/26 read in part, .[R1] Had a fall with back bruise this past week. with no interventionsReview of progress note dated 1/9/26 at 8:57 a.m., read in part, .pain assessment interview should be conducted. Resident had pain or hurting at some time during the last 5 days. How much of the time have you experienced pain or hurting over the last 5 days: Frequently. Over the past five days, the time has pain made it hard for you to sleep at night: Frequently. Over the past five days how often have you limited your participation in rehabilitation therapy sessions due to pain: Frequently. Over the past five days how often have you limited you day to day activities.because of pain: Frequently. Pain intensity :5 .Pain note: resident had a fall that resulted in a hematoma to the lower back.:Review of document titled NSG [Nursing] Skin Evaluation Effective date 1/14/26, read in part Bruising to lower middle back with hematoma.no interventions.signed 1/18/26.Review of document titled NSG [Nursing]: Skin Evaluation dated 1/18/26, read in part .Resident bruising to mid back and swelling noted.Review of Physician progress note dated 1/14/26 read in part, .resident being seen for routine 30-day regulatory review. C/o [complained of] pain at site of hematoma on back. C/o dysuria [difficulty urinating], C/o new urinary incontinence.recent fall with large hematoma on back.chronic pain syndrome.may be related to back hematoma. low back pain.large tender hematoma midline low back.warm compresses several times daily.Review of medication administration record (MAR) dated January 2026, read in part .Hot compresses to hematoma to lower back at least 3 times daily.order date 1/14/26. scheduled for 8:00am, 3:00pm, and 8:00pm. Hot compresses were not administered to R1 on the following dates with no indication why the hot compresses were not administered:1/16/26 at 3:00 p.m.1/20/26 at 8:00 a.m. and 3:00 p.m.1/24/26 at 3:00 p.m.1/25/26 at 3:00 p.m.1/27/26 at 3:00 p.m.Review of the MAR dated January 2026 read in part, Oxycodone. Oral tablet 7.5-300mg (milligrams).give 1 tablet by mouth four times a day for chronic pain 1/2/26 d/c (discontinued) date 1/20/26.scheduled for administration of medication at 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. The medication was not administered to R1 on the following dates and times with no indication why the pain medication was not administered:1/12/26 at 8:00 a.m., 12:00 p.m., 4:00 p.m.1/13/26 at 12:00 p.m. and 4:00 p.m.1/15/26 at 4:00 p.m.1/16/26 at 4:00 p.m.Review of the MAR dated January 2026 read in part, .Oxycodone 10 mg. Give 1 tablet by mouth four times a day for trochanter (thighbone) pain for 14 days. Order date 1/20/26.scheduled for administration at 8:00 a.m. 12:00 p.m. 4:00 p.m. and 8:00 p.m. The medication was not administered to the resident with no rationale why the medication was not administered:1/22/26 at 4:00 p.m.1/24/26 at 4:00 p.m.1/25/26 at 4:00 p.m.During an interview on 2/3/26 at 11:47 a.m., Assistant Director of Nursing (ADON) A acknowledged there was no indication why the hot/warm compresses were not administered on 1/27/26 at 4:00 p.m. and why pain medication was not administered as ordered by the physician. ADON A reported the licensed staff are expected to indicate on the MAR why the medication or treatments are not administered.Review of (MAR) January 2026 read in part, .Doctors order dated 1/14/26 for a lumbar spine x-ray.x-ray was completed on 1/16/26.Review of x-ray report dated 1/16/26 read in part, Clinical history: post fall pain.findings: compression fracture upper end plate of L1 vertebra [a collapse or break in the first lumbar vertebra often causing it to become wedge-shaped. Located at the junction of the mid-back and low-back.affected by.trauma leading to severe localized pain].Review of Pain Level Assessments dated December 2025 revealed R1 had an increase in intensity and frequency of pain since the fall despite R1 having chronic pain.During an interview on 2/3/26 at 11:00 a.m., the Director of Nursing (DON) acknowledged there was a delay in treatment and was not sure if the physician was notified of R1's increased pain. The DON reported I don't know why there were no non-pharmacological interventions such as cold or hot/warm compresses started prior to 1/14/26, cold and hot/warm compresses are considered a standard of care, there was no x-rays ordered, and the pain medication for R1 was not increased until 1/20/26.During an interview on 2/3/26 at 12:30 p.m., the DON reported There was an increase in the resident's pain, but it was not communicated to the physician.R1 complained of pain often and we were busy at that time because other people were sick.During a phone interview on 2/3/26 at 12:39 p.m., the Physician E reported, I assessed R1 the day of the fall and the bruise was very tender.R1 howled in pain when I lightly touched her lower back that day.the staff did not communicate with me regarding R1 having more pain.I was unaware until my follow up visit on the 14th. During a follow-up phone call the Physician E acknowledged that a normal standard of care would have been for the licensed staff to utilize ice packs for the first 48 hours and then use hot/warm compresses on a hematoma to reduce the swelling.Review of policy titled Pain Management date reviewed/revised 8/2/24, read in part .The facility must ensure that pain management is provided to resident who require such services consistent with professional stands of practice.the facility will recognize when the resident is experiencing pain.evaluate the resident for pain.manage or prevent pain, consistent with the comprehensive assessment .the interventions for pain management will be incorporated in to the components of the comprehensive care plan.non-pharmacological interventions will include.cold compress.facility staff will notify the practitioner if the residents pain is not controlled by the current treatment regimen.if re-assessment findings indicate pain is not adequately controlled the pain management regimen .will be revised.

This deficiency pertains to Complaint 2724132All times are in Eastern Daylight Time (EDT) unless otherwise notedBased on interview and record review, the facility failed to ensure care plans were reviewed and revised for one Resident #1 (R1) of three residents reviewed for care plan timing and revision, resulting in the potential for unmet resident care needs.Findings include:Resident #1 (R1)A review of R1's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 2/4/25 with active diagnoses that included: cancer, Chronic Obstructive Pulmonary Disease (COPD) [a lung disease that causes airflow obstruction, making it hard to breathe], and anxiety disorder. R1 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of intact cognition.Review of Incident report titled Fall with Injury dated 1/5/26 at 3:00 a.m., read in part .Resident.announced to staff at the nurse's station, Help I've fallen. This nurse and CNA immediately went to resident's room. Resident was now on her bed, resting on her bent legs, head down, back showing. On the resident's middle/lower back is a large hematoma [a localized collection of clotted or partially clotted blood that pools outside of blood vessels, typically within tissue, an organ, or a body space. Often caused by trauma] /abrasion one inch in height and three inches in length with areas of skin missing, slightly bleeding.resident stated a pain [level] of 6 on a 0-10 scale.Review of x-ray report dated 1/16/26 read in part, Clinical history: post fall pain.findings: compression fracture upper end plate of L1 vertebra [a collapse or break in the first lumbar vertebra often causing it to become wedge-shaped. Located at the junction of the mid-back and low-back . affected by . trauma leading to severe localized pain].Review of R1's care plan was not updated to address pain post incident or interventions for warm compresses. Review of policy titled Comprehensive Care Plans last reviewed 6/11/25, read in part . The comprehensive care plan will be reviewed and revised by the interdisciplinary team . care plan will be updated throughout the year as needed with any changes in the resident's plan of care .During an interview on 2/3/26 at 12:30 p.m., the DON reported no interventions were added to R1's care plan regarding non-pharmacological interventions for pain, assessing the pain from the fracture, or the warm compresses.that was a mistake, the care plan should have been updated.Review of policy titled Pain Management date reviewed/revised 8/2/24, read in part . The facility must ensure that pain management is provided to resident who require such services consistent with professional stands of practice, the comprehensive person centered care plan and the residents goals and preferences . the facility will recognize when the resident is experiencing pain . evaluate the resident for pain . manage or prevent pain, consistent with the comprehensive assessment and plan of care.the interventions for pain management will be incorporated in to the components of the comprehensive care plan . non-pharmacological interventions will include . cold compress . facility staff will notify the practitioner if the residents pain is not controlled by the current treatment regimen . if re-assessment findings indicate pain is not adequately controlled the pain management regiment and plan of care will be revised .

All times are in Eastern Daylight Time (EDT) unless otherwise noted.Based on observation, interview, and record review, the facility failed to implement an infection prevention and control program in accordance with facility policies to prevent the potential transmission of communicable diseases and infections resulting in the potential for the transmission of pathogens and the spread of infectious organisms to all 55 residents in the facility. Findings include:During medication administration on 8/13/25 at 12:56 PM, Registered Nurse (RN) E removed medications from blister packs (medication packages that organize and secure individual doses of medication within a sealed plastic and foil compartment) by pushing the medications from the blister pack directly into her ungloved hand before placing the medications into a medication cup or pill-crushing sleeve. RN E separated the plastic drinking cups by placing her ungloved fingers along the rim of the cups where residents drink.On 8/14/25 at 2:10 PM, RN E was observed at the cart containing back-up supplies of controlled substances. RN E dispensed a controlled substance from a blister pack directly into her unwashed, ungloved hand. When asked about placing medications into her hand, RN E said, I don't know why I do that. RN E confirmed a medication cup should be utilized instead of dispensing medications into her hand. Housekeeper (HKP) F was observed removing the soiled waste from the refuse receptacles on two medication carts on 8/13/25 at 12:50 PM. HKP F placed the full bags of dirty waste on the floor while placing new waste liners in the refuse receptacles.On 8/14/25 at 10:04 AM, RN G was observed completing dressing changes on the left distal medial foot and right gluteal cleft of Resident #9 (R9). RN G donned gloves before starting the dressing change procedure on R9's left foot. RN G removed the soiled dressing from the wound, cleansed the wound, and applied a treatment and dressing without performing hand hygiene or glove changes during the dressing change procedure and after touching the soiled dressing. After completing the dressing to R9's left foot, RN G performed hand hygiene and changed gloves before removing the dressing from R9's right gluteal. RN G disposed of the soiled dressing and completed cleansing, treatment, and dressing of the wound. RN G did not perform hand hygiene or change gloves during the procedure after touching the soiled dressing. The Director of Nursing (DON) was interviewed on 8/14/25 at 4:05 PM. When queried regarding dispensing of medications, the DON said a medication cup should be utilized to dispense medications from blister packs. When asked about the process for changing refuse from waste receptacles, the DON said the refuse bags were expected to be directly disposed of in refuse bins, containers in the soiled utility room, or taken to the main disposal container outside the building. The DON agreed refuse should never be placed directly onto the floor.The policy Medication Administration dated as reviewed/revised 7/24/25 read, in part: . Medications are administered.in accordance with professional standards of practice, in a manner to prevent contamination or infection.Remove medication from source, taking care not to touch medication with bare hand .The policy Clean Dressing Change dated as reviewed/revised 3/17/25 read, in part: . It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination.remove the existing dressing. Remove gloves.Wash hands and put on clean gloves.The policy Infection Prevention and Control Program dated as reviewed/revised 7/5/25 read, in part: . This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .

All times are in Eastern Daylight Time (EDT) unless otherwise noted.Based on interview and record review, the facility failed to ensure quarterly meetings of the Quality Assessment and Assurance (QAA) Committee were attended by the required members. Findings include:On 8/14/25 at 3:12 PM, the Social Services Coordinator (SSC) confirmed she was the designated coordinator of the facility's Quality Assurance Performance Improvement (QAPI) program. The SSC said committee meetings for QAA were held quarterly.The QAA meeting signature sheets were reviewed with the SSC. The signature sheets revealed QAA meetings were held on 10/16/24, 1/16/25, 4/30/25, and 7/30/25.The signature sheet for 4/30/25 and 7/30/25 did not contain the signature of the Administrator (NHA). The SSC was asked if the NHA attended the meetings on those dates, but she could not recall if the NHA was present at those meetings.The SSC reviewed the signature sheets and confirmed the absence of signatures for the NHA on 4/30/25 and 7/30/25. The SSC confirmed the signature sheets did not contain signatures of a governing board or someone in a leadership role with the authority to change facility systems.The undated policy Quality Assurance and Performance Improvement read, in part: . The QAA Committee shall be interdisciplinary and shall: a. Consist at a minimum of: i. The Director of Nursing Services; ii. The Medical Director or his/her designee; iii. At least three other members of the facility's staff, at least one of which must be the Administrator, owner, a board member or other individual in a leadership role.

All times are in Eastern Daylight Time (EDT) unless otherwise noted.Based on interviews, and record review, the facility failed to implement its policy and procedure to develop and revise individual resident specific comprehensive care plans revisions for three residents (Residents #32, #5 and #1) of 14 residents reviewed for care planning, resulting in the potential for unmet resident care needs and a failure to maintain their highest practicable physical, mental and psychosocial well-being. Findings include: Resident #1 (R1) Review of R1's Electronic Medical Record (EMR) revealed an initial admission to the facility on 1/10/25 with diagnoses including Alzheimer's disease, anxiety disorder, and dementia. Review of R1's Minimum Data Set (MDS) assessment, dated 7/15/25, revealed a Brief Interview for Mental Status (BIMS) score of 11, indicative of moderately impaired cognition. Further review of MDS Section GG (Functional Abilities and Goals) revealed R1 required substantial/maximal assistance for wheeling 150 feet once seated in her wheelchair. The care plan for R1 included a focus which read, I am an elopement risk/wanderer dated 4/29/25. This care plan included interventions of: - - Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. - WANDER ALERT: right ankle During an interview on 8/14/2025 at 10:20 AM, Registered Nurse (RN) I stated R1 had some changes in condition and a new MDS had been completed on 7/15/2025. On 8/14/25 at approximately 10:30 AM, R1 was observed in her room, and she was not wearing a wander alert guard (a device which prevents elopement). During an interview 8/14/2025 11:35, RN G stated, No she (R1) does not wander and had a significant change. RN G said R1 does not move her wheelchair at all and no longer wanders. RN G confirmed a wander alert guard was not in place for R1. During an interview on 8/14/25 at approximately 1:00 PM, RN I stated R1 did not wander and confirmed R1 did not propel her wheelchair. RN I agreed the care plan for R1 needed to be updated. Review of Fundamentals of Nursing ([NAME] and [NAME]) 8th edition revealed, If the patient's status has changed and the nursing diagnosis and related nursing interventions are no longer appropriate, modify the nursing care plan. An out of date or incorrect care plan compromises the quality of nursing care. Review and modification enable you to provide timely nursing interventions to best meet the patient's needs .It is necessary to revises related factors and the patient's goals, outcomes, and priories. Date any revisions. Revise specific interventions that correspond to the new nursing diagnoses and goals. Revisions need to reflect the patient's present status. [NAME], P. A., [NAME], A. G.,Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 257-258 the requisite knowledge to complete an accurate assessment .Review of the MDS 3.0 RAI Manual v1.16, Chapter 3 Section N: Medications, revealed .The intent of the items in this section is to Revisions need to reflect the patient's present status. [NAME], P. A., [NAME], A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 257-258 . Resident #32: Review of Face Sheet revealed R32 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Dementia Review of a Minimum Data Set (MDS) assessment for R32, with a reference date of 8/4/25 revealed a Brief Interview for Mental Status (BIMS) score of 3 out of a total possible score of 15, which indicated R32 was severely cognitively impaired. Further review of this MDS assessment read in part: Section E – Behavior-1. Behavior of this type occurred 1 to 3 days. R32 was coded at (1)- B. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) . Review of R32s MDS dated [DATE] read in part: Section E – Behavior-1. Behavior of this type occurred 1 to 3 days. R32 was coded at (1)- B. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) . Review of R32's Progress Behavior Note read in part: 7/13/2025 13:27 Behavior Note Text: Resident was agitated with staff during morning care. Resident was hitting staff and yelling at them. Resident spit morning med out on the floor. Resident is showing signs of increased pain and stiffness. Resident refused ROM with staff today. Review of R32's Progress Note read in part: 6/19/2025 00:04 .Progress Note Text: Resident has been disagreeable with other residents in the dining room. He has also been putting remote from Dining room TV in his pocket since yesterday. Review of R32's Progress Behavior Note read in part: 6/14/2025 18:25 Behavior Note Text: It was reported to writer that resident was verbally aggressive in dining room at lunch time. Yelling in the direction of another resident. It is noted resident. Review of R32's Progress Note read in part: 6/12/2025 10:36 Alert Note Text: When aide went in to do a check, resident was trying to strike at aide and was using fowl language. Resisting cares. On-site provider updated on resisting cares and combative behaviors on 6/11/25. Review of R32's Progress Note read in part: 6/11/2025 Progress Notes CHIEF COMPLAINT Asked to see resident due to increasingly aggressive behaviors over the last few days. Behavior was actually worse than it was 2weeks ago when I saw him for inappropriate behavior toward female staff members. Review of R32's Progress Note read in part: 5/27/2025 16:38 Behavior Note Text: Staff nurse reported to writer that resident has been gravitating towards specific female residents around dinner time/afternoon shift. Writer notified social services.Interviewed CNA who reported resident following female reaching for them. CNA and floor nurse reported no inappropriate touching by residents. Resident is easily redirected, but only for short periods of time. Review of current R32's current Care Plans read in part: Alteration in thought process r/t (related too) cognitive awareness impairment. Date Initiated: 02/15/2023. Interventions on this care plan did not reflect any changes, updates or revisions since 2023. Review of current R32's current Care Plans read in part: I have impaired cognitive function/dx of dementia or impaired thought processes r/t impaired decision-making, short-term memory loss. I have a history of increased confusion in the evening. I have a history of wandering into unoccupied rooms and urinating on the floor. Date Initiated: 02/15/2023. Further review of R32's care plans and interventions for this focused area were not updated or revised since 2/15/23. Resident #5: Review of Face Sheet revealed R5 was originally admitted to the facility on [DATE] with pertinent diagnoses which chronic kidney disease, stage 3. Review of a Minimum Data Set (MDS) assessment for R5, with a reference date of 7/28/25 revealed a Brief Interview for Mental Status (BIMS) score of 4 out of a total possible score of 15, which indicated R5 was severely cognitively impaired Review of R5's Progress notes read in part: 6/29/2025 05:05 Infection Note Text: Resident continues on oral antibiotic Augmentin for abscess on buttock . Review of R5's Progress notes read in part: 7/28/2025 05:14 Infection Note Text: Resident continues on oral antibiotic Levaquin for the treatment of UTI. Review of current R5's current Care Plans revealed there were no care plans that reflected R5s status of a long history of UTI's, nor was there a care plan in place indicating antibiotic use. Further review of R5's care plans revealed many of the focus areas, and interventions had not been updated/revised since 2022. Review of R5's Progress notes revealed: 7/28/2025 05:14 Infection Note Text: Resident continues on oral antibiotic Levaquin for the treatment of UTI. In an interview on 8/14/25 at 9:25 AM, Registered Nurse (RN) O it was a group effort to update/revise the care plans. RN O reported R32s' and R5s care plans should include aggressive behaviors, UTIs and antibiotic use, as well as appropriate updated interventions. In an interview on 8/14/2025 at 2:37 PM., Social Services Director (SSD) A reported she does not develop, or update/revise resident care plans. SSD A reported she thinks the nurses. Assistant Director of Nursing (ADON) or Director of Nursing (DON) are responsible for care plans. SSD A reported changes in resident behaviors should be added to care plans and revised as needed. SSD A reported, R32 should have had a behavioral care plan Focus of sexual/aggressive behaviors towards female residents in place, and or updates to his current care plan to reflect new behaviors. In an interview on 8/14/2025 at 1:22 PM., Director of Nursing (DON) reported Resident #5 has had a long history of UTIs with antibiotic use, and R5 has a history of aggressive/agitative behaviors. DON reported both R32 and R5's current care plans should have been updated and/or revised to reflect their current focus areas of concern. DON reported it is a team effort on resident care plans, and clearly some residents care plans have not been revised as they should be per policy and procedure. Review of a facility Policy with a revision date of 6/11/2025 titled Comprehensive Care Plans . read in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the president's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally[1]competent and trauma-informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the residents' preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans, as appropriate. f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate. 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: a. The attending physician or non-physician practitioner designee involved in the resident's care, if the physician is unable to participate in the development of the care plan. b. A registered nurse with responsibility for the resident. c. A nurse aide with responsibility for the resident. d. A member of the food and nutrition services staff. e. The resident and the resident's representative, to the extent practicable. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Examples include, but are not limited to:i. The RAI Coordinator. ii. Activities Director/Staff. iii. Social Services Director/Social Worker. iv. Licensed therapists. v. Family members, surrogate, or others desired by the resident.vi. Administration. vii. Discharge Coordinator. viii. Mental health professional. ix. Chaplain. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Care plans will be updated throughout the year as needed with any changes in residents' plan of care. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents' progress. Alternative interventions will be documented, as needed.7. The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative.8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

All times are in Eastern Daylight Time (EDT) unless otherwise noted.Based on interview and record review, the facility failed to send a copies of residents' written Notice of Transfer to representative of the Office of the State Long-Term Care Ombudsman for five Residents (#3, #56, #9, #59, & #44) of five residents reviewed for hospitalization. Findings include:Resident #9 (R9) was hospitalized on [DATE]. No documentation was in the EMR or on the written Notice of Transfer form indicating the Ombudsman was provided with a copy of the Notice of Transfer. Resident #3 (R3) was transferred to the hospital Emergency Department (ED) on 6/4/25. There was no documentation in the Electronic Medical Record (EMR) or on the written Notice of Transfer form indicating the Ombudsman was provided with a copy of the Notice of Transfer. Resident #56 (R56) was transferred to the ED on 6/1/25. No documentation was in the EMR or on the written Notice of Transfer form indicating the Ombudsman was provided with a copy of the Notice of Transfer. Resident #44 (R44) was transferred to the hospital ED on 7/26/25. There was no documentation in the EMR or on the written Notice of Transfer form indicating the Ombudsman was provided with a copy of the Notice of Transfer. Resident #59 (R59) was transferred to the hospital ED on 7/31/25. There was no documentation in the EMR or on the written Notice of Transfer form indicating the Ombudsman was provided with a copy of the Notice of Transfer. During an interview on 8/13/25 at 4:40 p.m., Social Services Director A reported that a Notice of Transfer from the facility is sent via email to the Long-Term Care (LTC) Ombudsman and she did not send the list of discharges to the ombudsman for June 2025 or July 2025. During a phone interview on 8/14/25 at 11:36 a.m., the LTC Ombudsman C reported that she had not received a list of discharges from the facility since March of 2025. Review of policy titled Transfer and Discharge date reviewed/revised 7/7/25, read in part .The transfer or discharge notice will be provided to. the.LTC Ombudsman.and the facility will maintain evidence that the notice was sent to the Ombudsman.

