Every finding on record at Loch Haven

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety. Staff failed to securely seal, label, date or store food items according to the facility policy. Staff failed to ensure surfaces and equipment were free from buildup of grease and debris and failed to ensure the dry storage room floor was clean, free of mouse droppings and debris. The facility failed to ensure the kitchen floors, walls and baseboards were clean and free of debris and failed to store dishes in a sanitary manner. The facility census was 69. Review of the facility policy titled Labeling and Dating Foods, dated 2020, showed once a package was opened, it will be re-dated with the date it was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. Review of the facility policy titled Refrigerator/Freezer Storage, dated 2020, showed freezer foods will be stored in containers or materials designed for freezer storage. 1. Review of the Consultant Summary, conducted by the facility's registered dietitian, on 07/23/26, showed the following items needed correction:-Observation of food items not labeled or dated in the dry storage room, in the refrigerators and in the freezers. Label food with use by date and discard expired foods;-Observation of the two-door refrigerator was dirty with food debris. Recommend cleaning refrigerator(s);-Observation of the bottom of the two-door refrigerator was dirty with food debris. Recommend cleaning refrigerator;-Observation of the grill needs cleaned, very dirty from use throughout the day. Recommend cleaning grill and empty grease trap;-Observation of the two-burner grill, needs to be cleaned and tray under the burners needs to be cleaned. Observation on 08/13/26 at 9:00 A.M., in the reach in freezer, showed the following:-An open bag of frozen beef patties was undated, unsealed, and open to air;-An open bag of gluten-free chicken strips was undated, unsealed, and open to air;-An open bag of potato puffs was undated, unsealed, and open to air;-A zipper bag containing cinnamon rolls was unlabeled and undated;-A zipper bag of diced peppers was unlabeled and undated;-A zipper bag of diced onions was unlabeled and undated. Observation on 08/13/26 at 9:10 A.M., in the dry storage room of the kitchen, showed mouse droppings were on the floors under the metal shelving units. The floor was dirty with brown debris and a white powdery substance. Paper trash and plastic wrappers were along the walls and underneath the metal shelving. Observation on 08/13/26 at 9:15 A.M., in the kitchen, showed the following:-A sticky brown residue was on the front and bottom of the reach-in kitchen refrigerator. Inside the reach-in kitchen refrigerator, there was a sticky brown residue on the bottom shelf and along the door seal; -The walls beside the dry storage room had brown spattered debris down the wall and on the baseboard;-The baseboard and floor along the wall throughout the kitchen had a layer of dark brown debris;-On a metal rack where plastic dishes were stored, several plastic bowls were stored upright on a tray with brown crusted debris along the bottom. Two plastic tubs with crusted brown debris along the bottom, contained a variety of smaller plastic bowls stored in an upright position;-On a lower metal rack where cooking pans were stored, large metal bowls and skillets were stored in an upright position.-There was a heavy accumulation of yellow drips on the wall behind and on the sides of the cooking equipment;-The flat-top griddle had a moderate accumulation of dark brown grease along the sides and underneath the griddle and on the shelves below the griddle;-The two-burner stove top had a thick layer of black encrusted debris across its surface. During an interview on 08/13/26 at 12:08 P.M., Dietary [NAME] D said the following:-He/She tried to assign dietary staff cleaning tasks but did not always get to it. Most of the dietary staff were aware of what needed to be done;-He/She cleaned the grill every few days but had been off for a few days;-The facility had been fighting mice for quite some time;-Custodial staff were responsible for cleaning the kitchen floors, including the floor in the dry storage room, daily. During interviews on 08/13/26 at 9:15 A.M., 12:00 P.M., and 12:45 P.M., the Dietary Manager said the following:-She expected the cook to clean the griddle and empty the grease trap daily after use. Staff had not emptied the grease trap recently after they used the griddle and grease spilled out under the griddle and shelves below. Staff should have cleaned the griddle;-She expected staff to date, label, and seal frozen food items in appropriate containers or zipper top bags;-The cook was responsible for assigning daily tasks to the dietary staff and assuring the tasks were completed;-Staff should store all clean dishes in a downward position to ensure they were kept clean. Staff should clean the tray or containers where clean dishes were stored weekly or as needed if dirty;-Staff should clean up messes as they occurred;-The custodial staff were responsible for cleaning the kitchen and dry storage floors on the night shift;-She expected staff to follow the facility policies regarding kitchen sanitation and food storage. During an interview on 08/13/26 at 12:30 P.M., the Custodial Manager said the following:-Custodial Staff C was responsible for cleaning and mopping the kitchen floors and baseboards on the night shift. The dietary staff were responsible for cleaning the floors in the dry storage room;-Custodial Staff C did not do a thorough job when he/she cleaned;-He/She only checked to ensure Custodial Staff C was completing his/her responsibilities if the Administrator asked him/her to. Custodial Staff C frequently checked off he/she had completed tasks that were not completed. During an interview on 08/13/26 at 11:35 A.M, and 12:15 P.M., the Administrator said the following:-The cook was responsible for assigning the kitchen cleaning tasks each day;-The Dietary Manger had oversight of assuring the cleaning tasks were completed;-The custodial staff had always been responsible for cleaning and mopping the kitchen floors, including the dry storage room, daily on the night shift. The Custodial Manager should review Custodial Staff C's check list each day to assure he/she completed his/her tasks;-If there was spillage in the refrigerator or on the walls, she expected staff to clean it when it occurred;-She expected staff to follow the facility policies on sanitation and food storage.-The facility had a pest control company that treated the facility and delivery areas monthly for mice and other pests. The facility had issues with mice on occasion. If there was an issue between the monthly visits, the pest control company could make an extra visit. 3019678

Based on interview and record review, the facility failed to identify the root cause of an altercation involving two residents (Residents #1 and #2), who had a diagnosis of dementia, in a review of seven sampled residents, following a physical altercation on 8/12/25, failed to effectively communicate the altercation to staff, and failed to develop individualized interventions to address the root cause and to prevent further incidents. On 8/15/25, Resident #2 approached Resident #1, in the same manner he/she did on 8/12/25, and knocked Resident #1 down with his/her walker. The facility census was 73. During an interview on 8/21/25 at 11:04 A.M., the Administrator said the following:-The facility did not have a policy for dementia care;-The facility did not have a policy for resident-to-resident altercations;-The facility had a policy for Wandering, but it was only specific to elopement risk and the functioning of Wanderguards (electronic monitoring devices). 1. Review of Resident #1's face sheet showed the following:-admission date 6/17/25;-Diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 6/24/25, showed the following:-Moderate cognitive impairment;-No inattention, disorganized thinking, or altered level of consciousness;-No hallucinations, delusions, or behaviors. Review of the resident's progress notes, dated 8/2/25 at 6:25 A.M., showed the resident was in his/her room, yelling at his/her roommate (Resident #2), you have my chicken. The resident said his/her roommate yelled at him/her. Review of the resident's progress notes, dated 8/4/24 at 3:36 A.M., showed at approximately 1:00 A.M., staff heard yelling coming from the resident's room. The resident's roommate (Resident #2) was upset as Resident #1 turned off the TV and wouldn't give the roommate the remote. The resident told the roommate (Resident #2) he/she doesn't even watch it, just wants it. Resident #1 gave staff the remote and the roommate watched TV. Review of the resident's progress notes, dated 8/7/25 at 6:22 A.M. showed the resident was screaming at his/her roommate (Resident #2), who was sleeping, saying get out of my house, you're not my son anymore! (The resident used profanity when speaking to Resident #2). Staff entered the room and found the resident lying in bed. Staff informed the resident where he/she currently was and that this home belonged to both of them. Review of the resident's Care Plan, updated on 8/7/25, showed the following:-The resident had delusions related to worsening of dementia;-The resident will interact appropriately with staff, other residents, and family members;-Do not confront, argue with, or deny the resident's belief system;-Encourage the resident to vent his/her feelings, fears, and anxiety;-Provide safe, quiet, low-stimuli environment during delusional periods;-Reinforce and focus on reality. Use clear and concise terms. Review of the resident's progress notes, dated 8/8/25 at 7:40 P.M., showed the resident tried to walk out the south 400 hall doors. The resident walked to the nurses desk and said his/her family member was with another resident (Resident #2) and that the resident (Resident #2) was trying to start a fight with his/her family member. Review of the resident's progress notes, dated 8/12/25 at 4:23 P.M., showed the resident walked in the hallway towards the door and had an interaction with another resident (Resident #2). The resident denied any pain and no skin concerns noted at this time. Staff educated the resident on safe practices when walking with a walker. Review of the resident's progress notes, dated 8/15/25 at 10:25 P.M., showed at approximately 9:00 P.M., staff heard someone scream from the 400 hallway. Staff entered the hallway and found the resident sitting on the floor, leaning on his/her right buttock with his/her arms on the cushion of the walker. The resident's left arm and right hand were bleeding. Another resident (Resident #2), stood behind the resident with his/her hands on his/her own walker, frowning and red faced, stating, I did it, I hit him/her. Staff intervened and assisted the resident to his/her room. During an interview on 8/20/25 at 10:34 A.M., the resident said the following:-He/She had multiple interactions with Resident #2, his/her former roommate;-He/She and Resident #2 got along at first;-Resident #2 got mad about little things like the TV or the window and wouldn't ask him/her to move, then would proceed to get madder;-Resident #2 ran into him/her with his/her walker on two different occasions;-On the first occasion (8/12/25), he/she was walking down the hallway. Resident #2 saw him/her and intentionally followed him/her, then ran into him/her with the walker;-On the second occasion (8/15/25), he/she was walking down the hallway. Resident #2 came out of his/her room, hit Resident #1's side with his/her walker, really hard, knocking him/her to the ground and causing injuries to his/her left arm and right hand;-Resident #2 moved to a different hallway after that and there had not been any more issues as he/she cannot see the other resident;-He/She was not scared or worried when Resident #2 was still in the same hall;-He/She was not mad at Resident #2. 2. Review of Resident #2's face sheet showed the following:-admission date 6/11/25;-Diagnoses included cognitive communication deficit. Review of the resident's care plan for cognitive loss/dementia, last reviewed/revised on 5/22/23, showed the following:-The resident can be forgetful at times and may need help making major decisions;-Give reminders on the time of day as needed;-Give the resident choices about his/her daily activities, including what to wear;-Provide visual reminders such as calendars and a clock to orient the resident to date and time of day. Review of the resident's admission MDS, dated [DATE], showed the following:-Severe cognitive impairment;-No inattention, disorganized thinking, or altered level of consciousness;-No hallucinations, delusions, or behaviors;-Diagnoses included non-Alzheimer's dementia. Review of the resident's progress notes, dated 8/4/25 at 3:07 A.M., showed at approximately 1:00 A.M., staff heard the resident yelling from his/her room. The resident was upset with his/her roommate (Resident #1) who had the TV remote. The resident wanted to watch TV, but the roommate turned off the TV and had the remote in his/her hand. The roommate (Resident #1) finally gave the remote to the resident to watch TV, used profanity and called the resident (Resident #2) a name. Review of the resident's progress notes, dated 8/7/25 at 4:48 P.M., showed the resident moved to a new room. (On the same hall, at the end of the hall farthest from the nurses station, near the emergency exit doors.) During an interview on 8/20/25 at 1:50 P.M., Certified Nurse Assistant (CNA) C said the resident voiced to him/her that he/she was upset about having to move rooms because he/she was in the room first. During an interview on 8/21/25 at 12:34 P.M., the Social Services Director said the following:-She was on vacation when the resident moved rooms on 8/7/25 so he/she was not involved in the move; -She did not follow up with the resident following the room move;-She was not aware the resident voiced being upset about the room move to other staff. During an interview on 8/20/25 at 11:58 A.M., the Administrator said the following:-Resident #1 and Resident #2 got along for about one and a half months before the outbursts started;-Verbal outbursts started first and became more frequent, resulting in moving Resident #2 to a different room on 8/7/25;-Resident #2 was moved since staff determined that he/she was the instigator or the first of the two residents to act out;-Resident #2 was moved to a new room on the same hall for continuity of care;-She was not aware Resident #2 told other staff he/she was upset about moving rooms;-There were no other issues between the two residents until a little standoff on 8/12/25, when both residents walked down the hallway with their walkers and neither resident wanted to move. There was no physical contact and no injuries;-After the standoff on 8/12/25, staff educated both residents about walker safety and staff was educated to increase monitoring for both residents for the remainder of the day when the residents were out of their rooms. Review of the resident's progress notes, dated 8/12/25 at 4:25 P.M., showed the resident was in the hallway and had an interaction with another resident (Resident #1). Educated the resident on safe practices when walking with a walker. During an interview on 8/21/25 at 1:33 P.M., Certified Nurse Assistant (CNA) K said the following:-He/She witnessed the residents' altercation on 8/12/25; -He/She walked around the corner to the 400 hall and saw Resident #1 wandering toward the end of the 400 hall. Resident #2 came out of his/her room and rammed his/her walker straight into Resident #1 multiple times;-Resident #1 put his/her arm out to block Resident #2's walker. Resident #2 yelled at Resident #1, used profanity, and called Resident #1 a name; -He/She separated the residents and asked Resident #2 why he/she was mad. Resident #2 said it was because Resident #1 took his/her room and kept bothering him/her by standing outside of Resident #2's new room;-He/She reported the altercation to his/her charge nurse (Registered Nurse (RN) J);-He/She did not recall any increased monitoring for either resident. During an interview on 8/21/25 at 9:56 A.M., RN J said the following:-The residents used to be roommates. Resident #1 had delusions and Resident #2 eventually got tired of them;-The residents had verbal arguments, usually over things like the TV remote, the lights, and the window, so staff separated the residents;-After the residents were in separate rooms (Resident #2 was moved to a different room on 8/7/25), Resident #2 began standing in his/her doorway, waiting for Resident #1 to walk by, then he/she would start a verbal argument. (Review of Resident #2's care plan showed no interventions to address this type of behavior directed toward Resident #1.)-On 8/12/25, the residents got into an altercation where Resident #2 hit Resident #1 with his/her walker;-He/She did not see the altercation, but CNA K witnessed it;-CNA K said Resident #2 was standing in his/her doorway. When Resident #1 walked by, Resident #2 came out of his/her room and pushed Resident #1 with his/her walker;-He/She notified the Administrator and the Director of Nurses (DON) following the altercation;-He/She did not recall doing any type of increased monitoring or interventions for either resident after the altercation on 8/12/25. Review of the resident's medical record showed no documentation staff implemented interventions to address the resident's behavior directed toward Resident #1 on 8/12/25 and to monitor the resident to ensure no further incidents occurred. Review of the resident's progress notes, dated 8/15/25 at 10:05 P.M., showed at approximately 9:00 P.M., a nurse in another resident room on the 400 hall heard someone scream from the hall. Upon entering the hallway, the nurse saw the resident standing with his/her hands on his/her walker, frowning, with a flushed face, stating, I hit him/her. I did it. Another resident sat on the floor and leaned on his/her right buttock near his/her walker with blood drops noted on the ground and on his/her arm. Staff separated the residents. The resident was initially resistant to return to his/her room, but eventually went with staff. DON and Administrator notified and advised to send resident to emergency room for evaluation. During an interview on 8/20/25 at 11:04 A.M., the resident said the following:-Resident #1 was bad, ornery, and mean to him/her, which made him/her angry;-He/She recalled hitting Resident #1 with his/her walker and said he/she would do it again;-If he/she did not have to see Resident #1 anymore, he/she was happy;-He/She did not want to be around Resident #1 because he/she was mean. During an interview on 8/20/25 at 3:29 P.M., RN G said the following:-He/She was aware the two residents had some prior issues;-Neither resident had ever said anything to him/her about not liking the other resident or wanting to hurt the other resident, however he/she noticed Resident #2 made facial expressions (eye rolling, grimacing, audible sighing, etc.,) to indicate he/she was annoyed with Resident #1's delusions and constant talking;-He/She was not aware of the incident involving the two residents on 8/12/25;-Staff was not given any additional direction or orders for additional monitoring or interventions for either resident (after the altercation on 8/12/25); -He/She was the charge nurse on the night of the 8/15/25 altercation;-As he/she went to a resident's room toward the end of the 400 hall, he/she saw Resident #1 wandering the hall, headed toward the exterior doors at the far end of the hall near Resident #2's room door. He/She did not think anything of it as Resident #1 had been doing this all evening;-He/She entered another resident's room to provide cares, was in the room for maybe a minute or two, and then heard a scream from the hallway;-He/She came out to the hall and found Resident #1 on the ground, and Resident #2 was standing over Resident #1 with his/her walker;-Resident #2 said Resident #1 made him/her mad and he/she would hit Resident #1 with his/her walker again. During an interview on 5/21/25 at 9:45 A.M., CMT H said the following:-He/She was aware of previous issues between the two residents, including verbal altercations, but was not aware of the incident that occurred on 8/12/25;-He/She was not aware of any increased monitoring or redirecting for either resident;-He/She was the medication technician for the 300 and 400 halls on 8/15/25;-As he/she walked to the nurses station to get the medication cart, he/she saw Resident #1 wandering to the end of the 400 hall;-He/She then heard a scream from the 400 hall;-He/She ran down the hall and immediately saw Resident #1 on the ground and Resident #2 pushing his/her walker at Resident #1;-He/She took Resident #2 to his/her room and discussed what happened. Resident #2 said he/she hit Resident #1 with his/her walker and would do it again. During an interview on 8/20/25 at 2:47 P.M., CNA F said the following:-Resident #1 was confused and talked about crazy things, which Resident #2 said he/she did not like, while they were roommates;-When Resident #2 voiced he/she did not like Resident #1's behaviors, CNA F notified the charge nurse, and the residents were moved to separate rooms (on 8/7/25);-He/She was not aware of the incident that occurred on 8/12 and was not aware of any increased monitoring or redirection for either resident;-He/She worked on 8/15/25, but did not see what happened as he/she was providing cares in a resident room on the 300 hall;-Prior to going into the resident room to provide cares, he/she saw Resident #1 wandering the halls, like normal; -He/She recalled hearing what sounded like a scream while he/she was providing cares to another resident;-When he/she exited the other resident room, approximately five minutes later, a CMT was by Resident #2's room door, Resident #1 was sitting on the ground, and the charge nurse was at the nurses station making a phone call. During an interview on 8/21/25 at 12:34 P.M., the Social Services Director said the following:-She was not aware of any issues between the two residents between the room move on 8/7/25 and the altercation on 8/15/25;-She was not notified and was not aware of the altercation involving the residents on 8/12/25. During interviews on 8/21/25 at 1:00 P.M., the DON said the following:-Resident #1 had delusions and started accusing Resident #2 of stealing his/her things;-As a result, Resident #2's behaviors escalated, resulting in verbal threats and arguments;-Staff moved Resident #2 to a new room (on 8/7/25) and increased monitoring of Resident #1's wandering;-As the DON, she should be involved in determining the cause for the behaviors, interventions, and updating the care plan;-She was not made aware of the altercation between the two residents that occurred on 8/12/25;-She expected staff to notify her and the Administrator of all resident-to-resident altercations;-Staff should update the care plans to include the resident's current needs. During an interview on 8/21/25 at 1:50 P.M., the Administrator said the following:-She expected staff to update care plans to include current care needs and interventions, including wandering and behaviors;-She expected staff to review and update the care plans as needed after a resident-to-resident altercation. Complaint 2591459

