Every finding on record at Lincoln Haven Nursing & Rehabilitation Community

This citation pertains to intake #3109721. Based on interview and record review the facility failed to ensure a safe discharge for one Resident (#12) of three residents reviewed for discharge planning. This deficient practice resulted in hospitalization with sepsis, dehydration, plugged feeding tube, aspiration pneumonia, and hospitalization for Resident #12. Findings include:Resident #12 (R12)According to intake #3109721 filed with the State Agency (SA) on 7/23/26, read in part Individual was discharged from LTC [Long Term Care] to his home.There was no power or running water upon arrival home. The individual was discharged with a Jujunostomy [sic] tube without homecare. The Jujunostomy [sic] was supposed to be set to run 50cc/hr [cubic centimeters/hour] for patency. There were no instructions provided on numbers to call if there was a malfunction with the pump. LTCF [Long Term Care Facility] discharged without a complete discharge plan.When staff went to his home, individual did not take morning medications due to not having a pill crusher. There was no follow up appointment scheduled, the individual has no transportation.Per staff individua [sic] had not started his tube feeding and was unsure of how often he was to run it. Individual was unable to verbalize how he was supposed to take medications. Per staff individual was no able to verbalize how to order more tube feeding supplies and cannot locate a syringe to add medications to the Jujunostomy [sic] tube.or trouble shoot his tube feed machine along with scheduling follow up appointments.Review of R12's most recent hospitalization medical records, dated 7/30/26 through 8/6/26, revealed an admission on [DATE] to a local hospital for sepsis, aspiration pneumonia, vomiting, dehydration, and plugged feeding tube.Review of hospital progress note, dated 8/1/26, read in part Patient seen today in follow-up for severe sepsis due to aspiration pneumonia and acute renal failure with J-tube dysfunction.the patient had no ability to operate tube feeds at home and the patient was trying to drink fluids but was vomiting repeatedly when oral intake was attempted. Patient spent approximately 2 weeks at home with little to no intake.informed this nurse when she arrived to patient's home patient was not well, drinking fluids and vomiting repeatedly. Patient was unable to demonstrate.how to operate home tube feed pump.reports inability to flush the J-tube,,,Review of hospital admission history & physical, dated 7/31/26, read in part .He was discharged to rehab facility on 5/29 and apparently has been back home for a couple of weeks.He states he has not been able to swallow anything since he has been home, regurgitating PO [oral] intake nearly immediately. Also has nausea, vomiting. He doesn't think he has done tube feeds in a couple of weeks. He presented to the ED yesterday for nausea, vomiting, intolerance PO intake and was found to be in acute renal failure.This was normal two weeks ago. WBC [white blood cell count] count 30.2. CT [cat scan].shows concern for aspiration pneumonitis.Some drainage was noted around the J tube exit site and possible malfunctioning J tube. There was concern this could be source of sepsis, general surgery was consulted for evaluation. He denies abdominal pain.On 8/10/26 at 10:55 AM, an interview was conducted with Complainant A who was asked about R12's discharge from a local skilled nursing facility (SNF) and confirmed their above allegations.On 8/10/26 at 11:13 AM, during an interview Community Mental Health (CMH) Staff B was asked when they went to visit R12 on 7/22/26 how they found R12. Staff B replied, The house was without power and water. They were hospitalized related to a plugged feeding tube. [R12] was drinking and vomiting. No home care was set up. No prior home visit to ensure safety.On 8/10/26 at 11:57 AM, during an interview CMH Staff C was asked what condition R12 was found in when they went to visit R12 on 7/22/26. Staff C replied, I was there to administer an injection. There was no power or water so there was no way to flush the feeding tube and was to get water flushes. [R12] was not hooked up to their tube feeding. [R12 did not take their medications the day before. The SNF highlighted [R12's] medication list and added d/c and I am not even sure if they [R12] knew what that meant. I did not see a pill crusher or a syringe to administer medications with. [R12] had no idea how to get medications refilled or refill tube feeding supplies and had no contact information for trouble shooting any complications with their tube feedings or machine to administer. [R12] had to follow-up with their gastroenterologist down state and [R12] had no transportation or appointment setup. No home care setup and was to be NPO [nothing by mouth].Review if R12's electronic medical record (EMR), revealed an original admission to the facility on 6/24/26 for rehabilitation with medical diagnoses of surgical aftercare following surgery on the digestive system, bipolar disorder, hyperlipidemia (elevated cholesterol), weakness, depression, dysphagia (difficulty swallowing), hypertension (elevated blood pressure), injury of esophagus, and need for assistance. R12 was discharged from the facility on 7/21/26 via transportation from the facility staff and vehicle to their home.Review of R12's progress note, dated 6/24/26, read in part Resident arrived to facility via ambulance at 1730 [5:30 PM].new orders received.to run jevity enteral feeding at gravity / 50ml [milliliters] per hour until pump arrives.He has a newly placed gastric tube after esophageal perforation with repair. History of.PTSD [post-traumatic stress disorder], hyperlipidemia, anxiety, bipolar disorder, depression.Review of R12's progress note, dated 7/17/26 at 8:41 PM, read in part Explained tube feeding and flushes to res [resident] as best as possible.Res does not show much enthusiasm with learning to feed himself. He did mention that his house has no electricity to operate pump.Review of R12's progress note, dated 7/19/26 at 11:03 PM, read in part .Again, went over how to operate machine.is still unsure of setting it.Review of R12's progress note, dated 7/21/26 at 11:17 AM, read in part Discharge planning is ongoing. This writer attempted to arrange home health services; however, placement has been unsuccessful at this time. [name of home care company] is unable to accept the patient due to concerns regarding the patient's swallowing needs. [name of home care company] is currently unable to accept new referrals due to capacity limitations. [name of home care company] does not provide services in the [town where R12 resides] area. At this time, home health services have not been set up.Resources for R12's living area were researched by this surveyor. There were three other possible home care companies which could have been contacted and R12's EMR lacked any documentation of reaching out to any of the other three home care companies prior to their discharge to home via facility vehicle.Review of R12's progress note, dated 7/21/26 at 1:36 PM, read in part .At 1315 [1:15 PM] resident was discharged to home via facility vehicle. This nurse sent all available meds with resident, reviewed medication list and follow up appointment.Review of R12's physician order, date received 7/7/26, start date 7/14/26, and end date open ended, revealed an order to discharge to home with PT/OT/ST [physical therapy/occupational therapy/speech therapy], health aides and nursing services.Review of R12's care plan, dated 6/24/26, revealed the inclusion of impaired pulmonary/respiratory status and lacked any other plans of care. (Still not sure this adds value to this deficiency)Review of R12's PT Discharge summary, dated [DATE], read in part .D/C [discharge] Destination: Home w/ Family Assistance.D/C Recs [recommendations] Discharge Recommendations: Home care Services with therapies.Review of R12's OT treatment encounter, dated 7/18/26, read in part .Response to Tx [treatment].Without skilled OT intervention, Pt [patient] is at risk for decreased independence/increased burden of care. Pt presents with limited self initiation of ADL [activities of daily living] and poor carryover of positional awareness.Review of R12's ST Discharge summary, dated [DATE], read in part .Discharge Recommendations and Status: Oral Intake.No solids.No liquids.Testing.Recommended GI [gastroenterologist] follow up immediately after discharge.Review of R12's OT Discharge summary, dated [DATE], read in part .D/C Destination: Home w/ Family Assistance.D/C Recs Discharge Recommendations: Home health services.On 8/17/26 at 8:45 AM, during an interview OT E was asked if R12 had a home visit prior to discharge or if R12 was set up with home care per therapy recommendations and replied, There was no home visit. I know they tried to set them up with home care but were unsuccessful.On 8/17/26 at 11:45 AM, during an interview Licensed Practical Nurse (LPN) I was asked if R12 had all the supplies at their home to complete his cares. LPN I replied, I did not send home with any syringes or a pill crusher. I told them they (R12) could get a pill crusher from the local pharmacy in town. I am not sure about a follow up appointment.On 8/17/26 at 12:15 PM, during an interview Housekeeper/Laundry G was asked if she was the staff member who transported R12 back to their home on 7/21/26. Staff G replied, Yes. He did not have power when I dropped him off. I took him to the bank to get money for his balance from his stay at the facility. The house looked a little disheveled. I told the director of nursing he was without power. He (R12) told me he was going to set up his own appointment for his follow up and needed transportation first.On 8/17/26 at 12:42 PM, an interview was attempted with R12 on his personal cell phone and no answer to the call was established.On 8/17/26 at 2:20 PM, during an interview PT N was asked if R12 should have been set up with home health care prior to discharge. PT N replied, Yes, even if it was just an evaluation and discharge at the time. Home health can see things in the home where we cannot, and they may be able to identify barriers to self-care. The doctor should have been made aware home care was not established.On 8/17/26 at 1:03 PM, during an interview Medical Doctor (MD) M was asked if he was aware R12 was not set up with home care prior to discharge per his orders. MD M replied, I should have been made aware. I would have held the discharge until home care was established.On 8/17/26 at 2:00 PM, during an interview Social Services Director (SDD) D was asked if she developed a plan of care for discharge or made notes regarding the discharge process for R12. SSD D replied, I just made the one note. I did not make any other notes. SSD D was asked if they communicated with the doctor, being unable to establish home health care services for R12 and replied, No, I did not.On 8/17/26 at 2:35 PM, during an interview the Nursing Home Administrator (NHA) was asked about the discharge process and planning. The NHA replied, The social services director is new. There should have been progress notes and a care plan right aware along with IDT notes. Should have made more notes regarding his [R12's] discharge process.According to R12's emergency department (ED) report, dated 7/30/26, read in part Pt [patient] to ED via city EMS [emergency medical services] with c/o [complaints of] Feeding Tube Problem.called EMS that the feeding tube wasn't working properly today. Was able to get feedings yesterday. Dried blood noted around tube.Vomiting with EMS. Pt states that he's been vomiting for weeks. Recently taken home after residing at [SNF name]. Pt A&Ox4 [patient alert & oriented to person, place, time, and situation].Review of hospital PT progress note, dated 8/6/26, read in part .Rec [requested] SNF as pt not able to ambulate a household distance. Skilled Physical Therapy is reasonable and necessary to maximize safety and independence with all functional transfers and functional mobility in order to return to prior level of functioning and ensure safe discharge.Review of hospital OT progress note, dated 8/5/26, read in part Patient demonstrates ongoing deficits in functional performance, including decreased strength, balance, endurance, and safety awareness, impacting independence with ADLs [activities of daily living]. Patient continues to require skilled occupational therapy services to address these impairments, promote functional independence, and reduce risk of decline or further injury.Review of hospital progress note, dated 8/3/26, read in part .Anticipated next site of care/Discharge Needs: Awaiting insurance authorization. Likely DC [discharge] to SAR [subacute rehab] at SNF. Placement issue with acceptance due to patient's Candida auris infection, will follow-up on urine culture to see if patient ex cleared this infection, which will make placement easier. Patient can be discharged as soon as proper placement has been organized.Review of hospital progress note, dated 8/2/26, read in part .Patient also continues on IV [intravenous] Unasyn [antibiotic] with leukocytosis [white blood cells] improving and today oxygen supplementation titrated down to 1 L [liters] by nasal cannula.is still profoundly weak.Review of policy titled, Discharge Planning Process, dated 1/25, read in part Standard: All residents will have a discharge plan that supports a smooth transition to home or to the next care setting. The foundation of the plan will be developed for most residents at the time of admission. Policy: Social services will initiate the discharge plan upon admission for all residents.Discharge and transitional care is completed in collaboration with the interdisciplinary team and the goals of the resident, family or guardian.Procedure.2. Social services will interview the resident and or family after admission to determine their discharge and wellness goals. 3.The Social worker will develop the resident's initial discharge planning care to include the resident's goals and plans. The care plan will be updated during care plan meetings and after resident choice conversations that relate to discharge planning.7.A Comprehensive Care Plan is developed within seven (7) days of completing the resident assessment.11. A member of the Interdisciplinary team should schedule an appointment to the residents home to ensure that functionality is feasible for the resident. This will also allow for better and more individualized discharge planning needs.13. The IDT will have a care plan transition meeting prior to the residents discharge.Review of policy titled, Discharge Plan, dated 1/25, read in part Standard: The facility will initiate a discharge plan for every resident that has been admitted to the facility.Policy: All Residents will have a discharge plan based on the most recent comprehensive assessment or quarterly review.Procedure.3. Social Services will assist the resident.in selecting a post-acute care provider if the resident will be discharged to.or HHA (home with home health agency).

Based on interview and record review the facility failed to provide a qualified dietitian, other clinically qualified nutrition professional, and/or director of food and nutrition services who met the required qualifications in the timeframe allowed. Findings include:On 03/30/2026 at 11:15 AM the dietary manager (DM) F stated she does not have her Certified Professional Food Manager Certification and she is not a Registered Dietitian. DM F stated she has only been at this facility for a short time and has not had a chance to obtain the certifications. She stated the facility does have a Registered Dietitian (RD) for the facility.On 03/31/2026 at 09:45 AM in a phone interview with RD N, when asked if she worked full time at the facility as the Registered Dietitian, she stated she came into the facility bi-weekly, with two visits per month and also conducts remote assessments. She stated she is a consultant for the corporation. During this phone interview, the nursing home administrator NHA, entered the room and stated that RD N was full- time for this facility. When asked, the NHA stated Dietary Manager F had been employed 6 weeks.On 03/31/2026 at 10:10 AM a review of RD Ns invoice showed billed hours to the facility for the month of December 2025, January of 2026 and February of 2026 showed a total number of billed hours (excluding travel time) to be 26.75 for all three months combined. Separated out, this broke down to 6.25 hours billed on 12/30/2025, 10 hours billed on 1/28/2026, and 10.5 hours billed on 2/28/2026.On 03/31/2026 at 10:00 AM during an interview with the NHA she stated that she does all of the food ordering and pretty much runs the kitchen due to Dietary Manager F being so new.

Based on observation, interview, and record review the facility failed to maintain general repair of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents in the facility. Findings Include:On 03/30/2026 at 11:05 AM observed the vegetable wash sink was indirectly connected to the floor drain, with the drain line extending down into and below the lip of the floor drain. During this observation, when asked what this sink is used for, Dietary Manager (DM) F stated that vegetables are washed in this sink.On 03/30/2026 at 12:21 PM observed the double doors for the closet in room [ROOM NUMBER] with the left closet door askew. The track that the door was to follow on top was damaged and no longer working, and the upper left portion of the left door was hanging away from the door frame about 5 inches.On 03/30/2026 at 2:17 PM observed the drain line coming from the third bin of the three-compartment sink extending down into and below the lip of the floor drain. DM F stated this three-compartment sink is where some utensils that do not go through the dish machine are washed, rinsed and sanitized.On 03/30/2026 at 2:20 PM observed the ice machine which is used for resident food prep and drinks had the drain lines extending down into and below the lip of the floor bowl drain, with no air gap present.According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. P

Based on interview and record review, the facility failed toEnsure follow-up care was documented for elevated blood glucose levels, and;Communicate with physician as ordered,for one Resident (R3) of one resident reviewed for insulin therapy. Findings include:Resident #3 (R3)According to R3's electronic medical record (EMR), R3 was admitted to the facility on [DATE] with medical diagnoses of diabetes mellitus, weakness, depression, and anxiety.Review of R3's physician order, dated 1/1/26, revealed an order for insulin lispro solution with a sliding scale of: If blood sugar is 150 to 200 give 2 units, if blood sugar is 201 to 250 give 4 units, if blood sugar is 251 to 300 give 6 units, if blood sugar is 301 to 350 give 8 units and if blood sugar is 351 to 400 give 10 units. Assess blood glucose levels three times a day prior to lunch, dinner, and bedtime. If blood glucose is greater than 400 call medical doctor.Review of R3's physician order, dated 4/17/25 until 1/1/26, revealed an order for insulin lispro solution with a sliding scale of: If blood sugar is 150 to 200 give 2 units, if blood sugar is 201 to 250 give 4 units, if blood sugar is 251 to 300 give 6 units, if blood sugar is 301 to 350 give 8 units and if blood sugar is 351 to 400 give 10 units. Assess blood glucose levels two times a day at 11:00 AM and 8:00 PM. If blood glucose is greater than 400 call medical doctor.Review of R3's blood glucose levels, dated 10/1/25 through 4/1/26 revealed 40 results over 400 milligram per deciliter (mg/dL). The physician was documented as notified only six of the 40 times R3's blood sugar was greater than 400. No follow-up blood glucose rechecks were documented to ensure the blood glucose was trending down or still elevated documented in the EMR.On 4/1/26 at 11:10 AM, an interview was conducted with R3 who was asked if he recalled any follow-up blood glucose checks after receiving extra insulin related to an elevated blood glucose over 400 and replied, I honestly can not recall. My memory comes and goes.On 4/1/26 at 11:50 AM, the Nursing Home Administrator (NHA) was interviewed and asked what her expectation was for nursing if a residents blood glucose result was greater than 400 and replied, I would expect the nurse to contact the physician and do a follow-up blood glucose and document it in the EMR.Review of facility policy titled, Diabetic Management Program, dated 01/2025, read in part Policy: This policy is designed to provide standardized guidance for diabetic management and ensure appropriate treatment is initiated for hyperglycemia and hypoglycemia episodes. It is important to note that some residents may require a different plan of care and that a physician's order takes precedence over the guidance contained within this policy in such instances.Procedure: Call physician immediately if blood glucose is >300, or as determined by a physician's order.recheck blood glucose per Physician order. Document blood sugar results, treatment and resident response to treatment in the medical record.