All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on observation, interview, and record review, the facility failed to provide oxygen services including obtaining physician orders for oxygen, physician orders for the oxygen flow rate (amount of oxygen delivered to the patient), and routine changing of oxygen tubing for one Resident #44 (R44) of three residents reviewed for oxygen services.Findings include:Resident #44 (R44)Review of R44's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 7/22/25, with active diagnoses that included: diabetes mellitus, wound infection, peripheral vascular disease (reduced circulation of blood to a body part) or peripheral arterial disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), respiratory failure, and chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs).During an observation on 8/13/25 at 9:31 a.m., R44 received oxygen via nasal cannula with undated oxygen tubing.During an observation on 8/14/25 at 9:57 a.m., R44 received oxygen via nasal cannula with undated oxygen tubing.During an interview on 8/14/25 at 10:00 a.m., R44 reported he was unsure when he started receiving oxygen, but he required oxygen when he was hospitalized in July prior to admission to the facility.Review of the Electronic Medical Record (EMR) revealed in the Treatment Administration Record (TAR) the oxygen tubing had not been changed in July or August.Review of the EMR revealed no physician orders for R44 to receive oxygen, no orders for the flow rate of oxygen, and no orders changing of oxygen tubing.During an interview on 8/14/25 at 3:06 p.m., the Director of Nursing (DON) reported she was unaware of when R44 started on oxygen and acknowledged there were no physician orders for oxygen, the flow rate of oxygen, and changing oxygen tubing. The DON reported that the residents who receive oxygen have the oxygen tubing changed weekly and the tubing is marked.Review of policy titled Oxygen Administration date implemented 7/14/22, read in part .Oxygen is administered under orders of a physician.based on.equipment setting for flow rates.change oxygen tubing and mask or cannula weekly and as needed.

All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on observation and interview, the facility failed to effectively maintain the physical plant including resident bathrooms. This resulted in water damage to the walls in resident rooms (shared bathrooms) 203/205 and 207/209, missing bathroom baseboard tiles, bathtub used for storage and the increased likelihood for further water damage, cross-contamination and bacterial harborage, with a possible decrease in the satisfaction of living, for residents who use these areas. Findings Include In an observation on 8/12/2025 at 2:50 PM., it was noted in the shared bathroom of rooms 203/205 the wall behind the toilet paint was bubbled out. This surveyor felt the wall and noted it to be wet towards the baseboards, and damp upwards behind the toilet. The drywall underneath was noted to have water damage on the entire backside wall of the toilet. This softened area of the wall extended upward approximately 3 1/2 feet, and when pushed lightly the right-side corner attached to the right wall (of the toilet) pushed inward, separating the corner of the wall to the right of the toilet, and the wall behind the toilet. 08/12/2025 2:30 PM Observation during facility tour with maintenance director showed baseboard tiles missing behind the toilet in the shared bathroom for rooms 308-310. The wall behind the toilet was also noted with water damage. 08/13/2025 at 9:12 AM during a tour of the facility with maintenance director J, the 200 wing Bath was noted being used for storage. The bathtub was noted full of equipment, and the tub was surrounded with unused equipment. When asked, maintenance director J stated that this bath has not been in use since 2019, and the line has not been flushed. He stated that all lines in the building get flushed on a regular basis, except for this bathtub line, and the outside taps. 08/13/2025 9:23 AM During a facility tour, while in the bathroom shared between rooms [ROOM NUMBERS], the wall behind the toilet was noted with water damage. Water damaged walls were also noted in the shared bathrooms between 207/209. Maintenance director J stated he was unaware of the water damage in these rooms.

Based on interview and record review the facility failed to ensure one resident (R2) of one Resident reviewed for PASARR (Preadmission screening/Annual Resident Review) obtained a PASARR level 2 (DCH-3878) evaluation to determine the appropriate setting for the individual and if specialized services were needed. This deficient practice resulted in the potential for unmet mental health needs. Findings include: All times are in Eastern Daylight Time (EDT) unless otherwise noted.Review of R2's electronic medical record (EMR) revealed an initial admission to the facility on 4/17/2023 with diagnoses including unspecified dementia with agitation and with psychotic disturbance and post-traumatic stress disorder. A review of R2's Minimum Data Set (MDS) significant change assessment, dated 6/5/25, revealed a Brief Interview for Mental Status (BIMS) should not be completed as the resident is rarely/never understood. Further review of MDS Section E under Behavioral Symptoms revealed R2 was coded as having both physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurring 1 to 3 days and Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) occurring 1 to 3 days. Further, these behaviors were noted to Significantly interfere with the resident's care. A review of the active physician's orders included an antipsychotic drug (Seroquel) prescribed 3/17/2025, as well as a current order for an antidepressant drug (Remeron) prescribed 6/12/2024. The care plan for R2 included:- a focus which read in part, I am resistive to care r/t (related to) . Anxiety, Dementia. I can become verbally and physically aggressive during cares.- a focus which read in part, I have impaired cognitive function/dementia or impaired thought processes r/t Dementia, impaired decision making, long term memory loss, pain, poor nutrition, short term memory loss.- a focus which read in part, I have potential to demonstrate verbal and physical behaviors (hitting, kicking, pushing, slapping, pinching etc.) r/t Dementia Poor impulse control,- a focus which read in part, I have a history of trauma that affects/has the potential to impact me negatively. PASARR Level I (DCH - 3877) instructions, Distribution: If any answers to items 1 - 6 in SECTION II is Yes, send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form (PASARR 2) DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record and provide a copy to the patient or legal representative. Although the PASARR Level I (DCH - 3877) dated 3/3/25 did contain answers of yes, the medical record did not contain a PASARR level 2 (DCH-3878) screening. During an interview on 8/12/2025 at approximately 4:30 PM, the PASARR level 2 (DCH-3878) for R2 was discussed with Social Services staff A. She confirmed she did not submit PASARR level 2 (DCH-3878) forms. On 8/14/2025 at 9:50 AM, the Assistant Director of Nursing (ADON) B searched but did not find a PASARR level 2 (DCH-3878) for this year (2025). ADON B could not find a PASARR level 2 (DCH-3878) for R2 for any previous year. It was determined the PASARR level 1 (DCH-3877) had been submitted 3/3/25, but the PASARR level 2 (DCH-3878) had not been received and no PASARR level 2 (DCH-3878) had ever been obtained. The facility policy titled Resident Assessment - Coordination with PASARR Program and dated as Reviewed/Revised 7/7/2025 read in part, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder (MD), intellectual disability (ID) or a related condition receives care and services in the most integrated setting appropriate to their needs. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID, or related condition, to the appropriate state-designated authority for Level II PASARR evaluation and determination. The Level II resident review must be completed within 40 calendar days of admission.

All times are in Eastern Daylight Time (EDT) unless otherwise noted.Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for 2 Residents (#5 & #32) of 14 residents reviewed for comprehensive care planning, resulting in recurring urinary tract infections (UTI's) for R5, and the potential for further unrecognized sexual and aggressive behaviors towards female residents as well as decline in uncommunicated care needs between disciplines and unmet care needs. This deficient practice resulted in the potential for unidentified and unmet individualized care needs.Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.16, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, revealed .the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident 's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care . Resident #5:Review of Face Sheet revealed R5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic kidney disease, stage 3.Review of a Minimum Data Set (MDS) assessment for R5, with a reference date of 7/28/25 revealed a Brief Interview for Mental Status (BIMS) score of 4 out of a total possible score of 15, which indicated R5 was severely cognitively impaired. Further review of the document revealed that R5 was coded under section GG as GG0130. Self-Care: (2)-Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort: (2) for C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment.Review of R5 MDS assessment dated [DATE], revealed: Section H - Bladder and Bowel- H0300. Urinary Continence- 2. Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) .Review of R5 MDS assessment dated [DATE], revealed: Section H - Bladder and Bowel- H0300. Urinary Continence- 3. Always incontinent (no episodes of continent voiding) .Review of R5's Progress notes read in part: 6/29/2025 05:05 Infection Note Text: Resident continues on oral antibiotic Augmentin for abscess on buttock .Review of R5's Progress notes read in part: 7/27/2025 09:31 N Adv - Dehydration Risk Evaluation Findings: Dehydration risk findings': Renal Disease or Liver Disease.Dehydration risk findings: Incontinence (bowel or bladder.Dehydration Risk Score: 8.0 When the Score Value is 4 or above the Resident is at Risk for Dehydration.Review of R5's Progress notes read in part: 7/28/2025 05:14 Infection Note Text: Resident continues on oral antibiotic Levaquin for the treatment of UTI.Review of R5's Current Care Guide (staff documentation of residents Activity of Daily Living (ADLS) 8/1/25-8/15/25 columns noted for documentation were as follows: Intervention- Time- Schedule for August 2025 (days separated in columns) -Position: All. read in part: Section: GG - Toilet Transfer and GG - Toileting Hygiene QShift (Q-every) revealed from 8/1/25-8/14/25 the document revealed R5 was Transferred to toilet, and Toileting hygiene was completed as follows for a 24 hour period: 8/1/25-8/13/25: 3 times per day, on 8/14/ 25 R5 was toileted 2 times in a 24 hour period.Review of current R5's current Care Plans revealed there were no Resident Focused Care Plans in place that reflected R5's status of a current and a history of UTI's, nor was there a care plan in place indicating antibiotic use.In an interview on 8/14/25 at 12:10 PM., Certified Nurse Aide (CNA) D Reported R5 often gets Urinary Tract Infections UTIs. CNA D reports she is not always informed when R5 has a UTI. CNA D reported R5 takes antibiotics off and off, and it should be carefully planned so that the CNA/nursing staff is aware of signs and symptoms of R5 when she is getting a UTI or has one. CNA D reported the resident care plans drive the CNA care guides, so all staff caring for the residents know the residents individual care needed. CNA D reported residents are to be toileted/check/changed every 2 hours on every shift.Resident #32:Review of Face Sheet revealed R32 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Dementia.Review of a Minimum Data Set (MDS) assessment for R32, with a reference date of 8/4/25 revealed a Brief Interview for Mental Status (BIMS) score of 3 out of a total possible score of 15, which indicated R32 was severely cognitively impaired. In an interview on 8/14/25 at 9:25 AM, Registered Nurse (RN) O reported care plan changes were the interdisciplinary team responsibility. RN O reported the reported it was a group effort to update/revise the care plans and whoever in the room had a computer would make those changes to the care plans. MDS Nurse O created the comprehensive care plan initially, but it is the responsibility of each department to update the care plan or during the IDT (Interdisciplinary Team) team meeting. RN O' reported residents are supposed to be checked/changed and toileted every 2 hours during each shift. In an interview on 8/14/2025 at 1:22 PM., Director of Nursing (DON) reported Resident #5 has had a long history of UTIs. DON reported R5 should have both focused areas of UTI and antibiotic use on her care plans. DON reported that any nurse can develop a care plan, update and revise care plans, but typically the MDS nurse should be updating and developing care plans with the assessments, the Assistant DON and/or herself will also put care plans in place. DON reported R32 should have had a care plan developed for behaviors towards other female residents as soon as the behavior occurred to ensure all staff were aware of the potential for abuse. Review of a facility Policy with a revision date of 6/11/2025 titled Comprehensive Care Plans . revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the president's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally1] competent and trauma informed.2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the residents' preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record.3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans, as appropriate. f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate.g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident.4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: a. The attending physician or non-physician practitioner designee involved in the resident's care, if the physician is unable to participate in the development of the care plan. b. A registered nurse with responsibility for the resident. c. A nurse aide with responsibility for the resident. d. A member of the food and nutrition services staff. e. The resident and the resident's representative, to the extent practicable. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Examples include, but are not limited to:i. The RAI Coordinator. ii. Activities Director/Staff. iii. Social Services Director/Social Worker. iv. Licensed therapists. v. Family members, surrogate, or others desired by the resident.vi. Administration. vii. Discharge Coordinator. viii. Mental health professional. ix. Chaplain.5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Care plans will be updated throughout the year as needed with any changes in residents' plan of care.6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents' progress. Alternative interventions will be documented, as needed.7. The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative.8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to follow physician orders for wound care for one Resident #44 (R44) of one resident reviewed for physician orders for the care of wounds. This deficient practice resulted in the potential for infection and a delay in healing.Findings include:Resident #44 (R44)Review of R44's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 7/22/25, with active diagnoses that included: diabetes mellitus, wound infection, and peripheral vascular disease (reduced circulation of blood to a body part) or peripheral arterial disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).Further review of the MDS Section M Skin Conditions revealed R44 had three venous and arterial ulcers.Review of discharge document from hospital dated 7/16/25, read in part .Wound follow up note from physician.There are chronic wounds on the left leg and foot.Left Lower Extremity (LLE) wounds.remove dressing, cleanse with saline. Please make sure to scrub wounds with gauze to remove any loose slough (necrotic tissue). Apply single layer xeroform(C) to all open wounds. Cover with ABDs (abdominal pad) and wrap with kerlix(C). Change dressing daily and as needed.During an interview on 8/13/25 9:30 a.m., R44 reported he has a couple open sores on his left foot or leg Review of the Treatment Administration Record (TAR) dated July 2025 revealed there were no treatments completed for the LLE wounds.Review of the TAR dated August revealed there were no treatments completed for the LLE woundsReview of the Electronic Medical Record (EMR) revealed there were no physician who ordered treatments for the LLE wounds.During an interview on 8/14/25 at 4:20 p.m., the Director of Nursing and Assistant Director of Nursing acknowledged there were no physician ordered treatments for the LLE wounds.Review of policy titled Clean Dressing Change last reviewed/revised 3/17/25, read in part .It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician orders will specify type of dressing and frequency of changes.

Based on interview and record review, the facility failed to ensure resident safety by implementing care planned interventions for two residents at high risk for falls (Resident R9 and R59) out of four residents reviewed for falls. This deficient practice resulted in subsequent falls with injury including a broken neck. Findings include: All times are in Eastern Daylight Time (EDT) unless otherwise noted.Resident #9 (R9) During an interview on 8/12/2025 at 1:32 PM, R9 stated, I fell from my recliner at night a few months back. I hit my head, and it knocked me out and I broke my neck. R9 was sitting in her recliner during the interview and her neck collar was at her side lying on her bed. She stated she had taken it off as it hurt her jaw. Review of R9's electronic medical record (EMR) revealed an initial admission to the facility on 4/9/25 with diagnoses including congestive heart failure, chronic respiratory failure, anxiety disorder, dependence on supplemental oxygen and difficulty walking. Review of R9's Minimum Data Set (MDS) assessment, dated 7/8/25, revealed a Brief Interview for Mental Status (BIMS) score of 10, indicative of moderately impaired cognition. Accident and Incident reports were requested for R9 and reports dated 6-28-25 and 7/2/25 revealed two falls. The 6/28/25 Accident and Incident report read in part, Nursing description: CNA (Certified Nurse Aide) reported resident on the floor in bathroom. Writer observed resident sitting on floor next to toilet facing sink, leaning right side against wall. Resident states, 'I slipped'. Report did not indicate interventions were added to the plan of care. Four days later the 7/2/25 Accident and Incident read in part, Nursing description: Called to resident room by CNA who had been sitting at main desk and heard a loud noise from resident room that sounded like a fall. Upon entering resident room noted to be lying on floor on back, head was facing the opposite bed and feet towards window. She did state she hit her head but unsure on what piece of furniture in room. Noted to have large bruise appearing on front, top forehead. Action Taken. resident transported to local hospital via ambulance. Incident Description: There were no witnesses, and incident was as noted above. As per provider orders, resident was transferred to (name of) ED (Emergency Department) and was diagnosed with a cervical fracture (a break in one or more of the seven vertebrae in the neck). During an interview on 8/14/2025 at 3:22 PM, the Director of Nursing (DON) was asked about these falls. The DON stated R9 had a BIMs of 14 at the time of the fall on 7/2/25 and returned from the hospital with a BIMS of 10 but was able to recall the event and cause. The DON stated the resident was care planned as a fall risk. The DON was asked if the care plan was updated after the fall on 6/28/25 to include interventions to prevent further falls. The DON was unable to find preventative interventions that had been added to the care plan even though the care plan for falls included the intervention of: Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate me/family/caregivers/IDT as to causes. Date Initiated: 04/10/2025 Resident #59 (R59) Review of R59's MDS assessment dated [DATE], revealed admission to the facility on 3/13/25, with active diagnoses that included peripheral vascular disease (reduced circulation of blood to a body part) or peripheral arterial disease(circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), diabetes mellitus, and malnutrition. Review of the incident report titled Fall with Injury dated 7/30/25, read in part .Nursing description.Certified Nurses Aide (CNA) notified nurse resident was on his back on the floor next to his bed.resident stated he slipped out of bed when trying to reposition himself.injuries report post incident.fracture.left hip. Review of radiology note from the hospital dated 7/31/25, read in part .left hip acute sub-capital hip fracture with impaction. Review of Electronic Medical Record (EMR) revealed R59 was readmitted to the facility on [DATE]. Review of R59's care plan revealed there were no interventions added to the care plan following the fall with fracture to prevent falls. During an interview on 8/13/25 at 3:55 p.m., the Director of Nursing (DON) acknowledged there were no interventions in R59's care plan following R59's fall with fracture to prevent falls. Review of policy titled Fall and Fall Risk Managing last revised March 2025, read in part .In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

This citation is related to Intake MI00148048 an MI00148473 Based on observation, interview, and record review the facility failed to ensure comfortable temperatures for a homelike environment for four Residents (#1, #2, #3, & #4) of four residents reviewed for comfortable temperature and homelike environment., resulting in expressions of physical discomfort. Findings include: Resident #1 (R1) Review of R1's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses including: arthritis, coronary artery disease (CAD), and Alzheimer's disease. R1 scored a 13 of 15 on the Brief Interview of Mental Status (BIMS) reflective of intact cognition. During an interview on 12/23/24 at approximately 10:15 a.m., R1 stated, It was cold in here a couple days ago . it has been cold in here for quite some time and it was cold in here a week ago when the weather changed . the staff have been wearing extra clothes and jackets to stay warm. Resident #2 (R2) Review of R2's MDS assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses including hypertension, depression, anxiety disorder, and Alzheimer's disease. R2 scored a 8 of 15 on the BIMS assessment reflective of moderate cognitive impairment. During an interview on 12/23/24 at 10:27 a.m., R2 stated, It has been cold in here since I moved here a little over a month ago .I have a large towel at the base of my window in my room because I could feel cold air coming in, I told them and someone from maintenance is supposed to fix it but they never came back to my room to do anything. During an observation on 12/23/24 at 10:30 a.m., this surveyor went into R2's room and observed a towel/bath blanket at the base of the window and when the towel was lifted the cold air could be felt coming into the room. Resident #3 (R3) Review of R3's MDS assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses including heart failure, hypertension, diabetes mellitus, and thyroid disorder. R3 scored a 14 of 15 on the BIMS assessment reflective of intact cognition. During an interview on 12/23/24 at 10:40 a.m., R3 stated, the staff is wearing jackets to stay warm . it is the coldest in here from midnight to seven a.m. I have told the staff and management here and nothing has changed, I wear my winter coat all the time just to stay warm . I have kept a log of the cold days and one of the maintenance guys has taken the temperature of my room and it has been 67 and 65 degrees in my room . they just won't fix the heat. Resident #4 (R4) Review of R4's MDS assessment dated [DATE], revealed admission to the facility on [DATE], with diagnoses including hypertension, diabetes mellitus and depression. R4 scored a 14 of 15 on the BIMS assessment reflective of intact cognition. During an interview on 12/23/24 at 12:50 p.m., R4 stated, It is cold in here . during the night and early morning it is the worst . I wear a hat on my head when I get cold and have lots of extra blankets . they don't seem to ever get it warm enough in here and there is always a draft, there is a draft by my window and if we keep the bedroom door open it feels colder. During an interview on 12/23/24 at 10:50 a.m., maintenance (Staff A) stated, We have known the temperature in the facility is low and the heaters at the end of the hallways have not been working . During an observation on 12/23/24 at 10:52 a.m., Staff A used a temperature gun to read the temperatures down the 100, 200, and 300 wings and revealed the following: the temperature on a wall on the 100 wing was recorded at 67 degrees. A temperature in a resident room on the 100 hallway was recorded at 65 degrees. The temperature on the wall in the hallway and in a resident room on the 200 wing was recorded at 68 degrees. A temperature in the hallway and in a resident room on the 300 wing was recorded at 68 degrees. During a telephone interview on 12/23/24 at 11:04 a.m., Maintenance Director (Staff) B stated, We first notice a problem with the heat about a week and a half ago .I don't know why the temperatures would be low today. During an interview on 12/23/24 at 11:15 a.m., Social Services Designee C stated, R3 has complained to me about how cold he is, and he usually wears his winter coat all day. During a telephone interview on 12/23/24 at 11:29 a.m., the Nursing Home Administrator (NHA) stated the temperature in the facility has to be 72 degrees. During an interview on 12/23/24 at 11:52 a.m., Certified Nursing Assistant (CNA) E stated, I have noticed it is cold in the hallway and it gets very cold in the facility . there have been a couple times I have worn my winter jacket to keep warm . it has been colder lately and the residents have been complaining . I have told the nurses and they tell us to dress the residents with long sleeved clothes. During an observation on 12/23/24 at 11:59 a.m., this Surveyor saw a long crack at the bottom of the door leading to the outside. The door was located at the end of the 300 hallway. During an observation on 12/23/24 at 12:01 p.m., this Surveyor saw a long crack at the bottom of the door leading to the outside. The door was located at the end of the 100 hallway. During an interview on 12/23/24 at 12:05 p.m., CNA D stated, The residents have complained about it being cold and I have told maintenance . there has been a draft at the ends of the hallways . there have been staff that wear jackets during their shift . the residents complain in the evening as I usually work that shift. During an interview on 12/23/24 at 12:16 p.m., Staff A stated, We know about the gaps under the doors on the end of the 100 and 300 wings and we usually will put blankets at the bottom of the doors. During an interview on 12/23/24 at 12:18 p.m., the Nursing Home Administrator (NHA) stated, I was not aware of the cracks under the doors. Review of facility policy titled, Safe and Homelike Environment date reviewed/revised 1/1/24, read in part . the facility will maintain comfortable and safe temperature levels .in resident areas between 71 and 81 degrees.

