Every finding on record at Kingsley Specialty Care

Based on observation, record review, and staff interview, the facility failed to provide adequate Cardiopulmonary Resuscitation (CPR), to a resident requiring CPR prior to the arrival of Emergency Medical Services (EMS) personnel for 1 resident (Resident #1). Resident #1 had requested CPR and was not breathing and had no pulse. Staff performed some compressions, but failed to perform airway resuscitation, and failed to continue the compressions until EMS took over. The facility had a crash cart and back board to perform CPR, but staff failed to utilize the available resources. EMS started CPR when they arrived and transported the resident to the hospital. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 2:35 PM. The facility staff removed the Immediate Jeopardy on [DATE] through the following actions: staff education on CPR policy and need to continue CPR until EMS arrives, conducting mock code drills to ensure staff is aware of resources to utilize, staff educated on team lead assigning roles during a code and staff involved in a code will have debriefing after the code to discuss events and determine opportunities for improvement. The scope lowered from a J to a D at the time of survey after ensuring the facility implemented education and their policy and procedures.The facility identified a census of 37 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included heart failure, hypertension, renal failure, diabetes, and chronic obstructive pulmonary disease.A Cardiopulmonary Resuscitation (CPR )and Do Not Resuscitate (DNR) order declaration form, documented it was the policy of the facility to provide CPR. Basic CPR referred to a means of opening and maintaining an airway, providing ventilation through rescue breathing, and providing circulation through the use of external cardiac compression. The resident understand that if they wished for the facility to start CPR to prolong life when biological death was not imminent, (i.e.: no signs of irreversible death), the facility would initiate CPR until emergency responders arrived. They also understood the type of CPR provided would consist only of chest compressions and breathing techniques taught in basic CPR training. They also understand the facility may utilize an automatic external defibrillator (AED) in conjunction with CPR. On [DATE], Resident #1 electronically signed that she wanted CPR initiated and/or the AED used to prolong the life of the resident when biological death was not imminent.The Progress Notes dated [DATE] at 12:50 a.m. documented Resident #1 had difficulty getting settled for the night. Her bowels were moving and she needed cleaned up several times. She stated she wanted to go to the hospital because she could not breath. Resident #1's vital signs were attempted and could not be read. The nurse went to obtain oxygen (O2) for the resident. A Certified Nursing Assistant (CNA) was in the room. The resident's Head of the Bed (HOB) was elevated and the CNA noticed her breathing slow down, and she couldn't respond. The CNA summoned the nurse. At 12:35 a.m. they began chest compressions. The resident had no pulse present. The other CNA called 911. The ambulance arrived at 12:40 a.m. and began CPR. The resident transported on a stretcher to the hospital at 12:55 a.m. At 2:25 a.m. a hospital nurse called to inform her of the resident's death.On [DATE] at 1:35 p.m. Staff A Registered (RN) stated the resident had loose stools, and the CNA's cleaned her up. They did not tell her she complained of SOB, and when they did she intended to get her oxygen (O2). She couldn't find all the working parts so she had gone to the basement to find them. She said then they called her urgently to her room. She had no respirations or pulse. The CNA said he had done some chest compressions, but she didn't know if he had. One CNA left to call 911 and the other to help other residents. She stayed in the room and did chest compressions. When she heard the ambulance come in she stopped compressions. They came in and started CPR.On [DATE] at 1:50 p.m. Staff B CNA stated she had not worked at the facility very long. She wasn't even sure what the other CNA's name was. She said Resident #1 had loose stools and said she couldn't breathe. She said they told the nurse, and she went to get her some O2. Staff C CNA thought they should call the hospital. Staff C called for help because Resident #1 was unresponsive. They were all in the room and Staff B asked if she should call 911, and she went to do that. Staff C tried to do CPR. She didn't know if Staff A did CPR. She said it all happened very quickly.On [DATE] at 2:08 p.m. an Emergency Medical Technician (EMT) on the Ambulance crew stated when they arrived to the resident's room, someone stood at the foot of the bed. She said they asked why they were not doing CPR, and the person she thought was the nurse said she was giving Resident #1 some air. She said the other EMT on the ambulance started CPR. Resident #1 was cyanotic from lack of oxygen. They did put her on the floor, but they started while she was in bed. She said it was 10 minutes from the time they received the call and entered the facility. She said the family had a question for them. They wanted to know if they had started CPR at the facility. She reiterated when they asked why they were not doing CPR the person said she was giving her some air. There was no O2 in the room.On [DATE] at 2:37 p.m. Staff C stated Resident #1 had loose stools and wanted cleaned up, but did not want to get up to the bathroom. She wanted to go to the hospital, she had difficulty breathing. Staff A went to get her O2, and had to go to the basement. Resident #1 became unresponsive and he radioed Staff A several times and she didn't respond. They had to yell for her. Staff A then looked for her code status and found on the computer the resident wanted CPR, and he started compressions. On [DATE] at 7:46 a.m. Staff B stated she helped Resident #1 earlier in the evening to the bathroom. She did not have complaints. Staff C said she had trouble breathing and Staff A went to get oxygen. Staff A went to the basement for something. She heard Staff C screaming Resident #1 wasn't breathing. It took a minute or 2 to find Staff A. They all went to the room and she was not breathing. Staff A didn't know if Resident #1 was a code. Staff B and Staff A went to the nurse's station and looked for the book with code status. They could not find it, so Staff A looked on the computer and found she was a full code. Staff C started chest compressions. Staff A checked a pulse and said she was gone, and it basically stopped. Staff C stopped compressions. She said then they left the room. She expected the nurse to take charge, but she kind of acted like she was in shock.On [DATE] at 11:10 a.m. the Director of Nursing (DON) showed the crash cart which sat across from the nurse's station. The crash cart contained an Ambu bag (to administer respiratory support) and oxygen. A backboard hung next to it. There were pads for the AED that hung on the wall. She did not know if the crash cart was used for the code for Resident #1.On [DATE] at 12:59 p.m. The other EMT on the ambulance department said when she went in the room there was a male CNA outside the room in the hall. There was not a crash cart or Ambu bag in the room, and she didn't know if the facility had those items. She said the nurse said she thought Resident #1 was gone, but the resident was warm, so they initiated CPR. Compressions to start and breathing when they were set up. They did move her to the floor. They put pads on for the AED, and they did shock her 1 time when prompted to.On [DATE] at 9:44 a.m. Staff A stated when she found the code status she went to the resident's room. She said Staff C said he had been doing CPR, but she didn't know if he had. Staff A was left alone in the room. She was flustered and hadn't thought to grab the crash cart and take it to the room. She did chest compressions until she heard the ambulance come in. She did not do rescue breathing because she didn't have a barrier. On [DATE] at 9:59 a.m. Staff C stated he learned the basics of CPR in the military and again in CNA training. He said he stayed with Resident #1 while Staff A and Staff B went to find Resident #1's code status. He said when Staff A yelled the resident was a full code he started chest compressions, and did them until Staff A came back to the room. Staff A checked a pulse and said Resident #1 was gone. Staff A told Staff C to grab a gown and wait for the ambulance and let them in. He said he did not do rescue breathing.On [DATE] at 9:57 a.m. the DON stated if a resident who wanted CPR had no respirations or pulse they should start CPR right away. She said they could do compressions only until they were able to get the crash cart. She said they would get some oxygen with the compressions alone, but the crash cart should be obtained as soon as possible so they could administer respirations. She said CPR should continue until one staff person took over for another or EMS took over. She said they had not done code drills that she knew of since she had been there (since after Thanksgiving). The DON stated she was unaware there may be a problem until the surveyor asked if the crash cart was used for the code. They had done some interviews with staff and identified some issues.The facility Cardiopulmonary Resuscitation and Do Not Resuscitate Orders procedure effective [DATE] documented it was the policy of the facility that residents have the choice to receive basic CPR, which included maintaining an airway, rescue breathing, and external cardiac compressions. Facilities must ensure residents understand that basic CPR would be initiated until paramedics arrived.

Based on record review, staff interview, and policy review, the facility failed to ensure an accurate account of controlled medications for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 37 residents. Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #3 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included heart failure, pneumonia, diabetes, and pain in right and left knees.The Care Plan dated 1/7/25 identified Resident #3 had pain related to his diagnosis. Interventions included monitoring and documenting side effects of pain medication. The resident used opioid medications. Interventions included administering opioid medication per physician order and monitoring for side effects.A facility report documented on 4/8/26 during the administration of Resident #3's scheduled morning dose of Oxycodone/APAP (narcotic/acetaminophen (Tylenol), the administering nurse identified a discrepancy in the resident's narcotic record sheet. Review revealed 5 doses of the medication were removed on 4/7/26, when only 3 doses were prescribed. They identified 2 nurses having access to the medication cart at the time these medications were signed out, Staff A Registered Nurse (RN) and Staff E Licensed Practical Nurse (LPN). The discrepancy raised concern for potential medication diversion, and an internal investigation immediately initiated.The investigation identified documentation irregularities, including an attempted forged nurse signature on the individual narcotic record. It appeared Staff E attempted to sign as Staff A on the narcotic record. Staff A stated it was not her signature. Staff E said she hit the ground running and thought Staff A had not given the medications since she said she had several medications left to give that night when Staff E reported for work.On 4/8/26 Staff A stated they did not do a narcotic count. She had to get to the 100 cart and start those medications. Staff E verified they did not do a narcotic count.A review of Resident #3's Individual Narcotic Record for Oxycodone/APAP revealed on 4/7/26 at 3:10 p.m. Staff A signed out an oxycodone for the resident. The record further showed an Oxycodone/APAP signed out at 4 p.m. 7 p.m. and 8 p.m. The final 2 signed out were dated 4/8/26, however on 4/8/26, 3 tabs were signed out as ordered. The 4 p.m. and 7 p.m. signatures were not legible. The 8 p.m. signature was Staff E.The Schedule for April showed on the 7th Staff A would work 2-10 p.m. and Staff E would work 6 p.m. to 6 a.m.The 300 hall Controlled Drugs-Count Record revealed Staff A did not sign on or off of the count sheet 4/7/26. Staff E signed as the on nurse at 2 p.m. (though she didn't come to work until 6 p.m.).Review of Controlled Drugs-Count Record revealed the following gaps in counts when keys were exchanged:On 2/1/26 at 6 a.m. no nurse on signature,On 2/1/26 at 6 p.m. no on or off nurse signature,On 2/3/26 at 6 p.m. no off nurse signature,On 3/8/26 with no time identified, no on nurse signature.On 3/23/26 at 4 p.m. with no on nurse signature,On 3/26/26 2 p.m. no nurse on signature,On 3/30/26 at an illegible time with no off nurse signature,On 4/2/26 2 lines with 6 a.m. with no sign on nurse signature on the 2nd,On 4/5/26 at 10 p.m. with no sign off nurse signature.On 5/19/26 at 4:15 p.m. the DON confirmed both staff counting the meds when exchanging keys, needed to sign the Controlled Drug Count Record, confirming the narcotic counts were correct.The facility policy Conducting a Controlled Substance Count effective February 14, 2022 directed beginning the narcotic count with the on-coming shift by counting the number of cards, then verifying each medication card to proper page number for actual count. Actually, count each card bubble and the actual medication. If the Controlled Substance Count was off, the off going medication passer must stay in the facility until direction was provided by the Director of Nursing (DON)/Administrator.

Based on record review and staff interview, the facility failed to follow the physician's orders for medication administration and blood sugars falling outside the identified parameters for 1 of 4 residents reviewed for medications (Resident #1). The facility reported a census of 37 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included heart failure, hypertension, renal failure, diabetes, and chronic obstructive pulmonary disease.The Care Plan dated 4/16/26 identified Resident #1 used insulin/hypoglycemic medications related to diabetes. The interventions included administering insulin medications as ordered by the physician and monitoring blood glucose as ordered. a. The Medication Administration Record (MAR) for March 2026 included Insulin Lispro 10 units 3 times a day with a start date of 3/24/26, hold if blood sugar less than 100. The MAR lacked blood sugar readings or insulin administration on 3/27/26.On 5/19/26 at 12:10 p.m. the Director of Nursing (DON) showed Resident #1 received long acting insulin at bedtime on 3/27/26. She was unable to find blood sugars, or why she did not receive the Insulin Lispro. She said physician's orders should be followed. If something was not done, the physician should be notified. b. The MAR for May 2026 included Accuchecks (blood sugar checks) before meals and at bedtime, with no results in the p.m. 5/4 and 5/6/26. The order included if the blood sugar was less than 70 or greater than 350, notify the physician. The blood sugar result was outside the parameters on 5/2/26 before lunch at 67, 5/4/26 at 405, 5/6/26 before breakfast 377 and before lunch at 379, and 5/7/26 before breakfast at 434.The MAR included Insulin Lispro per a sliding scale with nothing documented 5/5 or 5/6/26.The clinical record lacked documentation why the blood sugars and Insulin Lispro 10 units were not completed as ordered. The clinical record lacked documentation the facility notified the physician of the blood sugars that were not within the parameters.On 5/20/26 at 11:01 a.m. the Administer stated they had found nothing to indicate they had completed the insulin as ordered, or of notification of the physician of the blood sugars not within the parameters. On 5/21/26 at 11:48 a.m. Resident #1's physician stated she would expect to be notified of the blood sugars not within the parameters, and if not receiving her insulin per order.