Based on observation, interview, and record review, the facility failed to monitor fluids and provide the diet as ordered for one Resident (R4) of two residents reviewed for fluid concerns.Findings include:Resident #4 (R4)The electronic medical record (EMR) revealed a most recent admission date of 8/27/2025 with diagnoses including myocardial infarction (heart attack) and chronic kidney disease. The EMR also included a physician order dated 2/5/2026 which read 1500 cc (cubic centimeters which is 1.5 liters) Fluid Restriction Diet: Regular NAS (No Added Salt) and a physician order dated 3/31/26 Lasix was increased to 40 mg daily on 3/31/26 (Lasix is a diuretic or water pill used to treat edema or fluid retention.)During an interview on 3/30/2026 at approximately 1:30 PM, R4 stated his legs swell up. He was sitting in his wheelchair with his feet resting on his bed and elevated chest high.On 3/31/2026 at 12:08 PM, R4 was observed in the dining room slurping chicken noodle soup from a bowl. Licensed Practical Nurse (LPN) A stated he gave R4 a glass of water (4 ounces) and a glass of grape juice(4 ounces) . LPN A said, He drank the grape juice so fast I gave another 4 ounces of water as he was thirsty. The meal tray card for R4 read Regular, 1500cc Restr (Restriction). The tray card did not include No Added Salt as was indicated on the physician's order. The tray card read Beverages/Equipment Coffee with sugar, Grape Drink (8 Floz or fluid ounces), Lo Cal Fruit Punch (8 Floz).The EMR physician orders dated 1/18/2026 included, Obtain Daily weight r/t BLE (related to bilateral lower extremity or both legs) swelling & weight gain. The Medication Administration Record (MAR) included the daily weights and was reviewed from 3/2/2026 to 3/31/2026. No weights were recorded on 3/11, 3/16, 3/17, 3/18, 3/19, 3/23, 3/24, 3/25, 3/26, 3/27 or 3/29/2026.The MAR also had an area for documentation of 1500 cc Fluid Restriction Diet: Regular NAS Other. Nurses had signed the MAR twice per day for this order but there was no indication of the amount of fluids R4 had consumed.During an interview on 4/1/2026 at 1:00 PM, Certified Nurse Aide (CNA) E was asked about the procedure for recording fluids for residents with a fluid restriction. CNA E said, We just chart in the computer what residents take each meal. Sometimes there is a plan for fluids on the wall of the room. We observed R4's room , but there was not a plan on how to divide the 1500 cc fluids ordered per day. CNA E said, He (R4) does not have a plan, maybe the nurses have one.The EMR was reviewed on 4/1/2026 for fluids recorded in the vitals section of the chart per CNA E. On 3/31/26 120 cc was the only fluid recorded for the day, although R4 was observed drinking 8 ounces of water, 4 ounces of grape juice and approximately 6 ounces of chicken noodle soup at lunch to total 540 cc for that meal alone. The EMR did not have any fluids recorded on 3/4, 3/5, 3/10, 3/11, 3/16, 3/17, 3/18, 3/19, 3/24, 3/25, or 3/27/2026.During an interview on 4/1/2026 at approximately 1:10 PM, LPN D stated he did not record fluids given with medications. LPN D stated, The CNAs just document what we give with meds into their last meal. They add it in. When LPN D was asked how much fluid the nurses give with medication he replied he does not arrive to the facility until 10 AM and has no idea what the first shift nurses did. LPN D said he gave R4 medication twice a day with 2-3 ounces each time. So, I give about 5 oz a day. When LPN D was asked who was responsible to total and assess the fluids given per day, he replied the computer automatically totals the day.During an interview on 4/1/2026 at 1:20 PM, the Nursing Home Administrator (NHA) stated there was a binder for fluid documentation containing the daily fluid worksheets. The NHA said dietary should give 355 cc each meal (1. 47 cups per meal.) The page for 3/31/2026 was reviewed and at lunch there was a bold 355 cc written in for the allotment for lunch and 60 cc was recorded as consumed for lunch, although the EMR had 120cc recorded at lunch and R4 was observed to consume 540 cc.On 4/01/2026 at approximately 1:30 PM, Dietary Manager (DM) F was asked to print the breakfast, lunch and dinner meal tray cards for R4. They included fluids of:Breakfast: 4 oz juice, coffee with sugar (DM F stated a coffee cup is 8 oz.)Lunch: coffee (8 oz), grape drink (8 oz), lo cal fruit punch (8 oz)Dinner: coffee (8 oz), grape drink (8 oz), lo cal fruit punch (8 oz)The fluid total allotted on the meal tray card for R4 equaled 60 ounces or 1800 cc per day. This amount did not include the fluids given with the medication pass. This dietary total alone exceeded the physician order of 1500 cc per day.The care plan for R4 was reviewed and although the physician orders were focused on a fluid restriction, a salt limitation, medication to eliminate edema, and monitoring of weight gain due to fluid overload, there was not a care plan for this focus. There was only a care plan with a focus of a risk of dehydration D/T (due to) use of diuretic medication .During an interview on 4/1/2026 at approximately 2:00 PM, the NHA could not present documentation on how fluid restrictions were totaled each day to determine if the physician order of 1500cc was being met or exceeded.The undated policy titled FLUID RESTRICTIONS/HYDRATION was reviewed and read in part, Policy: Physician orders for fluid restrictions will be followed.Dietary and nursing will determine the amount of fluids to be given with meals and between meals. Fluid amounts will be reflected on the residents (SIC) tray card and nursing EMR at [NAME] (SIC) pass. Fluid restriction breakdown will be also (SIC) appear of (SIC) each resident's POC (plan of care).

Based on interview and record review, the facility failed to ensure the accuracy of assessments for one Resident (#29) of two residents reviewed for Hospice services. Findings include:Resident #29 (R29) Review of the electronic medical record (EMR) revealed R29 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure, atrial fibrillation, acute respiratory failure with hypoxia and hypertension. During an interview on 3/31/2026 at 9:30 a.m., R29's Legal Guardian (LG) R reported R29 was currently receiving Hospice services at the facility. Further review of the EMR revealed a Facility Notification of Admission, form signed and dated by the Hospice provider on 10/29/2025. Resident profile information gleaned from the EMR listed R29's primary payer as the Hospice provider. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report(s), dated 10/31/2025 and 3/20/2026 revealed R29 was admitted to Hospice on 10/29/2025 with a current benefit period through 4/26/2026. Review of R29's Minimum Data Set (MDS) assessments, dated 10/29/2025, 11/12/2025 and 1/27/2026, revealed the assessment data listed in Section O Other services. K1. Hospice Care, was not marked and line Z1. None of the Above. was checked, indicating R29 was not receiving Hospice care while residing in the facility. Review of the CMS 802 (facility matrix) provided by the Nursing Home Administrator (NHA) on 3/30/2026, revealed R29 not marked on the matrix as receiving Hospice care. On 4/01/2026 at 8:59 a.m., the facility MDS Coordinator, Registered Nurse (RN) I reviewed R29's MDS assessments, dated 10/29/2025, 11/12/2025 and 1/27/2026, and confirmed the resident was not coded for receiving Hospice services on the assessments. RN I reported she was unsure why the MDS did not include an accurate assessment as she was aware of R29 being admitted to Hospice services following a hospitalization in October of 2025. RN I reported there was ongoing discussion with LG R and R29 regarding Hospice admission and that once the decision for Hospice initiation was made, she may have forgot to go back in, and change the assessment to reflect Hospice services prior to submitting the 10/29/2026 and therefore all subsequent assessments did not reflect the provision of Hospice care. Review of the facility policy titled, Resident Assessment Comprehensive Assessments, updated 11/28/2017, revealed the following: To ensure that the Resident Assessment Instrument (RAI) is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identified each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified. This facility must conduct initially and periodically a comprehensive, accurate . assessment of each resident's functional capacity . The MDS/CAA assessment includes at least the following . O. Special treatments and procedures .

Resident #21 (R21)Review of R21's electronic medical record (EMR), revealed an admission date to the facility on 7/3/26 with medical diagnoses of multiple sclerosis (a chronic autoimmune disease of the central nervous system where the immune system attacks the myelin sheath protecting nerve fibers, causing inflammation and scar tissue), and major depressive disorder, recurrent and in full remission.On 3/30/26 at 12:35 PM, an interview was conducted with R21 in her room. R21 was noted to have a high back wheelchair sitting next to a table and R21 was resting in her bed. R21 was asked the last time she was up in her wheelchair and replied, It has been a few days. R21 was asked why she has not been up today and replied, I can only tolerate a couple hours in that wheelchair, it is not my normal wheelchair. R21 was asked where her normal wheelchair was and replied, It was here, but now it is back home. The facility will not let me have it here. I have a power wheelchair. I was able to use it at a different facility, but this one will not allow it. R21 stated, I was not aware when I admitted to the facility that I was not going to be able to use and keep my power wheelchair during my stay.Review of R21's care plan, dated 7/17/25, read in part .Problem: [resident name] has Alteration in ADLs [activities of daily living] self-care deficit r/t [related to] advance MS [multiple sclerosis].weakness. Goal.Resident's preferences will be honored to the extent possible. Approach: Allow resident time to perform and complete ADLs as able.Involve resident in care and decision making as much as possible. Offer choices when able.Status of bed mobility: assist x 1 prn [as needed].On 3/31/26 at 2:20 PM, an interview was conducted with Certified Occupational Therapy Assistant (COTA) O, who was asked regarding R21's power wheelchair and replied, It would be life changing for her to have her power wheelchair.Occupational therapy progress note, dated 7/21/25 for R21 read in part .Pt [patient] utilizes PWC [power wheelchair] in home environ, spending all day and even sleeping in it. Pt has bari-BSC [bariatric bedside chair] which she is able to complete PWC<>BSC w/o [without] utilizing SB [slide board].DON [Director of Nursing] to continue to attempt to allowance of PWC into this facility. Pt and SO [significant other] very upset, highly frustrated.Review of R21's progress note, dated 7/23/25 at 10:30 AM, read in part .PT [physical therapy)/OT (occupational therapy) continuing to work with [resident's name]. Requires total assistance with ADLs/transfers. Approved to bring in custom power chair for therapy evaluation of transfers/utilization.Care conference was completed on July 21st, with s/o (significant other) present for meeting. Plan is for s/o to bring in powerchair at earliest convenience, continue with therapy as tolerated.Review of R21's wheelchair assessment, dated 7/24/25, revealed R21 was safe to use power wheelchair and was able to navigate the power wheelchair joystick for positioning and driving. Assessment recommendations were to resume PWC for home use upon return home with caregiver.R21's progress note, dated 9/8/25, read in part, .Resident had a meeting with staff today and was wondering about going home, husband unable to care for her at this time and it was decided she will stay here longer and be re-evaluated next month. Resident was very tearful and will be evaluated for depression meds.Anticipate if depression addressed further intake may improve and weight will stabilize.On 3/31/26 at 3:16 PM, an interview was conducted with R21 in her room. R21 was lying in her bed resting and was asked if she could have her power wheelchair how would she feel and replied, It would change my whole attitude. It lifts my feet. I can change positions in it. I can lean back or sit up and move around. I really wish I could have my power wheelchair here. It would help me out. I would love to be able to keep it here in my room and utilize it like I did at home. My power wheelchair is my life. I would not be so contracted if I had my own power wheelchair.During an interview on 4/1/26 at 8:30 AM, with the Business Office Manager (BOM) G who was asked about the admission process and which policies were covered during the process and replied, I just do the basics like resident rights, transfer, bed hold, accounts, and other stuff like that. BOM G was asked if she covered the policy for power wheelchairs and replied, No, I do not cover that policy.Review of R21's admission agreement, dated 7/3/25, lacked any discussion of the facility policy regarding electrical appliances including power wheelchairs, electric razors, laptops, and curling irons.On 4/1/26 at 10:35 AM, an interview was conducted with Occupational Therapist (OT) P who was asked if R21 had her power wheelchair what that would do for her contracture in her left leg and replied, Her contracture has gotten worse in her left leg and was not there when she first admitted to the facility. She has not been getting out of bed related to pain. Her muscle tone has decreased in her left leg. I was told her power wheelchair was not allowed. She was evaluated for safety of use of her power wheelchair, and she passed and can work the controls better than I can that's for sure.During an interview on 4/1/26 at 1:40 PM, the Nursing Home Administrator (NHA) was asked why R21 was not allowed to have her power wheelchair and replied, She was not safe to us use it in the facility. The NHA agreed R21 should be re-evaluated for safety of use for her power wheelchair and acknowledged R21 would benefit from using her own custom power wheelchair in her room at the facility.Review of policy titled, Electrical Appliances Resident Rooms, dated 01/2024, read in part Policy: It is the policy of this facility that only authorized electrical appliances be permitted in resident rooms to create a friendly and comfortable homelike environment consistent with consideration for space, safety, and fire code requirements. Procedure.2. Motorized equipment such as wheel chairs are not permitted in house for safety of facility residents in small environment. Staff will consult facility administrator in further interventions if needed. Facility administrator has final decision if limited use if required.Review of policy titled, Activities of Daily Living (ADLs)/Maintain Abilities, dated 01/2025, read in part INTENT: It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person centered, and honor and support each resident's preferences, choices, values and beliefs. PROCEDURE: 1. Based on the assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. 2. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living.

Based on interview and record review, the facility failed to ensure resident's and/or their representatives were educated on the risks and benefits of prescribed psychotropic medications by obtaining informed consent prior to administration for two Residents (#7 and #21) of five residents reviewed.Findings include:Resident #7 (R7) Review of the Electronic Medical Record (EMR) revealed R7 was admitted to the facility on [DATE] and had diagnoses including bipolar disorder and generalized anxiety. Review of the March 2026 Medication Administration Record (MAR) revealed R7 was administered the following medications per physician order: Risperdal tablet (risperidone, an antipsychotic medication used to treat schizophrenia and bipolar disorder) 0.5 milligrams (mg), one tablet by mouth daily at bedtime. Date initiated: 11/11/2025. Review of R7's Psychoactive Medication Consent Form, gleaned from the EMR and dated 11/12/2024, revealed informed consent for the medication listed as Risperdal Consta IM [injectable form of antipsychotic medication], Q 2 Weeks [every two weeks]. It was noted the consent was signed by R7's responsible party on 11/12/2024. Review of physician orders revealed Risperdal Consta 12.5 mg/2 ml (milliliter); 1 ml; Intramuscular [IM]. For total dose of 6.25 mg IM. Once a day on [Sunday]. Every two weeks. The order was noted as discontinued on 11/11/2025. Further review of the EMR revealed no signed informed consent for R7's form and dosage change from Risperdal Consta 6.25 mg IM every two weeks to Risperdal 0.5 mg oral tablet daily, to include the risks and benefits of the change. During an interview on 4/01/2026 at 11:15 a.m., Social Services Designee, Staff H reported the process for obtaining informed consent applied to new medication orders and changes to existing medication orders. Staff H reported nursing was responsible for alerting her of changes to existing psychotropic medication orders to allow her to start the process for obtaining informed consent. Staff H reported she could not locate a signed consent for R7's change in form and dosage of Risperdal on 11/11/2025. Resident #21 (R21) Review of R21's electronic medical record (EMR), revealed an admission date to the facility on 7/3/26 with medical diagnoses of multiple sclerosis (a chronic autoimmune disease of the central nervous system where the immune system attacks the myelin sheath protecting nerve fibers, causing inflammation and scar tissue), and major depressive disorder, recurrent and in full remission. R21's progress note, dated 9/8/25, read in part, .Resident had a meeting with staff today and was wondering about going home, husband unable to care for her at this time and it was decided she will stay here longer and be re-evaluated next month. Resident was very tearful and will be evaluated for depression meds.Anticipate if depression addressed further intake may improve and weight will stabilize. Physician orders unveiled R21 was prescribed an antidepressant on 11/15/25. On 3/31/26 at 3:45 PM, an interview was conducted with R21 who was asked if she recalled signing a consent for her antidepressant and replied, No. I am not even sure if I am still taking an antidepressant. Review of R21's progress note, dated 11/16/25, read in part Resident reported concerns.about depression and feeling sad most of the time. She has requested for the provider to place her on another antidepressant.[doctors name] informed of conversation with resident and new orders placed in MAR (medication administration record): Effexor 75 mg capsule extended release QD (every day).Order placed in social workers box for further review. On 3/31/26 at 4:00 PM, an interview was conducted with the social services designee (SSD) H who was asked if R21 had a consent for her venlafaxine and replied, Let me look. She should have one in the EMR. The SSD H could not find a consent for R21's venlafaxine in the EMR and did not know why there was not one on file. Review of policy titled, Psychotropic Medication Use, dated 01/2025, read in part Policy: Residents are not given psychotropic medication unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record. Policy Explanation and Compliance Guidelines: 1. Psychotropic medications include, but are not limited to: antipsychotics, antidepressants, anti-anxiety, and hypnotics.3. Residents and/or representatives will be educated on the risks and benefits of psychotropic medication use, as well as alternative treatments/non-pharmacological interventions. 4. Residents who use psychotropic medications will receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the medication if possible.

