Every finding on record at Maple Woods Manor

This Citation pertains to Intake Numbers 3106714 and 3106784. Based on interview and record review, the facility failed to 1) Ensure that Pre-Dialysis and Post-Dialysis assessments and monitoring were completed and 2) Ensure that Dialysis communication forms were complete and included pre-dialysis and post-dialysis assessments, including the location and assessment of the dialysis access site, for one resident (Resident #4) of 3 residents reviewed for Dialysis care, resulting in the potential for a decline in condition and the inability for a prompt response to care needs. Findings Include: DialysisResident #4: A record review of the Face Sheet an electronic medical record (EMR) indicated Resident #4 was admitted to the facility on [DATE] with diagnoses: End Stage Kidney disease, Diabetes, dependence on renal dialysis, Alzheimer's Dementia, heart disease, Atrial Fibrillation, hypertension, weakness, history of falls, anemia, shortness of breath, peripheral vascular disease, and hypothyroidism. The resident was transferred to the hospital on 7/18/2026 for abnormal laboratory results and did not return.A review of the physician orders for Resident #4 identified the following: Hemodialysis scheduled 3x a week on Tuesdays, Thursdays and Saturdays of the week at the dialysis center. Facility departure time 1230. Chair time 1320, revision date 7/3/2026. Today is 7/10/26, wait a couple of days before attempting HD again, revision date 7/10/2026. Send to ER for eval/tx (treat) low HGB (hemoglobin) 6.7, dialysis to be done at hospital due to critical lab, revision date 7/18/2026.A review of the progress notes for Resident #4 revealed the following:7/3/2026 at 3:53 PM, an Interdisciplinary Documentation note, (Resident #4) was admitted on [DATE] from (the hospital). She was admitted with primary diagnosis of End stage renal disease. She has an AV fistula (arteriovenous an access site for dialysis) . Area is clean, dry and intact.7/6/2026 at 1:00 AM, a provider Encounter note, . She had a RUE (right upper extremity) AV fistula place in March 2026 that was mature to use.7/9/2026 at 3:24 PM, an Interdisciplinary Documentation note, Per hemodialysis communication; Pt. did not run her Tx (treatment). Arm had a infiltration. Made appt with (a vascular center) to get a cath placement. 2pm 7/10/26.7/14/2026 at 1:00 AM, a provider Encounter note, . RUE A-V Fistula 3/2026. She is scheduled for HD (hemodialysis) today.7/18/2026 at 10:48 AM, an Interdisciplinary Documentation note, Critical lab results (hemoglobin) 6.7, HCT (hematocrit) 21.9. last (hemoglobin) on 7/7/26, (hemoglobin) 7.7, HCT 26.3. Notified NP (Nurse Practitioner) .7/18/2026 at 11:01 AM, an Interdisciplinary Documentation note, Notified Dialysis of lab results per dialysis needs to be treated.7/18/2026 at 12:11 PM, an Interdisciplinary Documentation note, Dialysis phoned building and stated that per the nephrologist, send resident to the ER.A review of the Documents tab in the EMR revealed that there were 2 Hemodialysis Communication forms for the resident's stay at the facility from 7/2/2026 to 7/18/2026. One of the forms was not dated by the facility for the pre- dialysis assessment, but the Dialysis facility dated their assessment data as 7/9/2026 and the other form was dated 7/14/2026. Resident #4 was to receive dialysis 3 times a week on Tuesday, Thursday, and Saturday. The remainder of the dialysis days were unaccounted for.A review of the assessments for Resident #4 in the emr indicated there were no additional dialysis assessment or communication forms.A review of the Care Plans for Resident #4 identified the following: Resident #4) presents to the facility with altered functional mobility and ADL's (activities of daily living) related to acute respiratory failure secondary to cardiorenal system failures. has a complicated clinical history with longstanding renal failure. Dialysis Days/location: T, TH, Sat at (dialysis center) Must arrive by 12:30 for 1:20 PM chair time. Access Site: Right AV Fistula. Notify/Charge Nurse Immediately if observed bleeding from site, date initiated 7/2/2026 and revised 8/4/2026. (The resident discharged to the hospital on 7/18/2026. The Care Plans were revised 2 weeks after discharge). Hemodialysis required to remove urea & other toxic products from the blood: At risk for loss of vascular access; clotting, hemorrhage, infection. At risk for exacerbation of heart failure with inadequate dialysis or increased hypervolemia, date initiated 7/7/2026 and revised 8/4/2026 with Interventions including: Assess A-V fistula area for increase redness or warmth prn (as needed), Date initiated 7/7/2026 and revised 8/4/2026. Assess fluid volume excess as indicated for signs and symptoms (routinely completed at dialysis as well); routine weights,; JVD (jugular venous distention); breath sounds; peripheral and sacral edema assessments, date initiated 7/7/2026 and revised 8/4/2026. Establish communication with dialysis center process of communication is as follows: (this was blank), date initiated 7/7/2026 and revised 8/4/2026. Palpate thrill and auscultate bruit when not LOA (leave of absence) for dialysis treatment, date initiated 7/7/2026 and revised 8/4/2026.There was no identified documented routine assessment of the resident's dialysis access site. There were no documented assessments of the resident after return from dialysis and the Hemodialysis Communication forms were incomplete for many dialysis days of treatment for Resident #4.The Director of Nursing/DON was interviewed on 8/4/2026 at 11:50 AM about the dialysis assessment and communication forms for Resident #4. Discussed with the DON that there were 2 forms in the resident's medical record one for 7/9/2026 and one for 7/14/2026; There was no additional nursing assessment information in the medical record. Further review of the medical record indicated the nurses were not documenting when the resident went to dialysis or when they returned. There was no assessment information for Resident #4 after returning from dialysis.On 8/4/2026 at 3:30 PM, the DON provided copies of 2 Hemodialysis Communication forms for Resident #4. He said the staff went to the dialysis center that day and asked for the dialysis center assessments for Resident #4 for 7/7/2026 and 7/16/2026. The DON provided a copy of each form with assessment information including weights, vital signs and post-dialysis Assessment and recommendations for each day, as completed by the dialysis center. On both forms the Nursing Home facility had incomplete assessment information and neither form was signed by a nurse at the facility indicating they completed it. The DON was asked about this, and he said he would have to check to see which nurses were responsible for the documents. The DON provided the name of the dialysis center and the phone number at this time. There was no mention of the dialysis access device or site on the assessment/communication forms by the facility.On 8/5/2026 at 9:20 AM, Nurse J from the dialysis center was interviewed about Resident #4's dialysis treatments: She said the first day the resident arrived for dialysis was 7/7/2026 and there were difficulties with the dialysis access site: the resident received dialysis for 2 hours and 14 minutes.On 7/9/2026 Resident #4 went back to dialysis and they attempted to dialyze her. Nurse J said she ran for a short time, but the access site was infiltrated and they had to stop.On 7/10/2026 the resident was transferred for a vascular appointment to replace the access site. It was recommended by the vascular physician to wait to use the access site for a few days and the resident did not attend the 7/11/2026 appointment.On 7/14/2026 the resident returned to the dialysis center and dialysis ran for 3 1/2 hours.On 7/16/2026 the resident came back to the dialysis center. The 7/16/2026 Hemodialysis Communication form provided, Unable to run d/t (do to) bandages still in place from last tx (treatment). This caused indentations in access that prevented cannulation and good flow. RN (Nurse J) educated, Caregiver (facility), patient and Facility needs to come off the same day as (treatment). (The vascular center) called for appointment.During the interview with Nurse J, she said Resident #4 did not return to dialysis after 7/16/2026. The resident had 1 full day of dialysis over the two week period she was at the facility.On 8/5/2026 at 1:30 PM, the DON was interviewed about the lack of dialysis communication forms and assessments for Resident #4; he said they were going to work on it.A review of the facility policy titled, Dialysis Communication, date effective December 2021, provided, Purpose: To provide general guidance for communication and continuum of care for a resident requiring dialysis services at an external dialysis facility. Residents who require dialysis services will be provided care consistent with professional standards of practice, the comprehensive person-centered are plan and the residents' goals and preferences. Ongoing provision of assessment, care planning and provision of care with the dialysis facility will be in collaboration with facility services.

Based on observation, interview and record review, the facility failed store food in a sanitary manner and appropriately label and date food products. Findings include: On 6/1/26, at 9:15AM, an initial observation of the kitchen was completed with Dietary Manager (DM) L. The following findings were noted. Walk in Fridge:-Bacon was observed open with no open date or expiration date.-Eggs open with no open date or expiration date on the box.-Chopped Lettuce with a use by date 5/30/26.-Tomatoes with a use by date of 5/30/26.-Oranges no open date or expiration date,-Cream Cheese Cups with a use by date of 5/2/26, an additional full box of 100 cream cheese cups was discarded due to no date on the box. Dish Machine: No air gap on the drain. Walk in Freezer:-Chicken patties observed open with no open date or expiration date.-Sausage links open, some loose in the box, with no open date or expiration date. On 6/1/26 at 9:40AM, observations were made of the East Nourishment room refrigerator and freezer. The following findings were noted.-Apple juice use with a use by date 5/29/26.-Hot dogs in the freezer with a use by date of 10/22/25.-Ice Cream with no receipt date or discard date. The ice cream container was open. On 6/1/26 at 9:50 am, observations were made of the [NAME] Nourishment room refrigerator and freezer. The following findings were noted.-Orange Juice with a use by date of 5/29/26.-Ice Cream open, with no receipt date or discard by date on it.-Styrofoam containers with a date of 5/27/26, discard by 5/30/26On 6/1/26 at 10:00am, observations were made of the [NAME] Dining Room reach in refrigerator. The following findings were noted.-Grape Juice with a use by date of 5/26/26.-Orange Juice with a use by date of 5/28/26.-Multiple Juices with a use by date of 5/26/26. An interview was conducted with DM L. DM L was asked how long resident items can stay in the refrigerator after they are opened. DM L stated they are good for three days. DM L discarded the resident items that were not dated or had gone past the three days. DM L was asked about the undated and expired foods in the kitchen. DM L stated we have a lot of new staff here and it is just going to take education to get everyone on the same page to make sure items are being discarded and labeled and dated properly. DM L stated they are new to the facility in the last few months and they are actively working to get the staff educated. DM L discarded the unlabeled, undated and expired foods in the kitchen refrigerator and freezer. Review of the policy titled, Food Supply Storage & Dating, revealed, Procedure: General: 1. The used by date is the last date food can be consumed. Refrigerated Storage: 9. Rotate items: first in, first out. Discard food past the used-by date. Freezer Storage: 5. Foods stored frozen and unopened should be stored no longer than 6 months for quality purposes. Food that has been opened from the original packaging is to be stored in the freezer no longer than 90 days.6 Date and rotate items; first in, first out. Review of the policy titled, Resident Food from Outside Sources, revealed: Procedure: 3. Food can be labeled with the date and the name of the resident and stored in the nourishment room refrigerator.4. Prepared foods from families and outside sources will be stored in proper storage for 3 days (2 additional days from the day that food is brought into the facility.10. Facility staff will periodically clean resident rooms to ensure foods are within appropriate date range and suitable to consume.

Based on observation, interview and record review, the facility failed to ensure that: 1) Ongoing surveillance for the identification of infectious organisms causing Urinary Tract Infections/UTI's to enable analysis and reporting to prevent the spread of infection and 2.) Personal Protective Equipment/PPE was worn when indicated for residents in Enhanced Barrier Precautions/EBP, resulting in a lack of compliance with infection prevention and control standards of practice. Findings Include: Infection Control On 6/03/2026 at 10:16 AM during an interview with Infection Control Practitioner/ICP C, she said she was new to the ICP role since November 2025 and someone else was the ICP before her. During the interview on 6/3/2026 at 10:20 AM with ICP C, the Infection Surveillance Line Listings dated 6/2025-5/2026, were reviewed and revealed there was a pattern of resident Urinary Tract Infections/UTI identified on the Line Listings. The UTI's were treated with an antibiotic but there was no identification of an infectious organism to ensure the most effective antibiotic was used for the resident. The Infection Line Lists were incomplete. The Infection Line Lists had columns to include the Current Prescription, Infection, Infection Site, Organism Signs and Symptoms and several additional columns. The Organism was missing on most of the UTI infections indicating there were no laboratory results for a culture (identification of the infectious organism) that coincided with a sensitivity test (identification of the most effective or resistant antibiotics) as components of a laboratory test called a Culture and Sensitivity. Without the Culture and Sensitivity results identifying the infectious organism and appropriate antibiotics to treat the infection, there would be uncertainty whether the antibiotics prescribed were appropriate and cure the infection. If the antibiotics were ineffective, it could lead to growth of resistant microorganisms. Upon review of the Infection Line Lists from June 2025 through June 2026, there were 99 suspected UTI's identified and 54 did not identify an organism to ensure the appropriate treatment was provided: 54/99, 54.5% of the suspected UTI's were lacking Culture results from a Culture and Sensitivity test. This included 37 of 61 suspected UTI's from June 2025-December 2025 with 10/14 in August 2025 and 9/11 in September 2025. There were 17 of 38 suspected UTI's from January 2026 to June 2026 that did not have Culture results identifying an organism. On 6/3/2026 at 10:30 AM, the ICP C was interviewed and asked about the incomplete Infection Surveillance and the lack of identifying laboratory results for the Culture and Sensitivity tests for UTI's and she said she couldn't speak to the issue prior to her start in the role in November 2025, but the ICP said sometimes the antibiotics were started by the Medical Provider prior to obtaining a urinalysis and sending it to the laboratory for identification and Culture and Sensitivity testing with results. Also, she said some of the listings were a result of residents admitting to the facility with a diagnosis of UTI with antibiotic treatment and the infectious organism was not made available to the facility to track to ensure appropriate antibiotic treatment. The ICP was asked about the lack of analysis of the UTI's without the identifying organisms to prevent the spread of infection. The ICP was able to track the number of suspected UTI's but not the organisms responsible for the infections or to identify if they were resistant organisms including Multi-Drug Resistant Organisms/MDRO's. A review of the facility document titled, Infection Prevention and Control Assessment Tool for Long-term Care Facilities, undated provided . The facility has a process for reviewing infection surveillance data and infection prevention activities., this was checked Yes; The facility has a written surveillance plan outlining the activities for monitoring/tracking infections occurring in residents of the facility, this was check Yes. Resident #53: Observation and interview on 06/01/2026 at 9:20 AM with Registered Nurse (RN) P of Resident #53's peg tube observation noted a pre-opened saline flush 30 ml syringe opened and left at bedside, and a half full 100ml normal saline bottle at bedside, with no date opened. RN P came into the room and applied gloves, handled the skin cleanser bottle and a 4x4 gauze, applied the skin cleanser to the peg tube site and wiped. Observation of the peg tube site revealed the tube to be sutured in place into the skin, size 18 French tube. Observation of left side colostomy bag intact. Observation with RN P noted a Foley catheter bag with urometer not in a privacy bag. Observed with urometer chamber full of yellow liquid. RN P removed gloves and replaced with another pair of gloves to empty the urometer chamber into the larger Foley bag, then opened the Foley clamp and a puddle formed under bed, before the nurse could get the urinal in place. The Foley catheter was emptied into a urinal. RN P did not alcohol wipe the Foley spout prior to emptying or after emptying, proceeded to clamped shut spout and placed back into slide holder. Nurse P did not use a gown or handwash while providing direct care for peg site and Foley catheter emptying. Upon exiting the room, the surveyor noted that there was no Enhanced Barrier Precaution (EBP) sign posted outside the room to notify staff to use appropriate Personal Protective Equipment (PPE). Observation on 06/02/2026 noted that there was still no Enhanced Barrier Precaution (EBP) signposted outside the room to notify staff to use appropriate Personal Protective Equipment (PPE). Record review of the facility 'Enhanced Barrier Precautions' policy, dated 3/2025, revealed it is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions are an infection control intervention designed to reduce transmission of multi-drug-resistant organisms (MDROs) in nursing homes. Enhanced barrier precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices (peg tube, foley catheter). Observation and interview on 06/03/2026 at 12:28 PM with the Licensed Practical Nurse (LPN) Infection Control Preventionist (ICP) C regarding the procedure for direct care of residents with Foley catheters including enhanced barrier precautions should start with room/door signage, Urinary catheter emptying procedure- knock at door let them know what will be happening, wash hands and apply gown and gloves, provide privacy. Take the catheter bag out of privacy bag, have two alcohol wipes and a barrier for the floor, place the barrier between the graduate and floor, wipe end of spout on catheter with an alcohol wipe scrub 2-3 seconds, unclamp drain spout, draining urine into graduate container, clamp the spout and alcohol wipe end of spout, place in catheter bag, slide holder, look at urine (color, odor) and if different let nurse know, measure the ursine and dump. Need to use a clean graduate container. ICP C stated that yes, staff can use a urinal, but it needs to be wash out or rinsed clean. The State surveyor took the ICP C to room [ROOM NUMBER] for observation on 06/03/2026 at 12:41 PM to observe no Enhanced Barrier Precaution (EBP) no signage on door. There was a magnetic hook up high on the door with nothing hanging on it.

Based on observation, interview and record review, the facility failed to ensure palatable and appealing food for three residents (R6, R41 and R106) of five residents reviewed for food and a confidential group of residents. Findings include: Resident #106 (R106): R106 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease (COPD), chronic respiratory failure and cerebral infarction without residual deficits. On 06/01/2026 at 3:52PM, R106 was asked about the food the facility serves. R106 stated, the food is cold and she gets tired of getting cold food in her room. R106 says she has to have kitchen staff warm up items for her constantly. R106 stated that this occurs at all meals. On 06/02/2026 at 1:18PM, an interview was conducted with Dietary Manager (DM) L. DM L was asked if they have ever received complaints of cold food. DM L stated, I have and especially when I first started at the building. DM L stated the complaint is that by the time the food gets to residents in their rooms it is cold. We are losing temperature from the service area to the room. When I do get complaints, I do try to tackle them and see if there is a way we can change things or improve them. DM L was asked if the facility has insulated domes for the plates. DM L stated, yes and we have plate warmers as well. DM L stated that most of the cold food complaints comes from the west end and half of the central unit (serviced by west dining room). Resident #6: An interview on 06/01/2026 at 10:33 AM with Resident #6 revealed Cold foods if you eat in the rooms and that the Food is not that good. In an interview on 06/02/2026 at 8:03 AM, Resident #6 was up in her wheelchair stated that she was going to be leaving today for assisted living. When asked about the food at the facility she stated that it was not very good and most of the time the food was cold. The surveyor asked for examples of cold food items, and she stated that the eggs are cold in the mornings and the lunch if you eat in the dining room will be warm, but if she ate in the resident room the food was cold. When asked about the variety of choices the resident stated that it could be better, the other (alternative) choice menu was tiresome. Resident #49: In an interview on 06/01/2026 at 8:57 AM, Resident #49 stated that the food is cold and mushy, She does not like the food and the alternate menu takes too long to get if you request it during mealtime. Dining Observation: Observation on 06/02/2026 at 7:25 AM of the [NAME] dining room, noted 8-10 residents being served breakfast of Cinnamon French toast, oatmeal, sausage. Cook/server H and Dietary Aide I were plating the food items to trays. Observation of the tray line noted that the bottom insulated plate holder is coming off a large stack of dark blue bottoms from a shelf across from the steam table and the plates are in a stack from the plate rack with an open top and an insulated domed top is placed over the plate. The trays are placed on a rolling cart and then sent over to the beverage station for the Certified Nursing Assistance to fill the glasses and cups prior to leaving the dining room for hall trays. The rolling cart is then pushed out to the nursing units and then distributed to the resident rooms. In an observation on 06/02/2026 at 7:51 AM of the East dining room meal tray prep, the state surveyor followed a meal tray process from the meal is plated in the kitchen and placed on rolling cart. Certified Nursing Assistant (CNA) K prepped the rolling cart with beverages and then took the cart with 4 meal trays to the nursing care unit to room [ROOM NUMBER]. Random Resident #54 was presented with breakfast meal tray in her room. The state surveyor asked for permission from the resident to touch the bottom edge of the white ceramic plate and the plate was cold to the touch. There was no heat felt in the plate by surveyor. Resident #54 stated that the food is always cold. She does eat in her room most of the time. She has a cold plate, and they pour cold syrup over the French toast, and it just could be better. In an interview on 06/02/2026 at 8:00 AM, Certified Dietary Manager (CDM) L revealed that the [NAME] M plates were taken from a stack, on the counter. The cook grabbed stack of ceramic plates of 6, placed on countertop and plated food items to the plates. The CMD stated that the plates should remain in the plate warmer until ready to be used. Interviews on 06/02/2026 at 1:00 PM in the East dining room, revealed 9 of 10 residents stated that the food is cold, the plates are cold and it doesn't matter if they are in the dining room or eat in the resident room. Complaints of too much pasta, too many chicken and pork dishes, and the mashed potatoes have dry clumps from instant potatoes mix, need to be mixed more. Observation on 06/03/2026 at 7:46 AM observation of the west breakfast dining room, service is from the steam table, plate warmer was plugged in and the light was on yellow, observed cook to stack 5 plates with thermal bottoms into a stack right on top of each plate and set them on the edge of the steam table. The cook/server took time to read the meal tickets for residents prior to plating any food. An interview on 06/03/2026 at 9:09 AM with the Certified Dietary Manager (CDM) L revealed that the process it to cook everything in the kitchen and portion into steam tables pans, keep in hot oven, then 20 minutes closer to serve time the pans are place in a Cambro insulated box to take to the west dining room, and temp food items. At 7:00AM we start, we serve in dining room first, and then at 7:30 we start to shuttle out the meal trays on the tiered carts, and the CNAs put the drinks on the trays and take them to the hallway. We don't have thermal heated bottoms we just have the insulated bottoms. Yesterday the East breakfast plates were cool, the plate warmer was not on when you were watching the cook, she is our new cook and she is struggling a little, and the plates were cold. I did turn it on for her when I realized. The surveyor explained observation of the west dining room breakfast cook was Stacking the thermal bottom with a ceramic plate and would place another thermal bottom and a ceramic plate on top until she had a stack of 5 on top of each other. The CDM L stated no that should not be done, as the plates get cold. The plate should not be removed from the plate-warmer until the cook is ready to plate the food.