Based on record review and staff interview, the facility failed to ensure a resident on dialysis had needed equipment to facilitate treatment for 1 resident (Resident #1). The facility reported a census of 37 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included heart failure, hypertension, renal failure, diabetes, and chronic obstructive pulmonary disease. The resident received dialysis.The Care Plan dated 4/16/26 identified Resident #6 used insulin/hypoglycemic medications related to diabetes. Interventions included administering insulin medications as ordered by the physician, monitoring blood glucose as ordered, and monitoring for side effects (low blood sugar, headache, weakness, sweating and fainting) and effectiveness. The Care Plan identified the resident received hemodialysis on Monday, Tuesday, Wednesday and Fridays each week at the dialysis center. Interventions included encouraging the resident to go for the scheduled dialysis appointments.On 5/19/26 at 11:49 a.m. Resident #1's family member stated they were concerned about her care at the facility. The family member said Resident #1 did not have dialysis on 5/8/26.A facility form for Dialysis dated 5/6/26 contained the note Resident #1 needed to be in a hoyer (total mechanical lift) sling. She was unable to transfer or shift position in their chair.A Facility form for Dialysis dated 5/8/26 contained the note to please make sure Resident #1 had a lift sling.In an email on 5/20/26 at 1:50 p.m. the Dialysis Facility Administrator documented Resident #1's treatment orders were for 4x/week. (Mon, Tues, Wed, and Fri). The resident attended 5/4 (Mon) - and left over on fluid. She missed 5/5 (Tues) due to a doctor appointment. She received treatment 5/6 (Wed) - and left over on fluid. She missed 5/8 (Fri). In a follow up email on 5/20/26 at 2:38 p.m. the Dialysis Facility Administrator documented Resident #1 leaving over on fluid, meant she left above her estimated dry weight so she had extra fluid on board. They could only pull so much each treatment which is why it was very important to not miss treatment. On 5/8/26 Resident #1 arrived without a sling under her in her wheelchair, and she could not transfer on her own. They called the nursing home to bring a sling so they could transfer Resident #1 to the treatment chair to begin treatment. It took the nursing home over a hour to return, and by that point the patient no longer wanted to treat due to sitting and waiting so long, she was in pain and uncomfortable. They rescheduled the patient to have dialysis 5/9/26. On 5/20/26 at 3:45 p.m. the Director of Nursing (DON) said the resident could transfer with assistance, but did acknowledge the dialysis centers note about her needing a lift sling when she went for her dialysis treatment.A Long Term Care Facility Outpatient Dialysis Services Care Coordination Agreement between the facility and the dialysis center dated 5/4/26 included the long term care facility should ensure that each resident was prepared to spend an extended length of time at the dialysis facility, as necessary for the administration of the resident's prescribed treatment.

Based on record review, staff interview, the facility failed to ensure accurate and complete record of 1 resident missing dialysis for 1 resident reviewed (Resident #1). The facility reported a census of 37 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included heart failure, hypertension, renal failure, diabetes, and chronic obstructive pulmonary disease. The resident received dialysis.The Care Plan dated 4/20/26 identified Resident #1 received hemodialysis on Monday, Tuesday, Wednesday and Fridays each week at the dialysis center. Interventions included encouraging to go for the scheduled dialysis appointments.The Progress Notes dated 5/9/26 documented Resident #1 sent by ambulance to the hospital.On 5/19/26 at 11:49 a.m. Resident #1's family member stated they were concerned about her care at the facility. The family member said Resident #1 did not have dialysis on 5/8/26.The clinical record lacked documentation Resident #1 did not receive dialysis on 5/8/26.On 5/19/26 at 12:10 p.m. the Director of Nursing (DON) said it should be documented if the resident did not have dialysis on her scheduled day.

Based on record review and interviews the facility failed to notify physician of blood sugars not within parameters and when medication not given as ordered for 1 of 4 residents reviewed, (Resident#1). The facility reported a census of 37 residents. Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included heart failure, hypertension, renal failure, diabetes, and chronic obstructive pulmonary disease.The Care Plan dated 4/16/26 identified Resident #1 used insulin/hypoglycemic medications related to diabetes. The interventions included administering insulin medications as ordered by the physician and monitor blood glucose as ordered. a. The Medication Administration Record (MAR) for March 2026 included Insulin Lispro 10 units 3 times a day with a start date of 3/24/26, hold if insulin less than 100. The MAR lacked a blood sugar readings or insulin administration on 3/27/26.On 5/19/26 at 12:10 p.m. the Director of Nursing (DON) showed the resident received long acting insulin at bedtime on 3/27/26. She was unable to find BS's, or why she did not receive the Insulin Lispro. She said physician's orders should be followed. If something was not done, the physician should be notified. b. The Medication Administration Record (MAR) for May 2026 included accuchecks (blood sugar checks) before meals and at bedtime with no results in the p.m. 5/4 and 5/6/26. The order included if the blood sugar was less than 70 or greater than 350, notify the physician. The blood sugar result was outside the parameters on 5/2/26 before lunch at 67, 5/4/26 at bedtime, 405, 5/6/26 before breakfast 377 and before lunch at 379, and 5/7/26 before breakfast at 434.The MAR included Insulin Lispro per a sliding scale with nothing documented 5/4 or 5/6/26 in the p.m. The clinical record lacked documentation why the blood sugars and Insulin Lispro 10 units were not completed as ordered. The clinical record lacked documentation the facility notified the physician of the blood sugars that were not within the parameters.On 5/20/26 at 11:01 a.m. the Administer stated they had found nothing to indicate they had completed the insulin as ordered, or of notification of the physician of the blood sugars not within the parameters. On 5/21/26 at 11:48 a.m. Resident #1's physician stated she would expect to be notified of the blood sugars not within the parameters, and if not receiving her insulin per order.

Based on record review, staff interview, and facility policy review, the facility failed to report misappropriation of medication for 1 resident (Resident #6) to the Department of Inspections, Appeals and Licensing (DIAL) (the state survey and licensing agency). The facility reported a census of 37 residents. Findings include:According to the Minimum Data Set assessment dated [DATE], Resident #6 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included heart failure, chronic obstructive pulmonary disease and respiratory failure.The Medication Administration Record (MAR) for December 2025 showed Resident #6 had the order for Ondansetron disintegrating oral tablet every 8 hours as needed (PRN) for nausea.On 5/19/26 at 9:41 p.m. Staff D Licensed Practical Nurse (LPN) stated she started mid-December last year and was training with Staff E LPN. Staff D said at 1 point Staff E took a Zofran pill out, and took it herself. Staff D was shocked Staff E would take a resident's medicine in front of her. The next morning Staff D called the Administrator and told her.In an email 5/20/26 at 1:44 p.m. the Administrator identified Staff E took Resident #6's Zofran tablet.A Disciplinary Action Form dated 12/24/25 documented Staff E received a documented verbal warning for a performance/conduct infraction. It was reported and confirmed that Staff E became physically ill while on duty and subsequently self-administered a resident's prescribed PRN Zofran medication. The medication was the personal property of of the resident and prescribed solely for that resident's use. Administering or consuming resident medication for personal use was strictly prohibited and violated facility policy regarding medication administration and handling, resident's rights and property, and professional standards of conduct. As a Charge nurse Staff E was expected to demonstrate leadership and adherence to all facility policies at all times. A documented verbal warning was issued to the employee, and she was advised that any further violations may result in additional disciplinary action, up to and including termination.On 5/20/26 11:01 a.m. the Administrator stated she did not self-report (to DIAL) Staff E taking the Zofran because it was not a controlled substance.The facility Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy revised April 2021 documented if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source was suspected, the suspicion must be reported immediately to the administrator and other officials according to state law, including the state licensing/certification agency responsible for surveying/licensing the facility.

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report from Fiscal Quarter 2, 2025 (January 1 through March 31) review, facility staffing review, and staff interviews, the facility failed to meet staffing requirements in all three metrics. The facility reported a census of 31 residents.Findings include:The PBJ Staffing Data Report with a run date of 7/29/25 triggered submitted weekend staffing data excessively low within the quarter.Review of staffing for Nurses and Certified Nursing Assistants (CNAs) scheduled similarly for weekdays and weekends. In an interview on 8/7/25 at 3:34 PM, the Administrator reported recently being hired and not aware of how incorrect data was reported to CMS. The Administrator reported she expected data to be reported correctly and would look into the matter. The Reporting Direct-Care Staffing Information (Payroll-Based Journal) policy last revised October 2017 identified staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act.Policy Interpretation and Implementation1. Beginning with the fiscal quarter of 2016 (beginning July 1, 2016), direct-care staffing and census information will be reported electronically to CMS through the Payroll-Based Journal (PBJ) system.2. Direct-care staffing information includes staff hired directly by the facility, those hired through an agency, and contract employees.3. Providers who are employed by the facility (including physicians) are included in direct-care staffing information; providers who bill Medicare directly are not included.4. For auditing purposes, reported staffing information is based on payroll records, or other verifiable information.5. Information may be uploaded to the PBJ system manually, or through a payroll time and attendance system, or a combination of both.6. The PBJ system is accessed through the QIES at https://www.qtso.com/.7. Manual entries are made only by designated personnel with training on the PBJ user interface.8. Technical specifications for uploading data directly from a payroll or time and attendance system will be accessed through: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html.9. Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows:Fiscal Quarter Date Range Submission Deadline1 October 1- December 31 February 142 January 1- March 31 May 153 April 1 - June 30 August 144 July 1 - September 30 November 1410. Staffing data includes the number of hours worked each day by each staff member.11. Census data is reported each fiscal quarter and includes resident census on the last day of each month of the quarter.12. Definitions, instructions and examples of the PBJ user interface can be found in CMS' Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual. A current copy of this manual can be accessed at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html.13. A manual log is available to record information should the facility experience temporary internet outage and cannot record staffing data directly to the PBJ system. This log may also serve as a tool to record data that will be manually uploaded quarterly.

Based on observation, resident interview, staff interview and policy review the facility failed to provide food at an appetizing temperature to 4 of 20 residents reviewed (Resident #3, #5, #8 and #25). The facility reported a census of 31 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #3 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 8/4/25 at 1:03 PM Resident #3 stated the food is delivered cold to her room every day. Resident #3 stated all meals not a particular time. Resident #3 stated the meal came cold at lunch today. 2. The MDS dated [DATE] for Resident #5 documented a BIMS of 14 indicating no cognitive impairment. On 8/5/25 at 9:33 AM Resident #5 stated he told the Administrator that the food was cold and then the evening meal started to get hotter but lunch is almost always cold. 3. The MDS dated [DATE] for Resident #25 documented a BIMS of 15 indicating no cognitive impairment. On 8/5/25 at 7:55 AM Resident #25 stated nearly all the meals are served cool. Stated she does not ask the staff to reheat the food. Resident #25 stated she would like it if the food was served warmer. On 8/6/25 at 12:05 PM during a continuous observation of lunch service revealed Staff G, Lead [NAME] remove 6 servings of ham from the steam table, ham placed in food processor, ham blended to ground consistency, ham removed from food processor, 4oz scoop utilized to place ham on 4 plates, Staff G acknowledged his intent to serve the plate once all food was on the plates, surveyor requested temperature of mechanical ham, Staff G obtained a temperature of 114 degrees, Staff G removed mechanically altered ham from the plated into container with the other 2 servings of ham, ham placed in microwave, ham removed from the microwave, temperature of 170 obtained. On 8/6/2025 at 12:15 PM Staff G stated residents with room trays had complained about food being cold so the facility ordered warming pellets and received the warming pellets for the plates yesterday. On 8/6/2025 at 12:47 PM Staff H, Dietary Manager acknowledged the mechanical soft ham should not have been served at a temp of 114. Staff H stated her expectation was the serving / holding temperature for the food would be a minimum of 135 degrees. On 8/6/25 at 1:01 PM the Administrator expected all food would have been served at a minimum of 135 degrees. 8/6/25 at 3:18 PM Staff I, Registered Dietitian stated she expected food to have a holding temperature of at least 135 degrees. Staff I stated the mechanical soft should have had the temperature taken prior to serving and then reheated. Staff I stated her expectation was the mechanically soft ham would have been reheated to 135 degrees in the microwave because it was not considered leftover. Review of policy revised 4/19 titled, Food Preparation and Service documented the danger zone for food temperatures was between 41 degrees and 135 degrees. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. The longer food remains in the danger zone the greater the risk for growth of harmful pathogens. Therefore, potentially hazardous foods must be maintained below 41 degrees or above 135 degrees. Mechanically altered hot foods prepared for modified consistency diets remain above 135 degrees during preparation or they are reheated to 165 degrees for at least 15 seconds. 4. Observation on 08/06/2025 at 8:12 AM showed the kitchen staff knocked on Resident # 8’s door, during resident care, and reported the breakfast tray would be outside of the room. At 8:49 AM resident care ended, staff retrieved the tray from an uninsulated cart and served the breakfast tray to the resident. At 8:51 AM Resident #8 reported the breakfast to be cold. When asked how many days of the week meals are cold, the resident replied, six out of seven. When asked how many meals were cold in the six days, the resident replied, all three. Resident #8 consumes all meals in her room. In an interview on 8/7/25 at 3:34 PM, the Administrator reported staff should have provided a new breakfast tray for the resident. When asked if she had knowledge of the resident's concerns of cold food, the Administrator stated, we have ordered warming pellets for room trays. The Food Preparation and Service Policy last revised April 2019 identified the services employees prepare and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation Food Preparation, Cooking and Holding Time/Temperatures The “danger zone” for food temperatures is between 41°F and 135°F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. The longer foods remain in the “danger zone” the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained below 41°F or above 135°F. Potentially hazardous foods held in the danger zone for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if cooked and then cooled) may cause foodborne illness. Food thermometers used to check food temperatures are clean, sanitized and calibrated for accuracy. The following internal cooking temperatures/times for specific foods are reached to kill or sufficiently inactivate pathogenic microorganisms: Internal Cooking Temperature Raw Animal Foods 145°F for 15 seconds • Raw eggs cooked for immediate service • Fish (except as listed below) • Meat (except as listed below) • Commercially raised game animals, rabbits 155°F for 15 seconds • Ground meat (beef, pork) • Ground fish • Raw eggs held for service • Comminuted meat, fish, or commercially raised game animals • Injected or mechanically tenderized meats • Ratites (ostrich, [NAME] and emu) 165°F for 15 seconds • Wild game animals • Poultry • Stuffed fish, meat, pork, pasta, ratites & poultry • Stuffing containing fish, meat, ratites & poultry Fresh, frozen or canned fruits and vegetables are cooked to a holding temperature of 135°F. Raw food cooked in a microwave reach 165°F in all parts of the food. The item is rotated and stirred during the cooking process so that all parts of the food reached 165°F, and allowed to stand covered for at least two (2) minutes after cooking. Previously cooked food is reheated to an internal temperature of 165°F for at least 15 seconds. Reheated foods that are not consumed within 2 hours are discarded. Ready to eat foods that require reheating are taken directly from the sealed container or intact package from the food processing source and cooked to at least 135°F. Mechanically altered hot foods prepared for a modified consistency diet remain above 135°F during preparation or they are reheated to 165°F for at least 15 seconds. continues on next page Only pasteurized shell eggs are cooked and served when: Residents request undercooked, soft-served or sunny side up eggs; and Preparing foods that will not be thoroughly cooked (e.g., hollandaise sauce, French toast, ice cream, etc.). Unpasteurized eggs are cooked until all parts of the egg (yolk and whites) are completely firm. Only the number of eggs necessary for immediate service or baking are cracked and pooled (combined together). Eggs are not cracked and pooled for later use. Raw eggs with damaged shells are discarded. All raw fruits are washed thoroughly before serving. Food served once is not served again. Residents are discouraged from saving anything from their meals for later consumption. Residents are strongly discouraged from keeping potentially hazardous food in their rooms. Food Service/Distribution Proper hot and cold temperatures are maintained during food service. Foods that are held in the temperature “danger zone” are discarded after 4 hours. The temperatures of foods held in steam tables are monitored throughout the meal by food and nutrition services staff. Steam tables are never used to reheat foods.