Based on interview and record review, the facility failed to provide requisite bed hold information for three Residents (R3, R6, and R17) of four residents reviewed for hospitalizations. Findings include:Resident #3 (R3)R3 was transferred from the facility to the Emergency Department (ED) on 12/16/25. The electronic medical record (EMR) of R3 did not contain documentation pertaining to bed hold information provided to R3 and/or the resident representative of R3 as a result of the transfer to the ED on 12/16/25. R3's bed hold paperwork was blank and not filled out. Resident #6 (R6)R6 was transferred from the facility to the ED on 1/8/26, 3/19/26, and 3/27/26. The EMR of R3 did not contain documentation pertaining to bed hold information provided to R6 and/or the resident representative of R6 when R6 was transferred to the ED. R6's bed hold paperwork was blank and not filled out. Resident #17 (R17)The EMR of R17 documented transfers from the facility to the ED on 12/10/25 and 3/7/25. The EMR did not contain documentation of bed hold information provided to R17 and/or the resident representative of R17. R17's bed hold paperwork was blank and not filled out. On 3/30/26 at 4:00 PM, an interview was conducted with the Social Services Designee (SSD) H who was asked about the transfers and bed holds for R3, R6, and R17. SSD H provided a binder with the facility transfers and bed hold information. The SSD H confirmed that R3, R6, and R17 lacked a bed hold was provided during the time of transfers and none were scanned into the EMR. Review of policy titled, Bed Hold, dated 01/2022, read in part Policy: Our facility allows residents to hold or reserve a bed while absent from the facility due to hospitalization or therapeutic leave. This policy applies to all residents regardless of payment source and will be provided to the resident or the resident's representative at the time of admission and again with any emergency transfers from the community.Procedures: 1. The facility Social Worker or designee will provide a copy of the bed hold policy to the resident and/or the resident representative at the time of admission and again prior to a transfer due to hospitalization or therapeutic leave. The signed copies will be maintained in the resident's financial or personal file. 2. The facility shall provide the bed hold policy Acknowledgement to the resident or the resident representative with any resident initiated therapeutic leave or transfer to alternative healthcare community including a hospital admission. The acknowledgement will provide information to the resident and/or resident representative that explains the duration, the reserved bed payment policy and also facility permitting return of the resident to the next available bed.7. A copy of the resident's bed-hold or release record will be filed in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure proper storage of medications in two of two medication carts reviewed for pharmacy services. Findings include: On [DATE] at 10:30 AM, the [NAME] medication cart was observed, which was found to have three controlled substance medications that had been discontinued and remained in the medication cart as follows: a.) One blister pack from Resident #19 of tramadol 50 mg tablets that was ordered on [DATE] and discontinued on [DATE] with 9 of 15 remaining. b.) One blister pack from Resident #180 of lorazepam 0.5 mg tablets ordered on [DATE] and who was discharged from the facility on [DATE] with 15 of 15 remaining. c.) One blister pack from Resident #181 of lorazepam 1 mg tablets ordered on [DATE] and who was discharged from the facility on [DATE] with 11 of 13 remaining. On [DATE] at 1:24 PM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked about the destruction of controlled substances. The NHA replied, The nurses give them to the Director of Nursing (DON) and that nurse, and the DON destroy them at that time. Pharmacy destruction policy is followed by the two of them. The NHA was unclear as to how often this occurs. On [DATE] at 10:15 AM, an observation was made of the East medication cart, which revealed two loose tabs of alendronate 10 milligrams (mg) and a blister pack of the same medication that held 7 tabs of alendronate 10 mg that were to be dispensed every Tuesday to an unidentified resident. Registered Nurse B confirmed via the medication administration record (MAR) that the unidentified resident was given the medication on [DATE] at 5:42 AM by the night shift nurse, RN H. On [DATE] at 2:30 PM, an observation was made of the [NAME] medication cart-controlled substance log and the three controlled substances remained in the active medication cart supply. On [DATE] at 10:35 AM, and interview was conducted with the Director of Nursing (DON) who was asked how long discontinued controlled substances should be left in the active medication cart supply. The DON replied, I have been very busy lately and have not had time to destroy them. They should be destroyed as soon as possible if they have been discontinued so there is no concern for misappropriation. When asked about the loose pill in the medication cart, the DON explained they should not have loose pills, and stated the carts were just cleaned. The DON replied, It sounds like the resident did not get their full dose of the medication prescribed. I will look into this. On [DATE] at 10:50 AM, and interview was conducted with the NHA who was asked how often and when the last time the medication carts were cleaned out. The NHA replied, I just did them with Licensed Practical Nurse (LPN) E on Monday morning, the 24th of this week. The NHA was asked if loose pills should be left in the medication carts. The NHA replied, No, there should not be any loose pills in the carts, they were just cleaned out. Review of policy, Control Substances Discontinued/Disposal of Medications, dated ,d+[DATE], read in part Policy: When medications are discontinued by the Physician or if a resident is transferred / discharged and medications are not taken with him / her, or in the event of resident's death and the medication require destruction / disposal or if the prepared medication was refused or contaminated (dropped on the floor) the following procedures will be followed, all changes will be in accordance with state or pharmacological regulations. Procedure: 1. Reason for Destruction: Facility will remove medication(s) from the medication cart to be destroyed for the following reasons: a.) When an order to discontinue a medication is received. b.) The resident has been discharged from the facility; including transfer and expiration . Review of policy, Disposal / Destruction of Expired or Discontinued Medication, dated [DATE], read in part .2. Once an order to discontinue a medication is received, facility staff should remove this medication from the resident's medication supply . Review of policy, Maintenance of Medication Storage Areas, dated ,d+[DATE], read in part .A. Cart: 1. Clean inside and out, including crushing devices .

Based on observation, interview, and record review, the facility failed to treat pain timely for one Resident (#177) of one resident reviewed for pain. Findings include: Resident #177 (R177) Review of R177's face sheet, dated 2/25/25, revealed admission to the facility on [DATE] with diagnoses including, osteomyelitis (bone infection) of the right ankle and foot, peripheral vascular disease, hypertension, and diabetes mellitus. R177 was recently admitted for rehabilitation and was post-operative from an orthopedic surgery which included amputation of his right five toes and partial foot. On 2/25/25 at 12:26 PM, R177 was observed lying in his bed with a dressing on his right foot. R177 was asked what kind of operation he had on his foot. R177 replied, I had an infection, and they had to removed part of my foot including my toes. R177 was asked about pain and stated that he was comfortable when he left the hospital and when he first got to the facility, but now he was very uncomfortable. R177 stated his current pain level was an 8-9 (pain scale 0-10). R177 further explained his primary doctor prescribed him oxycodone with acetaminophen 10/325 milligrams (mg) one every four hours as needed. R177 was asked when the last time he had his pain medication and replied, Yesterday, before I left the hospital. Review of discharge paperwork, dated 2/24/25, revealed R177 underwent surgical amputation of his right foot on 2/20/25 and was sent to the facility with an order for oxycodone with acetaminophen 10/325 mg, one tablet by mouth every six hours as needed. Review of the initial admission assessment, dated 2/24/25, revealed R177 arrived in the facility at 6:20 PM. On 2/25/25 at 12:30 PM, an interview was conducted with Medical Director (MD) G who was asked about R177 and his pain medication. MD G replied, The staff called me last night and I told them to fax it to me and I never got the fax. I got a call this morning from the Director of Nursing (DON), and so I told them again to fax it and never received it, so I came in to sign the C-2 [controlled substance-2] form. MD G expressed he was frustrated he did not receive the C-2 form sooner. On 2/27/25 at 11:35 AM, an interview was conducted with the DON who was asked how new admissions receive controlled substance pain medications. The DON replied, Nursing must fill out a C-2 form and fax it to the doctor for an authorization signature. Then after the C-2 is signed, it is faxed to pharmacy for an authorization code. After nursing receives the code from the pharmacy, the medication can be pulled from back-up medication box and given to the resident until the medication is sent from the pharmacy. The DON was asked why the C-2 form did not get sent to the doctor after R177 was admitted to the facility. The DON replied, I left that to the admitting night nurse who did not send it to the doctor. On 2/25/25 at 12:39 PM, an interview was conducted with Licensed Practical Nurse (LPN) D who confirmed that there was oxycodone with acetaminophen 10/325 mg in the back-up medication box. LPN D also confirmed the same process for obtaining medication from the back-up box as the DON described. LPN D stated that she just faxed the C-2 form for R177 to the pharmacy and was going to check if the pharmacy had sent a response back in a little while. Review of R177's medication administration record (MAR), dated February 2025, revealed that R177 received a dose of oxycodone with acetaminophen 10/325 mg on 2/25/25 at 1:54 PM, approximately 20 hours after being admitted to the facility. R177 also underwent a dressing change in the morning of 2/25/25 without pain medication. On 2/26/25 at 8:10 AM, an interview was conducted with R177 who was asked how his pain management was going. R177 replied, I am so happy to finally get pain medication now. On 2/26/25 at 2:35 PM, an observation was made of R177 receiving a wound dressing change. R177 was asked to compare yesterday's wound dressing change to today's wound dressing change. R177 replied, Today went much better because I now have may pain medication. Review of policy, tilted, Pain Management, dated 01/2025, read in part Purpose: to provide an approach to pain management that provides the resident with optimal comfort, dignity and quality of life .7. The provider will be notified if comfort is not achieved following pain management interventions, for changes in pain characteristics, and/or with new onset pain or breakthrough pain.

Based on interview and record review, the facility failed to notify the physician of a change in condition related to blood glucose monitoring for one Resident (#5) of thirteen residents reviewed for a change in condition. Findings include: Resident #5 (R5): Review of R5's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including Parkinson's disease, and type two diabetes mellitus. Review of R5's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. Review of R5's EMR revealed the following physician's order: Insulin lispro insulin pen; 100 unit/mL (millimeter); amt (amount): Per Sliding Scale; If Blood Sugar is 200 to 250 [milligrams/deciliter, mg/dL] give 2 Units. If Blood Sugar is 251 to 300, give 4 Units. If Blood Sugar is 301 to 350, give 6 Units. If Blood Sugar is 351 to 399, give 8 Units. If Blood Sugar is greater than 400, call MD (medical doctor). Subcutaneous (under the skin) Four Times A Day 05:00, 11:00, 16:00 [4:00 PM], 20:00 [8:00 PM]. Review of R5's blood glucose levels in the prior 3 months revealed the following elevated blood glucose levels: 1. 2/25/25 at 19:52 [7:52 PM]: 425 mg/dL 2. 2/10/25 at 16:22 [4:22 PM}: 450 mg/dL 3. 12/8/24 at 15:13 and 15:17 [3:13 PM and 3:17 PM]: 472 mg/dL 4. 12/3/24 at 11:13 AM: 470 mg/dL 5. 11/25/24 at 11:11 AM: 493 mg/dL 6. 11/24/24 at 10:11 AM: 475 mg/dL Review of R5's EMR revealed the physician had not been notified of the blood glucose levels out of the acceptable parameters. On 2/27/25 at 9:08 AM, an interview was conducted with Registered Nurse (RN) B regarding the facility's blood glucose monitoring protocol. RN B indicated if a blood glucose reading is out of range, either greater than 400 mg/dL or less than 70 mg/dL, the facility physician should be notified. RN B stated a corresponding progress note should be entered into the resident's EMR indicating the blood glucose level, the physician's response, any symptoms experienced by the resident, and the results of the follow-up monitoring. RN B identified the potential dangers of hyperglycemia [high blood glucose levels] as an accumulation of ketones in the blood which may lead to a diabetic coma and even death. On 2/27/25 at 11:33 AM an interview was conducted with the Director of Nursing (DON) regarding blood glucose monitoring expectations. The DON confirmed a physician should be notified if blood glucose levels are less than 70 mg/dL or greater than 400 mg/dL. Review of the facility's Physician Standing Orders read, in part: .Notify physician of any glucose above 400 [mg/dL] . Review of the facility policy, Notification of Change, reviewed 1/2025, read, in part: .the resident's physician .must be notified when an event involving the resident occurs or when the resident experiences a change in condition . Call the physician and document using the SBAR [Situation-Background-Assessment-Recommendation] Communication Form and/or Progress note .document physician's orders and implement .document the resident's condition change and new orders on the 24 hr [hour] report log .monitor and reassess the residents status and response to interventions . Review of the facility policy, Diabetic Management Program, reviewed 1/2025, read, in part: This policy is designed to provide standardized guidance for diabetic management and ensure appropriate treatment is initiated for hyperglycemic and hypoglycemic episodes . call the physician immediately if blood sugar is > [greater than] 300 [mg/dL], or as determined by a physician's order .

Based on observation, interview, and record review, the facility failed to ensure interventions were implemented per physician's orders for one Resident (#16) of three residents reviewed for positioning and pressure ulcers. Findings include: Resident #16 (R16): Review of R16's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including peripheral vascular disease (a disorder that causes narrowing or blocking of the blood vessels) and cellulitis of the left lower limb. Review of R16's most recent Minimum Data Set (MDS) assessment, dated 12/20/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. On 2/25/25 at 1:03 PM, R16 was observed lying in bed. A pair of protective boots were observed placed on a recliner across the room. When R16 was asked if she wears the boots she replied, Sometimes. R16 indicated the staff did not always put them on. R16 denied refusing to wear the protective boots. On 2/26/25 at 11:44 AM, R16 was again observed resting in bed, with the pair of protective boots placed on a recliner across the room. Review of R16's EMR revealed the following physician order, initiated 9/30/24: Soft offloading boots to BLE [bilateral lower extremities] while in bed QS [every shift]. On 2/27/25 at 10:48 AM, an interview was conducted with Certified Nursing Assistant (CNA) A regarding R16's adaptive equipment needs. When asked if R16 wore the protective boots in her room, CNA A responded, Not very often. CNA A was asked if R16 was care planned to wear the protective boots to which she responded, I don't think so, but I can check. CNA A acknowledged they were unaware of the protective boots intervention for R16 because it wasn't listed in the care plan. On 2/27/25 at 11:05 AM an interview was conducted with Licensed Practical Nurse (LPN) C regarding R16's care plan. LPN C verified R16 had an existing physician's order to have soft boots applied at all times while in bed, however, it was not reflected in the care plan. LPN C indicated CNAs did not have access to residents' physician orders. Review of R16's EMR revealed the following progress note dated 9/30/24, which read in part: [R16's] bilateral heels are soft and slightly red/blanchable. Soft off-loading boots applied while in bed to help with pressure reduction . Review of R16's Braden Scale for Prediction of Pressure Sore Risk Assessment, dated 1/1/25, revealed a score of 14, indicative of a moderate risk. On 2/27/25 at 11:33 AM, an interview was conducted with the Director of Nursing (DON) regarding adaptive equipment expectations. The DON responded, At a bare minimum, splints should be entered into orders, but ideally they should be in the plan of care. The DON agreed CNAs would not know if a resident required adaptive equipment if it isn't in their plan of care. The DON stated, I'm going to add them right now [to the plan of care]. Review of the facility policy titled, Use of Assistive Devices, revised 1/2025, read, in part: .the use of assistive devices with be based on the resident's comprehensive assessment, in accordance with the resident's plan of care .a nurse with responsibility for the resident will monitor for the consistent use of the device .refusals of use .will be documented in the medical record .