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff did not securely seal, label, date, or store food items per manufacturer's instructions. Staff did not practice proper hand and glove hygiene, hair restraint usage, and consumption of personal food items. Staff did not maintain surfaces and equipment to be free from a buildup of grease and debris and did not ensure surfaces were sanitized properly. Staff did not ensure dishes and utensils were stored and handled in a sanitary manner. The facility census was 73. 1. Review of the facility policy, Food Storage (Dry, Refrigerator, and Frozen), dated 2020, showed the following:-Food shall be stored on shelves in a clean, dry area free from contaminants;-Food should be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety;-All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded;-Discard food that has past expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration;-Leftover contents of cans and prepared food will be stored and covered, labeled and dated containers and refrigerators and or freezers;-Store dry food 6 inches off the floor to allow for proper sanitation;-Dented cans are set aside in a separate labeled area of the storeroom to avoid using them and discarded according to vendor procedure. Review of the kitchen inspection, conducted by the facility's registered dietitian on 5/5/25, showed the following item needed correction: Recommend placing all opened items in a sealable bag or container with a label. Review of the kitchen inspection, conducted by the facility's registered dietitian on 6/9/25, showed the following item needed correction: Recommend placing all opened items in a sealable bag or container with a label. Review of the kitchen inspection, conducted by the facility's registered dietitian on 7/25/25, showed the following items needed correction:-Recommend keeping bins covered at all times. Flower bin and sugar bin are each missing part of their lid. This exposes them to cross contamination. Debris observed inside of sugar. Recommend discarding contents, clean bins, refill bins, and keep them covered;-Recommend to label all opened and prepped items;-Recommend checking labels on items daily and discard outdated products. Observation on 8/4/25 at 8:41 A.M., in the kitchen, showed the following:-In the reach-in cooler, approximately ten broken eggshells were intermixed in a carton of whole eggs;-In the reach-in freezer, open bags of French fries and buns loosely folded over and not securely sealed;-In the dry storage room, open bags of rotini, macaroni, baking chips, and brown sugar loosely folded over, not securely sealed, and did not have open dates indicated on the bags. Bulk bins of flour and sugar were uncovered, and the sugar was very clumpy and had a package of crackers in the sugar. A large bag of sugar had a metal scoop in the bag and the bag was not sealed. An onion was on the floor;-In the walk-in cooler, a head of cabbage, butter packets, kiwi, and applesauce cup were on the floor under the shelves;-In the walk-in freezer, a bag of tortillas and three frozen biscuits were on the floor. A bag of frozen beef patties was unsealed and open to the air. Observation on 8/4/25 at 9:48 A.M., in the special care unit kitchenette, showed the following:-In the cabinets, a box of pancake mix and a box of raisins were both unsealed. A jar of yeast, with the label that read 'Refrigerate or freeze after opening and use within four months. Best if used by February 2025,' sat unrefrigerated on the shelf;-In the refrigerator, sandwiches in zipper top bags were undated and unlabeled. Observation on 8/4/25 at 9:36 A.M., in the north activity room kitchenette, showed the following:-In the cabinets, an open bag of marshmallows was loosely folded over and not sealed;-On the countertop, scoops were stored in bulk containers of flour and sugar;-In the refrigerator, a plastic container containing a red sauce and a plastic container containing a light, gray-colored food item was both unlabeled and undated. Observation on 8/4/25 at 11:06 A.M., in the dry storage room, showed a can of black beans had heavy dent damage and was in service with the rest of the canned food items. Observation on 8/5/25 at 1:43 P.M., in the south utility room refrigerator, showed the following:-The sign on the refrigerator door said, 'The food and drinks in this refrigerator are for residents only, everything must be labeled and dated;'-In the freezer section, a cup of orange ice cream-like substance was uncovered, unlabeled, and undated;-In the refrigerator section, a bowl of a brown food item and a bowl of white and black food item were both unlabeled and undated. During an interview on 8/6/25 at 2:05 P.M., [NAME] V said food items should be labeled, dated, and sealed. During an interview on 8/6/25 at 2:33 P.M., the Dietary Manager said she expected food to be stored, prepared, and served under safe and sanitary conditions. She expected food items to be labeled, dated, and stored per label instructions and for there not to be dented cans, expired, or unsealed food items. Staff should discard eggshells in the trash. 2. Review of the facility policy, Proper Handwashing and Glove Use, dated 2020, showed the following:-All employees will use proper hand washing procedures and glove usage in accordance with state and federal sanitation guidelines;-The proper procedure for washing hands is as follows: -Turn on water as hot as comfortable; -Wet hands and apply soap; -Scrub 15 to 20 seconds or more getting under nails between fingers and all exposed areas such as back of hands and forearms; -Rinse hands thoroughly; -Dry hands with paper towel or air dryer; -Turn off faucet with paper towel;-All employees will wash hands upon entering the kitchen from any other location, after all breaks, and between all tasks;-Employees will wash hands before and after handling foods, after touching any part of the uniform, face, or hair;-Gloves are to be used whenever direct food contact is required;-Hands are washed before donning gloves and after removing gloves;-Gloves are changed anytime hand washing would be required. This includes when leaving the kitchen for a break or to go to another location in the building, after handling potentially hazardous raw food, or if the gloves become contaminated by touching the face, hair, uniform, or other non-food contact surfaces such as door handles and equipment;-When gloves must be changed, they are removed, hand washing procedure is followed, and a new pair of gloves is applied. Gloves are never placed on dirty hands, the procedure is always wash, glove, remove, rewash and re-glove. Observation on 8/4/25 at 8:41 A.M., in the kitchen near the handwashing sink, showed the step-pedal trash can was broken and would not open the lid with the step-pedal. Observation on 8/4/25 at 10:38 A.M., in the kitchen, showed [NAME] V used his/her gloved hands to open a package of raw meat and transferred the meat to a pan. After he/she discarded the raw meat wrapper, he/she changed his/her gloves and did not wash his/her hands. He/She opened a utensil drawer and obtained a spatula to assist Dietary Aide W frost a cake and then handed the spatula to Dietary Aide W to continue frosting the cake. Observation on 8/4/25 at 10:43 A.M., in the kitchen, showed Dietary Aide W dropped a measuring cup onto the floor, picked up the cup with his/her gloved hands, and did not wash his/her hands or change his/her gloves. With his/her gloved hands, he/she frosted a cake and sliced the cake into pieces. He/She then served the cake into individual bowls with a spatula, touching the sides of the cake as he/she slid the cake off the spatula into the bowls. Observation on 8/4/25 at 11:37 A.M., in the kitchen, showed the Dietary Manager used his/her gloved hands to obtain pieces of bread from a bag on a cart where she prepared sandwiches for the lunch meal service. She touched the handles of the cart, a serving utensil, and then wiped the side of her face with her gloved hands. She removed her gloves, washed her hands, and touched the lid of the broken handwashing sink trash can with her clean hands to open the lid and discard a paper towel. She put on gloves and continued preparing sandwiches at the cart. Observation on 8/4/25 at 4:54 P.M., in the kitchen, showed Dietary Aide Y served residents' food items from the steam table onto plates during the dinner meal service. He/She left the steam table to obtain a resident's drink by grasping and opening the door of the walk-in cooler with his/her gloved hands. He/She returned to the steam table, did not wash his/her hands or change his/her gloves, and continued serving food items. He/She touched utensil handles and grasped pieces of bread (served onto residents' plates) with his/her gloved hands. Observation on 8/6/25 at 2:25 P.M., in the kitchen, showed Dietary Aide X entered the kitchen and was texting on his/her phone. He/She did not wash his/her hands and put on gloves. Using his/her gloved hands, he/she grasped silverware by the eating surfaces of the utensils and wrapped the silverware into napkins. He/She washed his/her hands and turned off the faucet handles with his/her clean hands. He/She put on gloves and prepared pureed fruit at the food processor. As he/she added fruit to the food processor, he/she touched the fruit with his/her gloved hands. During an interview on 8/6/25 at 2:33 P.M., the Dietary Manager said she expected staff to not touch ready to eat food items with bare hands or soiled gloves. Staff should wash their hands prior to conducting clean tasks, when changing gloves, after conducting dirty tasks, and after picking up items from the floor. The step-trash can by the handwashing sink had been broken for a couple months. 3. Review of the facility policy, Cleaning Rotation, dated 2020, showed the following:-Equipment and utensils will be cleaned and sanitized according to the following guidelines or manufacturer's instructions;-Items cleaned daily: stove top, grill, exterior of large appliances;-Items cleaned weekly: hoods, filters, storerooms, shell, cupboards;-Items clean monthly: refrigerators, freezers, ingredient bins comma ice machines, food containers, walls. Review of the facility policy, Dishwashing: Machine Operation, dated 2020, showed the following:-Check the dishwashing machine for cleanliness before the start of each meal. Wipe down the dishwashing machine and clean per equipment cleaning procedure at the end of each workday. Remove any built up debris, lime, or scale as necessary or generally complete a thorough deliming per cleaning schedule or one time weekly. Review of the kitchen inspection, conducted by the facility's registered dietitian on 5/5/25, showed the following items needed correction:-Recommend to clean grease and debris from area surrounding flat top grill;-Recommend to clean carbon buildup from the top oven; Review of the kitchen inspection, conducted by the facility's registered dietitian on 6/9/25, showed the following items needed correction:-Recommend to clean carbon buildup on stove top;-Recommend to clean exterior (include top) of dish machine to remove debris build up;-Recommend cleaning food debris from bottom of reach-in freezer. Review of the kitchen inspection, conducted by the facility's registered dietitian on 7/25/25, showed the following items needed correction:-Recommend clean grease debris from hood vents and to clean hood vents weekly;-Recommend to clean food debris from exterior of dish machine;-Recommend to clean grease buildup on wall behind fryer and oven. Review of the facility's maintenance and inspection documentation showed the kitchen range hood six-month cleaning last occurred on 4/16/25. Observation on 8/4/25 at 9:07 A.M., in the kitchen and adjacent dining room, showed the following:-The food preparation sink and wall above it were splattered with dried brown, white, and gray-colored debris;-The two burner stove top had a thick layer of black encrusted debris across its surface;-There was a heavy accumulation of yellow drips on the wall behind and on the sides of the cooking equipment;-The range hood baffle filter above the fryer and flat-top griddle had a moderate accumulation of yellow grease;-The tops and sides of the dishwashing machine had a heavy accumulation of dried brown crusty debris;-The ice dispenser in the dining room had a heavy accumulation of dried white and brown drips and debris around the spout and dispensing mechanism. Observation on 8/5/25 at 1:43 P.M., in the south utility room refrigerator, showed sticky clear and brown residue on the shelves and in the bottom of the refrigerator. During an interview on 8/6/25 at 4:08 P.M., [NAME] V said a company cleaned the range hood. Facility staff did not clean the range hood baffle filters in between professional cleanings. During an interview on 8/6/25 at 2:33 P.M., the Dietary Manager said the area by the range and cooking equipment needed a deep cleaning. She would like staff to clean cooking equipment daily as staff had free time to clean the items. 4. Review of the facility policy, Hair Restraints, dated 2020, showed the following:-Staff shall wear hair restraints in all food production, dishwashing, and serving areas;-Hair restraints, hats, and or beard guards shall be used to prevent hair from contacting exposed food. Observation on 8/4/25 at 10:57 A.M., in the kitchen, showed the Dietary Manager wore a hair restraint but the hair restraint did not cover two-inch sections of hair on the sides and back of her head. She covered individual bowls of cake with plastic and placed the bowls on a cart. Observation on 8/4/25 at 11:35 A.M., in the kitchen, showed the Dietary Manager wore a hair restraint but the hair restraint did not cover two-inch sections of her hair on the front, sides and back of her head. She stood by open bowls of cake and instructed staff to pour milk into some of the bowls for pureed food items. During an interview on 8/6/25 at 2:33 P.M., the Dietary Manager said she expected staff to properly wear hair restraints when in the kitchen. 5. Review of the facility policy, Storing Utensils, Tableware, and Equipment, dated 2020, showed the following:-Employees will store utensils, tableware, and equipment according to the following guidelines;-Cleaned and sanitized utensils and equipment will be stored at least six inches off the floor in a clean, dry location in a way that keeps them from contamination by splash, dust, or other means;-Cleaned and sanitized equipment and utensils should be handled in a way that protects them from contamination. Spoons, knives and forks should be touched only by their handles. Cups, glasses, bowls, plates, and similar items should be handled so as not to touch any surface that may come into contact with food or a resident's mouth;-Store flatware and utensils with handles up so employees can pick them up without touching food contact surfaces. Observation on 8/4/25 at 12:10 P.M., in the kitchen at the steam table, showed Dietary Aide Y served residents' plates of food for the lunch meal service. He/She obtained a plate from the plate warmer. The plate had dried green food debris on the eating surface of the plate. He/She served a resident's food items onto the plate and placed it on the cart of food trays to go to the resident halls. Observation on 8/4/25 at 9:07 A.M., in the kitchen beverage area, three pitchers had brown staining across their interior surface and one pitcher had a large amount of moisture accumulation on the interior surface. During an interview on 8/6/25 at 2:33 P.M., the Dietary Manager said she expected dishes to be in good condition and properly cleaned and sanitized between uses. She expected dishes to be stored clean and free of moisture. 6. Review of the Sanitizing Bucket Chemical Logbook, located in the kitchen, showed the following:-A log sheet for June 2025 was blank;-No log sheets for July 2025 or August 2025. Observation on 8/4/25 at 11:25 A.M., in the kitchen, showed the Dietary Manager washed her hands at the handwashing sink and carried the paper towel (she used to dry her hands and turn off the faucet handle) in her hand as she picked up a clean pan. She held the paper towel in the same hand as the clean pan and took the pan to the dining room ice dispenser where she filled the pan with ice. She returned to the kitchen, sat the pan of ice on the preparation counter, and obtained additional paper towels (she was still holding the previous paper towel). She then used the old and new paper towels to wipe down a three-tier cart in the food serving and preparation area of the kitchen. She did not use sanitizing spray, nor did she use a sanitizing cloth obtained from a bucket of sanitizing solution. During an interview on 8/6/25 at 4:08 P.M., [NAME] V said staff should log the pH level of the sanitizing bucket solution every two hours on the sanitizing bucket log. During an interview on 8/6/25 at 2:33 P.M., the Dietary Manager said she expected staff to clean surfaces using cloths stored submerged in buckets of sanitizing solution. Staff should monitor and record the pH of the sanitizing solution on the log sheet during their shift. 7. Observation on 8/4/25 at 2:13 P.M., in the kitchen dishwashing room, showed Dishwasher Y ate food from a bowl next to the clean dish area where clean dishes were drying. During an interview on 8/6/25 at 2:33 P.M., the Dietary Manager said staff should not eat in the kitchen or dishwashing room and should instead eat in the office within the kitchen or in the staff break room.

Based on observation, interview and record review, the facility failed to provide care in a manner that enhanced residents' dignity and ensured full recognition of individuality for one resident (Resident #72), in a review of 18 sampled residents, and three additional residents (Residents #26, #32 and #57). The facility census was 72. Review of the facility policy, Assistance with Meals, revised March 2022, showed the following:-Residents shall receive assistance with meals in a manner that meets the individual needs of each resident;-Facility staff will serve resident trays and will help residents who require assistance with eating;-Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, - Do not stand over residents while assisting them with meals. 1. Review of Resident #26's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/22/25, showed the following:-Severely impaired cognitive skills for daily decision making;-Diagnoses of cerebral palsy (a condition marked by impaired muscle coordination (spastic paralysis) and/or other disabilities, typically caused by damage to the brain before or at birth) and quadriplegia (partial or total loss of function in all four limbs and torso); -Dependent on staff for eating. Review of the resident's Care Plan, dated 07/01/25 showed the following:-The resident will be assisted with ADLs and will have needs/wants met by staff;-Resident to be assisted with all meals/snacks/drinks-dependent with feeding/drinking. Observation on 08/04/25 at 12:10 P.M. in the dining room showed the following:-The resident sat in a reclining wheelchair;-Certified Nurse Assistant (CAN) H stood beside the resident while he/she fed the resident bites of pureed food. During an interview on 08/11/25 at 3:30 P.M., CNA H said he/she stood while feeding in the dining room to keep an eye on the other residents and to monitor for choking. 2. Review of Resident #32's Annual MDS, dated [DATE], showed the following:-Short and long-term memory problems;-Dependent on staff for eating;-Diagnosis of Alzheimer's disease (dementia). Review of the resident's Care Plan, revised 08/05/25, showed the following:-Provide set up, oversight, encouragement, cueing and assistance during eating and drinking;-Resident has a chewing problem related to cognition and was edentulous (no teeth);-Encourage resident to eat/drink during meals;-Resident requires assistance with eating. Observation on 08/04/25 at 12:05 P.M. in the dining room showed the following:-The resident sat in a reclining wheelchair at the table;-CNA B stood beside the table and fed the resident bites of pureed food. During an interview on 08/11/25 at 03:45 P.M., CNA B said the following: -Staff should probably sit next to a resident when they assisted residents; -Most of the staff, stood when they helped a resident to eat because several residents needed assistance, and staff did not want food to get cold. 3. Review of Resident #72's undated Continuity of Care Document (CCD), showed the following diagnoses included multiple sclerosis (MS, a progressive disease-causing damage to nerves), and dementia. Review of the resident's Care Plan, dated 03/06/23, showed the following: -Encourage the resident to eat/drink during meals;-The resident was still able to feed self at this time;-The resident had mild dysphagia (difficulty swallowing); -Regular diet with nectar thick liquids. Review of the resident's undated Physician Order Sheet (POS) showed finger foods to increase self-feeding/independence at meals, start date 03/31/25, open-ended (no stop date). Review of the resident's significant change MDS, completed by facility staff on 05/23/25, showed the following: -Severe cognitive impairment; -Partial to moderate assistance for eating; -Mechanically altered diet. Observation on 08/04/25 at 12:15 P.M. showed the following: -The resident sat in his/her wheelchair with his/her neck supported by a neck pillow at the dining room table; -The resident had a chicken salad sandwich and fried zucchini on his/her plate; a sealed container of apple sauce sate out of the resident's reach; -CNA B asked the resident if he/she wanted to be pulled up before CNA B started to feed the resident, the resident did not answer. -CNA B stood next to the seated resident, opened the container of applesauce, and fed the resident a few bites of applesauce while standing;-CNA B did not speak to the resident further during the meal. During an interview on 08/11/25 at 06:00 P.M., the Director of Nurses (DON) said the following: -She would prefer staff to sit next to a resident when assisting a resident to eat; -Sitting next to a resident allowed for a better interaction with the resident. During an interview on 08/11/25 at 06:35 P.M., the Administrator said staff should sit next to a resident and not stand if a resident needed assistance to eat.

Based on observation, interview and record review, the facility failed to ensure two residents (Residents # 27 and #72), in a review of 18 sampled residents, and one additional resident (Resident #26), were provided the right to choose schedules (including waking times) and make choices about aspects of their lives in the facility that were significant to the residents. The facility census was 72. Review of the facility policy, Quality of Life-Dignity, revised February 2020, showed the following:-Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem;-Residents are treated with dignity and respect at all times;-The facility culture is one that supports and encourages humanization and individuation of residents and honors resident choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay;-Some examples of ways in which respect for choices and values are exercised include schedules. Residents may choose when to sleep, eat, and conduct activities of daily living. 1. Review of Resident #27's care plan, last revised 06/03/25, showed the following: -Resident needed assistance with ambulation, transfers and activities of daily living (ADLs); -Resident transfers with staff assistance and sit-to-stand lift; -Offer resident toileting and position changes throughout the day, as well as assisting resident to and from the dining room area at mealtimes; -The resident's care plan did address preference for waking time. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/02/25, showed the following: -Severe cognitive impairment;-No behaviors or rejection of cares; -Substantial to maximal assistance for toileting; -Dependent for personal hygiene; -Substantial to maximal assistance for mobility;-Diagnosis of cerebral vascular accident (stroke) with hemiplegia (loss of ability to move one side of the body or the other). Observation on 08/06/25 at 04:10 A.M. showed the following: -The resident lay in bed with both eyes closed and appeared to be sleeping; -The resident wore a pajama top; -The resident's room was dark and the hallway lights were turned down low. Observation on 08/06/25 at 05:05 A.M. showed the following: -Certified Nurse Assistant (CNA) A came out of the resident's room; -The resident was dressed and sat in his/her wheelchair beside the bed; -The resident's head was down with both eyes closed and appeared to be sleeping. Observation on 08/06/25 at 06:10 A.M. showed the following: -CNA A pushed the resident in his/her wheelchair to the television room on the south wing of the facility; -The resident's head was down with both eyes closed, and appeared to be sleeping; -The overhead lights and television were on. Observation on 08/06/25 at 07:10 A.M. showed the following: -The resident sat in his/her wheelchair in the television room on the south wing of the facility; -The resident's head was down with both eyes closed and appeared to be sleeping. Observation on 08/06/25 at 07:30 A.M. showed the following: -An unidentified staff pushed the resident in his/her wheelchair from the television room to the dining room; -The resident opened his/her eyes initially, but then closed them again and appeared to be sleeping. Observation on 08/06/25 at 08:00 A.M. showed the resident sat at the dining room table in his/her wheelchair with his/her eyes closed, head down, and appeared to be sleeping. Observation on 08/06/25 at 08:30 A.M. showed the following: -The resident sat in his/her wheelchair at the dining room table with his/her eyes closed, and appeared to be asleep; -An unidentified staff told the resident it was time to wake up and began to set up the resident's breakfast tray. During an interview on 08/06/25 at 05:30 A.M., CNA A said the following: -The resident was a one-person assist, so night shift staff could get the resident up and dressed; -Getting the resident up and dressed early in the day helped day shift. During an interview on 08/06/25 at 12:50 P.M., the resident's power of attorney (POA) said the following: -The resident used to get up early, but not as early as the facility woke him/her up; -The resident would probably have liked to stay in bed until a time closer to breakfast. 2. Review of Resident #72's undated Continuity of Care Document (CCD), showed the resident's diagnoses included multiple sclerosis (MS, a progressive disease-causing damage to nerves) and dementia. Review of the resident's care plan, last revised 07/27/23, showed the following: -The resident required assistance with ADLs due to a diagnosis of MS; -The resident required assistance of one staff for morning cares, to include oral care, brushing hair, peri care and catheter care and deodorant; -The resident's care plan did not specify the resident's preference related to early rising. Review of the resident's significant change MDS, completed by facility staff, dated 05/23/25, showed the following: -Severe cognitive impairment; -No behaviors or rejection of cares; -Dependent for mobility. Observation on 08/06/25 at 04:10 A.M. showed the following: -The resident lay in his/her bed with eyes closed and appeared to be sleeping;-The resident wore a hospital gown. Observation on 08/06/25 at 07:10 A.M. showed the following: -The resident was dressed and sat in his/her wheelchair in the television room on the south wing of the facility; -The resident's eyes were closed and he/she appeared to be sleeping. Observation on 08/06/25 at 07:30 A.M. showed the following: -The administrator pushed the resident in his/her wheelchair from the television room to the dining room for breakfast; -The resident sat at the dining room table with his/her eyes closed and appeared to sleep. Observation on 08/06/25 at 08:30 A.M. showed the following: -The resident sat in his/her wheelchair at the dining room table, with his/her eyes closed and appeared to be sleeping; -Staff woke the resident up, set up his/her breakfast tray, and told the resident it was time to eat. During an interview on 08/06/25 at 11:52 A.M., the resident's family member said the following: -The resident was not typically an early riser; -He/She would prefer staff allow the resident to sleep later, unless there was a reason or need for the resident to get up. 3. Review of Resident #26's quarterly MDS, dated [DATE], showed the following:-Severely impaired cognitive skills for daily decision making;-No speech;-Diagnoses of cerebral palsy (a condition marked by impaired muscle coordination (spastic paralysis) and/or other disabilities, typically caused by damage to the brain before or at birth) and quadriplegia (paralysis of all four limbs);-Dependent on staff for eating, dressing, personal hygiene and bed to chair transfer;-Hospice care. Review of the resident's Care Plan, dated 07/01/25 showed the following:-The resident declined in physical abilities and ability to perform/assist with activities of daily living (ADLs) related to cerebral palsy/increased weakness;-Staff will assist the resident with ADLs and will meet the resident's needs/wants;-The resident's care plan did not specify the resident's preference related to early rising. Observation on 08/06/25 at 5:14 A.M. showed the following:-The resident lay in bed awake;-The resident was fully dressed;-A cloth mechanical lift pad was positioned underneath the resident in the bed. Observation on 08/06/25 at 5:27 A.M. showed the following:-The resident lay in bed with his/her eyes open;-Certified Nurse Aide (CNA) M and Certified Medication Technician (CMT) N hooked the lift pad up to the mechanical lift;-CNA M and CMT N transferred the resident from bed to his/her wheelchair. Observation on 08/06/25 at 7:05 A.M. at the nurses' station showed the following:-The resident sat in his/her wheelchair;-The resident was awake. Observations on 08/06/2025 in the dining room showed the following:-At 8:07 A.M., the resident sat in his/her wheelchair. Staff fed the resident breakfast; -At 8:16 A.M., staff finished feeding the resident breakfast;-At 8:25 A.M., the resident sat in his/her wheelchair in the dining room. The resident's eyes were closed. During an interview on 08/07/2025 at 11:11 A.M., the resident's representative said he/she thought getting the resident up around 5:00 A.M. was too early. During an interview on 08/06/25 at 5:27 A.M., CNA M said the following:-Staff (unknown name) directed him/her to get the resident up before he/she left at 7:00 A.M.; -He/She did not know if the resident preferred to get up early;-The resident was unable to verbalize his/her wants or needs. 4. During an interview on 08/11/25 at 6:05 P.M., the Director of Nursing (DON) said the following:-Staff should not wake a resident and get them up in the early morning if the resident was sleeping;-If the resident was cognitively impaired, the resident's representative should be asked about the resident's preference on rising. During an interview on 08/11/25 at 06:35 P.M., the administrator said the following: -Staff should not wake residents in the early morning hours if the resident was sleeping soundly; -If a resident was cognitively impaired, staff should ask the resident's representative about the resident's preference on rising.

Based on interview and record review, the facility failed to electronically transmit a Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) in a timely manner and in accordance with guidelines for one resident (Resident #18) in a review of 18 sampled residents and five additional residents (Resident #15, #25, #30, #32 and #36). The facility's census was 72. The facility did not provide a policy for MDS assessment and transmission upon request. Review of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) User's Manual, dated October 2024, showed the following: -For all non-admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the admission assessment, the MDS Completion Date must be no later than 13 days after the entry date;-Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software). 1. Review of Resident ##15 MDS record showed the following:- admitted on [DATE];-Significant Change MDS completed on 05/23/25;-Significant Change MDS accepted on 08/01/25;-The facility did not transmit the MDS within 14 days of the completion date. 2. Review of Resident #18's MDS record showed the following:-admitted on [DATE];-Quarterly MDS completed on 06/26/25;-Quarterly MDS accepted on 08/01/25; -The facility did not transmit the MDS within 14 days of the completion date.3. Review of Resident #25's MDS record showed the following: -admitted on [DATE]; -Quarterly MDS completed on 06/25/25;-Quarterly MDS accepted on 08/01/25; -The facility did not transmit the MDS within 14 days of the completion date. 4. Review of Resident #30's MDS record showed the following: -admitted on [DATE]; -Quarterly MDS completed on 06/02/25; -Quarterly MDS accepted on 08/11/25; -The facility did not transmit the MDS within 14 days of the completion date. 5. Review of Resident #32's MDS record showed the following: -admitted on [DATE]; -Annual MDS completed on 06/20/25;-Annual MDS accepted on 08/01/25;-The facility did not transmit the MDS within 14 days of the completion date. 6. Review of Resident #36's MDS record showed the following: -admitted on [DATE]; -Quarterly MDS completed on 06/21/25;-Quarterly MDS accepted on 08/01/25; --The facility did not transmit the MDS within 14 days of the completion date. During an interview on 08/11/2025 at 02:15 P.M. and 06:00 P.M., the MDS Coordinator said the following: -She was the Director of Nurses (DON) for the facility and the only staff person on-site who submitted MDS information;-She tried to submit MDS information weekly and could usually get that done; -The facility did have some consultants off-site who helped with entering MDS information; -She did not always review the MDS information submitted by the consultant for accuracy before signing; -The facility should follow the RAI manual regarding completion and submission of MDS assessments. During an interview on 08/11/2025 at 06:35 P.M., the administrator said the facility should follow the RAI manual regarding completion and submission of MDS assessments.