Based on Electronic Health Records (EHR) review, observation, document review, and staff interviews the facility failed to prepare food in a form designed to meet individual needs by sending incorrect consistency for modified diet ordered for 6 of 6 residents reviewed (Resident #7, #9, #10, #11, #13 and #22). The facility reported a census of 31 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #7 documented a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. The MDS also documented diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, unsteadiness on feet and generalized muscle weakness. Review of Resident #7's EHR titled, Orders documented an order for regular / no added salt diet with mechanical soft texture.Review or Resident #7's lunch meal ticket from 8/6/25 documented a mechanical soft diet with 1/2 cup of chopped brussels sprouts.2. The MDS dated [DATE] for Resident #9 documented a BIMS of 13 indicating no cognitive impairment. Review of Resident #9's EHR titled, Orders documented an order for regular / no added salt diet with mechanical soft texture.Review or Resident #9's lunch meal ticket from 8/6/25 documented a mechanical soft diet with 1/2 cup of chopped brussels sprouts.3. The MDS dated [DATE] for Resident #10 documented a BIMS of 0 indicating Resident #10 was rarely / never understood. Review of Resident #10's EHR titled, Orders documented an order for regular / no added salt diet with mechanical soft texture.Review or Resident #10's lunch meal ticket from 8/6/25 documented a mechanical soft diet with 1/2 cup of chopped brussels sprouts.4. The MDS dated [DATE] for Resident #11 documented a BIMS of 7 indicating severe cognitive impairment. Review of Resident #11's EHR titled, Orders documented an order for regular / no added salt diet with mechanical soft texture.Review or Resident #11's lunch meal ticket from 8/6/25 documented a mechanical soft diet with 1/2 cup of chopped brussels sprouts.5. The MDS dated [DATE] for Resident #13 documented a BIMS of 10 indicating moderate cognitive impairment. Review of Resident #13's EHR titled, Orders documented an order for regular / no added salt diet with mechanical soft texture.Review or Resident #13's lunch meal ticket from 8/6/25 documented a mechanical soft diet with 1/2 cup of chopped brussels sprouts.6. The MDS dated [DATE] for Resident #22 documented a BIMS of 12 indicating moderate cognitive impairment. Review of Resident #22's EHR titled, Orders documented an order for regular / no added salt diet with mechanical soft texture.Review or Resident #22's lunch meal ticket from 8/6/25 documented a mechanical soft diet with 1/2 cup of chopped brussels sprouts.On 8/6/25 at 12:05 PM a continuous observation of lunch service revealed Staff G, Lead [NAME] remove 6 servings of ham from the steam table, ham placed in food processor, ham blended to ground consistency, ham removed from food processor, 4oz scoop utilized to place ham on 4 plates and 1/2 cup spoodle utilized for whole brussels sprouts. Observation revealed all 6 mechanically soft diets received regular brussels sprouts on the plate for lunch. No mechanical soft brussels sprouts prepared for the lunch meal. Review of document titled, Therapeutic Spread Report Summer / Spring Menu 25 for Week 4 Wednesday Lunch documented mechanical soft diets were to receive 1/2 cup of chopped brussels sprouts.Review of document dated 8/6/25 titled Diet Type Report documented Resident #7, #9, #10, #11, #13, and #22 received mechanical soft diets.On 8/6/2025 at 12:47 PM Staff H Dietary Manager acknowledged the brussels sprouts served on 8/6/25 at the lunch service to the residents on a mechanically soft diet were not chopped and should have been. On 8/6/25 at 1:01 PM the Administrator stated her expectation was the brussels sprouts would have been chopped if that was how the menu read. On 8/6/25 at 1:24 PM Staff J, Dietary Aide acknowledged the mechanical soft diets had regular brussels spouts served to them during lunch on 8/6/25. Staff J stated he depended on the cook to serve the right consistency for residents on a mechanical soft diet. Staff J stated the dietary slips have the diets that should be served to the resident but only sees the dietary slips when the plates are not taken to the residents fast enough and the plated food gets backed up on the steam table.On 8/6/25 2:22 PM Staff G, Lead [NAME] acknowledged the brussels sprouts should have been chopped for the lunch meal on 8/6/25. Staff G acknowledged none of the residents that were on a mechanical diet received chopped brussels sports. Staff G explained that chopped brussels sprouts were on the menu and the residents did not receive them. Staff G explained he utilized the menu to determine what to prepare for the mechanically altered diets. Staff G stated he thought the brussels spouts were soft enough for the mechanical diets. Staff G stated Resident #10 ate too fast and was changed to a mechanical diet because he choked. Stated Resident #13 choked and was changed to a mechanical soft diet as a result as well.On 8/6/25 at 3:18 PM Staff I, Registered Dietitian stated mechanical soft brussels sprouts should be chopped or fork tender. Staff I stated the cooks should be following the menu if the menu stated the brussels spouts are chopped then they should be chopped.

Based on observation, staff interview, and policy review the facility failed to store food in accordance with professional standards by not dating open food items and not disposing of expired food items. The facility reported a census of 31 residents.Findings include:The initial kitchen observation on 8/4/25 at 10:50 AM revealed the refrigerator in the dish machine room had broccoli dated 7/25/25. The 3 door refrigerator had an open and undated bag of shredded cheese. The Dry storage had an open and undated 5lbs bag of egg noodles and an open undated 5lbs bag of tri color spiral noodles. The 2 door freezer had an open and undated bag of hush puppies. The [NAME] freezer chest had an open and undated bag of frozen chicken breasts. The 2 door stand up freezer had an open undated bag of pork chops and a bag of pork sausages that were dated but were not covered.On 8/4/25 at 11:00 AM Staff H, Dietary Manager stated all open food items should have the date the item was opened. Staff H stated the broccoli dated 7/25/25 should have been thrown away. Staff H explained her expectation was that all leftovers would be thrown out after 3 days. Staff H acknowledged all the food items in the kitchen without open dates. Staff H explained all of the food items without open dates would be thrown away immediately. On 8/6/25 at 1:01 PM the Administrator stated her expectation was all open food would be covered and labeled with an open date.Review of policy revised 10/17 titled, Food Receiving and Storage documented dry foods that are not stored in bins will be removed from original packaging, labeled and dated ( use bydate). All foods stored in the refrigerator or freezer will be covered, labeled and dated.

Based on observation, Electronic Health Record (EHR) review, policy review, resident interviews and staff interviews the facility failed to provide dignity and respect to 1 of 8 residents reviewed (Resident #7). The facility reported a census of 31 residents.Finding include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #7 documented a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. The MDS also documented diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, unsteadiness on feet and generalized muscle weakness. The MDS indicated Resident #7 required substantial / maximal assistance for transfers on and off the toilet and Resident #7 was completely dependent on staff for toileting hygiene.An observation on 8/4/25 at 1:15 PM revealed Staff A, Non Certified Aide (NA) entered Resident #7's room and shut the call light off. Resident #7 stated to Staff A he needed to go to the bathroom. Staff A told Resident #7 she could not take him to the bathroom on her own and would get someone to help. On 8/4/25 at 1:16 PM Resident #7 stated he needed to use the restroom that was the reason he turned the call light on. Resident #7 explained he told the staff he needed to use the restroom. An observation on 8/4/25 1:48 PM revealed Staff B, Activities Director turned Resident 7's call light on because the resident stated he needed to be changed and needed a staff to change him. On 8/4/25 at 1:49 PM Staff B, acknowledged Resident #7 stated he would come to the activity as soon as he got his brief changed. Staff B stated she turned the call light on so that a staff member would come and provide him personal care.An observation on 8/4/25 at 1:49 PM revealed Staff C, Certified Nursing Assistant (CNA) / Certified Medication Assistant (CMA) entered Resident #7's room and shut the light off. Staff C explained to Resident #7 she would have to have another staff to help provide personal care.An observation on 8/4/25 at 1:53 PM revealed Resident #7 audibly and visually sobbing.An observation on 8/4/25 at 1:55 PM revealed the DON enter Resident #7's room and speak to him about why he was crying.On 8/4/25 at 1:56 PM the DON stated Resident #7 was upset because he wanted to be changed and have personal care completed. The DON acknowledged Resident #7 stated he had been waiting. The DON stated Resident #7 wanted to go down to the activity.On 8/4/25 at 2:06 PM staff entered the room to assist Resident #7 after DON requested staff to help Resident #7.On 8/4/25 at 2:08 PM Staff A stated she entered Resident #7's room and shut the call light off in his room. Staff A stated she told Staff C that Resident #7 needed to be changed. Staff A stated staff did not go into the room because the surveyor was in the room when the staff came back down. On 8/4/25 at 2:18 PM Resident #7 stated he felt the staff had not provided him with dignity and was very upset the light was turned off 2 times without changing his wet brief. Resident #7 acknowledged the reason he was sobbing when the DON spoke with him was because he wanted to be changed and no staff had the time to change him. Resident #7 explained that was very upsetting to him.On 8/4/25 at 2:24 PM Staff C stated she was working on hall 3 and she cared for Resident #7 that day. Staff C stated Resident #7 had his light on and she shut it off and said she was busy with a 2 assist and she would be right back. Staff C explained Resident #7 told her that would be fine. Staff C stated Staff B did not tell her that Resident #7 needed help prior to when she entered Resident #7's room at 1:49 PM. Staff C stated the expectation was that call lights would be answered within 15 minutes and if they can't get to it will ask if it was an emergency or if it was something that could wait. On 8/6/25 at 4:16 PM the DON stated the lack of communication had led to the delay of care and Resident #7 being upset. The DON stated she had already spoken to staff about the situation once she had talked to Resident #7. The DON stated she could understand if Resident #7 felt he did not receive the appropriate respect or dignity in that situation.On 8/6/25 at 4:35 PM the Administrator stated she would have expected no delay in care and understood Resident #7 was upset. The Administrator acknowledged anyone in a similar situation would feel appropriate dignity and respect was not provided. Review of policy revised 12/16 titled, Resident Rights documented employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of that facility. These rights include the resident's right to be treated with respect, kindness and dignity.

Based on Medication Administration Record (MAR) - Treatment Administration record (TAR), Electronic Health Records (EHR) review, resident interviews and staff interviews the facility failed to represent an accurate assessment of the resident's status during the observation period of the MDS by not accurately assessing the use of insulin for 1 of 10 residents reviewed (Resident #7). The facility reported a census of 31 residents. Finding include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #7 documented a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. On 8/4/25 at 1:21 PM Resident #7 stated he was not on insulin. Review of Resident #7's MDS dated [DATE] documented 7 days insulin injections were received during the last 7 days and no order for insulin.Review of Resident #7's EHR titled, Orders documented no current order for insulin.Review of Resident #7's EHR titled, Orders documented basaglar kwik pen started 2/3/23 and discontinued 3/22/24 and insulin glargine started 4/29/22 and discontinued 7/6/22.Review of Resident #7's MAR - TAR for the month of May, June and July revealed no orders for insulin.On 8/6/25 at 4:03 PM Staff D, MDS Coordinator / Infection preventionist (IP) / Registered Nurse (RN) acknowledged the MDS that was completed for Resident #7 on 5/15/25 was entered in error when documenting the use of insulin. Staff D stated the MDS would be updated immediately. Staff D acknowledged Resident #7 did not have an order for insulin at the time of the MDS and was not receiving insulin at the time of the completion of the MDS on 5/15/25.On 8/7/25 at 4:00 PM the DON explained that her expectation was that the MDS would be completed accurately. The DON acknowledged Resident #7's MDS dated [DATE] was not accurately completed. The DON acknowledged that Resident #7 did not take insulin and did not have an order for insulin at that time. Email request for policy on accurate MDS assessment documented a response that the facility does not have a policy. The facility followed the Resident Assessment Instrument (RAI) guidelines.