Based on interview and record review, the facility failed to monitor and assess 2 Residents (#5 & #177) of 13 residents reviewed for quality of care. Findings include: Resident #5 (R5): Review of R5's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including Parkinson's disease, and type two diabetes mellitus. Review of R5's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. Review of R5's EMR revealed the following physician's order in part: Insulin lispro insulin pen; 100 unit/mL (millimeter); amt (amount): Per Sliding Scale; . If Blood Sugar is greater than 400, call MD (medical doctor). . Four Times A Day 05:00, 11:00, 16:00 [4:00 PM], 20:00 [8:00 PM]. Review of R5's EMR revealed the following progress note written by Licensed Practical Nurse (LPN) C on 2/14/25 at 4:51 PM: Resident with blood sugar of 518 [mg/dL]; asymptomatic. [Nurse Practitioner] .made aware. Verbal order received to give 15 units of insulin lispro x 1 now and recheck blood sugar in one hour; if not under 400 [mg/dL] call back . Review of R5's EMR did not revealed a follow-up blood glucose level. On 2/27/25 at 10:53 AM, an interview was conducted with LPN C regarding R5's blood glucose level of 2/14/25. LPN C confirmed general protocol is to notify a physician if a blood glucose level is above 400 mg/dL or below 70 mg/dL. LPN C stated the physician typically orders a re-check of blood glucose levels within an hour to determine if the level is trending up or now and determine if further interventions are needed. LPN C was unsure why a re-check in blood glucose levels was not documented on 2/14/25. On 2/27/25 at 11:33 AM, an interview was conducted with the Director of Nursing (DON) regarding expectations on blood glucose monitoring. The DON stated R5's blood glucose levels should have been re-checked and documented in the EMR per physician's orders. Review of the facility policy, Notification of Change, reviewed 1/2025, read, in part: The Residents physician and responsible party must be notified when an event involving the resident occurs or when a resident experiences a change in condition . document physician's orders and implement .monitor and reassess the residents status and response to interventions . 45123 Resident #177 (R177) Review of R177's face sheet, dated 2/25/25, revealed R177 was admitted to the facility on [DATE] with medical diagnoses including, osteomyelitis of the right ankle and foot, peripheral vascular disease, hypertension, and diabetes mellitus. R177 was recently admitted for rehabilitation and was post-operative from an orthopedic surgery which included amputation of his right five toes and partial foot. Review of the EMR initial admission assessment for R177, dated 2/24/25, revealed arrival to the facility at 6:20 PM. There was no baseline care plan that could be located in the EMR for the date range of 2/24/25 through 2/27/25. On 2/27/25 at 10:00 AM, during an interview regarding R177's care plans, Licensed Practical Nurse (LPN) C was asked who creates the care plans, and where they are kept. LPN C replied, The admitting nurse does a baseline care plan and then either the Director of Nursing or the Minimum Data Set nurse builds a comprehensive care plan. (R177's) baseline care plan is in this folder right here along with other admission papers. R177's admission papers had not been fully completed and were not accessible to Certified Nursing Assistance. Review of R177's baseline care plan, was not dated. Review of R177's physician orders, dated 2/24/25, revealed an order for insulin glargine pen and to give 35 units subcutaneous in the morning between 6:30 AM and 10:30 AM, and a second order for finger stick blood sugar monitoring before meals and at bedtime to be checked at 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. Review of R177's medication administration record (MAR) and vital sign monitoring, dated 2/24/25 through 2/27/25, revealed no recorded blood glucose monitoring on 2/24/25 at 8:00 PM, 2/25/25 at 6:00 AM, 11:00 AM, 4:00 PM, or 8:00 PM, and 2/26/25 at 6:00 AM. R177 had no recorded vital signs for new admission monitoring on 2/25/25. On 2/27/25 at 11:00 AM, an interview was conducted with the DON who was asked about the new admission process, glucose monitoring, and vital signs. The DON replied, I have been busy and have not scanned in or started the comprehensive care plan yet. New admissions should be getting a full set of vital signs twice a day. If a resident is on insulin or is diabetic, then blood glucose monitoring should be completed, especially if they are on a sliding scale. Review of the facility policy, Diabetic Management Program, reviewed 1/2025, read, in part, This policy is designed to provide standardized guidance for diabetic management and ensure appropriate treatment is initiated for hyperglycemic and hypoglycemia .

This citation relates to Intake #Mi00144666 and #MI00144651. Based on interview and record review, the facility failed to employ a qualified Certified Dietary Manager (CDM) to manage the food service department. Findings include: During the lunch meal on 6/3/24 at approximately 12:10 p.m., residents were asked about their meal. Five residents (R1, R2, R4, R6, and R7) reported concerns with minimal entree choices, limited or no alternates being offered, decreased palatability, and some missed meals due to the limited choices and poor quality of the food at some of the meals. During an interview on 6/4/24 beginning at 12:40 p.m. Registered Dietician (RD) L confirmed the was no current CDM (Certified Dietary Manager) or DM (Dietary Manager) working in the food services department. RD L clarified a CDM or DM working on becoming certified was expected to be working in the food services department consistently and regularly and understood the concern. RD L explained they only worked four to eight hours per month and were not acting as the CDM at the facility. RD L reported the Director of Nursing (DON) had assumed the role of Dietary Manger and had enrolled in a CDM class but had not yet started the classes. During the interview, this Surveyor reviewed R4's significant weight loss with RD L of 5% in the past month. RD L acknowledged they were not notified of R4's significant weight loss in one month of 5%, and the expectation is they would be made aware. RD L reported there had been no nutritional supplementation added per standards of practice, other than vitamins, and reported they would be following up. During an phone interview on 6/5/24 at 5:17 p.m., Staff M reported the Director of Nursing (DON) had been pulled from the DM role this past winter, around February, due to nursing staff needed to work on the midnight shift. Staff M reported they had intermittently observed or heard from the residents about food quality concerns, including inadequate food portions, palatability concerns, lack of consistent choices and alternates, and meal timeliness concerns. Staff M confirmed they were not aware of any foodborne illness. During an interview on 6/4/24 at approximately 1:30 a.m., the Nursing Home Administrator (NHA) confirmed there was no acting CDM or DM in the facility, as the DON was working on the midnight shift during the survey. The NHA reported they oversaw the kitchen staff and food services department in the interim. The NHA was asked about resident-reported concerns related to limited choice, decreased palatability, timeliness, and some missed meals and R4's weight loss. The NHA denied the concerns, and reported the DON was unavailable for interview at that time as they were sleeping the next couple hours at least due to working the midnight shift. The NHA reported they could answer questions about the kitchen and food, as they were supervising the department. The NHA confirmed they were not a CDM or DM, and they had not enrolled in the dietary management classes. The NHA reported they were ordering the food, addressing the menus, scheduling staff, and completing all the DM roles in the absence of a working DM. During an interview on 6/4/24 at approximately 5:15 p.m., the Regional Director of Operations, NHA, J, acknowledged there was no current acting CDM or DM in the facility recently, and understood the concern. NHA J reported they had not been made aware of resident-reported food concerns, or weight loss, and planned to follow-up.

This citation relates to Intake #MI00144651. Based on observation and interview, the facility failed to properly maintain resident equipment in safe, operating condition including two Residents (R2, R10) wheelchairs and residents' bed remote controls. This deficient practice resulted in two resident's wheelchairs being in disrepair, and the risk of injury to residents from lack of access to bed remote controls. Findings include: R2 Review of the Electronic Medical Record (EMR) revealed R2 had a recent score of 15/15 on the Brief Interview for Mental Status (BIMS) assessment, which showed R2 was cognitively intact. During an interview on 6/3/24 at 12:10 p.m., R2 was seated in a manual wheelchair at lunch, and reported staff were having problems operating their wheelchair. R2 stated, I have problems with the wheels on my wheelchair, it [the wheels] wants to go one way [to the side instead of straight]. During an observation on 6/3/24 at 12:15 p.m., R2's wheelchair was observed with worn wheels. There was no wheelchair cushion observed. R2 stated, I would like a wheelchair cushion. When I sit on it [the chair] it is very uncomfortable. R2 reported they did not have a bedsore. Surveyor did not test the wheelchair maneuverability at that time, as R2 was eating their lunch meal. R10 Review of the EMR revealed R10 had a recent score of 13/15 on the BIMS assessment, which showed R10 was cognitively intact. During an interview on 6/3/24 at approximately 3:10 p.m., R10 was asked about their care at the facility. R10 explained he was at the facility for therapy, and his wheelchair did not work, which concerned him as he was afraid of falling when the brakes did not lock. R10 added the brakes hurt his hands when he pushed them. During an observation on 6/3/24 at approximately 3:15 p.m., this Surveyor observed R10's high back reclining wheelchair had no plastic or rubber break covers, only thin metal brakes which were typically covered on wheelchairs. It was observed the wheelchair appeared worn, with foam covers worn and frayed where the headrest was prior attached and cracked left armrest upholstery. With the brakes activated, it was apparent the left brake did not lock or 'hold', as the wheelchair slid backward when the brakes were applied. R10 reported he had made staff aware, and they could all see it happening when they transferred him and the brakes did not fully engage. It was observed there was no seat cushion in the chair. R10 reported he would like his wheelchair repaired, and a cushion for comfort. During an observation on 6/3/24 beginning at 3:30 p.m., the Maintenance Director, Staff C was asked to observe R2's and R10's wheelchair with this Surveyor. Staff C confirmed both wheelchairs needed repair and observed the concerns regarding R2's wheelchair turning to the side when pushed forward, and R10's wheelchair brake not locking, the sharp metal edge where the headrest had been attached, covered by broken foam, no wheelchair brake covers, and no wheelchair cushions in both wheelchairs. The Nursing Home Administrator (NHA) arrived and observed the same concerns and planned to follow-up. Bed remote concerns During a phone interview on 6/4/24 at approximately 3:50 p.m., Staff G reported they learned several of the bed remotes were not working in the past few months, and Staff C was only able to order one replacement at a time per the NHA. During an interview on 6/4/24 at approximately 4:30 p.m., Staff C was asked if residents' bed remotes were removed from the residents' beds in the facility. Staff C confirmed they removed all the remotes from the residents' beds per the NHA, after the facility received a citation from the annual survey related to a hospital bed remote. Staff C stated, Our administrator made us pull all the remotes from the beds and I put them back on the same day, only a few hours later. Staff C confirmed the remotes were removed from all the residents' beds, not just those with cognitive impairment. Staff C was asked if this was a concern for any the residents, not being able to operate their bed remotes, especially for those who could do so independently. Staff C reported they did not hear resident complaints, but the staff reported concerns. Staff C stated they were removed to repair them, and there were no resident falls or other outcomes per their awareness. Staff C stated the NHA told them they could only order one bed remote a month for those which were in disrepair, so they did some finagling and switching of the bed remotes in lieu of replacement, which was needed for some of the remotes, and reported was not ideal. During an interview on 6/4/24 at approximately 5:30 p.m., the Regional Director of Operations, NHA J, was asked about the equipment concerns, and confirmed they were investigating administrative and employee concerns brought forward by facility staff. NHA J reported they had rounded the facility including equipment concerns on 6/4/24 and had found one bed remote not working, which they were addressing. NHA J reported their Director of Environment would be following up on any environmental concerns including equipment the next day. During a phone interview on 6/5/24 at 5:17 p.m., Staff M reported concerns regarding all the residents bed remotes being removed from the walls by directive of the NHA to maintenance staff. Staff M reported afterwards the cords were messed up and they were finicky on working since we got a citation. The Administrator pulled the bed remotes off the beds as part of her Plan of Correction and put three at the desk and made the aides share them. Staff M clarified the bed remotes were pulled off all the beds, for all the residents, not just the ones in the citations. Staff M noted they had trouble providing care for an ill, dependent resident because their bed was too low, and it took over 45 minutes to get a remote to feed the resident and provide care. Staff M reported the remotes were off the beds over 24 hours, and they were unaware of any accidents from this, or other outcomes. Staff M reported they and the aides had trouble getting to the remotes after they were replaced, causing awkward body mechanics, as they were zip tied under the beds when they were added back, and they were told they would be fired if they cut the zip ties.