Based on observation, interview and record review, the facility failed to ensure chemicals were secured in a locked storage area and not accessible to residents. The facility failed to ensure the electric range, located in the north activity room was disabled when not in use and staff were not present. The facility census was 72. 1. Review of Resident #62's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 06/17/25, showed the following: -Cognitively impaired; -Diagnosis of non-Alzheimer's dementia (a group of conditions causing cognitive decline, impacting memory, thinking and behavior, that are not due to Alzheimer's disease). Observation on 08/06/25 at 4:10 A.M. on the 400 hall showed the following:-The shower room door was unlocked and accessible to residents;-No staff was present in the area;-Resident #62 walked up and down the hallway; -Two bottles of Lysol disinfectant cleaner sat on the floor by the toilet. The label read, Warning: Causes substantial but temporary eye injury. Prolonged or frequently repeated skin contact may cause allergic reactions in some individuals. Do not get in eyes, on skin or on clothing. Storage and disposal: Store in areas inaccessible to children; -Two bottles of window cleaner sat on the floor by the shower stall. The label read, KEEP OUT OF REACH OF CHILDREN AND PETS;-A bottle of non-acetone nail polish remover sat on the shelf by the sink. The label read, Warning: Extremely flammable. Liquid and vapors may ignite. Keep out of eyes. Harmful if ingested. Keep out of reach of children;-A bottle of High Disinfecting Quotient (HDQ) disinfectant cleaner (hospital disinfectant cleaner and deodorant formulated to kill a broad spectrum of microorganisms) sat on the counter by the whirlpool tub. The label read, KEEP OUT OF REACH OF CHILDREN. DANGER. Observation on 08/07/25 at 05:35 P.M. on the 400 hall showed the following:-The shower room door was unlocked and accessible to staff and residents; -Two bottles of Lysol disinfectant cleaner sat on the floor by the toilet; -Two bottles of window cleaner sat on the floor by the shower stall;-A bottle of non-acetone nail polish remover sat on the shelf by the sink;-A bottle of High Disinfecting Quotient (HDQ) disinfectant sat on the counter by the whirlpool tub. 2. Observation on 8/4/25 at 9:48 A.M. showed a lower cabinet in the special care unit kitchenette was unlocked. Five residents were in the day room next to the kitchenette. The following items were located within the unlocked cabinet: -One bottle of bleach with a label that read, 'Danger: Corrosive. Causes irreversible eye and skin damage. May be fatal if swallowed. Hazards to humans and domestic animals. Physical and chemical hazards: strong oxidizing agent;' -One bottle of carpet and upholstery shampoo with a label that read, 'Caution: Keep out of reach of children. Harmful if swallowed. Causes eye irritation'; -One bottle of all-purpose cleaner with a label that read, 'Warning: Keep out of reach of children. Store in areas inaccessible to children. Hazards to humans and domestic animals. Warning: Causes substantial but temporary eye injury. Do not get in eyes, on skin or clothing'; -One bottle of peroxide disinfectant with a label that read, 'Caution: Keep out of reach of children. Causes eye irritation. Harmful if inhaled'. Observation on 08/04/25 at 11:57 A.M. on the Special Care Unit showed the lower cabinet, which contained cleaning chemicals, in the special care kitchenette remained unlocked. Four residents were at the kitchen table in this area. 3. Observation on 8/4/25 at 9:36 A.M., in the north activity room, showed the following: -A bag of fertilizer spikes, with a label that read, 'Keep out of reach of children and pets,' was in an unlocked drawer;-A sign above the electric range read, 'Stove must be turned off at the breaker box in closet after each use.' The range was able to be turned on. Three residents sat in the room, and no staff were present. During an interview on 8/6/25 at 3:49 P.M., the Activities Director said the breaker to the stove in the north activity room should be turned off after each use. She was unaware the breaker had not been turned off after the stove was used last. She was unaware the fertilizer spikes were unlocked. 4. Observation on 8/4/25 at 10:11 A.M., in room [ROOM NUMBER] (used for storage), located near the beauty shop and therapy department, showed three bottles of toilet bowl cleaner with labels that read, 'Store in areas inaccessible to children. Hazardous to humans and domestic animals. Corrosive can cause severe burns. May be fatal if swallowed. Keep out of reach of children. Can cause severe eye damage.' The room was unlocked, and no staff were in or near the room. 5. During an interview on 8/7/25 at 8:43 A.M., the Maintenance Director said chemicals and hazardous materials should be secured or locked from resident access. He was unaware of the items found unsecured and unlocked. During an interview on 08/11/25 at 6:05 P.M., the Director of Nursing (DON) said chemicals should be locked and inaccessible to residents. During an interview on 08/11/25 at 6:35 P.M., the Administrator said chemicals should be locked and inaccessible to residents.

Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week and failed to ensure the Director of Nursing (DON) worked as a charge nurse only when the facility had a census of 60 or less. The facility census was 72. 1. Review of the Facility Assessment, dated 07/09/25 showed the following:-Average daily census: 70;Staff included one Registered Nurse, Director of Nurses full time on days, an Assistant Director of Nursing (ADON) full time on days, and an RN or Licensed Practical Nurse (LPN), two for the day shift and one for night shift. 2.Review of the Licensed Nurse Schedule, dated January 2025, showed no hours of RN coverage for 01/01/25. Review of the Licensed Nurse Schedule, dated 01/07/25, showed no hours of RN coverage scheduled. Review of RN R's timecard, dated 01/07/25, showed he/she worked six hours and 45 minutes (did not fulfill the eight-hour requirement). 3.Review of the Census Activity Report, dated 01/11/25, showed the facility census was 68. Review of the Licensed Nurse Schedule, dated 01/11/25, showed the DON was scheduled to work 7:00 P.M. to 7:00 A.M. (12 hours). Review of the Daily Schedule, dated 01/11/25, showed the following:-Two LPNs worked 7:00 A.M. to 7:00 P.M.;-The DON worked 6:49 P.M. to 7:31 A.M. as charge nurse. 4. Review of the Census Activity Report, dated 01/12/25, showed the facility census was 68. Review of the Licensed Nurse Schedule, dated 01/12/25, showed the DON was scheduled to work 11:00 P.M. to 7:00 A.M. (8 hours). Review of the Daily Schedule, dated 01/12/25, showed the following:-Two LPNs worked 7:00 A.M. to 7:00 P.M.;-The DON worked 10:54 P.M. to 9:09 A.M. as charge nurse. 5. Review of the Licensed Nurse Schedule, dated January 2025, showed no hours of RN coverage for 01/17/25. 6. Review of the Licensed Nurse Schedule, dated 01/25/25, showed no hours of RN coverage scheduled. Review of the DON's timecard, dated 01/25/25, showed she worked six hours and 30 minutes (did not fulfill the eight-hour requirement). 7. Review of the Licensed Nurse Schedule, dated January 2025, showed no hours of RN coverage for 01/26/25. 8. Review of the Licensed Nurse Schedule, dated 01/29/25, showed no hours of RN coverage scheduled. Review of RN R's timecard, dated 01/29/25, showed he/she worked seven hours and 35 minutes (did not fulfill the eight-hour requirement). 9. Review of the Licensed Nurse Schedule, dated 02/08/25, showed no hours of RN coverage scheduled. Review of the DON's timecard, for 02/08/25, showed she worked six hours and 15 minutes (did not fulfill the eight-hour requirement). 10. Review of the Licensed Nurse Schedule, dated 02/09/25, showed no hours of RN coverage scheduled. Review of the DON's timecard, for 02/09/25, showed she worked six hours and 15 minutes (did not fulfill the eight-hour requirement). 11. Review of the Licensed Nurse Schedule, dated February 2025, showed no hours of RN coverage for 02/28/25. 12. Review of the Licensed Nurse Schedule, dated 03/04/25, showed no hours of RN coverage scheduled. Review of RN R's timecard, dated 03/04/25, showed he/she worked six hours and 45 minutes (did not fulfill the eight-hour requirement). 13. Review of the Licensed Nurse Schedule, dated March 2025, showed no hours of RN coverage for 03/14/25 and 03/28/25. 14. Review of the Licensed Nurse Schedule, dated May 2025, showed no hours of RN coverage for 05/23/25. 15. Review of the Licensed Nurse Schedule, dated 05/26/25, showed no hours of RN coverage scheduled. Review of RN R's timecard, dated 05/26/25, showed he/she worked seven hours and 15 minutes (did not fulfill the eight-hour requirement). 16. Review of the Licensed Nurse Schedule, dated June 2025, showed no hours of RN coverage on 6/28/25 and 06/29/25. 17. Review of the Licensed Nurse Schedule, dated 07/08/25, showed no hours of RN coverage scheduled. Review of the RN Consultant's timecard, dated 07/08/25, showed he/she worked six hours and 15 minutes (did not fulfill the eight-hour requirement). 18. Review of the Licensed Nurse Schedule, dated 07/12/25, showed no hours of RN coverage scheduled. Review of the DON's timecard, for 07/12/25, showed she worked five hours (did not fulfill the eight-hour requirement). 19. Review of the Licensed Nurse Schedule, dated 07/13/25, showed no hours of RN coverage scheduled. Review of the DON's timecard, for 07/13/25, showed she worked six hours (did not fulfill the eight-hour requirement). 20. Review of the Licensed Nurse Schedule, dated 07/18/25, showed no hours of RN coverage. 21. Review of the Licensed Nurse Schedule, dated 07/25/25, showed no hours of RN coverage scheduled. Review of the DON's timecard, for 07/25/25, showed she worked seven hours (did not fulfill the eight-hour requirement). 22. Review of the Licensed Nurse Schedule, dated 07/26/25, showed no hours of RN coverage scheduled. Review of the DON's timecard, for 07/26/25, showed she worked two hours and 45 minutes (did not fulfill the eight-hour requirement). 23. Review of the Licensed Nurse Schedule, dated July 2025, showed no hours of RN coverage on 07/31/25. 24. During an interview 08/11/25 at 6:04 P.M., the DON said the following:-Human Resources (HR) was responsible for the licensed nurse schedule;-The facility only had four RNs;-She was never scheduled to work as a charge nurse. She covered when there were call-ins. During an interview on 08/11/25 at 6:30 P.M., the Administrator said the following:-HR was responsible for ensuring RN coverage eight hours a day;-The facility tried to have an RN on duty eight hours a day;-Recently they had one RN out on medical leave and there were no agency RNs available;-The DON covered as charge nurse in emergency situations only.

Based on interview and record review, the facility failed to complete a performance review of each nurse aide at least once every 12 months and provide regular in-service education based upon the outcome of the reviews. The facility census was 72. The facility did not provide a policy for annual performance reviews. 1.Review of a list of current staff, dated 08/05/25 showed the following:-Certified Nurse Aide (CNA) I: Date of hire 04/15/09;-CNA J: Date of hire 07/03/23;-CNA H: Date of hire 07/04/07;-CNA B: Date of hire 10/20/22;-CNA L: Date of hire 02/10/11. Record review showed no documentation of nurse aide evaluations or annual performance reviews for CNA B, CNA H, CNA I, CNA J or CNA L. During an interview on 08/11/25 at 6:04 P.M., the Director of Nursing (DON) said the following:-Nurse aide evaluations/annual performance reviews had not been completed for a while;-If there were complaints regarding staff performance or skills, the Registered Nurse (RN) Consultant proved additional training to that staff member. During an interview on 08/11/25 at 6:30 P.M. the Administrator said the facility did not have nurse aide evaluations or annual performance reviews.

Based on observation, interview, and record review, the facility failed to provide food at an appetizing temperature. The facility census was 73. Record review of the facility policy, Serving Temperatures for Hot and Cold Foods, revised 2020, showed the following: -Food will be served at the following temperatures to ensure a safe and appetizing dining experience: -Vegetables - 135 degrees Fahrenheit (F) to 170 degrees F; -Fruits, desserts, and dairy products - 41 degrees F or below; -The cook will take temperatures of hot and cold food items using approved food thermometers prior to each meal service. Food temperatures will be recorded. 1. Review of food temperature logs, located in the kitchen, for all meals (breakfast, lunch, dinner) for 8/1/25, 8/2/25, and 8/3/25 were blank. 2. Review of the Diet Orders, printed 8/4/25, showed the following: -57 residents with a physician-ordered regular diet; -Nine residents with a physician-ordered mechanical soft diet; -Five residents with a physician-ordered pureed diet; -Two residents with a physician-ordered finger foods diet. 3. Observation on 8/4/25 from 4:30 P.M. to 5:16 P.M., in the kitchen at the steam table at the dinner meal service, showed Dietary Aide Y served food items onto residents' plates, added a plate cover to each plate, and placed the food items onto trays on a cart to be transported to each resident hall. He/She included a test tray of food items on the south hall cart. Observation on 8/4/25 from 5:17 P.M. to 5:32 P.M., staff served trays of food from the kitchen food cart to residents on the south hall (300-400 halls). Once all residents were served, the test tray was taken from the cart to be tested. Observation on 8/4/25 at 5:33 P.M., of the food items and food temperatures tested on the south hall test tray, showed the regular green beans were 116.6 and tasted cool. Review of food temperature logs, located in the kitchen, for the 8/4/25 dinner meal, showed the following: -Meal Service Holding Temperature (placed into steam table): Regular green beans were 190 degrees F; -Meal Service Holding Temperature (prior to serving from steam table): Regular green beans were 187 degrees F; 3. Review of food temperature logs, located in the kitchen, for 8/4/25 lunch meal, showed the following: -Final Internal Preparation Temperature: -Chicken salad cold plate: 39 degrees; -Regular and pureed cottage cheese and fruit plate: no temperatures were recorded. Observation on 8/4/25 from 11:40 A.M. to 12:17 A.M., in the kitchen at the steam table at the lunch meal service, showed Dietary Aide Y served food items onto residents' plates, added a plate cover to each plate, and placed the food items onto trays on a cart to be transported to each resident hall. Dietary Aide W and the Dietary Manager served food items onto plates that were served to residents in the adjacent dining room. Observation on 8/4/25 at 12:18 P.M., after all residents were served food on the resident halls and in the dining room, Dietary Aide Y prepared a test tray of food items. Observation on 8/4/25 at 12:19 P.M., of the food items and food temperatures on the test tray, showed the following: -The regular cottage cheese and fruit plate was 56.1 degrees F and tasted warm;-The chicken salad cold plate was 46.4 degrees F and tasted lukewarm;-The pureed cottage cheese and fruit plate was 45.7 degrees F and tasted lukewarm. Review of the recipes, for food items served on 8/4/25 at the lunch meal, showed the following:-Chicken salad cold plate: maintain less than 40 degrees F;-Pureed cottage cheese and fruit plate: maintain at 41 degrees F or below. During an interview on 08/05/25 at 11:06 A.M., Resident #50 said the following: -He/She usually ate in his/her room, when meal trays were served, the coffee was never hot; -Staff were often stopped when delivering meal trays and asked to do another task, so his/her food was often cold when served; -Last week his/her milk was clabbered, staff served another one and it was sour; -He/She had seen milk cartons sitting out for over 45 minutes; -Staff did not pay attention to keeping liquids and food at the right temperatures. 4. Review of food temperature logs, located in the kitchen, for the 8/6/25 lunch meal, showed no temperatures recorded in the Final Internal Preparation Temperature, Meal Service Holding Temperature (placed into steam table) or Meal Service Holding Temperature (prior to serving from steam table) columns. Observation on 8/6/25 at 12:19 P.M., after all residents were served the lunch meal, of food items and temperatures on the test tray, showed the following:-Ranch dressing 73 degrees F;-Tiramisu pudding cup: 51.4 degrees F;-Milk: 47.8 degrees F. Review of the recipe for Tiramisu pudding cup, served on 8/6/25 at the lunch meal, showed the food item should be maintained at 41 degrees F or below. 5. During interviews on 8/6/25 at 2:05 P.M. and at 4:08 P.M., [NAME] V said the following: -Staff should serve residents hot food items at a temperature between 145-160 degrees F; -Staff should serve residents cold food items at a temperature under 39 degrees F; -Staff should fill out the temperature log in the kitchen after food items are put into the steam table and prior to serving food items from the steam table. During an interview on 8/6/25 at 2:33 P.M., the Dietary Manager said she expected the temperature of hot food items to be 145-150 degrees F and cold food items 40 degrees F or below when served to residents.