Based on observation, interview and record review, the facility failed to operationalize policies and procedure for medication storage in two of four medication rooms and two of six medication carts, resulting in a lack of cleanliness in medication storage rooms, unsecured medications, open, undated, expired, and inappropriately stored medications. Findings include: A tour of the East Hall Medication Storage Room was completed with Registered Nurse (RN) G on 6/3/26 at 1:35 PM. Upon entering room, an oxygen tank was observed sitting to the left of the door directly on the floor and not in a holder. Multiple items were observed sitting directly on the floor including a wheelchair storage bag, a wheelchair cushion, a portable oxygen container holder for a wheelchair, a box of wound vac tubing, and open box of boost supplements, and an open box of piston syringes for tube feedings. Food was present in the medication refrigerator. The following expired medications were present in the medication room: - Two pack of Narcan spray 4 milligrams (mg); Expired: 2/2026 - Twenty-five 0.03-ounce (oz) packages of Bacitracin Zinc Ointment; Expired: 6/2023 - Eight Bisacodyl 10 mg suppositories; Expired: 2/2026 - Twelve Tylenol 650 mg suppositories; Expired: 3/2026 An unknown, live bug was observed moving across the floor in the medication storage room. During the tour, Infection Control (IC) Licensed Practical Nurse (LPN) C was asked to come into the East Hall medication room. Upon entering the medication room, IC LPN C was asked if it was okay to store items on the floor of the medication room and replied that it was not. IC LPN C was then asked to open the medication fridge and upon seeing the food items in the fridge, began to remove them. When queried if food items should be stored in the medication refrigerator, IC LPN C responded that food should not be stored in the same refrigerator as medications. A tour of the Central Hall Medication Room was completed on 6/3/26 at 2:16 PM with IC LPN C. An open and undated vial of Tuberculin (TB) Purified Protein Derivative (PPD) 5 TU (Tuberculin Units)/0.1 mL antigen solution was observed in the medication refrigerator. When queried if TB antigen solution should be dated when opened, IC LPN C verbalized it should be and would need to be disposed of. Multiple personal items, including bags, clothing, and beverages, were observed stored in a cabinet containing medications/medical supplies. When queried, IC LPN C verbalized the items belonged to nursing staff. IC LPN C was asked if nursing staff were supposed to store their personal items in the medication room, IC LPN C responded they were not and removed the items. On 6/3/26 at 2:19 PM, the Central Short Hall Medication Cart was observed unlocked and unattended by staff. IC LPN C was asked if the medication cart should be unlocked and unattended and indicated the cart should be locked. A tour of the unlocked cart was completed with IC LPN C at this time. The following items were observed: - Bisacodyl 10 mg suppository; Expired: 2/2026 - Eleven Tylenol 650 mg Suppositories; Expired: 3/2026 - 0.15 oz. Tube of Lidocaine 4%; Expired Additionally, various individual snacks were stored in the bottom left-hand drawer along with a container of cleaner. When queried regarding facility policy/procedure related to expired medications, IC LPN C verbalized expired medications should be removed and disposed of. When queried if snacks should be stored in the medication cart and in the same drawer as cleaner, IC LPN C responded they should not and removed the snacks. Review of facility provided policy/procedure entitled, Medication Storage & Stability (Revised: 4/2021) revealed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 2. Only licensed nurses, consultant pharmacist, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 8. Potentially harmful substances (such as test reagent tablets, household poisons, cleaning supplies, disinfectants) are clearly identified and stored in a locked area separately from medications. 13. Outdated, contaminated, or deteriorated medications. are immediately removed from stock, disposed of according to procedures for medication disposal. 14. Medications storage areas are kept clean, well-lit, and free of clutter and extreme temperatures. Medication Storage and Labeling: In an interview and observation on 06/01/2026 at 9:25 AM with Resident #63, during the initial screening process, stated that he has watched that loose pill in the hallway all night. He stated that is where they park the 'Pill Wagon' and he should pick it up and sell it to the potheads for money. Surveyor observed a white circular tablet on the floor outside of room [ROOM NUMBER]. Observation and interview on 06/01/2026 at 9:35 AM with Registered Nurse (RN) P, was called down the [NAME] long hall to observe the white tablet on the floor. RN P bent down and picked up the table and observed a scored white circular table with No29 on the back side. RN P did not know what the tablet was or where it came from, but that is the spot where the medication cart is parked at times when administering medications at the end of the hallway. Observation on 6/2/2026 at 7:37AM in the [NAME] long hall of the 'Pill Wagon' parked in the spot of the loose found pill located on 6/1/2026 in the hallway. A nurse was administering medications on the west south end hallway. Observation on 06/03/2026 at 7:42 AM of the west long hallway 'Pill Wagon' medication cart was parked in the same area of the hall as the loose tablet was found. The medication cart was not in use, and the nurse was seated at the nursing station at the other end of the hall.

Based on observation, interview, and record review the facility failed to provide a clean, comfortable and home-like environment to ensure that residents' room floors were clean in rooms [ROOM NUMBERS], dining room chairs were in good repair, and TV wall hangars were securely positioned, resulting in an unclean and potentially unsafe physical environment. Findings Include: On 6/2/26 an observation was made in room [ROOM NUMBER]-2. A wall-mounted television was coming loose. The top screw in the mount was out of the wall and the mount moved freely when touched. Environment On 6/1/2026 at 9:40 AM, upon entering room [ROOM NUMBER]-2 the floor in front of the resident's bed had a large rectangular brown stained floor, approximately 3 foot x 2 foot. The remainder of the floor appeared scuffed and stained as if it needed to be rewaxed. On 6/02/2026 at 9:10 AM, upon entering room [ROOM NUMBER]-1, the floor was observed to be scuffed and stained. There was food on it, and it was not clean. On 6/3/3036 at 3:15 PM, the Administrator was interviewed about the stained floors in the resident rooms [ROOM NUMBERS]. She noted it and said they would check on it. A facility policy was requested on 6/2/2026 at 4:24 PM and not received prior to exit on 6/3/2026 at approximately 4:50 PM. Dining Environment: Observation on 06/02/2026 at 12:50 PM of the [NAME] dining room noted 26 black bottoms with tan upper back dining chairs with peeling bilateral arm rest and one chair with the right-side arm rest padded piece missing, and the chair was still in use. All 26 chairs had some areas of split or peeling vinyl on the seats, backs, or arms of the chairs. Observation on 06/02/2026 at 1:03 PM of the East dining room while waiting for the resident council attendees to gather, the state surveyor observed 4 black bottoms with tan upper back dining room chairs to have the vinyl peeling of the seats, backs or arms of the chairs. In an interview on 06/02/2026 at 1:35 PM the Resident council attendees were asked about the condition of the dining room chairs Black bottoms and a tan upper back with the vinyl peeling off of them and 8 of 10 residents stated that the facility needed to repair or replace the dining room chairs and that the [NAME] dining room the chairs were even worst shape.

This citation pertains to Intake Number 3026069. Based on observation, interview and record review, the facility failed to ensure access to and answer call lights timely for three residents (#31, #49, #106) and a Confidential Group of Residents, resulting in the lack of timely care, residents' verbalizations of dissatisfaction with care and unmet care needs. Findings include: Resident #31: On 6/1/26 at 12:05 PM, Resident #31 was observed sitting in a recliner in their room. An untouched food tray was in place on the overbed table in front of them. An interview was completed at this time. When queried why they were not eating their food, Resident #31 adamantly responded they did not like what they received and that it was inedible. When asked if they were able to request something different to eat, Resident #31 responded they could but indicated it would be quite a while before someone answered their call light. Resident #31 pressed their call light at 12:08 PM. At 12:10 PM, two staff members were observed talking in the hallway in close proximity to Resident #31's room. Resident #31 also saw the staff. Upon saying it should not be long before one of the staff answer their call light, Resident #31 chuckled and said, It (call light) might be on but that doesn't mean they are looking at it. The light in the hallway directly above Resident #31's door, signifying the Resident's call light was on, was checked to verify it was working. The staff were still talking in the hallway. After talking for a couple more minutes, the staff members walked away without answering the Resident #31's call light. When queried if they needed assistance from staff to use the restroom, Resident #31 replied, Yeah. Resident #31 was then asked if staff assist them when they need help and replied, Depends on who is working. Resident #31 did not provide further details when asked. At 12:34 PM, a Certified Nursing Assistant (CNA) walked past Resident #31's room without acknowledging and/or answering the call light. Resident #31's call light remained on and unanswered at 12:34 PM. An interview was completed with Infection Control Licensed Practical Nurse (LPN) C on 6/1/26 at 12:35 PM. When queried what an acceptable time frame is for a Resident to wait for their call light to be answered, LPN C would not provide a specific time frame and stated, Should be answered as soon as possible. When queried if almost 30 minutes was acceptable, LPN C stated, That is not okay. I will go check. No further explanation was provided. Record review revealed Resident #31 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinsons disease, left hand contracture, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required set up to total assistance to complete Activities of Daily Living (ADLs). On 6/2/26 at 4:23 PM, an interview was completed with the Director of Nursing (DON) and Clinical RN N. When queried what an acceptable length of time to wait for a call light to be answered by a facility staff member, RN N responded that it varied from resident to resident and was what the individual resident felt was acceptable. The DON and RN N was informed of observation of Resident #31's call light being on for almost 30 minutes as well as staff standing in the hall talking and a CNA walking past without answering the light. When queried if that was acceptable, RN N verbalized it was not. Resident #49: In an interview on 06/01/2026 at 10:03 AM with Resident #49 revealed that the staff come in and shut the light off, and say they will come right back, but they don't come back. The weekends are the worst; the lights are a long time to get answered. They told Resident 49 that the light did not work outside the room. Resident demonstrated call light did work outside the room. Third shift are lazy, and don't check on us, there are a few bad apples. In an interview on 06/01/2026 at 1:51 PM, the Activities Director D brought the Resident Council meeting notes for review. The State surveyor requested concern forms from the meetings to review. In an interview and record review on 06/01/2026 at 2:48 PM with the Nursing Home Administrator (NHA) Record review of resident council meeting notes concerns was recorded on the Resident & Family Concern Reports. The surveyor requested reports to review. NHA to get resident & Family concern forms to be reviewed. Resident council meeting to be held at 1:00PM on 6/2/2026 in the East dining room. In an interview on 06/01/2026 at 3:37 PM Resident #49 Revealed: The call lights are taking longer, from half hour to an hour response time. The staff are shutting off the call light and staff don't come back- it does take the staff a long time to get what the residents want, again a half hour to an hour. At weekends the call lights are longer than 1 hour. Getting to the bathroom is slow and takes too long, the resident stated that they take a water pill and staff just tell them to wait. Record review on 06/02/2026 at 10:18 AM of Resident & Family concern forms for the last 6 months revealed that there were multiple concerns with call lights taking 30 minutes to an hour to get staff to respond. In interviews on 06/02/2026 at 1:00 PM in the East dining room confidential resident meeting with state surveyor inquired if Call light response was timely- 6 of 10 Residents acknowledged that they have waited an hour or longer to get call light assistance, and 4 of 10 stated that they had waited 20 to 30 minutes to use the restroom or get assistance. 9 of 10 residents (One did not respond) acknowledged short staffing usually over the weekends there are call-ins and no shows, the weekends are the worst for short staffing. That's when the call lights get longer waits for help. Resident #106 (R106): On 06/01/2026 at 3:46PM, R106 was asked if the facility answers call lights in a timely manner. R106 stated, no and that third shift is the worst, they will see my call light on and just stand outside of my room. I will yell out to them that I need help, and they will just keep walking by. I have this bell I can ring as well, when I see them standing outside my door I will ring it over and over until they finally come in. R106 was asked how long it takes to get her call light answered. R106 stated that it depends on the shift and who is working, but that most times it is at least 30 minutes and sometime up to an hour.

Based on interview and record review, the facility failed to provide documentation of adequate notice of Medicare Part A benefits non-coverage, including an Advance Beneficiary Notice of Non-Coverage for 2 residents (#20 and #101) of 3 Residents reviewed for notice of non-coverage of Medicare Part A benefits, resulting in the resident's inability to exercise the right to file an appeal in a timely manner. Findings include: Beneficiary Notification On 6/02/2026 1:00 PM during an interview with the Administrator, she said Business Office Manager Q was the person responsible for providing the Notice of Medicare Non-Coverage/NOMNC letters and Advance Beneficiary Notices/ABNs to Residents receiving Skilled Medicare Part A benefits when the Skilled care was going to be completed. She said the Business Office Manager Q did not know she was supposed to track the ABN/NOMNC and was working on compiling a list of residents who she had notified and provided a letter to. On 6/02/2026 at 1:20 PM, Business Office Manager Q was interviewed. She provided a list of discharged residents from skilled care/Part A services. She said she was assigned the task in November 2025 and did not know she was supposed to issue a letter of ABN until March 2026. Upon review of three residents, two Resident #20 and Resident #101 did not receive the required notification that their skilled care services were to end, what the cost of their stay at the facility would be, and that they had a right to appeal. Resident #20: Resident #20 was admitted to the facility on [DATE] after a fall with fracture and the last covered day of skilled care was 5/20/26. The NOMNC and ABN form were provided to the resident and signed by the resident's representative on 5/15/26, but the ABN was incomplete. There were 3 options for the resident/representative to choose from, including an appeal to the discontinuation of the services and start of resident pay for the care in the facility. None of the options were chosen. Resident #101: Resident #101 was admitted to the facility on [DATE]. A NOMNC was provided to the resident/representative and signed by the representative on 2/20/2026 acknowledging the last covered day of Medicare skilled care coverage was 2/23/2026. An Advance Beneficiary Notice of Non-Coverage/ABN was not provided to the resident/representative to inform the resident/representative of the cost of services if the resident agreed to pay for them, or to appeal the decision. On 6/02/2026 at 1:54 PM, during an interview with the Business Office Manager Q she said she issued the NOMNC's to the residents/representatives but was not consistent with providing the Advance Beneficiary Notice of Non-Coverage/ABN's. On further review of the list of Residents who had received Medicare Part A skilled care benefits at the facility from January 2026- May 2026, 10 residents/representatives did not receive an ABN when Medicare Part A skilled care benefits were ending. A review of the facility policy titled, Advanced Beneficiary Notice, effective date April 2004 and revised November 2022 provided, It is the policy of this facility to prepare and deliver to the resident or residents authorized representative an Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) when the utilization review entity expects that Medicare probably will not pay for or will not continue to pay for extended care items or services. Purpose: To ensure that beneficiaries receive adequate notice of liability to pay for services denied by the fiscal intermediary. To provide a beneficiary the right to an expedited determination process to dispute the end of their Medicare covered care.

Based on interview and record review, the facility failed to ensure that the advance directive form was completed and signed by a competent individual for one resident (#2) of 12 residents reviewed.Findings include:Resident #2: Record review revealed Resident #2 was originally admitted to the facility on [DATE] with diagnoses which included borderline personality disorder, mild intellectual disabilities, opioid dependence, Post Traumatic Stress Disorder (PTSD), and dependence upon dialysis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required set-up to no assistance to complete Activities of Daily Living (ADLs). Review of Resident #2's Electronic Medical Record (EMR) revealed a Physician Determination of Decision-Making Capability form specifying the Resident was Not capable of participating and/or making Medical Treatment Decisions for themselves. The form was signed by a Physician/Licensed Psychologist on 12/12/25 and the Attending Physician on 12/29/25. Documentation of a Durable Power of Attorney (DPOA) and/or Legal Guardian was not present in the Resident's EMR. Further review of Resident #2's EMR revealed an Advance Directive (AD) Resident Preferred Treatment Option form dated 1/15/26. The AD form was completed and signed by Resident #2 and witnessed by two facility staff on 1/15/26.Note: The AD form included a section with the option, The resident is not capable of making decisions and had no legal representation. but the section had not been utilized. An interview was completed with Social Worker (SW) O on 6/2/26 at 3:01 PM. When queried regarding Resident #2 being deemed incompetent on 12/29/25 and signing their AD form on 1/15/26, SW O stated, I can't speak to that, but I will take a look and get back to you. A follow-up interview was completed with SW O on 6/3/26 at 12:47 PM. When queried if they had an opportunity to review the AD and competency documentation in Resident #2's EMR, SW O responded they had. When queried, SW O stated, When (Resident #2) signed those forms, they were deemed incompetent. SW O was then asked if that was appropriate and per facility policy/procedure, SW O responded, No, that is not appropriate. When queried if they understood the concern, SW O stated, I'm aware. When queried why Resident #2 did not have a legal guardian when they had been deemed incompetent in December 2025, SW O stated, The facility was trying to get a public guardianship and the guardian company refused (Resident #2). SW O was asked when a request for public guardianship was filed, SW O stated, I followed up on 3/5/26 in my (EMR) note. No further explanation was provided. A facility policy/procedure related to advance directives and competency was requested at this time but not received by the conclusion of the survey.

Based on interview and record review, the facility failed to obtain informed consent for psychotropic medications for one resident (R76) of two residents reviewed for psychotropic medications. Findings include:Resident #76 (R76): R76 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include major depressive disorder and Alzheimer's disease. On 06/03/2026 at 8:36AM, record review revealed a physician's order for Ativan 0.5mg, one tablet by mouth four times a day for anxiety. The start date on the order was 3/26/26. Additional orders of Ativan that have been discontinued were reviewed. On 06/03/2026 at 8:39AM, record review revealed an informed consent for Ativan 0.5mg every six hours as needed. The date on the form is 9/16/25.-Ativan 0.5mg by mouth two times a day, starting 9/17/25, discontinued 12/25/25.-Ativan 0.5mg by mouth three times a day, starting 12/25/25, discontinued 3/26/26. On 06/03/2026 at 9:49AM, an interview was conducted with Social Work (SW) O. SW O was asked when informed consents are being completed. SW O stated, we get informed consent at the time of the start of the medication and any change of the medication. SW O was asked to describe what a change in medication meant. SW O stated it can be any change in dose or the number of times it's administered. SW O was asked why they thought those were missed. SW O stated, the previous SW may have just missed them. Review of the policy, Psychotropic Medication Gradual Dose Reduction (GDR) Guidance, revealed: Procedure: 13. The residents and/or resident authorized representative will be informed of the of the initiation of a psychotropic medication, the reason for use and the risks associated with the use of psychotropic medications.

Based on observation, interview and record review, the facility failed to ensure the provision of Activities of Daily Living (ADL) care to one resident (Resident #51) of five residents reviewed, resulting in lack of oral and nail care for a dependent resident. Findings include:Resident #51: Record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses which included heart failure, weakness, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and required maximum-to-total assistance to complete all ADLs with the exception of eating. On 6/2/25 at 1:24 PM, an observation of Resident #51 was completed with Registered Nurse (RN) G in the Resident's room. Resident #51 was confused, did not provide meaningful verbal responses when asked questions, and did not follow instructions. The Resident's teeth were observed to have a visible and significant accumulation of gray/green colored thick and viscous substance. When the Resident opened their mouth, thick stands of the substance visible on the Resident's teeth were observed stretching from their top to bottom teeth. RN G observed Resident #51's mouth at the same time and verbalized the Resident desperately needed oral care. A black colored, unknown substance was observed under the Resident's nails. When queried regarding the lack of oral care for Resident #51, RN G revealed the Resident is confused and does understand which makes care more difficult to provide but the lack of oral care was unacceptable. When queried regarding the black substance under the Resident's nails, RN G was unable to state what the substance was. Review of Resident #51's Documentation Survey Report for May 2026 revealed no documentation for oral care completion. An interview was completed with the Director of Nursing (DON) and Clinical Support Registered Nurse (RN) N on 6/2/26 at 4:23 PM. When queried if dependent residents should receive assistance to complete oral care, both the DON and RN N confirmed they should. The DON and RN N were then informed of observation of Resident #51's teeth and nails. When queried regarding the lack of oral and nail care, the DON indicated they would address the concern.

Based on interview and record review, the facility failed to perform timely skin assessments for one resident (R17) of two residents reviewed for skin conditions, resulting in missed skin assessments and the potential to not identify changes in skin integrity. Findings include:Resident #17 (R17): R17 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include dehydration, diarrhea, heart disease and weakness. On 06/01/2026 at 1:09PM, observation revealed that R17 has a sore on the left side of her nose. R17 stated that it was a cancerous lesion and that sometimes she will pick at it. On 06/03/2026 at 9:32AM, record review revealed that skin assessments were not completed from 3/26/26 to 5/4/26 for R17. On 06/03/2026 at 10:13AM, an interview was conducted with the Director of Nursing (DON). The DON was asked how often skin assessments are performed for residents. The DON stated they are done once weekly. The DON was asked why there was a gap in skin assessments being completed from 3/26/26 to 5/4/26 for R17. The DON stated, I cannot explain why they were missed; R17 was present in the building during those times. The DON stated they keep a list of skin assessments at the nurse's station that need to be completed weekly. Review of the policy titled, Skin at Risk Assessment, Documentation, Staging and Treatment, revealed: Procedure: 6. The following guidelines are reviewed and implicated as indicated for each individual risk factor:a. Daily skin inspections with am and pm care.

Based on observation, interview and record review, the facility failed to ensure that Restorative Nursing services were provided for 1 resident (Resident #95) of 2 residents reviewed for mobility. Findings Include:Resident #95: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #95 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: heart disease, kidney disease, diabetes, hypothyroidism, and arthritis. The MDS assessment, dated 3/25/2026, revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed partial to moderate assistance with sit to stand and transfers and walking greater than 50 feet. The resident needed substantial/maximal assistance with walking distances 150 feet or greater The MDS assessment for Resident #95 dated 7/12/2024 indicated the resident needed supervision/touch assistance with ambulation of 10 feet, 50 feet and 150 feet. The MDS assessment for Resident #95 dated 6/20/2025 indicated the resident needed partial to moderate assistance with ambulating/walking 10 feet and 50 feet and was dependent with ambulation for 150 feet. Resident #95 had declined from 2024 to 2025. On 6/01/2026 at 9:41 AM, Resident #95 was observed sitting in a wheelchair in her room. She said she didn't walk anymore and stated, They got rid of the walking program. The resident said she would like to walk and stated, I think it would take 2 people to walk with me, and they might not have enough staff. On 6/03/2026 at 10:08 A, during an interview with Therapy Manager T, she was asked if the facility had a Restorative nursing program. She said after a resident finished therapy, if restorative services were needed, a therapist would develop a plan for it and give it to the Unit Manager/UM. The UM would place the plan in the resident's chart for the Nurse Aides to follow. The Therapy Manager T said each unit had a binder with Restorative tab and the Nurse Aides were to check to see if a Resident had a plan. The Therapy Manager T said Resident #95 had an ambulation plan. A record review of the Tasks documentation in the electronic medical record/emr for Resident #95 identified Restorative-ROM (range of motion) and Restorative- Splint/Brace Assistance. A review of the past 30 days until 6/3/2026 indicated there was no documentation that Resident #95 received assistance with either task. There was no Restorative- Ambulation entry. On 6/03/2026 at 1:40 PM, during an interview with Unit Manager/UM U, she said there was a list of residents in the Communication book under the Restorative tab for ambulation. The document was viewed with the UM U and it provided. The Initial Date of Program was 2/17/26 with a heading for Cont. (continue); Date Reviewed- 4/29/26 and 5/27/26: each entry said Cont. (continue). The Tasks documentation was reviewed with the UM, and she said the resident was not receiving Restorative services for ROM or a Splint or Brace. She acknowledged there was no entry for Restorative- Ambulation. She said the resident was listed on the document to have Restorative ambulation. She said the program is usually 6-8 weeks long and the resident is re-evaluated during that time. Unit Manager U said a plan for Restorative ambulation was not on Resident #95's Care Plan. On 6/03/2026 at 2:24 PM, the Director of Nursing/DON was interviewed about the facilities Restorative Nursing program and said he was not sure about the Restorative program. When asked if there was a Restorative nurse responsible for the Restorative program, the DON said he was not sure and was just learning about it.