This citation relates to Intake #Mi00144666 and #MI00144651. Based on observation, interview, and record review, the facility failed to provide four Residents (R1, R2, R4, and R7) of 12 residents reviewed for food preferences and alternate meal options, who were reviewed for food concerns. Findings include: Some identifiers have been changed to Staff, as some of the interviewees requested confidentiality. R2 Review of R2's Minimum Data Set (MDS) assessment, dated 5/01/24, revealed R2 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease and depression. The assessment revealed R2 required set up with eating and moderate assistance with transfers. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed R2 was cognitively intact. During an observation on 6/03/24 at 12:10 p.m., R2 was observed eating in the facility dining room, seated in a manual wheelchair. R2's was observed feeding herself mashed potatoes and wax beans from her plate. R2 was asked about her lunch meal. R2 stated, The mashed potatoes and gravy is ok. It's all I had. I didn't want the fish .The only food they had today was fish and ravioli, so I didn't get a sandwich ;. I asked for something else. I don't like that either [ravioli]. I'm done. I'm a little hungry. On 6/03/24 at 12:20 p.m., Surveyor confirmed with the facility kitchen staff fish and ravioli were the only entrees available for the lunch meal. R2 reported she was offered snacks in the evening when she did not like the entree, but this was not acceptable to her, as she wanted meal alternatives, which were not always available. R2 described further how she never received fresh fruit, and liked oranges, apples, and grapes. R2 added, I have lost some weight. One day, I got a sandwich in a bag, fried bologna, and I just left it [did not eat the meal] .It was a few weeks ago, when they had no cook here. I went hungry . R4 Review of R4's MDS admission assessment, dated 4/15/24, revealed R4 was admitted to the facility on [DATE], with diagnoses including kidney disease, diabetes, malnutrition, and depression. The assessment revealed R4 required set-up for eating and moderate assistance for transfers. The BIMS assessment revealed a score of 15/15, which showed R4 was cognitively intact. During an interview on 6/3/24 at 12:30 p.m. R4 reported, The food should be a better quality, and explained, The salisbury steak meal is not real meat; it is like a TV dinner. R4 reported she sometimes missed meals, as she was not given another option if she did not like the meal. R4 described she did not like the sausage or ham, and stated, I don't eat the ham as it is really thick and I can't eat it. R4 reported one egg and a piece of toast was not an adequate breakfast, stating, I would like two eggs. When asked if they received any alternative meal selections, R4 reported, I am never given another option. Sometimes I don't eat . R4 reported she was frustrated with the food quality and lack of alternate choices offered, and said she was hungry sometimes. During an interview with the Nursing Home Administrator (NHA) on 6/4/24 at approximately 4:10 p.m., it was confirmed there were days residents received one egg and toast, as the egg served as a protein, and only 1 ounce was required to be served for breakfast, or an omelet, which was larger and had about 2 oz of protein. During an observation on 6/4/24 at approximately 4:30 p.m., Surveyor asked to see the portion size for a one ounce serving of eggs, with the NHA and Staff B. The NHA showed Surveyor a two-ounce ice cream style scoop and said this was typically the amount provided to residents. Staff B showed Surveyor a smaller scoop, 1/2 the size of the first scoop, which was one ounce, which they reported they sometimes used to serve the egg portion for each resident. It appeared to be a small serving size for an egg entree. Staff B was asked if they believed this would be an adequate serving size for the average resident. Staff B stated, It would not be enough for me . During a phone interview on 6/4/24 at 3:50 p.m., Staff G reported R4 had requested healthier food choices for the meals, and reported R4 did not like the meals at the facility, and there was nothing extra available. During an interview on 6/4/24 at approximately 2:30 p.m., Registered Dietician (RD) L was asked about kitchen staff providing 1 oz of eggs (small scoop) at some meals, and if this was considered an adequate portion of eggs. RD L reported the small scoop was equivalent to 1 oz, and there was no requirement for the facility to provide 2 oz or 2 eggs to facility residents. R1 A confidential complaint was received by the State Agency on 5/22/24, which noted R1 was not receiving an appropriate diet for her low salt needs, given her cardiac diagnosis. The complainant also reported R1 received a fried bologna sandwich and cream of mushroom soup for dinner during the past week, with no alternate offered, and was told, Everyone gets the same thing. The complainant noted there was no fresh fruit served, and kool-aide was served at meals as the beverage. The complaint alleged R1 did not receive dinner on 5/13/24, Mother's Day, and the food and drinks were not palatable. Review of R1's MDS assessment, dated 4/5/24, revealed R1 was admitted to the facility on [DATE], with diagnoses including heart failure, diabetes, malnutrition, and depression. The assessment revealed R1 required set-up with eating and was dependent for transfers. The BIMS assessment revealed R1 scored 15/15, which showed R1 was cognitively intact. During an interview on 6/3/24 at approximately 5:10 p.m., R1 was asked about their meals. It was observed R1 was wearing oxygen, a gown, and was in a bariatric bed. R1 stated, There is a lot of salt. I just don't like salt. I have two leaky heart valves. I did have swelling and it has gone down. Some of the food is horrible. Their chicken and dumpling soup .I wouldn't know what it is by looking at it . R1's dinner meal arrived during the interview. The meal was a ham sandwich, with a fruity appearing red watered-down drink, which R1 reported tasted good as it was cherry flavored. A banana was served with the meal. R1 stated she would have wanted soup with the meal, and stated, I don't remember if it was offered, and stated she does not like cream of mushroom soup but would take an alternate soup. R1 looked at her tray, and stated, Where is my dessert? Surveyor saw an unnamed staff member in the hall and asked about dessert. The aide reported the banana was the dessert. It was noted R1's tray card stated, NAS [no added salt] and a regular diet. During a phone interview on 6/3/23 at 6:27 p.m., the confidential complainant reported, They [facility staff] are not taking [R1's] preferences into account, and clarified R1 did not like the sandwiches, especially the bologna sandwiches, nor the cream of mushroom soup, which was frequently the only choice, canned gravy. The complainant clarified R1 had a heart condition and lymphedema, and should be receiving a heart-healthy meal. The complainant stated there were sometimes alternative choices offered, but not always. Per the complainant, R1 stated, It's crap for food. The complainant reported, On Mother's Day (5/13/24), [R1] did not even get dinner, I went there at 4:30 p.m., they had juice boxes, a sandwich [on the hall] and explained, [R1] said, 'I am getting hungry and frustrated,' and she did not get a sack lunch like the other residents. R1 reportedly receiving nothing to eat for dinner and thought the afternoon snack was her dinner. Her nurse reportedly asked what happened at 6:30 p.m., and said, 'I'm going to have to scrounge her up some food from the staff potluck today. It was confirmed R1 received a sack lunch, but later in the evening, well after the other residents. During a phone interview on 6/4/24 at approximately 3:00 p.m., Certified Dietary Manager (CDM) L acknowledged the residents received a bagged lunch passed by the Certified Nurse Aides (CNAs) on Mother's Day due to staff call-ins. CDM L confirmed R1's meal was not initially received, but clarified R1 received a bagged fried bologna sandwich meal later that evening, and reported she had a snack earlier that day. CDM L confirmed R1 was on a NAS (no added salt) diet, and this meant no extra salt packs, or extra food portions for salted food. CDM L conveyed they had no concern with R1 eating bologna sandwiches, cream of mushroom soup, bacon, or other salted food, and indicated the menu was adequate for R1 and a resident on an NAS diet. CDM L reported this alternate meal of fried bologna sandwich and cream of mushroom soup was considered adequate to meet the nutritional expectations for all facility residents. During a phone interview on 6/4/24 at 4:00 p.m., Staff G reported R1 told them they did not like the food, and reported they observed it was sometimes burnt, and there was not much food for the residents, who only had one choice for the meal most of the time. Staff G stated R1's family sometimes brought them food due to R1's food complaints. Staff G explained the dietary staff were allowed to leave the facility immediately after the dinner meal was served, so when residents had a food request for an alternate or for additional food, there was no kitchen staff available. Staff G clarified they had brought this to the Nursing Home Administrator's (NHA's) attention, and to the dietary staff, and were told this was acceptable. Staff G confirmed this resulted in an occasional missed meal for a resident when they did not like the meal being served, or no second helping was available when requested. When asked if any residents had missed a meal, Staff G reported R13 had missed extra food, as they had a big appetite and sometimes requested second helpings after staff had left the building. R7 During an interview on 6/3/24 at 12:44 p.m., R7 was asked about the food at the facility. R7 stated, Sometimes it is good, and sometimes it is not. Some of them [the kitchen staff] can't cook so much. R7 reported she skipped the meals sometimes, as there were sandwiches for dinner, as she did not like most of them. R7 reported she would like a regular dinner, with a meat, potato and vegetable, and bean soup. Review of R7's recent BIMS assessment revealed a score of 15/15, which revealed R7 was cognitively intact. An observation of the kitchen on 6/3/24 with the NHA following the lunch meal revealed an ample supply and variety of snacks, and an Always Available alternate menu, when requested. This included always available items like soup, peanut butter sandwiches, and items available upon request, including chicken patties, hot dogs, and hamburgers. The NHA reported they had distributed this to the facility residents, and these items were 'always available'. The NHA showed this Surveyor a one-page, undated paper which showed if residents wanted the meal or an alternate, and reported it was from today, and the CNA's had queried residents about the meal choices each day. Surveyor asked for the past two weeks of logs, and the NHA reported they were not saved and discarded daily. The NHA clarified they were the contact person for any food concerns, as they were acting supervisor of the dietary department, as the Director of Nursing (DON) would soon be assuming the role, however they were needed as a floor nurse to work the midnight shift this week. Review of the four-week menus, provided by the NHA on 6/3/24, revealed a four-week menu cycle, which was reportedly repeated each month. The menus provided were labeled on the top of each page (four total), Flexible Menu Fall/Winter 2019 -2020. It was noted there was an entree for each meal, however there was no alternate listed, or second meal choice. During an interview on 6/3/24 at approximately 4:10 p.m., the NHA was asked for clarification, and reported the alternate was usually leftovers from the day before, and they kept leftovers and served them again for up to three days, and they were not on the menu as they were typically served until they ran out. The NHA confirmed the menus rotated each month to the same menus every four-week cycle. It was noted the menu showed the larger meal was served at lunch, a heavier meal with a meat, potato or rice and a vegetable with a roll, and a lighter meal was served at dinner, frequently soup and sandwiches, and a few other types, such as a burger, a hot dog, ravioli, pizza, or chili. The menu items were basic, such as lasagna, fish, meat loaf, goulash, sloppy joes, spaghetti, salisbury steak, chicken, pork, or meatballs. The NHA reported regionally these types of foods were resident-preferences, and the menus were reviewed with residents. During a phone interview on 6/3/24 at 7:00 p.m., Staff D reported the menu was always the same each month, and rotated again the next month, and residents wanted more variety. Staff D reported the food had tons of salt, and residents were served a fruity drink mix sometimes, when they were supposed to be getting juice. Staff D explained, They [kitchen staff] cook for 27 residents and only have food for 27 residents. The NHA only buys enough food to cook for the number of residents. Anything else we cook extra we are told we are using too much . Staff D reported the alternates such as hot dogs could not be used per the NHA as they were needed for meals, and reported they could only use supplies for whatever was on the menu, so they could only give residents peanut butter and jelly sandwiches as the alternate. Staff D stated, We have the same food [for meals] we are giving as an alternate on the menu, like chicken noodle soup and a vegetable for dinner. Sometimes residents only get soup for dinner . During an observation on 6/3/24 at approximately 5:30 p.m. this Surveyor taste tested a dinner tray provided by the NHA and kitchen staff. The NHA and kitchen staff reported there were two extra sandwiches and an extra beverage, with a choice of grape or cherry. Surveyor tested the bologna sandwich, with two slices of meat, which had cheese, lettuce and tomatoes, and the ham salad sandwiches, and the grape beverage. Surveyor noted the sandwich was adequate in presentation, and the sandwiches were palatable although both tasted salty, especially the ham salad sandwiches, and the juice tasted like Kool-aide and was not grape juice. There was also a cherry beverage available. Review of the order supply sheets, requested for four weeks, showed orders for orange, apple, and cranberry juice, and for powered drink mixes, such as orange drink mix. The menus show a choice of juice and milk in the morning, and coffee or tea at dinner. During a phone interview on 6/5/24 at 5:17 p.m., Staff M reported concerns related to residents not receiving adequate meals, portions, and alternates. Staff M reported there had been no always available menu for entrees, and when they had recently requested a hot dog for a resident, they were told by kitchen staff the package could not be opened for one serving. Staff M added in the past few weeks goulash was served three days in a row. Staff M clarified they only saw the Always Available alternate menu the week of the survey. Staff M stated there was no Dietary Manger in the kitchen for the past couple months. Staff M expressed frustration for the residents, as they were reportedly not receiving adequate food portions and palliative, nutritive food. Staff M continued, sometimes the food was served too early, due to kitchen staffing reasons, and there was too long a gap between dinner and breakfast when this occurred. Staff M conveyed they had reported their concerns to the NHA, especially during the past couple of months, and the situation had not resolved. Review of the policy, Know Your Rights, by the (State) Department of Community Health, revealed, As a resident of a Medicaid Nursing Home, you have the same rights about your life, medical care, and personal treatment as others who live in the community. These rights are protected by rules made by both the State and Federal government .Quality of Your Medical Care. You have the right to receive necessary nursing, medical, and social services to reach and maintain the highest practicable physical, mental, and social well-being .Food: Most types of food are supplied by the nursing home. Nursing Homes must provide substitutes to food you don't like .Some food and items the home must provide: Daily nutritious meals and snacks, reasonable food substitutes of a similar nutritive value, dietary supplements .

This citation relates to Intake #MI00144651. Based on observation, interview, and record review, the facility failed to act on a concern for one Resident (R8) of one resident reviewed for grievances. This deficient practice resulted in feelings of frustration for R8, and lack of timely follow-up for damaged clothing. Findings include: Review of R8's recent BIMS assessment revealed a score of 15/15, which showed R15 was cognitively intact. R8 was interviewable and fully oriented. During an interview on 6/3/24 at 2:46 p.m., R8 revealed he was the resident council president, and had a concern about his pajama pants and other items returning from the facility laundry with bleach stains. R8 explained they reported their concern to laundry staff about two weeks prior and had not received any explanation of his pants being ruined, or follow-up, and expressed feeling frustrated. During an observation on 6/3/24 at 2:50 p.m., R8's red and black checkered pajama pants were observed in his closet with his permission. The pants had three holes in them, and there were bleach stains on the lower pant legs, at least 6 up on one side covering the pant leg. The threading was worn thin and the bottom of the pant legs were frayed. R8 reported he could not wear the pants anymore. It appeared the pants were damaged beyond wearing and needed to be replaced. R8 confirmed his pants had been sent to laundry undamaged. During an interview on 6/3/24 at 3:25 p.m., Laundry Staff B was asked about R8's damaged pants. Staff B reported R8 had made her aware of the concern over a week before, and acknowledged they were recently damaged by bleach in the laundry. Staff B explained the normal process was to report the concern to the Business Office Manager, Staff F, who would follow-up. Staff B clarified they had not reported the damaged pants to Staff F, as they did not have time over a week prior when R8 told them, and they had been off work a week since then. Staff B reported they should have filed a grievance form and confirmed they did not file one. During an interview on 6/03/24 at approximately 4:10 p.m., the Nursing Home Administrator (NHA) was asked about R8's damaged pajama pants, and the lack of follow-up. The NHA understood the concern, and reported they would replace R8's pants. The NHA confirmed the expectation was Staff B would have completed a grievance form and reported the damaged pants. Review of the (State) nursing home publication, Know your Rights . by the (State) Department of Community Health, undated, revealed, Basic rights .You have the same rights about your life, medical care and personal treatment as others who live in the community. These rights are protected by rules made by the State and local government. You are entitled to a clean, home-like living space. You may keep and use personal clothing .The following must be provided by the nursing home .Laundry Services .

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 25 residents. Findings include: 1. On 2/20/24 at 11:16 AM, at 11:42 AM and at 12:11 PM, Dietary Aide, staff B, was observed not using a hand barrier to shut off the faucet when done washing their hands. On 2/20/24 at 11:44 AM, the surveyor requested the facility's hand hygiene policy from Dietary Manager, staff I, to review. At this time the surveyor asked staff I if they had conducted any training with staff on the proper procedure to wash their hands to which they stated, Yes, and we have a sign posted above our sink. On 2/20/24 at 11:23 AM, and at 11:57 AM, Cook, staff A, was observed not using a hand barrier to shut off the faucet when done washing their hands. On 2/20/24 at 11:58 AM, the surveyor inquired with staff A if they were aware of the hand washing procedure requirements posted above the sink to which they replied, I forgot to use the paper towel didn't I? I'm used to working in kitchens with foot pedal sinks instead of the handles being on the faucet. On 2/20/24 at 2:25 PM, record review of an undated policy titled, When and how to wash your hands revealed, that the facility has a hand washing procedure in place identifying when it is required to wash hands and how it should be conducted. Review of the U.S. Public Health Service 2017 Food Code, Chapter 2-301.12 Cleaning Procedure, directs that: (C) TO avoid recontaminating their hands or surrogate prosthetic Devices, FOOD EMPLOYEES may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a HANDWASHING SINK or the handle of a restroom door.

Based on observation, interview, and record review, the facility failed to ensure a secured/locked medication cart, expired medications were removed from the active medication supply room and maintain clean and sanitary medication cart for one of two medication carts and one of one medication rooms reviewed for medication storage. This deficient practice had the potential for complications related to delivery of expired medications and or medications to be lost, stolen, accidental consumed by cognitively impaired residents. Findings include: On 2/20/24 at 10:44 AM, during a tour of the facility an observation was made of the [NAME] medication cart unlocked and unattended by nursing staff. The Director of Nursing (DON) was observed sitting in her office located down an adjacent hall from the medication cart which was out of her field of vision. The DON was asked who the nurse on duty was and replied, Here she (RN D) is right now, walking down the hall. On 2/20/24 at 10:46 AM, an interview was conducted with Registered Nurse (RN) D, and when asked, indicated she had just come from the kitchen which was on the opposite side of the building from the medication cart location. RN D was asked if the medication cart [NAME] should be unlocked and unattended with four residents and two non-nursing staff in the immediate area of the cart and replied, No. I must have forgot to lock it. On 2/20/23 at 12:05 PM, an inspection was conducted of the facility medication storage room with RN D. In the medication storage room refrigerator, an observation was made of a [name brand] purified protein derivative (PPD) solution [used to perform tuberculin (TB) testing on residents and staff] of 10 milliliters (ml), with a lot number of 66808, and opened date of 12/26/23. The PPD solution multi-dose vial had approximately one dose left. RN D was asked how long the solution was good to use after it was opened and replied, I am not sure. I would have to check with pharmacy. *Note the facility had three new admissions after the expired date. On 2/20/24 at 12:23 PM, an inspection was made of the medication cart West. The medication cart was found to have two loose pills in the second drawer. One capsule, colored blue and green, and identified as duloxetine 60 milligram (mg), and a second pill, half tab, colored white, oval shaped, and identified as losartan 50 mg. The medication cart [NAME] also contained in the second drawer multiple small pieces or paper in the bottom of the cart and tiny white round beads. RN D was asked if medication should be loose in the cart and if the cart should be clean and replied, No loose pills should be left in the cart. The medication cart needs to be cleaned. On 2/21/24 at 7:53 AM, the DON was interviewed regarding the medication cart being unlocked and unattended by nursing staff and the loose pills in the medication cart. The DON confirmed that medication carts are to be lock at all times unless nursing staff were at the cart. The DON also confirmed that any dropped and loose pills should be discarded at the time they are identified and placed in the drug buster. The DON was then asked about the multi-dose vial of PPD solution in the medication room and replied, I already threw that out. It is only good for 30 days. Review of facility policy titled Med Pass, dated 4/20, read in part, .IV. Maintenance of Medication Storage Areas, A. Cart, 1. Clean inside and out, including crushing devices. 2. Cart security is maintained during entire med pass .B. Med room .3. Multiple dose vials must be dated when first opened .it is the nursing staff's responsibility to make sure there are no excessive quantities or expired medications .D. Expiration Dates For Certain Drugs, Biologicals, and Records .Miscellaneous .tuberculin PPD vial, 30 days after opening .