Based on observation, interview and record review, the facility failed to ensure staff offered a nourishing bedtime snack to two residents (Resident #6 and Resident #11) in a review of 18 sampled residents and two additional residents (Resident #25 and Resident #50) when meals were served greater than 14 hours apart. The facility census was 72. The facility did not provide a policy for frequency of meals or bedtime snacks upon request. 1. Review of the undated Meals and Memories Cafe Mealtimes, posted by the dining room, showed the following:-Breakfast: 7:30 A.M. to 8:30 A.M.;-Lunch: 11:30 A.M. to 12:30 P.M.;-Supper: 4:30 P.M. to 5:30 P.M. (14 hours between the supper and breakfast meals). 2. Observation and interview of the facility resident council meeting on 08/05/25 at 11:00 A.M. showed the following: -Ten residents attended the meeting; -Some of the residents said they didn't receive routine snacks at bedtime. 3. During an interview on 08/05/25 at 11:06 A.M., Resident #11 said the following:-He/She did not routinely receive a bedtime snack;-He/She would take a bedtime snack if it was offered. 4. During an interview on 08/05/25 at 11:06 A.M., Resident #25 said the staff did not offer a bedtime snack. 5. During an interview on 08/05/25 at 11:06 A.M., Resident #50 said the following: -He/She did not routinely receive a bedtime snack;-He/She would take a bedtime snack if staff offered one. 6. During an interview on 08/07/25 at 8:35 A.M., Resident #6 said the following: -Staff did not offer a bedtime snack; -He/She would like staff to offer a bedtime snack routinely; sometimes he/she got hungry. 7. Observation on 08/11/25 at 04:00 P.M. showed the following food items/snacks in the south clean utility refrigerator: five (leftover) beef brisket sandwiches from lunch, dated 08/11, two single packs of saltine crackers, four individual containers of thickened apple juice, four individual containers of peaches, six ice cream sandwiches, three fudge bars and 20 individual containers of sherbert. 8. During an interview on 08/07/25 at 02:30 P.M., the Dietary Manager said the following: -The kitchen staff routinely provided evening snacks; -Items available for residents included peanut butter and jelly sandwiches, ham and cheese sandwiches, ice cream, yogurt, fresh fruit, and left-over fruit cups (if any) from supper; -The snacks were prepared in the kitchen, and were kept in the clean utility room refrigerators on each hall (north and south) and on the special care unit (SCU); -Nursing staff had access to snacks for the residents from the clean utility room refrigerators, and they also had a key to the kitchen if needed; -Residents would have to go to the nurses' station to request a snack;-If a resident could not go to the nurses' station, nursing staff could take a snack to the resident's room if the resident asked for one; -Some residents had refrigerators in their rooms with their own snacks available. During an interview on 08/07/25 at 02:35 P.M., Certified Medication Technician (CMT) C said the following: -The facility used to have a snack cart that went out between 07:00 P.M. and 08:00 P.M., that had multiple types of snacks on it, including hard cooked eggs), cookies and fruit, but it had not been offered to residents routinely for some time; -Residents had to request a bedtime snack if they wanted one; -If a resident did not know to ask for a snack, or was unable to ask for a snack, they would go without; -Staff did not routinely go from room to room to see if a resident wanted a snack. During an interview on 08/07/25 at 05:25 P.M., CMT E said the following: -He/She usually worked from 05:00 P.M. to 05:00 A.M.; -He/She was not familiar with staff offering bedtime snacks to residents in the evening hours; -If a resident was hungry, he/she could ask for a snack, or some residents had refrigerators in their rooms and kept their own snacks. During an interview on 08/11/25 at 06:05 P.M., the Director of Nursing (DON) said the following: -Bedtime snacks should be offered to all residents and immediately available for staff; -Food was available for residents in the clean utility room and the kitchen. During an interview on 08/11/25 at 06:35 P.M., the administrator said staff should offer bedtime snacks to all residents and snacks should be immediately available for staff to obtain and pass.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene in accordance with acceptable standards of practice to prevent the spread of infection for three residents (Residents #3, #40 and #45). The facility failed to ensure staff utilized Enhanced Barrier Precautions (EBP), as required by facility policy, when repositioning to one resident (Resident #6), who had a pressure ulcer with infection. The facility failed to ensure catheter drainage bags and tubing were kept off the floor to prevent risk of contamination for two residents (Residents #3 and #72), and failed to ensure nebulizer and bilevel positive airway pressure (BiPAP; a non-invasive ventilation method that delivers pressurized air to help individuals with breathing difficulties) masks were stored in accordance with facility policy for three residents (Residents #6, #11, and #3), in a review of 18 sampled residents. The facility census was 72. Review of the facility's undated Infection Control Policy showed it is the policy of the facility to use the manual Infection Control for Long Term Care Facilities in Missouri, as well as Center for Disease Control Guidelines. Body fluid precautions must be followed in all resident services. Review of Infection Control for Long Term Care Facilities: Emphasis on Body Substance Precautions, dated January 2025, showed the following:-Implementing the body substance precautions system should be always followed by all personnel regardless of the resident's diagnosis;-Gloves must be changed between contact with different body sites of the same resident;-Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of the gloves easier than to the skin on your hands. Handling medical equipment and devices with contaminated gloves is not acceptable;-Wash hands whenever they are soiled with body substances and when each resident's care is completed;-Clostridium difficile (C. diff; a bacteria that causes diarrhea and inflammation of the colon) can persist in the environment for months and is highly resistant to cleaning. Handwashing is the single most important means of preventing transmission of this disease. Body Substance Precautions should be used. Review of the facility policy, Handwashing/Hand Hygiene, dated 2001, showed the following: -The facility considers hand hygiene the primary means to prevent the spread of infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Use of an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after direct contact with residents; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with a resident's intact skin; -After contact with blood or bodily fluids; -After removing gloves; -The use of gloves does not replace hand washing/hand hygiene. Review of the facility's undated policy, Enhanced Barrier Precautions (EBP), showed the following: -Enhanced Barrier Precautions refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities; -The facility will ensure staff are trained in EBP and will maintain sufficient supplies to support implementation of EBP. EBP is used in conjunction with standard precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff's hands and clothing; -EBP are indicated for residents with any of the following: -Wounds and/or indwelling medical devices, even if the resident is not known to be infected or colonized with a MDRO; -Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (i.e.: Band-Aid) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers; -For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Transferring and changing linens. Review of the facility policy, Respiratory Care Process, dated 03/03/22, showed the following: -The following process is designed to provide consistent care of respiratory equipment and supplies used by residents receiving oxygen therapy and inhalation nebulizer therapy. It is everyone's responsibility to maintain the integrity of the respiratory supplies used by the residents of this facility;-Nasal cannula (a thin, flexible tube used to deliver oxygen or other gases directly into the nostrils) will be stored in clean zip lock bag that has been attached to equipment or near equipment when not in use by a resident; this includes portable oxygen tanks. This is done to protect the integrity and cleanliness of the cannulas; -Inhalation nebulizer equipment shall be rinsed of residue and stored in a zip lock bag near equipment between uses. This is done to protect the integrity and cleanliness of the nebulizer mask and chamber. 1. Review of Resident #3's Care Plan, dated 07/01/25, showed the following:-The resident had C. diff;-The resident had a urinary catheter (a flexible tube inserted into the bladder to drain urine) for urinary retention (inability to completely empty the bladder);-The resident needed assistance from two staff with most of his/her activities of daily living (ADLs) due to his/her history of strokes with right side paralysis (the loss of muscle function in part or all the body);-The resident needed two staff to assist with dressing, undressing and peri-care;-He/She was incontinent of bowel and needed to be changed when soiled. Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment instrument, required to be completed by facility staff), dated 07/02/25, showed the following:-Severe cognitive impairment;-Lower and upper extremity impairment on one side;-Dependent on staff for toileting hygiene and to roll left and right;-Indwelling urinary catheter;-Always incontinent of bowel;-Urinary tract infection (UTI; an infection in any part of the urinary system) last 30 days;-Diagnosis of stroke;-Isolation or quarantine for active infectious disease. Observation on 08/04/25 at 3:19 P.M. showed the following:-The resident lay away in bed;-The resident's BiPAP mask was uncovered and lay directly on the bedside table;-The resident's urinary drainage bag lay directly on the floor beside the resident's bed;-There was dark yellow urine with sediment (normal straw yellow without sediment) present in the urinary drainage bag and catheter tubing. Observation on 08/06/25 at 4:24 A.M. showed the following:-The resident lay awake in bed;-Certified Nurse Aide (CNA) A applied alcohol-based hand rub (ABHR), a gown and gloves;-CNA A entered the resident's room;-The resident was incontinent of loose feces;-CNA A provided front peri care with disposable wipes, assisted the resident to roll to his/her right side, and provided rectal peri care;-CNA A removed his/her gloves and gown and applied ABHR to his/her hands;-CNA A exited the resident's room;-CNA A returned to the resident's room and put on a clean gown and gloves;-CNA A placed a clean incontinence brief and cloth pad under the resident's buttocks and rolled the resident to his/her left side;-CNA A removed the soiled incontinence brief and cloth pads from under the resident and provided rectal peri care;-Feces was visible on the disposable wipes;-Without changing gloves and performing hand hygiene, CNA A pulled the clean incontinence brief and linens under the resident's buttocks, picked up and moved the resident's urinary catheter drainage bag and tubing, fastened the incontinence brief, and removed the resident's gown;-Wearing the same gloves he/she wore to clean feces from the resident's skin, CNA A placed a clean gown on the resident, picked up and bagged the soiled linens, and picked up and moved the urinary catheter drainage bag to the side of the bed. CNA A touched the bed control, changed the resident's bedsheet, touched, and moved the resident's wheelchair, opened the bathroom door, picked up the urinal, and opened up the spout on the resident's urinary drainage bag. CNA A emptied the urine into the urinal, cleaned the spout on the drainage bag with an alcohol pad, emptied the urine into the toilet, flushed the toilet and shut the bathroom door;-CNA A removed his/her gown and gloves, applied ABHR and exited the resident's room. 2. Review of Resident #6's undated Continuity of Care Document (CCD) showed the resident's diagnoses included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breath), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body), and unspecified wound left buttock. Review of the resident's care plan, dated 05/19/25, showed the following: -The resident had a stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle);-The resident had actual symptoms related to emphysema/COPD; -Respiratory therapy: nebulizer treatments as ordered. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Substantial to maximum assist for mobility;-Stage four pressure ulcer; -Oxygen use. Review of the resident's August 2025 physician order sheet (POS), showed the following: -Dakin's Solution (a topical antiseptic used to treat and prevent infections from wounds, burns, and surgery), small amount, 1/4 strength Dakin's wet-to-dry (dressing) two times a day, lightly pack wound making sure to get in the 2 o'clock tunnel (may use two-inch Kling for this). Clean wound with wound cleanser and secure with Medipore tape (a comfortable, breathable soft cloth medical tape). May use 1/2 strength as provided by pharmacy and dilute with one-part sterile water with one part Dakin's twice daily at 07:00 A.M. and 07:00 P.M. (order start date 07/17/25); -Ipratropium albuterol solution (a medication used to help control the symptoms of lung diseases such as COPD, used to treat air-flow blockage) for nebulization (the process of converting a liquid medication into a fine mist that can be inhaled) 0.5 milligram (mg)/3 milliliters (ml), inhalation, four times a day at 05:00 A.M., 11:00 A.M., 05:00 P.M., and 11:00 P.M., (order start date 08/01/22). Observation on 08/04/25 at 10:15 A.M. showed the following: -An enhanced barrier precaution (EBP)) was posted on the resident's door; -There was a three-drawer plastic container outside the resident's room that contained gloves, masks, and gowns;-A nebulizer face mask lay on the resident's nightstand and was not covered; -CNA B and Certified Medication Technician (CMT) C entered the resident's room, washed their hands, and donned gloves;-Neither CNA B nor CMT C put on a gown; -CMT C pulled down the resident's covers and assisted CNA B to pull the resident up and over to the right side in bed using the draw sheet beneath the resident; -CNA B leaned across the resident, rolled the resident onto his/her left side using the draw sheet under the resident; -CNA B's uniform touched the resident's clothing and bedding; -CMT C straightened the linens beneath the resident, then propped a pillow behind the resident's back; -CMT C's uniform touched the resident's linens and clothing. During an interview on 08/04/25 at 10:18 A.M., CNA B said the following:-The resident was on EBP due to a wound on his/her bottom; -Only gloves were needed when repositioning the resident, since the resident's wound was covered; -A gown would only be needed if staff messed with the wound. Observation on 08/11/25 at 04:00 P.M. showed the resident's nebulizer face mask lay uncovered on the resident's nightstand. During an interview on 08/11/25 at 04:00 P.M., the resident said the following: -He/She had a magnetic resonance imaging (MRI, a medical imaging technique that uses a strong magnetic field and radio waves to create detailed pictures of organs and tissues inside the body) the day before and he/she had osteomyelitis (an infection of the bone) of his/her wound;-He/She would need intravenous (through the bloodstream) antibiotics for six weeks. 3. Review of Resident #40's Care Plan, dated 05/20/22, showed the following: -The resident had urinary incontinence related to abnormality of gait and mobility, and may not get to the toilet on time; -Provide incontinence care after each incontinent episode. The resident often needed assistance with this, especially in the mornings. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 07/16/25, showed the following: -Cognitively impaired; -Independent for toileting hygiene; -Occasionally incontinent of bowel and bladder. Observation on 08/06/25 at 05:25 A.M. showed the following: -CNA A entered the resident's room and donned gloves; -CNA A did not use hand sanitizer or wash his/her hands before putting on gloves; -CNA A assisted the resident out of bed to the bathroom, pulled down the resident's pajama pants and incontinence brief, and assisted the resident to sit on the toilet; -CNA A removed his/her gloves and did not use hand sanitizer or wash his/her hands and left the resident's room;-CNA A returned to the resident's bathroom, donned gloves, and assisted the resident to stand; -CNA A did not use hand sanitizer or wash his/her hands before putting on gloves; -CNA A used a wet wipe and cleaned the resident's buttocks; -CNA A did not remove his/her gloves; -CNA A pulled up the resident's incontinence brief and pajama pants, touched the resident's back and assisted the resident back to bed; -CNA A removed the resident's shoes, pulled up the resident's covers, placed the call light within the resident's reach, and removed his/her gloves; -CNA A did not use a hand sanitizer or wash his/her hands after he/she removed his/her gloves. During an interview on 08/06/25 at 07:05 A.M., CNA A said the following: -Staff should wash their hands or use a hand sanitizer before and after providing personal care to a resident and before putting on gloves;-He/She did not carry a hand sanitizer and sometimes the sanitizer pumps were too far away to use quickly; -He/She did not think it was necessary to change his/her gloves if they appeared clean and did not look soiled. 4. Review of Resident #72's undated CCD, showed the resident's diagnoses included multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves, resulting in nerve damage between the brain and the body), dementia, and history of urinary tract infections (UTI). Review of the resident's Care Plan, dated 03/06/23, showed the following: -The resident had a suprapubic (inserted through a small incision in the lower abdomen, into the bladder) catheter related to neurogenic bladder (a condition when nerve damage impairs the bladder's ability to store and release urine effectively); -Do not allow tubing or any part of the urinary drainage system to touch the floor. Review of the resident's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Dependent for toileting; -Indwelling (urinary) catheter. Observation on 08/06/25 at 04:15 A.M. showed the following: -The resident lay in bed sleeping. The resident's bed was low to the floor; -The resident's urinary catheter drainage bag was covered with a privacy bag, but the top of the drainage bag and the catheter tubing lay on the floor; -There was a sign above the resident's bed that read, Please make sure the resident's catheter bag is not on the floor at NOC (NOC means night). During an interview on 08/06/25 at 07:05 A.M., CNA A said catheter drainage bags and tubing should not touch the floor because of the potential for infections. 5. Review of Resident #45's quarterly MDS, dated [DATE], showed the following:-Dependent on staff for toileting, dressing and personal hygiene;-Always incontinent of bladder. Review of the resident's Care Plan, with revision date of 02/24/25, showed staff were to provide incontinence care after each incontinent episode. Observation on 08/05/25 at 09:15 A.M., showed the following:-Without performing hand hygiene, Nurse Assistant (NA) G put on gloves and assisted the resident to walk to the bathroom; -While the resident sat on the toilet, NA G removed his/her gloves and put on new gloves without performing hand hygiene;-NA G removed the resident's pants and wet incontinence brief;-NA G did not change his/her gloves after removing the wet incontinence brief, and then put a clean incontinence brief and pants on the resident;-NA G removed his/her gloves, did not perform hand hygiene, and put on new gloves;-NA G cleaned the resident's skin that had been in contact with the urine soiled incontinence brief with a disposable wipe and pulled up the resident's incontinence brief and pants;-NA G removed his/her gloves and did not perform hand hygiene;-NA G assisted the resident to walk to his/her bed;-NA G touched the resident's hand, arms and legs while assisting the resident to bed;-NA G pulled the privacy curtain and left the room without performing hand hygiene. Observation on 08/06/25 at 06:57 A.M., showed the following:-CNA O put on gloves without performing hand hygiene and assisted the resident to the bathroom; -CNA O removed the resident's wet incontinence brief; -CNA O removed his/her gloves, did not perform hand hygiene, and put a clean shirt, incontinence brief and pants on the resident;-CNA O put on new gloves without performing hand hygiene;-CNA O cleaned the resident's skin that had been in contact with the urine soiled incontinence brief with disposable wipes; -CNA O did not change his/her gloves and pulled up the resident's incontinence brief and pants. During interview on 08/06/25 at 07:08 A.M., CNA O said the following: -He/She should change gloves when putting clean items on the resident;-He/She should perform hand hygiene as much as possible;-If the resident had a bowel movement, he/she would have removed his/her gloves and washed his/her hands;-He/She did not sanitize his/her hands between dirty and clean tasks during the resident's care but would have if the resident had a bowel movement. During interview on 08/11/25 at 02:44 P.M., NA G said the following:-He/She washed his/her hands before and after he/she was in a resident's room and after providing peri care;-He/She washed or sanitized his/her hands between glove changes. 6. Review of Resident #11's Care Plan, dated 03/27/25, showed the resident was to have a BiPAP on at bedtime and off in morning. Review of the resident's quarterly MDS assessment, dated 06/01/25, showed the following:- Moderate cognitive impairment;-Diagnoses included obstructive sleep apnea and dementia;-Substantial/maximal assistance needed dressing. Review of resident's Physician Orders, dated 06/03/25, showed an order for BiPAP on at hours of sleep (HS) and off in the morning; Observation on 08/04/25 at 03:45 P.M., showed the following:-The resident's BiPAP was on the resident's nightstand. The BiPAP tubing and full face mask were attached to the machine;-The mask and tubing were wrapped around the cane rail on resident's bed and were uncovered. Observation on 08/05/25 at 08:38 A.M., showed the resident's BiPAP was on the nightstand. The BiPAP full face mask and tubing were wrapped around the cane rail on the resident's bed and were uncovered. Observation on 08/07/25 at 11:06 A.M., showed the resident's BiPAP was on the resident's nightstand. The BiPAP full face mask and tubing were wrapped around the cane rail on the resident's bed and were uncovered. During interview on 08/11/25 at 05:37 P.M., Licensed Practical Nurse (LPN) P said the following:-He/She was not sure how the BiPAP and accessories were to be stored;-Staff used to store the tubing and mask in a bag when not in use;-He/She thought the mask and tubing should be stored in a bag. 7. During an interview on 08/11/25 at 06:05 P.M., the Director of Nursing (DON) said the following: -Staff should wash their hands or use a hand sanitizer between glove changes; -Catheter bags and tubing should be kept off the floor; -Oxygen tubing and BiPAP equipment should be stored in a plastic bag and not left open at the resident's bedside. -Staff should follow EBP when repositioning a resident with a wound, even if the wound was covered. Staff should wear a gown if they had contact with the resident's clothing and/or bed linens. During an interview on 08/11/25 at 06:35 P.M., the Administrator said the following: -Staff should wash their hands or use a hand sanitizer between glove changes; -Catheter bags/tubing should be kept off the floor; -Oxygen tubing, BiPAP equipment should be stored in a plastic bag and not left open at the resident's bedside. -Staff should follow EBP when repositioning a resident with a wound, even if the wound was covered. Staff should wear a gown if they had contact with the resident's clothing and/or bed linens.

Based on interview and record review, the facility failed to provide all staff with written documentation of education regarding the benefits, risks, and potential side effects associated with the COVID-19 vaccine and failed to maintain documentation related to staff COVID-19 vaccination status. The facility census was 72. Review of the facility's COVID-19 Staff Vaccination policy, dated October 2022, showed the following:-Before offering the COVID-19 vaccine, the staff member is provided with education regarding the benefits and risks, and potential side effects associated with the vaccine;-A vaccine administration record is provided to the individual and a copy if filed in the secure employee health file;-The infection preventionist (IP) maintains a tracking worksheet of staff members and their vaccination status;-The facility maintains documentation related to staff COVID-19 vaccination that includes, at a minimum, the following: -That staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; -That staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine; -A copy of the informed consent; -Verification of vaccination or documentation of exemption/delay. 1. Review of the facility's list of new employees, dated 11/2/23 through 8/5/25, showed the facility hired 158 new employees during this time. Review of employee files showed the facility had no documentation to show staff were educated on the benefits, risks and potential side effects associated with the COVID-19 vaccine and/or had been offered or refused the vaccine. During an interview on 08/11/25 at 02:44 P.M., Nurse Assistant (NA) G said the following:-He/She had worked in the facility for two months;-The facility had not educated him/her about the COVID-19 vaccine;-The facility did not offer the COVID-19 vaccine. During an interview on 08/07/25 at 03:30 P.M., Human Resources Staff said the following:-There was no COVID-19 vaccine documentation in the new staff files;-She was not aware it was still required. During an interview on 08/11/25 at 6:05 P.M., the Director of Nursing (DON) said Human Resources Staff was responsible for educating new hires and offering the COVID-19 vaccinations. During an interview on 08/07/25 at 03:00 P.M., the Administrator said the following:-The facility verbally informed staff about the latest COVID-19 vaccines;-There was no documentation of staff education regarding the benefits, risks and potential side effects associated with the COVID-19 vaccine;-There was no documentation of staff's COVID-19 vaccination status in the employee files.

Based on interview and record review, the facility failed to provide required in-service training for nurse aides that included dementia management training as part of the required minimum 12 hours of training per year. The facility census was 72. 1. Review of the Facility Assessment, dated 07/09/25, showed the following:-Staff training/education and competencies:-New hire training for nursing staff includes:-Dementia Care: Managing Challenging Behaviors;-Annual Education includes all the new hire training topics plus Corporate Compliance: The Basics for all staff, Overview of the Aging Process and Pressure Ulcer Prevention for all clinical staff. 2. Review of a list of current facility staff, dated 08/05/25, showed the following:-Certified Nurse Aide (CNA) I date of hire: 04/15/09;-CNA/Certified Medication Technician (CMT) C: date of hire 07/19/14;-CNA K date of hire: 12/7/19;-CNA J date of hire: 07/03/23. Review of a list of staff in-service education hours, dated 07/01/24 through 06/30/25, showed the following:-CNA I: 6.50 in-service hours. Dementia training hours blank;-CNA/CMT C: 8.00 in-service hours. Dementia training hours blank;-CNA K: 5.25 in-service hours. Dementia training hours blank;-CNA J: 2.75 in-service hours. Dementia training hours blank. During an interview on 08/11/25 at 6:04 P.M., the Director of Nursing said the following:-HR was responsible for ensuring CNAs have the required 12 in-service hours per year and she would expect this to be done;-There had been an issue getting the 12 in-service hours completed. During an interview on 08/11/25 at 6:30 P.M., the Administrator the following:-HR was responsible for tracking CNA in-service education;-The previous HR staff left at the end of 2024 and they could not find documentation of previous in-service hours;-The facility offered dementia training in January 2025, but they could not find documentation of the training;-She would expect the CNAs to receive 12 hours of in-service education annually including dementia training.

Based on observation, interview and record review, the facility failed to review and revise the care plan for two residents (Resident #2 and Resident #72) in a review of 18 sampled residents, to reflect the resident's specific condition and/or needs. The facility census was 72. Review of the facility policy, Goals and Objectives, Care Plans, revised 2009, showed the following: -Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence; -Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and: -Are resident oriented; -Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and can report whether the desired outcomes are being achieved; -Goals and objectives are reviewed and/or revised when there has been a significant change in the resident's condition and at least quarterly.;-The policy did not define expectations for review and revision of care plans. 1. Review of Resident #2's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 06/28/25, showed the following: -Cognitively impaired; -Hallucinations/delusions and verbal behaviors directed at others; -Rejection of cares; -Supervision/touching for personal hygiene and toileting;-Independent for mobility; -Diagnosis Alzheimer's dementia (a group of brain disorders that cause a decline in cognitive abilities like memory, thinking, and reasoning, and ultimately interfere with daily activities). Review of the resident's progress notes showed staff documented the following:-On 05/11/25 at 09:33 A.M., the resident refused a shower yesterday and today. The resident's family member was called to assist with getting the resident to the shower. At first, the resident was compliant, but then said he/she would not take a shower. The resident was physically and verbally aggressive to staff, and punched, scratched and hit them; -On 07/15/25 at 08:37 A.M., the resident walked up and down the hallway a lot this morning and carried a big pile of books in one arm and a baby doll in the other. The resident dropped the books on the floor, and when care staff attempted to pick them up, the resident tried to hit staff; -On 07/16/25 at 02:39 A.M., the resident was agitated and was physically and verbally aggressive; -On 07/19/25 at 10:35 A.M., the resident's family called the facility about the resident's care. Attempted to assist care staff with activity of daily living (ADLs), but the resident was noncompliant and combative with staff. The resident hit staff with a hanger and told him/her to get out, and that he/she did not want help. Observation on 08/04/25 at 09:50 A.M. showed the following: -A sign that read Security Camera in Use posted on the resident's door; -The resident sat on the edge of the bed and said in an agitated, high-pitched voice, What are you doing here! You were looking through my stuff! Review of the resident's care plan, revised 08/05/25, showed the following: -The resident was limited in ability to maintain grooming/personal hygiene related to dementia and not always cooperative with cares; -May have to use approach It's time to do our teeth as not always compliant with staff assistance. Review of the resident's care plan did not reflect the resident hallucinated and/or had delusions, verbal and/or physical behaviors, or that the resident had a security camera/device in use. During an interview on 08/07/25 at 08:47 A.M., Registered Nurse (RN) D said the following: -The resident had behaviors, called staff (derogatory) names, wandered into other resident's rooms, hit staff, and routinely refused cares; -The resident's family had a video device put in the resident's room to help monitor his/her care;-The family refused medications for behaviors so staff tried to learn the resident's patterns and do the best they could. 2. Review of Resident #72's undated Continuity of Care Document (CCD), showed the resident's diagnoses included multiple sclerosis (MS, a progressive disease-causing damage to nerves) and dementia. Review of the resident's Care Plan, dated 07/27/23, showed the following: -The resident had a diagnosis of MS and required assistance with cares; -The resident had a trapeze bar (a medical device attached to a frame above a bed, designed to assist residents who could use the upper body, with mobility and positioning in bed) to assist with transfers; -The resident used an electric wheelchair and was independent with locomotion;-Stand-up lift (also known as a sit to stand, a device used to transfer residents who can bear weight with the transition) used for transfers. Review of the resident's significant change MDS, completed by facility staff, dated 05/23/25, showed the following: -Severe cognitive impairment; -Used a wheelchair; -Dependent for mobility;-No falls since admission/re-entry or prior assessment. Review of the resident's Care Plan, last revised 05/27/25, showed the following: -The resident was at risk for falls related to dementia and decreased functional status related to MS diagnosis; -Remind resident not to transfer without assistance and remind him/her to use call light to ask for assistance; -Staff to use stand up lift for transfers. Observation on 08/04/25 at 09:50 A.M. showed the following: -The resident was out of the room; -A mechanical lift sling lay across the resident's bed; -A mechanical lift was positioned next to the resident's bed; -The resident's bed did not have a trapeze bar or frame attached to it. During an interview on 08/07/25 at 10:10 A.M. and 08/11/25 at 03:45 P.M., Certified Nurse Assistant (CNA) B said the following: -The resident used to be a sit-to-stand transfer but required the use of a mechanical lift for some time now; -The resident was unable to use a trapeze bar to assist him/her in bed for about one year now due to his/her physical decline; -He/She just knew the resident required a mechanical lift for transfers because he/she knew the resident well. During an interview on 08/11/25 at 04:00 P.M., CNA U said the following: -He/She just started working at the facility; -To find the transfer status of a resident, he/she could ask the charge nurse or check the care plan in the electronic medical record (EMR). 3. During an interview on 08/11/25 at 02:15 P.M. and 06:05 P.M., the Director of Nurses (DON) said the following: -Resident #2 had behaviors (refusal of care, verbal and physical interactions with staff) pretty much since his/her admission;-Resident #2's family requested a video device for his/her room and called frequently to check on the resident based on what he/she was doing or when the resident was not seen on camera; -Resident # 72 required a mechanical device for transfers and had not used a sit-to-stand for some time; she was not aware the resident had had a trapeze in the past;-A residents' care plans should reflect the specific problems, goals and interventions for each resident, and be updated routinely and as needed. During an interview on 08/11/25 at 06:35 P.M., the Administrator said that a resident's care plan should be updated routinely and as needed, and should reflect the specific problems, goals and interventions for each resident.

Based on observation, interview, and record review, the facility failed to ensure staff served meals to meet the nutritional needs of the residents when staff failed to prepare and serve food according to the physician's orders and spreadsheet menu. The facility census was 72. 1. Review of Resident #45's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 07/27/25, showed the following:-Severe cognitive impairment;-Diagnoses included vitamin deficiency, -Dependent on staff for eating;-Mechanically altered diet such as pureed food. Review of the resident's Care Plan, revised 02/24/25, showed the following:-The resident receives regular pureed diet;-Staff will need to feed the resident; -Monitor and record percentage of food intake. Review of the resident's Physician Orders dated 03/27/25, showed diet pureed texture, double portions with meals every day. Review of the Diet Spreadsheet Menu, for 8/4/25 (Day 2, Monday) Lunch, showed staff were to serve residents on pureed diets the following items and portion sizes:-One 4-ounce portion of pureed chicken salad;-One 4-ounce portion of pureed cottage cheese;-One 3.25-ounce portion of pureed fruit plate;-One 2.875-ounce portion of pureed breaded zucchini. Observation on 8/4/25 at 11:40 A.M., in the kitchen during the lunch meal service, showed Dietary Aide S served the following items and portion sizes onto the resident's plate:-Two 4-ounce scoops (total of 8 ounces) of pureed chicken salad; -One 4-ounce scoop of pureed cottage cheese/fruit plate;-One 4-ounce scoop of pureed zucchini.(Dietary Aide S did not serve the resident double portions of all the menu items. The resident should have received an 8-ounce portion of cottage cheese, a 6.5-ounce portion of fruit plate, and a 5.75-ounce portion of pureed zucchini.) Review of the Diet Spreadsheet Menu, for 8/4/25 (Day 2, Monday) Dinner, showed staff were to serve residents on pureed diets the following items and portion sizes:-Two 4-ounce portions (total of 8 ounces) of pureed beef and noodles;-One 3.25-ounce portion of pureed green beans;-One 2-ounce portion of pureed dinner roll/margarine. Observation on 8/4/25 at 4:39 P.M., in the kitchen during the dinner meal service, showed Dietary Aide Y served the following items and portion sizes onto the resident's plate:-Two 4-ounce scoops (total of 8 ounces) of pureed beef and noodles;-One 4-ounce scoop of pureed green beans;-No pureed bread.(Dietary Aide S did not serve the resident double portions. The resident should have received 16 ounces of beef/noodles, 6.5 ounces of green beans, and 4 ounces of pureed bread.) Observation on 08/04/25 at 5:08 P.M., showed the following:-CNA L fed the resident at a table in the dining room;-The resident's plate contained pureed beef and noodles that filled up a section on the divided plate and pureed green beans that filled another section of the divided plate;-The resident did not receive double portions;-The resident ate 100% of his/her meal. During an interview on 8/6/25 at 2:05 P.M., [NAME] V said staff were to follow the diet spreadsheet menu and residents' diet orders for food items and portion sizes. During an interview on 8/6/25 at 2:33 P.M., the Dietary Manager said the following:-She expected staff to follow the spreadsheet menu when preparing and serving food items to residents;-She expected staff to follow residents' diet orders;-She was unaware staff didn't serve Resident #45 double portions during the 8/4/25 lunch and dinner meal services.