All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on observation, interview, and record review, the facility failed to: 1. Ensure the correct use of personal protective equipment (PPE), 2. Post visual alerts at the entry for staff and visitors regarding information for hand hygiene and source control, and; 3. Post the process for everyone entering the facility of the recommended actions to prevent transmission of COVID-19 in accordance with standards of practice and Centers for Disease Control (CDC) recommendations for COVID-19, during an outbreak. Findings include: On 8/26/24, at approximately 12:30 p.m. the door to the facility's main entrance was observed closed for construction for the pouring of a concrete slab. The door at the end of the 100 unit was being utilized for entering and exiting the facility until construction was completed. On 8/26/24 at 12:30 p.m., Staff B said there was one resident who was positive for COVID-19. Staff B did not know when the resident tested positive or on which unit the resident who tested positive resided. Staff B said everyone who entered the facility was required to wear a mask while in the building. No visual alert was posted at the entry door to convey information regarding the use of source control, personal protective equipment (PPE), or performing hand hygiene. There was no identifiable process, posting, or visual alert to make everyone entering the facility aware of recommended actions or guidance to prevent transmission to others if they had: a positive viral test for SARS-CoV-2 (the coronavirus that causes COVID-19), symptoms of COVID-19, or close contact with someone with SARS-CoV-2 infection. There was a table to the left of the entry door containing a box of surgical masks and a box of N-95 masks. No hand sanitizer was available on the table. A hand sanitizer dispenser was located on the wall approximately 12 - 15 feet from the entry door past two residents' rooms. There was no waste receptacle for disposing of masks when exiting the facility. On 8/26/24 at 1:45 p.m. the doors to rooms [ROOM NUMBER] had observed signage posted indicating isolation precautions. The doors to the three rooms were open to the hallway. On 8/26/24 at 3:01 p.m., isolation signage was observed posted on the door to room [ROOM NUMBER]. The doors to the four rooms in isolation were open to the hallway with residents in the hallway outside the doors. The Infection Preventionist (IP) said there were five residents who had tested positive for COVID-19. The IP said Resident #36 (R36) tested positive on 8/23/24, and Residents #3 (R3), #43 (R43), #30 (R30), and #18 (R18) had tested positive on 8/26/24. The IP said the residents who had tested positive for COVID-19 all resided on the 200 unit. On 8/27/24 at 7:28 a.m., The 100 hall door being used for entrance and exit from the facility still did not have hand sanitizer, a waste receptacle, directions for the use of PPE or hand hygiene, or postings for recommended actions and guidance for people entering the facility if they experienced a positive viral test for SARS-CoV-2, symptoms of COVID-19, or close contact with someone with SARS-CoV-2 infection. On 8/27/24 at 8:40 a.m., Certified Nursing Assistant (CNA) C was observed walking up the 200 unit, opened the door at the end of the unit, exited the unit wearing the same mask she was wearing on the affected unit, and did not performing hand hygiene. On 8/27/24 at 8:41 a.m., Staff E was observed entering the building from the door at the end of the 200 unit. Staff E walked the length of the 200 unit without wearing a mask and exited the 200 unit without a mask. Staff E was asked why she was not wearing a mask. Staff E responded, I just walked in. I just got to work. She then exited through another door. Housekeeper F was present and explained, The main entrance is closed right now so staff is using one of the side doors, either on 100 hall or 200 hall. At 8:47 a.m., the Nursing Home Administrator (NHA) reported signage was placed outside the door at the end of 200 hall directing staff to utilize another door. On 8/27/24 at 8:49 a.m., R36, who had tested positive for COVID-19, was observed in his wheelchair on the 200 unit hallway with two other residents within six feet of R36. R36 was coughing openly and repeatedly without covering his mouth. On 8/27/24 at 9:18 a.m., Resident #13 (R13) was observed ambulating in the hallway. CNA D called for CNA C for assistance with R13. CNA C exited room [ROOM NUMBER] wearing gloves she was wearing in room [ROOM NUMBER]. CNA C went into room [ROOM NUMBER] where R13 resided with R36. CNA C obtained a wheelchair and took it to R13. CNA C placed her hand, still donned in the glove she had been wearing in room [ROOM NUMBER], around R13's arm and guided R13 into the wheelchair. CNA C went back into room [ROOM NUMBER] wearing the same pair of gloves and without performing hand hygiene. On 8/27/24 at 9:30 a.m , CNA D was observed through an open doorway assisting R36 in their room with positioning. R36 was openly coughing without covering his mouth. CNA D was not wearing eye protection. An observation was made of CNA D who exited the room, doffed the gown and gloves, and performed hand hygiene but did not remove the N-95 mask used while assisting R36 who was COVID-19 positive. CNA D exited the room and immediately walked down the hall and entered room [ROOM NUMBER] wearing the same mask used in R36's room. The resident in room [ROOM NUMBER] was placed on isolation precautions on 8/28/24 due to the resident showing signs and symptoms of COVID-19. On 8/28/24 at 7:39 a.m., the 100 unit door utilized for entry and exit from the facility still did not have a visual posting to convey information regarding the use of source control, personal protective equipment (PPE), or instructions for performing hand hygiene. There remained no identifiable process, posting, or visual alert to make everyone entering the facility aware of recommended actions or guidance to prevent transmission to others if they had: a positive viral test for SARS-CoV-2, symptoms of COVID-19, or close contact with someone with SARS-CoV-2 infection. The table to the left of the entry door had a box of surgical masks but no hand sanitizer or waste receptacle. The IP was interviewed on 8/28/24 at 8:42 a.m. The IP said staff were to wear gloves, gown, eye protection, and an N-95 mask when they are with residents who tested positive for COVID-19. The IP said only N-95 masks were required when working with residents on the unit who had not tested positive for COVID-19. The IP said surgical masks were being required on the other units in the building. The IP was asked about removing PPE when exiting a room after caring for a resident with COVID-19. The IP said staff should remove all PPE before exiting the room, perform hand hygiene, and put on a new mask immediately upon exiting the room. The IP said it was not permissible to wear the same PPE, including N-95 mask, from the room of a resident with COVID-19 into the hallway or into another resident's room. The IP confirmed staff were not to wear gloves from the care of one resident to another resident. The IP confirmed the facility adheres to CDC recommendations and guidelines to determine infection prevention and control practices and policies. The facility policy Covid Prevention and Response was reviewed with the IP. The policy included the need to post visual alerts regarding source control, recommended PPE, instructions for anyone entering the facility if they had a positive viral test for SARS-CoV-2, symptoms of COVID-19, or close contact with someone with SARS-CoV-2 infection. The IP said there should have been signage posted but admitted she had not posted anything at the 100-unit door that was being used for entrance and exit from the facility. The Centers for Disease Control (CDC) updated guidelines of 6/24/24 Infection Control Guidance: SARS-CoV-2 at https://www.cdc.gov/covid/hcp/infection-control/index.html, state the following, in part, regarding COVID-19 recommendations: .Ensure everyone is aware of recommended IPC [infection prevention and control] practices in the facility . .Post visual alerts (e.g., signs, posters) at the entrance .these alerts should include instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene) . .Establish a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following three criteria: a positive viral test for SARS-CoV-2, symptoms of COVID-19, or close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel) . .Provide guidance (e.g. posted signs at entrances .) about recommended actions for patients and visitors who have any of the above three criteria [a positive viral test for SARS-CoV-2, symptoms of COVID-19, or close contact with someone with SARS-CoV-2 infection] . .HCP (Health Care Personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should .use .N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) .

Based on interview and record review, the facility failed to ensure required members of the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly, resulting in the potential for decreased quality of care for all 54 residents living in the facility. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. Review of the QAPI committee meeting attendance logs with the Nursing Home Administrator (NHA) and the Corporate Director of Clinical Services, Registered Nurse (RN) A on 8/28/2024 at 4:23 p.m., revealed meetings were held on 8/14/2023, 1/30/2024, and 5/01/2024. Further review of the attendance logs revealed the following: 8/14/2023: Medical Director or designee not in attendance. 1/30/2024: Medical Director or designee not in attendance. Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI), last reviewed 4/22/2024, revealed the following, in part: The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan. The QAA Committee shall be interdisciplinary and shall consist at a minimum of: the Director of Nursing Services; the Medical Director or his/her designee; at least three other members of the facility's staff, at least one of which must be the Administrator, Owner, a Board Member or other Individual in a leadership role; and the Infection Preventionist.

Based on interview and record review, the facility failed to accurately report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid Services). This deficient practice resulted in the facility triggering for excessively low weekend staffing with the potential to affect all 54 residents. Findings include: (All times are recorded in Eastern Daylight Time unless otherwise noted.) Review of the CMS PBJ Staffing Data Report FY (fiscal year) Quarter 2 2024 (January 1- March 31) revealed the metric Excessively Low Weekend Staffing Triggered with Submitted Weekend Staffing is excessively low with infraction dates being : 1/6/24, 1/7/24, 1/13/24, 1/14,24, 1/20/24, 1/21/24, 1/27/24, 1/28/24, 2/3/24, 2/4/24, 2/10/24, 2/11/24, 2/17/24, 2/18/24, 2/24/24, 2/25/24, 3/2/24, 3/3/24, 3/9/24, 3/10,24, 3/16/24, 3/17/24, 3/23/24, 3/24/24, 3/30/24, and 3/31/24. During an interview on 8/28/24 at 12:47 p.m., Business Office Manager/Human Resources G stated, I submit the PBJ information, but the system generates the information .I don't review the data. During an interview on 8/28/24 at approximately 3:15 p.m., the Nursing Home Administrator (NHA) stated, I don't know why we would trigger for low weekend staffing. Review of facility policy titled Payroll Based Journal, provided to this surveyor on 8/28/24 .read in part, It is the policy of this facility to electronically submit .complete and accurate direct care staffing information . the Nursing Home Administrator (NHA), Human Resource Director, and Director of Nursing (DON) are responsible for verifying accuracy of the staffing data that is submitted to CMS using various facility audit forms.

Based on interview and record review the facility failed to ensure completion of monthly medication regimen reviews for four Residents (#41, #43, #46 and #9) of five residents reviewed for unnecessary medications, resulting in the potential for administration of unnecessary or inappropriate medications and adverse effects of administered medications. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. Resident #41 (R41) Review of R41's Medication Regimen Review(s),' found in the electronic medical record (EMR) revealed the following: 7/23/2024 at 10:24 p.m. Medication Regimen Review completed. One or more recommendations were made for this resident. To see these and other recommendations please refer to the Director of Nursing [DON] monthly consultation report. Further review of R41's EMR revealed no consultation report indicating what the pharmacist recommendations were, when it was received by the facility and provider, or how and when the facility followed up on the recommendations. R43 Review of R43's Medication Regimen Review(s),' found in the electronic medical record (EMR) revealed the following: 7/23/2024 at 10:23 p.m. Medication Regimen Review completed. One or more recommendations were made for this resident. To see these and other recommendations please refer to the Director of Nursing [DON] monthly consultation report. Further review of R43's EMR revealed no consultation report indicating what the pharmacist recommendations were, when it was received by the facility and provider, or how and when the facility followed up on the recommendations. R47 Review of R47's Medication Regimen Review(s),' found in the electronic medical record (EMR) revealed the following: 7/23/2024 at 10:24 p.m. Medication Regimen Review completed. One or more recommendations were made for this resident. To see these and other recommendations please refer to the Director of Nursing [DON] monthly consultation report. Further review of R47's EMR revealed no consultation report indicating what the pharmacist recommendations were, when it was received by the facility and provider, or how and when the facility followed up on the recommendations. On 8/27/2024 at 4:30 p.m., a request was made to the DON for the monthly consultation reports for R41, R43 and R47, including facility follow-up to the pharmacist's recommendations, as referenced in the EMR, for R41, R43, and R47 on 7/23/2024. On 8/28/24 at 1:37 p.m. the DON reported she receives the monthly recommendations from the pharmacy, prints the recommendations to present to the providers, who in return follow up with a new order or reason why they did not follow the pharmacy recommendation. The DON stated after the provider reviewed the recommendations the pharmacy reviews are returned to her to follow through with order input and documentation. The pharmacy recommendation forms are then presented to the medical records department for scanning into the respective resident's EMR. The DON confirmed she did not have the requested pharmacy recommendation forms for R41, R43 or R47, as previously requested, and could not account for when the recommendations were received and if follow up was conducted in a timely manner or at all. When asked how the facility ensures monthly medication regimen reviews were completed with appropriate follow-up for all residents, the DON reported she reviews a listing of resident's reviewed on a quarterly (every three month) basis. Review of the facility policy titled, Medication Regimen Review, last reviewed 8/01/2024, revealed the following, in part: Written communications from the pharmacist shall become a permanent part of the resident's medical record. 49735 A review of R9's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: anxiety disorder, depression, dementia, hypertension, and Alzheimer's disease. R9 scored 11 of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderately impaired cognition. Review of Electronic Medical Record (EMR) reealed that resident was perscribed Quetiapine fumarate (antipsychotic) and Sertraline (antidepressant). Review of (EMR) did not reveal a monthly Medication Regimen Review (MRR) completed by a licensed pharmacist for January 2024, March 2024, April 2024, June 2024, and July 2024. During an interview on 8/27/24 at 3:52 p.m., the Director of Nursing (DON) acknowledged that she could not find the Medication Regimen Review that was completed by the pharmacist in the EMR for January 2024, March 2024, April 2024, June 2024, and July 2024. Review of facility policy titled Medication Regimen Review date reviewed/revised . 8/1/24, read in part . the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist .the MRR is a thorough evaluation of the medication regiment of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with mediation .the pharmacist shall document either manually or electronically that each medication regimen review has been completed.

Based on observation, interview, and record review, the facility failed to ensure the return or destruction of Resident medications brought in from home and previously opened for nine Residents out of the total facility population of 54 Residents. This deficient practice resulted in the potential for medication diversion, and administration of undated, opened medications with the potential for reduced efficacy and cross-contamination of infectious organisms. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. During an observation on 8/28/24 at 3:21 p.m., four pink bins with individual Resident medication bottles, boxes, patches, tubes, drops, and powders were found in the medication storage room upper wall cabinets. The four pink bins contained the following items: 1st Bin: Five opened, undated, unlabeled tubes of topical medication; one opened, undated bottle of stoma powder; and one opened, undated bottle of antifungal medication. 2nd Bin: Four prescription bottles for R46, including Eliquis (anticoagulant), Lisinopril (antihypertensive), Extra Strength Pain Relief PM (Acetaminophen 500 mg with Diphenhydramine HCL 25 mg), and Metformin (for blood sugar control). 3rd Bin: A seven-day, daily pill [NAME] container marked as Five in a plastic container with unidentified pills. No resident identification was present. 4th Bin: 10 medication bottles, an Omeprazole box, and individually sealed medications that were unlabeled and not inventoried. The Residents identified by the facility for these medications included: R1, R51, R37, R31, R500, R501, R502, and R503. During an interview on 8/28/24 at approximately 3:25 p.m., when asked about the medications found in the unlocked cabinets, Registered Nurse (RN) K stated, They should not be here. They (medications) should have been sent home with the Residents, or they should have been discarded. During an interview on 8/28/24 at approximately 4:16 p.m., the Nursing Home Administrator and Corporate Director of Clinical Services A acknowledged the open, unlabeled and un-inventoried medications should not have been retained for an indeterminate amount of time in the facility medication room. Review of the Medication Storage policy, revised 1/17/24, revealed the following, in part: .Unused Medications: The medication room is routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. Review of the Destruction of Unused Drugs policy, revised 4/8/24, revealed the following, in part: .Unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed .

Based on interview and record review, the facility failed to ensure legal guardianship was renewed and active for one Resident (#41) declared incompetent by a court of law, of two residents reviewed for advance directives, resulting in the potential for unauthorized decisions made on the Resident's behalf. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. Resident #41 (R41) Review of R41's electronic medical record revealed a court document titled Report of Physician or Mental Health Professional, dated and signed by the court appointed physician on [DATE] deeming R41 not presently able to make informed decisions in the following areas: determining where to live; consenting to supportive services; handling personal financial affairs; and authorizing or refusing medical treatment. The prognosis for improvement in the individual's conditions is poor. Review of the Order Regarding Appointment of Temporary Guardian of Incapacitated Individual, dated and signed on [DATE], revealed Family Member (FM) J was designated as R41's temporary guardian with all authority and responsibilities granted and imposed by law. Further review of the document revealed this temporary guardianship shall terminate on [DATE]. Review of R41's most recent Care Directives, dated [DATE], revealed the directives were signed by FM J. On [DATE] at 1:30 p.m., the Nursing Home Administrator (NHA) was asked who to direct inquires to regarding advanced directives and resident guardianship. The NHA stated to direct inquiries to Registered Nurse (RN) K and the Director of Nursing (DON). On [DATE] at 1:33 p.m., RN K was asked to provide R41's current guardianship paperwork. On [DATE] at 1:45 p.m., the DON reported the facility did not have R41's current guardianship paperwork. The DON confirmed R41's temporary guardianship had expired and FM J was still listed as decision maker and actively making decisions on R41's behalf. The DON reported she contacted FM J to inquire about updated guardianship paperwork. The DON stated FM J would not be supplying a copy to the facility and he directed the facility to call the courthouse where the paperwork was filed to obtain a current copy. The DON reported obtaining the paperwork from the court would take a few days. Current, active guardianship paperwork, designating FM J as R41's legal guardian, was not provided prior to the end of the survey on [DATE]. Review of the facility policy titled, Resident Rights Regarding Treatment and Advance Directives, last reviewed [DATE], revealed the following, in part: during the care planning process, the facility will identify, clarify and review with the resident or legal representative whether they desire to make any changes related to any advance directive. The policy did not include a process for ensuring resident's legal guardianship was current and valid.

Based on interview and record review, the facility failed to provide responses to concerns/grievances for 4 Confidential Residents (CR301, CR302, CR303, CR305) reported during the Resident Council survey task. This deficient practice has the potential to result in unresolved resident concerns and a decreased quality of life. Findings include: (All times are recorded in Eastern Daylight Time unless otherwise noted.) During a confidential group meeting on 8/27/24 at 11:00 a.m., CR301 stated, we have a lot of the same complaints during resident council and they don't get taken care of. CR302 CR303, and CR305 all agreed. CR302 stated, We have the same concerns every month during resident council .we never hear anything back from the concerns we have, nothing changes. During an interview on 8/28/24 at 8:51 a.m., the Activity Director reviewed the resident council minutes and stated, I am not doing a very good job of reviewing the concerns and documenting them .I guess I could do a better job in charting the concerns or when they are reviewed with the resident council. Review of facility policy titled Resident Council Meeting last revised dated, 6/22/24 .read in part, the Activity Director shall be designated .to serve as a liaison .the liaison shall be responsible for .responding to written requests from the group meetings .the facility shall act upon concerns and recommendations .and communicate decisions to the council. 40383 The Resident Council meeting minutes were reviewed. The 6/12/24 meeting minutes New Business included a quote by one of the residents which read, The food tastes good and much improved, but it is still cold. There was not a Resident Council meeting in the month of July 2024. The Resident Council meeting minutes dated 8/1/24 revealed the Old Business section was the same as the Old Business from the 6/12/24 meeting and the items discussed as new business from that 6/12/24 meeting had not been carried forward. Many of the concerns brought up at the last meeting 6/12/24 including cold food were not noted in the 8/1/24 minutes as discussed or resolved.