Based on observation, record review, policy review and staff interviews the facility failed to provide 2 of 37 medications as ordered resulting in a medication error rate of 5.41. The facility reported a census of 31 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #8, dated 7/7/25 did not document a Brief Interview for Mental Status (BIMS). Review of EHR titled, Progress Notes dated 8/5/25 revealed a BIMS evaluation with a BIMS of 15 documented. The MDS documented diagnoses of essential hypertension and unspecified hypotension. An observation on 8/6/25 at 7:24 AM with Staff D, MDS Coordinator / Infection Preventionist (IP) / Registered Nurse (RN) present of Staff E, Registered nurse (RN) prepare medications for Resident #8, blood pressure obtained 140/70, midodrine 10mg removed from the drawer, midodrine reviewed with the MAR, midodrine 10mg removed from the bubble pack, the rest of Resident #8's medications removed from bubble pack, Staff E knocked on Resident #8's door, Staff E presented Resident #8 with medications, Resident #8 self administered medications with sips of water.Review of Resident #8 EHR titled, Orders documented an order for midodrine HCl Oral Tablet 10mg to give 10mg by mouth three times a day related to hypotension hold if the Systolic Blood Pressure (SBP) >110. Review of Resident #8's MAR - TAR documented a Physician's Order for midodrine HCl Oral Tablet 10mg to give 10mg by mouth three times a day related to hypotension hold if the Systolic Blood Pressure (SBP) >110. Review of Resident #8's EHR titled, Vitals / Blood Pressure Summary documented a blood pressure on 8/6/25 at 7:41 AM of 140/70. On 8/6/25 at 8:48 AM Staff D stated other than the parameters for Resident #8's midodrine not being followed she did not see any concerns. Staff D explained Resident #8's midodrine was given outside of the physician's parameters. Staff D stated the physician would be notified and would complete follow up blood pressures throughout the day. Staff D acknowledged Resident #8's midodrine should have been held because the systolic blood pressure was above 110. Staff D acknowledged Resident #8's systolic blood pressure was 140. On 8/7/25 at 4:00 PM the DON stated her expectation was that Resident #8's midodrine would have been held with a systolic blood pressure of 140 according to the physician's orders. The DON stated she expected the nurse to follow the medication checks prior to medication administration. 2. The MDS dated [DATE] for Resident #26 documented a BIMS of 2 indicating severe cognitive impairment. The MDS documented Resident #26 had a diagnosis of type 2 diabetes mellitus with other specified complications.Review of Resident #26's MAR-TAR documented a Physician's Order for NovoLog solution 100 UNIT/ML (insulin aspart). Inject 6 units subcutaneously three times a day with a start date of 7/25/25.Review of Resident #26's EHR titled, Orders documented a Physician's Order for NovoLog solution 100 UNIT/ML (insulin aspart). Inject 6 units subcutaneously three times a day with a start date of 7/25/25.An observation on 8/6/25 at 8:38 AM with Staff D, MDS Coordinator / Infection Preventionist (IP) / Registered Nurse (RN) revealed Staff F, Licensed Practical Nurse (LPN) draw up 2 units of NovoLog insulin, 2 units primed to check patency, 6 units drawn up, cleansed Resident #26's back upper arm with an alcohol wipe, NovoLog given in the back of the right upper arm, visual and audio observation of turning insulin pen down 2 clicks, insulin pen needle removed from Resident #26's arm clicking continued 2 times outside of the arm, Staff F acknowledged she had completed the insulin administration, surveyor requested to see the insulin pen and 2 units remained in the insulin pen. Staff A stated she would administer the rest with another needle in the left side abdomen. Staff A obtained a new needle for insulin pen, cleansed Resident #26's left abdomen with an alcohol wipe and injected the remaining 2 units of NovoLog insulin.On 8/6/25 at 8:48 AM Staff D acknowledged during the observation of insulin administration to Resident #26 it appeared the insulin was not administered appropriately. Staff D explained that it appeared the insulin was being administered after the needle had been removed from Resident #26's arm. Staff D stated her expectation was the insulin would have been administered appropriately. On 8/7/25 at 4:00 PM the DON stated the facility's expectation was medication would be administered appropriately according to the physician's orders. The DON stated in the incident with Resident #26's insulin administration she expected all 6 units would have been administered to Resident #26 in one dose and all in the upper right arm at once. The DON explained when Staff F had not given all 6 units at once she would have expected with a second needle being applied to the insulin pen that 2 more units would have been primed to ensure patency of the needle. The DON explained the facility's expectation was medication errors would not occur and all appropriate administration steps would be followed.Review of policy revised 4/19 titled, Administering Medications documented medications were to be administered in a safe and timely manner, and as prescribed. The individual administering the medication checks the label 3 times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for that resident.

Based on observations, record review, staff interviews and policy reviews, the facility failed to provide proper hand hygiene after resident care for 2 of 2 residents reviewed (Resident #8 and #26). The facility reported a census of 31 residents.Findings include: 1. Observation on 08/06/2025 at 8:02 AM showed Staff K, Certified Nursing Assistant, (CNA) and Staff C, CNA performed hand hygiene, donned personal protective equipment (PPE) of a gown and gloves then provided care for a catheter and bowel movement incontinence. When finished Staff K removed the soiled gown and gloves, used the left hand to hold the trash receptacle, then used the right hand to place soiled PPE into the trash. Staff K next placed her right hand on top of the soiled PPE, and pushed the soiled PPE down further into the trash receptacle. Without performing hand hygiene Staff K arranged the resident’s sheet and bedside table. In an interview on 8/7/25 at 3:34 PM, the Administrator reported she expected staff to complete hand hygiene immediately after removing solid gloves. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #26 documented a Brief Interview for Mental Status (BIMS) of 2 indicating severe cognitive impairment. The MDS documented Resident #26 had a diagnosis of type 2 diabetes mellitus with other specified complications. An observation on 8/6/25 at 8:38 AM with Staff D, MDS Coordinator / Infection Preventionist (IP) / Registered Nurse (RN) revealed Staff F, Licensed Practical Nurse (LPN) complete hand hygiene, apply gloves, draw up 2 units of NovoLog insulin, 2 units primed to check patency, 6 units drawn up, cleansed Resident #26’s back upper arm with an alcohol wipe, NovoLog given, Staff F removed gloves picked up insulin supplies, placed hands on the handles of Resident #26’s wheelchair, wheeled Resident #26 down the hall to the medication cart, retrieved keys, unlocked the medication cart, placed supplies in the medication cart, completed hand hygiene and wheeled Resident #26 to the dining room table. On 8/6/25 at 8:48 AM Staff D stated her expectation was hand hygiene would have been completed after gloves were removed before contamination of any surfaces, pushing Resident #26 up the hall and prior to returning supplies to the medication cart. On 6/7/25 at 4:00 PM the DON stated the facility’s expectation was hand hygiene would be completed after gloves were removed before contamination of any surfaces, pushing Resident #26 up the hall and prior to returning supplies to the medication cart. Review of policy revised 8/19 titled, Handwashing / Hand Hygiene documented This facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations before and after direct contact with residents, after contact with a resident’s intact skin, after contact with blood or bodily fluids and after removing gloves.

Based on observation, Electronic Health Record (EHR) review, staff interview, policy, and Medication Administration Records - Treatment Administration Records (MAR-TAR) review the facility failed to provide needed services in accordance with professional standards by administering a medication that should have been held related to parameters for 1 of 3 residents (Resident #8). The facility reported a census of 31 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #8, dated 7/7/25 did not document a Brief Interview for Mental Status (BIMS). Review of EHR titled, Progress Notes dated 8/5/25 revealed a BIMS evaluation with a BIMS of 15 documented. The MDS documented diagnoses of essential hypertension and unspecified hypotension. An observation on 8/6/25 at 7:24 AM with Staff D, MDS Coordinator / Infection Preventionist (IP) / Registered Nurse (RN) present of Staff E, Registered Nurse (RN) prepare medications for Resident #8, blood pressure obtained 140/70, midodrine 10mg removed from the drawer, midodrine reviewed with the MAR, midodrine 10mg removed from the bubble pack, the rest of Resident #8's medications removed from bubble pack, Staff E knocked on Resident #8's door, Staff E presented Resident #8 with medications, Resident #8 self administered medications with sips of water mixed with Miralax.Review of Resident #8 EHR titled, Orders documented an order for midodrine HCl Oral Tablet 10mg to give 10mg by mouth three times a day related to hypotension hold if the Systolic Blood Pressure (SBP) >110. Review of Resident #8's MAR - TAR documented a Physician's Order for midodrine HCl Oral Tablet 10mg to give 10mg by mouth three times a day related to hypotension hold if the Systolic Blood Pressure (SBP) >110. Review of Resident #8's EHR titled, Vitals / Blood Pressure Summary documented a blood pressure on 8/6/25 at 7:41 AM of 140/70. On 8/6/25 at 8:48 AM Staff D stated other than the parameters for Resident #8's midodrine not being followed she did not see any concerns. Staff D explained Resident #8's midodrine was given outside of the physician's parameters. Staff D stated the physician would be notified and would complete follow up blood pressures throughout the day. Staff D acknowledged Resident #8's midodrine should have been held because the systolic blood pressure was above 110. Staff D acknowledged Resident #8's systolic blood pressure was 140. On 8/7/25 at 4:00 PM the DON stated her expectation was that Resident #8's midodrine would have been held with a systolic blood pressure of 140 according to the physician's orders. The DON stated she expected the nurse to follow the medication checks prior to medication administration. Review of policy revised 4/19 titled, Administering Medications documented medications were to be administered in a safe and timely manner, and as prescribed. The individual administering the medication checks the label 3 times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication.

Based on clinical record review, facility policy and interviews the facility failed to permit a resident to return to the facility after hospitalization for 1 of 1 residents reviewed (Resident #39). The facility reported a census of 31 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #39 documented a discharge assessment with return anticipated for an unplanned short-term general hospital stay.The Clinical Progress Notes for Resident #39 showed on 3/10/25 at 9:01 PM showed the resident admitted to the hospital. The notes showed no documentation for readmission.In an interview on 8/4/25 at 1:32 PM, the locally assigned Office of the State Long-Term Care Ombudsman (OSLTCO) reported on March 7, 2025 the facility's Business Office Manager (BOM) called to discuss Resident #39's Medicare coverage ended and that he owed a substantial outstanding balance. The BOM reported Resident #32 wanted to remain at the facility until he had the strength to go home, but refused to pay. The BOM told the Ombudsman the OSLTCO needed to tell the resident he had to pay for services. The BOM stated to the Ombudsman, he cannot just stay here without paying. On 3/18/25 at 1:00 PM the Ombudsman arrived at the facility, talked with the Administrator, and discovered the resident no longer resided at the facility after hospitalization. The Ombudsman inquired if the resident's goal was to return to the facility, whether he received a bed hold notice, and if an involuntary discharge notice was served. The Administrator, uncertain about the details, brought the Ombudsman to speak to the BOM. The BOM reported bed hold notices are not provided to residents if outstanding debt to the facility is owed upon hospitalization per policy, and as per the facility's admission agreement. In an interview on 8/6/25 at 11:37 AM, the BOM reported Resident #39 was transferred to the emergency room and did not return. When asked if the resident wanted to return to the facility, the BOM reported per the facility's admission agreement residents are not allowed to hold open a bed if a balance is owed. When asked if the resident was not permitted to return to the facility because he owed money, the BOM stated, I wasn't the one who would talk to him about returning, that would have been the social worker or corporate. In an interview on 8/6/25 at 12:11 PM, the Nurse Consultant reported she had no knowledge of the discharge of Resident #39, and would find the intake specialist for more information. The Administrator reported being recently hired, and also had no knowledge of the discharge.In an interview on 8/7/25 at 11:11 AM, Staff L, Central Intake reported Resident #39 transferred to the hospital and signed a Bed Hold form but due to an extended stay at the hospital the bed hold was stopped to prevent further billing. Staff L stated, Resident #39 agreed to a payment plan, he wanted to stop the bed hold charge because he wasn't going to be ready for discharge for quite awhile. In an interview on 8/7/25 at 11:44 AM, when asked if Resident #39 was allowed to return to the facility after hospitalization, Staff M, Regional Finances stated a bed hold was allowed even with a past due amount. Staff M reported she worked with the case manager at the hospital, Resident #39 wanted to let the bed hold go to prevent further billing. The hospital Case Manager notes for Resident #39 dated 3/12/25 at 10:52 AM documented the following:Social Worker called from Facility, Care Liaison, Staff L. States patient did not do a bed hold and has other issues with the facility (Care Liaison did not elaborate). The Patient can't return to the facility or other facilities owned by the company.In an interview on 8/7/25 at 3:34 PM, the current Administrator reported if a resident's account is past due they should be permitted to return from the hospital to the facility. The undated admission Agreement dated 8/20/24 documented the resident shall have the option to hold the bed indefinitely; however, Resident will not be allowed to hold open a bed during a temporary absence if the account is past due. The Bed Hold Policy/Authorization date effective 3/10/25 showed to be signed by Resident #39 on 3/12/25. The Discharge Summary and Plan dated December 2016 failed to address readmissions to the facility.