Based on interview and record review, the facility failed to follow their antibiotic stewardship policy and consistently track infections and antibiotic use for one resident (Resident #3) in a review of 18 sampled residents. The facility census was 72. Review of the facility's undated policy, Antibiotic Stewardship, showed the following:-The facility will record all antibiotics used in the facility on a resident-to-resident basis (dose, duration, indication);-The facility will alert the attending physician when antibiotics have reached 14 days and obtain new orders. Review of the facility's Surveillance for Infections policy, dated January 2022, showed the following:-The Infection Preventionist (IP) will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions (TBP) and other preventative interventions;-The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organism and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections;-Infections that will be included in routine surveillance include those with;-a. Evidence of transmissibility in a healthcare environment;-b. Available processes and procedures that prevent or reduce the spread of infections;-c. Clinically significant morbidity or mortality associated with infection (e.g., pneumonia, urinary tract infections (UTI), Clostridioides difficile (C. Diff)) ((inflammation of the colon caused by the bacteria Clostridium difficile);-d. Pathogens associated with serious outbreaks (e.g., invasive Streptococcus Group A, acute viral hepatitis, norovirus, scabies, influenza);-If TBP or other preventative measures are implemented to slow or stop the spread of infection, the IP will collect data to help determine the effectiveness of such measures;-The IP or designated infection control personnel is responsible for gathering and interpreting surveillance data;-For targeted surveillance and reporting through the Centers for Disease Control and Prevention (CDC) National Health Safety Network (NHSN), follow the surveillance protocols for each module using the data collection tools provided at https://www.cdc.gov/nhsn/ltc/index.html;-For targeted surveillance using facility-created tools, follow these guidelines; -Daily: Record detailed information about the resident and infection on an individual infection report form; -Monthly: Collect information from individual resident infection reports and enter line listing of infections by resident for the entire month; -Monthly: Summarize monthly data for each nursing unit by site and by pathogen; -Monthly/Quarterly: Identify predominant pathogens or sites of infection among residents in the facility or in particular units by recording them month to month and observing trends; -Monthly/Quarterly: Compare incidence of current infections to previous data to identify trends and patterns;-Obtain the month's total resident days from the business office and use this data as the denominator to calculate the monthly infection rate. 1. Review of Resident #3's urinalysis (a physical and chemical test of the urine), dated 01/21/25, showed the following:-Blood 2+ (normal is negative);-Urine clarity: turbid (normal is clear);-Urine nitrites (a byproduct of bacteria converting nitrates (which are normal in urine) into nitrites): positive (normal is negative);-Bacteria: many (normal is none seen);-Urine protein confirmation SSA: 1+ (normal is negative);-White cells: greater than 100 (normal is 0-3);Test Comments: (Culture) Call lab within 48 hours to request culture of this specimen;-Noted by staff on 01/22/25. Review of the resident's medical record showed no documentation staff requested a culture of the 01/21/25 specimen. Review of the resident's physician's orders, dated 01/21/25, showed an order for ciprofloxacin (antibiotic) 250 milligrams (mg) by mouth twice daily for seven days for UTI. Review of the resident's Medication Administration Record (MAR) dated January 2025 showed the resident received ciprofloxacin 250 mg by mouth twice daily 01/22/25-01/29/25. Review of the resident's C-difficile Toxins Antigen Test (CDToxAG), dated 07/30/25, showed a positive result which indicated the presence of C. difficile toxin in a fecal sample (normal result is negative). Review of the resident's physician's orders, dated 07/31/25, showed an order for Vancomycin (antibiotic) 125 mg by mouth four times a day for C. diff. Review of the resident's MAR dated 08/01/25 showed the resident received Vancomycin 125 mg by mouth four times daily 08/01/25-08/07/25. During an interview on 08/06/25 at 01:28 P.M., Registered Nurse (RN) Consultant said her only role as IP was to double check and make sure antibiotic orders were entered correctly into the computer. During interview on 08/06/25 at 10:40 A.M. and 08/11/25 at 6:05 P.M., the Director of Nursing (DON) said the following:-She printed out a list of residents who received antibiotics and reviewed the list with the Medical Director weekly;-She was responsible for gathering and interpreting surveillance data and looked at the Arsana (tool used for long term care facility infection surveillance and hand hygiene);-She kept up with cultures and sensitivities to make sure the residents were on the correct antibiotic. She reviewed the information with the Medical Director weekly;-Staff obtained cultures for infections when physician's orders were received; -She did not keep an infection treatment and tracking record;-She did not keep a line listing of infections by resident;-She did not keep a facility wide monthly infection report;-She did not keep a facility wide 12 month pathogen trends report;-She did not compare incidence of current infection to previous data to identify trends;-She did not calculate the monthly infection rate. During an interview on 08/11/25 at 6:30 P.M., the Administrator said the following:-She, the DON, and the RN Consultant serve as the IPs and were responsible for gathering and interpreting surveillance data;-Cultures were obtained when the physician prescribed them;-She did not keep an infection treatment and tracking record;-She looked at the progress notes and Arsana daily;-She did not keep a facility wide 12 month pathogen trends report;-She did not calculate the monthly infection rate.

Based on interview and record review, the facility failed to ensure staff notified the resident and/or the resident's representative in writing of a transfer to a hospital and failed to provide the bed hold policy at the time of transfer to four residents (Resident #3, #10, #74 and #78) or the resident representatives, in a sample of four residents reviewed related to discharge or transfer. The facility census was 72. Review of the undated document, Bed Hold Statement and Notice of Emergency Transfers, showed the following:-The facility established and maintains policies and procedures regarding transfer, discharge, and provision of services for all individuals. Upon admission to the facility and again if the resident is transferred to an acute care hospital, the resident (if able) or responsible party is information of the policy on bed holds;-The goal of the facility is to re-admit, after hospitalization, all residents who meet admission guidelines and whose needs can be met with our available services. To assure the assigned previous room is held for you, if the resident room type (example: private, suite, semi-private) has occupancy of 90% or higher it is necessary to pay 75% of the daily base rate to hold the specific room. Medicare and Medicaid do not pay for bed hold therefore it is necessary for this charge to be paid by the resident. If you choose not to reserve the bed, the resident and/or responsible party must notify the social services department or business office within 72 hours of the discharge. The facility will admit the resident to the first available bed if the bed has not been held;-Notice of Emergency Transfers: When a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable, according to 42 CRF 483.15 (4)(ii)(D). Documentation in the resident's progress notes stating resident or resident representative has been notified will meet the criteria for notification of emergency transfer. 1. Review of Resident #3's Face Sheet showed he/she had a responsible party. Review of the resident's electronic health record (EHR) census report showed the resident was transferred to the hospital and hospitalized from [DATE] through 06/20/25 and again on 06/21/25 through 06/22/25. Review of the resident's EHR showed no documentation the facility gave the resident a written transfer notice or a copy of the facility's bed hold policy for his/her hospitalizations on 05/05/25 and 6/21/25. 2. Review of Resident #10's Face Sheet showed he/she had a responsible party. Review of the resident's EHR census report showed the resident transferred to the hospital on [DATE]. Review of the resident's Progress Notes, dated 08/01/25, showed the following:-At 8:14 P.M., staff called the on-call physician. Orders were received to send the resident to the hospital;-At 11:26 P.M., the resident admitted to the hospital. Review of the resident's medical record showed no documentation the facility issued the resident or the resident's representative with a written notice of transfer when he/she was transferred to the hospital on [DATE]. 3. Review of Resident #74's Face Sheet showed he/she was his/her own responsible party. Review of the resident's Progress Notes, dated 06/19/25, showed the following:-At 10:15 A.M., the nurse received a call from the physician reporting abnormal labs and to send the resident to the emergency room if the resident continued to be confused;-At 11:20 A.M., the resident transferred to the hospital by ambulance. Review of the resident's EHR census report showed the resident was hospitalized from [DATE] through 06/27/25. Review of the resident's EHR showed no documentation the facility gave the resident or the resident's representative a written transfer discharge notice or bed hold notice when he/she was transferred to the hospital on [DATE]. 4. Review of Resident #78's Face Sheet showed he/she had a responsible party. Review of the resident's EHR census report showed the resident transferred to the hospital and was hospitalized from [DATE] to 12/11/24. Review of the resident's Progress Notes, dated 06/30/25, showed the following:-At 1:09 P.M., the nurse received a call from the primary care physician (PCP)/triage nurse with orders to send the resident to the emergency room to be evaluated based on behaviors that morning;-The nurse called and spoke with resident's responsible party. Review of the resident's EHR census report showed the resident transferred to the hospital and was hospitalized from [DATE] to 07/22/25. Review of the resident's EHR showed no documentation the facility gave the resident or the resident's representative a written transfer discharge notice or bed hold notice for his/her 12/10/24 or 06/30/25 hospitalization. 5. During an interview on 08/11/25 at 06:05 P.M., the Director of Nursing (DON) said the following:-The charge nurse should provide the resident with a written notice of transfer/discharge and bed hold policy if they are transferred to the hospital emergently;-Agency nurses may not always remember to provide the notice and the policy. During an interview on 08/11/25 at 06:35 P.M., the Administrator said the following:-The charge nurse should provide the resident with a written notice of transfer/discharge and bed hold policy when they were transferred to the hospital emergently;-The bed hold policy was sent with the resident on a transfer to the hospital.

Based on interview and record review, the facility failed to ensure one resident (Resident #2), in a review of seven sampled residents, received the necessary care and services in accordance with professional standards of practice when the facility failed to assess and report Resident #2's complaint of right eye pain, redness, watering, and blurry and dim vision timely. The resident was involved in a physical altercation with Resident #1 on 02/10/25, where both resided on the facility's Special Care Unit (SCU - dementia care unit). Resident #2 reported to family and staff in the days following that his/her eye hurt. Multiple staff in the SCU, including Certified Medication Technicians (CMT) and a Certified Nursing Assistant (CNA), reported to licensed staff (nurses that worked off SCU unit and were to go to that unit to assess any reported issue), the resident's complaints and concern with his/her right eye. Licensed staff failed to come to the unit to assess the resident's eye concerns reported by unit staff. The resident was seen by his/her physician on 02/26/25 after a resident's family member brought the concern with the resident's eye becoming worse, and the physician recommended the resident be seen by his/her eye physician. The resident was seen by an optometrist (professionall who specializes in eye and vision care), on 02/27/25 who recommended further evaluation by an ophthalmologist (physician who specializes in eye and vision care including surgery). The resident had sustained a dislodged lens in his/her right eye that required treatment with eye drops and a surgical procedure to correct the condition caused by blunt force trauma. The facility census was 69. Review of the facility policy titled Physician Notification, revised 11/2020, showed the charge nurse will notify physician of an accident or incident involving residents (falls, etc.). 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/02/24, showed the following: -The resident had both short and long term memory problems; -Rarely/never understood; -Inattention and disorganized thinking behavior present, fluctuates; -Wandered four to six days of the last seven days; -Wandered and was at significant risk of getting into a potentially dangerous place; -Wandering significantly intruded on the privacy of activities of others; -Diagnoses of stroke and dementia; -Able to walk 50 feet with two turns with supervision or touching assist; -No limitation in upper or lower extremity range of motion. Review of the resident's care plan, dated 12/08/24, showed the resident had socially inappropriate/disruptive behavioral symptoms as evidenced by wandering into others' rooms. Review of the resident's progress notes, dated 02/10/25 at 6:28 P.M., showed the following: -At 6:15 P.M. this evening resident went into another resident's room through the bathroom and grabbed that resident's (Resident #2's) right arm leaving a bruise the shape of a line on that resident's right bicep; -Called and spoke with resident's family member and a message was sent to nurse practitioner. Review of the resident's care plan, revised 02/11/25, showed the following: -When the resident was awake, encourage him/her to stay in the day room; -If the resident leaves the day room, complete frequent rounds to check on him/her; -Remove resident from other residents' rooms and unsafe situations as needed. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition with a BIMS of nine; -Diagnoses of dementia, anxiety and depression. Review of the resident's progress notes, written by Licensed Practical Nurse (LPN) C, dated 02/10/25 at 6:46 P.M., showed the following: -At 6:15 P.M. another resident (Resident #1) came into Resident #2's room through the bathroom and grabbed Resident #2's arm, leaving a bruise the shape of a line on Resident #2's right bicep (muscle on the front of the upper arm); -Called and spoke with Family Member H and on call physician. Review of the facility's self-report, dated 02/11/25, showed the following: -Resident #1 entered Resident #2's room from the shared bathroom because Resident #1 got turned around and went into Resident #2's room by mistake; -There was an altercation between Resident #1 and Resident #2; -Resident #1 obtained some superficial scratches to his/her arm; -Resident #2 had a reddened area/bruise from where Resident #1 grabbed his/her arm; -Families and physicians notified; -No new orders received. Review of the resident's care plan, revised 02/11/25, showed he/she currently resided in the SCU due to wandering and need for safety. Review of the resident's progress notes showed staff documented on 02/11/25 at 2:00 P.M., after lunch the resident was walked up the hall and asked about that girl/boy that grabbed his/her arm; he/she did not recall who it was, but did show staff the bruise on his/her arm. There was no documentation the resident was involved in another altercation or experienced a fall or other injury other than the one documented on 02/10/25. Review of the resident's physician's progress note, dated 02/12/25, showed the following: -Resident was evaluated for right arm bruise and dementia; -The resident was apparently in some sort of altercation with one of the other residents; -The resident ended up with a bruise on his/her upper right arm. Review of the resident's progress notes dated 02/12/25 through 02/26/25 showed no documentation the resident was involved in another altercation or experienced a fall or other injury other than the one documented on 02/10/25. Review of the SCU undated report sheet (written report from lead Certified Medication Technician (CMT) to lead CMT)) showed the resident complained of his/her right eye being watery for a few days. Review of the resident's progress notes, dated 02/26/25 at 3:18 P.M., showed the following: -Care plan conference held; -Condition report given and medications reviewed; -Resident's right eye has some redness and was watery, the resident was on Claritin (antihistamine medication) for allergies. Review of the resident's progress notes, documented by Registered Nurse (RN) D, showed staff documented the following: -On 02/26/25 at 4:00 P.M., the resident was seen on rounds by his/her physician for right eye being red and watery; -The resident rubbed at it (his/her right eye) while the physician was in with him/her; -The resident said at first that he/she got whacked by someone (no issue reported or seen) and then he/she mentioned something flying by him/her and whacking his/her eye; -Physician looked at the resident's right eye and said he recommended the resident see his/her ophthalmologist. Review of the resident's encounter report, completed by Optometrist M, dated 02/27/25, showed the following: Problem exam: -Red and watering right eye; -Ongoing since 2/10/25; -Lady/Man attacked the resident at the facility. Eye has been bothering him/her ever since. The resident was hit with a book in his/her right eye; -The resident's right eye hurt in the corner; -Right eye distance visual acuity: 20/200 (normal vision 20/20); -Right eye lens: inferiorly, interior capsule was covering the upper third of vision; -Decentered (normal placement is centered) intraocular lens (IOL). Refer to Ophthalmologist L. Review of the resident's progress notes, dated 02/27/25 at 5:00 P.M., showed staff documented the following: -The resident returned from an appointment with Optometrist M; -Optometrist M noted the resident said he/she was hit in the eye with a book by another resident and said that it (right eye redness, watering and vision difficulty), was an issue since the altercation earlier in the month with his/her neighbor; -Optometrist M said that his/her implant from cataract surgery appeared to have been displaced inferiorly (towards the bottom or below); consultation arranged with Ophthalmologist L on 03/04/25. Review of the resident's encounter report, completed by Ophthalmologist L, dated 03/04/25, showed the following: Reason for visit: Decentered IOL, right eye; -The resident said the right eye was hit, blunt force trauma, on 02/10/25; -The resident and his/her family member think he/she was possibly hit with a book or a rolled up magazine at the facility he/she resides in; Severity: moderate; Context: blunt force trauma to the right eye and face; Association: loss of vision; Care plan: subluxed IOL (the implanted lens has partially shifted out of it's intended position within the eye), inferiorly, in the bag; -Plan to lower intraocular pressure, right eye (high intraocular pressure can be caused from damage to the eye's drainage system; the eyes drainage system can be damaged from trauma, leading to increased pressure and potential vision loss); -Begin instilling Latanoprost (eye drops used to lower eye pressure) one drop both eyes at bedtime, return to clinic in one month; -Discussed surgical intervention to address the subluxed IOL; -The resident was not interested in proceeding in a referral to the eye surgeon at this time; -The resident was concerned, with his/her age, about proceeding with surgical intervention. Review of the resident's progress notes, dated 03/04/25 at 4:33 P.M., showed the resident returned from (ophthalmologist) appointment with a new order for Latanoprost eye drops. During an interview on 03/06/25 at 11:35 A.M., Resident #2 said the following: -He/She stayed away from Resident #1; -He/She did not know when or who did it, but he/she was hit on the right side of his/her head/eye by something; he/she was hit with a book or a box; -After he/she was hit on the right side of his/her head, his/her right eye and right ear hurt; -He/She told all the nurses that his/her right eye was bothering him/her; -His/Her vision was perfect before he/she was hit on the right side of his/her head; -Now his/her vision in the right eye was dim and his/her right eye still hurt; -His/Her family member took him/her to the eye doctor. During an interview on 03/06/25 at 3:25 P.M., the resident's Family Member G said the following: -On 2/10/25, staff notified Family Member H that Resident #2 was in an altercation with another resident and received a big bruise on his/her arm; -When Family Member H visited with Resident #2 on 2/11/25, Resident #2 had redness around his/her right eye; -He/She saw Resident #2 three to four days after the altercation (2/13/25 or 2/14/25); -When he/she visited Resident #2 on 2/13/25 or 2/14/25, Resident #2 had redness around his/her right eye and complained of his/her right eye burning. Resident #2 told him/her that he/she was hit in the right eye with a book; -He/She did not think to tell staff about Resident #2's right eye on 2/13/25 or 2/14/25 as he/she was hoping it would improve. During an interview on 03/07/25 at 8:46 A.M., the resident's Family Member H said the following: -He/She visited Resident #2 several times a week; -Staff notified him/her on 02/10/25 that Resident #2 had a bruise on his/her arm from an altercation with another resident; -He/She visited Resident #2 on 02/11/25. Resident #2 had a red spot on his/her right temple and his/her right eye was red; -On 2/11/25, Resident #2 said a woman/man hit him/her with something on the side of his/her head; -Resident #2's eye kept getting redder and redder; -Resident #2 told him/her that he/she just couldn't see out of his/her right eye and that his/her vision was very blurry; -They did not discuss Resident #2's eye complaints during the care plan meeting on 2/26/25; -On 2/26/25 after the meeting, Resident #2 again told him/her that he/she just couldn't see out of his/her right eye; -Resident #2 had cataract removal in the past and had 20/20 vision; now Resident #2's vision was blurry; -In order to restore Resident #2's vision in his/her right eye, it must be surgically repaired; -Resident #2 did not want surgery because he/she did not want to be anesthetized (be given medication to be put to sleep to have a medical procedure/surgery). During an interview on 03/07/25 at 3:17 P.M., the resident's Family Member I said the following: -On 02/22/25, Resident #2 complained about his/her right eye and told him/her that he/she was hit in the face; -On 2/22/25, Resident #2's right eye was very red around the rim and the resident said his/her vision was blurry; -On 02/22/25, he/she reported the resident's complaints to an unknown staff member at the desk, he/she asked the staff member if he/she knew about the resident's eye; -On 02/22/25, the staff at the nurses' station said they had looked at Resident #2's eye and it was looking better; -On 02/22/25, he/she told staff, something needs to be done about Resident #2's eye; -On 02/26/25, after the resident's care plan meeting, he/she reported the resident's complaints to staff and the resident was seen by his/her physician on 02/26/25; -The resident told Optometrist M that he/she was hit in the right eye with a book by another resident. During an interview on 03/06/25 at 11:50 A.M., Certified Nurse Aide (CNA) B said the following: -Staff that worked the unit told the nurses (Licensed Practical Nurse (LPN) C and RN O) about the resident's complaint of pain in his/her right eye; -The nurses did not come to the unit and look at the resident's right eye. During an interview on 03/06/25 at 2:15 P.M., Certified Medication Technician (CMT) A said the following: -When the resident complained of his/her right eye hurting, he/she (CMT A) verbally reported it to both Registered Nurse (RN) O and LPN C; -For at least one month, staff has been reporting to the charge nurses that the resident complained about his/her right eye and no one came and looked at it until RN D and the resident's physician came and looked at the resident's right eye. During an interview on 03/10/25 at 5:37 A.M., CMT J said the following: -The resident complained about his/her right eye being blurry and not being able to see out of it; -He/She reported the resident's complaints regarding his/her right eye to Licensed Practical Nurse (LPN) C (he/she did not recall when he/she had reported). During an interview on 03/06/25 at 12:02 P.M. and 12:28 P.M., LPN C said the following: -Resident #1 wandered in and out of other resident rooms; -On 02/10/25, Resident #1 wandered into Resident #2's room and Resident #1 grabbed hold of Resident #2; -Resident #2 had a bruise to his/her arm and Resident #2 gave Resident #1 a skin tear; -On 2/10/25, he/she was not aware of any injury to Resident #2's eye and did not see any redness on or around the resident's right eye; he/she was the nurse on duty the day the altercation occurred; -No staff told him/her about the resident's right eye complaints. During an interview on 03/09/25 at 6:16 P.M., RN O said the following: -Staff in the SCU were responsible for notifying the charge nurse (the charge nurse was not stationed in SCU) of any resident complaints or altercations; -Staff reported to him/her a few weeks ago that the resident's eye was red; -He/She looked at the resident's eye and it was red; -He/She thought the resident's eye was red because he/she was rubbing it; -He/She instructed staff to make sure the resident's hands were clean to prevent infection; -He/She may have sent a note to the resident's physician but he/she was not sure. During an interview on 03/06/25 at 3:50 P.M., RN D said the following: -He/She was not aware of the resident's complaints regarding his/her right eye until 02/26/25 after the resident's care plan meeting; -He/She did not see anything in the resident's progress notes regarding his/her right eye being injured; -The resident told his/her physician that he/she got whacked by someone in his/her right eye; -When he/she questioned staff in the unit, on 02/26/25, regarding the resident's right eye, they reported the resident had been complaining about his/her right eye for some time; -He/She would expect staff to document and report resident concerns/complaints to the charge nurse or him/her to be reported on to the physician. During an interview on 03/12/25 at 3:17 P.M. Optometrist Assistant N (assistant to Optometrist M) said the following: -The resident was seen by Optometrist M due to an injury to his/her right eye; -The lens on the resident's right eye was dislodged and needed to be put back into place surgically; -The vision in the resident's right eye was much worse than in his/her left eye; -The resident's vision in the right eye would not improve without surgery. During an interview on 03/11/25 at 1:55 P.M., Ophthalmologist Assistant K (assistant to Ophthalmologist L) said the following: -The resident said his/her right eye was hurting; -The resident had cataract removal many years ago; -Blunt force trauma caused the lens to sublux inferiorly (the lens is no longer in the middle of the eye); -The injury to the resident's right eye could not have occurred by rubbing his/her eye; -The injury significantly affected the resident's vision in his/her right eye; -Without surgery, the resident's vision would not improve. During an interview on 3/17/25 at 2:15 P.M., the resident's physician's nurse said the following: -The resident's physician was not aware of the resident's complaints regarding his/her right eye until 02/26/25; -The resident's physician would expect to be notified by staff if the resident complained of redness and/or pain in his/her right eye. During an interview on 03/07/25 at 3:49 P.M., the Director of Nursing said the following: -She would expect staff to assess the resident and notify the physician if the resident complained of eye pain; -She reviews residents' progress notes daily and was not aware of the resident's complaints regarding his/her right eye. During an interview on 03/07/25 at 3:55 P.M., the Administrator said she would expect staff to notify the physician if the resident complained of eye pain. She was not aware the resident was complaining about his/her right eye. MO 250291