Based on interview and record review, the facility failed to assess and monitor weights and ensure that interventions to promote nutrition and prevent weight loss were in place for one resident (Resident #49) of 3 sampled residents reviewed for food and nutrition. Findings include: Record review of the facility's 'Weight Management' policy, dated 4/2015, revealed it is the policy of the facility that resident's weight will be monitored by the IDT (Interdisciplinary Team) in accordance with the nutritional plan of care. 5.) in the event of a patterned significant unplanned weight loss/gain the IDT team is responsible for assessing and implementing individualized interventions. (a.) Parameters for evaluating significance of unplanned or undesired weight loss/gain are: i. 5% in 30 daysii. 7.5% in 90 daysiii. 10% in 180 days iv. Or insidious loss over a prolonged period. 6.) The nutritional plan of care is evaluated a minimum of quarterly and indicated to determine if current interventions are being followed and if they are effective in attaining nutritional and weight goals. Resident #49:Record review of Resident #49's weight log task revealed fluctuations in weightsOn 01/22/2026, Resident #49 weighed 259 lbs. On 01/29/2026 seven days later, Resident #49 weighed 245.9 lbs. which is a -5.06% Loss in 7 days. Record review of nutrition care plan had no additional interventions added. Record review of Resident #49's progress notes revealed that there were no notes addressing a 13.1-pound weight loss. On 02/5/2026, Resident #49 weighed 257 lbs. On 02/12/2026 seven days later, Resident #49 weighed 233.0 lbs. which is a 24-pound weight loss in 7 days. Record review of nutrition care plan had no additional interventions added. Record review of Resident #49's progress notes revealed that there were no notes addressing a 24-pound weight loss. On 03/05/2026, Resident #49 weighed 252.4 lbs. On 03/12/2026, Resident #49 weighed 241.6 lbs. which is a 10.8-pound loss or -4.28% Loss in 7 days. Record review of nutrition care plan had no additional interventions added. Record review of Resident #49's progress notes revealed that there were no notes dated 3/12/2026 addressing a 10-pound weight loss. Record review of Resident #49's nutritional dietary note, dated 3/22/2026, revealed resident #49 had a weight loss of 10.4 lbs., in less than 30 days, 41% loss, 8.6# gain in 90 days, 30.4# loss since admission/90 days. Resident is on a regular diet, with thin liquids. Feeds self. Remains on steroids, Cymbalta, and edema in bilateral lower legs. Has diagnosis of heart failure- weight fluctuation is due to that. Resident also would like to see dentists for loose dentures. Resident was visited during lunch time and ate 100% of the alternate that she requested Nutritional quarterly update: 4/23/2026 diet order general, mechanically altered diet, thin liquids. Resident is consuming 75% of most meals. Weight trend: 4/16/2026 250 lbs., 3/12/2026 241.6 lbs., 1/29/26 245.9 lbs. No significant weight changes noted recommend continuing with current diet as ordered. On 05/07/2026, Resident #49 weighed 257.6 lbs. On 05/12/2026, Resident #49 weighed 240.2 lbs. which is a 17.4-pound weight loss in -6.75% Loss in 6 days. Record review of nutrition care plan no interventions added. Record review of Resident #49's progress notes revealed that there were no notes dated 5/12/2026 addressing a 17.4-pound weight loss. Record review of Resident #49's nutritional care plan dated initiated on 1/19/2026 interventions included: Assess and document hydration assessment prn; skin turgor, dry mucous membranes Date Initiated: 01/19/2026 Evaluate laboratory values in relation to nutritional needs prn Date Initiated: 01/19/2026 Evaluate significant weight change with routine weights Date Initiated: 01/19/2026 Nutritional Supplements per Dietary Assessment Date Initiated: 01/19/2026 Refer to ADL flow sheet for diet specifications Date Initiated: 01/19/2026 Registered Dietician evaluation prn Date Initiated: 01/19/2026 Review preferred treatment options related to tube feedings prn Date Initiated: 01/19/2026 Serve Diet as ordered Date Initiated: 01/19/2026 In an interview and records review on 06/03/2026 at 10:11 AM with Registered Dietitian (RD) E stated that she started at the facility on 4/6/2026 and has been getting to know the residents, she works 3 days a week at the facility. The RD E stated that back in January 2026 through April 2026 there was an agency RD or regional corporate RD covering the building at that time. So, the monitoring of the weight loss was to be done by the corporate RD. RD E stated that Resident #49 is on her list to see today. Record review of the nutritional notes revealed that there were 3/ 22/2026 and on 4/23/2026 notes, but no recommended care plan interventions. The RD E and state surveyor reviewed Resident #49's weight log and care plan interventions together and there were no updated interventions since 1/19/2026.

Based on observation, interview and record review, the facility failed to store and maintain respiratory equipment in a sanitary manner and ensure oxygen administration as ordered for three residents (R5, R106, R116) of three residents reviewed for respiratory care. Findings include: Resident #5: On 6/1/26 at 10:21 AM, Resident #5 was observed sitting in a recliner in their room. A Continuous Positive Airway Pressure (CPAP) mask was laying exposed and uncovered on top of a visibly soiled blanket on the Resident's recliner. The Resident had oxygen in place via nasal cannula (NC) at 3.5 liters (L) per minute. An interview was completed at this time. When queried regarding cleaning and storage of their CPAP mask, Resident #5 revealed they take it off and do not have a specific place where they store it. Resident #5 was asked how often facility nursing staff clean the mask and machine and indicated they had not seen staff clean the equipment. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included anxiety and diabetes mellites. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required stand by to substantial assistance to complete Activities of Daily Living (ADLs). Review of Resident #5's Health Care Provider (HCP) orders in the Electronic Medical Record (EMR) revealed the following orders: - Oxygen: Maintain O2 (oxygen) at 2L via nasal cannula to sustain SpO2 (oxygen saturation) of 91% or greater. Check saturation level Q (every) shift (Ordered: 6/1/26) - CPAP. Cleaning: every day shift for Respiratory Equipment Mask cushion / nasal pillows: wash with mild soap and warm water; rinse and airdry. Humidifier chamber: empty remaining water each morning; let air-dry (Ordered: 4/26/26) - CPAP. Cleaning: every day shift every 7 day (s) Tubing / hose: wash in warm soapy water, rinse well, hang to air-dry. Headgear/chinstrap: hand-wash hang to air-dry. (Ordered: 4/26/26) Resident #116: On 6/1/26 at 10:12 AM, Resident #116 was observed sitting in their room. The Resident was receiving supplemental oxygen via NC. The oxygen tubing was not dated. A nebulizer machine with connected administration set was sitting on the top of the Resident's dresser. The nebulizer administration set was connected and exposed with visible fluid present in the medication chamber. An interview was completed at this time. When queried, Resident #116 verbalized they wear oxygen via NC continuously. When queried how often they receive nebulizer treatments, Resident #116 replied, Last one yesterday. I haven't got one yet (this morning), probably because I haven't said anything yet. When queried if staff clean and dry the nebulizer administration set after use, Resident #116 did not provide a response. Record review revealed Resident #116 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), pulmonary embolism (blood clot in lung), and pneumonia. Review of Resident #116's admission Assessment dated 5/29/26 revealed the Resident was alert and orientated X 4 (person, place, time, and situation) and had a normal gait. An interview was completed with the Director of Nursing (DON) and Clinical RN N on 6/2/26 at 4:38 PM. When queried regarding facility policy/procedure related to nebulizer equipment and maintenance following treatment administration, the DON stated, Should rinse it out and let (air) dry. After being informed of observations of Resident #116's nebulizer administration set, the DON did not provide an explanation. When queried regarding storage and cleaning of CPAP masks, the DON revealed the mask should be cleaned and air dried on a barrier. The DON was then informed of the observation of Resident #5's oxygen flow rate and the rate not matching the order. When queried, the DON indicated the administration rate should match the ordered rate. Review of facility policy/procedure entitled, Oxygen Use; Storage & Handling of Concentrators & Compressed Gas Cylinders (Revised: November 2010) revealed, Policy. Oxygen delivery will be according to physician order. Resident #106: R106 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease (COPD), chronic respiratory failure and cerebral infarction without residual deficits. On 06/01/2026 at 4:00PM, observation revealed a nebulizer mask next to the bed, it was stored intact with fluid in the medication chamber. The tubing on the nebulizer was dated 5/15/26. R106 sated that she last had a breathing treatment around 10am the morning of 06/01/26. On 06/01/2026 at 4:15PM, an interview was conducted with Unit Manager (UM) J. UM J was asked how often the tubing is changed for nebulizers. UM J replied that the tubing is changed weekly. UM J was asked what the process is for nebulizers after the treatment is completed. UM J stated that the nurses are supposed to take the nebulizer apart, rinse it out and allow it to dry on a paper towel after the treatment is completed. The findings of the dating on the tubing and nebulizer with medication still in the nebulizer were verified with UM J. UM J stated they would take care of the tubing and nebulizer right away. On 06/02/2026 at 8:57AM, observation revealed a nebulizer intact on the bedside table, fluid was noted in the medication chamber. Review of the policy titled, Small Volume Nebulizer Treatment and Compressor Care, revealed: Care of the Nebulizer Mask/Mouthpiece: After each treatment, rinse the nebulizer cup and delivery system with warm water, rinse thoroughly. Shake off excess water and let it air dry on a clean water absorbent barrier placed on a counter or table. The tubing is stored in a bag between use. Tubing and nebulizer delivery system are weekly and PRN (as needed).

Based on observation, interview and record review, the facility failed to develop and operationalize policies and procedures to ensure comprehensive assessment and care of dementia for one resident (#51) of one resident reviewed resulting in a lack of implementation and revision of personalized and meaningful non-pharmacological interventions and care approaches to attain and promote the highest practicable well-being. Findings include:Resident #51:Record review revealed Resident #51 was originally admitted to the facility on [DATE] with diagnoses which included dementia with other behavioral disturbances, depression, and difficulty walking. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and required maximum to total assistance to complete all Activities of Daily Living (ADLs) with the exception of eating. The MDS further detailed Resident #51 displayed no behaviors and had no limitations in Range of Motion (ROM). On 6/2/26 at 12:50 PM, Resident #51 was observed being pushed in a wheelchair in the Hallway of the facility. The Resident was positioned in a regular wheelchair footrests, but their legs and feet were behind the footrests. Resident #51's feet did not touch the floor. On 6/2/26 at 1:00 PM, Resident # 51 was observed in the hallway of the facility near the East Hall Dining Room. The Resident was yelling out loudly and constantly. The Resident was not verbalizing and sensical words while yelling. They were sitting in the same wheelchair with their knees bent and legs behind the footrests. The Resident's feet were still not touching the floor, and their back was not positioned against the back of the wheelchair. The Resident's body was tense; they were displaying facial grimacing and looked discernibly uncomfortable. During a confidential group interview on 6/2/26 at 1:00 PM in the East Hall Dining Room, three out of three residents who reside on the East end of the building verbalized concerns regarding Resident #51 screaming throughout the day. The confidential residents disclosed Resident #51 starts screaming at 1:00 AM and continues until the afternoon. Throughout the confidential group meeting, Resident #51 was able to be heard screaming with the dining room doors closed. From 1:00 PM to 1:24 PM, Resident #51 remained sitting in the hallway, in the same position in the wheelchair, and continuously yelling out. During this timeframe, several staff members walked past the Resident without acknowledging them and/or attempting to assist them. One staff member was observed stopping, touching Resident #51's arm, telling them they were okay, and walking away while the Resident continued to yell out. An interview was completed with Registered Nurse (RN) G on 6/2/26 at 1:24 PM. When queried regarding Resident #51 yelling out, RN G stated, I think (Resident #51) has pain. RN G revealed Resident #51 due for medications at this time and began to prepare medications for administration. With further injury, RN G verbalized the Resident's pain medications had been adjusted. When queried regarding non-pharmacological interventions for pain, RN G indicated they were unaware of any interventions. RN G was queried regarding the Resident's cognitive status and ability to verbalize needs and pain levels and responded that Resident #51 had dementia, was very confused, and dependent upon staff to meet their needs. Resident #51 continued to yell out while RN G prepared the medications and during interview. Following preparation of the medications and interview, Certified Nursing Assistant (CNA) S approached the Resident and told them, It's okay but the Resident continued to yell out. CNA S was observed attempting to bend the Resident's knees to move their legs forward and place them on the footrests. Resident #51 yelled out louder and displayed facial grimacing while CNA S moved them. The Resident's knees remained flexed and bent, and the Resident's buttocks moved forward more while their upper back moved back in the wheelchair. RN G asked CNA S if they were taking Resident #51 back to their room and CNA S responded that they were. Resident #51 continued to yell and scream out while CNA S propelled them down the hall to their room. An observation of the Resident with RN G in the wheelchair revealed the Resident's buttocks and lower back were approximately six inches away from the back of the seat. When queried regarding the position of the Resident's knees and their Range of Motion (ROM), RN G responded that both of Resident #51's knees were contracted and did not straighten. CNA S pushed Resident #51 into their room in the wheelchair and informed RN G they needed to get the lift (Hoyer -mechanical lift used to lift and transfer dependent individuals) and assistance to put Resident #51 in bed. When queried regarding Resident #51's lower extremity ROM, CNA S responded that the Resident's knees are always bent backwards (towards their buttocks) and do not straiten. CNA S exited the room at this time. Resident #51 continued to yell out continuously. RN G attempted to give Resident #51 their crushed medications in pudding via spoon, but the Resident clenched their teeth while continuing to make loud noises. Resident #51 was reaching their hand out and grabbed my hand. I began to sing Bell Bottom Trousers (Popular WW2 song from 1944/1945) and Resident #51 immediately stopped yelling out and took their medications. When I stopped singing, Resident #51 asked me to sing again. Upon exiting the room, Resident #51 was not yelling out. An interview was conducted with RN G after exiting Resident #51's room on 6/2/26 at 2:10 PM. When queried regarding how the Resident stopped yelling with singing and interventions, RN G stated, We did have a radio in there (Resident room) for a while but (Resident #51) started yelling over it. When queried if Resident #51 preferred a specific type of music or if they were yelling when certain music was played, RN G revealed they did not know. RN G verbalized Resident #51 seems to be calmer when they sit with them and talk to them. Review of Resident #51's Electronic Medical Record (EMR) revealed a Social Services care plan entitled, (Resident #51) has the potential for psychosocial distress related to: anticipated dementia progression, expressing sadness / anger / empty feeling over lost roles and status (Initiated and Revised: 12/18/24). The care plan included the interventions:- Family in to visit for socialization and support as able (Initiated: 12/18/24)- Identify behavioral precipitants, if possible, to assist with further defining effective dementia care and trauma informed care (Initiated: 12/18/24)- If behavioral, rule out pain, decrease stimulation (Initiated: 11/21/25)- Maintain a calm environment as able (Initiated: 12/18/24)- Acknowledge residents mood and behavior; conveying acceptance toward the resident while rejecting negative behavior (Initiated: 12/18/24)- Allow opportunities for expression of individuality which include: reading (Initiated: 12/18/24)- Behavior monitoring as identified on the individualized log; utilize log for patterning and intervention revision as indicated (Initiated: 12/18/24)- Evaluate changes in mood and socialization (Initiated: 12/18/24)- Behavior Meeting: 6/4/25, 1/8/26 (Initiated: 6/6/25; Revised: 1/8/26)- Behavior monitoring as identified on the individualized log; utilize log for patterning and intervention revision as indicated (Initiated: 12/18/24)- Evaluate changes in mood and socialization (Initiated: 12/18/24) Another care plan entitled, (Resident #51) has experienced a recent loss of spouse (Initiated and Revised: 4/22/26). The care plan included the interventions:- Explain the stages of grief related coping strategies, and grief work through each stage (Initiated: 4/22/26)- Explore with the resident previous effective and ineffective coping mechanisms (Initiated: 4/22/26)- Identify relationships for the resident to draw on (Initiated: 4/22/26)- Implementation of visual checks (insert frequency) for the purpose of: (Blank) (Initiated: 4/22/26)- Provide opportunities to listen and support communication of feelings (Initiated: 4/22/26)- Support grief reactions (Initiated: 4/22/26)- Treat primary mood disorder by: quite (sic) environment, soft music, redirection (Initiated and Revised: 4/22/26) Review of Resident #51's EMR revealed the Resident had documentation of agitation and yelling out beginning in 2025. Per documentation, Resident #51 was taking Prozac (antidepressant medication) daily when they were admitted . During their stay at the facility, Depakote (anticonvulsant medication used as a mood stabilizer) 250 milligrams (mg) three times a day (TID) was added in August 2025 due to increased mood swings and verbal behaviors associated with dementia, Ativan (anti-anxiety medication) TID was added in November 2025 due to agitation and yelling related to progressive dementia, and Tylenol with Codeine (Tylenol #3- narcotic pain medication) TID was added in May 2026 due to concerns of pain related to increased behaviors. Documentation in Resident #51's EMR detailed: - 3/10/26: Healthcare Provider Acute/Follow-Up. Progress Note.Chief Complaint. Agitation. seen today for reports of agitation. Plan: Agitation due to Dementia. - 4/9/26 at 2:47 PM: Interdisciplinary Documentation. Spoke with (Family Member V) r/t (related to) addition of Prozac (antidepressant medication) 20 mg (milligrams) daily r/t depressive disorder. (Family Member V) is in agreement with addition of medication - 4/24/26: Healthcare Provider Acute/Follow-Up. Progress Note. recently lost (spouse) who was in the facility as a resident. Although significant dementia, it is possible that (spouses) passing may be affecting (Resident) . Seen at nurses' station, up in wheelchair. Seems agitated. Yelling out. - 5/28/26: Physician Acute/Follow-Up. seen today for agitation. recently lost (spouse) who was in the facility as a resident. Although significant dementia, it is possible that (spouses) passing may be affecting (Resident) . Patient has been having some episodes of yelling out in the hallway and resistive to cares. Decision to place patient on T-3 (Tylenol #3- narcotic pain medication) to ensure relief from pain . - 5/28/26 at 10:21 AM Type: Interdisciplinary Documentation. Following behavioral health meeting, and recommendations from NP. Writer placed call to (Family Member V) to go over recommendations of scheduled Tylenol #3 . (Family Member V) in agreement with (Resident #51 showing signs of pain and started scheduled pain medication. An interview was completed with Social Worker (SW) O on 6/2/26 at 3:05 PM. When queried regarding Resident #51, SW O verbalized the Resident had dementia and had behavioral monitoring in place. When queried regarding the Resident yelling out and personalized, resident-centered interventions related to their dementia, SW O indicated they would need to review the care plan. SW O verbalized they did not want to make care plan interventions so specific that staff only did the interventions specified on the care plan. When asked if reading was an appropriate intervention for Resident #51, with their current cognitive level and progression of dementia, SW O did not provide a direct response and indicated they would need to review the Resident's information and provide follow up. On 6/2/26 at 4:23 PM, an interview was completed with the Director of Nursing (DON) and Clinical RN N. When queried regarding Resident #51 yelling in the hallway, the DON and RN N revealed they were aware of the behavior. The DON and RN N were informed of observation of Resident #51 yelling in the hallway for over 30 minutes, staff walking past without acknowledging the Resident, ineffectiveness of staff telling Resident #51 they were okay, and how the Resident stopped yelling when I sang to them. When asked about the lack of personalized interventions related to dementia care including personalized, the DON and RN N verbalized understanding and indicated they would review the Resident's EMR. The DON and RN N were then queried regarding observation of the Resident's lack of ROM and staff statement indicating their Bilateral Lower Extremities (BLE) were contracted, the DON confirmed the Resident did have impaired ROM in BLE. When asked about Resident #51's wheelchair positioning, including observation of their legs not being positioned on the footrests, the Resident's visible discomfort when their legs were moved to be positioned on the footrests as well as the space behind their back/buttocks, the DON and RN N responded they would have Therapy evaluate the Resident for positioning. The DON and RN N were asked if Resident #51 was able to verbalize if they were uncomfortable, they indicated the Resident was not. When queried why facility staff had not identified the Resident's inability to articulate and verbalize discomfort and concerns with positioning and had the Resident evaluated by Therapy previously, an explanation was not provided. Upon request for the facilities dementia management and care policy/procedure, RN N responded that the facility does not have a policy/procedure pertaining to dementia management. Review of Resident #51's EMR revealed the Resident was not receiving restorative nursing services related to limited ROM. Review of Resident #51's Documentation Survey Report for May 2026 included a section titled Behavioral Care every shift (three shifts per day). Review of Behavioral Care documentation revealed 24 times with no (blank) documentation. Review of the documentation completed revealed revealed the resident displayed behaviors a total of 12 times including crying three times, Disruptive sounds four times, Verbal Aggression/Swearing four times, and Negative Statements once. On 6/3/26 at 9:04 AM, an interview was completed with Clinical RN N regarding Resident #51. RN N revealed a Therapy Eval was ordered for Resident #51 related to wheelchair positioning and the therapy determined a Broda chair Broda chair (specialized, reclining and cushioned wheeled chair with solid leg rests used for individuals with limited mobility to provide advanced positioning and comfort) was more appropriate for the Resident. RN N further revealed the facility was going to have Activities do more person-centered activities with Resident #51. An interview was completed with a cognitively intact Resident (Resident #2) who resides in the same hall of the facility as Resident #51 on 6/3/26 at 10:06 AM. When queried regarding how they are treated by facility staff, Resident #2 responded they are able to take care of themselves and it is the people who can't that they worry about. When asked what they meant, Resident #2 stated, (Resident #51) yells out all the time and they do nothing for them. Just let them yell and scream. With further inquiry, Resident #2 revealed Resident #51 yells out during the day and the night in both the hallway and in their room. Resident #2 stated, You can tell (Resident #51) in pain, and they (staff) don't do nothing. When asked what they meant when they said the staff don't do anything, Resident #2 responded that facility staff either ignore Resident #51 or just tell them they will be alright which does not work. Resident #2 further revealed they chose to stay in their room with the door closed because of the yelling. On 6/3/26 at 11:00 AM, an interview was completed with RN G. When queried regarding Resident #51, RN G revealed Therapy had evaluated the Resident and recommended a Broda Chair. RN G stated, (Resident #51) looks so much more comfortable in the Broda. With further inquiry, RN G revealed the Resident had not been crying (yelling) out like they had been previously since being in the Broda chair. On 6/3/26 at 11:28 AM, Resident #51 was observed sitting in a Broda chair in their room with their eyes open. The Resident was slightly reclined, and their legs were slightly elevated. Resident #51 was not yelling out and appeared comfortable with no non-verbal signs/symptoms of distress and/or pain observed. When spoke to, Resident #51 made eye contact but did not provide meaningful responses to questions. An interview was conducted with the DON and RN N on 6/3/26 at 11:36 AM. When queried regarding Resident #51, the DON verbalized they spoke to Family Member Witness V and were updating the care plan with personalized interventions. When asked why the care plan had not been updated previously to include personalized interventions prior to identification during survey, an explanation was not provided. When queried why Resident #51 had not been evaluated for positioning previously, when increased pain was considered and scheduled pain medication was implemented, a response was not provided. The DON and RN N were informed of observation of Resident #51 in the Broda Chair and staff statements of decreased behaviors. Resident #51's lack of assessment, evaluation, and implementation of individualized care interventions directed towards understanding and relieving the Resident's distress to promote physical and psychosocial comfort and wellbeing with dementia diagnosis were discussed with the DON and RN N. The DON and RN N verbalized understanding of the concern but did not provide further explanation. An interview was completed with Physical Therapy Staff W on 6/3/26 at 2:32 PM. When queried who had evaluated Resident #51 for positioning needs, Therapy Staff W replied, OT (Occupational Therapy) evaled them. When queried if it would be possible to review the OT note pertaining to Resident #51's evaluation, Therapy Staff W reviewed the Resident's Therapy documentation and stated that the OT did not complete their note. A review of the Resident's therapy EMR with Therapy Staff W revealed the OT note was opened but no clinical documentation related to positioning needs and evaluation had been documented. A follow-up interview was completed with SW O on 6/3/26 at 12:57 PM. When queried if they had reviewed Resident #51's EMR, SW O indicated they had and stated, We added some things in the care plan and one-on-one (activities) in the care plan. When queried if the reason for Resident #51 yelling out continuously was related lack of understanding the Resident's dementia, SW O replied, Yeah, for sure. SW O then stated, The DON talked to (Family Member V) and (Resident #51) really likes gospel music. SW O verbalized they went to see Resident #51 today and they were interacting with the gospel music and not yelling out. Review of Resident #51's EMR revealed the DON authored the following note on 6/3/26 at 10:09 AM, Interdisciplinary Documentation. (Family Member V) was contacted today to discuss (Resident #51's) preferences and hobbies to provide more effective comfort measures. (Family Member V) shared that (Resident #51) responded positively to her providing a hug and sharing pictures of her grandkids. (Family Member V) also noted that attempting to provide that same intervention with random videos/pictures of children laughing/playing that (Resident #51) did not respond in the same manner. (Family Member V) noted that (Resident #51) often enjoyed old TV westerns such as [NAME] and Lone Ranger but is no longer able to watch them as the action within these shows now causes distress. Other noted hobbies/activities [NAME] used to enjoy were quilting, sewing, knitting, and scrapbooking, but (Family Member V) provided the observation that [NAME] is no longer capable of carrying out these activities. (Family Member V) stated that she too had noticed the increase in behaviors such as moaning/shaking/mumbling and believes these are related to both the recent passing of (Resident #51's spouse) and her research of 'Dementia crying'. This writer discussed with (Family Member V) offering to have (Resident) up out of bed later in the evening on days where (they are) available for visit. Review of facility provided policy/procedure entitled, Care Planning Process: Admission, Comprehensive & Short Term (Revised: 11/2017) revealed, Policy. It is the policy of this facility to utilize the results of the MDS assessment to develop, review, and revise resident care plans. To ensure prompt assessment and delivery high standard Person-Centered Care and to communicate resident needs. The facility did not have a policy/procedure pertaining to Dementia care and/or management.