Based on observation, interview and record review, the facility failed to prevent resident to resident abuse for 2 residents (Resident #46, & Resident #37) of 6 residents residents reviewed for abuse. This deficient practice resulted in Resident #30 twisting Resident #46's right wrist causing pain, fear and increased anxiety, and Resident #42 perpetrating physical abuse to Resident #37 and another resident unknown with the potential for further continued abuse of residents residing in the facility to go unrecognized and the potential for further harm. (All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted.) Findings include: Resident #46 Review of an Admission Record revealed Resident #46, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: generalized anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #46, with a reference date of 6/20/23 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #46 was mildly cognitively impaired. During an interview on 8/16/23 at 10:30 AM., Resident #46 reported Resident #30 has come into her room on multiple occasions. Resident #46 reported Resident #30 had come into her old room before she moved into this new room. Resident #46 reported that not that long ago, maybe a few weeks Resident #30 was in her room and fell asleep in her bed while Resident #46 was out with family. Resident #46 reported her (Family Member (FM) H) requested the bedding was changed after (Resident #30) slept in her bed. Resident #46 reported not long after that day, another day Resident #30 came back into her room while she was sitting in her (Resident #46's) recliner. Resident #46 reported both her and her roommate Resident #15 were yelling out for staff to come and get Resident #30 out of their room. Resident #46 reported when she went to stand up, she (Resident #46) grabbed onto her walker with her right hand. Resident #46 stated (Resident #30) grabbed onto my right arm/wrist twisting it and squeezing my wrist very hard. Resident #46 reported she started to holler out you are hurting me, stop you are hurting me. Resident #46 reported her right arm/wrist hurt for days afterwards and had some bruising. Resident #46 stated my wrist (right) hurt so bad because last year I fell and broke that arm, so it already had an injury . Resident #46 reported she is very afraid of (Resident #30) and has been for a while now . Resident #15 Review of an Admission Record revealed Resident #15, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 7/1/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #15 was cognitively intact. During an interview on 8/16/23 at 10:45 AM., Resident #15 reported a month or so ago Resident #30 entered her room and Resident #30 headed towards her (Resident #15's) roommate Resident #46. Resident #15 reported her roommate Resident #46 was sitting down in her own recliner. Resident #15 reported Resident #46 yelled for help and told Resident #30 to leave their (Resident #15 & Resident #46's) room. Resident #15 reported once Resident #46 started to yell out for staff help Resident #30 walked up to Resident #46 who was reaching for her walker attempting to stand up. Resident #15 reported she saw Resident #30 grabbing onto Resident #46's right wrist and twisting Resident #46's wrist while she (Resident #30) was squeezing Resident #46's right wrist. Resident #15 reported at that time both herself (Resident #15) & Resident #46 were yelling for staff's assistance. Resident #15 reported it took a few staff members to get Resident #30 out of their room and Resident #46 was crying during the incident and saying you are hurting me. Resident #15 reported after the incident Resident #46's right wrist was in a lot of pain, and she (Resident #15) could see bruises on Resident #46's right wrist the following day. Resident #15 reported Resident #30 continues to enters her room often, despite the stop sign on the doorway. During an interview on 8/16/23 at 4:35 PM., Nursing Home Administrator (NHA) A reported she was not aware of any incident of Resident #30 going into Resident #15 & #46's room and/or any concerns from Resident #15 & #46. NHA A reported she would look for any notes and or grievance forms regarding any incidents with these residents. NHA A reported she had just started as the new NHA at the facility and recalls a Care Conference meeting with family members of Resident #46 's towards the end of June/early July 2023. NHA A reported she does not recall the details of anything concerning from the care conference meeting with Resident #46's family member(s). Requested pertinent documentation on 8/16/23 at 4:45 PM., from NHA A including incident accident reports, concern/grievance forms, care conference notes and any information in regards to Resident #30's altercation with Resident #46. During a phone interview on 8/17/23 at 12:10 PM., FM H reported in late June 2023 another female resident (name omitted Resident #30) entered Resident #46's bedroom and grabbed her (Resident #46) by her right wrist/arm twisting and squeezing it. FM H reported it was very concerning that just anyone can walk in her (Resident #46's) room and do as they please. FM H reported Resident #46 suffers from anxiety, and when something triggers her (Resident #46), anxiety symptoms are panic attacks, tearfulness, stomach issues and at times Resident #46 needs a lot more reassurance from family members. FM H reported Resident #46 has changed rooms 3 times to get farther away from Resident #30. FM H reported Resident #30 has repeatedly entered Resident #46's room and has been found sleeping in Resident #46's bed. FM H reported Resident #46 has many family members that are in the facility often, and the family members are very involved with Resident #46's care. FM H reported there have been multiple calls from Resident #46 to family members about how afraid, and anxious Resident #30 makes Resident #46 feel. FM H reported she has been in the facility enough times along with other family members who have seen Resident #30's behaviors of going in and out of resident rooms, trying to get out of the doors, and lashing out at other residents and staff. FM H reported she had concerns about Resident #30 and wondered if staff are doing enough not only to protect Resident #46 and other residents, but also keeping Resident #30 safe from other residents who may lash out at Resident #30 when she goes into other rooms. FM 'H reported she requested a meeting after the incidents in June 2023. FM H reported a Care Conference was held and (NHA A) did not seem to be hearing my concerns. FM H stated (NHA A) and the other staff present told me my mom (Resident #46) was exaggerating the incident . FM H reported there was no exaggeration of the incident, everyone knows what Resident #30's behaviors are, and staff and management should be keeping a closer eye on Resident #30 for everyone's safety. FM H stated My mother (Resident #46) always says don't say anything because I (Resident #46) will get in trouble . It breaks my heart I had her put here (the facility) to be safe, and right now I don't feel it is very safe . FM H reported she and Resident #46 have requested many times the last few weeks from nurses and management a copy of the incident reports from Resident #30 sleeping in her (Resident #46's) bed, and grabbing her (Resident #46's) right wrist, and have not received the reports, let alone any communications about the incidents. FM H stated (Resident #46) is [AGE] years old, and was driving up until she (Resident #46) admitted here. I don't want my mom to live her last years in pain, fear and misery this has been a very difficult time for our family, we should not have to be this worried and fearful for (Resident #46) safety . Resident #30 Review of an Admission Record revealed Resident #30, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: dementia, severe, with agitation. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 6/11/23 revealed a Brief Interview for Mental Status (BIMS) score of 00/15 which indicated Resident #30 was severely cognitively impaired. Further review of the MDS assessment Behavior Symptom - Presence & Frequency revealed Resident #30 coded for #1. Wandering - Presence & Frequency Has the resident wandered .#1. Behavior of this type occurred 1 to 3 days . In a 7 day look back period Review of Resident #30's Care Plans revealed: 1/26/21 Focus- I (Resident #30) am an elopement risk/wanderer r/t (related to) dx (diagnosis) of dementia. I have a hx (history) of wandering into other resident rooms which significantly intrudes on other residents' privacy or activities Interventions: Staff to redirect me (Resident #30) out of other resident rooms and to my room or common area-Date Initiated: 11/16/2022 Redirect me (Resident #30) to my room or a common area before I enter into other resident's rooms-Date Initiated: 07/25/2023 7/05/2021 Focus-I (Resident #30) have potential to demonstrate physical/verbal behaviors such as swearing at other residents, going through my roommates' belongings, unplugging my roommates TV and becoming combative and slapping other resident that may be making noise, walking next to me or the general area. I (Resident #30) am very impulsive and unpredictable. I (Resident #30) do not single out certain residents or staff. I (Resident #30) can become physically and verbally combative without escalations or warning signs r/t Dementia with behavioral disturbances. I (Resident #30) can also become possessive over certain chair or couches. per family I prefer to sleep on a couch . 3/28/2023 Focus-I (Resident #30) have a behavior problem r/t dementia. I (Resident #30) have hx of breaking items, pushing things off tables and on to the floor, taking food off of other resident plates, taking other resident snacks out of their hands. I (Resident #30) will state I didn't do anything if asked about behaviors During an interview on 8/23/23 at 1:51 PM., MDS-RN (MDS/RN) V reported she recalled a month or so ago there was an incident when Resident #30 had to be removed from Resident #46's room. MDS/RN V reported it was about Resident #30 grabbing Resident #46's wrist. MDS/RN V reported she could not remember all the details of the incident. In an observation on 8/23/23 at 3:01 PM., Resident #30 was in main dining room attempting to push on the exit door to go outside. Resident #30 began to walk around the dining area, and then sat down on a chair. Resident #30 was noted to be tearful. In an observation on 8/23/23 at 3:16 PM., Resident #30 was walking near the nurse's station attempting to get into the medication cart. Resident #30 was randomly touching items on the nursing station counter, medication cart and then proceeded to attempt to open doors for shower rooms, conference room, and service hall entry door. Resident #30 then started to touch and pull on the hand sanitizer dispenser on the wall. Certified Nurse Aide (CNA) O came out of dining area, walked around the nurses' station, and noticed Resident #30 at the hand sanitizer dispenser. CNA O attempted to redirect Resident #30 with some difficulty at first, after approximately 10 minutes Resident #30 complied with CNA O's attempts at redirection and Resident #30 agreed to sit down in a wheelchair. Resident #30 was noted to be tearful during this observation. During an interview on 8/23/23 at 4:04 PM., Registered Nurse (RN) L reported there was an incident with Resident #46 and another resident (RN L could not recall 2nd residents name) a few months ago. The other resident wandered into Resident #46's room and staff had to intervene once they heard Resident #46 hollering for help. RN L reported Resident #46 does not typically exhibit behaviors. RN L reported she thinks the incident had to do with the other resident grabbing and twisting Resident #46's arm. During an interview on 8/23/23 at 4:39 PM., Licensed Practical Nurse (LPN) S reported Resident #30 had entered Resident #46's room a few months back and fell asleep in Resident #46's bed. LPN S reported she did not recall all the details but does remember that Resident #46 was out of the facility with family, and when they (FM H and Resident #46) returned to the facility they were upset because they wanted the bedding changed after Resident #30 had fallen asleep in the bed. LPN S reported not long after that something else happened where Resident #30 went into Resident #46's room again, and some sort of altercation happened. LPN S reported Resident #46 does not exhibit many behaviors at all but does get anxious when Resident #30 gets near her (Resident #46). LPN S reported Resident #46 is afraid of Resident #30. During an interview on 8/24/23 at 9:11 AM., Certified Nurse Aide (CNA) J reported there was an incident that Resident #30 went into Resident #46 room and slept in her bed. CNA J reported Resident #30 has a lot of behaviors and has many altercations with other residents. CNA J reported Resident #30 often wanders into other residents' rooms, lashes out and hit other residents, and has hit family members visiting residents who reside in the facility. CNA J reported Resident #46 does not have many behaviors, if any at all. CNA J reported Resident #46 can be anxious at times, but typically because a wandering resident is close to her doorway or trying to get into her room. CNA J reported she has worked with Resident #46 since her admission in late 2022, and to her knowledge has never hit, or become combative with any staff or other residents. CNA J reported Resident #46 was very pleasant, had a lot of family involvement and often went out of the facility with family and her friends. During an interview on 8/24/23 at 9:20 AM., CNA/SS P reported she now works as the Social Services (SS) staff member. SS P reported in her first week of being in the role of Social Services it was brought to her attention that Resident #30 had grabbed Resident #46's wrist. SS P reported shortly after hearing of the incident a meeting was held with NHA A, Director of Nursing (DON) B and Resident #46's FM H. SS P reported FM H was concerned about Resident #46's safety, and the fact that Resident #46 was afraid of Resident #30 and wanted us to ensure safety for Resident #46. SS P reported she has not had any behaviors from Resident #46 besides at times anxiety is increased. SS P reported Resident #30 has had multiple incidents/altercations with residents including a family member. Review of Resident #46's Electronic Medical Record (EMR) revealed documentation of: Nurse Practitioner (NP) Q 6/27/2023 09:06 onsite note .Chief Complaint: Chief complaint: patient (Resident #46) is seen today for right wrist pain .This is a [AGE] year-old female patient (Resident #46) who is seen today per nurse request .Patient (Resident #46) is a very concerned about her right wrist and forearm as she states that she is continuing to have pain in the area. She (Resident #46) said that her wrist and arm were twisted and twisted hard, and she (Resident #46) is not able to use her fingers like she did prior to that incident During an interview on 8/24/23 at 11:20 AM., Nurse Practitioner (NP) Q reported on 6/27/23 she had completed an examination of Resident #46. NP Q reported she (Resident #46) told me on 6/27/23 that a resident came into her room recently and she (Resident #46) was asking her (the other resident) to leave and then the other resident grabbed her (Resident #46's) wrist hard and twisted it. NP Q reported she did not know who the other resident was, but she (NP Q) did report to upper management. NP 'Q reported she has not heard of any behaviors from Resident #46 but at times has increased anxiety especially when residents who wander get close to her doorway or try to get in her room. NP Q stated she (Resident #46) was anxious just talking about it . that day she told me she (Resident #46) was fearful and anxious, she looked anxious about it NP Q reported she made sure the nurse (did not recall what nurse) knew about her (Resident #46's) anxiety at the time of her (NP Q's) visit and then ordered an x-ray of (Resident 46's) wrist. During an interview on 8/24/23 at 12:16 PM., MDS-RN V was re-interviewed and reported she was in attendance of a meeting with a few members (NHA A, CNA/SS, and FM H). MDS-RN V reported the meeting was regarding Resident #30 entering Resident #46's on multiple occasions, once falling asleep in her bed, and another time when Resident #30 entered and grabbed Resident #46's wrist. MDS-RN V stated I (MDS-RN V) know (NHA A) had spoken to Resident #46 and Resident #46 explained what happened to her wrist. MDS-RN V reported Resident #46 told (NHA A) that it was Resident #30 who grabbed and hurt her wrist. Resident #37 Review of an Admission Record revealed Resident #37, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: autistic disorder. Review of a Minimum Data Set (MDS) assessment for Resident #37, with a reference date of 6/24/23 revealed a Brief Interview for Mental Status (BIMS) score of 04/15 which indicated Resident #37 was severely cognitively impaired. Review of an Incident/accident for Resident #37 revealed: 6/7/2023 Writer was in nursing office and heard yelling coming from the nurses desk/dining room entrance area r/t (related to) an altercation happening between two residents. Writer and fell ow nurse ran to the dining room (both arriving at the same time) and observed .(Resident #42) holding (Resident#37's) right arm telling him (Resident #37) to stop yelling like that Resident Description: (Resident #37) .He pinched me . Resident #42 Review of an Admission Record revealed Resident #42, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia, severe with psychotic disturbance. Review of a Minimum Data Set (MDS) assessment for Resident #42, with a reference date of 5/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 03/15 which indicated Resident #42 was severely cognitively impaired. Review of an Incident/accident for Resident #42 revealed: 6/7/2023 Writer was in nursing office and heard yelling coming from the nurses desk/dining room entrance area r/t an altercation happening between two residents. Writer and fell ow nurse ran to the dining room (both arriving at the same time) and observed (Resident #42) holding (Resident#37's) right arm telling him to stop yelling like that Resident Description: The only comment resident (Resident #42) gave writer at the time of the incident was this guy (Resident #37) shouldn't be in here yelling at people like that . Review of an Incident/accident for Resident #42 revealed: On 6/22/23 About 0730 CNA called for assist 100 hallway outside of room [ROOM NUMBER]. Writer observed resident (Resident #42) intertwined with CNA and resident 1435 (unknown resident). CNA states they were inside room assisting when they heard (Resident #42) state I'm gonna punch you in the gut .CNA opened door and saw (Resident #42's) hand make contact with 1435 (unknown resident) stomach (surveyor noted discrepancy on the incident/accident report with resident identifier 1435, unable to locate resident 1435 in facility electronic medical record (EMR) .). During an interview on 8/23/23 at 3:30 PM., Certified Nurse Aide (CNA) N reported Resident #42 had a lot of behaviors, was difficult to redirect, and at times he has struck out at other residents and staff. CNA N reported the staff had to keep a very close eye on Resident #42 along with quite a few other residents such as Resident #30 who were known to wander and roam into to other residents personal space. CNA N reported both Resident #30 and Resident #42 have had multiple resident to resident altercations with other residents, and both Resident #30 and Resident #42 sometimes just randomly would lash out. Review of the policy, Abuse and Neglect, reviewed 07/11/23, revealed: It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The term abuse (abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation) will be used throughout this policy unless specifically indicated .Reporting .It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility .Serious Bodily injury: The term serious bodily injury is defined as an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation .Serious Bodily Injury reporting - 2 Hour Limit: If the events that cause reasonable suspicion and allegation involve abuse or result in serious bodily injury to a resident, the covered individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion .All other injury reporting - Within 24 Hours: If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the covered individual shall report the suspicion not later than 24 hours after forming the suspicion .Harm is a negative outcome that has compromised the resident's ability to maintain or reach the highest practicable physical, mental, or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services .

This deficiency is related to Complaint Intakes MI00131768 and MI00136585. Based on observation, interview, and record review, the facility failed to provide care to prevent skin breakdown, promote healing, and prevent infection related to pressure injuries for two Residents (R104 and R155) out of two residents reviewed for pressure injuries. This deficient practice resulted in harm to R104 when their pressure ulcer wound infection progressed to organ failure, and the development of facility acquired pressure injuries for both R104 and R155. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. Resident R104 Review of R104's MDS assessment, dated [DATE], revealed R104 was readmitted to the facility on [DATE] with active diagnoses that included: stroke, heart failure, coronary artery disease (CAD), hemiplegia (paralysis of one side of the body), malnutrition, depression, and chronic obstructive pulmonary disease (COPD). R104 scored 9 of 15 on the BIMS, reflective of moderate cognitive impairment. Skin conditions identified in Section M - Skin Conditions of the MDS assessment revealed R104 had one Stage II, and one Unstageable pressure injury. Section E0800. Rejection of Care - Present & Frequency was documented on the [DATE] MDS assessment as 0. Behavior not exhibited. R104 required extensive, one-person physical assistance with bed mobility. During a telephone interview on [DATE] at 5:44 p.m., Family Member (FM) EE reported the facility Nurse Practitioner (NP) Q had told FM EE that R104 had gone septic (when an infection-fighting process turns on the body, causing the organs to work poorly) from (infected) pressure injuries. FM EE stated, [NP Q] acknowledged that [R104's] rapid decline was due to the wounds (infected pressure injuries). FM EE said she was unaware that [R104] had significant wounds (pressure injuries). FM EE, also an advanced practice medical clinician, stated, I assumed and put my trust in them that they would do the right thing in putting a barrier on the wound and change (R104's) position. FM EE stated, We (family members) were the ones that ended up turning (repositioning) him, because nursing care was not there. That is when we discovered how bad the wounds were. I don't believe they even had dressings . The one on his hip was necrotic (covered with black eschar). The tissue was black and dead and there was a foul odor. He was laying directing on the sacral wound . They told us to wear gloves when we touched him . I would have expected the wounds to have dressings (applied to them) and the wounds to have been debrided . seeing how severe it was, it was concerning . Observation of undated photographs provided by Complainant FF showed the following: Photo 1: appeared to be a large right trochanter (hip) pressure injury covered with blackish eschar, making the wound unstageable. Photo 2: a small heel pressure injury, scabbed over with residual yellow colored topical ointment/liquid similar to iodine color on the wound. Photo 3: a large, coccyx/sacral pressure injury with black eschar, yellowish slough, and irregular wound edges. Wound was bordered by pink, inflamed skin with apparent infectious process. No dressing was visible on the wound, and the bedding underneath the R104 was partially saturated with bloody, and brownish puss. This wound appeared to be unstageable. Photo 4: a picture of the large coccyx/sacral pressure injury from the side view, showing the tissue swelling and discoloration around the area of the wound. Review of a [DATE] Incident Reported related to development of multiple Stage II pressure injuries, one to coccyx and one under the right gluteal fold, revealed the following, in part: [RN V] assessed the area and documented in the Skin and Wound application the presence of the two (new) pressure injuries. During an interview on [DATE] at 1:58 p.m., the DON was asked to review R104's last six months of nursing progress notes for any documentation from the nursing staff that R104 had refused turning and repositioning. The DON reviewed progress notes from [DATE] through [DATE], and following her review said that no documentation of [R104's] refusal to turn or reposition was found in any of the six months of nursing notes.). When asked what nursing staff would be expected to do if a CNA reported [R104] had refused turning and repositioning, the DON stated, I would expect the nurses to make a progress note. When asked if it would also have been documented as a refusal in the Certified Nurse Aide (CNA) documentation on turning and repositioning, the DON stated, Honestly, I don't know if they can document a refusal on turning and repositioning. The DON confirmed the CNA Task to document on resident repositioning was not set up for documentation. When asked how I would know [R104] refused repositioning, or was just not repositioned by facility staff, the DON looked at me silently, and after a silent delay stated, I get what you are saying. When asked what documentation was available as evidence to show R104's refusal to turn and reposition, the DON remained silent and did not answer. At this same time the DON was asked to review R104's coccyx/sacral wound where there were two separate openings, one below the sacral wound that showed a depth was present but was not documented on the Skin and Wound documentation. The DON agreed there were two wounds visible on this picture, one above and one below. When a copy of the wound documentation was requested, the DON stated, I really don't know about wounds because I don't do the wounds. I honestly don't know how to print this. During an interview on [DATE] at 2:18 p.m., the DON was asked for what physician orders were in place at the time of identification of R104's greater trochanter (right hip) wound. The DON reviewed R104's physician orders, prior to his expiration in the facility on [DATE], and when the review was completed, the DON stated, I don't see one (physician order for greater trochanter pressure injury treatment). Review of R104's Physician Orders between [DATE] and [DATE], provided by the facility on [DATE], revealed the following, in part: 1. Apply betadine to pressure ulcer on medial aspect of left heel. Cover with 4x4 and wrap with gauze every day shift for wound care. Start Date [DATE], End Date [DATE]. 2. Apply Butt Paste to open areas surrounding coccyx BID (twice daily), every day and evening shift for Pressure ulcers. Start Date [DATE], End Date [DATE]. 3. Coccyx Ulcer: Cleanse with wound wash, Apply skin prep around wound. Apply Medi honey to yellow necrotic area. Cover with 4x4 and change QD every day shift. Start Date [DATE], End Date [DATE]. 4. Dolphin (Specialty pressure reduction mattress), Order Date [DATE], NO Start Date, End Date [DATE]. 5. Dressing change to unstageable pressure ulcer Right hip. Cleanse with NS (normal saline), apply skin prep over area, cover with an Allevyn. Change every 48 hours every day shift every other day for pressure ulcer. Start Date [DATE], End Date [DATE]. 6. Dressing change to unstageable pressure ulcer right hip. Cleanse with NS, apply skin prep around wound bed, cover wound bed with Medi honey and 4x4 gauze every day shift for pressure ulcer. Start Date [DATE], End Date [DATE]. 7. hospitalization FOR ACUTE TREATMENT IF DEEMED NECESSARY BY THE PHYSICIAN. Start Date [DATE], End Date [DATE]. 8. NO intravenous hydration. YES, to IV antibiotic Therapy. Order Date [DATE], NO Start Date, End Date [DATE]. Review of R104's Pressure Injury Timeline, provided by the Nursing Home Administrator (NHA) on [DATE] at 12:15 p.m. [Central Daylight Savings Times (CDST)] revealed the following information: [DATE], Coccyx Pressure - [NAME] Terminal Ulcer Unstageable (Note: Photo observation of two separate wound areas: coccyx with visible depth, and sacral enlarged with slough and eschar.) [DATE], Coccyx Pressure - [NAME] Terminal Ulcer Unstageable 3.91 cm 2.16 cm (Note: Two wounds present in photo, coccyx pressure injury and sacral pressure injury.) [DATE], Coccyx Pressure Stage 2 0.51 cm 0.39 cm (Note: photo shows dressing covering sacral area previously reddened and coccyx pressure injury.) [DATE], Coccyx Pressure Stage 2 0.81 cm 0.59 cm [DATE], Coccyx Pressure Stage 2 0.39 cm 0.39 cm [DATE], Coccyx Pressure Stage 2 0.77 cm 0.55 cm [DATE], Coccyx Pressure Stage 2 0.71 cm 0.63 cm [DATE], Coccyx Pressure Stage 2 0.9 cm 0.73 cm Re-opened Sep 19, 2022, Coccyx Pressure Stage 2 0 cm 0 cm Resolved. [DATE], Coccyx Pressure Stage 2 0.79 cm 0.39 cm [DATE], Coccyx Pressure Stage 2 0.92 cm 0.43 cm [DATE], Coccyx Pressure Stage 2 0.61 cm 0.3 cm [DATE], Coccyx Pressure Stage 2 0.46 cm 0.79 cm [DATE], Right Trochanter Pressure Unstageable 2.25 cm 4.08 cm (Note: Photo observation shows wound bed all necrotic with dark eschar.) [DATE], Right Trochanter Pressure Unstageable 3.34 cm 5.74 cm [DATE], Right Trochanter Pressure Unstageable 5.35 cm 4.22 cm [DATE], Right Trochanter Pressure Unstageable 3.33 cm 2.44 cm [DATE], Right Trochanter Pressure Unstageable 4.53 cm 5.67 cm [DATE], Right Trochanter Pressure Deep Tissue Injury 5.67 cm 7.21 cm New (Note: showed a photo of R104's right trochanter with a deep purple bruise inside a much larger reddened and abraded right hip. Appears to have resulted from a fall or trauma injury to the right hip. The dimensions as listed on the Wound Evaluation revealed an area of 29.96 centimeters (cm), length of 5.67 cm and with of 7.21 cm.) Review of R104's right trochanter Wound Evaluations revealed the following, in part: 1. [DATE] showed a photo of an open wound, covered with yellowish slough, with an apparent depth to the wound that was not measured. 2. [DATE], showed a photo of the right trochanter with two separate wound areas on the right hip partially covered in slough. 3. [DATE], showed a photo of the right trochanter, significantly enlarged (measurements: area: 16.38 cm2, Length 5.35 cm, Width 4.22 cm) with two separate areas open, with visible in the photo with an unmeasured depth. 4. [DATE], showed a photo of the entire greater trochanter area with dark, necrotic eschar covering the entire, previously multiple wound areas. Measurements of: Area 13.25 cm2, Length 3.34, Width 5.74. Significant worsening of wound visibly apparent in the photo. Review of Physician visits for R104 between ,d+[DATE] and ,d+[DATE] revealed physician visits were performed on [DATE] and [DATE] for R104. Review of R104's Care Plans revealed the following: 1. Focus: I have had a Cerebral Vascular Accident (Stroke), Date Initiated: [DATE] . Interventions . Turn and Reposition q (every) 2 hours and PRN (as needed), Keep body in good alignment. Date Initiated: [DATE], Canceled Date: [DATE] (date of expiration). 2. Focus: Bowel/Bladder . I am only to wear blue incontinence pads, no underwear, briefs, or pullups as they can cause pressure injuries. Date Initiated: [DATE], Cancelled Date: [DATE]. 3. Focus: Hx of reoccurring pressure injury to my coccyx and heels r/t hx of pressure injury, immobility, poor nutrition, and failure to thrive. I have unavoidable pressure injury to left heel and coccyx r/t refusal to eat refusal of medications and noncompliance with turning and repositioning program. Date Initiated: [DATE], Cancelled Date: [DATE] . Interventions/Tasks: Avoid positioning me on my coccyx area. I am often noncompliant with reposition wedge. Remind me the importance of keeping pressure off coccyx. Date Initiated: [DATE], Cancelled [DATE] . Follow facility policies/protocols for the prevention/treatment of my skin breakdown. Date Initiated [DATE], Cancelled Date [DATE]. 4. Focus: Comfort Measures Only . Date Initiated [DATE], Date Cancelled: [DATE]. 5. Focus: ADLs (Activities of Daily Living . BED MOBILITY: I am an Assist x 1, Date Initiated: [DATE], Cancelled Date: [DATE]. During an interview on [DATE] at 2:44 p.m., RN V was asked for any evidence to show R104 refused turning and repositioning by facility staff. RN V said there was no task for turning and repositioning that was documented by the CNAs. When asked how a CNA would document that R104 did refused turning and repositioning, RN V said they (CNAs) would have to tell their nurse who would do a progress note. RN V stated, Apparently they (CNAs) do not document turning and repositioning at all . During an interview on [DATE] at 11:35 a.m., CNAs CC and N confirmed they had provided direct care to R104 when he was in the facility. When asked how they had documented R104's refusal to turn and reposition, CNA CC and N looked puzzled, individually, and then looked at each other with a questioning look, eyes raised. CNA N stated, He didn't refuse. CNA CC also said he never refused. When asked if CNA CC and CNA N believed R104 was consistently repositioned by facility staff, both said they did not think he was always repositioned. During an interview on [DATE] at 2:46 p.m., NP Q was asked what she had told the family regarding R104's sudden decline prior to his death on [DATE]. NP Q said they would need to review notes related to R104. NP Q said R104 had the pressure injuries four, five, and six months prior to his death. NP Q said R104 refused a lot of turning, which had been reported to her by the nursing staff she rounded with. NP Q stated, I was very open and honest with the family that the infected pressure ulcers were the cause of the decline (R104's rapid decline) . it developed rather quickly. NP Q said it looked like a terminal Kennedy ulcer to her, and agreed the right great trochanter, and coccyx/sacral wound were all unstageable. NP Q stated, There was thought about antibiotics. There was discussion about going to the wound clinic. When asked if those discussions were documented, NP Q turned her head from side to side, and stated, I hope I documented that. When asked if the pressure ulcer wound infections were a factor in R104's organ failure (including renal and heart failure), NP Q paused and stated, It is a combination of all three (pressure ulcer infection, renal and heart failure). One (the pressure ulcer infection) led to the other two (renal and heart failure). When asked to clarify that the pressure ulcer wound infections lead to R104's organ failure, NP Q acknowledged that was her belief. Resident #155 During an observation on [DATE] at 12:06 p.m., Licensed Practical Nurse (LPN) D assisted R155 to stand for an observation of a potential pressure injury following a staff transfer. A pressure ulcer dressing was applied to the coccyx area this morning by [NP Q]. Observation of the coccyx area revealed a small, circular Stage II pressure injury on R155's left, interior buttock cheek. The pressure injury had no drainage, and no slough was present on the wound. R155 stated, It was really killing me back there (left buttock) . After repositioning it really hurt. During an interview on [DATE] at approximately 12:15 p.m., NP Q confirmed she had examined R155 that day and applied a dressing to a Stage II pressure injury on R155's left inner buttock. NP Q confirmed it was not a sacral or coccyx wound but would be considered a left inner buttock pressure injury. Review of R155's Care Plans, with the following interventions all updated [DATE], revealed the following, in part: - I have pressure injury to buttock. Date Initiated: [DATE]. - Interventions will be put in place to prevent decline in wound and maintain my comfort. - Administer treatments as ordered and monitor for effectiveness. - Assess me and attempt to determine underlying cause of wound, alleviate causes if possible. - Assess/record/monitor wound healing per facility policy. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. - Educate me/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. - Encourage fluids with each interaction. Review of R155's Physician Orders revealed the following, in part: Foot cradle for end of bed at all times, every shift for skin integrity. -Order Date: [DATE] 19:29 (7:29 p.m. CDST) Cleanse coccyx wound with wound wash, apply skin prep around area, apply Lidocaine 4% cream to wound, cover with Allevyn. every day shift every 2 day(s) for coccyx wound until healed. Start Date: [DATE] 0600 (6:00 a.m., CDST) Cleanse coccyx wound with wound wash, apply skin prep around area, cover with Allevyn. every day shift every 2 day(s) for coccyx wound until healed. -Start Date: [DATE] -D/C (discontinue) Date: [DATE] During an interview on [DATE] at 9:42 a.m., Resident #155 reported they sustained a pressure ulcer (on [DATE]), shortly after their admission to the facility, when they were positioned in bed incorrectly with the bed pad, causing shearing of their buttocks skin. Resident #155 described the incident as follows: I could feel the [skin] tear after they [nursing staff] lifted the edges of the [bed] pad, and it felt like a knife going in. They were going to roll me to the center of the bed, and [when] they pulled on the pad, I said, 'Oh my goodness,' and after that they started using a [wound treatment] cream. Resident #155 reported the new pressure ulcer was still present, and was located a bit lower than the tailbone, and clarified, It hurts. As soon as I move the wrong way, then I feel it again. My son and daughter know. They [family] were very disappointed in it [the development of the pressure ulcer]. During an interview on [DATE] at 12:55 p.m., R155 was sitting in a recliner, with bilateral feet elevated on the recliner footrest. When asked about any sores on her bottom, R155 stated, Well I talked to the Doctor (NP Q) who said that they were going to try lidocaine on a patch to help with the pain from the pressure injury. R155 said they had not started the lidocaine and the pressure injury was still painful. R155 said they had not been in to do the dressing changes, since the dressing was changed last week. R155 said she had asked if they could take the foam dressing off at night and that is what they had been doing. R155 said they had not put any lidocaine on her dressing as she had not had pain relief. R155 said when the staff sat her straight up in bed or in the chair, she sits right on the pressure injury, and it is really painful then. The resident said she knew they were not supposed to sit her straight up, but all the staff didn't know that. Review of R155's Physician Visit Progress Notes revealed the following: [DATE] Physician Visit - review of integumentary - no mention of any pressure injuries. [DATE] Physician Visit NP - Asked to see pressure injury HPI: This is a [age] female with a history of COPD and heart failure is seen today per nurse request to assess open area on the left buttocks. The area was originally a shearing wound of unknown etiology. Over the past 24 hours staff report that the wound has become larger. Patient states that she is having pain in the area where the wound is present. She states that she has a hard time staying off of the area when she is up in her wheelchair and reclining chair. She states that she needs the head of the bed elevated at 45 degrees in order to breathe at night and it is very uncomfortable for her to lay on her side . The nurses were applying butt paste to the area bid and prn, but the wound has increased in size and depth and requires a different treatment . NP .Integumentary: Stage 2 pressure ulcer on left buttocks. Measured by nurses using the PCC wound app - (0.63 x 0.59 cm) x 0.1 cm, wound with 90% granulation tissue and 10% yellow slough, no drainage noted, no warmth or evidence of infection noted .1.: Pressure ulcer of left buttock, stage 2. Abrasion left buttocks with no stage II pressure ulcer. Wound was being treated with butt paste, but it has increased in size . Staff instructed to report any change in status of the wound to this provider . Review of R155's Treatment Administration Record (TAR) on [DATE] 01:04 p.m., revealed the left inner buttock cheek pressure injury was described as a coccyx wound. The sacral bruising was identified as a Stage II sacral pressure injury on [DATE] by NP Q. During an interview on [DATE] at 2:22 p.m., the DON asked to review Skin and Wound Documentation and provide date of First development of R155's left buttock wound. The DON reviewed the computer screen silently, as she tried to determine when the wound originated for R155. The DON stated, No, I do not see a skin and wound documentation for [DATE]) . I guess I can't be sure when this started. Review of the Wound History Screen on the DON computer showed R155's left inner buttock wound was initially assessed by RN V 14 days ago, on [DATE]. [Regulatory Compliance Officer G] updated 155's Wound Evaluation 5 days previous on [DATE]. Measurements were 0.31 area, 0.76 cm length, and 0.55 cm width. The Photo taken on [DATE] showed an abrasion pressure injury with top layer of skin off R155's left interior buttock cheek. The photo taken on [DATE] included measurements of 0.63 cm length x 0.59 cm width. R155's right interior buttock pressure injury was listed as new on [DATE]. When asked when the wound started, the DON stated, It appeared that it started on the 8th, when that (the initial wound) was found. During an interview on [DATE] at 2:35 p.m., RN V said R155's right interior buttock cheek wound started as an abrasion. RN V confirmed the second, [DATE] photo of the wound appeared more like a pressure injury. RN V confirmed that the CNAs are responsible to report any new skin changes. RN V stated, I think that they (CNAs) interpret that if it (wound) was there (already), they would not have to report any changes in a previously identified skin concern. During an observation on [DATE] at 3:34 p.m., Resident R155 was laying on her right side in bed. The old dressing, which was not dated or initialed was removed from R155's right buttock. Licensed Practical Nurse (LPN) S confirmed there was no date or dressing on the dressing removed from R155.