Based on observation, interview, and record review, the facility failed to adequately monitor one resident's (Resident #1's) monitoring device (a small wristwatch-sized device (Tag) worn by a resident or attached to an asset (wheelchair, walker) that will trigger an alarm if in close proximity of an activation field; usually an exit door), per the manufacturer's instructions to ensure it functioned appropriately and would alert staff if the resident attempted to leave the facility without staff knowledge, in a review of 14 sampled residents. The resident was assessed as at risk for elopement and utilized a monitoring device as an intervention to address that risk. On 3/2/24 at 7:24 A.M., the resident exited the facility through the main entrance without staff knowledge in his/her motorized wheelchair. The monitoring device alarm system did not function and alarm when the resident exited the facility. The resident traveled approximately one half mile, on a paved road with no shoulder or side walk, before a concerned citizen saw the resident and contacted 911 and the resident's spouse. There were 24 residents identified as elopement risk that utilized the monitoring devices as an intervention to prevent elopement. The facility census was 68. The Administrator was notified on 3/11/24 at 3:30 P.M. of the Immediate Jeopardy (IJ), which began on 3/2/24. The IJ was removed on 3/11/24, as confirmed by surveyor onsite verification. Review of the manufacturer manual for the monitoring device used by the facility dated May 27, 2003, showed the following: -A Tag is defined as a small wristwatch-sized device worn by a resident or attached to an asset (wheelchair, walker); -When the resident enters an activation field (near an exit door or other area with a Tag alarm), the tag sends a signal to the zone controller (box mounted on the wall at exit/locked doors) and the controller responds by sounding an alarm; -For maximum protection of residents, the manufacturer recommends the Tags be tested on a weekly basis; -The Tags can be tested by entering the Tag in a monitored zone or by using a Tag Activator/Deactivator (TAD) device to test functionality. Review of the facility policy, Missing Residents - Elopement, dated 11/11/17, showed the following: -Elopement assessments will be completed on all new admissions, during quarterly assessments, and as needed on current residents; -If a resident is determined to be an elopement risk, a monitoring device (Tag) will be applied; -Placement of the Tag (monitoring device) will be monitored by the medication nurse twice a day. -The policy did not address testing of Tags weekly (per manufacturer's recommendations) by entering a monitored zone or by using a TAD device to check for functionality and battery life. 1. Review of Resident #1's care plan, updated on 3/6/23, showed the following: -The resident had a memory/recall problem related to dementia. At times the resident will forget he/she is in a nursing home and wants to go home. He/She has presented with exit seeking behaviors in the past; -Redirect the resident when he/she enters unsafe areas; -Resident was usually alert and oriented to person, place, and time of day. There are times he/she needed reorientation and reminding that he/she resides at the facility; -A Tag (monitoring device) was applied to the resident's wheelchair. The Tag is checked every shift for a blinking red light by the certified medication tech (CMT) and documented; -All staff are to respond to alarms and call for assistance if needed to return the resident into the facility; -The resident required assistance with activities of daily living (ADLs); -Once in his/her electric wheelchair the resident was independent with locomotion; -The resident required a stand-up lift (a mechanical lift used to transfer an individual from one seated surface to another) to transfer; -The resident was at risk for psychosocial well-being (the state of mental, emotional, and social health of an individual) and at risk for elopement related to the resident wanting to go home; -Elopement risk assessment every three months. Review of the resident's elopement risk assessment, dated 9/1/23, showed the resident was at risk for elopement. Review of the resident's medical record showed no documentation staff completed a quarterly elopement risk assessment for the resident in December 2023 per facility policy. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 2/29/24, showed the following: -The resident's cognition was intact; -The resident used an electric wheelchair; -The resident was dependent on two or more staff for dressing, toileting, and bathing; -The resident required substantial to maximum assist from staff members for transfers; -The resident had impaired range of motion on one side of his/her lower extremities; -The resident did not exhibit wandering behaviors; -The resident used a wander/elopement alarm daily. Review of the facility's undated investigation regarding the resident's elopement showed the following: -(On 3/2/24) at 7:05 A.M. to 7:10 A.M. Registered Nurse (RN) B saw the resident at the south nurse's desk; -At 7:15 A.M. to 7:20 A.M., Certified Nursing Assistant (CNA) F visualized the resident and instructed him/her to move into the dining room to eat breakfast; -At approximately 7:50 A.M., CNA F told RN B the resident never made it to the dining room for breakfast; -RN B went to the resident's room but he/she was not there; -RN B got a phone call from the resident's spouse that the resident was seen on a two-lane, black top road; -When the resident returned to the facility his/her Tag device did not alarm; -The resident's Tag did have a red blinking light; -CMTs check functionality twice daily by looking for a red blinking light on the device and document on the resident's medication administration record (MAR); -Five other residents' Tags were tested (no description given how they were tested ); -Maintenance Staff A completed alarm checks on all exit doors (no description given of how staff checked the alarms). During an interview on 3/11/24 at 9:51 A.M., the resident said the following: -He/She did go outside and went down a hill and up a hill; -The resident could not recall or answer any other questions regarding his/her elopement on 3/2/24. Observation of the resident on 3/11/24 at 9:51 A.M., showed a Tag attached to the back side of the resident's wheelchair that had a red blinking light. Review of the resident's face sheet, dated 3/11/24, showed the following: -The resident was his/her own person; -The resident had diagnoses that included multiple sclerosis (a disease that affects the central nervous system; brain, spinal cord, and optic nerves), dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions and solve problems), cognitive communication deficit (difficulty with thinking and how someone uses language), contracture (deformity and rigidity of joints) of right ankle, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), lack of coordination, and abnormalities of gait (manner of walking) and mobility. During an interview on 3/11/24 at 2:10 P.M., Certified Nurse Aide (CNA) F said the following: -At 7:15 A.M. to 7:20 A.M., on 3/2/24, the resident was headed towards the north nurse's station in his/her electric wheelchair; -CNA F asked the resident if he/she was going to eat breakfast and the resident said he/she would turn around and head back to the dining room; -At 7:45 A.M., CNA F took a resident to the north hall and did not see Resident #1; -CNA F asked nurses at the north and south nurse's stations if they had seen Resident #1 and no one had seen the resident; -CNA F started looking throughout the inside of the facility for the resident; -A call came in from someone that told a staff member (unsure which staff member) the resident was outside; -CNA F went back to the dining room to continue to assist residents. During an interview on 3/12/24 at 2:40 P.M. a community member said the following: -He/She was driving on 3/2/24 at about 7:50 A.M. when he/she saw Resident #1 on a two-lane blacktop road; -The resident was headed west in the eastbound lane; -The community member stopped and asked the resident his/her name. The resident replied and said he/she was out for a daily stroll; -The community member recognized the resident's name and tried calling the facility, but no one answered; -When no one answered at the facility the community member called 911 and reported the resident's location; -The community member then called the resident's spouse; -The resident was dressed in long sleeves with a shirt over the top; the resident wore socks. The resident did not wear a jacket or shoes; -The community member got a blanket from his/her car and put it around the resident's shoulders and waited until the highway patrol arrived. During an interview on 3/12/24 at 8:21 A.M., the resident's spouse said the following: -At 7:55 A.M. on 3/2/24, a community member called him/her at home and said they found the resident on a two-lane blacktop road; -The community member said the resident did not know where he/she was; -The community member said he/she tried to call the nursing home, but here was no answer, so he/she called 911; -At 7:58 A.M. on 3/2/24, the resident's spouse called the facility and told them where the resident was located; -The facility staff said they would get the facility van to transport the resident back to the facility; -At 8:33 A.M. on 3/2/24, the resident's spouse called to check on the resident and was told the resident was not back at the facility yet; -At 8:52 A.M. on 3/2/24, the facility called and told the resident's spouse the resident was back at the facility, uninjured; -The resident's spouse was very upset the resident was able to leave the facility without staff knowledge and that it took the facility so long to get the resident back to the facility. Observation on 3/12/24 at 9:15 A.M., of the route the resident would have taken from the facility to where he/she was found, showed the following: -The front door of the facility the resident used to exit the facility is an automatic sliding door that opens when anyone gets within a certain distance from the automatic door's motion sensor; -The front door exits into the facility parking lot; -The city street in front of the facility is a two-lane municipal blacktop; -The resident would have traveled in his/her wheelchair approximately one tenth of a mile and turned left onto the two-lane municipal blacktop with a steep hill and no shoulder. The street travels through a wooded area; -Once the resident was at the bottom of the hill he/she would have turned left onto a two-lane blacktop service/outer road with a speed limit of 45 miles per hour with moderate traffic. Review of wunderground.com showed the temperature on 3/2/24 at 7:55 A.M. was 31 degrees Fahrenheit and mostly sunny. During an interview on 3/12/24 at 3:39 P.M., RN B said the following: -On 3/2/24 Resident #1 was at the south desk when he/she came on duty; -RN B went to check on a few residents and gather lab work on a resident; -When RN B returned to the nurse's station CNA F said Resident #1 had not made it to breakfast; -RN B went to check the resident's room but he/she was not in the room; -When RN B returned to the nurse's station, the resident's spouse called and said the resident was found on a two-lane blacktop road near the facility; -RN B thought the road the spouse talked about was in front of the facility. RN B went outside looking for the resident but did not see him/her; -Licensed Practical Nurse (LPN) C was also outside looking for Resident #1 at the same time and got a phone call from CMT D; -CMT D said the resident was on a two-lane blacktop road a little further from the facility and the highway patrol was with the resident; -RN B went back in the facility to call the on-call transport driver to pick up the resident; -RN B asked Maintenance Staff G to go sit with the resident until the transport driver could pick the resident up; -Maintenance Staff G ended up walking beside Resident #1's electric wheelchair and guided the resident back to the facility; -When the resident returned to the facility his/her Tag did not alert the alarm at the front entrance of the facility; -RN B checked the Tag and it had a red blinking light, but since it did not alert the system to alarm, RN B replaced it; -RN B tested five more residents with Tags by taking them to the front door and making sure they would alarm. All five of the Tags alarmed when tested ; -RN B did not know if any other Tags were tested . During an interview on 3/12/24 at 4:37 P.M., Maintenance Staff G said the following: -Maintenance Staff G arrived at the facility parking lot when a nurse told Maintenance Staff G he/she needed to go look for Resident #1; -Maintenance Staff G went driving and looked for the resident. Maintenance Staff G found the resident on a two-lane blacktop road; -Police were with the resident so he/she left the resident to go back to the facility and notify the nurse of the resident's location. The nurse told him/her to go back to Resident #1 and sit with the resident until the transport van could get the resident back to the facility; -After waiting with the resident for a few minutes, Maintenance Staff G decided to help guide the resident in his/her electric wheelchair back to the facility because Maintenance Staff G was not sure how long it would take the facility van to get to the resident and wasn't sure how long the battery would last in the resident's electric wheelchair; -When Maintenance Staff G and the resident got close to the facility, Maintenance Staff G called and let the nurse know and the nurse met them at the front of the building. The nurse took over care of the resident at that time. During an interview on 3/20/24 at 4:06 P.M. the local county sheriff's deputy said the following: -On 3/2/24, the deputy arrived to the site of the resident at about 8:00 A.M.; -The resident did not know where he/she was or where he/she was going; -The resident complained that he/she was cold; -The resident looked like he/she was dressed in pajama clothes; -A facility maintenance staff came and sat with the resident; -The facility said they would send the facility van to pick up the resident; -After waiting for 30 minutes to an hour the facility maintenance staff decided to help the resident guide his/her electric wheelchair back to the facility; -The facility never did send the van to pick up the resident. During an interview on 3/11/24 at 9:14 A.M., Maintenance Staff A said the following: -He/She tests all doors in the facility with an extra Tag device to see if the doors will alarm; -He/She did not test the Tags on residents at the exit doors, he/she had an extra Tag that he/she used to test the door alarms. During an interview on 3/11/24 at 10:04 A.M., CMT L said the following: -First thing on the day shift, a notice for the residents with a Tag pops up on the medication administration record (MAR) to check that resident's Tag; -He/She looks at the Tags to make sure the red light is blinking; -If the red light is blinking it is working appropriately; -If the red light is not blinking, he/she reports it to the nurse, and it will get replaced. During an interview on 3/11/24 at 11:03 A.M., CMT M said the following: -A reminder pops up on the resident's MAR (for residents with a Tag) to check the Tag each day; -If the Tag has a red blinking light it is working okay. During an interview on 3/11/24 at 10:58 A.M., RN H said the following: -It was the responsibility of the person passing medications to check Tags to see if they were working; -He/She has not taken a resident with a Tag to an exit door to see if it would alarm; -Maintenance had an extra Tag they used to check the exit doors to make sure they alarmed. During an interview on 3/13/24 at 12:48 P.M., the Manufacturer of the monitoring system's technical support person said the following: -The only way to detect if the Tags are functional is to test with the TAD or have a Tag in the monitored zone. -The TAD will detect a low battery; -The TAD will detect functionality of the Tag. During interviews on 3/11/24 at 11:20 A.M., 12:47 P.M., and 1:15 P.M. the administrator said the following: -Nursing staff completed a random check on five residents with Tags to make sure they were working properly by taking the resident to an exit door to make sure they would alarm. They did not test all of the residents with the monitoring devices. This was completed after Resident #1 eloped from the facility; -Resident #1 had attempted to leave the facility many times in the past and the Tag always alarmed. This was the first time it did not alarm for Resident #1; -The front doors of the facility are unlocked daily about 5:30 A.M. No one physically monitors the front doors between 5:30 A.M. and 7:30 A.M. Monday through Friday or on Saturdays and Sundays. -The residents with an electronic monitoring device have a notice on their MAR for the CMTs to document that they made sure the resident had the Tag on their person, walker or wheelchair and to make sure there was a red blinking light on. If there was a red blinking light it means the device is working properly and would alarm when close to an exit door (monitored zone). She was not aware of the recommendations in the manufacturer's guidelines. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO232613

Based on interview and record review, the facility failed to ensure fall interventions were implemented as directed per the resident's plan of care and physician's orders [REDACTED].#1) of five sampled residents. The plan of care directed staff to monitor the resident's bed alarm to ensure the alarm was functional. On 2/3/20 the resident transferred him/herself from bed and fell , fracturing his/her hip. The resident's bed alarm did not function to alert staff of the resident's activity. The facility census was 90. Review of the undated facility policy, Resident Accident/Incident Reporting, showed the following: -If the incident is a fall, the charge nurse completes the Fall Assessment Report Form or Matrix Fall Event Form; -The resident should not be moved from the scene of the fall until the initial assessment by the licensed nurse is completed; -The policy did not address interventions to prevent falls including the use of bed and chair alarms and the monitoring of these devices for proper function. 1. Review of Resident #1's face sheet showed the following: -admitted on [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's care plan for falls dated 1/3/19 showed the following: -On 1//19, staff were to equip the resident with a device that monitored rising per the family's request. This was a bed alarm and wheelchair alarm. Staff were to check for proper functioning of alarms and placement; keep the resident's bed in lowest position with brakes locked; keep call light in the resident's reach at all times and answer the call light promptly, and provide the resident with safety device/appliance such as a walker and wheelchair. The care plan directed staff to monitor the resident in his/her room that he/she didn't get his/her feet tangled in his/her oxygen tubing or nebulizer tubing, keep the resident in the line of sight to ensure safety since the resident believed he/she could transfer without assistance and would take him/herself to the bathroom without assistance; -On 2/1/19, the resident was found sitting on the floor in front of the recliner. The alarm pad was underneath the resident, but the alarm cord was not plugged into the box; -On 2/9/19, the resident had an unwitnessed fall from the bed; -On 2/21/19, physical therapy began strengthening and gait training three times a week for four weeks; -On 3/8/19, the resident had an unwitnessed fall at the bedside; -On 4/16/19, the resident had a witnessed fall from the chair with a personal alarm on the chair and bed; -Interventions for the 4/16/19 fall: Continue with [MEDICATION NAME] (anti anxiety medication), as ordered for anxiety, re-educate on the use of the call light and waiting for assistance; -On 4/29/19, staff found the resident on the floor beside the bed. The resident's alarm was not alarming and the call light was not on. The resident slid down and wore socks on his/her feet, there were no injuries; -Intervention for the 4/29/19 fall: Staff to encourage the resident to remove his/her shoes after supper and place gripper socks on the resident to prevent sliding if the resident happens to get up; -On 5/16/19, the resident slid off the bed mattress on to the fall mat with the bed in the lowest position; -On 6/14/19, staff found the resident sitting on the fall mat next to the bed. The resident said he/she went to turn and slid out of bed; -On 6/14/19, the resident fell while walking with family and a Certified Nurse Aide (CNA); -On 6/17/19, staff found the resident sitting on the floor on the mat beside the bed; -Staff documented on 6/19/19 for staff to observe the resident frequently and place him/her in a supervised area when he/she was out of bed; -On 6/24/19, therapy staff made signs to cue the resident to call for help before he/she transfers. They were red stop signs that said STOP, call for help, Don't fall and placed on the wall in the resident's line of sight; -On 7/2/19, the resident slid from the recliner; -On 7/12/19, a physician's orders [REDACTED]. Staff to make sure the alarm was working, the cord was intact and the clip into the box was intact. If this was not functioning, staff to call central supply and have it replaced immediately. Review of the resident's progress notes dated 12/17/19, showed the following: -At 9:08 A.M. staff documented the resident tried to fix his/her wheelchair and slid out of it while in the hallway. The fall was unwitnessed. There was no injury and staff assisted the resident back into the wheelchair with the assistance of two staff. The chair alarm in the wheelchair was not functioning properly and staff to alert maintenance; -At 6:20 P.M., the resident made several attempts to get up today on his/her own. Staff offered to walk with the resident who said he/she had a problem with his/her legs and believed that he/she would be going home to a local town; -Staff replaced new alarm pads in the chair and they were working. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/24/19, showed the following: -Moderately impaired cognition; -Independent in bed mobility; -Transferred with extensive assistance of one staff; -Extensive assistance of one staff to walk in room and corridor; -Extensive assistance of one staff to use the toilet; -Not steady and only able to stabilize with human assistance when moving from seated to standing position and when walking; -No falls since admission or previous MDS assessment (the MDS did not address the resident had a history of [REDACTED]. -Bed and chair alarm used daily. Review of the resident's care plan for falls last revised 1/3/20, showed the following: -On 12/17/19 at 9:08 A.M., staff documented the resident had a fall in the hallway when trying to stand and fix the wheelchair, the resident became unsteady causing the resident to fall; -Staff looked at the wheelchair and assessed that it was functioning well. Maintenance notified to look at the wheelchair; -Staff were to remind the resident to alert staff for assistance and not to stand independently. Review of the Resident's Physician order [REDACTED]. -[DIAGNOSES REDACTED]. -An order dated 7/12/19 - 2/26/20 to check bed and chair alarms TID to make sure they are working. Make sure the alarm is working, the cord is intact and the clip into the box is intact. If this is not functioning, call central supply and have it replaced immediately. Three times a day - 7:00 A.M. - 10:00 A.M., 12:00 P.M. - 3:00 P.M., 7:00 P.M. - 10:00 P.M. Review of the resident's progress notes dated 2/3/20 at 1:43 A.M., showed the following: -At 1:00 A.M., Certified Nurse Aide (CNA) B notified Licensed Practical Nurse (LPN) D charge nurse, the resident was lying on the floor in his/her room on the left side; -The resident said he/she got up with the walker and was getting something off his/her desk and fell ; -The resident complained of left hip pain and thought he/she might have broken his/her hip; -The charge nurse assessed the resident and the resident would not move the lower left extremity; -The charge nurse called the physician and family, and transferred the resident to the hospital. Review of the resident's event report dated 2/3/20, showed the following: -LPN D found the resident on the floor in the resident's room; -The resident was walking with the walker; -The fall was not witnessed by staff; -The resident complained of excruciating pain in the left hip and would not move the left hip; -The resident was transferred to the hospital for further evaluation. Review of the resident's medical record dated 12/17/19-2/3/20 showed there was no documentation staff checked the bed and chair alarm three times daily as directed in the resident's plan of care and per physician's orders [REDACTED].>Review of the resident's hospital x-ray report dated 2/3/20 showed a left femoral neck (hip) fracture. During interview on 2/18/20 at 12:20 P.M., CNA E said the following: -The resident's dementia was worse over the past month or more; -The resident sometimes used a call light, but the resident liked to transfer him/herself and try to reach for his/her walker; -The resident was not able to stand with the walker on his/her own, but thought he/she could do this on his/her own. During interview on 2/27/20 at 9:40 A.M., CNA F said the following: -He/She was not sure how often to check the resident's bed and chair alarm; -There was no set guidance about checking the alarms. During interview on 2/19/20 at 8:50 A.M. and 3/3/20 at 11:36 A.M., CNA B said the following: -He/She reported several times to staff about the resident's broken bed alarm clip and that the cord would fall out and it would not alarm; -The resident had dementia and was confused the evening before the resident fell ; -Usually the resident would turn on his/her call light for staff to assist him/her to the bathroom in the night; -The resident did not turn on his/her call light the night he/she fell ; -The last time he/she checked, the resident was in bed asleep at approximately 11:30 P.M.; -The last time he/she checked on the resident, the bed alarm was plugged in since the resident had not gotten up all night (when he/she comes to work at 7:00 P.M., the resident was usually in bed); -He/She was charting at the desk on the computer when he/she heard a noise and saw the resident's bedside table moved out of its normal place; -The resident usually sat on the side of the bed and turned on the call light, but when he/she went into the room, the resident was on the floor; -The resident had gotten to his/her walker over by his/her desk and fell ; -No bed alarm sounded; -The resident kept saying, I broke my hip. During interview on 2/19/20 at 4:05 P.M., LPN D said the following: -He/She was working at the bottom cottage when CNA B called about the resident falling; -The resident lay by a table in the room on his/her left side; -The resident said, I'm hurting and I think I broke my hip; -CNA B said he/she was sitting at the desk and charting when the resident got up with his/her walker; -The resident usually turned on the call light for assistance to the bathroom, but did not turn on the call light that night; -CNA B said he/she did not hear the bed alarm sound, even though the door was open and directly across from the nurse's desk; -He/She heard a thump and saw the resident's table move and ran to find the resident on the floor; -There was nothing said to him/her until that moment about the little clip on the alarm had been broken off. During interview on 2/19/20 at 3:50 P.M., LPN C said the following: -The day before the resident fell , he/she worked the day shift; -The bed and chair alarm were working. One of the clips on the resident's bed was not working well, but he/she did not check it; -The resident would set off the chair alarm quite often when he/she got to the edge of the wheelchair and it would alarm; -The day after the resident fell and went to the hospital, the bed alarm's clip (broken), was up on the nurse's desk for the maintenance man or central supply to pick up. During interview on 2/27/20 at 9:53 A.M. and 1:43 P.M., LPN A, nursing unit coordinator, said the following: -The resident's bed alarm was not working and it did not alarm the night the resident fell ; -CNA B reported the bed alarm was broken and not working; -When LPN A checked the bed alarm, the cord was not fully attached to the box and it did not alarm; -He/She was not sure how often to check the resident's bed alarms to see if they were working; -He/She thought maintenance would check the alarms routinely; -Staff should check the bed and chair alarms routinely to see if they would alarm when they do their bed checks; -If a bed alarm needed replaced, he/she would call maintenance to bring him/her another alarm; -If one needed replaced on night shift, the charge nurse should call other units to find one. During interview on 2/27/20 at 11:53 A.M., the maintenance director said the following: -He repaired bed and chair alarms when the locking tab breaks which will cause it not to alarm; -Staff bring the bed and chair alarms to the central supply office in the basement and place them on a cart for him to repair; -The maintenance department did not install the bed and chair alarms or routinely check for proper function on the residents' beds or wheelchairs; -Staff did not ask him to repair the resident's bed alarm. During interview on 3/4/20 at 12:36 P.M., the Director of Nursing said the following: -If the staff felt the resident was a fall hazard, they would put the resident in line of sight for a period of time when needed; -The nurse would assess and make decision to place a resident in their line of sight; -The resident was a frequent faller; -The resident had been in line of sight before, but had floor mat, low bed, and bed alarms the family wanted. The resident had not fallen for a while; -They tried to dissuade use of bed and chair alarms; -The resident did not remember to use the call light and needed help to get up. During interviews on 2/18/20 at 12:38 P.M., 2/19/20 at 3:45 P.M., and 3/4/20 at 4:00 P.M., the administrator said the following: -The resident fell and broke his/her right arm and hip in 2017 and was a frequent faller; -The resident had a bed alarm and knew how to unplug it for it not to alarm; -Staff was to monitor the bed and chair alarms; -If there was an issue with the chair and/or bed alarm, staff should put in a maintenance request; -She was unaware if staff recorded when they checked the bed and chair alarms; -She was unaware if there was a physician's orders [REDACTED]. MO 3