Based on observation, interview and record review, the facility failed to ensure a medication administration error rate of less than 5% when three medication errors were observed for two residents (#19 and #104) from a total of 25 observations, resulting in a medication error rate of 12%.Findings include: Resident #104:A medication pass observation was completed with Licensed Practical Nurse (LPN) F for Resident #104 on 6/3/26 at 7:35 AM. LPN F indicated Resident #104 wanted their Voltaren 1% (topical pain relief medication) gel and would need to obtain the medication from the medication room where it was kept. LPN F entered the medication room and after looking in the drawers, verbalized the Voltaren gel was not there. When asked what they were going to do, LPN F revealed they would let the Resident know they did not have it. Upon entering Resident #104's room, the Resident had their knee brace down waiting for application of the Voltaren gel and LPN F told them their Voltaren gel was not available. The Voltaren gel was not administered and omitted. Resident #19:On 6/3/26 at 7:47 AM, a medication pass observation for Resident #19 was completed with LPN F. LPN F removed a Humalog insulin KwikPen 100 units/milliliter (mL) pen (insulin pen for treatment of diabetes mellitus) from the medication cart for Resident #19, attaching the needle, and turned the dial to select 5 units for administration. LPN F did not prime the insulin pen. LPN F then sat the pen down directly on top of the medication cart. LPN F proceeded to remove all of Resident #19's oral medications in the prepacked pharmacy medication packets from the medication cart, as well as a Norco 5 milligram (mg)/325 mg (narcotic pain medication) tablet, crushed all the medications together, and mixed with pudding. One of the medications LPN F had removed from the medication cart and crushed was mirabegron 25 mg Extended-Release 24-hour (extended-release medication used to treat overactive bladder). When asked why they crushed the Resident's medications, LPN F responded that the Resident prefers to have their medications crushed and they are always crushed. LPN F then closed the medication cart and verbalized they were ready to administer the medications. Prior to administering the medications to Resident #19, LPN F was stopped and asked extended-release medications should be crushed. LPN F responded that extended-release medications are generally not crushed. When asked why they had crushed an extended-release medication for administration to Resident #19, LPN F revealed they were unsure which medication was extended release. Resident #19's Medication Administration Record (MAR) was reviewed, and LPN F confirmed the Resident's mirabegron 25 mg was an extended-release medication and should not be crushed. After disposing of the crushed medications, LPN F prepared the oral medications again and proceeded to go to Resident #19's room with their medications including the insulin pen at 8:24 AM. LPN F was stopped prior to administration again and asked if they had primed the insulin pen. LPN F responded they had not and stated they thought the pen only needed to be primed when it was used for the first time. LPN F proceeded to prime the pen with the current needle on it, dispose of the current needle, and put a new needle on the pen without priming it. LPN F administered the insulin pen in Resident #19's right upper arm. LPN F held the dose injector knob down for two seconds and then held the pen in place for seven additional seconds without holding the dose injector knob down.An interview was completed with LPN F immediately after exiting Resident #19's room. When queried why they primed the insulin pen, disposed that needle, and then put on a new needle but did not prime it, LPN F did not provide an explanation. When queried why they only held the dose injector knob down for two seconds, LPN F revealed they were unsure how long they had held it down but knew the pen had to be held in place. No further explanation was provided. An interview was completed with the Director of Nursing (DON) and Clinical Support Registered Nurse (RN) N on 6/3/26 at 8:55 AM. When queried if extended-release medications should be crushed, both the DON and RN N responded they should not. When asked if insulin pens should be primed prior to administration, the DON and RN N both verbalized they should. After being informed of identified concerns during the medication pass observation for Resident #'s 104 and 19 with LPN F, the DON and RN N verbalized understanding. Review of facility policy/procedure entitled, Medication Administration by the Various Routes (Revised: December 2024) revealed, It is the policy of this facility to administer medication in agreement with standards of practice.

Based on interview and record review, the facility failed to ensure that residents were competent to sign a binding arbitration agreement prior to the resident signing it for one resident (Resident #36) of 3 residents reviewed for arbitration agreements and a Confidential Group of 10 Residents who were aware of the meaning of an arbitration agreement from a census of 104 residents. Findings Include: Arbitration A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #36 was admitted to the facility on [DATE] with diagnoses: Non-traumatic brain dysfunction, Alzheimer's disease, diabetes, heart disease, hypothyroidism, anxiety, depression and arthritis. The admission MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 6/15. On 6/1/2026 at 9:25 AM during the Entrance Conference with the Administrator, she was asked if the facility used Arbitration agreements and she stated, Yes, we do. A list of residents who signed the document indicating they wanted arbitration was requested. On 6/2/2026 at 2:05 PM, the Administrator provided a list of resident who signed Arbitration agreements in the facility. There were 44 of 104 residents that signed they wanted it. Upon review of arbitration agreements for 3 residents including Resident #36, it revealed the resident signed the document on 5/4/2026. Upon further review of the Medical record for Resident #36, it identified a document titled, Physician Determination of Decision Making Capability. The document was signed by two medical providers. The facility Medical Director A signed the document on 5/4/2026 indicating, As the resident's attending physician, I am making a medical determination that the above named resident is no longer capable of understanding the Bill of Rights and participating in Medical Treatment Decisions. On 5/13/2026 an additional medical provider signed the document indicating the resident was no longer capable of making medical treatment decisions. On 6/02/2026 at 3:05 PM, admission Director B was interviewed about the facility's arbitration agreements. She said she reviewed them with the resident or their representative by the next day after admission or Monday if admission was on a Friday. When asked how she determined if a resident was able to make a competent decision to sign the document, as indicating they would want arbitration, she said if they had a Power of Attorney/POA she would contact that person or if they sounded confused she would ask a Nurse or Social Worker. During the interview with the admission Director B on 6/2/2026 at 3:05 PM, the arbitration agreement that Resident #36 signed was reviewed. She said the resident had signed the document. Reviewed with the Admissions Director that the resident's physician had determined she was not capable of making medical decisions on the same day 5/4/2026. The Admissions Director B said she was not aware of that. On 6/3/2026 at 3:25 PM, the Administrator was asked about residents signing the arbitration agreements when they were not able to make their own decisions and she said the facility was looking into that. A review of the facility policy titled, Voluntary Binding Arbitration Agreement, date effective August, 2024 provided, Policy: It is the policy of this facility to present the Voluntary Binding Arbitration Agreement (VBAA) to Resident/Resident's Legally Authorized Representative (Representative) after the admission paperwork is completed. The policy did not mention assessment of the residents' competence prior to signing the document. In interviews on 06/02/2026 at 1:00 PM in the East dining room with confidential residents, the state surveyor inquired if residents were familiar with the arbitration agreements. 10 of 10 residents that attended the meeting did not know what the arbitration agreement was, or if they had signed an arbitration agreement. The surveyor stated that grievances with the facility are discussed and the resident and facility reach a resolution by mutual agreement without the use of the legal system.

Based on interview and record review, the facility failed to add interventions for weight loss for one resident (Resident #49). Record review of the facility 'Care Planning Process: Admission, Comprehensive & Short Term' policy dated 11/2017 revealed it is the policy of this facility to utilize short term care plans if indicated for short term conditions that may warrant increased assessment & observation. The purpose was to ensure prompt assessment and deliver high standard person-centered care and to communicate resident needs. To ensure the results of the comprehensive assessment are used to develop, review, and revise the resident's comprehensive plan of care. 3.) Care plans are initiated to address interventions for prevention of functional decline, rehabilitative and restorative care, health maintenance issues, skin care, discharge potential, safety and wandering/exit seeking behavior, nutritional Resident #49:Record review of Resident #49's weight log task revealed fluctuation in weightsOn 01/22/2026, the resident #49 weighed 259 lbs. On 01/29/2026 seven days later, the resident #49 weighed 245.9 lbs. which is a -5.06% Loss in 7 days. Record review of nutrition care plan had no additional interventions added. Record review of Resident #49's progress notes revealed that there were no notes addressing a 13.1-pound weight loss. On 02/5/2026, the resident #49 weighed 257 lbs. On 02/12/2026 seven days later, the resident #49 weighed 233.0 lbs. which is a 24-pound weight loss in 7 days. Record review of nutrition care plan had no additional interventions added. Record review of Resident #49's progress notes revealed that there were no notes addressing a 24-pound weight loss. On 03/05/2026, the resident #49 weighed 252.4 lbs. On 03/12/2026, the resident #49 weighed 241.6 lbs. which is a 10.8-pound loss or -4.28% Loss in 7 days. Record review of nutrition care plan had no additional interventions added. Record review of Resident #49's progress notes revealed that there were no notes dated 3/12/2026 addressing a 10-pound weight loss. Record review of Resident #49's nutritional dietary note, dated 3/22/2026, revealed Resident #49 had a weight loss of 10.4 lbs., in less than 30 days, 41% loss, 8.6# gain in 90 days, 30.4# loss since admission/90 days. Resident is on a regular diet, with thin liquids. Feeds self. Remains on steroids, Cymbalta, and edema in bilateral lower legs. Has diagnosis of heart failure- weight fluctuation is due to that. Resident also would like to see dentists for loose dentures. Resident was visited during lunch time and ate 100% of the alternate that she requested Nutritional quarterly update: 4/23/2026 diet order general, mechanically altered diet, thin liquids. Resident is consuming 75% of most meals. Weight trend: 4/16/2026 250 lbs., 3/12/2026 241.6 lbs., 1/29/26 245.9 lbs. No significant weight changes noted recommend continuing with current diet as ordered. On 05/07/2026, the Resident #49 weighed 257.6 lbs. On 05/12/2026, the Resident #49 weighed 240.2 lbs. which is a 17.4-pound weight loss in -6.75% Loss in 6 days. Record review of nutrition care plan no interventions added. Record review of Resident #49's progress notes revealed that there were no notes dated 5/12/2026 addressing a 17.4-pound weight loss. Record review of Resident #49's nutritional care plan dated initiated on 1/19/2026 interventions included: Assess and document hydration assessment prn; skin turgor, dry mucous membranes Date Initiated: 01/19/2026 Evaluate laboratory values in relation to nutritional needs prn Date Initiated: 01/19/2026 Evaluate significant weight change with routine weights Date Initiated: 01/19/2026 Nutritional Supplements per Dietary Assessment Date Initiated: 01/19/2026 Refer to ADL flow sheet for diet specifications Date Initiated: 01/19/2026 Registered Dietician evaluation prn Date Initiated: 01/19/2026 Review preferred treatment options related to tube feedings prn Date Initiated: 01/19/2026 Serve Diet as ordered Date Initiated: 01/19/2026In an interview and records review on 06/03/2026 at 10:11 AM, Registered Dietitian (RD) E stated that she started at the facility on 4/6/2026 and has been getting to know the residents, she works 3 days a week at the facility. The RD E stated that back in January 2026 through April 2026 there was an agency RD or regional corporate RD covering the building at that time. So, the monitoring of the weight loss was to be done by the corporate RD. RD E stated that Resident #49 is on her list to see today. Record review of the nutritional notes revealed that there were 3/ 22/2026 and on 4/23/2026 notes, but no recommended care plan interventions. The RD E and state surveyor reviewed Resident #49's weight log and care plan interventions together and there were no updated interventions since 1/19/2026.