This citation relates to Intake #MI00138093. Based on interview and record review, the facility failed to provide effective safety interventions to prevent two falls with major injury (a hip fracture with surgical fixation, and a non-operable femur fracture) for one Residents (#154) of six residents reviewed for falls. This deficient practice resulted in surgical intervention, hospitalization , functional and medical decline, and increased pain requiring additional opioid pain medication. Findings include: All times are noted in Eastern Daylight Time unless otherwise noted. Review of Resident #154's Emergency Department transfer report, dated 05/20/23 at 2309 [11:09 p.m. report time] revealed, [Hospital EMS] is dispatched to [facility] to transport a female patient [Resident #154] with possible broken hip to [hospital] . Upon immediate response arrived to find the patient [Resident #154] lying supine in bed on 3L [Liters] O2 [Oxygen] via NC [nasal cannula]. Patient states she was walking without her walker when she fell , landing into a wall and then falling to the ground. Patient hit head on a radiator, denies loss of consciousness, blurred vision, or headache. Patient states she got up and was unable to bear weight on the right side Staff heard pt fall in bedroom. Stated she fell while trying to open her window without using her walker . Review of Resident #154's emergency room History and Physical report, dated 05/20/23 at 2302 [11:02 p.m.], revealed, Patient [Resident #154] presents to emergency department via EMS [ambulance] after she had a mechanical fall. [Resident #154] states that she could not find her walker and 1 of the nurses was looking for when she tried to get up and go ahead walking. She tripped and fell injuring her right hip and also hit the right side of her scalp .Medical Decision Making: Closed nondisplaced [properly aligned] intertrochanteric fracture of right femur, initial encounter, acute illness or injury. Contusion of scalp. Going to [higher acuity hospital for surgery] hospital emergency department .X-ray hip and pelvis shows a right hip fracture. CT head is read negative . Review of Resident #154's Emergency Department transfer report, dated 05/20/23 at 2309 [11:09 p.m. report time] revealed, [Hospital EMS] is dispatched to [facility] to transport a female patient [Resident #154] with possible broken hip to [hospital] . Upon immediate response arrived to find the patient [Resident #154] lying supine in bed on 3L [Liters] O2 [Oxygen] via NC [nasal cannula]. Patient states she was walking without her walker when she fell , landing into a wall and then falling to the ground. Patient hit head on a radiator, denies loss of consciousness, blurred vision, or headache. Patient states she got up and was unable to bear weight on the right side Staff heard pt fall in bedroom. Stated she fell while trying to open her window without using her walker . Review of Resident #154's acute hospital stay discharge summary, dated 05/25/23, revealed Resident #154 had a discharge diagnosis of Fall with right intertrochanteric hip fracture, status post short intramedullary nail placement [internal fixation to repair the fracture], metastatic lung cancer .COPD without exacerbation, oxygen dependent, chronic atrial fibrillation [heart rhythm irregularity] . Anticipated discharge date was noted as 05/26/23. During a phone interview on 8/11/23 at 4:33 p.m., Family Member (FM) BB reported Resident #154 had a fall with a hip fracture at the facility on 5/20/23, when there was no walker at Resident #154's bedside, and the nursing aide left. Resident #154 was left unattended when they went to get find a walker. FM BB reported they observed Resident #154 could not stand up properly on admission to the facility on [DATE] and had been given a walker by physical therapy to transfer, due to leg weakness and debility from pneumonia, malnutrition and other medical conditions. FM BB clarified they knew Resident #154 was at high risk for falls, and her room was hot and Resident #154 got up and tried to open the window, and slipped and hit her head on the radiator, and sustained had a hip fracture, which required surgical intervention. FM BB reported during their visits, Resident #154 often waited up to 30 minutes for their call light to be answered. FM BB stated staff would complain about Resident #154 having their call light on, and Resident #154 would call her spouse in the night, as her call light wasn't being answered. FM BB added Resident #154 had a second fall on 6/3/23 out of bed, without injury, and a third fall on 6/6/23, when she fractured her femur, which was non-operable due to Resident #154's medical frailty. FM BB explained Resident #154 required five stiches to her head after the fall on 6/5/23, was hospitalized , and did not return to the facility. FM BB conveyed they were unclear how this third fall occurred out of bed, as they did not believe Resident #154 was strong enough to get out of bed herself. FM BB reported all of Resident #154's falls occurred when she was left alone, without a walker, and had inadequate supervision. FM BB reported they had asked for additional fall interventions, such as bedrails or an alternative mattress but none were provided, although reportedly promised to them by the facility management. Review of Resident #154's Minimum Data Set (MDS) assessment, dated 5/20/23, revealed Resident #154 was admitted to the facility on [DATE], with diagnoses including respiratory failure with hypoxia (low oxygen), lung disease, heart failure, depression, and malnutrition. The assessment revealed Resident #154 was 65 tall and weighed 84# upon admission. The assessment showed Resident #154 required supervision for bed mobility, transfers, walking, and toileting. Resident #154 was admitted on opioid [narcotic, controlled classification] pain medication. Review of #154's MDS assessment, dated 5/29/23, revealed Resident #154 was readmitted to the facility on [DATE], with a new diagnoses of hip fracture and surgical repair with fixation [securing of joint]. The assessment revealed Resident #154 required extensive two-person assistance with bed mobility and toileting, and was unable to perform transfers or walking, and showed Resident #154 was occasionally incontinent of urine, and was incontinent of bowel. The assessment revealed Resident #154 required additional days of opioid pain medications. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 10/15, which showed Resident #154 had moderate cognitive impairment. The assessment showed Resident #154 required use of a walker for functional mobility. Review of Resident #154's Accident and Incident Report, dated 5/20/23 at 19:50 p.m. (7:50 p.m.), revealed Resident #154 was found lying on the floor on their right hip at the end of their bed in front of the window, facing the window. Resident complained of right hip pain 10/10 pain (with 10 being the highest), and reported she hit her head on the heater vent. Her right leg was described as shorter than the left, and she was unable to move her right leg without severe pain. She was wearing regular socks and was ambulating without her front wheeled walker. Resident #154 stated she was trying to open the window and lost her balance. The staff named as present was Certified Nurse Aide (CNA) X. Review of Resident #154's progress note, dated 05/20/23 at 22:20 (10:20 p.m.), by Registered Nurse (RN) V, revealed Resident #154 was ambulating without assistance and fell and hit her head and her right hip while trying to open the window in her room, and was sent to the Emergency Department. The note revealed Resident #154's spouse was notified, along with physician and the Administrator. Review of facility documentation provided related to this incident via emails and multiple requests from the team leader showed no interviews or witness statements by CNA X or RN V related to this fall/incident on 05/20/23. Review of Resident #154's progress noted, dated 05/26/23 at 18:44 [6:44 p.m.], revealed, Resident [#154] was a return admit to our facility after surgical repair of a right hip fracture at 1430 [2:30 p.m.] today via ambulance .Resident [#154] has two surgical wounds covered with bandages to right thigh, uses bed pan .husband visiting at this time . Review of Resident #154's Fall Care Plan, accessed 7/24/23, revealed, I am at risk for falls at home with injury, rt [related to] fx [fracture] with surgical repair, weakness, SOB [short of breath] overestimation of ability Ensure that I am wearing appropriate footwear (non-skid socks] when ambulating or mobilizing in w/c .I utilize a FWW [front wheeled walker] for ambulation; ensure it is placed near my bed to prompt me to use it and ask for assistance . Review of Resident #154's Mobility (activities of daily living) Care Plan, accessed 7/24/23, revealed, Mobility. 05/18/23 .Ambulation: assist with FWW. Date initiated: 05/18/23 .Mobility device: Walker. Date initiated: 05/18/23. Transfers: Physical Assist x 1. Date initiated: 05/18/23 . Review of Resident #154's fall assessment report, dated 5/20/23 at 22:22 [10:22 p.m.] revealed a score of 80, which showed Resident #154 was deemed a high fall risk, given any score above 45 was designated as high fall risk. Review of Resident #154's pain assessment, dated 5/20/23 at 20:00 [8:00 p.m.], revealed pain at the right trochanter (hip) at sharp pain with movement and 10/10 pain [with 10 as the highest pain]. Review of Resident #154's Accident and Incident Report, dated 6/5/23 at 01:51 a.m by RN W, revealed, .We [nursing staff] were at the nurse's station and heard a 'thump'. Resident [#145] was sitting on the floor in her room in front of the closet, facing the window. She had a 3 cm [centimeter] laceration above her right eye. She complained of pain [radiating] from her right hip to right knee. [Resident #145 was] unable to bear weight on right leg. [Resident #145 was] Assisted to bed. Cleansed and applied ice pack to laceration above eye .Orders to send to ED [emergency department] for evaluation. Report called to ED 911 called and resident out with ambulance .[Resident #145] was wearing grippy socks and a hospital gown at the time of the fall .Resident [#145] stated she was attempting to toilet herself but later stated she was going [walking] to the closet] . Pain level was 2/10. The intervention in this fall report was: 06/05/23: I utilize a FWW [front wheeled walker] for ambulation; ensure it is placed near my bed to prompt me to use it when ambulating independently. This intervention revealed Resident #145 did not have their walker designated on the Care Plan until 06/05/23, after their third fall, although physical therapy designated use of the walker for transfers and mobility at the time of therapy evaluations on 05/18/23 and 05/26/23 and during subsequent sessions per their documentation, interviews, and therapy progress notes. Review of RN W's witness statement, dated 06/05/23, revealed, Staff [nursing staff] heard a 'thump' and went to investigate. Resident [#154] was sitting on the floor in front of her closet, facing the window. There were no additional witness statements provided, and no additional description of incident, per request. During a phone interview on 08/22/23 at 8:34 a.m., Resident #154's Power of Attorney (POA) Y, was asked about Resident #154's falls at the facility. POA Y reported the first time Resident #154 fell at the facility (on 5/20/23) and fractured her hip, she did not have a walker in her room, which concerned them. POA Y reported the staff were not answering the call light timely, and just prior to the fall (the same day) Resident #154 called him because she had waited 45 minutes for assistance. POA Y stated, [Resident #154] should have been supervised more and had her walker with her. POA Y reported [Resident #154] had been given a walker upon arrival to the facility by physical therapy, on 5/18/23, and should have been wearing gripper socks during one of the falls (on 05/20/23) and required use of a walker for transfers and ambulation during her stay. During an interview on 8/23/23 at 9:34 a.m., the Rehabilitation Director, Physical Therapy Assistant U, was asked about Resident #154's falls, and when the walker was provided. PTA U reported Resident #154 was evaluated by Physical Therapy on 5/18/23, and confirmed they treated her frequently during therapy. PTA U recalled a walker being provided to Resident #154 in their room upon evaluation on 5/18/23, as they had reviewed the physical therapy evaluation and had treated Resident #154 before their fall on 5/20/23. PTA U stated, Every day we came to transfer [Resident #154] she had a walker in her room. When asked if Resident #154 should have been wearing gripper socks when she fell on [DATE], PTA U affirmed Resident #154 should have always had on gripper socks, as her gait was unsteady at times. Review of Resident #154's Physical Therapy progress note, dated 05/19/23, and reviewed with PTA U, showed Resident #154 was using a FWW during the treatment, and PTA U confirmed they should have always had a walker during transfers in their room. PTA U reported Resident #154 was very unsafe without the walker, and staff had been instructed to transfer Resident #154 with the walker, including during their entire stay, for functional transfers with staff assistance. Review of Resident #154's nursing progress note, dated 5/18/23, at 20:15 [8:15 p.m.] revealed, Resident [#154] arrived with husband from [hospital]. [Resident #154] ambulates with SBA [stand by assistance] and walker .Stage 1 pressure area to coccyx. A & O x 3 [alert and oriented x three spheres], able to verbalize. Continent of B & B [bowel and bladder]. Further review of Resident #154's Care Plan revealed there was no Care Plan intervention added for Resident #154 to have their walker available for transfers until 6/5/23, after the second fall with major injury (femur fracture, non-operable). A telephone call was placed on 8/23/23 at 11:27 AM to interview RN W regarding Resident #154's falls on 5/20/23 and on 6/5/23, however no call was returned by the end of the survey. A telephone call was placed on 08/23/23 at 11:32 a.m. to interview CNA X regarding Resident #154's fall on 5/20/23. No call was returned by survey exit on 08/24/23. Surveyor reviewed schedule of staff working on 06/05/23 night shift at the time of Resident #154's fall on 6/5/23. RN V verified this was the shift the fall occurred, which was verified by the incident report time. The schedule showed CNA P, CNA J, and CNA Z were working on the night shift on 6/5/23 when the second fall with major injury occurred for Resident #154. A telephone call was placed on 8/24/23 at 07:57 a.m. to interview CNA Z regarding the incident (as they worked the night shift on 8/24/23), with no call returned by the end of the survey. During an interview on 8/24/23 at 9:04 a.m., CNA J was asked about Resident #154's fall with major injury on 6/5/23 and had no recollection of the incident. During an interview on 8/24/23 at 9:10 a.m., the nursing aide schedule dated 6/5/23 for the night shift was reviewed with CNA P. CNA P acknowledged they were working on 6/5/23 on the shift when the incident occurred but had absolutely no recall of the details of Resident #154's fall. CNA P verified they were working in the building as a CNA and on shift (6/5/23) when the fall occurred. The schedule on 6/5/23 did not specifically designate who was assigned to Resident #154's hall. CNA P reported all staff shared resident responsibilities, and this was why the schedule did not designate who was working on Resident #154's hall (the 300 hall). During an interview on 8/24/23 at 10:12 a.m., RN V was asked about Resident #154's fall on 5/20/23. RN V reported they were on shift doing medication pass when one of the aides heard yelling and a thump and went into [Resident #154's] room and notified them Resident #154 was on the ground by the window. RN V confirmed Resident #154 reported they were trying to open the window and CNA X was working when the incident occurred. RN V clarified CNA X reported they had left Resident #154 alone, as they went to look for Resident #154's walker, and thus the fall was unwitnessed. RN V confirmed Resident #154 should have had her walker by the bedside, as she used a walker for mobility at that time, since admission, and understood the concern with Resident #154 not having the walker readily available and not wearing gripper socks. RN V denied any abuse occurred and reported Resident #154 did not have a roommate at that time. RN V reported no abuse concerns were discovered or reported to them by family or staff. RN V denied any staffing concerns when the fall occurred. Surveyor requested documentation of Resident #154's daily pain levels during this interview and did not receive this information by time of survey exit. RN V reported they did know the details of Resident #154's fall on 06/05/23, as RN W was the nurse who worked on 6/5/23, and they no longer worked at the facility. During an interview on 8/24/23 at 11:52 a.m., Nurse Practitioner (NP) Q was asked about Resident #154's falls, and not having the walker at the bedside. NP Q reported they knew the walker was supposed to be at the bedside for Resident #154 and understood the concerns, as they understood Resident #154 required a walker during their stay for safe transfers and assisted ambulation. Review of the policy, Fall Prevention Program, revised 8/1/2022, revealed, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individual level of risk to minimize the likelihood of falls .1. The facility utilizes a standardized assessment for determining a resident's fall risk . The nurse will .initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk .5 a. Implement universal environmental interventions that decrease the risk of resident falling .b. Implement routine rounding schedule. c. Monitor for changes in resident's cognition, gait, ability to rise/sit, and balance. d. Encourage residents to wear shoes or slippers with non-slip soles [such as gripper socks] .High risk protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan .Provide interventions that address unique risk factors measured by the risk assessment toll: medication, psychological, cognitive status, or recent change in functional status. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive devices. ii. Increased frequency of rounds (supervision). iii. Sitter [1:1 supervision], if indicated. iv. Medication regimen review. v. Low bed. vi. Scheduled ambulation or toileting assistance . Review of the policy, Abuse and Neglect, reviewed 7/11/23, revealed: .Harm is a negative outcome that has compromised the resident's ability to maintain or reach the highest practicable physical, mental, or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services .