Based on interview and record review, facility staff failed to ensure one resident (Resident #1), in a review of five sampled residents was free from significant medication error. The resident had diabetes and required the use of insulin to treat. The facility failed to provide staff training or education on how to use the resident's insulin pump ([MEDICATION NAME] 530G System -a pump used to deliver rapid or short-acting insulin through a catheter placed under the skin), which caused the resident to miss two doses of insulin (a hormone that allows the body to use sugar (glucose) from food for energy or to store glucose for future use. Insulin helps keeps your blood sugar level from getting too high or too low). The resident experienced confusion and extremely high blood glucose levels, which caused him/her to miss his/her [MEDICAL TREATMENT] (treatment for [REDACTED]. The resident was sent to the hospital where he/she presented very confused and lethargic. The resident returned to the facility with a significant change in condition. The facility census was 109. 1. Record review of the [MEDICATION NAME] 530G System User Guide, (for Resident #1's insulin pump (a medical device used to administer insulin under the skin. The device includes a pump, a reservoir for insulin and an infusion set - needle and cannula to deliver the insulin under the skin), https://www.accessdata.fda.gov/cdrh_docs/pdf12/P 0c.pdf, dated 2012, showed the following: -The [MEDICATION NAME] 530G System is intended for continuous delivery of basal insulin (at user selectable rates) and administration of insulin boluses (one time dose given all at once) for the management of diabetes mellitus requiring insulin as well as for the continuous monitoring and trending of glucose levels in the fluid under the skin (subcutaneous); -Patients should be instructed to follow the provided user guides for insertions and care of infusion sets, if an infusion site becomes irritated or inflamed, the infusion set should be removed and another placed in a new location; -Due to the use of insulin, there is risk related to the infusion of insulin and the potential interruptions of insulin delivery; -These general risks may include [MEDICAL CONDITION] (high blood sugar). 2. Record review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 11/2/17 showed the following: -Cognition was intact; -Eats independently; -Transfers and toilets with limited assistance of one staff; -Always continent of bowel and bladder; -[DIAGNOSES REDACTED]. Record review of the resident's care plan, dated 11/09/17, showed the following: -Problem: Diabetes mellitus; -Goal: Blood glucose ranges within limits set forth by the physician with absence of signs of [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION]; -Approach: monitor blood glucose as per physician orders; -Monitor for signs of [MEDICAL CONDITION]; -The resident has an insulin pump. Be sure to change cartridge, chamber and site every three days; -Accu Checks (a device/procedure used for determining the approximate concentration of blood glucose) as ordered by physician; -[MEDICAL TREATMENT]. Record review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Blood glucose check before meals and at bed time (6:00 A.M., 11:00 A.M., 4:00 P.M. and 8:00 P.M.); -[MEDICATION NAME] (a fast acting insulin) solution, 100 unit/ml subcutaneous as directed per insulin pump, ([MEDICATION NAME] 530G System), four times a day (bolus dose depends on the resident's blood sugar readings and intake of carbohydrates (sugars/starches); 6:00 A.M., 11:00 A.M., 5:00 P.M. and 8:00 P.M.; -Insulin pump site (infusion site) to be changed every third day between 7:00 P.M. and 7:00 A.M. Record review of the resident's Licensed Nurse Medication Administration History, dated 4/1/18 through 4/30/18, showed on 4/3/18 at 7:00 P.M. to 7:00 A.M., staff changed the resident's insulin pump site. Record review of the resident's nursing observation record, dated 4/4/18, showed the following: -At 12:44 A.M., the resident was nauseated and sick to his/her stomach and vomiting blood; -One time order for [MEDICATION NAME] 10 units for meter reading (blood sugar reading) above 600 (normal blood sugar range prior to a meal per American Diabetes Association is 80-130 milligrams per deciliter); -There was no documentation on the physician's orders [REDACTED]. -At 4:19 A.M., the resident's blood sugar was 400; -Staff planned to recheck the resident's blood sugar reading at the resident's 6:00 A.M. bolus of insulin and check the reservoir (a plastic cartridge that holds the insulin that is locked into the insulin pump. It comes with a transfer guard, a blue piece at the top that is removed before inserting the reservoir into the pump that assists with pulling the insulin from a vial into the reservoir on the infusion set - includes the thin plastic tubing that delivers insulin from the pump to the body; similar to a syringe and generally holds a two to three day supply of insulin) to make sure it was changed out. Record review of the resident's Vitals Report, dated 4/4/18 at 5:50 A.M., showed the resident's blood sugar was 300 mg/dl. Record review of the resident's Licensed Nurse Medication Administration history, dated 4/4/18 at 6:00 A.M., showed the resident's blood sugar was 300 mg/dl. Record review of the resident's Licensed Nurse Medication Administration history, dated 4/4/18 at 11:00 A.M., showed the resident's blood sugar was high. Record review of the resident's Vitals Report, dated 4/4/18 at 12:35 P.M., showed the resident's blood sugar was off scale. The blood sugar was high and above 400. Record review of the resident's physician's office summary view and telephone encounter, dated 4/4/18 at 1:08 P.M., showed the following: -Reason: blood sugars; -Message: At 1:08 P.M., the night shift nurse last night didn't get the resident's insulin pump hooked up correctly so the insulin pooled under the skin and wasn't doing the resident any good today; -Licensed Practical Nurse (LPN) D checked the resident's sugar and it was over 600 mg/dl; -LPN D rechecked an hour later and the resident's blood sugar was still over 600 mg/dl; -LPN D would like to know if the physician had any suggestions on what to do; -Actions taken: At 3:01 P.M. (4/4/18); -LPN D called back and said the resident wasn't as responsive as he/she was earlier; -The resident's family member was really worried; -The meter still read high so they know the blood sugar was over 600 mg/dl. Record review of the resident's Vitals Report, dated 4/4/18 at 3:50 P.M., showed the resident's blood sugar was 588 mg/dl and acceptable range was 60-400 mg/dl. Record review of the resident's physician's office summary view and telephone encounter, dated 4/4/18 at 3:52 P.M., showed the physician directed staff to send the resident to the emergency room . Record review of the resident's Licensed Nurse Medication Administration history, dated 4/4/18 at 4:00 P.M., showed the resident's blood sugar was 588 mg/dl. Record review of the resident's physician's office summary view and telephone encounter, dated 4/4/18, showed the following: -At 4:09 P.M., LPN D said they finally got a blood sugar of 588 mg/dl; -The resident's physician said if the resident was still not responding appropriately he/she was to be sent to the emergency room ; -At 4:57 P.M., LPN D called back and resident's blood sugar was 485 mg/dl; -LPN D was sending the resident to the emergency room as the resident's family member was upset and the resident would like to go as well. Record review of the resident's nurse's note, dated 4/4/18 at 7:39 P.M. showed the following: -The resident's blood sugar read high this afternoon; -Staff inspected the insulin pump and noted that it was not functioning properly; -Staff changed the tubing and reservoir; -The pump administered 13 units of insulin, rechecked blood sugar and the reading was still high; -Called physician's office regarding situation; -Around 1:00 P.M. staff reported the resident was not responding as he/she usually did; -The physician's office was called again regarding current status; -The resident was slow to answer; -His/her blood sugar reading was 588 and the pump administered 12 units; -Called the physician's office again to inform him/her of the resident's blood sugar and current status; -Received call from physician's office with orders to send the resident to emergency room for evaluation and treatment if resident's status does not improve; otherwise recheck his/her blood sugar in two hours and give 2 units of insulin if blood sugar greater than 300 mg/dl; -Spoke with resident and he/she requested to go to the emergency room for evaluation and treatment; -The resident left with the ambulance at 5:45 P.M. Record review of the resident's hospital's history and physical, dated 4/4/18 at 7:25 P.M., showed the following: -Chief Complaint: The resident presents with altered mental status and [MEDICAL CONDITION]; -The resident had a history of [REDACTED]. -The resident presented to the emergency department with complaints of [MEDICAL CONDITION] and confusion onset today; -The emergency medical staff reported the resident resided at the facility and had an insulin pump changed incorrectly last night so he/she did not receive any insulin; -The insulin pump was changed today due to the resident's blood glucose being between 400-600; -The resident had been confused since 1:00 P.M.; -The resident received 700 cc of normal saline (used for fluid loss and to restore sodium chloride balance) per the medical emergency system; -The resident reports with cough, headache and abdominal pain; -Evidently after the insulin pump was changed today he/she continued to have diminished level of consciousness but was nonspecific and there had been no details of how he/she acted throughout the day; -They have and heard reference the resident was somnolent (sleepy, drowsy); -They had not heard about chest pain or breathing difficulty or eating activity; -He/she had not been out of his/her room; -Review of systems: the history and review of systems are limited due to the resident's current condition; -Positive for cough, abdominal pain, [MEDICAL CONDITION], headaches and confusion; -Elderly, somnolent and minimally responsive; -He/she will answer a few questions and then start to stare off; -Intermittent wet coarse cough; -Tongue looks exquisitely dry; -Pulmonary/chest: Stridor (a harsh vibrating noise when breathing) present; -Tenderness in the left lower quadrant of his/her abdomen; -Displays tremor; -Able to open his/her eyes and answer one word questions but not able to stand task; -He/she stares and in a different direction and then becomes unresponsive after a couple of questions and does not follow commands. Review of the resident's complaint report, dated 4/20/18, showed the following: -On 4/20/18 at 4:30 P.M., Resident #6, Resident #1's spouse who shares a room with Resident #1, wanted to make a complaint regarding Registered Nurse (RN) C changing the resident's insulin pump reservoir (holds a two to three day supply of insulin) and needle set (used to deliver the insulin) on 4/4/18 at 5:00 A.M.; -He/she believed RN C did not take the blue needle cover off of the device and thus the resident did not receive the correct insulin; -Resident #6 said that because he/she could see Resident #1 and his/her care, he/she asked RN C if he/she removed the needle cover; -He/she thought RN C might not of heard him/her or if RN C responded and he/she could not understand RN C; -On 4/4/18 at 12:00 P.M., LPN D changed the administration set (to the insulin pump) and the cap/needle cover was on; -The resident's blood sugar was high and Resident #6 asked LPN D to give the resident insulin but he/she did not; -At 4:45 P.M., the resident wanted to go to the hospital and was sent by ambulance, leaving at 5:45 P.M.; -Resident #6 reported as of 4/20/18, the resident can't hold a phone or feed him/herself and was confused, he/she feared Resident #1 had permanent damage; -Other family members visited the resident in the hospital and expressed concerns the resident would never be the same again. Record review of the resident's complaint report, dated 4/20/18, showed the following: -On 4/27/18 at 1:30 A.M., LPN D said when he/she was checking the resident's blood sugar to get data or just following up on how the resident was doing, he/she was not sure of which, he/she noticed the safety cap was not flat against the resident's skin and then he/she saw the blue cap under the shield; -Resident #6 saw it and said it was wrong; -Resident #6 was the primary educator for staff on use of the insulin pump. Record review of the facility's investigation dated 4/23/18 at 2:30 P.M. showed: -On 4/4/18, when the insulin pump was inspected, it was noted that the safety cap was over the needle and was not removed prior to adhering to the resident's body; -When the device was removed the insulin had pooled at the resident's skin under the cap/adhesive dressing. Review of the resident's hospital progress note, dated 4/23/18 at 5:34 P.M., showed the following: -Assessment: Prior to initial admission on 4/4/18 the resident had missed [MEDICAL TREATMENT] due to difficulties with uncontrolled blood glucose levels and problems with his/her insulin pump; -The resident also been experiencing confusion at that time with blood glucose levels as high as 700 mg/dl; -He/she presented very confused and lethargic. Review of the resident's physician progress notes [REDACTED]. -Follow-up from the return to the hospital; -The resident was in and out of the intensive care unit (ICU) at the hospital after failure of his/her diabetic insulin pump here at the facility and his/her blood sugars getting extremely high; -The hospital was able to continue with [MEDICAL TREATMENT] and get his/her blood sugars under better control; -His/her mentation did improve some, however he/she was not back to his/her baseline; -Resident #6 said the resident was slowly improving but was slow to respond and very weak; -The resident was unable to feed him/herself independently. Record review of the resident's nurse's progress note, dated 4/26/18 at 12:00 P.M. showed: -The resident was assisted to sit on the edge of the bed but was very weak and doesn't always hold his/her balance; -The resident didn't take initiative to feed him/herself so the nurse assistant helped him/her with breakfast; -The resident was incontinent of bowel and bladder and didn't know he/she was incontinent. Review of Resident #1's significant change MDS dated [DATE] showed the following: -Cognition was severely impaired; -Evidence of an acute change in mental status from the resident's baseline; -Required supervision of one staff with eating; -Transfers and toilets with limited assist of two staff; -Frequently incontinent of bowel and bladder. During interview on 4/30/18 at 11:45 A.M., Resident #6 said the following: -Resident #1 has an insulin pump; -There was a blue cover that protects the needle and the blue cover wasn't removed which prevented the insulin from coming out of the needle; -He/she asked RN C if he/she had taken the cover off of the needle and he/she doesn't know if RN C heard him/her; -Resident #1 told the staff he/she wanted to go to the hospital around 4:45 P.M., he/she had felt sick and had confusion; -He/she used to take care of the resident's insulin pump until his/her ALS (amyotrophic lateral [MEDICAL CONDITION], a progressive [MEDICAL CONDITION] disease that affects nerve cells in the brain and the spinal cord) progressed; -The staff checked on the resident between 11:30 A.M. and 12:00 P.M. and changed the tubing and opened the reservoir and by the time the reservoir was open it was too late and the resident's blood sugars were too high; -He/she asked staff to give Resident #1 insulin but they needed physician orders [REDACTED]. -After Resident #1 went to the hospital he/she was more confused, hollered out in pain more and lost sensitivity of her bowel and bladder; -He/she said when Resident #1 was first admitted to the facility staff wasn't familiar with the insulin pump and asked Resident #6 to show them. He/she taught Registered Nurse (RN) E and RN E passed on the information. He/she thought staff would have known how to operate the insulin pump; -His/her concern was what if his/her ALS advanced or he/she was out of the building, who would educate staff on the insulin pump; -The facility staff told him/her staff would receive training on the insulin pump. During an interview on 4/30/18 at 3:50 P.M., Resident #6 said the following: -At noon (4/4/18), Resident #1's blood sugar was above 600; -He/she tried to get staff to give the resident insulin but the resident's physician didn't call back until 4:45 P.M.; -The resident went to the hospital on [DATE] feeling sick and didn't return until 4/24/18; -The resident didn't go to [MEDICAL TREATMENT] on 4/4/18 because his/her sugars were high and he/she was so sick. During interview on 5/1/18 at 6:54 P.M., LPN D said the following: -RN C had changed the resident's tubing during the night shift and his/her blood glucose had been high; -He/she didn't remember if he/she had done an Accu Check on the resident mid-morning, the aides said something about the resident not feeling well; -He/she looked at the resident's quick set (an infusion set includes the thin plastic tubing that delivers insulin from the pump to the body) and noticed it wasn't placed right and he/she changed it; -The resident's blood sugar was in the 400's; -He/she called the resident's physician three times that day (4/4/18) to get orders; -He/she wasn't sure if he/she documented all the calls to the resident's physician because there was something else going on that day; -At approximately 3:00 P.M. or 4:00 P.M. the resident's mental status had changed. The resident had previously been alert and oriented times three (person, place and time); -He/she finally got in touch with the resident's physician because the resident's blood sugars were so high (588 at one time); -The resident's mentation came and went; -The resident wanted to go to the hospital; -The Emergency Medical Technicians (EMT's) asked if the resident's mental status was normal and he/she told them no and the resident's mental condition had worsened in the ambulance; -At some point during the morning the resident asked him/her to cancel his/her [MEDICAL TREATMENT] appointment because he/she didn't feel good; -Resident #6 trained LPN D on how to use the insulin pump; -There were normally orders for when to contact the physician when a resident's blood glucose was above a certain number and he/she considered any glucose reading over 400 abnormal for the resident; -He/she didn't document the resident's insulin because it was preset in the pump by his/her endocrinologist; -He/she was not aware of any insulin policy or procedures; -He/she had not seen manufacturer guidelines for the insulin pump; -He/she had not seen the guidelines for the quick set; -He/she could not remember if he/she reported the medication error to the Director of Nursing (DON). During an interview on 4/30/18 at 1:35 P.M., RN A said: -Resident #6 taught staff how to use Resident #1's insulin pump; -The facility did not assess Resident #6 or staff on competency of using the insulin pump; -He/she used the pamphlet that came with the box of the quick set when he/she first changed the infusion set. During an interview on 5/1/18 at 7:58 P.M., RN C said the following: -The resident was sick around midnight (4/4/18) and he/she tried to change the pump around 1:00 A.M. (4/4/18); -He/she was concerned the resident's blood sugar was too high and thought there was a malfunction in the pump and it needed to be changed out; -He/she had no idea the resident wasn't getting insulin; -This was the first time he/she had to change the reservoir; -He/she received a quick five minute run down from another nurse on how to change the reservoir; -He/she did not feel comfortable, but had to do it; -There was no staff that he/she was able to ask for help; -He/she didn't know the needle wasn't inserted right or the cap was left on; -He/she was not educated on checking the blood sugar after the reservoir was changed to ensure the resident was receiving insulin or how to troubleshoot if he/she was having problems; -He/she was told about the medication error one week later after the resident was hospitalized ; -There was no parameter for the resident's Accu Checks; he/she was told it was built into the pump. During an interview on 5/1/18 at 9:15 A.M., the MDS Coordinator said the following: -There were no instructions for the resident's insulin pump; -He/she did not provide staff education on the resident's insulin pump; -He/she knew the resident was having trouble with his/her blood sugars during the afternoon (4/4/18) and his/her baseline mentation had changed; -The resident was becoming more confused; -He/she told the nurse to call the physician's cell phone; -The operator's manual on the insulin pump could not be found and the resident was not admitted with the operator's manual. During an interview on 5/1/18 at 9:20 A.M., the Unit Coordinator said: -He/she had not educated staff on how to use the insulin pump; -He/she was unable to find the operator's manual for the pump and the resident did not bring one with him/her to the facility. During an interview on 4/30/18 at 10:17 A.M., the facility nurse consultant said the following: -He/she took report from Resident #6 regarding the medication error; -Resident #1 had juvenile diabetes (a chronic condition in which the pancreas produces little or no insulin that begins in childhood) and came to the facility with an insulin pump; -Resident #6 was coaching staff on how to use the insulin pump; -On 4/4/18, RN C was changing the resident's quick set; Resident #6 asked the RN if he/she took the cap off of the quick set tubing (to allow the insulin to flow); the RN didn't know what Resident #6 was asking so he/she went on with what he/she was doing; -Licensed Practical Nurse (LPN) D went to check on the resident and wasn't sure if he/she was responding and when LPN D checked the infusion set site and the disc (filled with insulin) wasn't fitting flat and was buckled. LPN D pulled it back and a little blue cap was adhered to the end and there was a pooling of blue liquid (insulin); -The resident didn't have insulin from approximately 5:00 A.M. until 12:00 P.M. (missing two bolus doses of insulin); -It was a medication error and the resident had to go to the hospital; -RN C received his/her training from Resident #6; -He/she was not sure if Resident #6 was checked for competency for his/her procedure using the insulin pump; -Resident #1 asked to go to the hospital; -He/she was not sure if the medication error was investigated; -LPN D should have reported the medication error to someone; -The unit coordinator would have been responsible for educating the resident and staff on the insulin pump. During an interview on 4/30/18 at 8:30 A.M., 5/1/18 at 11:15 A.M. and 5/7/18 at 10:57 A.M., the DON said: -The nurse consultant took care of the medication error regarding the insulin; -The resident was back from the hospital and had a decline in his/her condition; -The resident was admitted from home to the facility; -He/she assumed the resident and his/her spouse (Resident #6) knew how to use the insulin pump; -He/she expected staff to know about the insulin pump; -They should have obtained a video from the manufacturer or trained staff with YouTube (a free video sharing website that makes it easy to watch online videos) videos; -He/she was not aware of the medication error until the nurse consultant started investigating; -The medication error should have been reported to the DON and physician; -There was a meeting every morning where staff could notify him/her of a medication error; -There was no policy and procedure on medication errors or insulin pumps; -He/she said there should have been Accu Check parameters; -He/she would expect staff to call the medical director if the attending physician was not returning their phone calls; -The MDS coordinator and unit coordinator were responsible to provide training on the insulin pump; -He/she would expect staff to document the amount of insulin the resident received; -He/she would try to get a report from the resident's pump to show insulin, blood sugar and carb count activity but wasn't sure they had the proper computer cables to do this; -He/she would expect staff to remove the cap from the needle; -He/she would expect staff to recheck the resident's blood sugar after changing the resident's insulin pump reservoir and replacing the needle; -He/she was on call 24/7 and staff could call him/her if they had questions regarding the resident's insulin pump; -He/she would have to refresh his/herself on the use of the insulin pump. During an interview on 5/2/18 at 9:43 A.M., the resident's physician said the following: -The staff attempted to give insulin and the insulin pump wasn't working; -He/she would not expect Resident #6 to educate staff on the resident's insulin pump; -If the pump was working and the resident received insulin this may have prevented the resident's change in condition; -He/she was under the impression the DON and staff were educated on how to use the insulin pump; -The facility should have contacted the insulin pump manufacturer or the resident's endocrinologist's office for training; -He/she would expect staff to indicate there was an emergency when they were attempting to contact him/her; -He/she said often times the physician orders [REDACTED]. -He/she would have expected to be notified of resident Accu Checks that are not within range of the resident's Vitals Report. During interview, on 5/4/18 at 8:29 A.M., the resident's endocrinologist said the following: -He/she was not aware the resident missed two doses of insulin; -He/she would expect the facility to be responsible to set the Accu Check parameters and notify the resident's physician if the resident's blood sugars were below 80 or over 400; -If the resident had four blood sugars over 400 he/she would expect staff to change the site the insulin was administering into the resident and let him/her know; -It was imperative the resident received insulin because when the body doesn't receive insulin the body starts breaking down tissue and this was the last step of survival; -The resident was hospitalized with fluid overload and heart failure; -He/she would have expected staff to document carbohydrates, Accu Checks and insulin; -This information was available from the insulin pump via special software provided by the manufacturer; -The information was needed to manage the resident's diabetes; -The facility could have contacted the manufacturer from the insulin pump company which provides education on the insulin pump; -He/she would have expected one staff at the facility at all times to know how to operate the insulin pump while Resident #6's ALS progressed or notify him/her so he/she could assess if the resident was still appropriate for the pump. During an interview on 5/11/18 at 11:40 A.M., the administrator said the following: -He/she would expect a medication error to be documented and reported to the charge nurse, unit coordinator and DON; -If the resident was unable to operate his/her own insulin pump he/she would expect staff to be trained; -He/she would have expected the DON to set up training on the insulin pump; -Training should have been initiated after the medication error was discovered; -He/she would expect the resident's care plan to encompass the care the resident required and with any change in the resident's condition. MO# 4