Based on clinical record review, policy review and staff interview the facility failed to revise and update care plans to include appropriate interventions for residents to prevent repeated fall and injuries for 3 out of 3 residents reviewed (Resident #1, #2 and #3). The facility reported a census of 34 residents. Findings included: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of neurological disorder, dysphagia, and stroke. The MDS showed Resident #2 ' s cognitive skills for daily decision making as moderately impaired. Review of the facility Incident Reports from a look back period starting on admission 11/8/24 through 12/31/24 showed Resident #2 fell four times. The Incidents Reports for Resident #2 showed the following falls: a. On 11/8/24 at 11:00 PM- resident found with his back on the floor. b. On 11/9/24 at 4:53 PM- resident found sitting on the floor. c. On 11/25/24 at 10:47 PM- resident found on the floor sitting on both knees. d. On 12/7/24 at 9:47 AM- resident found with his stomach on the floor. The Care Plan for Resident #2 showed no focus area or fall interventions for November or December 2024. 2. The MDS assessment dated [DATE] for Resident #3 documented diagnoses of coronary artery disease, diabetes, and arthritis. The MDS showed the Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. Review of the facility Incident Reports from a look back period starting on 10/1/24 through 12/31/24 showed Resident #3 fell six times. The Incidents Reports for Resident #3 showed the following falls: a. On 10/2/24 at 5:30 AM- resident found sitting on the floor. b. On 10/6/24 at 10:30 PM- resident found sitting on a box in her closet. c. On 10/19/24 at 10:00 PM- resident found laying on the floor. d. On 10/24/24 at 2:00 PM- resident found laying on the floor. e. On 11/17/24 at 8:00 AM-resident found with right hip slightly sitting on floor. f. On 11/20/24 at 4:50 PM- resident found on the floor in the fetal position. The Care Plan for Resident #3 showed no fall interventions added to the care plan for the following dates: a. 10/6/24 b. 10/24/24 c. 11/17/24 d. 11/20/24 e. 11/29/24. 3.The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented the initial reentry to the facility from a short term general hospital stay. The Clinical assessment dated [DATE] for Resident #1 showed the Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. On 10/14/24 reassessment of the BIMS showed a score of 1 which indicated severe cognitive impairment. The Medical Diagnosis for Resident #1 showed diagnoses of dementia, blindness, cerebral infarction, and heart failure. The Fall Risk Evaluation dated 10/8/24 for Resident #1 showed the fall risk score of 13, which indicated a high risk of falling. The Care Plan for Resident #1 identified the resident unable to ambulate and required an assist of two persons for transfers. The care plan interventions for the look back date of October 2024 through December 2024 identified the following fall interventions: Initiated on 10/31/24- Body pillow along edge of bed to help establish a bed boundary. Initiated on 12/19/24- I have lateral support in my wheelchair to prevent leaning to the side. The Incident Report dated 10/14/24 at 11:23 PM for Resident #1 identified resident found sitting on the floor in front of the bed, legs crossed, and with the call light cord wrapped around her legs. Resident #1 noted to have new dark purple bruises to the right arm, chest and back. Predisposing physiological factors included confusion, gait imbalance, impaired memory, weakness/fainted. The facility failed to take measures to reduce falls and injuries by not placing appropriate fall interventions onto the care plan. The Incident Report dated 10/19/24 at 7:50 AM for Resident #1 identified resident attempted to stand without assistance, tripped over wheelchair pedals then fell to the floor, which resulted in an injury to the forehead and subsequently sent by emergency medical services to the emergency department where had steri strips placed to the 3cm laceration to mid forehead. The facility failed to take measures to reduce falls and injuries by not placing appropriate fall interventions onto the care plan. The Incident Report dated 10/30/24 at 8:15 AM for Resident #1 identified resident found sitting on the floor at the bedside. A new lump occurred to the back of the resident ' s head and a skin tear to the left elbow. The facility initiated an intervention for a body pillow along the edge of bed to help establish a bed boundary. The Incident Report dated 11/4/24 at 4:20 AM for Resident #1 identified staff responded to a noise in the hallway to find the resident lying on her left side in front of the wheelchair in the hallway. Resident unable to give a description of what she was trying to do. The Resident sustained an abrasion to the left side of her scalp and a new red bruise to the left shoulder. The facility failed to initiate a care plan intervention with the previous fall from wheelchair on 10/19/24 which resulted in a ER visit. The facility failed to take measures to reduce falls and injuries by not placing appropriate fall interventions onto the care plan after this fall on 11/4/24. The Care Plan Process policy dated January 2015 identified: a. The care plan will be reviewed and revised by the team at least quarterly. b. All problems needs, occurrences, goals and approaches will be evaluated at each care plan meeting. Determination we made as to whether or not a problem, need, or concern has been resolved or needs to be readdressed. If resolved, clearly indicate and date.If a problem, need, or concern is not resolved within six months, the problem, need, or concern and approach needs to be re-evaluated and revised. Documentation completed on interdisciplinary notes. c. The residents condition will be a reassessed new problems comma's needs, or concerns would be added as identified. d. The care plan will be an ongoing reflection of the current treatment plan. And deletions can be made on the plan of care with residents approval without holding a care plan conference, as long as the change does not constitute a permanent, significant change. The Falls Protocol Quick Reference policy dated January 2015 identified follow up after a fall occurs: a. Evaluate effectiveness of interventions that were implemented. b. Revised residents' plan of care with the additional interventions that are identified. c. Communicate care plan changes interventions to the resident and direct care staff. In an interview on 1/9/24 at 12:26 PM, the Administrator reported she expected the nurse to initiate a fall intervention immediately after a resident fell . The Administrator reported she expected a new fall focus area be initiated with fall interventions the first time a resident falls after admission.

Based on clinical record review, observation, staff interviews, and facility record review, the facility failed to provide adequate fall interventions and communicate inventions via the care plan to prevent falls that resulted in injury for 1 of 3 residents reviewed (Residents #1). The facility reported a total census of 34 residents. Findings included: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented the initial reentry to the facility from a short term general hospital stay. The Clinical assessment dated [DATE] for Resident #1 showed the Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. On 10/14/24 reassessment of the BIMS showed a score of 1 which indicated severe cognitive impairment. The Medical Diagnosis for Resident #1 showed diagnoses of dementia, blindness, cerebral infarction, and heart failure. The Fall Risk Evaluation dated 10/8/24 for Resident #1 showed the fall risk score of 13, which indicated a high risk of falling. The Care Plan for Resident #1 identified the resident unable to ambulate and required an assist of two persons for transfers. The care plan interventions for the look back date of October 2024 through December 2024 identified the following fall interventions: Initiated on 10/31/24- Body pillow along edge of bed to help establish a bed boundary. Initiated on 12/19/24- I have lateral support in my wheelchair to prevent leaning to the side. 1. The Incident Report dated 10/14/24 at 11:23 PM for Resident #1 identified resident found sitting on the floor in front of the bed, legs crossed, and with the call light cord wrapped around her legs. Resident #1 noted to have new dark purple bruises to the right arm, chest and back. Predisposing physiological factors included confusion, gait imbalance, impaired memory, weakness/fainted. The facility failed to take measures to reduce falls and injuries by not placing appropriate fall interventions onto the care plan. 2. The Incident Report dated 10/19/24 at 7:50 AM for Resident #1 identified resident attempted to stand without assistance, tripped over wheelchair pedals then fell to the floor, which resulted in an injury to the forehead and subsequently sent by emergency medical services (EMS) to the emergency department (ED). The facility failed to take measures to reduce falls and injuries by not placing appropriate fall interventions onto the care plan. The emergency room Record dated 10/19/24 at 8:51 AM for Resident #1 revealed the provider noted the resident presented via ambulance after a fall in which the resident tripped, fell and hit her head. The resident sustained a forehead laceration. The resident required a computed tomography (CT) to rule out brain injury. No brain injury found. Resident #1 received steri-strips to the 3 cm laceration located on the mid forehead then discharged back to the facility. 3. The Incident Report dated 10/30/24 at 8:15 AM for Resident #1 identified resident found sitting on the floor at the bedside. A new lump occurred to the back of the resident ' s head and a skin tear to the left elbow. The facility initiated an intervention for a body pillow along the edge of bed to help establish a bed boundary. 4. The Incident Report dated 11/4/24 at 4:20 AM for Resident #1 identified staff responded to a noise in the hallway to find the resident lying on her left side in front of the wheelchair in the hallway. Resident unable to give a description of what she was trying to do. The Resident sustained an abrasion to the left side of her scalp and a new red bruise to the left shoulder. The facility failed to initiate a care plan intervention with the previous fall from wheelchair on 10/19/24 which resulted in a ER visit. The facility failed to take measures to reduce falls and injuries by not placing appropriate fall interventions onto the care plan after this fall on 11/4/24. In an interview on 1/8/25 at 10:22 AM, Staff D, Register Nurse (RN) reported past non-compliance actions and forms completed for lack of fall interventions being updated on care plans. Staff D stated, the interdisciplinary team failed to update and monitor care plans in the morning meeting. In an interview on 1/9/25 at 7:42 AM, Staff A, Licensed Practical Nurse (LPN) reported the nurse is expected to immediately initiate a new intervention after a fall. Staff A stated, Even if it's not going to be a long term intervention we still put it on the care plan then the management staff reviews the falls the next day in their meeting. When asked if the nurse is expected to place the intervention onto the care plan after the fall, Staff A replied, I will place the intervention into the care plan if it's not a repeated fall. If it's an easy intervention then I will immediately put it in the care pan but if not, I will reach out to the MDS/Care Plan nurse. When asked if Resident #1 had bruising to her face and or forehead, Staff A stated, both. They were from falls that occurred pretty close together, both falls the resident hit her head. In an interview on 1/9/25 at 8:12 AM, when asked what she would do for interventions if a resident fell , Staff B, Certified Nursing Assistant (CNA) stated, I would follow what the nurse tells me to do for an intervention. If the resident falls out of bed I make sure the bed is lowered to the floor. Staff B reported, I don't put anything into the care plan. When asked where she would look to find fall interventions, Staff B replied in the kardex or charting. In an interview on 1/9/25 at 9:35 AM, the MDS/Care Plan Nurse reported after a fall the floor nurse should initiate an intervention and document the intervention in risk management. The next day the Director of Nursing (DON) reviewed the falls then reported to the MDS/Care Plan Nurse if the care plan needed to be changed or updated. The MDS/Care Plan Nurse reported the plan after today is for the management team to review the falls in the morning meeting. When asked why the care plan failed to be updated after falls for Resident #1 the MDS/Care Plan Nurse stated, I think the old DON tried to handle everything himself, there was no collaboration. When asked if the MDS/Care Plan Nurse was informed of when Resident #1 fell , she stated, no. When asked if Resident #1 had bruising to her face and body, MDS/Care Plan Nurse stated yes, from falls. In an interview on 1/9/25 at 10:27 AM, Staff C, CNA reported the charge nurses developed interventions for residents after a fall. Staff C reported fall interventions could be found on the kardex. When asked if Resident #1 had injuries to her forehead or face, Staff C stated, yes from falls. Staff C explained she found the resident after an unwitnessed fall in the dining room which resulted in an injury to the resident's forehead. Staff C recalled another fall where Resident #1 fell from bed which resulted in a bump to the forehead and head. The Falls Protocol Quick Reference policy dated January 2015 identified follow up after a fall occurs: a. All falls are reviewed during daily quality assurance meetings with interdisciplinary team. b. Review completed investigation for cause/ Contributing factors. c. Evaluate effectiveness of interventions that were implemented. d. Revised residents' plan of care with the additional interventions that are identified. e. Communicate care plan changes interventions to the resident and direct care staff. f. Conduct staff education/re-education/disciplinary action as needed. Quality assurance and Assessment a. All falls are reviewed weekly by Fall Safety Committee. b. Evaluate the effectiveness of interventions that have been implemented for each resident following a fall. c. Compile a log of falls who assist in evaluation of problems. Review on a quarterly basis to identify trends and patterns to assist in further prevention actions. In an interview on 1/9/24 at 12:26 PM, the Administrator reported she expected the nurse to initiate a fall intervention immediately after a resident fell . The nurse should then enter the intervention into risk management.The Administrator reported the next day the management team reviewed the fall and intervention then after an appropriate intervention decided would enter the intervention onto the care plan which would also update the kardex. When asked which staff was responsible for entering the intervention onto the care plan, the Administrator reported she left that up to the DON and MDS to decide. When asked how the facility failed to ensure appropriate fall interventions were initiated and failed to enter the interventions onto the care plan after a fall, the Administrator reported, she didn't know but thought the DON must have communicated the information verbally to staff and the DON and MDS miscommunicated as to who was going to update the care plan.

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report from Fiscal Quarter 3, 2024 (April 1- June 30) review, facility staffing review, and staff interviews, the facility failed to meet staffing requirements in three metrics. The facility reported a census of 33 residents. Findings include: The PBJ Staffing Data Report with a run date of 9/4/24 triggered no data submitted for the quarter, excessively low weekend staffing, and failed to have licensed nursing coverage 24 hours a day for four or more days within the quarter and less than 24 hours per day licensed nursing coverage. Review of staffing for nurses and Certified Nursing Assistants (CNAs) scheduled similarly for weekdays and weekends. The Reporting Direct-Care Staffing Information (Payroll-Based Journal) policy directed staff to electronically report staff and census information to CMS in compliance with 6106 of the Affordable Care Act. In an interview on 9/13/24 at 3:23 PM, the Administrator reported knowledge of the requirement of submitting staffing data to CMS. The Administrator reported staffing information would be reported sufficiently in the future.