All times were recorded in Eastern Time. This citation pertains to intake # MI 332. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent the elopement of one vulnerable Resident (#38) of four residents reviewed for elopement. This deficient practice placed Resident #38 and 16 other facility residents identified as at risk for elopement at risk for injury, accident, or serious harm up to and including death. Findings include: An Immediate Jeopardy resulted when Resident #38 eloped from the facility into the community on 6/22/22 at approximately 6:15 p.m. unbeknownst to staff. The facility became aware when Resident #38 was returned to the facility approximately five minutes later by a neighbor [Neighbor HH]. The facility self-identified the deficient practice and put corrective actions in place. The facility was found to be in substantial compliance during the survey ending 7/19/22 and was given past noncompliance. On 7/19/22 at approximately 4:58 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), with the management team present per their preference, were informed the Immediate Jeopardy had been identified related to Resident #38's facility elopement into the community on 6/22/22 at approximately 6:10 p.m. The Immediate Jeopardy template was delivered verbally and in writing via email to the NHA during this meeting, per S.A. management directive, and an abatement plan was requested. The NHA confirmed Resident #38 was placed on a 1:1 supervision on the date of the elopement (6/22/22), with 15 minutes checks and close supervision after the elopement, and staff were educated to provide Resident #38 with redirection including conversation and other person-centered interventions based on Resident #38's past employment in mining and mechanical work. The DON confirmed Resident #38's Care Plan was updated. Review of the Facility Reported Incident (FRI) report received by the State Agency (S.A.) on 6/23/22 revealed on 6/22/22 at 6:15 p.m., Resident #38 exited the facility unauthorized at approximately 6:15 p.m., and was returned to the facility from the community within five minutes by a neighbor. The report noted Resident #38 had no injuries and no adverse outcome was found. A 1:1 supervision was immediately implemented. Review of the facility Investigation Summary, submitted to the S.A. on 6/28/22, further revealed Resident #38 had a diagnosis of dementia with behavioral disturbance and was severely cognitively impaired. Further interventions were implemented after Resident #38 was returned to the facility, included a full resident head count, with all residents accounted for, and a door and alarm audit, with all functioning properly. The cause of the incident was determined to be an employee shut off the door alarm when they had observed another resident open and then close facility door (door two on resident hall 200), which activated the outer exit door alarm, which the employee (CNA BB) then disengaged. Facility determined Resident #38 eloped from the facility during this same incident. The policy was updated to include observations outside building when alarm was activated and conducting a full resident head count. All staff had been reeducated and audits of the process were ongoing by the time the S.A. arrived for the abbreviated survey on 7/10/22. Review of Resident #38's Minimum Data Set (MDS) assessment, dated 6/06/22, revealed admission to the facility on [DATE], with diagnoses including dementia with behaviors, kidney disease, lupus (an auto immune disease), history of falling, diabetes, and hypertension. Resident #38 required limited one-person assistance for transfers, walking in corridor, dressing, and hygiene, and supervision for toileting and locomotion (in wheelchair) on and off unit. The Brief Interview for Mental Status (BIMS) revealed a score of 4/15, which indicated Resident #38 had severe cognitive impairment. The behavior section revealed Resident #38 demonstrated physical and verbal behaviors directed towards others, and wandering behaviors 1 to 3 times during the look-back assessment period. An observation on 7/10/22 at 3:32 p.m. revealed Resident #38 propelled his manual wheelchair at the nurse's station on the resident unit. He reported he was doing well when asked, then demonstrated garbled speech which was unintelligible. Resident #38 was unable to describe the elopement incident or answer questions about what had occurred. Review of Resident #38's most recent wander assessment, dated 5/31/22, showed a score of 14, with 8 and above designated as high risk for wandering, which would include elopement. Previous wander assessments since admission revealed Resident #38 was an elopement risk when admitted to the facility. Review of Resident #38's current Care Plan, accessed 7/11/22, revealed Resident #38 was designated as having impaired cognitive function dementia, and at risk for wandering and elopement. Treatment interventions for wandering behaviors to prevent elopement included assessing for fall risk, distraction, monitoring for fatigue and weight loss, and person-centered conversation when exit seeking. The most recent intervention related to the 6/22/22 elopement was, Frequent monitoring during times of exit seeking. Review of Resident #38's Accident and Incident Report dated 6/22/22 at 18:50 p.m. (6:15 p.m.), by Licensed Practical Nurse (LPN) Z, revealed LPN Z was getting ready to leave building for day and heard the [facility] doorbell. Resident [#38] was noted to be outside the front entrance with neighbor (Neighbor HH) to the facility. Neighbor HH stated that Resident [#38] was across the street tinkering with a mailbox, and stated his wheelchair was caught on the curb. Resident was brought back into the facility, and proper notifications made. A resident head count was done, and a head-to-toe assessment body assessment of Resident #38 was completed, there were no concerns. 15 minute checks were initiated and the wander guard system was checked and functional. Resident #38 was noted as only oriented to person and was identified as having wandering behaviors. All Staff were educated on the importance of checking alarms before shutting them off. The intervention put in place was frequent checks during times of exit seeking behaviors. Review of physician progress note dated 6/23/22 by Nurse Practitioner CC, .Chief complaint: Elopement on 6/22 [22] evening .[Resident #38] had wheeled his wheelchair across a nondiseased [sic] street by the facility and was found by the neighbor [HH]. [Resident #38] was fixing the mailbox. The neighbor had called the care center and the staff did return patient to the facility without incident [sic] [Resident #38] is evaluated today for any signs of injury. Nursing staff did do a full body assessment on patient [Resident #38] once he returned to the facility and there was no evidence of any physical injury or distress. Patient [Resident #38] has been having increased behaviors becoming more aggressive, exit seeking, and not being able to be redirected. This has been going on for about three weeks . Prior physician notes during June, 2022, by NP CC referenced increased behaviors and exit seeking for Resident #38. During an interview on 7/12/22 at 12:49 p.m., Resident #38's CNA DD confirmed Resident #38 had recently demonstrated exit seeking behavior and had exited the door on the 300 hall in the last couple of days, within the line of sight of staff, who assisted Resident #38 back into the facility with verbal prompting and the assistance of a nurse. The NHA was notified of this report after the interview. During an interview on 7/12/22 at 5:46 p.m., Maintenance Director, Staff EE, reported regarding Resident #38's elopement, they understood the alarm beeped [engaged] at Door 2 [on the 200 resident hall] when Resident #38 exited the facility on 6/22/22. Staff EE confirmed the two doors on the resident care units (200 and 300 halls) opened immediately once the outer exit door was pushed open, as they were unlocked, with a visual and audible alarm sounding once pushed open, which stay activated (on) until staff turned the door alarms off. Staff EE reported staff had been instructed to leave the exit door alarms on until they know why they engaged. Observations with the NHA and Staff EE revealed both the 200 and 300 hall doors alarmed immediately when Staff EE opened the doors to test them, and staff responded appropriately. Velcro stop signs were observed at both of these outer exit doors, to give residents a visual cue not to attempt to open these doors. All facility doors and alarms were viewed the Staff EE and the NHA. The NHA reported all outer doors in the facility did activate immediately with the visual and audible alerts, which was observed. Both denied any video surveillance was available at this facility to observe the elopement or monitor the entrance or exit doors for review by facility staff. On 7/12/22 beginning at approximately 5:50 p.m., Resident #38 was observed on the 300 hall becoming restless and propelling his wheelchair towards the exit, stating he had to go to work and get to his truck. Staff intervened and redirected Resident #38. Wandering and exit seeking behavior was noted during this observation. On 7/13/22 at 8:58 a.m., the NHA and Staff EE showed surveyor routine door alarm check logs. Staff EE was asked how often they completed alarm door checks and responded a minimum of weekly but now daily since the elopement. Staff EE reported they had found no alarm malfunctions during these alarm checks, or after Resident #38's elopement. On 7/13/22 at approximately 9:05 a.m., Surveyor observed facility resident elopement risk posting placed in nursing/staff areas (nonpublic) in the facility, including at the nurse's station and in the nursing conference room. The elopement posting showed 17 residents at risk, with pictures of each resident with their name. Resident #38 was on the elopement risk posting. On 7/13/22 at 10:18 a.m. Surveyor was accompanied by the NHA to the neighbor's (HH's) home who found Resident #38. The walk included exiting the 200 hall door, walking down a short, narrow facility sidewalk to the parking lot, across the parking lot, and to the paved street. The neighbor's house was the third house from the facility, on the opposite side of a quiet subdivision street. The NHA confirmed this was the route Resident #38 had eloped from the facility on 6/22/22 unsupervised. The NHA then returned to the facility. Surveyor knocked on two doors, and stayed for at least five minutes, with no response. Surveyor had been provided with the neighbor's name and address, but the facility did not have their phone number nor a witness statement. And this Surveyor was unable to obtain this information. On 7/13/22 at approximately 12:15 p.m. the Rehabilitation Director, Physical Therapist Assistant (PTA) II walked this same distance to the neighbor's (HH's) home and concurred this distance (one way) was approximately 1000 feet from the facility, which was just less than 1/5 of a mile. PTA II confirmed Resident #38 was on their caseload, they were familiar with Resident #38, and reported Resident #38 would be unsafe unsupervised in the community. PTA II reported Resident #38 demonstrated the need for limited physical assistance and poor safety awareness and had impaired orientation to his situation and surroundings. During an interview on 7/13/22 at approximately 10:30 a.m., LPN AA confirmed they were on shift and doing shift report with LPN Z when Resident #38 was returned to the facility by the Neighbor [HH] on 6/22/22 at approximately 6:20 p.m. LPN AA confirmed the cause of Resident #38's elopement was CNA BB shut off the door alarm at the end of the 200 hall, when another female resident was visualized at the end of this same hall at the door. LPN AA described Resident #38 as wearing a t-shirt, blue jeans, a long sleeve shirt, and a coat over the shirt, and the temperature outside as pretty warm. LPN AA confirmed Resident #38 was not injured, the door exit alarm was functional, the wander alert anklet was functional, and the incident cause was staff not following up on the door alarm activation. Review of the regional weather report, retrieved from wunderground.com, accessed on 7/27/22 at 7:55 a.m., area weather history on 6/22/22 at 6:54 p.m., revealed an area temperature of 74 degrees. During a phone interview on 7/14/22 at approximately 11:00 a.m., CNA FF acknowledged working on another resident hall on 6/22/22 during the afternoon shift. CNA FF stated she learned the incident occurred after receiving immediate education by the nursing staff, right after the incident occurred. CNA FF reported the cause of the incident was the policy/process was not followed. CNA FF confirmed they had received additional education in addition to the education they received on 6/22/22 on the night of the occurrence, regarding elopement prevention and responding to facility alarms, including making outside observations and doing an immediate head count when an alarm was engaged. During a joint interview with the NHA and the Director of Nursing (DON) on 7/13/22 at 11:22 a.m., both confirmed the incident had occurred, and the root cause was staff error, staff not observing/going outside the door at the perimeter of the building/property. Both reported Resident #38 was not injured, and no other elopements had occurred. The NHA explained Resident #38 was outside the facility approximately five minutes, based on the time the alarm activated and when staff reported Resident #38 was returned to the facility. The DON confirmed Resident #38 did typically wear a long-sleeved shirt every day and was wearing a button up flannel. The DON reported a head count was done once the incident was discovered. The NHA confirmed the policy was updated as process expectations would be to do a perimeter check, and then an immediate headcount, as well as all staff were educated, drills were conducted including an actual simulation with a resident, and a separate 1:1 education with CNA BB. Both confirmed ongoing monitoring of the staff, and audits of this process. During an interview on 7/13/22 at 2:57 p.m., LPN AA reported she was doing shift report in the facility conference room, and heard the door panel alarm go off, and it was turned off not long after. LPN AA stated when she and LPN Z had finished their shift report, they heard the doorbell ring. LPN Z told her Resident #38 had gone outside the facility. LPN AA confirmed an immediate head count was done, with all residents were accounted for, door exit alarms were operational, and nursing staff did an immediate in-service with all staff to prevent this from recurring. Regarding the weather, LPN AA reported it was sunny outside, but was not aware of a temperature. LPN AA reported the cause was the facility process was not followed as CNA BB turned off the alarm without checking outside or requesting a head count. LPN AA reported the event occurred between 5:30 and 6:15 p.m. but could not recall a time specifically. LPN AA reported Resident #38 frequently demonstrated exit-seeking behaviors such as looking for his truck. During an interview on 7/17/22 at 9:09 a.m., CNA GG confirmed they were not present when the incident occurred but recalled Resident #38 being on 15 minute checks for at least 10 days after the elopement occurred. CNA GG confirmed she had received education regarding elopement prevention, process, and alarm response. During an interview on 7/18/22 at 3:12 p.m., CNA BB reported that on 6/22/22 she was on a break when she heard the outer door alarm sound on the 200 hall. CNA BB reported she assumed it was another resident they had observed opening the 200 hall exit door; this resident was inside the facility but had the door opened. CNA BB reported she did look out the door opening but did not step outside and look for anyone as CNA BB assumed the other resident had activated the alarm, so CNA BB shut the door alarm off and deactivated the alarm and was not aware Resident #38 had eloped the facility from this exit door. She could not recall the weather or the time of the occurrence, or the time, other than the elopement occurred around 6:00 p.m. or 6:30 p.m. CNA BB reported she recalled a neighbor (HH) bringing Resident #38 back shortly after. CNA BB confirmed she received an immediate education by the nurses as did all staff, as CNA BB acknowledged she had turned off the 200 hall door exit alarm. CNA BB reported she provided a return demonstration with proper use of the door alarm on the same shift to the nurses, and had participated in in-services, mock drills, etc. When asked what she could have done to prevent the occurrence, CNA BB reported she could have walked outside and looked better. During observations on 7/19/22 at approximately 4:00 p.m., four residents identified as elopement risk were visualized wearing wander guard alert bracelets on their ankles, Residents #38, and three other residents identified by the facility as wander/elopement risk. The NHA confirmed 17 residents were at risk for elopement. Findings were reviewed with S.A. section manager, who confirmed with the S.A. Resident #38's elopement rose to the level of Immediate Jeopardy (IJ), with consideration for past noncompliance, as staff educations, monitoring, and audits had been completed timely, and prior to the inception of the annual recertification survey and abbreviated survey, beginning on 7/10/22. On 7/19/22 at approximately 4:58 p.m., the NHA and the DON, with the management team present per their preference, were informed the Immediate Jeopardy had been identified related to Resident #38's facility elopement into the community on 6/22/22 at approximately 6:10 p.m., and an earlier elopement on 5/16/22. The immediate jeopardy template was delivered verbally and in writing via email to the NHA and DON during this meeting. On 7/19/22, Surveyors verified the following interventions were put in place and were effective to remove the immediacy: 1. As of 6/22/22, beginning at 6:15 p.m., Resident #38 received 1:1 supervision for the entire afternoon and night, with 15 minute checks and close supervision beginning on 6/23/22. It was verified the physician, facility NHA and management, and responsible parties were immediately notified. It was verified Resident #38 was not injured. 2. On 6/22/22, at approximately 6:15 p.m., a facility head count was completed by nursing staff, with every resident accounted for. 3. On 6/22/22 at approximately 6:15 p.m., an immediate audit of facility door alarms was completed, with all activating and fully operational. Velcro stop signs were also placed at outer exit door exits on resident units. 4. On 6/22/22 beginning at approximately 6:15 p.m., the facility policy/process regarding elopement was updated, and all staff were immediately educated to make observations of resident hall exit doors upon activation, and to complete an immediate head count, including a 1:1 counseling education with CNA BB. All staff were subsequently educated, including an elopement practical drill. 5. On 6/22/22 beginning at approximately 6:15 p.m., facility staff and subsequently Maintenance Director, Staff EE , began daily, and a minimum of weekly testing and monitoring of alarmed exit doors, with logging verified. 6. The facility demonstrated ongoing evidence of monitoring/audits, including elopement drills, random interviews and/or practical alarm responses, overseen by the DON. 7. Exploration of alternate door alarm options, including quotes obtained by the NHA. It was noted the exit door alarms were immediately activated by a visual and loud audible alert. It was noted two of the resident hall unit exit doors (for the 200 and 300 halls) had this type of immediate alert, and did not have wander alert activation bars to activate the wander alert bars. Wander alert bars were present at the main facility entrance area and the back facility exit doors, as well as a few other doors. Resident #38 eloped from Door 2 on the 200 hall during both elopements. Surveyors confirmed these documents and interventions were in place per observations, interviews and additional record review. Past non-compliance (PNC) was determined appropriate for this citation during an abbreviated survey on 7/19/22, as of 6/22/22, upon State Agency (S.A.) review, as the involved resident (#38) was returned safe to the facility post community elopement without injury, and the facility provided appropriate supervision upon return, the elopement policy and care plan were updated, the alarm system was operational, with staff consistently responsive, and employee education, monitoring, and audits were completed to prevent further elopements prior to the initiation of the annual survey on 6/10/22. Past-compliance was confirmed onsite by S.A. manager and Surveyor, via employee interviews, observations, and record review. Review of the updated facility policy, titled, Elopement and Wandering Residents dated/copyright 2021, provided by the NHA and confirmed as current and updated, revealed, Elopement occurs when a resident leaves the premises or a safe area without authorization .and/or any authorization to do so .Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systemic approach to monitoring and managing resident at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation, and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary .Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff .Procedure for locating a missing resident. a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol, Code Green. B. The designated facility staff will look for the resident .Procedure post elopement A social services designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults .Staff may be educated on the reasons for the elopement and possible strategies for avoiding, such as behavior. An incident report will be completed .F. When repeated elopement attempts occur, after the facility has exhausted possible care approaches, the resident may be referred for alternate placement in an appropriate facility .