Based on observation, interview, and record review, the facility failed to consistently implement, evaluate, and modify interventions as necessary to address prevention of falls for three residents (Resident #1, #7 and #8) of eight sampled residents. Resident #7 sustained injuries from multiple falls including a compression fracture, closed head injury (trauma in which the brain is injured) and fractured ribs. The facility census was 136. 1. Review of the facility policy Accident/Incident Prevention and Reporting, dated 10/7/14, showed the following: -It is the policy to aggressively seek to correct situations that may result in injury to any person; - The monthly safety committee is a regular forum for discussion of safety concerns; -If the incident is a fall, the Fall Assessment Report Form is completed by the charge nurse and a copy is made and submitted to the Director of Nursing (DON) for review; -Injuries from all causes are documented in the nurses' notes; -The physician and responsible party are to be notified promptly. 2. Record review of Resident #7's care plan, reviewed and updated 11/23/15, showed the following: -Falls: history of falling related to falls at home prior to admission; -Assure the floor is free of glare, liquids and foreign objects; -Encourage the resident to assume a standing position slowly; -Keep call light in reach at all times; -Encourage the resident to use environmental devices such as hand grips, hand rails, etc.; -Keep personal items and frequently used items within reach; -Leave night light on in room; -Obtain physical therapy consult for strength training, toning, positioning, transfer training, gate training, mobility devices, etc. as needed; -Provide proper, well-maintained footwear; -Provide resident an environment free of clutter; -Provide resident with safety device/appliance: walker; -Educate resident to always notify staff of any fall and bathroom needs; -Educate resident to ask staff to help his/her spouse with things; -Encourage resident to call for assist to get things from under the bed. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/25/16, showed the following: -Understands and is understood; -Cognition was moderately impaired; -Independent with walking in room or corridor; -Independent with transfers, locomotion on and off the unit, toilet use and personal hygiene; -The resident was not steady with moving from seated to standing position, walking, turning around, moving on and off the toilet, or surface-to-surface, and able to stabilize without staff assistance; -Mobility devices: Walker; -Always continent; -Had two falls with injury since prior assessment (11/25/15); -Received antidepressant and diuretic; -[DIAGNOSES REDACTED]. Record review of the resident's Morse Fall Scale (a rapid and simple method of assessing a resident's likelihood of falling), undated, showed the resident's total score was 40 (a score of 25-44 indicated moderate risk). Record review of the resident's fall assessment dated [DATE] untimed, showed the following: -Location of fall: Room; -What happened: The resident said he/she was putting on his/her pants and fell over, the resident was found in his/her bedroom in front of the closet with his/her pants down in a sitting position; -Injuries: 7.3 cm (centimeter) x 2.5 cm scraped area to right buttocks; -Interventions: Assessed for injury, assisted off floor via facility's policy, vital signs and abrasion treated; -Previous history of falls; -[DIAGNOSES REDACTED]. -The resident didn't experience problems when using appliances, just doesn't always use; -The resident was trying to change pants while standing; -Fall followed similar pattern of previous falls. Review of the resident's care plan showed no evidence staff evaluated the effectiveness of current interventions or implemented new interventions to prevent future falls following this fall. Record review of the resident's fall assessment dated [DATE] at 6:45 A.M., showed the following: -Location of fall: In room between the electric wheelchair belonging to the resident's spouse and sink beside the cabinet; -What happened: The resident reported walking to his/her wheelchair, losing his/her balance and falling into his/her spouse's wheelchair and down (to the floor). Staff found the resident on his/her right side (lying position); -The resident hit his/her head on the bedside cabinet; -Injuries: Skin tear to left elbow, complaint of back pain, left upper arm pain and chest at pacemaker area; -Interventions: Assessment, ice to head, up to bed with Hoyer lift (mechanical lift), sent to emergency room for evaluation; -Previous history of falls; -[DIAGNOSES REDACTED]. -The resident didn't experience problems when using appliances, just doesn't always use; -The resident was doing usual activities and walking; -Fall followed similar pattern of previous falls. Review of the resident's nurse's note, dated 4/8/16 at 9:10 P.M., showed the following: -At 6:45 P.M., the resident was lying on the floor between the sink and his/her spouse's wheelchair with his/her head against the bedside cabinet corner. The resident lost his/her balance; fell into his/her spouse's wheelchair, then to the floor onto his/her right side, hitting his/her head on the cabinet. Staff noted the resident to have a skin tear and a very small bruise on his/her left arm near his/her elbow. Staff assisted the resident up via Hoyer lift to the bed. The resident complained of pain in his/her low back, left upper arm into the chest towards left pace maker area. The resident was transported to the emergency room , report was given and informed it would be a very long wait, when the ambulance arrived they decided to take the resident to another emergency room due to the resident's complaints and crying with pain; -At 11:10 P.M., encourage resident to ask for staff assist when ambulating. Review of the resident's hospital discharge summary, dated 4/8/16 showed the following: -Diagnosis: [REDACTED]. -Discharge instructions: Blunt trauma (physical trauma to body part) and thoracic strain (injury to the soft tissue of the back). Review of the resident's care plan showed no evidence staff evaluated the effectiveness of current interventions or implemented new interventions to prevent future falls following the fall on 4/8/16. Review of the resident's nurse's note dated 4/9/16 at 8:00 A.M. showed the resident was in bed crying and complaining of being in a lot of pain. Review of the resident's nurse's note dated 4/10/16 at 1:00 P.M., showed the resident had been using his/her wheelchair and ambulating in his/her room only. He/she complained of back and left hip discomfort/pain. Record review of the resident's fall assessment dated [DATE] at 1:30 A.M., showed the following: -Location of fall: Room; -What happened: Resident found on floor beside bed, said he/she was reaching for water and slid onto his/her buttocks on the floor; -Interventions: Assisted to bed by staff with Hoyer lift (mechanical lift); -Previous history of falls; -[DIAGNOSES REDACTED]. -The resident experienced no problems using walker or wheelchair; -The resident was reaching out; -Fall followed similar pattern of previous falls. Record review of the resident's fall assessment dated [DATE] at 11:00 A.M., showed the following: -Location of fall: Room; -What happened: Found on knees on floor with arms on spouse's recliner; -Injuries: Right knee red; -Interventions: Vital signs, assessment and transferred to recliner; -Previous history of falls; -[DIAGNOSES REDACTED]. -The resident experienced problems when using walker; -The resident was doing usual activities; -Fall followed similar pattern of previous falls; -Prior to fall resident was normal. Record review of the resident's nurse's note dated 4/11/16 at 11:00 A.M., showed the resident was found on the floor on his/her knees with his/her arms on his/her spouse's recliner. The resident said he/she would stay in his/her bed or chair; he/she would ask for help because his/her legs did not work anymore. Review of the resident's care plan showed no evidence staff evaluated the effectiveness of current interventions or implemented new interventions to prevent future falls following the resident's two falls on 4/11/16. Record review of the resident's nurse's note dated 4/12/16 showed the following: -At 9:30 A.M., the resident was up at the desk crying and stating his/her back hurt; -At 12:45 P.M., orders were received for CT (computed tomography-special x-ray test) of the head, labs and urinalysis. Review of the resident's physician's progress note dated 4/13/16 at 3:38 P.M., showed the following: -Subjective: The resident was being evaluated for a fall in his/her room. He/she fell hurting his/her left shoulder and also his/her low back. He/she had a CT scan of his/her entire spine, which did not show any acute fracture. He/she does have past rib fractures that were noted; -Physical exam: He/she was tender over the shoulders and over the lower back; -Note: The fall occurred on 4/8/16; he/she seemed a little sleepier with his/her pain medications. He/she was self-propelling in a wheelchair. He/she doesn't really want to be up walking right now; -Assessment: Fall in his/her room, left shoulder pain from the fall and low back pain from the fall; -Plan: Will plan to repeat the x-ray of his/her lumbosacral spine (picture of the small bones in the lower part of the spine), he/she will also have physical therapy (PT) and occupational therapy (OT) evaluate and use ice therapy. Record review of the resident's fall assessment dated [DATE] at 9:30 P.M., showed the following: -Location of fall: Room; -What happened: Attempting to sit in recliner and slid onto bottom on floor; -Interventions: Assessed for injuries and vital signs taken; -Previous history of falls; -[DIAGNOSES REDACTED]. -The resident experienced no problems when using wheelchair and walker, just does not always use; -The resident was reaching down; -Fall followed similar pattern of previous falls. Review of the resident's care plan showed no evidence staff evaluated the effectiveness of current interventions or implemented new interventions to prevent future falls following the resident's fall on 4/14/16. Review of the resident's nurse's note dated 4/20/16 at 7:20 P.M., showed the resident told the physician he/she had been vomiting after every meal. Review of the resident's physician progress notes [REDACTED].M. showed the following: -Subjective: The resident was being evaluated for vomiting, his/her gastroesophageal reflux disease, and his/her lumbar compression fracture. He/she had fallen and suffered a compression fracture. He/she had an appointment with another physician to have it repaired. The resident had reflux and had been on Omeprazole (used to reduce acid in the stomach) 20 mg a day. He/she had been having some increased vomiting since his/her injury. Because of that his/her Omeprazole was increased to twice a day; Assessment: Vomiting, gastroesophageal reflux disease and lumbar compression fracture; Plan: Await the vertebroplasty (a procedure in which a special cement is injected into a fractured vertebra) of the compression fracture and increase Omeprazole to 20 mg twice a day. Record review of the resident's fall assessment dated [DATE] at 5:05 A.M., showed the following: -Location of fall: Room; -What happened: Attempting to get up from recliner and slid onto floor onto buttocks; -Interventions: Assessment and vital signs taken; -Previous history of falls; -[DIAGNOSES REDACTED]. -The resident experienced no problems when using wheelchair and walker, just does not always use when needed; -The resident was reaching up and responding to bladder urgency; -Fall followed similar pattern of previous falls; -Prior to fall resident was quiet and resting in recliner. Record review of the resident's fall assessment dated [DATE] at 3:40 P.M., showed the following: -Location of fall: Parking lot; -What happened: The resident said she was trying to wheel him/herself to the driveway and fell out of chair; -Injuries: Skin tear to left elbow; -Interventions: Range of motion, vital signs, assessment, and sent to emergency room ; -Previous history of falls; -[DIAGNOSES REDACTED]. -The resident was doing usual activities; -Fall followed similar pattern of previous falls; -Prior to fall the resident was in his/her room. Review of the resident's nurse's note dated 4/27/16 at 3:40 P.M., showed: -The resident was found in the parking lot on the ground by the sidewalk, he/she had fallen out of a wheelchair and hit his/her head on the sidewalk; -Staff had assisted the resident to the wheelchair and brought him/her back into the building and cleansed his/her elbow; -Orders were received to send the resident to the emergency room for evaluation. Review of the resident's care plan showed no evidence staff evaluated the effectiveness of current interventions or implemented new interventions to prevent future falls following the resident's falls on 4/25/16 and 4/27/16. Review of the resident's nurse's notes dated 4/27/16 at 7:00 P.M., showed the resident was up ad lib in the hall with his/her wheelchair and frequently asked for pain medications. Review of the resident's physician consult, dated 5/4/16 at 9:45 A.M., showed: -Consult for back and leg pain; -Findings of a L1 (first lumbar vertebra) compression fracture. Record review of the resident's fall assessment dated [DATE] at 6:00 P.M., showed the following: -Location of fall: Room; -What happened: Found on floor on right side, voiced got dizzy with ambulation and fell ; -Injuries: Skin tear to right forearm, head, right hip and back pain; -Interventions: Assessed, neurological checks and ambulance to emergency room ; -Previous history of falls, most recent fall 3/21/16 at 4:30 A.M. (most recent fall documented was 4/27/16); -[DIAGNOSES REDACTED]. -The resident was doing usual activities and responding to bowel/bladder urgency; -Fall followed similar pattern of previous falls; -Prior to fall the resident was sitting in recliner. Review of the resident's physician progress notes [REDACTED].M. showed the following: -Subjective: The resident fell about 20 minutes ago. He/she was headed to take his/her tray over to the sink and he/she caught his/her arm on the wheelchair and fell . He/she hit his/her head and complained of right posterior head pain. He/she had a large skin tear on his/her right forearm that was bleeding and was cleansed and wrapped with gauze. He/she also had right hip pain that was new. He/she does have back pain, which he/she had a history of [REDACTED]. The staff had called the emergency medical system (EMS). EMS placed a C spine collar (neck brace) on the resident and loaded her on a scoop (device to move injured people); -Objective: Posterior right head pain, trochanteric (bony prominence toward the near end of the thigh bone) region hip pain which is increased with palpation at that area, low spine and low back pain and to palpate it is tender over her vertebra; -Assessment/Plan: Fall with a closed head injury (trauma in which the brain is injured); -Right hip pain, to be evaluated in the emergency room ; -Back pain, to be evaluated in the emergency room ; -Right arm skin tear was cleansed and wrapped. Review of the nurse's note dated 5/5/16 at 6:45 P.M., showed staff found the resident on the floor in his/her room on his/her right side. The resident became dizzy when walking and fell , hitting his/her head and right hip. He/she complained of head, hip and low back pain. He/she had a skin tear on his/her right forearm. The resident was taken to the emergency room . Review of the resident's emergency discharge instructions, dated 5/5/16, showed the resident was seen after a fall in which he/she hit his/her head. He/she also complained of back pain (not new pain-chronic lower back pain), and right hip pain. The resident will be sent back to the facility. He/she needs to be placed on fall precaution. The facility received instructions for a concussion (mild brain injury), usually caused by a bump or blow to the head from a fall, motor vehicle crash or sports injury. Review of the resident's care plan showed no evidence staff evaluated the effectiveness of current interventions or implemented new interventions to prevent future falls following the fall on 5/5/16. Review of the resident's nurse's note, dated 5/6/16 at 10:20 A.M., showed the resident's nurse practitioner was aware of the resident's low blood pressure found around the recent fall and neuro checks. Review of the resident's Nurse Practitioner's progress note, dated 5/6/16 at 10:30 A.M., showed the resident had gone to the emergency room last evening and the charge nurse let him/her know the resident had some soft blood pressures after his/her arrival back to the facility. He/she had been given pain medication as well as Ativan and his/her systolic (the top number, which is also the higher of the two numbers, measures the pressure in the arteries when the heart beats) blood pressure. The resident was sleepy from his/her fall and hitting his/her head last evening. Assessment/Plan: Decrease the resident's Lisinopril (treats high blood pressure and heart failure) and have staff hold the blood pressure medication if his/her systolic is 106 or below and call him/her at that point. Review of the resident's care plan showed no evidence staff updated the care plan to reflect the resident's blood pressures or implemented new interventions to monitor the resident's blood pressure to prevent future falls. Review of the resident's nurse's notes, dated 5/9/16 at 5:00 P.M., showed the resident had a procedure for low back fracture. Has dressing at site to remain on for 24 hours. Has back brace to wear when up. Resident teaching on this. Review of the resident's nurse's note, dated 5/10/16 at 4:15 P.M., showed the resident became tearful this afternoon, he/she had pain in his/her back and legs. He/she had brace on except when lying down. The dressing was off of his/her lower back. There was two steri-strips on two-one centimeter incisions on back. Review of the resident's annual history and physical, dated 5/11/16, showed the following: -Chief complaint: The resident had a complaint of pelvic pain. He/she fell last week and was seen in the emergency room and had full x-rays, which did not show any new problems. Since he/she had been seen for an old L1 compression fracture; he/she had a kyphoplasty (procedure for treating painful compression fractures) on the 9th. The resident's physician did ask for an evaluation and a pelvic x-ray; -Past history: Muscle weakness, polymyalgia rheumatica (is a syndrome that causes pain and stiffness in the hips and shoulders), dorsopathy (various diseases of the back or spine), myositis (inflammation in the muscles), difficulty walking and unspecified intracranial injury with loss of consciousness of unspecified duration when he/she fell on the ice this past winter; -Past surgical history: Kyphoplasty this past week. (5/9/16) He/she had a pacemaker implanted, and subdural hematoma (result of a serious head injury); -Inventory of systems: Multiple bruises and areas that are covered from skin tears from his/her falls and he/she complains of pelvic pain over the bone; -Physical exam: Skin: skin tears with dressings and some bruising on his/her arms and right leg. He/she does have pelvic pain when getting up from sitting and when lying down. He/she was alert and oriented. Review of the resident's care plan showed no evidence staff updated the resident's care plan to reflect the resident's recent surgery (Kyphoplasty). Review of the resident's hospital clinical note dated 5/25/16 at 1:49 P.M., showed the following: -Subjective: The resident presented in the pain clinic for a little over two week follow up after he/she received an L1 kyphoplasty on 5/9/16. The resident had fallen several weeks prior to that date and had experienced a compression fracture that continued to worsen over time. He/she also had a retropulsed fragment (burst fractures result from axial loading most often secondary to motor vehicle accidents and falls). The resident had a history of [REDACTED]. -Review of symptoms: Positive for significant cognitive changes with short-term memory deficits. He/she had a history of [REDACTED]. He/she does have multiple bruises on his/her arm and legs and some skin tears. Record review of the resident's quarterly MDS, dated [DATE], showed the following for the resident: -Understand and understood; -Cognition was moderately impaired; -Did not walk in room or corridor; -Independent with transfers, locomotion on and off the unit, toilet use and personal hygiene; -The resident was not steady with moving from seated to standing position, walking, turning around, moving on and off the toilet, or surface-to-surface, and able to stabilize without staff assistance; -Mobility devices: Walker -Always continent; -Had two falls with no injury and two falls with injury since prior assessment (2/25/16); -Received antidepressant and diuretic; -[DIAGNOSES REDACTED]. Review of the resident's physician progress notes [REDACTED].M., showed the following: -Subjective: The resident was out in his/her wheelchair today out around the sidewalk near some flower pots when he/she tipped over and landed against a pot. He/she suffered a contusion on the cheek on the left side and now he/she is also having some shoulder pain that is mainly over the point of the shoulder. He/she was unable to raise his/her arm over his/her head; -Physical exam: He/she had limited range of motion of the left shoulder compared to the right. He/she is tender over the acromioclavicular joint (joint at top of the shoulder). He/she had a small abrasion over the left side of his/her cheek; -Plan: Will get an x-ray of the left shoulder and will continue to encourage safety with his/her wheelchair. Review of the resident's nurse's note dated 5/27/16 at 4:55 P.M., showed the resident was found laying on the ground outside. Orders received for x-ray of left shoulder for pain. Review of the resident's care plan showed no evidence staff evaluated the effectiveness of current interventions or implemented new interventions to prevent future falls following the resident's fall on 5/27/16. Review of the resident's nurse's note dated 5/29/16 at 6:00 A.M., showed the resident reported a bruise (5 cm purple and tender), he/she thought he/she received it from a previous fall. Review of the resident's nurse's note dated 6/7/16 at 3:40 P.M., showed staff found the resident in front of the bathroom door on his/her hands and knees crying. The resident said, I really cracked my knee up. It was difficult to get out of the resident what happened due to the resident being so uncomfortable at this time. The resident was assisted up with staff and the use of the Hoyer lift. The resident had a purple bruise to the right knee. He/she complained of right knee and hip pain. There was shortening and external rotation of the lower left extremity. Staff passively moved the resident's left extremity and he/she had complaints of right hip pain. The resident was sent to the hospital. Record review of the resident's fall assessment dated [DATE] at 6:40 P.M., showed the following: -Location of fall: Room; -What happened: Resident got out of wheelchair without locking wheels and fell to floor; -Nursing intervention: Range of motion assessment; -Previous history of falls; -[DIAGNOSES REDACTED]. -Experiences problems when using wheelchair; -Fall followed similar pattern of previous falls. Review of the resident's nurse's notes dated 6/9/16 at 6:40 P.M., showed staff found the resident on the floor. The resident's spouse said the resident got up out of his/her wheelchair without locking the breaks and fell to the floor. Record review of the resident's falls assessment dated [DATE] at 7:30 P.M., showed the following: -Location of fall: Room; -What happened: Resident was attempting to move his/her spouse's electric wheelchair at his/her request and slid onto the floor and hit the back of his/her head on the night stand; -Nursing intervention: Range of motion assessment; -Previous history of falls; -[DIAGNOSES REDACTED]. -Experiences problems when using wheelchair; -The resident was doing usual activities; -Prior to fall the resident was in his/her room getting ready for bed. Record review of the resident's fall assessment dated [DATE] at 8:00 P.M., showed the following: -Location of fall: Room lying on left side partially under bed 2; -What happened: The resident said he/she was attempting to get an item out of spouse's recliner, lost his/her balance and fell to the floor, over bed table nearby, was wearing glasses; -Injuries: Bruise to left upper jaw 1/2 cm (centimeter) X 2 1/2 cm, 1 1/2 cm x 1 cm skin tear to left index knuckle, 1/2 cm skin tear between first and second finger on left hand, two 1 cm skin tear to left elbow and 1 1/4 cm x 1 1/4 cm skin tear to left lateral elbow; -Nursing intervention: Neurological checks, range of motion, Hoyer lift (mechanical lift) to bed, cleansed skin tears with normal saline and ointment applied; -Previous history of falls; -[DIAGNOSES REDACTED]. -Experiences problems when using wheelchair; -The resident was doing usual activities and walking; -The fall followed a similar pattern to resident's previous falls. Review of the resident's nurse's note, dated 6/11/16 at 8:00 P.M., showed the resident was found on floor in his/her room laying on his/her left side partially under spouse's bed with over bed table nearby. He/she was attempting to get item out of spouse's recliner and lost his/her balance. He/she sustained a bruise to his/her left upper jaw 1/2 cm (centimeter) x 2 1/2 cm, 1 1/2 cm x 1 cm skin tear to left hand index knuckle, 1/2 cm skin tear between first and second finger on left hand, two 1 cm skin tear to left elbow and 1 1/4 cm x 1 1/4 cm skin tear to left lateral elbow. Record review of the resident's fall assessment dated [DATE] at 11:15 P.M., showed the following: -Location of fall: Bathroom; -What happened: Resident was found in fetal position in the bathroom; -Injuries: Two skin tears to left hand approximately 1 cm long and bruise to left knee; -Nursing intervention: Assessment, range of motion, and assisted with Hoyer lift with four staff assist to bed; -Previous history of falls; -[DIAGNOSES REDACTED]. -Experiences problems when using wheelchair; -The resident was doing usual activities; -The fall followed a similar pattern to resident's previous falls. Review of the resident's nurse's note dated 6/14/16 at 12:30 P.M., showed the resident was sitting on floor by the bed and recliner. Review of the resident's nurse's note dated 6/15/16 at 11:20 P.M., showed on 6/14/16 the resident was found on the bathroom floor in a fetal position. The resident said he/she hit his/her head. The resident had two skin tears approximately 1 cm long on his/her left hand. The resident was Hoyer lifted with four staff assist back to bed. Record review of the resident's fall assessment dated [DATE] at 4:30 P.M., showed the following: -Location of fall: Room; -What happened: The resident said he/she was getting something out of the closet and fell backwards; -Injuries: Sent to emergency room ; -Previous history of falls; -[DIAGNOSES REDACTED]. -Experiences problems when using wheelchair; -The resident was doing usual activities and reaching up; -The fall followed a similar pattern to resident's previous falls. Review of the resident's nurse's note dated 6/24/16 at 4:30 P.M. showed the resident fell behind the door in his/her room trying to get something out of his/her closet. It was hard for staff to get in the resident's room because the resident was on the floor and blocking the door,staff had to go in next room, through the bathroom, to get to the resident. He/she complained of his/her head hurting. He/she went to the emergency room . Review of the resident's nurse's note dated 6/25/16 at 10:05 A.M., showed the emergency room physician notified the facility of x-ray results which showed the resident fractured his/her left 2nd and 3rd ribs. The emergency room wanted the resident to be watched, if the resident was displaying labored breathing or severe pain the facility was to send the resident back to the emergency room . Review of the resident's care plan showed no evidence staff evaluated the effectiveness of current interventions or implemented new interventions to prevent future falls following the resident's falls on 6/7/16, 6/9/16, 6/10/16, 6/11/16, 6/14/16, 6/15/16, or 6/24/16. During interview on 7/5/16 at 12:55 P.M., the resident said he/she falls a lot. He/she said sometimes it takes staff awhile to answer his/her call light but when he/she goes to hollering, because he/she can't get up, the staff will come. During interview, on 7/18/16 at 8:05 A.M., Registered Nurse (RN) A, Unit Coordinator, said the resident had many fractures and had been sent to the emergency room multiple times. A compression fracture was found during a routine visit; the resident had a bad back and was receiving injections due to chronic pain. He/she did fall on 5/5/16 and had a CT of the spine which showed progressed L1 compression fracture. This was most likely from falling because he/she won't call for help. The resident gets up and down on on his/her own and knows how to remove his/her alarms. Staff knew to check on the resident often because he/she will not ask for help. RN A was responsible to update the care plan after a resident falls but he/she had not had time do to so. He/she talks to staff regarding the resident's falls and