Based on interviews and record review the facility failed to provide tracheal suctioning for 1 out of 1 resident with a [CONDITION(S)] reviewed (Resident #25) which resulted in immediate jeopardy to resident health and safety. Resident #25 was admitted to the facility on [DATE] and had a capped [CONDITION(S)] in place. The resident was non-verbal and unable to make her needs known. The resident came to the facility with [CONDITION(S)] care orders for twice a day and to have [CONDITION(S)] suctioning as needed along with oropharyngeal suctioning as needed. The facility did not provide any [CONDITION(S)] suctioning from 5/6/21 to 8/18/21. The resident was sent to the emergency room (ER) on 8/18/21 after staff noticed gurgling sounds coming from the resident who had thick green/gray [MEDICATION(S)] in the mouth and a large amount of brown/yellowish [MEDICATION(S)] was coming from the [CONDITION(S)]. The resident was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The Minimum Data Set (MDS) with an Assessment Reference Date of 8/13/21 for Resident #25 showed the resident had a Brief Interview Status Score of 12 which indicated moderate cognitive impairment. Resident #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed the resident was totally dependant of 2 staff assist for transfers, locomotion, and toilet use. Review of the Patient Summary from the Hospital dated 3/22/21 stated on 2/20/21 Resident #25 developed worsening symptoms and became unresponsive. The patient was unable to protect her airway and was intubated on 2/20/21. The patient had ongoing difficulty with dysphagia and handling her own secretions. A [CONDITION(S)] was placed on 2/26/21 due to need for long term mechanical ventilation. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . No apparent gag reflex noted with suctioning. Plan: no plans for decannulation until neuro status improves, still requires a bit of suctioning and having some drooling, added a abdominal binder for cough and vocal support. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan: still requires suctioning, having some drooling. Review of the Electronic Heath Record (EHR) showed the resident was admitted to the facility on [DATE] from the Hospital. Review of the Transfer/Discharge/Active Orders from the Hospital with a faxed date of 5/5/21 at 11:59 AM, showed the resident to have Discharge Nursing Orders for [CONDITION(S)] care every day at 8:00 AM and 8:00 PM, for respiratory therapy orders, to continue oropharyngeal suctioning as needed, and to continue [CONDITION(S)] suctioning as needed. Review of the facilities admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #25's current Care Plan showed the resident was unable to care for the [CONDITION(S)], the [CONDITION(S)] was a capped [CONDITION(S)] and to perform [CONDITION(S)] care every shift. Review of the Treatment Administration Record for the months of May 2021, June 2021, July 2021 and August 2021 lacked any documentation of oropharyngeal or [CONDITION(S)] suctioning. Review of the Speech Therapy Treatment Encounter Notes dated 5/7/21 stated to see initial evaluation. Initial Evaluation dated 5/7/21 stated findings included resident to have poor coordination of respirations with phonation, [CONDITION(S)] present with cap. Risk factors were, due to documentation of physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for pneumonia, social isolation, and aspiration. Further testing with fiber optic endoscope evaluation of swallowing (FEES) is indicated. Review of the Speech Therapy Encounter Note dated 5/17/21 stated the Speech Language Pathologist ( SLP) participated in the FEES evaluation, patient demonstrated aspiration with all consistencies. The SLP provided education to the patient and the skilled nursing facility (SNF) staff regarding risk for aspiration, pneumonia due to aspiration of secretions. SLP discussed concerns of need for staff training for deep suction. Note dated 5/24/21 stated the patient demonstrated significant wet vocal quality and coughing throughout the session. The SLP spoke with the DON requesting that the patient receive deep suctioning as soon as possible and regularly following the episode of care. Note dated 5/26/21 stated the patient demonstrated significant wet vocal quality and coughing throughout the session. The SLP spoke with the Nurse Practitioner regarding concerns that the patient needed suctioning. The Progress Note dated 5/25/21 at 10:30 AM stated the DON contacted the Nurse Practitioner (NP) about the Speech Therapies concerns with the resident's lungs and suctioning. The NP stated she would see the resident on 5/26/21. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The EHR lacked any documentation that an ENT consult was made. Review of the Speech Therapy Encounter Note dated 5/31/21 stated the Speech Language Pathologist (SLP) the SLP focused on oral care, there was significant signs and symptoms of aspiration observed with secretions throughout the entire session. The SLP noted that the nursing staff at the facility had wanted to pursue removal of the [CONDITION(S)]. Review of the FEES Evaluation Report dated 5/17/21 stated upon insertion of the scope, noted significant [CONDITION(S)] of the larynx and poor management of secretions were observed. During interview with SLP on 8/24/21 at 9:09 AM the SLP stated when she was at the facility on 5/7/21 the suction equipment was sitting in box in Resident #25's room. She stated that staff made the comment they were not prepared to take this resident and the corporation pressured them into admitting her. The SLP stated while at the facility on 5/17/21 the suction supplies were still sitting in box in the same place. The SLP asked the staff if they could set up the suction equipment as they were going to be conducting the FEES test and wanted the suction in place for safety reasons. The SLP stated the staff told her they would have to watch a U-Tube video on how to set it up. The SLP stated she talked with the DON after the study and informed her of her concerns with the lack of suctioning and the need to provide training to the staff. The SLP stated on her visit to the facility on [DATE] the suctioning equipment was in the box again in the same place, she stated that once again she talked to the DON about her concerns with the lack of suctioning. The SLP stated while she was in the building on 5/26/21 she informed the NP who was in the building about the concerns of the lack of suctioning. The SLP stated that when in the building on 5/31/21 the nursing staff informed her they were looking into having the [CONDITION(S)] removed. The SLP stated the resident was removed from skilled care on 6/7/21 which was the last visit she made and while in the facility the suctioning equipment was located in a box in the resident's room. Review of the Progress Notes in the EHR showed the following entries: - On 8/4/21 at 6:32 PM Resident #25 continues to spew white foamy sputum. - Progress Note on 8/7/21 at 2:54 PM stated resident continues to spew white foamy sputum. - Progress Note on 8/8/21 at 6:19 PM stated the resident continues to spew white foamy sputum. - Progress Note dated 8/18/21 at 1:56 PM stated the resident seemed to have gurgles around 8:00 AM, upon auscultating, lung sounds were clear but resident remained to moan. Mouth was swabbed and orally suctioned, the contents were green/gray in color and thick. Progress Note dated 8/18/21 at 1:56 PM written by the Director of Nursing (DON) stated this nurse in with Licensed Practical Nurse (LPN) found resident to have thick brownish yellow [MEDICATION(S)] coming out the sides of her mouth. The resident is audibly gurgling even after oral suctioning. Upon taking off the [CONDITION(S)] cap, a large amount of brownish yellow [MEDICATION(S)] comes out of the [CONDITION(S)]. The resident is suctioned at this time and tolerates it well. Audible gurgling sounds are better. The provider was contracted and resident sent to the emergency room (ER). - Progress Note dated 8/24/21 at 6:28 PM stated a call was placed to Hospital for an update on Resident #25. The resident is waking up a little more, going to diuresis her and she still remains on the ventilator. During interview on 8/25/21 at 10:10 AM the NP A stated she was aware of the concerns from the SLP and talked to the DON about it. Stated she was informed from the DON that Resident #25 was not being suctioned at the hospital so they didn't need to do it here. The NP A stated her assessments didn't show any concerns at the time but could not tell me when the last time she saw the resident. During interview on 8/25/21 at 11:47 AM the DON stated she did not feel Resident #25 needed to be suctioned because her [CONDITION(S)] was capped and the order for suctioning was PRN and the resident showed no signs of needing it. The DON stated the resident was not being suction in the hospital so why would she need to be suctioned here. When the DON was asked if [CONDITION(S)] care consisted of suctioning, she did not answer. During interview on 8/25/21 at 11:23 AM Staff I RN stated she never suctioned Resident #25. Staff I stated the DON was concerned about taking this resident and was pressured by the corporate office to take her and the DON told her she was concerned her staff could not take care of this resident. Staff I RN stated this was the first resident with a [CONDITION(S)] they had and nobody at the facility had ever taken care of one before. During interview on 8/25/21 at 10:27 AM with the Nurse Manager in Hospital taking care of Resident #25 she stated the resident is still currently on a ventilator and still requires suctioning throughout the day. She stated they have been suctioning her about 3-4 times a shift. During interview on 8/25/21 the Physician who is the Critical Care Specialist in charge of the care of Resident #25 for current hospitalization , when asked about the need for suctioning she stated at the minimum the resident should be suctioned every 8 hours and more if needed. During interview on 8/25/21 at 12:27 PM with Staff M Registered Nurse (RN) who cared for the resident at the Hospital prior to admission to the nursing home stated they suctioned the resident at least once a shift and should be done as needed also. She stated the longest time staff should go without suctioning the resident is one shift if the patient is not needing it. When asked if the resident's [CONDITION(S)] could go three months without suctioning she stated Oh no, absolutely not, it should be done when [CONDITION(S)] care is being done at the least. Review of the Course Completion History for [CONDITION(S)]/[CONDITION(S)] Care Training, showed that 5 nurses at the nursing home received the training between the dates of 5/18/21 to 6/16/21. The remaining 5 nurses remained untrained in [CONDITION(S)] care. Review of the facility's [CONDITION(S)] Care policy dated 1/2015 stated the purpose of [CONDITION(S)] care is to maintain patent airway, evacuate secretions, and to prevent and or reduce infection. The policy stated the suction equipment is needed and should be assembled at the bedside. The policy also stated documentation should include. date, time, color and consistency of secretions. Abatement: The facility was notified of the Immediate Jeopardy on 8/25/21 at 4:15 PM and given the IJ template at 4:25 PM. The Facility abated the immediate jeopardy on 8/25/20 by taking the following actions: 1. Upon admission and readmission of future residents that would have a [CONDITION(S)] and need [CONDITION(S)] care, all nurses will be educated on [CONDITION(S)] care with competency performed prior to any care provided for that resident. 2. All admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 7:00 PM on 8/25/21 all current nurses had completed Relias training on [CONDITION(S)] and [CONDITION(S)] Care and the scope and severity was lowered to a D.

Based on record review and staff interview, the facility failed to provide adequate supervision to prevent accidents for 1 of 2 residents reviewed, (Resident #9). The facility reported a census of 33 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #9 scored 4 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required limited assistance with ambulation in the corridor. The resident was unsteady, but able to stabilize without human assistance when walking. The resident's [DIAGNOSES REDACTED]. The Care Plan in effect 1/2/20 and dated 5/15/19, identified the resident had an actual fall with serious injury, partial [MEDICAL CONDITION], related to an instance of poor balance. The interventions in place on 1/2/20 included the resident ambulated without an assistive device with 1 assist (dated 8/29/19). A Therapy Communication form dated 5/21/19 documented they recommended to please walk the resident to/from all meals and activities with contact guard assist (CGA). A Progress Note dated 1/2/20 at 9:05 a.m. documented a Certified Nursing Assistant (CNA) ambulated with resident after breakfast to the shower room down hall 1. The resident ambulated faster than normal with the CN[NAME] The resident lost her balance falling down onto her right hip and right elbow. The resident did not hit her head. No internal/external rotation noted to the resident's extremities and the resident denied pain/discomfort at the time of fall. The resident assisted up with assist of 2 and partial weight bearing on the right leg, and full weight bearing on the left. The resident transferred to the wheel chair. Appointmet made with the resident's provider. The resident experienced increased pain to the right hip at rest. At 5:23 p.m. received notification from the emergency room the resident admitted with acute fracture right trochanter. A hospital History and Physical dated 1/2/20 documented the resident had an acute [MEDICATION NAME] impacted [MEDICAL CONDITION] region of the femur. An Operative/Procedure Report dated 1/3/20 documented the resident underwent [REDACTED]. The Progress Notes dated 1/6/20 at 1:01 p.m. documented the resident returned to the facility from the hospital. The Progress Notes dated 1/10/20 at 12:00 p.m. documented the physician faxed about increased pain since return from the hospital. New orders received for [MEDICATION NAME] 50 mg 2 times a day (BID) for 14 days. During an observation on 1/14/20 at 6:53 Staff D, CNA and Staff E, CNA assisted the resident. Staff transferred the resident using a gait belt and the resident indicated pain with standing. During an interview on 1/13/20 at 1:45 p.m. Staff A, CNA stated (1/2/20) he walked with the resident after breakfast going to the bath. She had shoes on and he held onto her hand. She started walking faster, lost her balance and fell . He said the resident had stand by assist (SBA) of 1 person, and did not utilize the gait belt. He said she walked steady until she went down. During an interview on 1/14/20 at 7:06 a.m. Staff D, CNA stated prior to the fall on 1/2/20 the resident had SBA with holding her hand to slow her down. Staff E, CNA stated the resident had SBA of 1 holding her hand because she could get to trotting and needed told to slow down. The clinical record lacked any documentation of a rationale for changing the resident from CGA to a lesser assist of SB[NAME] During an interview on 1/14/20 at 4:27 p.m., the Director of Nursing (DON) stated the aides told her the resident set the alarm off all the time and got up and going. The resident didn't want the gait belt and didn't want to be touched so they discontinued the alarm and made her SB[NAME] During an interview on 1/15/20 at 8:42 a.m. Staff C, CNA stated he did walk with the resident in the hallway and would use a gait belt if she had a bad day. He said she was still kind of shaky on the 1st broken hip. He said when she walked she wouldn't stop so she needed someone side by side with her. During an interview on 1/15/20 at 11:07 a.m., the Physical Therapy Aide (PTA) stated when he did a screen it consisted primarily of questions to the resident that included if they had difficulty with ambulation. He would not watch her walk for the screen but he had seen her around the facility with staff with the hand hold. He said she did wander down to the therapy room [ROOM NUMBER] time. He said if the facility had asked him about changing from CGA to SBA he would have discussed it with the Physical Therapist (PT) and Occupational Therapist (OT). During an interview on 1/15/20 at 12:36 p.m., the Nurse Consultant stated they do not have a policy for SBA but it meant walking with the resident without hands on. She said they can change assistance levels but it should be documented why they are doing it. During an interview on 1/15/20 at 12:44 p.m., the Physical Therapist stated if a resident was not on case load and the facility wanted a recommendation about changing from CGA assist he would not feel comfortable making one based on their observations. He would want to know from the PTA, someone qualified in therapy, about the resident's status with transfers, standing, pivot, etc Otherwise they would need an evaluation. During an interview on 1/15/20 at 1:04 p.m., OT stated they put the resident on CGA which meant hands on the gaitbelt, because the resident had no carryover with safety and a [DIAGNOSES REDACTED]. She said the resident was a difficult case and would not participate in therapy. She said SBA was different for therapy than for the facility. She said SBA for therapy meant within arms length with a gait belt on the resident. She considered SBA per the nursing home (definition) supervision. She said usually the facility would go ahead and change assist status if the resident needed more help, but usually at least wanted an opinion if they were going to provide them less assistance. She said walking with the resident holding their hand as opposed to using a gait belt would make it more difficult to keep a resident from falling but every little bit helped. The facility policy, Gait Belts (for use in ambulation and transfer) (MONTH) (YEAR) edition, identified gait belts should be used by all staff, to allow for easier handling of residents which should help avoid injuries, both to residents and staff.