MI 459 Based on observation, interview, and record review, the facility failed to provide an environment free from physical, psychosocial and sexual abuse involving eight Residents (#4, #12, #22, #24, #31, #33, #85, & #86) of nine residents reviewed for abuse. This deficient practice resulted in a determination of immediate jeopardy with the likelihood of sustained physical, psychosocial and sexual abuse to affect the entire facility population. The immediate jeopardy (IJ) began on 10/3/21 when Resident #22 had made an allegation to the Director of Nursing (DON) involving Resident #31 attempting to crawl into bed with her. The DON subsequently did not investigate and dismissed the allegation made by Resident #22 based on her own observations alone. It was determined through interviews that Resident #31 if fact did attempt to crawl into bed with Resident #22 and had to be redirected from the room by staff. Resident #22 subsequently had another incident with Resident #31 on 10/30/21 where Resident #31 returned to the room of Resident #22, fondled her chest area and was kissing on her body. The concern of Resident #31's wandering and behaviors was reported to the facility Nursing Home Administrator (NHA) on 11/1/21 by Resident #22's daughter. Other male and female residents affected by the unmanaged behaviors of Resident #31 included Resident #4, Resident #12, Resident #24, and Resident #33, Resident #85, and Resident #86. The Administrator was notified of the IJ situation on 11/9/21 at 3:30 p.m. and and abatement plan was requested. The immediate jeopardy was removed on 11/9/21 at 4:57 p.m. when the abatement plan was approved. The deficient practice continued at a level of potential for more than minimal harm until an onsite review confirmation of the full plan of correction to prevent Resident #31's behaviors from impacting others residents psychosocially and/or physically. Findings include: Resident #22 A review of the admission Minimum Data Set (MDS) assessment for Resident #22 dated 10/3/21, revealed a Brief Interview for Mental Status (BIMS) assessment of 6, indicating severe cognitive impairment. A review of the face sheet for Resident #22 revealed admission to the facility on [DATE] with diagnoses including [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Preadmission Screening (PAS)/Annual Resident Review (ARR) document for Resident #22 dated 9/10/21 revealed no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #22 presented no evidence of mental illness or dementia, no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the progress notes section of the Electronic Medical Record (EMR) for Resident #22 revealed the following note as it pertained to the first incident with Resident #31: 10/03/2021 (4:04 p.m.) resident (#22) had barrier strip up on door, and another resident (#31) got in her room and startled her, resident (#22) called daughter, daughter spoke with this nurse all upset about resident wandering wanted a one on one with other resident (#31) that wanders, informed Daughter we are doing our best to keep (Resident #31) out of the room, daughter states she will speak with (Director of Nursing [DON]) tomorrow, informed resident (#22) we will shut doors into her hall to prevent this wandering resident (#31) into her room, she stated thanks, Authored by Registered Nurse (RN) L. The only other progress note in the EMR relating to the second incident was dated 11/4/21 at 2:45 p.m. which read: Resident #22) moved to room [ROOM NUMBER] for more privacy. Family is aware. Authored by Social Services Director (SSD) H. There were no other progress notes observed in the EMR discussing the second incident in any detail. On 11/9/21 at 12:29 p.m., during an interview, Family Member (FM) M stated she had received a call after the first incident occurred and stated she had a conversation with the DON. FM M stated she told the DON she was upset about her mother reporting the first incident to her and stated they needed to do more to supervise Resident #31. FM M stated she was on the phone with Resident #22 during the second incident around 11/1/21 and I could hear Resident #22 crying during the incident. FM M stated she recalled she had to call the facility three times and on the third time she got a hold of (Certified Nurse Aide [CNA] N) who stated she went down to check on (Resident #22) .but they did not because I was on the phone wither her the whole time. Then I told her no they didn't, then (CNA N) backtracked and stated they were with another resident. Then my mother called back after I called the facility and she was still crying . and then stated she could hear .staff in the background say tell your daughter everything is ok and that she could stop crying. FM M stated this occurred in the evening around 8 or 9 p.m. The staff told me that my mother resembles his wife . and FM M stated she told the facility they needed to do more to supervise him. FM M identified Resident #31 by name. FM M stated the first incident was around when Resident #22 first admitted (9/28/21) to the facility and stated Resident #31 wandered into Resident #22's room and Resident #31 tried to crawled into bed with her. FM M stated the facility told her (Resident #31) did not try to crawl into bed with Resident #22. On 11/09/21 at 1:13 p.m., during an interview, Resident # 22 stated Resident #31 had come into her bedroom and touched her inappropriately. Resident #22 stated Resident #31 had also gotten into bed with her, and kissed her. Resident #22 motioned to her upper arms and breast area when demonstrating where Resident #31 had touched her inappropriately. When asked what the facility had done to stop the issue from happening again, Resident #22 stated The only thing I have gotten back is we'll try to keep a closer eye on (Resident #31). Resident #22 stated she told her nurse she needed to call my daughter and called her crying and Resident #22 told FM M she was very upset because (Resident #31) was trying to jump into bed with her. When asked who she reported this incident to, Resident #22 stated she reported the incident to the DON. When asked what the facility response was, Resident #22 stated the DON had told her she would take care of it. Resident #22 stated, It's like I go to bed at night and sleep with one eye open. I just don't feel safe around (Resident #22) . I have anxiety, and I have more anxiety now because of this. It upset me really bad to have a man jump into my bed to touch me and feel me . They would put this sticky thing up across the door, and (Resident #31) would still come through. On 11/12/21 at 11:17 a.m., The NHA was asked for any investigations surrounding the allegations made by Resident # 22 against Resident #31. The Administrator stated she put them on grievance forms based on what was known to the facility and provided two grievance forms. When asked if either incident had been reported to the State Agency (SA), the NHA stated based on what was known to the facility, they did not report either incident to the SA. The NHA stated Resident #22 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The NHA was asked for documentation of this from the discharging hospital to the facility and stated she would request it. A review of the grievance form provided by the NHA for Resident #22 dated 10/3/21 read in part: Heard Resident (#22) yelling. Entered (Resident #22's Room when she stated that (Resident #31) crawled into her bed with her. (Resident #22) then rephrased and stated that (Resident #31) attempted to crawl. into (Resident #22's) bed .Located (Resident #22's) location to ensure he wasn't near (Resident #22's room) .When I heard (Resident #22) yelling, I entered her room to see what happened. (Resident #22's) bed was in an elevated position. (Resident #31) wasn't in her room. I didn't pass (Resident #31) in the hall on the way to (Resident #22's) room and when I looked outside of the room, (Resident #31) was in the hall at the opposite end of the building. Based on the evidence, I didn't see how it would be possible for the concern to have occurred as (Resident #22) yelled when I was in the hall near her room and (Resident #22) had stated that is when it occurred . At the bottom of the form was a hand written note in the margin from the NHA which read, admitted ,d+[DATE] (2021) few days later said event. and was signed by the NHA. A review of the grievance form provided by the NHA for Resident #22 dated 11/1/21 read in part: (Resident #22) concerned with Resident #31 wandering into her room .the moved he (illegible) bed spoke to her and (Resident #22) yelled for staff to assist. (FM M) in for discussion in the afternoon. (Resident #22) thought a room change would help. (Resident #22) stated further away better. On 11/12/21 at 11:51 a.m., during an interview, CNA I stated Resident # 22 admitted to the facility in late September and recalled an incident with Resident #31 being reported to her shortly after Resident #22's admission to the facility. CNA I stated Resident # 22 had told her Resident #31 was in her room and Resident #22 was afraid of Resident #31. CNA I stated Resident #22 reported to CNA I, Resident #22 was afraid to get hurt. On 11/12/21 at 11:56 a.m., during a follow-up interview, Resident # 22 was as able to accurately state when she admitted to the facility and what hospital she came from. Resident #22 was also able to state the appropriate current month and year. When asked about who responded to the incident where Resident #31 actually touched Resident #22, Resident #22 stated she thought it was CNA N. Resident #22 stated the first time Resident #31 entered the room he tried to get in the bed but could not because the bed was much higher than it was during the interview time. Resident #22's recounting of the events mirror the grievance forms provided by the facility. Resident #22 stated the first incident was when Resident #31 tried to get into the bed but it was too high. Resident #22 stated the DON had entered the room but Resident #31 had already been removed by another staff member. On 11/12/21 at 12:37 p.m., during an interview, the DON stated Resident #22 was in room [ROOM NUMBER] at the time of the first incident on 10/3/21 (per the date on the grievance form for incident #1). The DON stated she was passing medications in the hallway at the time. The DON stated it was late afternoon between 4 p.m. and 6 p.m. on 10/3/21. The DON stated she heard Resident #22 yelling really loudly. The DON stated she ran down to Resident #22's room and Resident #22 proceeded to tell the DON Resident #31 tried to crawl into bed with Resident #22. The DON stated she was in the hall passing medications on that side of the building when Resident #22 started yelling. The DON stated there was no one in the hall as she traveled towards the yelling from Resident #22. The DON stated Resident #22 first told her Resident #31 crawled into bed with Resident #22. The DON then asked Resident #22, He crawled into bed with you? The DON then stated Resident #22 rephrased her statement and said, 'No, (Resident#31) tried to crawl into bed with me.' The DON stated she looked back out the door to ascertain where Resident #31 was and noted he was walking at the other end of the hall and facing away from the DON. When asked approximately how much time had passed from receiving the allegation by Resident #22 before she went looking for Resident #31, the DON stated approximately 30 seconds. This would have afforded Resident #31 who was independently ambulatory enough time to have walked to the end of the other hall as described by the DON, which was approximately a total of 150 feet in distance from one end of the hall to the other end. The DON stated Resident #22 was a fairly new resident and had a stroke. When asked what was done in response to this allegation, the DON stated she asked the staff that day to keep a closer eye on Resident #31. When asked, if there were any staff interviews to determine what happened, the DON stated she felt it was unnecessary. When asked why she felt it was unnecessary, the DON stated based on her own observations, she had ruled out that the incident happened. However, CNA Q, during an interview below, indicated having to remove Resident #31 from Resident #22's room after visualizing Resident #31 attempting to crawl into bed with Resident #22. The DON stated she felt Resident #31 could have easily confused Resident #22's room for his own as it was on the same side in the same location on opposite ends of the hall at the time. The DON stated she believed the incident happened on 10/2/21 because she was working on the floor as a nurse that day. When asked why the grievance sheet stated the date of 10/3/21, the DON stated she made an error in the date. The DON stated (Resident #31) did have a habit of touching things and touching people but not sexually per say. According to the staffing sheet provided by the facility, there were two CNA's on for Day shift when this incident occurred. The DON stated she was the only nurse on and had two CNA's on for 10/2/21 with a census of 39 residents at the time. On 11/12/21 at 1:02 p.m., during an interview, CNA F stated Resident #31 did go into various resident rooms. CNA F stated she recalled being told to keep a closer eye on him in the past, but stated Resident #31's behavior was an everyday thing because Resident #31 was always going in and out of rooms. When asked if it was hard to keep up with him, CNA F stated Sometimes, Yes. When asked about staffing, CNA F, stated it was very difficult to keep up. CNA F stated she had to prioritize showers, bed checks, charting, and keeping track of Resident #31. On 11/15/21 at 10:31 a.m., during an interview, SSD H stated she was aware of the second incident between Resident #22 and Resident #31 from the grievance form dated 11/1/21. SSD H stated, when issues like what happened with Resident #22 and Resident #31 come up, it gets pulled away from her and taken over by the NHA and the DON. SSD H stated Resident #31 did not belong here from the day he arrived. When asked why, SSD H stated the facility did not have the staff to manage him. When asked about the 10/3/21 incident, SSD H stated she had not heard about the incident. SSD H stated the Minimum Data Set (MDS) assessment nurse told her about the incident. SSD H stated she approached the DON about the second incident when she found out about it and was told it was already taken care of. SSD H stated there were frequent altercations involving Resident #31 with various residents and Resident #31 was getting mean. When asked about most recent room move for Resident #22 on 11/4/21, SSD stated this was because Resident #31 was in Resident #22's room again. SSD H stated she was instructed by the DON to stay out of the incident. SSD H stated approximately two and a half weeks ago Resident #86 reported to SSD H, Resident #31 had grabbed his wrist so hard he thought it was going to break. SSD H stated Resident #86 wanted her to find him a different place to live. SSD H stated Resident #86 told her next time Resident #31 came into his room he was gonna lay him out flat. SSD H stated she attempted to calm Resident #86 and stated she would take care of the issue and to please not retaliate. SSD H stated she told the DON about the incident and stated the DON told SSD H it was already handled and to not worry about it. SSD H stated she also texted the NHA about the issue and never heard back about it. The SSD stated she was directed to go in and ask in general how the residents were doing but was directed not to ask about the incidents and to only document positive interactions. On 11/15/21 at 3:30 p.m., during a follow-up interview, Resident #22 was informed the facility alleged Resident #22 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #22 stated, Why would I go around telling them another resident touched me if it didn't happen. I am just trying to protect myself, and I feel like I am the one on trial here . On 11/16/21 08:35 a.m., during an interview CNA Q confirmed having to take Resident #31 out of Resident #22's room on 10/3/21 when Resident #31 was attempting to crawl into bed with Resident #22. CNA Q confirmed having to remove Resident #31 from Resident #22's room when the first incident occurred and stated the DON was notified about it. On 11/16/21 at 12:17 p.m. during a follow-up interview, the DON was asked how she came about the grievance form having the wrong date. The DON stated after review of their staffing, she believed it was 10/2/21 where Resident #22 alleged Resident #31 entered her room and tried to climb into her bed. The DON stated she recalled she was working the floor for the alleged incident, and she was on the floor for 10/2/21 but not 10/3/21. The DON stated, this was why she believed it was 10/2/21 and not 10/3/21. The DON stated she was on the hallway passing meds with the med cart. The DON believed the grievance form was dated for 10/3/21 in error and stated stated she had completed the form a couple of days after the incident. However, the grievance form was not filled out until the identification of the IJ, per interview with the NHA below. When asked why it was determined to be Not Confirmed when Resident #22 alleged Resident #31 tried to crawl into bed with her, the DON stated because she was in the middle of the incident and from her perspective, felt the incident could not have taken place. The DON stated this was also the reason no other interviews were necessary. On 11/17/21 at 9:24 a.m., during a follow-up interview, Resident #22 was asked how she felt about her experiences with Resident #31 now that the facility had addressed the issue. Resident #22 stated she feels much better. When asked if there was a problem with any other residents in the facility, Resident #22 stated there were no incidents with any other residents. Resident #22 stated she felt safe now. On 11/17/21 at 9:38 a.m., during an interview, the NHA stated the grievance form for 10/3/21 involving Resident #22's statement of Resident #31 attempting to crawl into bed with her was filled out last week by the DON on Tuesday 11/9/21 when the Survey Team brought forth the concern. The NHA stated the DON recalled the issue happened a few days after Resident #22's admission. The NHA stated the DON reported Resident #22 had approached the DON in the hallway at first while passing meds to say Resident #31 crawled into bed or tried to crawl into bed with Resident #22. The NHA then changed her statement after this Surveyor reviewed the content of the grievance form dated 10/3/21 with the NHA. The NHA then stated the DON responded to screaming and went down to find out what was going on with Resident #22. The NHA stated she was informed by the DON of Resident #22's allegation. The NHA stated the story from Resident #22 reported to the DON went from Resident #31 crawling into bed with Resident #22, to Resident #31 tried to crawl into bed with Resident #22. When asked what was expected of the facility staff to do for potential sexual abuse in a situation such as this, the NHA stated, Assuming it was witnessed by a staff member it should be reported immediately. The NHA stated she filled out the grievance/complaint form for Resident #22 on 11/1/21 but could not determine the date when it occurred. There were no interviews conducted on the grievance report form provided by the NHA for 11/1/21 until 11/11/21 and 11/12/21 after the IJ was identified. During the course of this interview the NHA confirmed she was present during police interviews conducted with with Resident #4, #12, & #22 on 11/9/21. The NHA stated her husband was also an area police officer. When asked about documentation from the discharging hospital about Resident #22's alleged accusatory behavior, the NHA stated she had requested the information and was waiting for a response from the hospital. Interviews between the NHA and the DON on when the Grievance/Complaint Form for 10/3/21 was filled out conflicted. The second incident was determined to have happened on October 31st, 2021 based off the interview details with RN R below. On 11/18/21 at 7:50 a.m., during an interview, RN Rstated he did recall having a reported incident where the staff reported to him Resident #31 was yelling about [NAME] being in her room. RN R stated the incident happened approximately 2-3 weeks ago, but could not be certain exactly when it occurred. RN R stated FM M came up to talk to the facility staff the following day because she was upset about it. RN R stated the staff had Resident #22 call her daughter back the night it happened and had Resident #22 tell FM M she was ok. RN R stated FM M was going to come up that night, but then after Resident #22 told FM M she was ok, FM M waited and came up the following day to talk to the NHA. A review of the police report, incident No: 21- 6, dated 11/9/21 with a dispatch time of 4:30 p.m. for Resident #22 read in part: (Resident #22) stated she was also a victim of un-wanting touching by (Resident #31) .(Resident #22) stated this was not the first time it has taken place. I asked (Resident#22) if the first incident had been reported to the staff in the nursing home. (Resident #22 stated yes it had been. I asked (Resident #22) to talk to me about the new incident that had been reported as of yet. After several minuets (sic) of interviewing (Resident #22) it was discovered that there was only one incident not two. Also the one incident that was reported was admitted by (Resident #22) to be made up and never taken place. The one incident regarding (Resident #22) and (Resident #31) was witnessed by (FM M) over the telephone. (Resident #22) admitted that the incident was made up when questioned. (Resident #22) allegation (sic) was (Resident #31) came into her room and sat down and started touching her all over her body. But when to further explain the incident it was discovered that the act was impossible by the furniture layout inside of the room. Further more it was also noted that the staff was following (Resident #31) when he had entered the room of (Resident #22). (Resident #31 was quickly turned around and made to exit the room by the staff at (the facility) . The police report conflicts with the staff interviews below, as CNA J and CNA S had not acknowledged seeing Resident #31 in Resident #22's room or redirecting Resident #31 from Resident #22's room. The report also contradicts direct care staff who confirmed through interviews there were two separate incidents between Resident #22 and Resident #31. The police report revealed the officer had not interviewed any floor staff regarding the incidents before alledging only one incident had occurred. Furthermore, follow-up interviews by this Surveyor for Resident #22 remained consistent on the details of each incident without any cueing. On 11/18/21 at 8:18 a.m., during an interview, CNA S stated she recalled the incident for Resident #22 and Resident #31 she was involved in was approximately two weeks ago. CNA S stated she and CNA J were attending to another unidentified resident when they heard Resident #22 yelling coming from the hall. CNA S stated CNA J directed her to find out what was going on. CNA S stated she did not report anything to anyone because she did not see a reason to. When asked why she felt this way, CNA S stated they located Resident #31 laying in bed. However, CNA S stated she did not recall much about the night because it was so long ago. On 11/18/21 at 8:37 a.m., during an interview, CNA J stated the incident involving Resident #22 and Resident #31 was a couple of weeks ago. CNA J stated she and CNA S were in with Resident #23 in the bathroom in room [ROOM NUMBER] performing toileting with the door closed. CNA J stated once they opened the door, they heard Resident #22 screaming and yelling and sent CNA S down to see what was going on. CNA J stated she heard the phone ringing so she went to answer it and it was FM M. CNA J stated FM M wanted someone to go and check on Resident #22. CNA J stated she informed FM M CNA S was already down there but she would go and see what was going on. CNA J confirmed FM M told her she was on the phone with Resident #22 when she was screaming. CNA J stated FM M was quite upset and she could barely get two words in. CNA J stated Resident #31 was not in Resident #22's room when she arrived and did not see him when she was walking down to Resident #22's room. CNA J Stated Resident #31 was in his room, standing up, and pacing in his room, so we put him to bed. CNA J stated he was in room [ROOM NUMBER]. CNA J stated she reported this incident to RN R and stated to him Resident #31 was in her room. Interviews between CNA J and CNA S conflicted on how they found Resident #31 at the time of the incident. On 11/18/21 at 9:32 a.m., during a follow-up interview, Resident #22 was able to recall both incidents reported to this Surveyor without any cueing. When asked to recall the specifics, Resident #22 was able to recall first incident with Resident #31 was when he attempting to crawl into bed with her. Resident #22 was able to recall the second incident was where Resident #31 was touching and kissing her and demonstrated the action as previously reported to this Surveyor by placing her hands over the top half of her torso, breast area and front. Resident #22 then stated she had been scared about being at the facility, but now feels safe. Resident #22 indicated she was aware Resident #31 was no longer in the building. Resident #24 A review of the admission MDS assessment for Resident #24 dated 10/4/21, revealed a Brief Interview for Mental Status (BIMS) assessment of 12, indicating mild cognitive impairment. On 11/9/21 at 11:41 a.m., during an interview, Resident #24 stated there were two residents who wander. Resident #24 stated they had a tendency to come into his room. Resident #24 stated he had to (Yell) at them so they will turn around. Resident #24 stated Resident #31 had come into his room and peed in the corner one day. On 11/15/21 at 10:59 a.m. SSD H stated she had overheard issues surrounding wandering for Resident #31 into Resident #24's room. SSD H stated nothing was directly reported to her from Resident #24. Resident #86 On 11/9/21 at 10:37 a.m., during an interview and observation, Resident #86 stated another Resident (#31) entered his room when he first got here and grabbed on to his wrist and bruised it from grabbing his wrist so hard. A bruise was visible on left wrist Resident #86. Resident #86 stated he did not recall exactly when it happened, but did state he could protect himself and would knock Resident #31 on his *ss the next time he came in. A review of the progress notes in the EMR revealed no documentation of the incident. On 11/17/21 at 1:10 p.m., during an interview, Maintenance Supervisor (MS) D stated Resident #86 reported to him last Thursday 11/11/21 about a bruise on the wrist of Resident #86 when he mentioned Resident #31 grabbed his wrist and squeezed. MS D stated this prompted him to look at Resident #86's wrist where he observed a bruised area. MS D stated he was aware of Resident #22 reporting having her boob grabbed by Resident #31 from another staff member. On 11/17/21 at 2 p.m., incident reports for Resident #86 since admission were requested from the DON. The DON stated she would check, but was almost certain there were no incidents reported for Resident #86. On 11/17/21 at 2:45 p.m., during an interview, SSD H stated approximately two and a half weeks ago Resident #86 reported to SSD H, Resident #31 had grabbed his wrist so hard he thought it was going to break. SSD H stated Resident #86 wanted her to find him a different place to live. SSD H stated Resident #86 told her the next time Resident #31 cameinto his room he was gonna lay him out flat. SSD H stated she attempted to calm Resident #86 and stated she would take care of the issue and to please not retaliate. SSD H stated she told the DON about the incident and stated the DON told SSD H it was already handled and to not worry about it. SSD H stated she also texted the NHA about the issue and never heard back about it. A review of the skin assessments in the EMR for Resident #86 show no documentation of bruising on either wrist as confirmed by staff MS D, and observed by this Surveyor on 11/9/21 at 10:37 a.m. Resident #85 On 11/17/21 at 4:22 p.m., during an interview Resident #85 stated she did have two encounters with Resident #31 coming into her room. Resident #85 stated the first incident, Resident #31 took his thumb and stroked on the underside of her chin several times. Resident #85 demonstrated the action to this Surveyor starting from the back of the jaw toward the chin area. Resident #85 stated, on the second incident, Resident #85 told staff Resident #31 came in and took a blanket off her. Resident #86 stated this happened early on when she first admitted to the facility. Resident #85 stated the staff were told about both incidents. Resident #33 A review of the quarterly MDS assessment for Resident #33 dated 10/19/21 revealed a BIMS assessment of 14, indicating cognition was intact. On 11/17/21 at 4:34 p.m., during an interview, Resident #33 stated she had experienced an incident about four weeks ago where Resident #31 wandered into her room and sat on her bed. Resident #33 stated she tried to push Resident #31 off the bed and Resident #31 pushed her back. Resident #33 stated she told the staff about it and the staff told Resident #33 that Resident #31 has rights. Resident #33 stated she responded by saying I have rights too, what about my rights. Resident #33 stated this made her feel like she was a prisoner at the facility and she felt like her concern was disregarded. A review of the facility policy Abuse Prevention Program Policy & Procedure with a review date of 1/2021, read in part: Each resident has the right to be free from abuse, neglect and corporal punishment of any type by staff or anyone. The facility will provide a safe resident environment and protect residents from abuse .(The Facility) has prevention programs in which policies and procedures safeguard our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraints ., verbal, mental, and sexual. 'Abuse' is defined as 'the willful infliction of injury .with resulting physical harm, pain, or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .'Sexual abuse,' is defined as 'non-consensual sexual contact of any type with a resident.' 'Willful,' defined as used in the definition of 'abuse,' 'means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.' 'Alleged violation' is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abus [TRUNCATED]