Based on observation, interview, and record review, the facility failed to: 1) effectively perform proper staff/visitor entrance screenings; 2) implement effective surveillance of a COVID-19 outbreak to control the spread of infection; 3) establish adequate communication between departments to limit the spread of infection for employees and residents; 4) follow transmission-based precautions with proper PPE (Personal Protective Equipment) use; and 5) provide consistent staffing assignments for direct-care staff. These deficient practices resulted in Immediate Jeopardy for the continued spread of COVID-19 throughout the facility. (All times reflect Eastern Time Zone) Facility's COVID-19 data as of 10/23/20 at 1:35 p.m. sent via electronic communication by the Nursing Home Administrator (NHA) reflected the following: Total residents in facility: 46 Total number of residents infected with COVID-19 in the facility: 42 Total number of staff infected with COVID-19: 23 out of 53 Total number of resident deaths with COVID-19: 5 Total number of resident deaths related to COVID-19: 2 Review of facility provided, COVID+ List-10/23 identified the first COVID-19 positives affected two staff members on 9/29/20 and then the first two residents contracting COVID-19 were identified on 10/3/20. The following week (10/4-10/10) identified an additional seven staff and 22 residents were positive for COVID-19. Week three (10/11-10/17) identified three additional staff and 16 residents were positive for COVID-19. Immediate Jeopardy was identified at F 880 on 10/20/20 during a COVID-19 Infection Control Survey/abbreviated complaint survey. The Immediate Jeopardy began on 10/20/20 at 9:30 a.m. after multiple observations were made of staff inappropriate PPE use with COVID-19 residents, staff non-adherence to COVID-19 Wing restrictions, there was no access to current October 2020 Resident Line-Listing Surveillance Data and mapping, and the identification of increased spread of COVID-19 to both residents and staff. The previous NHA (Staff) B said both the NHA and DON (Director of Nursing) were out of the building due to COVID-19 symptoms, but indicated they could be reached by phone. Staff B stated the facility's Infection Preventionist, Licensed Practical Nurse (LPN A), was currently one of two nurses within the facility performing direct resident care. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy via telephone at 2:00 p.m. and an Abatement Plan was requested and approved the same day. The Immediate Jeopardy was removed on 10/21/20, and the deficient practice continued at widespread potential for more than minimum harm until the verification of an approved plan of correction. Findings include: SURVEILLANCE CONCERNS On 10/20/20 at 9:55 a.m., during a telephone Entrance Conference, in the presence of Staff B, the NHA was asked to provide the last three months (August, September, and October 2020) of Resident Line-Listing Infection Surveillance and facility mapping. Staff B provided August and September 2020 data while still on-site on 10/20/20 at approximately 12:35 p.m. When asked about missing October 2020's data, Staff B indicated that was all she had. On 10/20/20 at 3:18 p.m., during a telephone conference interview with NHA, Nurse Consultant N, Nurse Consultant Y, Nurse Consultant Z, and the DON, the October 2020 Resident Line-Listing Infection Surveillance and mapping was again requested. On 10/21/20 at 9:45 a.m., during a telephone interview, the NHA was again asked for October 2020's Resident Line-Listing Infection Surveillance and mapping. The requested surveillance was sent via electronic communication by the NHA on 10/21/20 at 8:20 p.m. During a telephone interview on 10/22/20 at 11:23 a.m., LPN A, in the presence of the NHA, provided the latest positive test results for COVID-19 which identified four new resident infections on the 100 Wing and five additional staff (three Certified Nurse Aides (CNAs) and two nurses). LPN A confirmed all five staff had recently worked on the 100 Wing. The two nurses worked on the 100, 200, and 300 Wings. PPE CONCERNS/DEDICATED WING STAFFING On 10/20/20 at 10:24 a.m., during the initial tour, the 100 Wing's double doors contained a sign that indicated it was a White Zone and a KN95 mask was required to enter. While in the 100 Wing on 10/20/20 at 10:25 a.m., during an interview, CNA G explained the 100 Wing being a 'White Zone' meant no residents currently on the 100 Wing were showing signs or symptoms of COVID-19, residents were not potentially exposed to other COVID-19 individuals, and/or the residents had fully recovered from COVID-19. When CNA G was asked about working on dedicated Wings, she said she worked on the 300 Wing the prior day (10/19/20) which had all the most recent positive COVID-19 residents, or residents showing signs/symptoms for COVID-19. CNA G stated the nurse working on the 100 Wing that day (10/20/20) was working both 100 and 300 Wings. On 10/25/20 at approximately 10:27 a.m., a staff person was observed entering the 100 Wing and unlocked the medication cart and withdrew several syringes with bare hands. The staff person identified herself as Infection Preventionist, LPN A. When asked if she was the nurse working on the 100 and 300 Wing, LPN A said no and indicated she was working on the 200 Wing. When LPN A was asked to be interviewed, she said she had not been responsible for Infection Control since she became ill earlier in the month and indicated she had been scheduled to work on the Wings to perform direct resident care. When asked who her Infection Control designee was, LPN A identified Staff B. During an interview on 10/20/20 at 12:37 p.m. Staff B confirmed she had not completed any specialized training in infection prevention and control. The DON was electronically sent COVID Resident Rosters and mapping which were provided by Staff B shortly after entrance on 10/20/20 for the following dates: 10/19/20, 10/18/20, 10/17/20, and 10/16/20. During a telephone interview on 10/21/20 at 11:06 a.m., the DON confirmed receipt of the electronically sent documents for review (COVID Resident Rosters and mapping) and was aware the documents had been completed by Staff B and explained the documents were used to identify where residents were each day that had tested positive for COVID-19. It was pointed out to the DON that the resident locations were not accurate with the identification of COVID + residents with the red and yellow coloring used. The DON replied, I know what you're talking about. I'll check with the facility for more information. The DON was again asked for October's Resident Infection Line-Listing and mapping, which had not yet been received. The DON confirmed that LPN B should not have left the 200 Wing and entered the 100 Wing during her shift on 10/20/20, to prevent possible cross-contamination of COVID-19 to both residents and staff on the 100 Wing. The DON identified the nurses' desk and the 100 Wing as a Clean Zone. When asked how it could be considered a Clean Zone when the 300 Wing nurse, Registered Nurse (RN) C was observed on 10/20/20 seated at the desk using a computer right next to CNA G seated at the same desk. The DON did not respond. On 10/20/20 at 10:55 a.m., during the initial tour, the 200 Wing indicated it was a Red Zone by a posted sign and the following PPE was required to enter the Wing: gloves, gown, N95, and faceshield. Observations on the 200 Wing found most resident doors wide-open and Resident # 205, who wore a cloth facemask, self-propelling down the hallway. Review of facility provided, COVID + List -10/23 showed Resident #205 was positive for COVID-19 on 10/3/20 which was now three days past a 14-Day Quarantine time which would have allowed Resident #205 to transfer off the Wing sooner. During an observation on 10/20/20 at approximately 11:06 a.m., CNA I (who was at the end of 200's Wing) took off a blue gown, surgical mask, and an N95 mask and held them in her bare hands, then opened the exit door and disposed of the PPE supplies in the garbage can located outside the building. CNA I then picked up a hydrating drink off a cart outside and proceeded to walk away from the building. No hand hygiene was observed. During an interview on 10/21/20 at 11:06 a.m., the DON confirmed staff leaving the 200 Wing at the end of their shifts should not remove their soiled mask and faceshield while standing in the hallway on the 200 Wing. The DON explained the soiled mask and faceshield should be removed outside of the building and hand hygiene performed after their removal. During the same interview, the DON explained residents located on the 300 Wing were considered the most ill with active COVID-19 infection and/or suspicion of COVID-19 infection pending lab confirmation. When asked about dedicated staffing, the DON said only positive COVID-19 staff worked with positive COVID-19 residents. On 10/20/20 at 11:12 a.m., while at the only nurses' desk (outside all Wings), an interview was conducted with RN C who confirmed she had remained negative for COVID-19, but had been scheduled to work both the 100 and 300 Wings simultaneously on the same day. RN C expressed concern for possible cross-contamination risk since the 100 Wing contained the only location with non-COVID affected residents with active illness, and the 300 Wing contained residents who were most ill with active COVID-19 infection. RN C said when she exited the building after her shift, she departed through the 300 Wing exit and re-entered the facility through the service hallway to enter her departure time on the Entrance Screening Log. During a telephone interview on 10/21/20 at 11:06 a.m., the DON confirmed receipt of the electronically sent documents for review (COVID Resident Rosters and mapping) and was aware the documents had been completed by Staff B and explained the documents were used to identify where residents were each day that had tested positive for COVID-19. It was pointed out to the DON that the resident locations were not accurate with the identification of COVID + residents with the red and yellow coloring used. The DON replied, I know what you're talking about. I'll check with the facility for more information. The DON was again asked for October's Resident Infection Line-Listing and mapping, which had not yet been received. The DON confirmed that LPN B should not have left the 200 Wing and entered the 100 Wing during her shift on 10/20/20, to prevent possible cross-contamination of COVID-19 to both residents and staff on the 100 Wing. The DON identified the nurses' desk and the 100 Wing as a Clean Zone. When asked how it could be considered a Clean Zone when the 300 Wing nurse, Registered Nurse (RN) C was observed on 10/20/20 seated at the desk using a computer right next to CNA G seated at the same desk. The DON did not respond. On 10/20/20 at 10:55 a.m., during the initial tour, the 200 Wing indicated it was a Red Zone by a posted sign and the following PPE was required to enter the Wing: gloves, gown, N95, and faceshield. Observations on the 200 Wing found most resident doors wide-open and Resident # 205, who wore a cloth facemask, self-propelling down the hallway. Review of facility provided, COVID + List -10/23 showed Resident #205 was positive for COVID-19 on 10/3/20 which was now three days past a 14-Day Quarantine time which would have allowed Resident #205 to transfer off the Wing sooner. During an observation on 10/20/20 at approximately 11:06 a.m., CNA I (who was at the end of 200's Wing) took off a blue gown, surgical mask, and an N95 mask and held them in her bare hands, then opened the exit door and disposed of the PPE supplies in the garbage can located outside the building. CNA I then picked up a hydrating drink off a cart outside and proceeded to walk away from the building. No hand hygiene was observed. During an interview on 10/21/20 at 11:06 a.m., the DON confirmed staff leaving the 200 Wing at the end of their shifts should not remove their soiled mask and faceshield while standing in the hallway on the 200 Wing. The DON explained the soiled mask and faceshield should be removed outside of the building and hand hygiene performed after their removal. During the same interview, the DON explained residents located on the 300 Wing were considered the most ill with active COVID-19 infection and/or suspicion of COVID-19 infection pending lab confirmation. When asked about dedicated staffing, the DON said only positive COVID-19 staff worked with positive COVID-19 residents. On 10/20/20 at 11:12 a.m., while at the only nurses' desk (outside all Wings), an interview was conducted with RN C who confirmed she had remained negative for COVID-19, but had been scheduled to work both the 100 and 300 Wings simultaneously on the same day. RN C expressed concern for possible cross-contamination risk since the 100 Wing contained the only location with non-COVID affected residents with active illness, and the 300 Wing contained residents who were most ill with active COVID-19 infection. RN C said when she exited the building after her shift, she departed through the 300 Wing exit and re-entered the facility through the service hallway to enter her departure time on the Entrance Screening Log. ENTRANCE SCREENING CONCERNS Review of Entrance Screening Logs (10/5/20 through 10/22/20) showed staff had completed the COVID-19 screening and indicated signs and symptoms on 34 separate entries. The signs and symptoms included: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or bode aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. The screening form read in part, If I become ill while in the building with any of the above symptoms, I will inform staff and leave the building. Staff/Visitor temperatures are only recorded one time upon entrance to the facility and not upon exit as indicated in the facility's Pandemic Coronavirus (COVID19) Policy and Procedure, last revised 10/7/20. Review of facility provided, COVID-19 Facility Plan (undated) read in part, All staff must screen in prior to entering the building. If any possible s/s (signs and symptoms), do NOT come to (the) building, call your supervisor and you will be provided additional directions . During an interview on 10/20/20 at 10:25 a.m., while on the 100 Wing, CNA G said she enters the building through the service hallway and performs her own Entrance Screening without the supervision of another staff person. During an interview on 10/20/20 at 11:06 a.m., while on the 200 Wing, Staff AA said after she completes her shift, she was expected to exit the building through the 200 Wing exterior door and to call the facility and have another staff member write her departure time on the Entrance Screening log. During an interview on 10/20/20 at 11:09 a.m., while on the 200 Wing, CNA J indicated he filled out a different form (not on the Entrance Screening Log) to indicate what time he left facility. During an interview on 10/20/20 at approximately 11:30 a.m., Staff B was asked who reviewed the Entrance Screening Logs for any signs and symptoms of COVID-19 before beginning their shifts. Staff B did not respond. Staff B was shown Entrance Screening Logs for several days of staff indicating acute illness. Staff B was asked about CNA K who indicated on 10/16/20 the following COVID-19 signs/symptoms: cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, sore throat, congestion, or runny nose. When concerns were expressed to Staff B regarding the facility having ill staff working, Staff B said, Right. During a telephone interview on 10/20/20 at 2:25 p.m., the NHA said a nurse (from the previous shift) provides direct oversight for the oncoming shift during the Entrance Screenings for all three shifts. During a telephone interview on 10/21/20 at 2:41 p.m., CNA K confirmed she had called the facility on 10/16/20 and indicated she was experiencing body aches, extreme fatigue, nasal and eye drainage, sore throat, and had a cough. She was told she needed to take cold medicine and to come into work. Review of [DIAGNOSES REDACTED]-COVID Test Results indicated CNA K had a rapid COVID-19 test performed by the DON which was positive. CNA K was asked if she had worked and observed other staff persons who appeared ill on the wings. CNA K said she had been pulled off her assigned 300 Wing to replace CNA V on the 200 Wing the previous week. CNA K said CNA V was seen slumped over on a chair, with cold rags around his neck, with shallow breathing. During a telephone interview on 10/22/20 at 10:45 a.m., Staff H confirmed sick calls were directed to her during the day shift when she was working and indicated in her absence, sick calls were taken by the nurse in charge. Staff H confirmed she was not a nurse and explained she completed an Absent Sheet when staff called in to work and made a copy for Payroll and Infection Control. Staff H was asked to electronically send a copy of staff call-ins from 10/5/20 to 10/22/20. Review of CNA V's facility provided Absence Report dated 9/26/20, read in part, can't breathe .has not been to work all this time as he is so sick, he is COVID positive 10/22/20. During a follow-up interview on 10/22/20 at 3:56 p.m., Staff H was asked to clarify her indication when CNA V had last worked. Staff H confirmed CNA V had worked on 10/11/20 for a four-hour shift from 2-6 p.m. and on 10/12/20. Staff H said, (NHA) took him to the hospital because he was so sick and couldn't drive. Review of facility provided Entrance Screening Log for 10/11/20 and 10/12/20 showed CNA V had not completed a COVID-19 screening for either date. Two unsuccessful telephone interview attempts with CNA V were made on 10/21/20 at 2:57 p.m. and on 10/22/20 at 3:40 p.m. CNA V's voicemail box was full; therefore, a message to return the call was not possible. Review of Facility Reported Incident, dated 10/10/10, read in part, Two employees were positive for COVID. One employee facility already knew .DON called the other employee (CNA R) and left her a message to call the facility about her test. (CNA R) called the facility back at 4:02 p.m. and talked to the DON. The DON told her she was positive .and (CNA R) stated yeah, I know already the night shift nurse (RN E) told her and she continued to finish her shift .This was neglect on the nurses part, keeping the CENA working after being told she was positive and not informing supervisor nor Administration . Review of CNA R's Entrance Screening on 10/8/20 at 2156 (9:56 p.m.) showed the following signs/symptoms of COVID-19: fatigue, muscle or body aches, sore throat, and congestion or runny nose; it also documented she left the faciity on [DATE] at 6:00 a.m. after completing her entire shift. On 10/22/20 at 11:17 a.m., a telephone interview was conducted with RN E who discovered CNA R was COVID-19 positive on a lab report. RN E confirmed she had not reviewed the Entrance Screening Log that indicated CNA R had COVID-19 signs and symptoms before her shift began on 10/8/20. When asked why CNA R wasn't sent home after discovering her positive COVID-19 lab result, RN E said because she thought there was no one who would come in to replace her. On 10/22/20 at 1:09 p.m., during a telephone interview, Staff B confirmed she was the NHA on 10/8/20. When asked who RN E was expected to notify after discovering the positive COVID-19 results for CNA R, Staff B indicated the NHA and/or the DON should have been immediately notified for further direction. One unsuccessful telephone interview attempt with CNA R was made on 10/22/20 at 9:24 a.m. and a voicemail was left to return the call. Review of Entrance Screening Log showed LPN L had COVID-19 signs and symptoms on 10/16/20, 10/17/20, and 10/18/20 which included: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, congestion or runny nose, nausea or vomiting and diarrhea. Two unsuccessful telephone attempts with LPN L were made on 10/21/20 at 2:33 p.m. and again on 10/23/20 at 10:48 a.m. A voicemail was left to return the call each time. Review of [DIAGNOSES REDACTED]-CoV Test Results shows the DON received a rapid COVID-19 test on 10/18/20 which indicated a positive result. Review of Entrance Screening Log on 10/19/20 showed the DON entered the facility on 10:50 a.m. (no exit time was recorded) with the following sign/symptoms of COVID-19: fever or chills, shortness of breath or difficulty breathing, and muscle or body aches. Review of Entrance Screening Log on 10/21/20 (after the Abatement Plan was accepted) showed CNA T had the following signs and symptoms of COVID-19: fatigue, muscle or body aches, headache, new loss of taste or smell, congestion or runny nose, unanswered response for sore throat, nausea or vomiting, and diarrhea. The log read 2300 (11:00 p.m.) and read in part, Retested and sent home by (LPN L) at 11:00 p.m. During a telephone interview on 10/25/20 at 6:09 p.m., CNA T said she called the facility prior to her shift due to not feeling good and spoke with LPN U who directed her to come in earlier (prior to her 10:00 p.m. shift) to be tested for COVID-19 by a rapid test. CNA T said she arrived at the facility on 10/21/20 around 9:30 p.m. and completed the Entrance Screening Log and entered her time of arrival. CNA T then waited in the lobby while LPN U obtained the rapid COVID-19 screening kit. At 10:00 p.m., CNA T was directed to begin working on the 300 Wing since LPN U could not access the screening kit since she did not have a key. At 10:45 p.m., CNA T was told by LPN L to leave the 300 Wing and to go home. CNA T denied she changed her entrance time into the facility to 2300 (11:00 p.m.) on the Entrance Screening Log. During a telephone interview on 10/20/20 at 2:25 p.m., the NHA was asked why staff were working with signs and symptoms of COVID-19 infection. The NHA stated staff were permitted due to the facility's identification of staffing shortages. When asked about utilizing temporary staffing agencies, the NHA said he did not have the resources. Review of facility requested COVID-19 Outbreak Timeline, read in part, on a document provided Summary of QAPI meetings 10/7/20 : .Crisis staffing strategy implemented, COVID+ staff to work in red zones only, wear facemask for source control at all times .10/11 .All staff that are not COVID + to wear N95 masks at all times . Review of Centers for Disease Control and Prevention (CDC) Strategies to Mitigate Healthcare Personnel Staffing Shortages found on https://www.cdc.gov/coronavirus/2019-ncov/hcp/mitigating-staff-shortagess.html read in part, If the HCP (healthcare personnel) develop even mild symptoms consistent with COVID-19, they must cease patient care activities and notify their supervisor .prior to leaving work .If shortages continue despite other mitigation strategies, consider implementing criteria to allow HCP with suspected or confirmed COVID-19 who are well enough and willing to work but have not met all Return to Work Criteria to work . Review of facility's Pandemic Coronavirus (COVID19) Policy and Procedure (last revised 10/7/20) read in part, 4. Employees are to call in for their shift if they are ill and will be immediately sent home if showing signs and symptoms during their shift. If temp >99, cough or shortness of breath, or sore throat the employee must notify their supervisor and Infection Control Nurse or designee .5. Employees are to be screened upon entering the facility before their shift and have their temperature taken, as well as upon leaving the facility at the end of the shift. If the employee has temp>100, cough, shortness of breath, or sore throat they are to leave the facility immediately after being screened . COMMUNICATION: On 10/20/20 at 2:08 p.m., while in front of the nurses' desk, RN C and CNA G were asked to locate the facility's COVID-19 Policy/Procedure. A black binder, which contained other policies/procedures, was looked through and no COVID-19 Policy/Procedure was found. Staff B approached, and the same request was made to locate the facility's COVID-19 Policy/Procedure that staff would have access to for reference while providing care to residents. Staff B said it was recently updated and she would provide a copy from the front office. Staff B returned and provided a copy of Pandemic Coronavirus (COVID19) Policy and Procedure last revised 10/6/20. On 10/21/20 at 3:39 p.m., the NHA, via electronic communication, was asked to verify the latest revision of the facility's Pandemic Coronavirus (COVID19) Policy and Procedure that contained a revision date of 10/6/20. The NHA replied on 10/21/20 at 3:57 p.m. and provided another revision dated on 10/7/20. During an interview on 10/21/20 at 11:06 a.m., the DON confirmed she did not have computer program access to retrieve COVID-19 test results for staff and residents. Access was only granted for the nurse consultant (unidentified) and Staff B.