Based on observation, record review and staff interview, the facility failed to ensure that the resident environment remained as free from accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents reviewed. Resident #12 used a merry walker and fell . The resident sustained [REDACTED]. A death certificate identified the cause of death as blunt force trauma due to the fall and the manner of death was accident. Facility census was twenty-nine (29) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of [DATE], revealed Resident #12 admitted to the facility on [DATE] from a community setting and the resident discharged on [DATE] to an acute hospital. The resident had impaired short and long term memory problems and moderately impaired decision making skills. The resident had the following indicators of delirium: inattention and disorganized thinking. The resident had wandering behaviors that occurred daily. The resident required extensive staff assistance with bed mobility, transfers, ambulation in room and corridor, dressing, toileting, eating, personal hygiene and bathing. The resident was frequently incontinent of bowel and bladder. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident with falls since admission to the facility, one with injury and one with major injury. The resident was 65 inches tall and weighed 121 pounds. A fall risk assessment dated [DATE] identified the resident with a score of 20. A total score of 10 or above represented high risk. A resident assessment/data collection form dated [DATE] revealed the resident had a [DIAGNOSES REDACTED]. The care plan did not identify the use of a merry walker. The care plan did not address how they would monitor the wandering resident to ensure safety. On [DATE] at 10:16 a.m. the director of nursing (DON) identified the resident assessment/data collection form as the resident's care plan. A merry walker ambulation device assessment dated [DATE] and completed by the physical therapist (PT) identified the resident's primary [DIAGNOSES REDACTED]. A treatment encounter note dated [DATE] identified PT performed trained the resident with the sit to stand transfers from the merry walker seat to ensure the resident could safely transfer independently. The resident could transfer safely. PT instructed the resident with walking using the merry walker. The resident could safely ambulate using the merry walker independently with periodic supervision of staff. The resident could turn corners and change directions with instruction. PT performed a merry walker assessment indicating the need for the merry walker. A treatment encounter note dated [DATE] revealed PT adjusted the resident's merry walker to improve the resident's ability to sit down. PT instructed the resident with sit to/from stand transfers from the merry walker seat. The resident ambulated using the merry walker with supervision. A treatment encounter note dated [DATE] revealed the resident fell over the weekend. The resident was in the merry walker when he/she got stuck between 2 wheelchairs and tipped the merry walker over. PT fit the resident with a new merry walker that had a seat to allow the resident to sit when he/she got fatigued. PT adjusted the merry walker to the resident's size. PT instructed the resident with the new merry walker. The resident could ambulate with the walker in the facility. PT provided cues to improve the resident's ability to avoid hitting objects. On [DATE] a restraint advisement form revealed the resident's responsible party signed the form giving consent for merry walker use. 1st Incident: Nurses notes dated [DATE] at 10:30 a.m. and documented by Staff A RN (registered nurse) revealed staff found the resident tipped over in the merry walker on hands and knees in the day room next to 2 other residents in wheelchairs. The resident did not call for help. The resident denied pain and there was no evidence of injury. Staff assisted the resident back up to his/her feet. The entry identified the resident as agitated. The resident pushed his/her way through people and objects in merry walker and drank other resident's beverages at empty seats in the dining room. Staff administered Ativan (antianxiety) to help the resident relax. Staff also proved 1 to 1 attention to the resident for the rest of the shift after the fall. On [DATE] at 9:47 a.m. Staff A RN stated when the [DATE] fall occurred, it appeared that the resident tried to push his/her way through two wheelchairs. The resident was on his/her hands and knees still in the merry walker with the top of the merry walker forward in between the 2 parked wheelchairs. Staff A stated the resident must have gotten hung up. Staff A felt the merry walker was appropriate for the resident because the resident never sat still. A fall investigation for nurses dated [DATE] and completed by Staff A revealed when the form asked if there were any observable problems related to the way the resident used the equipment (merry walker), Staff A wrote the resident leans forward and rams into things. In the area of what contributed to the fall, Staff A wrote the resident tried to push their way through objects. The fall investigation contained a statement from Staff B CNA (certified nurse aide), dated [DATE] that revealed the resident needed more one on one in response to the question what factors could have contributed to the fall? and under the question what new interventions would you suggest to prevent the fall from happening, Staff B wrote that the facility needed more staff to accommodate the resident's higher level of care. On [DATE] at 11:44 a.m. Staff B stated when the [DATE] fall occurred the resident tried to squeeze between 2 wheelchairs. Staff B stated the resident needed more attention from staff because he/she would get into things and rearrange things. Staff B thought the resident got around well in the merry walker and that the resident seemed safe in it. On [DATE] at 10:50 a.m. the PT stated he felt the resident was safe to use the merry walker independently. The resident did a good job of avoiding obstacles and residents. After the [DATE] incident, they gave the resident a different merry walker. On [DATE] at 12 p.m. PT stated the different merry walker was wider and more stable. 2nd Incident: Nurses notes dated [DATE] at 7:55 a.m. and documented by Staff A RN revealed staff found the resident lying on his/ her left side still in the merry walker on the floor of the beauty shop. The left side of the resident's face was on the floor with a moderate amount of blood and a visible tooth lying in the blood. Upon evaluation, staff notes a 3 centimeter (cm.) laceration to the chin with 7 cm. swelling to the cheek and bleeding from the upper lip and oral cavity. Bilateral eyes were equal and reactive to light. Range of motion was intact and staff found no other injuries. Staff applied steri strips to the chin laceration which the resident later took off. The resident still wanted up and to move around per usual. Staff applied ice to the resident's face and administered acetaminophen (analgesic) and Ativan to help with restlessness. The resident's spouse arrived and staff informed the spouse of the incident. Staff notified the clinic and the resident transported to the clinic for evaluation of the injuries. Nurses notes on the same date at 11:45 a.m. revealed the resident received 7 stitches to the chin at the clinic and then the resident transported to ER (emergency room ) for x-rays of facial injuries as the clinic does not do those types of x-rays. At 1:30 p.m. ER phoned and said the resident had a broken mandible/jaw on CT (computerized tomography). On [DATE] at 6:30 p.m. (late entry for 6:30 p.m.) the resident's son called to say the resident expired at the hospital. The fall investigation for nurses dated [DATE] and completed by Staff A RN revealed when asked if there were any observable problems related to the way the resident used the equipment (merry walker) that could have contributed to the fall, Staff A wrote that the resident tried to force their way through objects when the walker gets caught. When asked if any environmental factors contributed to the fall, Staff A wrote that the resident went into the beauty shop and likely caught the merry walker on scale. The nurse identified Resident #12 was confused at all times, and had internal risk factors (decline in functioning and decline in cognition) as factors that contributed to the incident. The immediate action to prevent another event was one to one. Staff C CNA documented she would suggest one to one supervision as an intervention to prevent another fall. An ER report dated [DATE] at 11:37 a.m. identified the impression as fracture right mandible condyle with displacement, fractured front portion of the maxilla extending into the left maxillary sinus, 2 front incisors on the right are lifted forward, fluid in the left maxillary sinus and significant soft tissue swelling over the upper lip on the left cheek with small amount of blood within the subcutaneous tissue left cheek. On the same date at 2:22 p.m. the ED physician discussed the case with the hospital and they accepted the resident for admission. A hospital history and physical (H&P) dated [DATE] at 6:52 p.m. revealed the resident was walking with the walker when the wheel of the walker stuck and the resident fell forward and hit his/her face to a handle in the nursing home. The resident was found to have a fracture of the mandible and maxilla and the case was discussed with a plastic surgeon who agreed to evaluate and probably take the resident to the operation theater when the swelling went down. A hospital discharge summary dated [DATE] identified the physician informed the resident's family that the resident was high risk for surgery given the resident's dementia and how the resident looked. The resident went for surgery on [DATE] and open reduction and internal fixation of the mandible fracture was performed. After surgery, the resident later that night became unresponsive with problems breathing. A chest x-ray showed right lung atelectasis versus infiltrate. The resident deteriorated over the next few hours and expired on [DATE] at 4:21 p.m. Staff Working When the [DATE] Incident Occurred: On [DATE] at 9:47 a.m. Staff A RN stated she had just seen the resident in the hallway in his/her merry walker 3 minutes tops before the incident. Staff C CNA called for Staff A and Staff A observed the resident in the doorway of the beauty shop on his/her stomach with left side of the face on the floor. There was blood on the floor with a tooth in it. Staff A described the resident as still in the merry walker just as if you turned the merry walker from upright to its side-as if you just tipped it over. She stated the resident did not lose consciousness. The resident could move everything and his/her vitals were OK. The resident had a good sized laceration in the chin that hung open and was deep. Staff A steri stripped the laceration. There was swelling to the gums and lip right away and one tooth was out and the 2 front teeth appeared pushed up into the gum. The left cheek was swollen and puffy. Staff A thought the incident occurred around 8 a.m. Staff A called the clinic and the resident went per facility van. Staff A thought the merry walker got caught on something. During the resident's [DATE] fall, the bottom of the merry walker got stuck and the resident kept trying to push it and the top tipped forward. Staff A stated she thought if the merry walker bottom got stuck then the top must be tipable. Staff A stated she had not seen the resident hung up before, just maybe with the [DATE] fall. Staff A stated she had not seen the resident in the beauty shop before. She stated the weigh scale was by the doorway of the beauty shop when the incident occurred and Staff A wondered if the resident wandered and caught the merry walker wheel in it. She identified a ramped area on the scale where the wheel could catch. It appeared that was what occurred based on where the resident landed. The bottom of the walker was right by the scale and the resident extended from there to the doorway. Staff A tried to shut the beauty shop door the weekend of [DATE] and it would not latch and would slowly open back up. On [DATE] at 10:38 a.m., interview with Staff A and the Administrator revealed, Staff A stated she informed the Administrator of the beauty shop door not latching. The Administrator stated he did not recall but after the incident the facility put a lock on the door. On [DATE] at 9:30 a.m. observation showed the beauty shop door shut and locked with a sign on the door to keep the door closed when not in use. On [DATE] at 3:46 p.m. observation of the weight scale showed a sloping area on the left side of the scale adjacent to the doorway of the beauty shop and an opening under the ramp area where a merry walker wheel could get caught (see photos). On [DATE] at 10:05 a.m. Staff C CNA stated she worked on the day of the incident. Staff C stated the resident was hard to reason with. When staff got him/her up that morning, one staff needed to guide the resident while another staff talked to the resident. After they got the resident in the merry walker, the resident roamed around. Staff C took a resident to breakfast and when she came out, the resident was on the floor in the doorway of the beauty shop. At the time, Staff C stated they kept the beauty shop door open. Staff C stated the merry walker must have tipped. Staff C didn't see or hear anything. The resident received injuries from the fall. Staff C stayed with the resident while Staff A checked him/her. The resident hit their head and knocked out a tooth. Staff C stated there was a lot of blood coming from the resident's oral cavity. Staff C didn't notice the resident having any issues while using the merry walker before. On [DATE] at 11:39 a.m. Staff D CNA stated she worked on the day of the incident. Staff D stated the resident did have a problem with the merry walker. The resident would tip and run into staff. Staff D reported the beauty shop was (door) was never shut. On [DATE] at 12:01 p.m. Staff E CNA she worked another hall on the day of the incident. She went to the beauty shop after the incident to see if she could help but there was a nurse and 1 or 2 staff assisting so she went back to her hall. Staff E stated she saw the resident earlier before the incident going up and down the hall in the merry walker and was OK at that time. Staff E stated staff tried to keep an eye on the resident and when they didn't see him/her then they would go find the resident. The resident would occasionally bump into something with the merry walker otherwise no concerns. On [DATE] at 1:35 p.m. Staff F CNA stated she worked the other hall on the day of the incident. The resident would get caught on things occasionally. Staff F felt the resident needed one to one. Staff F stated the resident would not sit still. The resident would get up and down constantly. The resident would go in rooms and get into things. On [DATE] at 10:16 a.m. the Director of Nursing (DON) stated the resident admitted to the facility on [DATE] from a private pay memory care unit. The family stated the resident was nonambulatory. After the resident arrived on [DATE], the resident was in a wheelchair and staff was one to one with the resident because of restlessness. Therapy evaluated the resident that day and said the resident could safely use a merry walker. The resident tipped the merry walker forward on [DATE] after getting between 2 wheelchairs. Therapy again evaluated the resident after that fall and gave the resident a different merry walker because of the seating system. Therapy felt the merry walker was safe. `When asked about the merry walker not included on the initial plan of care, the DON stated she educated staff on the merry walker and a half hour restraint record. She stated it was a verbal face to face education. On [DATE] Staff A saw the resident go up and down the hall while she passed pills. At one point the resident went in the beauty shop and the merry walker tipped over and the resident hit the floor and hit their head on the doorway. No one witnessed the incident. The DON stated she thought the resident went in the beauty shop and turned and rolled onto the weight scale ramp or caught the merry walker wheel on the ramp and lost his/her balance. After the incident they lock the beauty shop door and moved the scale. On [DATE] at 2:58 p.m. Staff F CNA stated she didn't remember a face to face education regarding the merry walker. On [DATE] at 3:04 p.m. Staff G CNA stated she did not remember a face to face education regarding the merry walker. Other staff: On [DATE] at 2:22 p.m. Staff H LPN (licensed practical nurse) stated she had concerns regarding the resident and the merry walker. The resident would get close to things and get in a room and not know how to get out. On [DATE] at 5:14 p.m. Staff I CNA stated she thought the resident was safe in the merry walker but the resident needed a dementia unit. On [DATE] at 2:10 p.m. Staff J CNA stated the resident could get stuck while using the merry walker and staff would assist the resident from the situation. Death Certificate A death certificate revealed the resident expired on [DATE] at 4:21 p.m. The immediate cause of death was complications of blunt force trauma due to or as a consequence of: fall. Manner of death was listed as accident. The description of the injury was fell against door frame, struck face/head with the date of the fall listed as [DATE].