This citation pertains to Intake MI 064. Based on interview and record review, the facility failed to ensure an appropriate response for a change in condition for one Resident (#32) of 12 residents reviewed for quality of care. This deficient practice resulted in the deterioration of Resident #32's condition and subsequent death. Findings include: Resident #32 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #32's most recent Minimum Data Set (MDS) Assessment, dated [DATE], revealed Resident #32 was cognitively intact. Further review of Section E of the MDS Assessment, revealed Resident #32 had not exhibited rejection of care. A review of Resident #32's electronic medical record (EMR) revealed the following progress note, entered and signed by the Director of Nursing (DON): [DATE] 17:38 (5:38 p.m.), [Recorded as Late Entry on [DATE] 08:46 AM] as resident approached this writer, observed drooping to resident's left facial features. speech is garbled but wording and responses remain appropriate. Large amount of drooling is observed and food sitting in the side of his mouth. tongue is not midline- it leans to the left . resident is a full code status but stated he doesn't wish to go to the hospital for evaluation. he was asked x3 and responded all 3 times that he wishes to remain in-facility. call placed to (NP) on call for (Physician O) relayed the above information. will continue to monitor resident and order received for ST (speech therapy) to eval and treat. resident is agreeable to this. A review of the Medical Treatment Decision of Resident, signed by Resident #32 and dated [DATE], revealed the following, in part: Directive: Do you wish to prepare an advance directive at this time? No. I wish to have cardiopulmonary resuscitation (CPR) - Yes. I wish to be hospitalized if medical staff feels it to be necessary - Yes. I wish to be placed on [CONDITION(S)] - Yes. I wish to have artificial nutrition - Yes. I wish to have artificial hydration - Yes. I wish to have medication for comfort - Yes. I wish to have IV antibiotics and medications - Yes. During an interview with the DON was asked to recall the event involving Resident #32 on [DATE]. The DON reported she had been charting at the nurse's station, looked up from her work and observed Resident #32 sitting in his wheelchair with left-side facial droop. The DON reported when asking Resident #32 if he was ok, she noticed his speech was garbled and he was drooling. The DON confirmed Resident #32 appeared to be experiencing a stroke (blood supply to part of the brain is cut off or reduced). The DON stated she asked Resident #32 again if he was ok. The DON reported Resident #32 did not seem to realize what was happening. The DON stated, he didn't know he was having a stroke. The DON reported she asked the Resident if he would go to the hospital for evaluation but Resident #32 only wanted to know if it was time to go outside and smoke. The DON reported she called the nurse practitioner to report on Resident #32's condition and of Resident #32 stating he did not want to go to the hospital. The DON reported Resident #32 was his own person and no family was notified. The DON reported Resident #32 could answer questions as normal so she honored his request. The DON reported she was not sure if Resident #32 understood his condition was serious or that he may expire as a result of refusing to go to the hospital. The DON reported she suspected Resident #32 continued to experience TIAs (transient ischemic attacks, a/k/a mini-strokes) throughout the following days, preceding his death on [DATE]. In an interview on [DATE] at approximately 11:45 p.m., Certified Nurse Aide (CNA) K reported she had cared for Resident #32 on the morning of [DATE]. CNA K reported she remembered the day well because she returned from her scheduled days off to find Resident #32 incoherent, lying in bed. CNA K reported she had cared for Resident #32 on many occasions prior to [DATE] and Resident #32 had always been very active and conversational. CNA K reported upon approaching Resident #32 the morning of [DATE] she was surprised and how much his condition had deteriorated. CNA K stated she was not sure if Resident #32 could have made decisions as he was sleeping most of the time. Further review of Resident #32's EMR revealed the following progress note entered and signed by the Nursing Home Administrator, in part: [DATE] 03:28 (3:28 a.m.) [Recorded as Late Entry on [DATE] 09:29 PM] Spoke with (Resident #32) with our SSD (Social Service Director) on his advance directive decisions. (Resident #32) was able to relate with me at this time cognition was alert x3. (Resident #32) asked that his code status be changed to a DNR (Do Not Resuscitate). I asked him if he wanted his (family name redacted) involved at this time or notified from here on out he said no. He said he was comfortable not in pain. ST evaluated him relating to his diet tolerance. (Resident #32) has stated that he wants to go with (funeral home name redacted), he desires to be cremated when the time comes and for any remaining money to be donated to the facility. When asked what he would like the money spent on he said, to the people here. We discussed hospice services, he would like (name redacted). Discussed waiting to his UA result came back if neg then to proceed with hospice services. (Resident #32) stated he is comfortable with where he stands and that he doesn't care what happens to his ashes when cremated. It was noted that the progress note was dated [DATE] at 3:28 a.m. A review of the Medical Treatment Decision of Resident, signed by Resident #32 and dated [DATE], revealed the status of Resident #32 had been changed to the following: Directive: Do you wish to prepare an advance directive at this time? No. I wish to have cardiopulmonary resuscitation (CPR) - No. I wish to be hospitalized if medical staff feels it to be necessary - No. I wish to be placed on [CONDITION(S)] - No. I wish to have artificial nutrition - No. I wish to have artificial hydration - Yes. I wish to have medication for comfort - Yes. I wish to have IV antibiotics and medications - Yes. A review of a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Description: ST (Speech Therapy) clarification order requested to address dysphagia (difficulty swallowing) 5x/wk x 30 days. A review of Resident #32's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient has had rapid decline in health and opted for DNR (Do Not Resuscitate) and did not wish to be shipped to ED (Emergency Department). Patient unable to discuss wishes for palliative care, Social Services instructed to speak with family . CNS: unable to make needs known. Plan: Patient is counseled and encouraged. No changes to regimen. Orders given for Social Services to discuss palliative care with family. During a telephone interview on [DATE] at 1:58 p.m., Physician O reported he could not remember if he was able to speak with Resident #32 during his assessment of the Resident on [DATE]. Physician O directed this Surveyor to refer to the progress note he had written on [DATE] at 9:11 a.m. Physician O stated it appeared Resident #31 had experienced a stroke and he was surprised by Resident #32's condition. When asked why he had directed Social Services Director (SSD) H to speak with family regarding Resident #32's condition, Physician O reported his instructions were possibly due to Resident #32's inability to articulate his wishes. Physician O reported he could not remember for sure. A review of a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Once. One Time: 12:00. Further review of Resident #32's EMR revealed no documentation regarding contact with Resident #32's family. During an interview on [DATE] at 12:32 p.m., the NHA reported she understood the concern regarding Resident #32's change in condition on [DATE]. The NHA reported she was unsure if Resident #32 had any insight into his condition or if his condition had been explained to him when identified by the DON on [DATE]. The NHA confirmed prior to [DATE], Resident #32 had wished for full resuscitation and hospitalization , if staff felt it was necessary, according to the Medical Treatment Decisions of Resident, form signed by Resident #32 on [DATE]. The NHA reported she had been an emergency medical technician (EMT) and understood that a stroke is a medical emergency. The NHA confirmed having a stroke could be a very stressful situation for Resident #32. The NHA acknowledged that although Resident #32 could answer questions appropriately, he may not have understood the ramifications of refusing to go to the hospital, as advised by the DON on [DATE]. When asked if the DON should have immediately called for emergency assistance when identifying Resident #32 was having a stroke, on [DATE], the NHA stated she was unsure. The NHA stated she understood the concern regarding Resident #32's decision-making capabilities while acutely ill, as Resident #32 may not have known the extent of his condition. The NHA confirmed Resident #32 had agreed to Speech Therapy. The NHA was asked if the fact that Resident #32 agreed to Speech Therapy indicated Resident #32 had believed he would recover, the NHA reported she was unsure. When asked if Resident #32's family had been involved in the decision-making, per Physician O's recommendation, the NHA reported Resident #32 had a strained relationship with his only known relative and therefore no family contact was made. A request for the facility policy regarding resident change in condition was requested at the time of the interview. A review of Resident #32's Physician Orders revealed no new care orders, in addition to the order for the Speech Therapy Evaluation on [DATE], had been received or initiated for the care of Resident #32 from the time his condition was identified on [DATE] through his death on [DATE]. No diagnostic testing had been ordered or completed after Resident #32 began to exhimit symptoms of stroke on [DATE]. Further review of Resident #32's EMR revealed no documented nursing assessments of Resident #32's condition on [DATE] or [DATE]. Resident #32 expired at the facility on [DATE] at 4:25 p.m. A review of the facility policy titled, Notification of Change, provided by the NHA and last reviewed on ,d+[DATE], revealed the following, in part: Interventions: The Licensed nurse will use professional judgment any time that in their opinion the resident requires immediate medical attention. Assessment: . Presence of Advance Directives . Call 911 in emergency situations: such as unconsciousness, [CONDITION(S)], fall with head or neck injury, and or other traumatic injury, respiratory arrest, unresponsiveness, uncontrolled bleeding, dislodged shunt, suspect MI, this list is not all inclusive. Notification: 3. When the situation is emergent or becomes emergent the licensed nurse may initiate the 911 system . Outcome Evaluation: Monitor and reassess the resident status and response to interventions. The physician should develop a working diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Mayo Clinic's online resource, Stroke, accessed [DATE], a stroke is a medical emergency, and prompt treatment is crucial. Early action can reduce brain damage and other complications.