This citation pertains to Intake Numbers 2685912 and 2701537.Based on interview and record review the facility failed to protect one resident's (Resident #302) right to be free from neglect, resulting in 1. Significant delay in the administration of enteral nutrition and hydration; 2. Discharge medication orders (insulin and tube feed formula) were not followed without a rationale; 3. Untimely intervention for persistently elevated blood glucose levels and lack of communication to the practitioner; and 4. An ongoing respiratory assessment and monitoring of an acute infection with antibiotic administration, which led to an unnoticed change in condition requiring hospitalization. Findings Include:On [DATE] at approximately 2:30 PM, a review was conducted of Resident #302's medical records and it revealed he was admitted to the facility on [DATE] at approximately 6:30 PM with diagnoses that included, Cerebral Infarction, Pneumonia, Dysphagia, Type 2 Diabetes. Further review of the record yielded the following:Hospital Discharge Records [DATE]: Diet currently NPO (nothing by mouth) due to severe oropharyngeal dysphagia. requires PEG tube feeding (Glucerna 1.5 cal (calories), 60 mL (milliliter) /hr (hour)goal rate, 1440 mL, 2160 kcals (kilocalories).Medication management.diabetes (insulin lispro.) During the hospital course (Resident #302) exhibited altered mental status, described as lethargic, drowsy, unresponsive and nonverbal. the cognitive and behavioral state is likely related to his acute ischemic multifocal posterior circulation stroke.Diagnosis.Type 2 diabetes mellitus.Discharge Diagnosis List.Diabetes. admission Assessment [DATE]: .confused, short-term memory problem, long-term memory problem.blood sugar 216.DM (diabetes mellitus) .resident is very confused and can be combative at times, does not understand that he has a rm mate and thinks someone is taking his money. Care Plan: .Report hyperglycemia signs and symptoms to supervising nurse.Obtain diagnostics tests/labs per health care practitioner order. On [DATE] at approximately 2:00 PM, the DON (Director of Nursing) and Corporate Consultant T stated there are batch orders embedded into their electronic medical system for enteral nutritional and the nurse would then need to tailor the specifics of the order to the resident. A review was conducted on Resident #302's hospital discharge records and MAR (Medication Administration Record). The discharge records indicated the following:Insulin lispro (insulin lispro 100 units/mL (milliliter) injectable solution) Dose:0-18 unit subcutaneous four times a day with meals and at bedtime. There was a handwritten note by facility staff by the order, placed note in Dr (doctor) book for clarification on [DATE].Glucerna 1.5 cal, 60 mL/hr (hour) goal rate, 1440 mL, 2160 kcals, 119 g (grams) protein, 1093 mL FW (free water).estimated fluid needs: 2254-2454 mL/day. Upon admission the facility switched his enteral nutrition to Jevity 1.5 (rather than the Glucerna that was listed in his discharge orders) and he was not administered his enteral nutrition until [DATE] around 2:00 PM (according to the MAR). Furthermore, his insulin was not ordered and administered by the facility until [DATE]. The DON was asked for rationale for the above- he reported he would investigate the above and follow up. On [DATE] at 5:00 PM, Nurse O reported Resident #302 was a two person assist and strictly NPO (nothing by mouth). His wife was very in tune with his needs and would typically alert her if he was in pain or anything out of the ordinary. Nurse O was asked what were the blood sugars parameters when they needed to contact their practitioners and she stated anything above 400 they would typically contact the physician for further direction. On [DATE] at 9:11 AM, Complainant D reported upon Resident #302 arriving at the facility it appeared they did not have any of his discharge information and they had to contact the medical floor at the hospital to provide information regarding Resident #302's enteral nutrition rate. Earlier in the week prior to him being transferred to hospital he appeared to be at his baseline but as the week progressed he declined. He was in bed, asleep and difficult to arouse. The day he was transferred to the emergency room he was asleep with the fan blowing on his face and upon getting closer there was sweat beating down his face. The nurse assigned made the excuse that she only comes every week or so and was not familiar with the resident. The complainant stated Resident #302 had been like this for a few days with no interventions from the facility and he passed away a week later in the hospital. On [DATE] at approximately 9:30 AM, the DON reported he spoke to their Nurse Practitioner regarding Resident 302's insulin order. After the practitioner reviewed the chart and spoke to the resident ( the day after admission -[DATE]) it was found the resident was not on a home insulin regime prior to admission to the hospital. They entered an order to check Resident #302's blood sugars on [DATE] but it did not pull over to the MAR. This error was rectified on [DATE]. The DON was asked if there were any notes detailing the discussion the Nurse Practitioner had with Resident #302. The DON stated it was not explained fully in his documentation why the insulin was not reordered.On [DATE] a Care Conference was held for Resident #302 and the document stated Severely cognitively impaired. It is unknown how the resident would be able to provide medical history regarding medications to the facility practitioner.Resident #302's medication order dates and time of administration were reviewed:[DATE] MAR (Medication Record):Medication Orders:Jardiance Oral Tablet 25 MG- for Type 2 Diabetes Mellitus. Started on [DATE] ( 13 days after admission).Lantus Solostar 100 Unit/ML solution pen injector- inject 20 units subcutaneously at bedtime for Type 2 Diabetes Mellitus. Started on [DATE] (14 days after admission).Amoxicillin-Pot Clavulanate Oral Tablet for infection. Started on [DATE] and completed on [DATE].Enteral Feed Orders:Enteral Feed Order: every 4 hours for Tube Feeding Tap water flush- 150 volume to be flushed in 24 hours- 600 cc per day of free water for medication pass. First administered on [DATE] at midnight.Enteral Feed Order: Jevity 1.5 at 65/ml per hour for a total of 1560 cc infuses in 24 hours. First administered on [DATE] at 2 PM (evening). Enteral Feed Order: Glucerna 1.5 at 65/ml per hour for a total of 1560 cc infused in 24 hours. Started on [DATE]. It can be noted Glucerna was listed on Resident #302's diet order upon admission to the facility. Medication Audit Report:Enteral Feed Order: every 4 hours for Tube Feeding Tap Water FlushFirst administrated on [DATE] at 1:00 AM (this was approximately 6 hours after admission to the facility).Enteral Feed Order every shift for Tube Feeding- Jevity 1.5 at 65/ml per hourFirst administered on [DATE] at 17:10 ( approximately 23 hours after admission to the facility). On [DATE] at 10:35 AM, an interview was conducted with Physical Therapy Assistant (PTA) E. He reported he worked with Resident #302 on strengthening, balancing and safe transferring. He first worked with the resident on [DATE] and he initially seemed to be making progress as he was walking about 20 feet and at one point close to 100 feet. But prior to his discharge to the hospital, he was going backwards. He had a posterior lean and his transfers were becoming more difficult. Resident last days of therapy were [DATE] and [DATE] and those were difficult days for him. He was total for transfer and max assist of two. He appeared to show physical decline, seemed lethargic and did not appear to be at his baseline toward the end of his stay. On [DATE] at 1:50 PM, an interview was conducted with Speech Therapist F regarding her work with Resident #302. Therapist F reported he was NPO with a PEG (Percutaneous Endoscopic Gastronomy tube) and she was working on swallowing, cognition and language. He could not articulate what he wanted but his wife was there and able to assist in goal setting. He recalls him having flat affect and responded with expression level words and at time phrases. On [DATE] she wrote that the PTA stated Resident #302 was attempting to eat a weight and when she assessed him, he stated he indicated he had pain in his mouth. Therapist F observed a white coating on his tongue and informed the nurse regarding it who stated that he was something refused the spray that assisted. She reported all the appropriate individuals were informed of his change in condition. Review was conducted of Resident #302's therapy documentation:Physical Therapy:[DATE]: .Patient has had physical decline this week with increased lethargy. Nursing has been made aware.Speech Therapy:[DATE]: Patient's PTA reported that the patient was attempting to eat a weight.SLP (speech therapist) alerted rehab manager who spoke with clinical care coordinator and NP as well due to concern for change in status reported by PTA. On [DATE] at 2:40 PM, an interview was conducted with CNA (Certified Nursing Assistant) G regarding Resident #302. The CNA stated she recalled him being a hoyer lift and mumbling when he talked. Shortly before he was sent out to the hospital, they were assisting with getting him up and he became dizzy, seemed increasingly tired and appeared like he was going to pass out. He was not sitting up correctly in his wheelchair and slumped forward some. Soon after this occurred, he was transferred to the hospital for evaluation. On [DATE] at 1:00 PM, CNA H reported upon admission Resident #302 was a hoyer lift and then two persons assist. Toward the end of his stay he began to decline and transferring him became increasingly difficult as he was dead weight. But at the beginning of his stay, he would assist with the transfers. On [DATE] at 2:40 PM, an interview was conducted with Nurse C regarding Resident #302. Nurse C reported she was the nurse that completed his admission and that note regarding the insulin was due to the hospital not providing the sliding scale parameters. She recalled asking the oncoming nurse to contact the doctor for clarity regarding the order. Nurse C stated she did check his blood sugar, and it was not alarming at 216. They contact the physician when levels are 300 and above. During his stay she was alerting the practitioners that his blood sugars were high.Review was conducted of Resident #302's Progress Notes:Progress Notes:[DATE] at 14:48: This A.M. his BS ( blood sugar) was 510. Order was obtained to give 20 units of regular insulin. At noon his BS was 449. His wife was here to visit at 1330. She wanted resident to be sent to (Emergency Room). She stated she noted a change in condition on Wednesday. He was seen by the NP on Friday. Labs ordered for tomorrow. at 1413 report called to nurse.Ambulance arrived and transported resident to hospital. [DATE] at 01:00: (Resident #302) was seen today for PT ( Physical Therapy) reported he has increased fatigue and weakness. Patient stated he has not been sleeping very good and he is tired. Blood sugars have been increased and are being monitored.Labs ordered. [DATE] at 01:00: .(Resident #302) was seen today for Acc checks. Nursing came to me today. He had a blood sugar this morning of 435. He is not on medications for diabetes.Past medical history. type 2 diabetes mellitus.unable to obtain ROS due to confusion.Start Jardiance. Cont (continue) to monitor checks accuchekcs. A1C.XXX[DATE] at 01:00: .Check accuchekcs, A1C XXX[DATE] at 01:00: .pt (patient) confused this am gives different answers than yesterday. told me he was living on the street, single.thinks its is [DATE].Type 2 diabetes mellitus without complication, unspecified whether long term insulin use.check accuchekcs, A1C. [DATE] at 01:00: .Type 2 diabetes mellitus without complication, unspecified whether long term insulin use: currently no meds, check labs with A1C. There was no documentation located regarding the following:Nursing assessment regarding his change in condition or transfer forms.Antibiotic use for diagnosis of pneumoniaRespiratory assessments/ monitoring for progressing or improvement of pneumonia.Assessment/monitoring of PEG tube site.Notification to physicians regarding the numerous elevated blood sugar levelsA1C lab results as requested by the physician.Delay in providing enteral nutrition and hydration Review was conducted of Resident #302's Blood Sugar's from 9-8-25 to 9-21-25. The 29 times that Resident #302's blood sugars were above 300. It can be noted there was a delay in facility intervention to address his consistently high and unmanaged blood sugar levels and it was unknown who was monitoring the levels closely:[DATE] at 16:54: 333XXX[DATE] at 15:30: 308XXX[DATE] at 11:38: 332XXX[DATE] at 15:40: 334XXX[DATE] at 08:16: 329XXX[DATE] at 08:20: 309XXX[DATE] at10:27: 315XXX[DATE] at 11:41: 341XXX[DATE] at 16:05: 300XXX[DATE] at 10:06: 435XXX[DATE] at 12:44: 455XXX[DATE] at 16:52: 385XXX[DATE] at 07:33: 409XXX[DATE] at 11:09: 419XXX[DATE] at 16:02: 383XXX[DATE] at 08:55: 304XXX[DATE] at 11:48: 333XXX[DATE] at 17:10: 359XXX[DATE] at 07:00: 315XXX[DATE] at 11:48: 339XXX[DATE] at 15:55: 315XXX[DATE] at 14:55: 301XXX[DATE] at 16:47: 386XXX[DATE] at 07:32: 378XXX[DATE] at 12:59: 406XXX[DATE] at 16:15: 392XXX[DATE] at 20:59: 386XXX[DATE] at 08:06: 510XXX[DATE] at 11:35: 449.0 On [DATE] at 1:50 PM and 4:18 PM phone contact was attempted with Nurse L regarding Resident #302. Nurse L was the nurse assigned to care for the resident the day he was transferred to hospital. There was no answer and voicemail was left. On [DATE] at 3:00 PM, an interview was conducted with CNA M regarding Resident #302. CNA M recalled the resident initially being a hoyer lift and then a two-person assist. Around the week of his discharge, he became increasingly weak and it was difficult to complete a transfer with just two people as he was dead weight. She stated he appeared to be more lethargic and unable to assist them with dressing/undressing or his transfers. EMS (Emergency Medical Services) Run Report [DATE]: .Call received on [DATE] at 14:06 and unit on scene at 14:18. dispatched to the above nursing home with lights and sirens for AMS (altered mental status). Upon EMS arrival the patient was lying in bed, diaphoretic, responsive to pain only, and an irregular breathing pattern. Staff stated that he has been like this for 4 days and has had a BGL sustained above 500 for those 4 days . He was assessed further and he was hyperglycemic and tachycardic. Wife states that he had 2 strokes within the last year leaving him with cognitive deficits and that hes usually AOX1 and talkative.He was placed on oxygen due to his irregular breathing pattern. An IV was attempted but he would pull away and flail his arm with each IV attempt.blood sugar 589. Hospital Records:admitted on [DATE]- [DATE] .Normally AO1 (alert and oriented x1) and talkative, now not speaking, breathing heavily. Sugar has been over 500 for last four days.according to EMS, patient has been persistently hyperglycemic over the course of the last 3 days.Ataxic breathing noted.who was admitted with altered mental status hypernatremia, hyperglycemia, and sepsis. On admission, he was found to be obtunded, febrile, tachypneic, and found to have severe hypernatremia with serum sodium of 168, Hyperglycemia (glucose >400), acute kidney injury (Cr peaked at 4.4), and E. coli bacteremia likely secondary to a urinary source (UA with pyuria, blood cultures positive for E. coli). Patients was also noted to have elevated troponins. Infectious Disease was consulted for management of E. coli bacteremia and recommended continuing IV cefepime and metronidazole. Hospice team was consulted. Patient placed on morphine drip and admitted to inpatient hospice for continued comfort care. Eventually patient expired on [DATE] at 1910. Called to see patient for unresponsiveness. On exam the patient did not respond to verbal or physical stimuli. Absent heart and breath sounds for over 1 minute. Absent peripheral pulses. Pupils are fixed and dilated; absent corneal reflex. Patient pronounced dead at 1910 on [DATE]. On [DATE] at 4:55 PM, an interview was conducted with the DON and Administrator regarding Resident #302. The DON explained on admission the nurse assigned to the resident inputs the medications into the system, it is verified by a 2nd nurse (typically their hall partner) and the 3rd check is the next shift or the Clinical Care Coordinator.The DON was asked to clarify what occurred with Resident #302's missed insulin order. He stated the practitioners spoke to the residents and he was not on insulin at home which is why the order was not followed. He continued they began an oral diabetic medication on [DATE] and Lantus on [DATE] with notification to the practitioners on [DATE] regarding the increased glucose levels. A review of Resident #302's blood sugars and they were over 300 ten times ([DATE]-[DATE]) without intervention by the facility. The facility was unable provide any other interventions implemented.The DON stated after their review they were unable to ascertain why Resident #302 was ordered Jevity versus Glucerna (listed on discharge medication list). It can be noted Glucerna is enteral nutrition formulated for patients with diabetes. The DON was asked if a 24- and 12-hour delay, respectively is satisfactory for enteral nutrition residents to be administer their tube feeding formula and hydration. The Administrator reported it should not have taken that long for the resident to be administered his tube feeding. The DON was uncertain as to why this occurred as there was no documentation related to the delay. The DON was asked if a resident is admitted on an antibiotic for pneumonia what would their assessment and monitoring of the resident entail. He stated there would be a handwritten short term care plan related to the antibiotic and diagnosis. Nurses would complete respiratory assessments that would include vitals, lung sounds, depths, and efforts. The assessment could be tied to the MAR or a separate progress note. He was asked to review Resident #302's record to find any documentation regarding his admitting diagnosis of pneumonia and antibiotic usage. The DON was unable to find any assessments, monitoring, short-term care plan or mention of the resident and his admitting diagnosis of pneumonia with antibiotic usage. The DON reported he was unsure as to how this was missed.The DON was queried if the PEG tube site is assessed for residents. The DON stated it is and there is an order that is inputted to prompt nurses to complete it. The DON was queried if there was any assessment documentation for the skin integrity, placement, etc. the DON reviewed Resident #302's record and was unable to locate any documentation regarding his site. Review was conducted of the facility procedure entitled, Standing Orders, reviewed [DATE]. The procedure stated, Hypoglycemia/Hyperglycemia. If blood Sugar > 400 Notify the Nurse Practitioner / Physician. Review was conducted of the facility policy entitled Assessment & Management of Diabetes, revised [DATE]. The policy stated, . To systematically manage and improve the care of residents with diabetes. To promote evidenced-based management of individuals with diabetes.Complete the nursing admission, medication review, laboratory testing as ordered, in addition to ordered blood sugars, finger-stick testing may be completed as a nursing judgement as indicated, communicating results to the health care practitioner as indicated. Review was conducted of the facility policy entitled, Interdisciplinary Documentation and admission Assessments, revised [DATE]. The policy stated, .Documentation: used in this reference to mean any written or electronically generated information about a resident that describes care or services provided. The medical record reflects assessment facts and other information relative to the course of treatment provided.

This citation pertains to Intake Numbers MI00153484 and MI00153865. Based on interview and record review the facility failed to promptly assess a change in condition for one resident (Resident #501) of two residents reviewed for pain, resulting in a delay in pain treatment and discovery of bilateral femur fractures. Findings include: Resident #501: On 6/20/2025 at 9:45 AM, Resident #501 was observed sleeping in bed and did not appear to be in any distress. Two CNA (Certified Nursing Assistants) in the room shared the resident is a two person assist and fully dependent on care. On 6/20/2025 at 10:42 AM, Maintenance Director O shared the Shower Aide informed her as they were lowering Resident #501 in the bed (via mechanical lift) it tilted forward. She explained the pivot point was too tight which caused the Hoyer to tilt, but they were able to safely lower the resident to the bed. On 6/20/2025 at 11:05 AM, CNA P stated she last showered Resident #501 on 5/27/2025 and was assisted by CNA H. As they were placing the resident back in bed (via mechanical lift) the legs on the machine closed and the lock was not properly functioning. The Hoyer hit CNA P in the shoulder and CNA H in the leg but the resident was unharmed. On 6/20/2025 at 11:50 AM, Family Member K shared during her visit on 6/1/25 she noticed he was rocking back and forth more intensely which indicated he was in pain. She pulled back his covered and observed his left leg was externally rotated and the right leg was extended straight out on the bed. She notified the nurse that she wanted him transferred to the emergency room for imaging and further treatment. His nurse completed her assessment, and he displayed pain and winced upon his foot being touched. Family Member K continued a CNA noticed his increase in pain and informed her that is why they did not get him up on 6/1/2025. She added the facility has been unable to provide an explanation as to how the bilateral fractures occurred. On 6/20/2025 at approximately 12:15 PM, a review was conducted of Resident #501's medical record and it indicated he admitted to the facility on [DATE] with diagnoses that included, Anxiety, Heart Failure, Dementia, Hypertension, Schizoaffective Disorder and upon admission back to the facility on 6/5/2025 fracture of right and left femur neck. Resident #501 is fully dependent upon staff to meet all his daily needs. Further review yielded the following: Progress Notes: 5/30/2025 at 05:36: Called sister with results per sister's request. Sister stated that resident has had ongoing lethargy x 2 days, and she is concerned since he had a mild fever yesterday and was pocketing food . 6/6/2025 at 12:48: Resident readmitted to facility r/t bilateral femoral fractures . There were no progress notes or assessments regarding Resident #501 increased pain and externally rotated leg and subsequent transfer to the Emergency Room. Care Plan: .Non-ambulatory .total assist with bathing, monitor for impaired skin integrity .assist of two, heard of bed should be elevated for comfort .Provide physical assistance to accept nutrition by mouth .identify sources of discomfort .(Resident #501) is unable to relay pain symptoms: use FLACC pain scale . Skin Assessment: 5/27/25: Residents skin remains warm, dry and intact. Mucous membranes are moist and pink. Skin turgor age appropriate. No open areas or bruising noted . Pain Assessments: 5/27/25 at 20:31: 0 5/27/2025 at 22:29: 0 6/1/2025 at 15:27: 0 ( this was the day his leg was discovered to be externally rotated by his sister). May 2025 MAR (Medication Administration Record): Resident #501 received Acetaminophen on 5/29/25 at 1737 and 5/30/25 at 1806 for pain. Resident #501 was not administered any other pain medications outside of these two times in May 2025. Hospital Discharge Records: Imaging: Acute complete slightly impacted angulated fracture at the right femoral head/neck junction .suspected acute complete fracture of the left femoral head/neck junction .acute significantly displaced fracture of both femurs at the head/neck junction . Orthopedic Surgery Consult Note: Patient is [AGE] year old male presenting with bilateral hip pain. Sister at bedside helping to provide collateral. Reports the past few days she has noticed patient being more uncomfortable .both extremities are externally rotated, left one appears slightly more shortened compared to the right one .Appears to have some discomfort with passive motion of his hips . RLE (right lower extremity): externally rotated . LLE (left lower extremity): Externally rotated . Hospital Course: This is [AGE] year old male with bilateral femoral neck fractures status post unknown mechanisms. Patient is nonambulatory at baseline and does not assist with transfers. Medicine was consulted for medical management. Thorough discussion and shared decision making with the patients family occurred and ultimate decision for nonoperative management was reached . Facility Investigation Conclusion: .during investigations with staff and residents, abuse, neglect or misappropriation was not identified. Based on interviews and record reviews it can be concluded that these injuries present at subacute and may be a result of previous injury and/or pathological in nature . On 6/20/2025 at 12:25 PM, Nurse E reported there was nothing communicated in report regarding increased pain for Resident #501. CNA S alerted her in the evening that she needed to assess Resident #501 but before she was not able to make it to the his room, his sister came to get her. Nurse E shared Resident #501's left leg had slipped off the pillow and resembled the shape of a frog leg. His sister asked why his leg was externally rotated when, from her observation it did not appear to be externally rotated. Nurse E slid her hand under his heel, and he winced and said ohhh ohhh. From there, their on-call practitioners were contacted and orders were provided to send him out. Nurse E was asked why there was no documentation regarding her assessment of resident. She reported she did not complete a progress note or the transfer documentation as she was extremely busy. She stated she knows that it was required of her and the DON (Director of Nursing) asked her a few times to complete the necessary documentation and she failed to do so. On 6/20/2025 at 1:10 PM, an interview was conducted with East Unit Clinical Care Coordinator C regarding Resident #501. She reported she was alerted that Monday that he went out to the hospital and was not aware his leg was externally rotated. Resident #501 is a mechanical lift and fully dependent on staff to meet their needs. She expressed he has always rocked back and forth but they had various levels on intensity. If his rocking was harder paced that would indicate a need for further assessment. On 6/20/2025 at 1:30 PM, CNA H stated Resident #501 does not move his legs and it takes two staff to care for him due to his stature. She stated she does not recall any reports from the 3rd shift regarding an increase in pain. She added he did rock back and forth and his sister indicated that was a sign of pain/discomfort. But the rocking was not consistent. CNA H expressed when providing incontinence care he would typically grimace when cleaning his genital area but she was not sure if that was due to him being sensitive or uncomfortable with a woman providing care. On 6/20/2025 at 1:55 PM. Nurse R reported Resident #501 rocked back and forth but it was not continuous throughout the day. She stated she noticed it more upon his return from the hospital as he would rock and makes and noise. On 6/20/2025 at 2:30 PM, CNA S was interviewed regarding Resident #501. The CNA stated on Saturday (5/31/25) when she arrived to work she noticed he was in increased pain. She noticed it as if they were getting him into his chair and tuning and repositioning him. CNA S shared he was grunting more and seemed uncomfortable. Additionally, she observed the left leg was bent into the right and that is atypical as he does not move his legs. She stated she had never seen him like that and informed the nurse about his increased pain and his leg, but was unsure if an assessment was conducted. CNA S reported it was discussed during their shift reports and passed along to 1st and 3rd shift. She said on Sunday evening the 1st shift aide did not get him out of bed due to his increase in pain. She added she heard that after this shower on 5/27/2025 is when the change in condition initially occurred and added that he was sensitive in his genital area during incontinence care. On 6/20/2025 at 4:05 PM, an interview was conducted with CNA G regarding Resident #501. Upon her arrival to work on that Tuesday evening (5/27/2025) she was informed in report that he had a shower in the latter part of 1st shift and slept the majority of 2nd shift. As CNA D and N were providing care to Resident #501's roommate he (Resident #501) woke up and they stated his eyes were rolling to the back of his head, he gritted his teeth, was grimacing and making noises like a horse. This was not his baseline and the aides alerted the nurse who after reviewing his chart stated his behavior was due to his diagnosis but to the aides this was far beyond his regular behaviors. CNA G stated she recognized he was in pain, as he was pressing his hands into his groin area and did not want to move them. On 6/20/2025 at 4:25 PM, CNA N shared she was providing care to the roommate of Resident #501. While they were doing care Resident #501 began to breathe harshly and she initially thought he was snoring. It sounded abnormal so they checked on him, they attempted to gain his attention, but he was not responding (he would look at the staff typically). Upon closer observation his eyes were rolled into the back of his head and when they tried to touch him he had a visceral reaction. He clenched his body, and he was breathing like they had never heard him do before. The noises he made were not normal either and it appeared he is was in agony. When they touched him, he began to cry and yelped out. CNA N alerted the nurse to his change and she completed a chart review and vitals. Upon her assessment she stated he has these movement due to his diagnosis, the CNA reported what they observed was not his baseline nor his typical movements. On 6/20/2025 at 4:50 PM, an interview was conducted with CNA D regarding Resident #501. She reported on the night of 5/27/2025 they were providing care to another resident and heard Resident #501 make an odd noise. When they pulled the curtain back, they saw Resident #501's eyes were rolling in the back of his head which lasted a few minutes. They were calling his name but he did not turn his head toward them like he normally would. He was pressing his body into the bed in a jerking movement. CNA D reported this was atypical of him. They did alert the nurse to this, but she attributed it to his current diagnosis set. On 6/23/2025 at 11:05 AM, Therapy Director J reported Resident #501 was fully dependent upon staff for his daily care. When he admitted to the facility he was fully dependent with max assist and that did not change during his stay at the facility. She added they did range of motion with his arms which they did see improvements with but they were completing the range of motion not him. Therapy did not work with his legs but looking at the notes there would not have been any gains made. On 6/23/2025 at 12:30 PM, Nurse I reported she did pick up 3rd shift a few weeks ago and recalled the aides reporting Resident #501 seemed to be in more pain than usual. She stated he was rocking back/forth and puffing his lips out and blowing. Nurse I shared she had never worked with him before and after chart review found his diagnoses that attributed to his rocking and blowing. Nurse I was asked if she administered pain medications and she stated she did not, as after he was repositioned, he appeared more comfortable. Nurse I stated she did not complete a progress note but added it on the 24-hour nurse report form. It can be noted from the investigation that it was discovered Resident #501 has an increase in pain and change in condition on the night of 5/27/25. Multiple staff indicated he was visibly uncomfortable and in increased pain days prior to his sister observing his leg being externally rotated. This information was relayed to nursing staff but there was no subsequent nursing progress notes or assessments which led to his delay in treatment and recognizing the change in condition. On 6/23/2025 at 5:20 PM, the Administrator and DON (Director of Nursing) shared Resident #501 was transported to the hospital for pain on 6/1/2025. They were not aware of his fractures until 6/4/25 and that is when the investigation began. They concluded from their investigation Resident #501 did not have a change in condition that would have alerted the staff to complete additional assessments. He was transferred to the hospital at the behest of his responsible party. The DON and Administrator were informed Resident #501 did have a change in condition the night of 5/27/2025 and continued until his sister recognized his externally rotated leg five days later. They reported they were unaware he had a change in condition as staff did not report it to them during their investigation. It can be noted an aide did mention in her statement she noticed his leg was turned oddly but there was no further follow-up regarding this statement. 6/24/2025 at 12:20 PM, Medical Director BB was asked if he received notification from the facility regarding increased pain and behaviors outside of the norm for Resident #501 on the night of 5/27/2025 or morning of 5/28/202, he stated he did not. Medical Director BB was informed the resident began to display increased pain that continued throughout the week and abnormal behaviors. He reported he was not made aware of this. Review was conducted of the facility policy entitled, Change in Resident Condition Physician /Family Notification, revised March 2021. The policy stated, .To ensure provision of the necessary care and services to meet the highest practicable physical, mental and psychosocial well being of each resident . The resident has a significant change in physical, mental, or psychosocial status i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications . On 6/24/2025 at 9:37 AM, the Administrator reported the facility does not have a policy for pain.