Based on clinical record review, family, staff and physician interview, the facility failed to perform assessments regarding complaints of pain following a decline in status for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 36 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 ' s BIMS (Brief Interview for Mental Status) score of 9 identified Resident #1 as moderately cognitively impaired. The MDS revealed Resident #1 required limited assistance of one staff member for bed mobility and ambulation. Resident #1 required extensive assistance of one staff member for transfers, toileting, personal hygiene and bathing. A balance during transitions and walking test identified Resident #1 as not steady but able to stabilize without staff assistance when moving from seated to walking, turn around while walking and moving on and off toilet and surface to surface transfers. Resident #1 utilized a walker and wheelchair for mobility. Resident #1 ' s MDS [DIAGNOSES REDACTED]. Resident #1 experienced two or more falls with no major injury since the previous assessment. The Care Plan, dated 9/5/12, identified Resident #1 as fall risk due to limited vision and independent in his/her room with transfer and ambulation in his/her room with a walker. Resident #1 self-propelled a wheelchair for distances and required use of grab bars in the bathroom for transfer. The care plan, updated 5/11/15, identified Resident #1 required the assistance of 1 staff person to transfer following a change in condition. The clinical record revealed the following: Nurse ' s Notes, dated 5/11/15 at 3:00 a.m., revealed Resident #1 found on the floor in his/her room. According to the Nurses Notes Resident #1 complained of right hip pain with internal rotation and following communication with the physician at 3:25 a.m. an order was received to send Resident #1to the hospital for evaluation. Resident #1 left the facility at 4:00 a.m. via ambulance. A Nurse ' s Notes dated 5/11/15 at 10:00 a.m. revealed an admission to the hospital for treatment. A hospital History and Physical dated 5/11/15 revealed [DIAGNOSES REDACTED]. According to the History and Physical the plan was conservative treatment versus surgical intervention. Nursing Notes dated 5/13/15 at 2:15 p.m. revealed Resident #1 returned to the facility alert and oriented to person and place. Resident #1 required 2 staff member assistance with transfer. Hospital discharge information dated 5/13/15 revealed physician orders [REDACTED]. Physical therapy notes dated 5/19/15 revealed Resident #1 ambulated 55' with a wheeled walker and minimal assistance. The physical therapist assessed one staff assist Resident #1 required in his/her room for gait and transfer, which indicated improvement from 5/13/15 discharge orders of 2 staff. Physical therapy notes dated 5/21/15 revealed the therapist provided manual therapy to Resident #1's right hip to reduce muscle spasms and promote relaxation. The physical therapist documented Resident #1 demonstrated facial grimace with pressure. Resident #1 reported ice to the affected area helped a little but was not effective at this time. Nursing Notes dated 5/21/15 at 9:15 a.m. revealed Resident #1 reported pain and the facility received a telephone order from the physician for Resident #1. Physical therapy notes dated 5/22/15 revealed Resident #1 very fearful of any movement and reported severe pain. Resident #1 had minimal movement to complete heel slide. Nursing Notes dated 5/22/15 at 10:50 p.m. revealed Resident #1 identified pain to the right hip area, and on 5/23/15 at 10:00 a.m. revealed Resident #1 reported pain from the right hip to knee area. Nursing Notes dated 5/24/15 at 4:15 a.m. revealed Resident #1 reported severe right hip and thigh pain with any movement. Documentation revealed the nurse observed Resident #1's muscles twitching. Pain medication was administered. Nursing Notes dated 5/24/15 at 9:40 a.m. and at 3:55 p.m. revealed Resident #1 reported pain with every movement and utilized ice for comfort. Resident #1 remained in bed. Nursing Notes dated 5/25/15 at 4:30 a.m. and at 9:00 p.m. revealed Resident #1 reported right hip and thigh pain with repositioning. Nursing Notes dated 5/26/15 at 2:50 p.m. revealed the nurse observed Resident #1 cried out in pain. The nurse ' s notes documented notification to the physician for an update. Resident #1 refused to get out of bed due to pain. The clinical record revealed Resident #1 reported it felt like the muscle was pulled back and forth. Physical therapy notes dated 5/26/15 revealed Resident #1 failed to tolerate hip flexion position and has a hard time sitting in his/her wheelchair and was unable to get out of bed due to pain since last week. The physical therapist documented he assisted nursing staff members to transfer Resident #1 per Hoyer lift (mechanical lift) into his/her wheelchair to minimize pain with transfer for a physician's appointment. The physical therapist noted nursing staff reported Resident #1 admitted to the hospital for intertrochanteric fracture. Review of a physician clinic note dated 5/26/15 revealed Resident #1 evaluated for a follow-up to the previous identified closed [MEDICAL CONDITION] on 5/11/15. Resident #1 presented to the clinic related to increased pain and muscle spasms. The evaluation and repeat X-Ray revealed a progression from the 5/11/15 radiology examination and noted an Acute right intertrochanteric [MEDICAL CONDITION] with subacute greater trochanteric [MEDICAL CONDITION] and appearance of angulation, impaction and displacement. The physician discussed interventions with Resident #1 and family. According to the clinic notation Resident #1 was sent to the hospital for surgical repair of the right [MEDICAL CONDITION]. Review of the hospital postoperative notation dated 5/26/15 revealed Resident #1 received a Right femoral intramedullary nailing for intertrochanteric [MEDICAL CONDITION]. On 6/2/15 at 7:12 p.m. Resident #1's family member stated Resident #1 fell at the facility and sustained a [MEDICAL CONDITION] evaluated on 5/14/15 or 5/15/15 and according to the evaluation no surgical repair required at that time for the crack. The family member stated Resident #1 returned to the facility for therapy. During a doctor office visit on 5/20/15 Resident #1 reported a staff member moved his/her bad leg wrong and caused increased pain. The family member stated Resident #1 was usually alert and oriented and that morning his/her memory was good. Resident #1's son notified the facility Staff L and Staff F, both registered nurses (RN) of the reported concern. On 6/5/15 at 10:20 a.m. Staff K, certified nursing assistant (CNA), was interviewed and stated she provided transfer assistance to Resident #1 when he/she stated oh, ouch. Resident #1 complained of pain to his/her right hip so Staff K stopped the transfer and asked if he/she was ok. Resident #1 pointed to the right hip and reported hip pain in the same place as before. (According to the clinical record Resident #1 sustained a [MEDICAL CONDITION] following a fall on 5/11/15). Staff K notified Staff F, registered nurse (RN), of pain reported by Resident #1 at the time of transfer. On 6/9/15 at 11:59 a.m. Staff F, RN was interviewed and confirmed Resident #1's son notified her Resident #1 reported Staff K threw him/her out of bed. Staff F confirmed Staff K notified her of increased pain reported by Resident #1 during a transfer. Staff F stated Resident #1 reported he/she had increased pain, so she notified the physician. Staff F stated Resident #1 had a previously scheduled physician's appointment. Staff F acknowledged she failed to document the information provided by staff, resident and family member in the clinical record. Staff interviews as follows: a. On 6/2/15 at 10:45 a.m. Staff A, CNA stated Resident #1 had increased pain and protected his/her leg. Staff A stated Resident #1 pretty much stayed in bed and requested staff not to move him/her due to pain. b. On 6/2/15 at 1:15 p.m. Staff B, CNA, stated Resident #1 screamed out in pain if staff touched the back of his/her wheelchair. c. On 6/2/15 at 1:45 p.m. Staff C, CNA, stated Resident #1 complained he/she was in a lot of pain. According to Staff C Resident #1 required 3 plus staff members to reposition due to pain with movements. d. On 6/2/15 at 2:00 p.m. Staff D CNA, stated after the fall Resident #1 was good, however something changed the day he/she went to the doctor and the hip really started bothering him/her. Staff D stated staff could barely touch Resident #1 due to pain and requested staff stop. Staff D stated staff members used a Hoyer lift (mechanical lift) for transfers and Resident #1 screamed out ouch. e. On 6/2/15 at 2:05 p.m. Staff E, CNA, stated on either 5/21/15 or 5/23/15 staff transferred Resident #1 into bed due to increased pain and he/she never got out of bed again due to pain. Staff E stated Resident #1 appeared to have a lot of pain. f. On 6/2/15 at 2:19 p.m. Staff F, RN, stated Resident #1 cried out in pain during movement and only appeared comfortable lying down. g. On 6/2/15 at 6:53 p.m. Staff I, CNA, stated Resident #1 exhibited pain with movement. On 6/4/15 at 10:20 a.m. the physician stated Resident #1 reported increased pain on the 5/20/15 physician appointment. Decision was to treat conservatively at that visit. The physician verbalized concern regarding Resident #1 reported increased pain as a result of injury received during a transfer. The physician stated he phoned the facility to report the concern and was informed Resident #1 apparently fell coming back from the bathroom.

Based on record review and interviews, the facility failed to provide accurate assessment and timely interventions for one (1) of nine (9) residents reviewed. Resident #2 sustained adverse physical changes in condition from 6/30/14 to 7/13/14 and the clinical record lacked accurate assessments and timely interventions. The facility reported a census of 38 residents. Findings included: A review of the Medication Administration Record [REDACTED]. According to the MDS dated [DATE], the resident required two staff assistance for toileting, bed mobility, transfers, eating and personal hygiene; and one staff assistance for dressing. The resident scored 4 out of 15 on the Brief Interview for Mental Status (BIMs) test which identified memory and cognitive impairments associated with daily decision making skills. A physician's orders [REDACTED]. ([MEDICATION NAME] is an oral anticoagulation medication frequently used to thin blood and prevent blood clots for patients with [MEDICAL CONDITION]. The [DIAGNOSES REDACTED]. When the heart is in [MEDICAL CONDITION], the heart muscle "flutters" and blood may pool and clot rather than effectively circulate throughout the cardiovascular system. The blood clot can in turn remain lodged in a vessel and form a [MEDICAL CONDITION] (blood clot.) Hospice nursing notes dated 5/13/14 showed the nurse assessed Resident #2 with 1+ [MEDICAL CONDITION] to his/her right foot and ankle. The nurse noted an increase of 11 pounds over 2 weeks even though the resident's food intake showed "poor to fair" appetite. The hospice nurse notified Resident #2's physician and received an order for [REDACTED]. Nurse's Notes showed the following: a. On 6/30/14 at 12:45 p.m. the nurse assessed Resident #2 with "mild [MEDICAL CONDITION]." The clinical record lacked evidence to indicate where [MEDICAL CONDITION] was noted and lacked evidence to indicate an accurate assessment of "mild" [MEDICAL CONDITION]. b. On 6/30/14 at 8:15 p.m. the nurse assessed Resident #2's right foot "remains of [MEDICAL CONDITION]" and noted the resident's lower extremities were a "purple color" and pedal pulse was present. The clinical record lacked evidence staff notified Resident #2's physician of the right foot [MEDICAL CONDITION] and purple lower extremity. c. On 7/1/14 at 10:45 a.m. the nurse assessed Resident #2 with "mild [MEDICAL CONDITION]" to his/her bilateral lower extremities. The clinical record lacked evidence to indicate an accurate assessment of "mild" [MEDICAL CONDITION]. d. On 7/13/14 at 1:20 p.m. the nurse documented Hospice was notified of "concerns." Hospice documentation on 7/14/14 included notification by the facility of the resident's behaviors observed and medication information regarding the behaviors. The facility clinical record lacked evidence of any nursing assessment by the facility nurses on from 7/1/14 through 7/13/14. The July 2014 hospice notes were received by the facility per facsimile (fax) on 7/23/14 after the surveyor requested hospice notes for the month of July 2014. (Hospice nursing notes documented the following: On 7/3/14 at 9:15 a.m. the hospice nurse assessed Resident #2 with 3-4+ [MEDICAL CONDITION] to the right foot/calf and noted the resident's right calf measured 10.5" (inches) and the left calf measured 8" a difference of 1.5 inches. On 7/7/14 at 11:45 a.m. the hospice nurse assessed Resident #2 with 3-4+ [MEDICAL CONDITION] to the right ankle and calf region. On 7/10/14 at 3:15 p.m. the hospice nurse assessed Resident #2 with 3+ [MEDICAL CONDITION]. ) e. The Nurse's Notes documented on 7/14/14 at 11:00 a.m. the nurse assessed Resident #2 had 4+ [MEDICAL CONDITION] to his/her right lower extremity and that hospice nurse was present and notified the resident's physician. (Pitting [MEDICAL CONDITION] is measured by the numeric number and a "+" sign. The numeric portion, for example 3+, reflected the number of seconds required for the imprint of the nurse's fingertip to disappear after gently pressed into the [MEDICAL CONDITION] area. To accurately assess [MEDICAL CONDITION] the nurse will gently press one fingertip into the affected [MEDICAL CONDITION] area then count the number of seconds required for the indentation to disappear.) Hospice notes, dated 7/14/14, indicated the facility nursing staff notified hospice and requested an increased dose of an antipsychotic medication due to increased behaviors. f. The Nurse's Notes documented on 7/15/14 at 9:45 a.m. the nurse assessed Resident #2 had 3+ [MEDICAL CONDITION] to the lower extremity, but lacked evidence to identify the affected extremity. The nurse elevated the resident's legs. Hospice notes, dated 7/17/14 showed the hospice nurse assessed Resident #2's left leg "purple" in color and cool to touch. The hospice nurse was unable to elicit a positive Homan's sign and noted only a faint pedal pulse present. (Homan's sign is a test which may indicate a potential blood clot when the toes on the affected leg are pushed backwards (dorsiflexion) elicits calf pain in the patient's affected extremity.) g. The Nurse's Notes documented the following: on 7/19/14 at 3:50 p.m. the nurse assessed Resident #2's left knee was swollen and had 2+ [MEDICAL CONDITION] to his/her bilateral lower extremities. The nurse's assessment showed that the left lower extremity was "blue" in color and the hospice nurse was present and family was aware of the change in status. The nurse then documented Resident #2's family approved a hospital transfer if the resident's pain was "unbearable." The clinical record lacked evidence of an assessment of Resident #2's pain. The Nurse's Notes documented the following: on 7/20/14 at 10:00 a.m. the nurse assessed Resident #2 had 4+ [MEDICAL CONDITION] to his/her left lower extremity which was now "purple" in color and slightly cool to touch. The nurse documented that Resident #2 did not display signs or symptoms of pain but had increased anxiety. On 7/20/14 at 1:00 p.m. the nurse documented the physician was in the facility, assessed Resident #2 and spoke with the resident's family. New orders were received to begin [MEDICATION NAME] by mouth and [MEDICATION NAME] subcutaneous injections for a [DIAGNOSES REDACTED].) On 7/20/14 at 6:30 p.m. the nurse assessed Resident #2 had 4+ [MEDICAL CONDITION] to his/her left lower extremity and displayed no signs or symptoms of pain. On 7/21/14 at an undocumented time, the nurse assessed Resident #2's left leg as "swollen" with no redness, and painful to touch. The nurse documented the hospice nurse was in the facility and a new order was received for [MEDICATION NAME], (an oral liquid narcotic pain medication.) The Nurse's Notes documented on 7/22/14 at 10:00 a.m. the nurse assessed Resident #2 with 3+ [MEDICAL CONDITION] to the left lower extremity and a negative Homan's sign. The facility's clinical record lacked evidence of accurate and timely assessments of Resident #2's lower extremities. The resident's care plan, updated on 7/22/14, reported the resident had a [MEDICAL CONDITION] ([MEDICAL CONDITION] or blood clot) which required oral and injected medication to thin the resident's blood. On 7/23/14 at 3:20 p.m. the facility Director of Nursing stated she would expect nursing staff to be specific in assessment documentation and include a numeric value, such as 1 or 2, for "mild" [MEDICAL CONDITION]. The Director of Nursing confirmed she would expect staff to notify the physician of the above changes in status. On 7/24/14 at 9:01 a.m. Resident #2's physician stated that when the symptoms initially presented Resident #2's family was "non-[MEDICATION NAME]" and choosing comfort measures such as hospice rather than active treatment. The physician reported the clot was probably already in motion & probably did not make a difference with the [MEDICAL CONDITION] outcome; however the physician stated the blood clot may have resolved more quickly if treatment was initiated earlier. The facility policy titled Change of Condition/Hot Chart Protocol, dated March 2007, defined a change in condition is an alteration from normal status. The policy directed staff to document observation/assessment of the resident, to include response to interventions until the problem resolves. The facility policy titled Change of Condition/Hot Chart Protocol, dated March 2007, indicated that a condition change is an alteration from normal status which required physician notification.