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE APPROPRIATE SAFETY MEASURES WERE IN PLACE FOR ONE (#102) OF TWO RESIDENTS REVIEWED FOR FALLS WITH FRACTURES, OF FIVE SAMPLED RESIDENTS, FROM A TOTAL OF 32 RESIDENTS IN THE FACILITY. THIS FAILURE RESULTED IN HARM TO RESIDENT #102 WHO fell AND SUSTAINED A INTERTROCHANTERIC FRACTURE OF THE RIGHT HIP, REQUIRING SURGICAL INTERVENTION. FINDINGS INCLUDE: THE FACE SHEET REVEALED THAT RESIDENT #102 IS A [AGE] year OLD MAN admitted TO THE FACILITY 9/28/11, WITH [DIAGNOSES REDACTED]. THE MEDICAL RECORD REVEALED A COURT DOCUMENT TITLED "ORDER APPOINTING GUARDIAN AD LITEM, ATTORNEY/LAWYER-GUARDIAN AD LITEM" DATED 11/18/11, NAMING A COURT APPOINTED GUARDIAN FOR RESIDENT #102, DUE TO THE FACT THAT RESIDENT #102 WAS UNABLE TO MAKE HIS OWN DECISIONS REGARDING MEDICAL AND FINANCIAL ISSUES. THE MINIMUM DATA SET (MDS) assessment dated [DATE], REVEALED RESIDENT #102 NEEDED ASSISTANCE OF ONE WITH TRANSFERS AND WITH AMBULATION IN THE CORRIDOR. THIS MDS ALSO SHOWED THAT RESIDENT #102 WAS NOT STEADY WITHOUT HUMAN ASSISTANCE AND WHILE TURNING AROUND TO CHANGE DIRECTION. THE "FALLS PREVENTION RISK ASSESSMENT" DATED 9/28/12 AND 1/11/12, DETERMINED RESIDENT #102 WAS AT "MODERATE" RISK FOR FALLS. THE MEDICAL RECORD REVEALED A "RISK FOR FALLS" CARE PLAN UPDATED 10/26/12; HOWEVER, NO EVIDENCE OF SAFETY DEVICES OR OTHER METHODS TO PREVENT FALLS, SUCH AS ALARMS TO ALERT STAFF TO THE RESIDENT'S MOVEMENTS,WAS SHOWN ON THE FALL CARE PLAN. THE "PT (PHYSICAL THERAPIST) - PROGRESS REPORT AND DISCHARGE SUMMARY" DATED 1/5/12, READ "DUE TO SAFETY REASONS, THE PATIENT REQUIRES VERBAL CUES FOR AMBULATION." THE "OT (OCCUPATIONAL THERAPY) THERAPIST PROGRESS REPORT AND DISCHARGE SUMMARY" DATED 1/6/12, READ "PRECAUTIONS: RISK FOR FALLS." A REVIEW OF NURSING "PROGRESS NOTES" DATED 1/11/12, REVEALED (RESIDENT #102) WAS NOTED TO BE LAYING ON THE FLOOR WITH NO NOTED INJURIES. THE "FALL POST ASSESSMENT AND INVESTIGATION" DATED 1/11/12, READ "RESIDENT (#102) INSTRUCTED AND HAS AGREED TO NO FURTHER INDEPENDENT TRANSFERS UNTIL CLEARED BY R.P.T. (REGISTERED PHYSICAL THERAPIST)." NO FURTHER INTERVENTIONS WERE ADDRESSED. THE NURSING "PROGRESS NOTES" DATED 1/12/12, REVEALED "RES (RESIDENT #102) TRANSFERS SELF TO WHEELCHAIR." THERE WAS NO EVIDENCE, IN RESIDENT #102'S MEDICAL RECORD, OF A PHYSICAL THERAPY EVALUATION FOLLOWING THE 1/11/12 FALL, TO ASSESS RESIDENT #102 FOR SAFE TRANSFERS. DURING AN INTERVIEW ON 4/3/12 AT 8:30 A.M. WITH THE DIRECTOR OF NURSING (DON), SHE STATED "HONESTLY, NO I HAVE NO ADDITIONAL INFORMATION FOR YOU. NO, I DIDN'T HAVE PT RE-EVALUATE HIM (RESIDENT #102) ...I STRUGGLE WITH RESIDENTS LIKE HIM...I DIDN'T TRY PUTTING ALARMS BACK ON HIM BECAUSE HE WAS SO NON-COMPLAINT.... NO, I DO NOT HAVE ANYWHERE DOCUMENTATION THAT RISKS/BENEFITS WERE EVER REVIEWED WITH THE RESIDENT OR HIS RESPONSIBLE PARTY. NO, I DON'T THINK HE WAS COGNITIVELY AWARE ENOUGH TO BE MAKING THOSE DECISIONS. BUT, I HONESTLY DIDN'T KNOW WHO HIS RESPONSIBLE PARTY WAS AND NO, I DID NOT INVOLVE THEM...OR DISCUSS SAFETY INTERVENTIONS (WITH THEM)....NO, WE DID NOT INCREASE (VISUAL) CHECKS RELATED TO ANY FALLS...". A "THERAPY SCREEN FORM...QUARTERLY SCREEN" DATED 3/2/12, READ NEXT TO THE CHECKED BOX, "EVALUATION RECOMMENDED: ...POOR SAFETY AWARENESS (E.G. NOT LOCKING BRAKES OR REACHING FOR WHEELCHAIR)." THERE WAS NO EVIDENCE IN THE RESIDENT'S MEDICAL RECORD OF FURTHER ACTION TAKEN RELATED TO HIS SAFETY ISSUES. THE FACILITY REPORTED INCIDENT (FRI) DATED 3/8/12, REVEALED RESIDENT #102 fell IN THE THERAPY ROOM ON 3/4/12 AT 4:00 P.M., WHILE UNSUPERVISED BY STAFF. THE FRI INVESTIGATION SHOWED RESIDENT #102 WAS TRANSFERRING INDEPENDENTLY FROM HIS WHEELCHAIR TO AN ARM CHAIR, AND THE CHAIR TIPPED OVER AND HE fell . THE FRI INVESTIGATION REVEALED THAT ON 3/5/12 AT 7:30 P.M., RESIDENT #102 WAS COMPLAINING OF SEVERE PAIN IN HIS RIGHT THIGH AND WAS SENT TO emergency room (ER). THE "ER NOTE" DATED 3/5/12, READ: "[DIAGNOSES REDACTED]." THE HOSPITAL "OPERATIVE NOTE" DATED 3/6/12, INDICATED RESIDENT #102 HAD "PROCEDURE: OPEN REDUCTION/INTERNAL FIXATION (FOR THE RIGHT HIP)." IN AN INTERVIEW WITH THE DON ON 4/3/12 AT 11:00 A.M., SHE STATED "NO, WE DIDN'T START ANYTHING DIFFERENT RELATED TO THE FALL ON 1/11/12 OR THE QUARTERLY THERAPY ASSESSMENT. NO ALARMS, PRESSURE OR TABS (ALARMS) RELATED TO HIS NON-COMPLIANCE IN THE PAST. NO VISUAL CHECKS...NO, WE DID NOT DISCUSS THE RISK OR BENEFITS OF THE ALARM USE WITH RESIDENT (#102) OR THE GUARDIAN...I FEEL BAD, I MESSED UP. I CAN'T CHANGE WHAT HAPPENED BUT I CAN CHANGE THINGS IN THE FUTURE." THE FACILITY POLICY TITLED, "FALLS PREVENTION PROGRAM" CHAPTER 1 DATED 1/08, READ "IT IS THE POLICY OF THIS FACILITY TO ASSESS EVERY RESIDENT FOR HIS OR HER RISK OF FALLING. IDENTIFYING RISK FACTORS, FOLLOWED BY TIMELY AND APPROPRIATE INTERVENTIONS, IS KEY TO A SUCCESSFUL PROGRAM. THE GOAL OF THE FALL PREVENTION PROGRAM IS TO MODIFY OR ELIMINATE RISK FACTORS AND THEREBY REDUCE THE LIKELIHOOD OF FUTURE FALLS." THE FACILITY POLICY TITLED "FALLS PREVENTION PROGRAM" CHAPTER 1.1 (DATED 1/08) READ: "ONGOING: THE RESIDENT'S FALL PREVENTION PROGRAM CARE PLAN WILL BE REVIEWED AND OR REVISED TO ENSURE THAT THE INTERVENTIONS ARE UPDATED BASED ON IDT (INTERDISCIPLINARY TEAM) RECOMMENDATIONS WITH EACH QUARTERLY OR CHANGE IN STATUS CARE PLAN MEETING." ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION DURING A TRANSFER TO PREVENT ACCIDENTS FOR ONE RESIDENT (#1) OF THREE RESIDENTS REVIEWED FOR TRANSFER ASSISTANCE, FROM THE TOTAL 31 FACILITY RESIDENTS. THIS FAILURE RESULTED IN HARM TO RESIDENT #1 WHEN SHE SUSTAINED A PAINFUL FRACTURE TO THE RIGHT FEMUR. FINDINGS INCLUDE: THE REVIEW OF RESIDENT #1'S CLINICAL CHART FACE SHEET SHOWED SHE HAS RESIDED IN THE FACILITY SINCE 2/04/10. THE FACE SHEET DOCUMENTED HER [DIAGNOSES REDACTED]. THE 10/13/11 MINIMUM DATA SET (MDS) ASSESSMENT SHOWED RESIDENT #1'S COGNITION AS SEVERELY IMPAIRED. THE 10/13/11 MDS DOCUMENTED, ALTHOUGH RESIDENT #1'S THINKING PROCESSES WERE DISORGANIZED, SHE USUALLY UNDERSTOOD WHAT WAS SAID TO HER AND WAS USUALLY UNDERSTOOD WHEN SHE SPOKE. RESIDENT #1'S 8/11 CARE PLAN SHOWED SHE WAS AT RISK FOR FALLS DUE TO HER POOR SAFETY AWARENESS. THE CARE PLAN DOCUMENTED HER NEED FOR EXTENSIVE, TWO PERSON ASSISTANCE WITH TRANSFERS; EITHER USING THE PIVOT TRANSFER TECHNIQUE OR TWO PERSON ASSISTANCE WITH THE USE OF A SIT-TO-STAND MECHANICAL LIFT. THE HOSPICE SERVICES FORM TITLED, "CERTIFICATION EVALUATION" (REV. 08/11) DOCUMENTED RESIDENT #1 WAS RECEIVING HOSPICE SERVICES AT THE FACILITY. THE "CERTIFICATION EVALUATION" FORM AND THE 12/10/11 HOSPICE "AIDE/HOMEMAKER CARE PLAN" SHOWED RESIDENT #1 WAS TO BE TRANSFERRED USING "2 PERSON SIT TO STAND TRANSFER." THE FACILITY'S MECHANICAL LIFT POLICIES/PROCEDURES WERE REVIEWED. THE FACILITY'S DOCUMENT TITLED, "CRITERIA FOR SIT STAND LIFT USE" (NO DATE) DOCUMENTED, "...1. THIS PROCEDURE ALWAYS REQUIRES A TWO PERSON ASSIST..." A REVIEW OF THE FACILITY'S 12/19/11 INCIDENT INVESTIGATION REPORT DOCUMENTED ON 12/12/11 AT APPROXIMATELY 8 A.M., HOSPICE CERTIFIED NURSE AIDE (CNA) "A" WAS WITH RESIDENT #1 IN THE BATHING/SHOWER ROOM ATTEMPTING TO TRANSFER HER FROM HER WHEELCHAIR TO THE SHOWER CHAIR USING THE SIT-TO-STAND MECHANICAL LIFT. THE REPORT DOCUMENTED WHEN RESIDENT #1 WAS IN THE LIFT AND BEING MOVED TO THE SHOWER CHAIR SHE, RESIDENT #1, REMOVED BOTH FEET FROM THE LIFT FOOT PLATFORM, AND THEN WAS "DANGLING IN THE SLING." PER THE INVESTIGATION REPORT, BECAUSE HOSPICE CNA "A" COULD NOT ACCESS THE WHEELCHAIR OR THE SHOWER CHAIR, SHE SLOWLY LOWERED RESIDENT #1 TO THE FLOOR WITH RESIDENT #1'S LEGS "FOLDED UNDERNEATH HER (RESIDENT #1)". THE REPORT DOCUMENTED HOSPICE CNA "A" THEN REMOVED THE LIFT SLING AND POSITIONED RESIDENT #1 ON THE FLOOR WITH "HER RIGHT KNEE BENT AND TWISTED." AFTER THE INCIDENT, STAFF IDENTIFIED EXTENSIVE SWELLING TO RESIDENT #1'S RIGHT THIGH AND HER COMPLAINT OF PAIN. RESIDENT #1 WAS SENT TO THE emergency room . THE X-RAY DOCUMENTED RESIDENT #1 HAD FRACTURED HER RIGHT FEMUR JUST ABOVE THE KNEE. INTERVIEWS WERE CONDUCTED WITH CERTIFIED NURSE AIDE (CNA) "H" AND CNA "F", ON 1/11/12 AT 11:43 A.M. AND 12:30 P.M. RESPECTIVELY. BOTH CNAS SAID THEY CONDUCTED THE TWO PERSON ASSIST FOR RESIDENT #1, TRANSFERRING HER FROM HER BED TO HER WHEELCHAIR THE MORNING OF THE INCIDENT, BEFORE 7 A.M. AND BEFORE RESIDENT #1'S SHOWER. CNA "H" STATED, RESIDENT #1 WAS SMILING AND GAVE NO INDICATION OF PAIN. CNA "F" SAID SHE PUT RESIDENT #1'S TED HOSE ON AND HER LONG PANTS. SHE STATED RESIDENT #1 WOULD HAVE TOLD HER IF SHE WAS IN PAIN. CNA "F" SAID RESIDENT #1'S LEGS WERE NOT SWOLLEN AT THE TIME SHE DRESSED HER. AN INTERVIEW WAS CONDUCTED WITH HOSPICE CNA "A" ON 1/11/12 AT 10:55 A.M. HOSPICE REGISTERED NURSE (RN) "B" WAS IN ATTENDANCE. HOSPICE CNA "A" STATED SHE HAD ASSISTED RESIDENT #1 DURING THE TRANSFER. SHE STATED SHE DID NOT HAVE HELP DURING THE TRANSFER. HOSPICE CNA "A" EXPLAINED SHE HAD ALWAYS TRANSFERRED RESIDENT #1 ALONE USING THE SIT-TO-STAND LIFT. THE HOSPICE "CERTIFICATION EVALUATION" FORM AND THE HOSPICE "AIDE/ HOMEMAKER CARE PLAN" WERE REVIEWED WITH HOSPICE CNA "A" AND HOSPICE RN "B". BOTH HOSPICE STAFF ACKNOWLEDGED THE FORMS DOCUMENTED RESIDENT #1 WAS TO BE ASSISTED WITH TWO PEOPLE DURING TRANSFERS WITH THE SIT TO STAND LIFT. HOSPICE CNA "A" STATED, "I THOUGHT THE CARE PLAN MEANT SHE (RESIDENT #1) WAS A TWO PERSON ASSIST IF A LIFT WASN'T USED..." THE ADMINISTRATOR AND DIRECTOR OF NURSING WERE INTERVIEWED ON 1/11/12 AT 3 P.M. THEY BOTH STATED THE FACILITY POLICY WAS CORRECT AND ALL RESIDENT TRANSFERS USING THE SIT-TO-STAND LIFTS WERE WITH TWO PERSON ASSISTANCE. THE DON SAID, "...I DON'T HAVE THE DOCUMENTATION, BUT I KNOW THAT INFORMATION WAS SHARED WITH HOSPICE STAFF..." THE ADMINISTRATOR EXPLAINED SHE HAD COMPLETED A RE-ENACTMENT OF THE TRANSFER WITH HOSPICE CNA "A" ON 12/13/11. SHE SAID, DURING THE RE-ENACTMENT SHE, THE ADMINISTRATOR, PLAYED THE ROLE OF RESIDENT #1. THE ADMINISTRATOR STATED, "WHEN MY KNEE HIT THE FLOOR AND THE WAY (HOSPICE CNA "A") POSITIONED MY LEGS, IT WAS REAL PAINFUL TO MY RIGHT KNEE." THE ADMINISTRATOR SAID SHE BELIEVED THE FRACTURE OCCURRED DURING THE TRANSFER WITH THE LIFT. THE DON AND THE ADMINISTRATOR BOTH CONFIRMED, IF THERE HAD BEEN TWO PEOPLE ASSISTING WITH THE TRANSFER AND RESIDENT #1 HAD DIFFICULTY STANDING ON THE LIFT PLATFORM, ONE STAFF WOULD HAVE STAYED WITH RESIDENT #1 AND THE ADDITIONAL STAFF WOULD HAVE RETRIEVED THE WHEELCHAIR WITH RESIDENT #1 BEING PLACED BACK IN THE CHAIR. INSTEAD, RESIDENT #1 WAS LOWERED TO THE FLOOR BY HOSPICE CNA "A", PUTTING PRESSURE ON THE RESIDENT'S FEMUR/KNEE AREA WHICH RESULTED IN THE KNEE BEING BENT AND TWISTED. ( )