Unless otherwise noted all times noted are in Eastern Standard Time (EST). Based on observation, interview, and record review, the facility failed to complete bed rail assessments to determine resident need for bedrails, resulting in immediate jeopardy (IJ) due to harm (Resident #44) and the likelihood of entrapment and serious harm for two additional Residents (#7 and #23), of three residents reviewed for bed rails. This deficient practice resulted in the likelihood of entrapment, serious injury or harm, and/or death, for all facility residents using bed rails without assessment of appropriateness for medical condition, and safety. The immediate jeopardy began on 10/27/18 at 10:00 p.m. when Resident #44 rolled over a side bed rail, and fell to the floor resulting in a [MEDICAL CONDITION]. Immediate jeopardy was identified on 6/3/19 at 1:01 p.m. with notification of the immediate jeopardy to the Nursing Home Administrator (NHA) on 6/3/19 at 3:10 p.m. An abatement plan was requested from the facility. The immediate jeopardy was removed on 6/3/19 at 8:30 p.m., when the facility received acceptance of, and began implementation of its IJ Abatement Plan for removal of the immediate jeopardy, that included: Resident #44 was assessed for bed rail use, POA (Power of Attorney) contacted, assist rails secured in the upright (assist/mobility) position, signage posted regarding assist rails in the upright position at all times, raised perimeter mattress ordered for Resident safety, master care plan and CNA care plans updated, and nursing staff on duty were in-serviced on current bed rail updates. Resident #7 was assessed for bed rails use, POA contacted and in agreement with removal of assist rails from bed, assist rails (bed rails) removed by Maintenance Director (A), raised perimeter mattress ordered for Resident safety, signage placed stating no assist rails (bed rails), care plans were updated, and nursing staff in-serviced. Resident #23 was assessed for assist rails (up in mobility use position) during the day, and down (side bed rail position) at night. Care plans were updated and nursing staff were in-serviced. Midnight shift will be in-serviced before the start of shift 6/3/19. Day shift will be in-serviced before start of shift on 6/4/19. All nursing staff will be in-serviced on the updated (bed rail) policy and procedures on or before 6/7/19. All residents in the facility will have an assist (bed) rail assessment done by the nursing management staff on, or before 6/7/19. All residents will have the recommendations of the assessments implemented by then. The policy and procedure on assist rail usage will be updated to include the facility assessment, its recommendations and implementation. All new residents will have this (bed rail) assessment done upon admission per the updated policy. The Director of Nursing (DON), Registered Nurse (RN)/Assistant Director of Nursing (ADON E), and Licensed Practical Nurse (LPN)/MDS Coordinator F will be responsible for implementation of the assist (bed) rail policy and assessment and the implementation of recommendations. The QAPI (Quality Assurance Performance Improvement) committee and the NHA shall be responsible for monitoring of policy and implementation. Noncompliance remained at a level of no actual harm with potential for more than minimal harm, until confirmation of completion of the abatement plan, and verification of the facility process to ensure resident assessment of bedrail need and safety has been completed. Findings include: Resident #44: Review of Resident #44's Minimum Data Set (MDS) assessment, dated 5/10/19, revealed Resident #44 re-entered the facility on 11/5/18, with the following diagnoses, in part: [MEDICAL CONDITION], non-Alzheimer's dementia, visual hallucinations, paranoid personality disorder, and restlessness and agitation, and fracture of left femur. Resident #44 had lower extremity impairment on one side, required extensive, two-person assistance with bed mobility, was totally dependent upon staff for transfers and toilet use, and used a wheelchair for mobility. Resident #44 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS) reflective of severely impaired cognition and had an activated Durable Power of Attorney (DPOA). Review of an Incident/Accident Report, dated 10/27/18, revealed Resident #44, .was in bed and got out by rolling over assist rails, fell to floor . at 8:00 p.m. (Central Standard Time (CST)). Resident #44 was transferred to an acute care hospital for evaluation, with [DIAGNOSES REDACTED]. Review of the Emergency Department (ED) Admission Information, dated 10/27/19 at 2059 (8:59 p.m. CST), History: Patient . presenting with falls. The history is provided by the nursing home . Pt (patient) brought to ED via W/C (wheelchair) by (Facility) staff with c/o (complaint of) pt. climbing out of bed and falling on floor . Triage Notes at the ED at 21:08 (9:08 p.m. CST) included the following, in part: Patient in today due to fall at nursing home patient climbed over rails of bed and fell . Review of Resident #44's Interim Incident/Accident Report, dated 10/27/18 at 2000 (8:00 p.m. CST) documented on the backside a Post Fall Assessment which revealed, Assist rails down. On 05/31/19 at 9:47 a.m. the DON was interviewed regarding Resident #44's fall from bed on 10/27/18. The DON stated, (Resident #44) told us that she went over the side rail (side bed rail). They were supposed to be down in the half side rail position, when in bed, per the DPOA. On 5/31/19 at 10:09 a.m. LPN F confirmed bed rail consent and care plans both showed assist rails (up in mobility position) were authorized and listed as an intervention prior to Resident #44's fall. LPN F confirmed the siderails were down (in the side bed rail position) at the time of the Resident's 10/2018 fall, and per the DPOA consent they should not have been. On 05/31/19 at 10:13 a.m. the DON and ADON E, after review of Resident #44's 10/27/18 Post Fall Assessment, both agreed the Assessment indicated Assist Rails Down. Both the DON and ADON [NAME] confirmed this meant the assist rail was in a side bed rail position on the bed, blocking exit from the bed. On 06/03/19 at 12:16 a.m., RN M was interviewed, via telephone, regarding Resident #44's use of bed rails. RN M stated, . I see the (Resident #44's) siderails down most of the time . (Resident #44's) bed rails are down. (Resident #44) tends climb out (of the bed). She can scoot between them (side bed rails) . On 06/03/19 at 12:29 a.m., 12:42 a.m., 10:55 a.m., Certified Nurse Aide (CNA) N, CNA J, and CNA R, respectively, were interviewed via telephone. All reported Resident #44's bed rails were down, horizontal across the bed at night. All three CNA's reported Resident #44's continued attempts to exit the bed with bilateral side rails in place. CNA J stated, .She will sit up, and then she will lean over .She tried to go out of the top of the rail . CNA R stated, The bed rails were down (in the horizontal bed rail position on 10/27/18) .She does scoot to the bottom of bed to try to get out . When asked if there were other resident's with side bed rails that still attempt to exit the bed, CNA J stated, (Resident #23). You (staff) hear the alarm and she is working her way down to get up. Review of Resident #44's Bedside Rail Consent/Release Form, dated 5/8/17, revealed consent was given by Resident #44's Power of Attorney (POA) for In Place, Assist Rails (in the upward mobility bar position), with Both Side (of the bed) noted with a check mark. The line for In Place, Bedside Rails was blank. The form was witnessed by Social Service Designee (Staff) C. Upon Resident #44's readmission on 11/5/18, following the fall with fracture, a new Bedside Rail Consent/Release Form was documented for In Place, Bedside (side bedrail position) with a check mark next to Both Sides. Review of a facility Siderail Guidance form, dated (MONTH) 7, 1997 from Health Care Financing Administration (HCFA), Department of Health and Human Services, initialed by Resident #44's POA upon admission, revealed the following, in part: If a resident/representative request siderails, then facility staff has a responsibility to assess the resident and the request, to talk about the risks involved with the resident/representative, and describe alternative individualized care practices that may be safer and appropriate for that resident .The decision regarding whether to raise siderails needs to be made after clinical evaluation at the bedside and interdisciplinary care planning. Review of Resident #44's Alteration in Physical Functioning care plan, initiated 2/15/18 and updated 8/15/18, revealed the following in part: Extensive assist x 1 with bed mobility. Assist rails x 2 in place to aide with repositioning . Review of Resident #44's ADL (Activities of Daily Living) Functional/Restorative Record, dated 8/15/18 (prior to fall) revealed the Resident required one-person assist for bed mobility, two-person assist for transfers and positioning, with Section [MI] Restraints/Enablers documenting assist rails (upward mobility position) x (times) 2. Side rails Night only was crossed off in black ink. Resident #23: On 5/28/19 at 3:29 p.m. Resident #23 was observed sleeping in bed with the half side rail on the exit (left side viewed from the footboard) side of the bed. An assist rail was visible on the right side of the bed, which was positioned right next to the wall. Review of Resident #23's MDS assessment, dated 4/10/19, revealed Resident #23 required limited assistance with bed mobility, positioning, and ambulation in room. Resident #23 scored 5/15 on the BIMS, reflective in severely impaired cognition. Resident #23 had a DPOA. Review of Resident #23's Bedside Rail Consent/Release Form, signed 4/11/17 by Resident #23's DPOA revealed the following consent: In Place: Bedside Rails, Both Sides checked (handwritten in Only At Night), and In Place: Assist Rails, Both Sides checked. Review of Resident #23's Alteration in Physical Functioning Care Plan, initiated 1/10/2019, revealed: Limited assist x 1 with bed mobility. Siderails x 2 in place at night . No documentation of a bed rail assessment was found in the entirety of Resident #23's or Resident #44's medical records. On 5/30/19 at 8:40 Maintenance Director /Staff A was asked for documentation of current bed rail assessment for all residents in the facility. Staff A stated, I go through and make sure there are no gaps. When asked for the measurement documentation, Staff A stated, Well, you can tell if there is a gap . When we do a deep clean, housekeeping will let me know if there are any bed rails that need to be tightened. That is the only issue - if they need to be tightened . Staff A confirmed all facility beds had bilateral rails. Staff A demonstrated how the side rail could be placed in three positions: back toward the head of the bed (for transfer only), up in the assist rail (mobility/grab bar position), or down, in the side bed rail position blocking exit from the middle of the bed. Staff A provided a form entitled, Resident Roster, with Bed/Frame Checks 3/20/2018 hand-written on the Roster. Room numbers and resident names were listed on the Resident Roster. Hand-written documentation of shims being added to the assist rail; either on the left side, right side, or both sides in 29 facility rooms. When this Surveyor asked for bed/bed rail assessments and measurements for new admissions since 3/2018, Staff A indicated this form was the only documentation available. Bed entrapment zone measurements were not provided for any resident bed. Review of a (Brand Name) Bed Rails brochure, copyright 2013, revealed the following: 1. Assist Rail: Half rail that mounts to the midsection of the bed. Easy pull knob for 3-way positioning: Guard, Assist and Transfer . Review of the (Brand Name Bed) Instructions and Warranty, received from the NHA on 6/3/19 at 10:40 a.m., revealed the following, in part: Assist Rail Operation: It is important that caregivers know how to operate the Assist Rails safely. Assist Rails lock in two positions and allow patient transfer in a third unlocked position: 1. In the Guard (side bed rail) position, the patient is contained in the bed with a subtle reminder of the edge location. 2. In the Assist (upward mobility/grab bar position), the patient is aided in entering and leaving the bed. Note: The Assist Rail can travel beyond the Assist position (upward and backward toward the head of the bed) position to allow patient transfer to and from the bed with the rail out of the way. Warning: Once transfer is complete the rail must be returned to either of the locking positions (Guard or Assist) to avoid patient entrapment. On 5/30/19 at 8:52 a.m. ADON [NAME] was asked about facility bed rails. ADON [NAME] confirmed every bed in the facility had side rails, and stated, A new resident can go into any bed, because all of the residents have rails . many of our patients are not ambulatory, so they will have the use of the side rails . it is rare if you have a family member that refuses (side rails), and we also assess the patient based on common sense to see if they are going to need a bed alarm, or a tab alarm . I don't assess them for bed rail safety and usage . I don't have a role in side rail assessment . On 5/30/19 at 9:05 a.m. the Social Services Designee /Staff C was asked about determination of bed rail use for new admissions to the facility. Staff C stated, The resident or responsible party decides if they would like assist rails or the side rails. They (side rails) don't go down the whole length of the bed, they only go halfway, and they (resident/responsible party) give consent to that. I am not aware of any assessment that is performed .I don't do a resident assessment (for side rail use) .When a resident isn't their own person the families first preference is side rails to keep them from falling out of bed. They read the Siderail Guidance (and initialed it). Staff C said the initialed copy of the Siderail Guidance was in their financial file stored in the front office. When asked if there were any beds with assist rails/side rails permanently disabled or removed from use, Staff C stated, Not that I am aware of. On 5/30/19 at 9:16 a.m., when asked about bed rail assessments in the facility, Certified Occupation Therapy Assistant (COTA) KK stated, We can suggest bed rails for certain residents if we feel, and they feel that it is easier to transfers. Otherwise we don't particularly do much for the side rails - other than knowing whose need to be down (in the side bed rail position) when they are in bed . I don't know if the facility assesses them (bed rails) . I don't recall ever participating in bed rail assessments, or any therapist specifically participating in it (bed rail assessment). On 5/30/19 at 9:25 a.m., when asked about facility assessment of resident bed rails, the Nursing Home Administrator (NHA) stated, Yes, I understand we need to have an assessment for resident use of bed rails and going forward we will be doing that. The NHA confirmed bed rail assessments had not been performed. Review of the facility Restraint Protocol, dated 2/2010, received from the DON on 6/3/19 at 10:30 a.m., revealed the following, in part: If the side rail has the effect of restraining the resident and meets the definition of a physical restraint for that individual, the facility is responsible to assess the appropriateness of that restraint. Prior to employing any restraint, the facility must assess the resident to properly identify the resident's needs . On 6/3/19 at 10:30 a.m., when asked about completion of bed rail assessments for facility residents, the DON confirmed no bed rail assessments had been performed for any resident. The DON stated, I know we needed an assessment for bed rails, and we didn't have one . None of our bed rails are locked out (of use) currently. I believe it (side rail on all beds) has that mechanism to change positions (from side bed rail, to assist rail for mobility, to transfer only position) . Resident #7 On 5/28/19 at 4:05 p.m. bilateral bed rails were observed up and positioned in the middle of Resident #7's bed, with the head of the bed at approximately 30% elevated. On 5/30/19 at 2:29 p.m., Resident #7's Care Plans, dated 11/20/18 revealed, Alteration in physical functioning/self grooming deficits r/t (Resident #7) has decreased mobility secondary bilateral upper and lower extremity limitations/contractures and cognitive/communication deficits. Interventions noted on the same Care Plan, dated 3/11/19, revealed, total assist x 2 with bed mobility. Siderails x 2 in place . A 3/1/19 Range of Motion Flow Sheet note, written by Licensed Practical Nurse (LPN) F, revealed, (first) Quarterly review completed at this time. Resident continues with bilateral (upper) and (lower) extremity limitations/contractures. Remains dependent on staff for all needs . On 6/3/19 at 1:04 p.m., a facility Consent/Release Form was reviewed. The form indicated the use of both side rails for Resident #7, and was signed by the Residents DPOA and dated 2/2/16. No bed rail assessment was found anywhere in Resident #7's chart indicating the Resident had been assessed for the use of bed rails.

Based on interview and record review, the facility failed to provide nursing services by sufficient numbers in accordance with resident care plans for one resident (Resident #100) who fell when left unattended while being toileted of four residents reviewed for falls from a facility population of 59 residents. This deficient practice resulted in harm to Resident #100 when he fell in his bathroom and required hospitalization and pain relief medication due to cervical spine and septum fractures received from a fall and placed 17 residents dependent on a minimum of two staff for toileting and transfer assistance at an increased risk for falling. Findings include: All times in this report are Central Standard Time. An abbreviated survey was conducted [DATE]-[DATE] in response to a facility reported incident (FRI) which occurred on [DATE]. The FRI report, dated [DATE], read in part: "On [DATE] at 12:10 p.m. {Certified Nurse Aide (CNA) "D"} placed {Resident #100} on the toilet. {CNA "D"} followed plan of care by staying with resident in bathroom. While supervising the resident, {CNA "D"} heard resident (#101) -room [ROOM NUMBER]- activate both her tabs alarm and her seat belt alarm. {CNA "D"} reacted by crossing the hall, safely securing {Resident #101}, and returned to find {Resident #100} on the floor between bathroom and bedroom. {CNA "D"} states he was gone approximately one minute to one minute and half. {CNA "D"} immediately informed charge nurse. {Resident #100} was assisted by charge nurse and stabilized immediately. {Resident #100} was transported to {local hospital} by ambulance at approximately 12:20 PM." During an interview with CNA "D" on [DATE] at 2:35 p.m., he confirmed he assisted Resident #100 to the bathroom on [DATE]. When asked if another staff assisted with Resident #100's transfer to the bathroom on [DATE], CNA "D" stated "No." When asked why he didn't let someone else answer the alarm sounding from Resident #101's room, CNA "D" stated, "I knew nobody else was on the wing... {CNA "E"} was on the other wing." An interview was conducted on [DATE] at 3:50 p.m. with CNA "E", who was asked about the events of [DATE]. CNA "E" stated she was assigned to "bells and trays" with CNA "D" that day, which meant she and CNA "D" were on the halls while the other four CNAs on the day shift were helping feed residents in the dining room. CNA "E" stated she was "coming out of the dining room" when she found out Resident #100 had fallen. CNA "E" stated, "At that time (about noon) everybody heads in and helps take residents back to their rooms... (a housekeeping staff) told me they needed an aide and a nurse in {Resident #100's} room... the nurse came and then left right away to call an ambulance." LPN "G" was interviewed via telephone on [DATE] at 12:12 p.m. She stated she was passing medications on another hall when she was told by an activities aide to go to room [ROOM NUMBER] due to a resident's fall. LPN "G" stated, "I called 911. I felt he (Resident #100) needed assistance right away." An interview was conducted via telephone on [DATE] at 3:35 p.m. with LPN "H", who was also working the day shift on [DATE]. Regarding Resident #100's fall, LPN "H" stated, "I was on (another) hall passing meds (medications) when it happened. {LPN "G"} hollered to me... {CNA "D"} was on the (200) wing alone. His partner (CNA "E") was in the dining room." When asked who was expected to respond to an alarm sounding on the 200 wing during mealtimes, LPN "H" stated, "If one of us nurses were on the hall we would've helped... there is a portion of time during the day at least half (of the aides) are in the dining room... If {CNA "D"} hadn't answered {Resident #101's) alarm, she would've probably fallen and been hurt." A review of the local hospital "Emergency Department Visit Record" dated [DATE], indicated Resident #100 was admitted to the Emergency Department (ED) at 12:38 p.m. on [DATE] and was triaged as "Semi-Urgent" at 13:06 (1:06 p.m.) with neck collar put in place. The Radiology results of the CT (computerized topography) scan dated [DATE], reads under "Impression": "1. Fractures of the lamina of C1 bilaterally.... 2. Fractures of both maxillary sinuses, nasal bones, and nasal septum." The ED "History and Physical" dated [DATE] at 2200 (10:00 p.m.), indicated under "Plan": "Patient {Resident #100} is admitted now for supportive care... possible instability of his neurologic status with the fractures and the need to make sure patient is comfortable as he does not speak well..." [MEDICATION NAME] injection was ordered [DATE]. Resident #100 died at the hospital on [DATE] at 5:30 a.m. The Administrator was asked for the "Nursing Staff Report" to include total hours worked for all nurses and aides for the previous two weeks, including the date of the incident ([DATE]). A review of the total staffing hours reported showed the facility met the minimum staffing required by the state regulations. However, a review of the CNA care plans for the 59 residents at the facility at the time of this abbreviated survey, indicated 16 of these residents needed two person assist with transfers/toileting, and one resident needed three person assist. The facility "Alarm Indicator" form showed 26 of the 59 facility residents had a personal alarm when in bed, 12 of these residents also had a personal alarm when in a chair, 9 had alarming seat belt to their wheelchairs, and 11 had bed alarms. During the above cited interviews with CNA "D", CNA "E" and LPN "H", all three staff indicated during mealtimes, ,[DATE] CNAs were in the dining room assisting residents, making them unavailable to assist with transfers/toileting or to respond to alarms. ( ) --

Based on observation, interview and record review, the facility failed to provide adequate assistance to maintain sitting and standing balance to prevent a fall resulting in harm for one resident (Resident #100) and failed to provide assistive device (personal alarm) as directed in the plan of care for one resident (Resident #102) of four residents reviewed for falls out of a total facility population of 59 residents. This deficient practice resulted in Resident #100 falling in his bathroom requiring hospitalization and pain relief medication due to cervical spine and septum fractures received from the fall, and the potential for injury for Resident #102 while she was without a personal alarm. Findings include: All times in this report are Central Standard Time. An abbreviated survey was conducted [DATE]-[DATE] in response to a facility reported incident (FRI) which occurred on [DATE]. The FRI report dated [DATE], read in part: "On [DATE] at 12:10 p.m. {Certified Nurse Aide (CNA) "D"} placed {Resident #100} on the toilet. {CNA "D"} followed plan of care by staying with resident in bathroom. While supervising the resident, {CNA "D"} heard resident (#101) -room 206- activate both her tabs alarm and her seat belt alarm. {CNA "D"} reacted by crossing the hall, safely securing {Resident #101}, and returned to find {Resident #100} on the floor between bathroom and bedroom. {CNA "D"} states he was gone approximately one minute to one minute and half. {CNA "D"} immediately informed charge nurse. {Resident #100} was assisted by charge nurse and stabilized immediately. {Resident #100} was transported to {local hospital} by ambulance at approximately 12:20 PM." A review of Resident #100's "Admission Record" indicated he was an [AGE] year old man admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #100's durable power of attorney for health care (DPOA-HC) was activated on [DATE] per the facility "Care Directives", therefore a family member was making health care decisions for Resident #100 since that time. Resident #100's "Fall Risk Assessment" completed on [DATE] by Licensed Practical Nurse (LPN) "B", showed the Minimum Data Set (MDS) Coordinator scored him as "High Risk" for falls, as he had been following previous assessments dated [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Resident #100's care plan for "Alteration in physical functioning r/t (related to) decreased mobility and cognitive impairments" (updated [DATE] by LPN "B") included the interventions: "Total assist x 2 (times two staff) with toileting... Total assist x 2 with transfers." Resident #100's care plan indicated he used a wheelchair as his main mode of transportation. Resident #100's annual Care Area Assessment (dated [DATE]) for falls, indicated "Difficulty maintaining sitting balance", "Difficulty maintaining standing position" and reads in part: "Resident (#100) requires physical support to maintain a sitting and standing position." Resident #100's MDS assessment dated [DATE], indicated his functional status for toilet use was "Total Dependence" with "Two+ persons physical assist" and his balance was assessed as "Not steady - only able to stabilize with assistance." This [DATE] MDS assessment indicated Resident #100 was cognitively impaired with short term and long term memory problems. An interview was conducted on [DATE] at 2:35 p.m. with CNA "D", who assisted Resident #100 with toileting on the day of his fall. When asked if another staff had assisted with Resident #100's transfer to the bathroom on [DATE], CNA "D" stated "No." CNA "D" stated he believed Resident #100 was a ",[DATE] person transfer". When asked how he would find out a resident's need for assistance, CNA "D" stated, "When I review them {the CNA care plans}... can't say how often I do that." When asked why he left Resident #100 alone to answer the alarm sounding from Resident #101's room, CNA "D" stated, "I knew nobody else was on the wing... {CNA "E"} was on the other wing." CNA "D" stated when he finished assisting Resident #101, he returned to Resident #100's room and found him on the floor. "It looked like he got up and made it a couple of feet..." When asked where in the room he found Resident #100, CNA "D" stated: "His feet were at the doorway of the bathroom and his head was in the bedroom area... I yelled for help... not sure who ran and got the nurse." An interview was conducted on [DATE] at 3:50 p.m. with CNA "E", who was asked about the events of [DATE]. CNA "E" stated she was "coming out of the dining room" when she found out Resident #100 had fallen. CNA "E" stated, "At that time (about noon) everybody heads in and helps take residents back to their rooms... (a housekeeping staff) told me they needed an aide and a nurse in {Resident #100's} room... the nurse came and then left right away to call an ambulance." An interview was conducted via telephone on [DATE] at 12:12 p.m. with LPN "G", who was working on [DATE] when Resident #100 attempted to leave his bathroom unassisted and fell . When asked about the incident, she stated, "I got called to {Resident #100's} room by the Activities Aide... she said 'Come to Room 203 (Resident #100's room) quick - there's a fall'... He {Resident #100} was just outside the bathroom on the floor... I saw he was bleeding really bad... I called 911. I felt he needed assistance right away... I called the nephew (DPOA-HC), the doctor, the hospital..." When asked if Resident #100 was responsive when she arrived, LPN "G" stated, "{Resident #100} usually didn't say much... his eyes were open... we applied pressure and ice to his nose... he remained on the floor (until ambulance arrived)." A review of the local hospital "Emergency Department Visit Record" dated [DATE], indicated Resident #100 was admitted to the Emergency Department (ED) at 12:38 p.m. on [DATE] and was triaged as "Semi-Urgent" at 13:06 (1:06 p.m.) with neck collar put in place. The Radiology results of the CT (computerized topography) scan dated [DATE] reads under "Impression": "1. Fractures of the lamina of C1 bilaterally.... 2. Fractures of both maxillary sinuses, nasal bones, and nasal septum." The ED "History and Physical" dated [DATE] at 2200 (10:00 p.m.), indicated under "Plan": "Patient {Resident #100} is admitted now for supportive care... possible instability of his neurologic status with the fractures and the need to make sure patient is comfortable as he does not speak well..." Morphine injection was ordered [DATE]. Resident #100 died at the hospital on [DATE] at 5:30 a.m. In an interview with Resident #100's physician (Doctor "K") on [DATE] at 1:10 p.m., he stated Resident #100 was dependent on staff assistance for transfers, and he could self-propel in his wheelchair, but was not able to communicate much verbally since his previous stroke. Doctor "K" stated he went to the hospital to see Resident #100 the night of the fall: "{Resident #100} was breathing and had a cervical collar on... I reviewed his case with the (ED) physician. His injury was not life-threatening, but due to his advanced age and dementia he was not a good surgical candidate..." The investigation and interview with CNA "D" on [DATE] at 2:35 p.m. revealed on [DATE] at 12:10 p.m., the facility failed to provide the required physical support for Resident #100 when CNA "D" left Resident #100 (who required physical support for sitting and standing as noted in Resident #100's CAA dated [DATE]) unattended in the bathroom to respond to another resident's alarms. This failure resulted in harm to Resident #100 due to a subsequent fall which resulted in multiple fractures to Resident #100. Resident #100 expired at the hospital after family and his physician determined Resident #100 was not a suitable surgical candidate. ( ) A review of Resident #102's medical file revealed on her Admission Record (dated [DATE]), she is a [AGE] year old woman admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her 30 day MDS assessment dated [DATE], showed Resident #102 scored a 13 out of 15 on her Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. This MDS assessment also showed Resident #102 required supervision and setup help during transfers, walking and using the toilet; she normally used a walker as a mobility device. A care plan was initiated for Resident #102 on [DATE] with the focus: "Risk for falls r/t (related to) decreased mobility/weakness and vision loss secondary to macular degeneration." Interventions included, but were not limited to, standby assist of one person with transfers, ambulation and toileting. This care plan was updated on [DATE] to include a personal alarm and bed pad alarm to her bed. During an interview with Resident #102 on [DATE] at 9:30 a.m., she sat in a chair next to her bed. It was observed no personal alarm was attached to Resident #102's clothing. Part of a black string was observed near Resident #102's pillow on her bed; after this Surveyor pulled the bed sheet back, a personal alarm was found under Resident #102's pillow with the string hanging, unattached to the resident. This Surveyor immediately summoned the Director of Nursing (DON), who came into the room and attached Resident #102's personal alarm to her clothing. The DON and this surveyor then immediately spoke with CNA "J," who stated she had not put Resident #102 back in her room after breakfast, but the Occupational Therapist (OT "I") had. The DON and this Surveyor then went to speak with OT "I", who on [DATE] at approximately 9:45 a.m., stated, "Yes, I brought (Resident #102) back to her room after her therapy but I did not attach an alarm to her. I wasn't aware that she was care-planned to have alarms. When was she put on alarms?" (# )