This citation pertains to Intake Number MI00149458. Based on observation, interview and record review, the facility failed to operationalize policies and procedures for skin/wound assessments and prevent the development of pressure ulcers for three residents (Resident #1, Resident #2, and Resident #3) of three residents reviewed for wound and skin care, resulting in Resident #1's development of facility- acquired Stage III pressure ulcer to the coccyx area, five suspected deep tissue injuries on the right and left feet and pain; Resident #2's development of facility-acquired right buttock pressure wound stage II and right ischium pressure wound stage IV, and the potential for wounds to go undetected and untreated, pain and wound infection. Findings include: A review of the facility document titled Wound Measurement, revealed, .Suspected Deep Tissue Injury-Purple or maroon localized area of discolored intact skin or bold-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue . and .Stage III-Full thickness tissue loss, Subcutaneous fat may be visible but bone, tendon or muscle and not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling . Resident #1: A review of Resident #1's medical record revealed an admission into the facility on [DATE] and readmission on 1/12/25 with diagnoses that included Alzheimer's disease, weakness, obesity, pressure ulcer of sacral region stage 3 with onset date 11/24/24, pressure-induced deep tissue damage of right heel with onset date 11/21/24, and pressure-induced deep tissue damage of left heel with onset date 11/21/24. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident had severely impaired cognitive skills for daily decision making and was dependent on staff for oral hygiene, toileting hygiene, bathing, personal hygiene, transfers and needed partial/moderate assistance to roll left and right. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no unhealed pressure ulcers/injuries. A review of the MDS dated [DATE] revealed the Resident had one unhealed pressure ulcer/injury that was documented at a Stage 3 pressure ulcer and five current unhealed pressure ulcers/injuries at Unstageable-Deep tissue injury and zero of the number of these unstageable pressure injuries that were present upon admission/entry or reentry. A review of Resident #1's Wound Measurement documentation in the medical record revealed the following: -Date 11/21/24, Observations: Site: Right outer foot, Type: Pressure, Length 1.5 cm (centimeters), Width 1 cm, Stage: Suspected Deep Tissue Injury. Assessment notes included: (Resident #1's name) has an unstageable wound to her right outer foot. She is severely cognitively impaired due to dementia. She relies on staff for repositioning. Her appetite is fair. She is incontinent of her bladder and bowels. Staff assist her to reposition prn (as needed) -Date 11/26/24, Observations: Site: right heel, Type: Pressure, Length 2.9 cm, Width 3.3 cm, Stage Suspected Deep Tissue Injury; Site: left heel, Type: Pressure, Length 0.7 cm, Width 0.2 cm, Stage Suspected Deep Tissue Injury; Site: Right Small Toe, Type: Pressure, Length 0.7 cm, Width 0.4 cm, Stage Suspected Deep Tissue Injury; Site: Right outer foot, Type: Pressure, Length 1.6 cm, Width 1.1 cm, Stage Suspected Deep Tissue Injury; Site: Left outer foot, Type: Pressure, Length 3.0 cm, Width 1.2 cm, Stage Suspected Deep Tissue Injury. Assessment notes included: (Resident's name) was assessed this morning while resting in bed. She has finished her breakfast (provided by staff) throughout the course of the assessment. During palpation over the areas of impairment (Resident's name) demonstrates brief symptoms of pain via facial grimacing, sharp intake of break (breath) and minor pulling away of the extremity. The right heel presents with a large, fluid filled blister and darkened tissue beneath. The discoloration on the outer edge presents as dark maroon in color and is flush with the skin. Similar presentation superior near the pinky toe. The left foot presents with a large area on the outside of the foot that is maroon around the edges and light in the center. This area is soft, boggy and retaining a small amount of fluid. The left heel also presents with a non-blanchable reddened area, boggy in nature. Since observing the discolorations (Resident name) has been provided with bilateral lower extremity prafo boots. She is using a pressure relieving mattress; however, a bariatric bed and air mattress have both been requested. She had recently been referred to skilled therapies for evaluation of her wheelchair positioning and a new wheelchair is in process of being obtained at the facility. -Date 12/6/24, Observations: Site: right heel, Type: Pressure, Length 2.9 cm, Width 3.3 cm, Stage Suspected Deep Tissue Injury; Site: left heel, Type: Pressure, Length 0.7 cm, Width 0.2 cm, Stage Suspected Deep Tissue Injury; Site: Right Small Toe, Type: Pressure, Length 0.7 cm, Width 0.4 cm, Stage Suspected Deep Tissue Injury; Site: Right outer foot, Type: Pressure, Length 1.6 cm, Width 1.1 cm, Stage Suspected Deep Tissue Injury; Site: Left outer foot, Type: Pressure, Length 3.0 cm, Width 1.2 cm, Stage Suspected Deep Tissue Injury. Assessment notes included: (Resident's name) was assessed this morning while resting in bed. During palpitation over the areas of impairment. The right heel presents with a large, fluid filled blister and darkened tissue beneath. The discoloration on the outer edge presents as dark maroon in color and is flush with the skin. Similar presentation superior near the pinky toe. The left foot presents with a large area on the outside of the foot that is maroon around the edges and light in the center. This area is soft, boggy and retaining a small amount of fluid. The left heel also presents with a non-blanchable reddened area, boggy in nature. Since observing the discolorations (Resident's name) has been provided with bilateral lower extremity prafo boots. She is using a pressure relieving mattress, however, a bariatric bed and air mattress have both been requested. She had recently been referred to skilled therapies for evaluation of her wheelchair positioning and a new wheelchair is in process of being obtained at the facility. The bariatric bed and air mattress had not been initiated when mentioned they were requested on 11/26/24. -Date 12/12/24, Observations: Site: right heel, Type: Pressure, Length 3 cm, Width 2.5 cm, Stage Suspected Deep Tissue Injury; Site: Right Small Toe, Type: Pressure, Length 1.5 cm, Width 0.4 cm, Stage Suspected Deep Tissue Injury; Site: Right outer foot, Type: Pressure, Length 1.6 cm, Width 1.1 cm, Stage Suspected Deep Tissue Injury; Site: Left outer foot, Type: Pressure, Length 3.0 cm, Width 1 cm, Stage Suspected Deep Tissue Injury. Assessment notes included: (Resident's name) has an unstageable wounds to her right outer foot, right foot near her small toe and Left foot. She is severely cognitively impaired due to dementia. She relies on staff for repositioning . -Date 12/19/24, Observations: Site: Coccyx, Type: Pressure, Length 4 cm, Width 3cm, Depth 0.1 cm Stage: III; Site: right heel, Type: Pressure, Length 2.9 cm, Width 3.3 cm, Stage Suspected Deep Tissue Injury; Site: left heel, Type: Pressure, Length 3 cm, Width 2 cm, Stage Suspected Deep Tissue Injury; Site: Right Small Toe, Type: Pressure, Length 0.7 cm, Width 0.4 cm, Stage Suspected Deep Tissue Injury; Site: Right outer foot, Type: Pressure, Length 1.6 cm, Width 1.1 cm, Stage Suspected Deep Tissue Injury; Site: Left outer foot, Type: Pressure, Length 3.0 cm, Width 1.2 cm, Stage Suspected Deep Tissue Injury. Assessment notes included: (Resident's name) has multiple pressure wounds to her body. She relies on staff to reposition her. Her appetite is poor and she relies on staff to feed her. She is incontinent of her bladder and bowels . Treatments are completed as ordered. She is on an alternating air mattress. -Date 12/26/24, Observations: Site: Coccyx, Type: Pressure, Length 4.5 cm, Width 3cm, Depth 0.1 cm Stage: III; Site: right heel, Type: Pressure, Length 2.9 cm, Width 3.3 cm, Stage Suspected Deep Tissue Injury; Site: left heel, Type: Pressure, Length 30.5 cm, Width 20.5 cm, Stage Suspected Deep Tissue Injury; Site: Right Small Toe, Type: Pressure, Length 0.75 cm, Width 0.43 cm, Stage Suspected Deep Tissue Injury; Site: Right outer foot, Type: Pressure, Length 1.65 cm, Width 1.1 cm, Stage Suspected Deep Tissue Injury; Site: Left outer foot, Type: Pressure, Length 3.0 cm, Width 1.2 cm, Stage Suspected Deep Tissue Injury. Assessment notes included: (Resident's name) has multiple pressure wounds to her body. She relies on staff to reposition her. Her appetite is poor and she relies on staff to feed her. She is incontinent of her bladder and bowels . Treatments are completed as ordered. She is on an alternating air mattress. -Date 1/16/24, Observations: Site: Coccyx, Type: Pressure, Length 5 cm, Width 4cm, Depth 3 cm Stage: III; Site: Right outer foot, Type: Pressure, Length 1.5 cm, Width 1 cm, Stage: Suspected Deep Tissue Injury; Site: Left outer foot, Type: Pressure, Length 1 cm, Width 1 cm, Stage Suspected Deep Tissue Injury. Assessment notes included: (Resident's name) was readmitted with 3 pressure areas. She relies on staff to reposition her. She is now receiving tube feeding. She is incontinent of her bladder and bowels. She is at risk for further break down due to the diagnosis of Alzheimer's, depression, CKD (chronic kidney disease), HTN (hypertension) and hypothyroidism. Staff reposition her prn. Staff assist her to complete meals and fluids. Staff provide incontinence care upon rising, before and after meals, at HS (nighttime) and prn. Treatments are completed as ordered. She is on an alternating air mattress. Prafo boots are applied at HS and PRN. There was a description of the coccyx wound but not of the other wounds. A review of the progress notes revealed a lack of assessment of the other wounds. A review of Resident #1's medical record revealed a lack of documentation of the resident being repositioned and a lack of documentation regarding the application of the Parfo boots. A review of Resident #1's Short Term Care Plan Wound and Skin, revealed a care plan on 11/20 for the problem Potential for infection as evidence by: Redness and Tenderness was indicated, handwritten 1.5cmx (by) 0.8 cm deep tissue injury to outer R (right) foot. The Approaches included, Medication as Ordered, Ensure culture ., Document presence of S/S (signs and symptoms) of infection ., Assess nutritional needs ., Ensure availability of fluids, Notification of authorized representative PRN, Assess pain level within EMAR, TX (treatment) as ordered, Document compliance with TX and response to TX prn, Consult Health Care Practitioner PRN, Weekly/prn measurement of the area, Positioning guidelines/other indicated approaches for this resident: (no items documented). No further guidelines or approaches were identified on this care plan for positioning or other indicated approaches. The Short Term Care Plan had documentation for vital signs, drainage, odor, surrounding warmth, surrounding edema and compliant with positioning guidelines. A review of Resident #1's Short Term Care Plan Wound and Skin, revealed a care plan on 11/24 for the problem Potential for infection as evidence by: Symptoms: Stage I pressure injury coccyx with similar approaches as listed above with approach #10. Add indicated additional approaches to protect the residents skin to the permanent plan of care: (no other approaches were listed.) Further documentation was requested of the Short Term Care Plans (STCP) after the Resident returned from the hospital but was not received prior to the exit of the survey. A review of Resident #1's care plan revealed a Focus (Resident's name) is at risk for altered functional mobility and ADL's . Intervention for Skin, after the onset of pressure ulcers, included: Skin Impairment Location: both feet, sacrum revision on 11/27/24 Heels elevated in bed as tolerated; Inspect heels with care and report to charge nurse as indicated **Parfo boots to be worn ATC (around the clock) as tolerated, with a revision date on 11/27/24. The care plan and STCP-for potential for infection, lacked the identification of the multiple facility acquired pressure ulcers, and STCP for each individual wound with a lack of person centered approaches/interventions for the prevention and healing of the wounds and updated as wounds developed. A review of Resident #1's weekly nursing skin assessments revealed a skin assessment done on 8/28/24 and then on 9/11/24, 14 days apart; 11/27 skin assessment completed then not completed until 12/9 which was 12 days since the last skin assessment completed, then completed on 12/18 which was 9 days since the previous skin assessment completed; skin assessment completed on 12/18 from which the Resident was discharged to the hospital on 12/30 which was nine days between the completed skin assessments and transfer to the hospital. On 1/17/25 at 11:25 AM, an observation was made of Resident #1 lying in bed. The Resident did not engage in conversation but nodded yes for surveyor to watch dressing change completed with Clinical Care Coordinator, Nurse E and Nurse K. The old dressing was removed from the coccyx wound, area opened, reddened. The old dressing had packing that was covered by a foam dressing. When asked about the packing, Nurse K indicated that the order was not for a packing but both Nurses indicated it was a good idea and Nurse E indicated she would have the treatment order changed. The area was cleansed and Santyl applied to the wound bed and covered with a border foam dressing. An observation was made of the air mattress on the bed with settings of normal pressure, #3 comfort level and float. On 1/21/25 at 10:34 AM, an observation was made with Clinical Care Coordinator (CCC), Nurse E of Resident #1's feet and heels. An observation was made of Resident #1's feet and legs with dry flaking/peeling skin on bilateral feet and lower legs. The right heel where the blister had been, had pink skin and was not open, the outer foot areas had a brownish area in the middle of the wound bed and were not open. An observation was made with Nurse E of the air mattress machine. The settings were on 3-harness/comfort level and the air circulation was on float. When asked why the air mattress was on float, the CCC reported that she was not aware of the difference between float and alternating, but indicated she thought it was the air flow through the mattress. The Nurse indicated that they put all the air mattresses on alternating, and it should not be on float. The Nurse switched it to alternating. Resident #2: A review of Resident #2's medical record revealed an admission into the facility on [DATE] and readmission on 3/20/23 with diagnoses that included diabetes, Alzheimer's disease, weakness, Fournier gangrene and pressure ulcer of right buttock with onset date 11/21/24. A review of Resident #2's MDS dated [DATE] revealed the resident had one Stage 2 pressure ulcer that was not present upon admission/re-entry, had a Brief Interview of Mental Status score of 11/15 that indicated moderately impaired cognition, was dependent on staff for transfers and needed partial/moderate assistance with mobility to roll left and right. A review of the MDS dated [DATE] for Significant change revealed the Resident had two Stage 2 pressure ulcers that were not present upon admission/re-entry and had one Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) that was not present upon admission/re-entry. A review of Resident #2's Short Term Care Plan Wound and Skin, revealed a care plan on 11/21 for the problem Potential for infection as evidence by: Purulent Drainage was indicated, handwritten unstageable wound to right buttock. The Approaches included, Medication as Ordered, Ensure culture ., Document presence of S/S (signs and symptoms) of infection ., Assess nutritional needs ., Ensure availability of fluids, Notification of authorized representative PRN, Assess pain level within EMAR, TX (treatment) as ordered, Document compliance with TX and response to TX prn, Consult Health Care Practitioner PRN, Weekly/prn measurement of the area, Positioning guidelines/other indicated approaches for this resident: (no items documented). No further guidelines or approaches were identified on this care plan for positioning or other indicated approaches. The Short Term Care Plan had documentation for vital signs, drainage, odor, surrounding warmth, surrounding edema and compliant with positioning guidelines. A review of Resident #2's Wound Measurement documentation in the medical record revealed the following: -Dated 11/25/24, Observations: Site: Left heel, Type: Pressure, Length, 1.8 cm, Width 0.6, Depth 0.1, Stage: II; Site: Right Ischium, Type: Pressure, Length 3 cm, Width 4.2 cm, Depth 0.1, Stage: II, Right Ischium irregular shaped similar to a star. Assessment notes: There is a wound on resident's right ischium in the skin fold which is believed to be some pressure likely but also moisture excoriation based on the shape of the wound. The wound has several thin areas that stretch away from the center base [due to skin folds] giving it a star like shape. It is superficial at this time. His heel continues to heel slowly and is better when he is compliant with elevating his legs. There are no s/s of infection. The wound bed remains beefy red. -Dated 1/20/25, Observations: Site: Right buttock, Type: Pressure, Length 1 cm, Width 3 cm Depth 0.2 cm, Stage II; Site: Left buttock, Type: denuded blister, Length 1 cm, Width 1cm, Stage II; Site: Right Ischium, Type: Pressure, Length 1 cm, Width 1 cm, Depth 0.1 cm, Stage IV. Assessment notes: [assessment completed today for 1/17/2025] Wound on his right ischium [also labeled as right gluteal fold in the treatment orders] continues to heal slowly 2' (secondary) to poor oral intake especially poor protein intake despite protein supplement . He wound edges are healed to a more round shape [from original star-like shape]. There is scant drainage noted on previous dressing and no drainage noted during cleansing. The wound edges are flush with wound bed which remains pink. The peri wound area is appropriate for ethnicity and remains intact. There is no slough or s/s of infection. He has been more compliant with bed rest however he has been requesting that staff position him with pillows to help float his sacrum coccyx are but not actually lying on his side. Resident encouraged and tolerated lying on his side with pillows behind his back and supporting his leg for a short period of time. His heels remains pink and intact [free from pressure of breakdown]. New pressure area observed over the weekend to the right of his gluteal fold/right buttock/sacrum. The area is unusually shaped linear curve. The wound bed is beefy red with scant sanguineous drainage noted. Left Buttock across the gluteal fold [from right buttock wound] is a denuded blister [skin firm and slightly gray from blister stretching out skin and reabsorbing] Peri wound is pink and intact also. A review of the wound measurement documentation revealed wound measurements and assessments completed on 11/25/24 and then on 12/6/24, 11 days apart. A review of Resident #2's Skin Assessments from 8/26/24 to present revealed the following: 8/26/24 completed. 9/15/24, 20 days past the last skin assessment completed on 8/26/24. 10/13/24 and then after 14 days, skin assessment completed on 10/27/24. 11/3/24 and then after 14 days, skin assessment completed on 11/17/24. 11/21/24 and then after 10 days, skin assessment completed on 12/1/24. 12/1/24 and then after 35 days, skin assessment completed on 1/5/25. On 1/21/25 at 1:15 PM, an observation was made with Resident #2 of the dressing change to the buttock and ischial pressure wounds completed by Nurse J. The Resident was lying in bed, answered questions and engaged in conversation. Nurse J had removed the old dressings from the three areas, right buttock, left buttock and ischial wound. The dressing on the right buttock had drainage, the Nurse had used a 4 x 4 to cleanse the wound than folded the 4 x 4 over and cleansed the wound on the left buttock. The Nurse used the same 4 x 4 to cleanse both wounds and had not changed gloves and performed hand hygiene between the cleansing of the two wounds. The old dressing on the left buttock did not have any drainage. The Nurse got another 4 x 4 and started to clean the wound on the right ischial prior to changing gloves and performing hand hygiene. The Nurse stopped and leaving the 4 x 4 at the ischial wound, changed his gloves. It was noted that a small open area was observed by the Nurse of the Residents scrotum. The area was cleansed, and ointment was applied. Resident #3: A review of Resident #3's medical record revealed an admission into the facility on [DATE] and discharged on [DATE] with diagnoses that included enterocolitis due to Clostridium difficile, rhabdomyolysis, diabetes, heart failure and kidney failure. A review of Resident #3's Skin Assessments revealed a skin assessment completed on 12/4/24 and then completed next 12 days later on 12/16/24 and then not completed again until 12/30/24, 14 days after. On 1/21/25 at 11:46 AM, an interview of conducted with the Director of Nursing (DON) regarding the lack of skin assessments for Resident #1 and 2 and lack of assessment of the wound for Resident #1. The DON indicated that CCC, Nurse E might have her wound notes from week to week that are not in the electronic medical record. The lack of consistent skin assessments on a weekly basis was reviewed. The DON stated, Yes, I can see that the documentation is a concern. When asked about the air mattress alternating versus float, the DON indicated that it should be alternating and when addressed that the care plan did not have the machine settings, the DON indicated that they put the settings on the pump and can add alternating to the sticker. On 1/21/25 at 2:30 PM, an interview was conducted with CCC, Nurse E regarding Resident #1's development of the facility acquired pressure ulcers. When asked about facility policy on doing weekly skin assessments, a review was conducted of the lack of consistent weekly skin assessments. The Nurse indicated skin assessments were to be completed weekly. The Short Term Care Plan (STCP) for wounds were reviewed. The Nurse indicated that there should be a STCP for each wound. A review of the STCP revealed there was not a care plan for each individual wound. The Nurse indicated that the Nurses look at the wounds daily, and document on the STCP. A review of the STCP revealed that documentation had not occurred daily, and the documentation was not available for all wounds. The documentation would be for that specific wound with one STCP for each wound. Resident #2's wounds were reviewed with CCC, Nurse E. The Nurse reported that the left buttock origination was 1/19/24 and stated, I followed up on it yesterday, a denuded blister. A review of progress notes revealed that the wound had not been documented on 1/19/24 and the Nurse stated, I don't know why she didn't mention it in her note. The ischium was reported as started 11/21/24. A review of the STCP dated 11/21/24 listed Unstageable wound to right buttock, but the wound measurement documentation revealed two wounds at that time to the left heel and right ischium. The Nurse reported that each wound should have their own care plan, and the nurses were to document daily on the wounds. A review of the documentation of symptoms revealed that they were not done daily. The Nurse indicated that they are kept in a binder and once the page is filled, it is uploaded into the medical record. A request for the STCP's for Residents #2 and #1 were requested. The Nurse reported that our expectations are daily for the dressing and short term care plan documentation, and that there should be one for each wound. When asked who sets up the STCP, the Nurse reported the charge nurses or who ever discovers it, they should be adding a STCP in. A review of Resident #2's medical record revealed not all wounds identified with a care plan. The dressing change completed on Resident #2 with Nurse J was reviewed. The concern of professional standards of care for infection prevention was discussed with CCC, Nurse E. Review of the facility policy Skin at Risk Assessment Documentation, Staging & Treatment last revised January 2020 revealed, Policy: It is the policy of this facility to assess resident risk factors for the development of impaired skin integrity .It is the policy of this facility to assess skin on a regular basis to determine whether changes in the patient's skin condition have occurred. Weekly measurements and narrative assessments are conducted on existing pressure injuries .9. Re-assess and measure a pressure ulcer a minimum of weekly .10. Document the appearance of the wound with considerations to the physical characteristics as applicable to the resident: a. Location b. Stage c. Size d. Color e. Peri-wound condition f. Wound edges g. Sinus tracts or tunneling h. Exudate i. Odor .

Based on observation, interview and record review, the facility failed to ensure an ongoing and comprehensive nutritional assessment and timely implementation and evaluation of person-centered interventions to prevent weight loss for one resident (Resident #94) of two residents reviewed, resulting in Resident #94 experiencing a severe weight loss and the likelihood for a decline in overall health status. Findings include: An observation of Resident #94 occurred on 2/12/24 at 11:53 AM in their room. The room was dark, with the light with the overhead lights off and the window shades closed. The Resident was in bed, with one leg half off the bed and their eyes open. The Resident had a gaunt appearance. When spoke to, Resident #94 made eye contact and smiled but did not provide a verbal response. The Resident's lips were noted to be dry with peeling skin. There were no beverages on the dresser next to the bed and/or the overbed table. Record review revealed Resident #94 was admitted to the facility on [DATE] with diagnoses which included heart disease and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment, dated 1/2/24, specified the Resident was severely cognitively impaired and required setup assistance for eating. The MDS further revealed the Resident did not have a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not receiving a therapeutic or mechanically altered diet. On 2/13/24 at 8:08 AM, Resident #94 was observed sitting in their wheelchair in the hallway of the facility. The Resident did not have a beverage within reach. Resident #94 was thin with a gaunt appearance. On 2/14/24 from 8:49 AM to 9:05 AM, Resident #94 was observed in the hallway of the facility sitting in their wheelchair across from the nurses' station, between the activity/dining room entrance and the medication cart. The Resident was unattended by staff, fidgeting, and did not have a beverage within reach. Review of Resident #94's care plans revealed a care plan entitled, Potential risk factors for nutritional concerns include lactose intolerance to milk to drink, dementia . has had a good appetite and enjoys meals in the dining room most days . has had some recent decline in intake, weight loss, change in swallow--goal for adequate intake, some weight gain as able (Initiated: 10/5/23; Revised: 1/29/24). The care plan included the goal, Adequate hydration will be maintained as evidenced by good skin turgor, moist mucous membranes, and no undesired weight loss and the following interventions: - Evaluate significant weight change with routine weights (Initiated: 10/5/23) - Honor Special Food Preferences: enjoys raisin bran, pizza, salad with ranch, honey on toast, juices, flavored water, cannot tolerate milk to drink (lactose) but can tolerate ice cream, and similar (Initiated and Revised: 10/5/23) - Nutritional Supplements per Dietary Assessment: 206 (fortified) juice with meals (Initiated: 10/5/23; Revised: 1/22/23) - Refer to ADL flow sheet for diet specifications (Initiated: 10/5/23) - Registered Dietician evaluation prn (as needed) (Initiated: 10/5/23) Review of Resident #94's EMR revealed another care plan entitled, Altered functional mobility and ADL's related to impaired cognition secondary to the diagnosis of Dementia . (Initiated and Revised: 10/5/23). This care plan included the interventions: - (Resident #94) needs redirection frequently . has meals in the EDR (dining room) . (Initiated and Revised: 10/16/23) - Diet: Pureed (Initiated: 1/28/24) - Eating: Provide set up assistance. Encourage intake, offer snacks (Initiated: 10/5/23; Revised: 10/12/23) - Liquids: Thin-regular, spout cup (Revised: 2/8/24) A review of Resident #94's weight documentation in the EMR was completed. As of 2/14/24, the Resident experienced a severe weight loss of 15.04% since their admission the facility and a 6.98% weight loss over the past month. Weight documentation in Resident #94's EMR included: - 10/5/23: 166.2 (pounds) lbs. - 11/8/23: 167.4 lbs. - 12/6/23: 163.4 lbs. - 12/11/23: 161.2 lbs. - 12/18/23: 157.6 lbs. - 1/4/24: 147 lbs. - 1/12/24: 151.8 lbs. - 2/14/24: 141.2 lbs. (15.04 % weight loss since 10/5/23 and a 6.98% Loss from 1/12/24) Review of Resident #94's Health Care Provider orders in the Electronic Medical Record (EMR) revealed the Resident's diet order was changed to Regular diet Pureed texture, Thin consistency on 1/28/24. From 10/5/23 to 1/27/24, Resident #94's diet order was, Regular diet Mechanical Soft texture, Thin consistency. The reason listed in the order for the change was suppose to be downgraded to pureed. There were no Healthcare Provider orders for nutritional supplements, weight monitoring, food intake monitoring, and/or diagnostic laboratory testing for nutritional status monitoring. Resident #94's EMR did not include task documentation of daily food and/or hydration intake (Food Intake Record-FAR). Review of Resident #94's Nutritional Services Quarterly Review dated 1/4/24 detailed the following, Current Weight: 157.6 . Weight Changes . None . regular diet, regular texture, thin liquids . appetite good, eating > 50% of meals . Nutritional Review . on a regular texture diet with thin liquids, and tolerates it well . has had some increased behaviors recently and appetite has not been as good . is eating better . Awaiting reweigh to ascertain weight changes but anticipate some loss . Goal for continued adequate oral intake as able remains at risk for weight loss . Assessment was signed on 1/5/24 by Certified Dietary Manager H. Note: Resident #94's EMR detailed they weighed 147 lbs. on 1/4/24. Review of Progress Note documentation revealed the following: - 10/5/23 at 12:58 PM: Interdisciplinary Documentation . admitted to our facility this morning . came from home . alert to person and situation. He has dementia/Alzheimer's and is confused . independent for transfers and dependent upon staff for ADL cares . is incontinent . is on regular diet with thin liquids, sits at assist table in dining room and requires encouragement with eating, mostly to stay on track . - 12/23/23 at 10:27 AM: Interdisciplinary Documentation . (Spouse) called today and expressed concerns of resident sleeping too much . states when here for the Christmas party the other day (Resident #94) kept falling asleep in their chair and seemed to have little to no interest in eating . - 12/23/23 at 2:36 PM: Interdisciplinary Documentation . CNA (Certified Nursing Assistant) report that resident did wake up and have some breakfast this morning, states had 25-50% of breakfast with assistance and for lunch ate about 25% but kept closing eyes . did awaken easily by the call of name but was holding the food in mouth. Lots of encouragement was provided during meal . - 1/22/24 at 8:12 AM: Interdisciplinary Documentation . weight is trending down with decreased oral intake. Staff assisting as needed with intake. Variable intake likely r/t (related to) recent behaviors . Recommend addition of 206 juice with meals for weight maintenance. Notified therapy of recent pocketing, possible swallowing difficulty. - 1/28/24 at 6:07 AM: Interdisciplinary Documentation . Per report, resident was having trouble chewing foods. Diet was downgraded to pureed. Diet slip filled out and gave to kitchen . - 1/29/24 at 12:35 PM: Interdisciplinary Documentation . diet was downgraded to puree texture over the weekend. Change in medications done--note recent weight loss, supplements now in place. Goal for weight maintenance as able or slow gain. Updated plan of care. - 2/7/24 at 7:33 AM: Interdisciplinary Documentation . continues with poor oral intake despite encouragement and assist as well as alternatives offered . refuses to open mouth for staff, often at mealtime, sometimes taking a few bits, sometimes no intake at all. Discussed oral intake with unit coordinator. Supplements in place, but poor intake overall. - 2/8/23 at 12:45 PM: Interdisciplinary Documentation . Nursing staff requested spout cup with meals for support for independent intake. Updated menus. Further review of Resident #94's EMR revealed documentation of behaviors throughout their stay in the facility including increasing behaviors on 10/16/23. An interview was completed with Therapy Manager I on 2/14/24 at 10:38 AM. When queried if Resident #94 was receiving any therapy services, Director I stated, Not on therapy. When asked if the Resident had been evaluated for therapy services, Director I replied, (Resident #94) does not have a med B benefit for therapy and revealed the Resident had never been evaluated and/or picked up by therapy services due to lack of insurance coverage. On 2/14/24 at 12:43 PM, an interview was conducted with Certified Dietary Manager H. When asked who had completed Resident #94's nutritional assessments, Manager H revealed they completed resident nutritional assessments. When queried if the facility had a Registered Dietician, Manager H responded that a Registered Dietician was available but not present in the building. When queried regarding Resident #94, Manager H revealed they were aware of the Resident's significant weight loss and stated, Staff started feeding (Resident #94) within the past month. With further inquiry regarding the weight loss, Manager H stated, (Resident #94) had an increase in behaviors and their intake started going down. Manager H was asked when the Resident started to display increased behaviors with decreased intake and replied they were unsure of the timeframes. When queried food and fluid intake is documented in the EMR, Manager H replied, Nursing started documenting in the notes this past week. A review of progress note documentation was completed with Manager H at this time. Review revealed inconsistent documentation which included breakfast and lunch intake on 2/7/24, 2/8/24, 2/12/24, and 2/13/24. When queried if there was a task for intake documentation, such as a FAR, Manager H reviewed the EMR and revealed a task for intake monitoring/documentation was not active. Manager H stated, I can trigger that (intake task documentation/FAR). When asked why intake monitoring was not already in place for a Resident with significant weight loss, Manager H replied, I can't answer that. Manager H then stated, I just triggered it (EMR task for intake monitoring documentation). When queried how often Resident #94 is supposed to be weighed, Manager H replied, Weekly. When queried why weekly weights were not completed in the EMR, Manager H reviewed the EMR documentation and confirmed weights had not been completed weekly but did not provide further explanation. When asked if Resident #94's weight loss was unintended, Manager H confirmed it was. Manager H was then asked what interventions had been implemented and/or attempted to prevent the Resident #94 undesired weight loss and stated, 206 juice supplement three times a day was added 1/22/24. When queried who administered the supplement, Manager H disclosed dietary services place it on the Resident's food trays. When asked how they monitored if Resident #94 received the 206-juice supplement, if they drank it, and how much they drank, Manager H replied they did not know. Manager H revealed there was no current documentation of intake. When asked if Resident #94 received other beverages on their food tray, Manager H responded, Yes. Manager H was then asked how they would distinguish if the Resident consumed the 206-supplement juice or another beverage when reviewing the intake documentation task which they triggered in the Resident's EMR and revealed they would not know. Manager H then stated, I am adding it to the MAR. When queried if nursing staff will administer the supplement and document on the MAR, Manager H specified the supplement will continue to be served on the Resident's food trays prepared by dietary staff. When queried regarding the facility procedure for administering, monitoring and documenting nutritional supplement intake, Manager H indicated nursing staff will have to follow up with (Resident #94's) aide when documenting if Resident #94 received and drank the supplement. When queried what Resident #94's Usual Body Weight (UBW) was, Manager H revealed they believed it was their admission weight. Manager H was then asked what Resident #94's total caloric needs were, if their need had changed following their weight loss, and location of documentation. Manager H reviewed the Resident's most recent nutritional assessment and stated, Not in the assessment. With further inquiry regarding when they first identified the Resident's weight loss, Manager H stated, On January 4th, I was waiting for a reweight. When asked to explain the process for a reweight, Manager H revealed they were waiting until the weight obtained the following week. When queried if they thought the weight was inaccurate, Manager H indicated did. Manager H was then asked why they would wait a week to obtain another weight if they thought the weight was inaccurate and revealed they always wait until the next weekly weight prior to making changes. Resident #94's Nutritional Services Quarterly Review assessment dated [DATE] was reviewed with Manager H at this time. When queried regarding documentation on the assessment specifying the Resident had a good appetite and was eating greater than 50% of their meals when intake was not documented consistently and a FAR was not in place, Manager H replied they thought intake looked good from nursing notes. All of Resident #94's documented weights were reviewed with Manager H at this time. When queried why no weights were obtained between 12/18/23 (157.6 lbs.) to 1/4/24 (147 lbs.) and for the week of 11/12/23 to 11/18/23, Manager H was unable to provide an explanation. Review revealed Resident #94 experienced a 5.85% weight loss from 11/8/23 (167.4 lbs.) to 12/18/23 (157.6 lbs.). Manager H verified the Resident's weight loss began in December 2023. When queried if they had identified, assessed, and documented on the weight loss in December, Manager H reviewed the EMR and confirmed they had not documented a note or assessment. When asked, Manager H revealed they need to improve their documentation. When queried if they implemented any interventions in December 2023, Manager H reviewed the care plan including the care plan history and revealed there were no new interventions. With further inquiry regarding interventions, Manager H revealed the only interventions that had been added to the care plan were the 206-juice supplement with meals on 1/22/24 and a diet downgrade on 1/28/24 to pureed. When queried why Resident #94's diet was downgraded, Manager H revealed nursing staff had verbalized concerns that Resident #94 was pocketing food. When queried if a speech evaluation was completed, Manager H indicated they did not know. When asked if they had attempted fortified foods, Manager H revealed they had not. When asked the rationale, Manager H did not provide a response but indicated they would add fortified foods. When queried if the Resident received a snack, Manager H revealed the Resident is able to have a snack but since it is not ordered, a snack is not specifically prepared for them. When queried how they monitor if the Resident is eating a snack for their nutritional needs, Manager H revealed they do not. When asked if they had attempted finger foods, favorite foods, stimulation, assistance, and/or modifying the times Resident #94 eats, Manager H revealed the only other intervention in place was nursing staff assistance to eat when needed. When queried regarding the quarterly MDS assessment dated [DATE] specifying the Resident had not had a weight loss, when a recent weight had not been completed and the Resident had a 5.85% loss from 11/8/23 to 12/18/23, an explanation was not provided. When queried if they were able to see a concern related to Resident #94's weight loss including lack of timely interventions and comprehensive evaluation/reevaluation, Manager H revealed they did and verbalized understanding. An interview was completed with the Acting Director of Nursing (DON) Registered Nurse (RN) A on 2/14/24 at 3:01 PM. When queried regarding the reason for Resident #94's admission, RN A revealed the Resident's family were no longer able to care for them at home. When queried if Resident #94 was at risk for weight loss upon admission, RN A indicated they were. RN A was informed of observations of Resident #94 without a beverage in reach. When asked, RN A indicated the Resident should have a beverage available and in reach. Resident #94's weights and weight loss were reviewed with RN A at this time. When queried regarding interventions implemented to prevent weight loss, RN A stated, I do know the girls (staff) assist (Resident #94) with meals as needed. RN A was queried regarding facility policy/procedure related to obtaining resident weights and stated, Most of our weights are weekly. When asked why Resident #94's weights were not completed weekly, RN A was unable to provide an explanation. When queried if it is reasonable to make follow up on weights, RN A stated, That is reasonable. RN A was then queried regarding the Resident's diet being downgraded to pureed without having a speech therapy evaluation. RN A indicated a therapy screen should have been completed. After reviewing the EMR, RN A revealed they were unable to locate documentation of a speech therapy screen related to possible pocketing when eating. When queried if Resident #94 receives snacks and how staff monitor if they consumed the snack, RN A stated, If it is ordered, then it would be charted on. RN A reviewed Resident #94's EMR and stated, Not there. When asked, RN A confirmed the lack of documentation of Resident #94's intake. When queried how the Resident's nutritional status is accurately and comprehensively monitored when their intake is not documented, RN A confirmed it could not. When queried regarding the lack of interventions, RN A stated, I agree. An interview was completed with the facility Administrator on 2/15/24 at 8:10 AM. When queried regarding Resident #94's severe weight loss including lack of monitoring, assessment, and implementation of interventions, the Administrator revealed they were aware of the concern and agreed. The Administrator verbalized the concern would be addressed. Review of facility policy/procedure entitled, Weight Management (Effective April 2015, Revised: (Blank) revealed, Purpose: To assist the resident to maintain acceptable parameters of nutritional status such as body weight and protein levels . 5. In the event of a patterned or significant unplanned weight loss . the IDT is responsible for assessing and implementing individualized interventions . 7. Improving intake via wholesome foods is generally preferable to adding nutritional supplementation . Examples of interventions to improve food/fluid intake include: a. Fortification of foods. b. Offering smaller, more frequent meals. c. Providing between-meal snacks or nourishments. d. Increasing the portion sizes of a resident's favorite foods and meals; and providing nutritional supplements. 8. The nutritional plan of care is evaluated a minimum of quarterly and as indicated to determine if current interventions are being following and if they are effective .

Based on observation, interview, and record review, the facility failed to 1.) assess and monitor for urinary/catheter changes for Resident #33 and prevent facility acquired urinary tract infections for three (3) Residents (#9, #76, #95) resulting in the likelihood for bladder injury, cross contamination and facility acquired urinary tract infections requiring antibiotic therapies. Findings Include: Record review of facility 'Urinary Tract Infection; Catheter Associated UTI's (CAUTI's) Prevention & Surveillance Guidelines' policy dated 10/2011 revealed it is the policy of the facility to apply evidenced-based guidelines to alterable risk factors in the development of nosocomial Urinary Tract Infections (UTI's) . Resident #9: In an interview and observation on 10/31/22 at 10:27 AM with Resident #9 during the entrance tour of the survey revealed a catheter with large amount of urine, estimated over 1000cc hanging at the bedside with a leaf privacy flap. In an interview with Resident #9 about his catheter revealed about the catheter, the resident stated that it hurts sometimes and gets plugged up. Resident #9 stated that he had a Urinary Tract Infection (UTI) and it hurt and bleeds at times. Record review of Resident #9's Urinalysis lab results dated 10/25/2022 revealed a positive result. Record review of Resident #9's Medication Administration Record (MAR) for the month of October 2022, revealed that Keflex (antibiotic) 500mg oral was started for infection. Observation and interview on 11/02/22 at 07:51 AM of Resident #9 while lying in bed revealed Observed urinary catheter with a bag with privacy flap, bag is full 1300 cc and touching the floor. Resident #9 was able to raise his bed to get the catheter off the floor but left the bed up higher than usual. Resident #9 stated that no one (staff) has given him water yet or emptied his catheter bag. In an interview on 11/02/22 at 08:40 AM with the Director of Nursing (DON) was asked about the emptying of catheter bags? The DON stated that catheter bags should be emptied at the end of each shift. The first shift started at 6:00 AM, the state surveyor questioned the 1300 cc estimated amount in the catheter bag of Resident #9, and that the catheter bad was laying on the floor. The DON stated that the catheter bag should not be touching the floor and cross contamination was brought up from dirty floors to catheter bag, and no there should not be that much urine in the bag this early in the morning. The DON revealed that Resident #9's catheter bag has a filter due to his urine sediment is heavy in the urine and if the bag is full then the filter cannot filter out the sediment. In an interview on 11/02/22 at 01:48 PM with the Infection Control Preventionist (RN/ICP) T stated that Resident #9 did have a Urinary Tract Infection (UTI) with catheter in place. Record review of infection control logs revealed that in March 2022, Resident #9 did get a UTI culture was Proteus Mirabilis and E. Coli and had a catheter in place. Now, in October 2022 he has another UTI with Klebsiella pneumonia and was placed on Keflex. Yes, it was facility acquired. He has had repeat UTIs the catheter is changed when the physician orders it. We collect the urine sample with a sterile syringe, and we follow Lippincott 8th edition. In an interview on 11/02/22 at 4:21 PM with the Director of Nursing (DON) Follow up: The DON stated that she did go down to Resident #9's room, and you were right the catheter bag is 2000 cc bag and it did have 1300cc and was hanging low. His Certified Nurse Assistant (CNA) D was talked to about why it was not emptied. A foley bag It should be emptied 1 time a shift and this one was not. Record review on 11/03/22 at 09:03 AM of Certified Nurse Assistant (CNA) D paper form 'Performance review and Clinical Skills Check' dated 9/1/2022 and signed by the Infection Control Preventionist as checked off as Satisfactory. Resident #76: Record review of Resident #76's Minimum Data Set (MDS) quarterly dated 9/6/2022 revealed a [AGE] year-old female with brief interview of mental status of Zero. Resident #76's medical diagnosis included: hypertension, peripheral vascular disease, non-Alzheimer dementia, depression, psychotic disorder, weakness, difficulty walking, and low back pain were some of the diagnoses. Record review of section G: Functional status revealed toileting and personal hygiene were coded as #4 (total dependence- full staff performance every time #2 One-person physical assist. Section H: Bladder and Bowel: always incontinent of both urine and bowel. Record review on 11/01/22 at 4:32 PM of Resident #76's urinalysis dated 9/16/2022 result was positive. Record review of Resident #76's Medication Administration Record for the month of September 2022, Keflex 500mg oral three times a day was started on 9/18/2022 for urinary tract infection. In an interview on 11/0/22 at 01:35 PM with the Infection Preventionist T revealed that Resident #76's in September 2022 had a urinalysis cultured results of E. Coli and was put on Keflex antibiotic. The Infection Preventionist T revealed that this was a facility acquired Urinary Tract Infection, and that there was no Peri care education was done at that time. Resident #95: Record review of Resident #95's Minimum Data Set (MDS) quarterly dated 8/23/2022 revealed an [AGE] year-old female with brief interview of mental status of Zero. Resident #76's medical diagnosis included: coronary artery disease, hypertension, septicemia, urinary tract infections, non-Alzheimer dementia, anxiety, depression, and psychotic disorder were some of the diagnoses. Record review of section G: Functional status revealed toileting were coded as #3 (Extensive assistance- full staff provided weight bearing support) Support provided: coded #3 Two-person physical assist. Section H: Bladder and Bowel: frequently incontinent of both urine and bowel. Record review of Resident #95's progress notes revealed that in the month of July 2022 Resident #95 had a change of condition with lethargy. Record review of Resident #95's July 2022 Medication Administration Record (MAR) revealed on 7/28/2022 Resident #95 received Rocephin 1 gram Intramuscular. Record review of the Infection Control July antibiotic log revealed that there was record of the antibiotic injection noted. Record review of Resident #95's urinalysis on 7/29/2022 revealed positive for E. Coli and started antibiotic. Record review and interview on 11/02/22 at 01:42 PM with Infection Preventionist T revealed that Resident #95's had a facility acquired urinary tract infection, she was hospitalized , came a back to the facility with Peripheral Inserted Central Catheter (PICC) line and ertapenem intravenous (IV) antibiotic daily. The Infection Preventionist T stated that the organism was e. Coli. The state surveyor asked about the last facility Peri care education was given to staff. Infection Preventionist T stated that the 1st week of October 2022 with skills check week. Interview with Infection Preventionist T revealed that Resident #95 had a Urinary Tract Infection (UTI) in July 2022 with lethargy and hospitalization . The Urinalysis came back on 7/29/22 culture positive for E. Coli. Resident #95 came back from hospital stay in first week of August on Meropenem IV with PICC line. Infection Preventionist T stated that yes it was facility acquired. The Infection Preventionist T looked through large white binder for peri care education. There was none done, but it was covered in the October 2022 skills labs. There was no return demonstration observed of staff. Rocephin antibiotic 1 gram IM was given on 7/28/2022, but I didn't get it on the antibiotic log. The physician did a risk vs benefits note in the progress notes. 39059 Resident #33 On 10/31/22, at 12:33 PM, Resident #33 was lying in their bed. They had a urinary catheter hooked to the bed frame. The urine in the tubing was noted to have an orangish red color. There was a strong urine odor to the room. On 11/01/22, at 12:35 PM, an observation along with Nurse Y of Resident #33's catheter was observed. The catheter tubing had sediment and blood noted. Nurse Y was asked what they saw and Nurse Y stated, cloudy urine with sediment and Nurse Y was asked if they saw blood at all and Nurse Y stated, yes, it looks like bloody sediment. Nurse Y was asked to pull the blanket back for an observation of the catheter insertion site which was through the lower abdominal wall. The site had bloody drainage and no dressing noted. On 11/01/22, at 12:59 PM, Infection Control (IC) Nurse T entered Resident #33's room to assess their urine color and odor. IC Nurse T looked at the catheter bag and stated, they saw hematuria (blood in urine.) IC Nurse T assessed the catheter tubing and was asked what they saw and IC Nurse T stated, bloody sediment. IC Nurse T was asked if they smelled a strong urine odor in the room and IC Nurse T stated, yes, I will get ahold of the doctor. Most likely change the catheter and get a urine. On 11/02/22, at 3:30 PM, a record review of Resident #33's electronic medical record revealed a readmission on 6/24/2022 with diagnosis of Urinary Tract Infection (UTI), MS and Hemiparesis. Resident #33 required extensive assistance with all Activities of Daily Living (ADL) and had severely impaired cognition. A review of the physician orders revealed Change indwelling catheter only as needed per physician orders based on clinical indicators such as infection, obstruction or sediment. Start Date 6/27/2022 . An added physician order to obtain a urine sample was added during survey of . Obtain UA (urinalysis) with culture if indicated one time only .Start Date 11/1/2022 . A review of the progress notes revealed 11/1/2022 14:59 (2:59 PM) . Suprapubic catheter was replaced this afternoon in compliance with facility protocol and quality measures as the previous indwelling catheter was no longer functioning as intended. Orders . for catheter replacement were followed, and the resident tolerated the procedure will. Catheter was placed, urine return was obtained, and catheter was stabilized to the proximal lower extremity. Urine specimen was obtained for culture and sensitivity . On 11/03/22, at 10:26 AM, The Director of Nursing (DON) was asked what the expectation of the nurse of a resident who has a urinary catheter and the DON stated, the expect the nurses assess the catheters. On 11/03/22, at 12:15 PM, a record review of the facility provided UA result for Resident #33 resulted the following: . Culture received . OUT OF RANGE RESULT REVIEW .UA COLOR ORANGE . UA APPEARANCE TURBID . UA BILIRUBIN SMALL . UA BLOOD LARGE . UA PROTEIN 100 . UA NITRITES POSITIVE . UA LEUKOCYTES ESTERASE LARGE . UA WBCS >100 . UA RBCS >100 . UA SQUAMOUS EPTHELIAL CELLS 10-25 . UA BACTERIA 4 + .

This Citation Pertains to Intake Numbers MI 719 and MI 004. Based on interview and record review, the facility failed to complete skin and wound assessments and provide interventions to prevent a pressure ulcer from worsening for one resident (Resident #1) of three residents reviewed for pressure ulcers, resulting in Resident #1 developing a Stage IV pressure ulcer that required hospitalization , IV antibiotics and surgical intervention. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment, dated 05/26/21, revealed that the resident had severe cognitive decline with a Brief Interview for Mental Status (BIMS) score of 3/15. Resident #1 needed extensive-to-total assistance with all care including 2-person assistance with bed mobility and transfers. Section M of the MDS assessment revealed the resident had a Stage 3 pressure ulcer (National Pressure Injury Advisory Panel- NPIAP Pressure Injury Stages, 2016, 'Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence . The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear . Stage 3 Pressure Injury: Full-thickness skin loss-Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present . The resident was discharged to the hospital from 7/28/21-8/2/21 and again on 8/11/21 without readmission. A review of a Hospital, After Visit Summary, dated 7/28/21-8/2/21 revealed: Admitting Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the physician orders identified an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the medical record, assessments, progress notes and documents for Resident #1, did not reveal any documentation of a wound on 3/5/21. The resident was transferred to the hospital for a change of condition from 2/11/21-2/23/21. An Admission Assessment, dated 2/23/21 and locked 2/24/21 provided: . Resident's skin is warm dry and intact . some bruising on right and left antecubital (arm) areas . right forearm has 2 cm x 2 cm skin tear that is scabbed over . No open areas noted on coccyx and is clean and intact . A review of the resident's Skin Assessments revealed the following: A skin assessment was completed on 2/26/21 and not again until 3/10/21: almost 2 weeks later. 3/10/21: Observations: (there is no assessment data; no site; no type of wound; no length, width, depth or stage.) . Assessment Notes: (Resident #1's) skin is intact . Skin clean and dry. Open area to coccyx. Dressing Intact. The assessment was contradictory and provided no specific information on what the wound looked like. It was the first reference to the coccyx wound since the 3/5/21 treatment order. 3/15/21: Observations: Site-Sacrum; Type-Pressure; Length 5 cm; Width 4 cm; Depth 0.1 cm; Stage 3; Left Gluteal fold, Pressure, 1.5 cm x 1.5 cm x 0 cm, Stage 2 (NPIAP, 2016; Pressure Injury Stages: Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis . the wound bed is viable, pink or red, moist and may also present as an intact or ruptured serum-filled blister . These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel .) . at risk for altered skin integrity due to his decreased mobility and impaired cognition . He relies on staff to reposition him . An alternating air mattress will be applied to his bed. Staff assist him to reposition (as needed) . A review of the Care Plans for Resident #1 provided, . at risk for altered functional mobility and ADL's (activities of daily living) . date initiated 8/26/20 and revised 8/11/21 with Interventions: Skin: Apply barrier cream with incontinence care (as needed); inspect skin with bathing and care; report impaired skin integrity to charge nurse, dated 8/26/20; Skin: Heels elevated in bed as tolerated; Inspect heels with care and report to charge nurse as indicated. 3/15/21- Alternating air mattress applied to bed, date initiated 8/26/20 and revised 3/15/21 . There was no additional mention of interventions for prevention of skin breakdown or repositioning to prevent further breakdown. A review of the resident's Care Plan titled, . potential risk for impaired skin integrity related to: history of fragile skin, poor nutritional intake, impaired functional mobility and or incontinence . date initiated 8/26/20 and revised 8/26/20 with Interventions: Measure open areas upon admission, weekly, prn (as needed), date initiated 8/26/20 and Skin inspections with am/pm care and showering report abnormal to the charge nurse, date initiated 8/26/20. The Skin Care Plan had not been updated with new interventions to aid in preventing skin breakdown since 8/26/20. A review of a document for Resident #1 titled Wound Measurement,, dated 8/6/21, identified the following: Site: Sacrum, Pressure, 7 cm length x 6 cm width x 3 cm depth, Stage 4 (NPIAP, 2016, Stage 4 Pressure Injury: .Full- thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone . ); Sacrum - area is undermining at 12 o'clock 4 cm; Treatment goal: Undeterminable; . Wound bed: Eschar- dry, black/brown, dead tissue; Exudate (drainage): Sanguineous- bloody type; Assessment Notes & Review of Treatment Effectiveness: . at risk for altered skin integrity due to his decreased mobility and impaired cognition . He relies on staff to reposition him. He has been compliant with repositioning . relies on staff to feed him . alternating air mattress in place. Staff assist him to reposition prn (as needed) Staff float his heels to provide pressure relief . The interventions mentioned 8/6/21 were the same as those on the Skin assessment dated [DATE] and Care Plans dated 8/26/20 and 3/15/21. The facility repeatedly mentioned repositioning prn (as needed), with no specifics for what that meant. New interventions were not initiated on the Care Plan to aid in further skin breakdown, as on 8/6/21 a left heel wound was identified as a Stage 2 and the Coccyx/sacral wound was now a Stage 4 with dead tissue and an indeterminable treatment goal. A further review of the physician orders indicated the wound treatment had varied and a nutritional supplement was added 8/3/21 prn as needed, but additional interventions were not identified. On 8/24/21 at 12:04 PM, Confidential Person E was interviewed and provided, He had an ulcer on his back and on his heel. He did not have those when he went there. He had to have the ulcer cleaned out at the hospital. They said it went to the bone. The doctor at the hospital asked what he would want to have done and I said, 'He would not want to die of a bed sore. The doctor said, 'Of course not.' He has been in the hospital twice for the same sore. About a month ago the nurse said, 'I have to pack the wound (place gauze inside it). He now has a PICC line (Peripherally inserted central catheter) for 6 weeks of antibiotics. This last time he was in the hospital for about a week. He is in a different facility now. He was so uncomfortable. He would say he hurt down there. On 8/25/21 at 1:51 PM, during an interview with Physician H about Resident #1's wounds it was revealed, His sacral wound was pretty big. There were some areas of necrosis (dead tissue). It was painful for him to move. It took about 3 people. He also had lower extremity wounds. He'd gone to the hospital, and they debrided (surgically removed the dead tissue). He wasn't doing very good towards the end before he went to the hospital. An interview with Corporate Nurse O on 8/25/21 at 3:00 PM provided, I saw the same thing you did. It looks like an order was written on 3/5/21, but they didn't assess the wound until 3/10/21. Nurse O was asked how often the Skin Assessments were completed and she said, At least weekly. On 8/26/21 at 12:05 PM, Unit Manager A was interviewed about the 3/5/21 wound order for Resident #1 and stated, He was on the west unit when I wrote that order. I was helping out. I believe on of the Charge Nurses told me about it and I put the order in for them. The first time I saw the wound was on 3/15/21 when he came to my unit (east). The Manager was asked how often the nurses should complete Skin Assessments and said the Skin Assessments were complete once or twice a week and they were scheduled with the resident's showers. A review of the facility policy titled, Skin at Risk Assessment: Documentation, Staging & Treatment, dated August 2002 and revised 1-2020 revealed, It is the policy of this facility to assess resident risk factors for the development of impaired skin integrity and intervene as indicated . to assess skin on a regular basis to determine whether changes in the patient's skin condition have occurred . To provide prompt identification and intervention . and provide evidenced based guidance on effective strategies to promote pressure ulcer healing . Individualize the resident's goals and interventions .

Based on observation, interview and record review, the facility failed to ensure restorative nursing services were provided and monitored per residents plan of care for 7 residents (Residents #16, #17, #27, #35, #57, #69 and #111) of 12 residents reviewed for restorative services, resulting in pain, worsening contracture and decline. Findings Include: Resident #17 According to admission face sheet, Resident #17 was a [AGE] year old female admitted to the facility on [DATE], readmitted [DATE], with [DIAGNOSES REDACTED]. Per observation, Resident #17 required staff assistance with all Activities of Daily Living (ADL) care, and was receiving Enteral Feeding for nutritional needs. Review was done of Resident #17's clinical record, and revealed an active order for 'Restorative ADL Nursing Programs & Applications' of fall interventions per licensed nurse assessment; as documented in the medical record & nursing assistant documentation. Review of Resident #17's Activities of Daily Living (ADL) Care Plan dated as initiated 5/16/18, revised on 6/7/18, documented under 'Focus' to Continue with contracture prevention with ROM (range of motion) and splinting. Under Restorative 'Interventions Stretch-Splint' documented Passive ROM to BLE (bilateral lower extremities) in all planes of motion with 30 second holds x 5 repetitions. Apply bilateral knee contracture braces for duration of 3 hours. Notify nurse of any noted skin impairment or redness when doffing braces. Left wrist and elbow extensions ROM. Complete 2 sets x 10 reps daily as tolerated. Left resting hand splint on 6 hour daily, then remove. Complete as tolerated. Notify nursing supervisor if signs of redness occur. Observations made on 7/16/18, during initial tour, at 9:00 AM, Resident #17 did not have bilateral leg braces applied to lower extremity contractures while resting in bed. On 7/17/18, 3 different observations were made at different intervals (9:00 AM, 11:30 AM, and 2:00 PM ) throughout the day, no leg braces were applied to lower extremity bilateral leg contractures. On 7/18/18, at 9:00 AM, during an observation of staff performing personal care, there were no bilateral leg braces applied to Resident #17, while she was resting in bed. Certified Nursing Assistant Q was performing ADL care on Resident #17 and was saying relax your legs while trying to clean the perineal area and catheter tubing. Resident #17's legs were bent at the knees and pulled up towards her body. CNA Q was having some difficulty cleaning the area. CNA Q was asked if Resident #17 was suppose to wear leg braces at any time through the day. CNA Q replied, She used to wear them, but has not had them on for quite some time now, and her legs are getting worse. It is difficult to clean her peri area and catheter some times, as her legs are so tight and continue to pull up closer to her hips. She does not wear them any more. I am guessing it hurts sometimes. She can't tell me, but she is hard to get to relax to be able to clean her. I take my time and do the best I can. CNA Q was asked if it was her responsibility to apply the leg braces and verbalized that Restorative staff are the ones who used to apply the leg braces, not us. I know she is getting worse with the legs, because it is so hard to do her care. She was not this difficult before and her legs were not this tight. Not like they are now. An interview was conducted with Restorative Nursing assistant W on 7/18/18, at 9:20 AM, about Restorative Services for Resident #17. CNA W was asked if Resident #17 was suppose to have splints/leg braces on every day, and replied Let me check, I am not sure. CNA W entered Resident #17's room and looked at the Kardex (CNA Care Guide) and said, She is supposed to wear them for 3 to 4 hours every day. CNA W was asked where they document that the task is being completed and said, We document in the Kiosk (computer on the wall) when it is completed. CNA W was asked if this service was supposed to be done every day, and documented every day, and said, Yes, after we do what we are supposed to, or what they are supposed to have on. Review was done of previous 30 day documentation for 'Restorative-Splint/Brace Assistance' from look back period of 6/19/18, through 7/17/18, revealing lack of documentation that Restorative services for braces/splints were being completed. 30 days was the only look back period to be able to view in Point Click Care. There was no documentation noted on 6/22/18, related to splint/brace assistance. On 6/23/18, documented 'No' to spending 15 or more minutes completing this task. There was no documentation again until 6/26/18, ( 4 days) as completion of the task. On 7/8/18, it was documented that the task was completed, but then not again until 7/11/18. Then from 7/11/18, until 7/17/18, (7 days) there was no documentation that the task was being completed. 12 days out of 30 days revealed that there was no indication that Resident #17 was receiving Restorative Services as indicated on her current active Care Plan. Resident #16 A review of the Face Sheet and Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated the resident needed 1-person assistance with bed mobility, transfers, ambulation, toileting, hygiene and bathing and balance was unsteady. A review of the physician order dated 10/16/17 revealed, Restorative ADL (activities of daily living) Nursing Programs. Review of the ADL Care Plan dated 10/16/17 revealed, Interventions: RESTORATIVE: (strengthening/ambulation), BLE (bilateral lower extremity) ROM (range of motion) in all planes of motion using 2lb (pound) weight. Complete 2 sets x 15 reps (repetitions), 3 times/week as tolerated. Date Initiated: 12/22/2017, Revision on: 05/03/2018 A review of the Restorative Nursing documentation -Active Range of Motion (AROM) for (MONTH) and (MONTH) (YEAR) revealed there were only five entries for June: 6/18, 6/22, 6/24, 6/27 and 6/28, to indicate the resident received the Restorative service and four entries for July: 7/2, 7/6, 7/11 and 7/12. A record review of a 7/13/18 Therapy Evaluation indicated Resident #16 had a significant change related to the need for increased lower extremity assistance, dressing and transfers and recommended Occupational Therapy (OT) to work with the resident. On 7/17/18 at 9:17 am, during an interview with Clinical Care Coordinator (CCC) GG, she stated, Generally when therapy is getting ready for discharge from their services, they will send me a Therapy Notifications Alert. It says what they have been working on and what they (the resident) should continue. Therapy recommended Restorative services for (Resident #16), but we just referred her back to therapy (7/12/18). CCC GG said she was the nurse that oversaw the Restorative program for the Central Unit. When queried if someone reviewed the resident's documentation of restorative services and progress made while in the program, she stated, Not really. The rule of thumb is for about 6 weeks of restorative, sometimes it's longer. They really enjoy it. I look at their functional ability. If they are having changes, I refer them back to therapy. Generally, the Restorative aides will tell me. It is not generally documented. The CCC said there was no monthly summary note or documentation to review progress. When queried how the Restorative Aides would know what Restorative services to provide for the resident's she stated, The Restorative Care plan tells them what to do. We have someone here 7 days a week. The Restorative documentation for Resident #16 was reviewed with CCC GG who stated, It looks like she missed a couple of days. I have her for once daily. The CCC identified a notebook on her desk with Restorative Plans for the residents on the Central Unit. Resident #35 During the initial tour on 7/16/18 at 10:25 am, Resident #35 was observed lying in bed. He made eye contact and attempted to answer questions. Knee braces were observed on the floor. A record review of the Face Sheet and MDS dated [DATE] indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed the resident had severed cognitive decline and needed total 1-2 person assistance with all care and had an impairment in ROM bilaterally in the upper and lower extremities. The MDS further indicated the resident received Restorative Nursing services for PROM (passive range of motion). A review of the physician orders for Resident #35 revealed there was no order for Restorative Nursing Services. A review of the ADL Care Plan, date initiated 7/6/16, revised 12/14/16, Interventions: RESTORATIVE PROGRAM: 1) Don/Doff bilateral knee contracture braces for duration of 3 hours. Perform skin checks after doffing. 2) Apply Hip Abductor Pillow Between Knees while braces donned with bolster pillow under bilateral knees, Date Initiated: 06/20/2018. ROM: Passive Range of Motion to all joints within their limits . as he has limited joint mobility, Provide ROM a minimum of 5 reps (repetitions) as tolerated with am and pm care. Report inability to complete or a change in range of motion to your charge nurse. Date Initiated/revised: 07/06/2016. A review of the Restorative Documentation completed by the Certified Nursing Assistants (CNA's) for (MONTH) and (MONTH) (YEAR) revealed the following: June: 2 entries for ROM from 6/18 to 6/30/18 and July: 3 entries from 7/1/18-7/17/18. The ROM was not documented as provided twice daily per the Care Plan. The Restorative Documentation for Splint/Braces for (MONTH) and (MONTH) (YEAR) provided: No documentation for June. The month of (MONTH) had 7 entries- 7/5, 7/6, 7/9, 7/11, 7/12, 7/14, 7/16. The braces were not applied daily for 3 hours per the Care Plan. On 7/17/18 at 9:12 AM, during an interview with CCC HH she said she was the Restorative Nurse for the West Hall. The CCC reviewed a Restorative book at the nurse's desk that contained a Restorative Plan for Resident #35. The CCC stated, A Splint/brace and ROM Restorative program was communicated by the Therapy department. The residents Care Plan Restorative Program, Don/doff bilateral contracture braces, max wear time 3 hours, was reviewed with the CCC who stated, I believe it is daily. The Restorative documentation of the brace application for (MONTH) was reviewed with the CCC for 7/5-7/17/18 with 8 of 17 days documented. The CCC stated, They are supposed to document. The prior months documentation was not accessible in the medical record. During the interview, the CCC further stated, If the restorative aide reports back that there was an issue with the splint they would report to me. When queried what the Restorative Nurses role was the CCC stated, Maintaining the master list and being the point of contact. When queried if the Restorative Nurse is providing a look back or summary of how the resident is doing, she stated, No. A review of the FMP (functional maintenance plan) written by OTR (Occupation Therapist Registered) O from 4/30-6/19/18 for Resident #35, [DIAGNOSES REDACTED]. Resident #57 A record review of the Face sheet and MDS dated [DATE], indicated Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed the resident had full cognitive abilities and needed total assistance with all care and was receiving Restorative nursing services for ROM and splint/brace application. A review of the physician orders dated 3/10/17 revealed: Restorative ADL Nursing Programs. A review of the ADL Care Plan, dated, initiated 4/8/16, revised 3/6/18, Interventions: Restorative: (strengthening)-BUE (bilateral upper extremities) exercises in all planes of motion. Use 1 lb. weight on right. Complete 2 sets x 15 reps (repetitions) daily as tolerated. Hand bike x 15 minutes, 3x (times)/week as tolerated. Shoulder pulleys x 10 minutes, 3x/week as tolerated. BLE (bilateral lower extremities) exercises (knee raises and extensions). Complete 2 sets x 10 reps daily as tolerated. Gentle stretch of left knee into extension with 30 second hold x 10 reps daily as tolerated, Date Initiated: 05/05/2017, Revision on: 04/20/2018, AROM: Active Assistive range of motion to all joints a minimum of 5 repetitions as tolerated with am and pm care. Report inability to complete or a change in range of motion to your charge nurse, Date Initiated/revised: 04/08/2016. A review of the Restorative Documentation completed by the Certified Nursing Assistants (CNA's) for (MONTH) and (MONTH) (YEAR) revealed the following: ROM for (MONTH) (YEAR)- No documentation for 6/24/18 or 6/26/18. (MONTH) (YEAR)- No documentation for 7/4/18 or 7/7/18. Splint/Brace Assistance for (MONTH) (YEAR): Only documented as completed on 6/22, 6/23, 6/24 and 6/27/18. There was no documentation that the Splints/braces were applied in (MONTH) (YEAR). On 7/18/18 at 9:30 am, an interview with OTR O revealed, the resident received therapy services from 2/14- 4/18/18 and the therapist recommended a Restorative Nursing program for daily ROM and bilateral knee splints 3-5 times a week. Resident #69 A record review of the Face Sheet and MDS dated [DATE], indicated Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS further revealed the resident had full cognitive abilities and needed total assistance with all care except for eating; The resident had limited ROM upper and lower extremities and received Restorative services for ROM and Splints. A review of the ADL Care Plan initiated 12/18/13, revised 6/8/18 revealed, Interventions: Restorative (ROM/Splint): Perform BLE manual stretching in all planes of motion to tolerance 3x per week, RUE (right upper extremity) and LUE (left upper extremity) ROM to all joints in all planes of motion 15 reps x 2 sets daily as tolerated. Use 1lb. weight for LUE as tolerated. Right hand splint to be worn 6-8 hours/day as tolerated. Report to therapy or nursing any changes in skin condition. Left AFO brace to be worn 6-8 hours/day as tolerated. Report to therapy or nursing any changes in skin condition, Initiated: 10/20/2015. During a review of the Restorative Nursing Documentation for (MONTH) and (MONTH) (YEAR), the following were noted: ROM (MONTH) (YEAR)- No documentation for 6/20, 6/21, 6/22, 6/23, 6/24, 6/25, 6/26, 6/28 and 6/29/18 and (MONTH) (YEAR)- No documentation of ROM provided on 7/2, 7/3, 7/4, 7/8-7/13, 7/15 and 7/16. Splint Application (MONTH) (YEAR)- No documentation for 7/2, 7/4, 7/8, 7/11, 7/12 and 7/16/18. An Interdisciplinary Note dated 7/11/18 revealed, Referral sent to therapies for evaluation. (Resident #69) has reported increased pain over the past several days, experienced most often with ROM, stretching and donning of her splint . describes pain as shooting that radiates up her arm or leg and towards the center of the body. On 7/17/18 at 11:39 AM, during an interview with Restorative CNA II provided, (Resident #69) receives Restorative, ROM every day and splints for hand contractures. An interview on 7/17/18 at 1:55 PM with CCC GG revealed, She has restorative 3x/week, bilateral lower extremity ROM and right left upper extremity ROM- 2 sets x 15 reps daily, with hand weights for the left side. Right hand splint and left AFO (ankle foot orthosis) brace for 6-8 hours/day as tolerated. Restorative documentation was reviewed with the CCC and she stated, For ROM and the splints, they are documented less than daily. I don't have daily (documentation). There's a few holes. On 7/12/18 I sent a nursing referral. The last Therapy Screen stated, Increased pain during ROM, recommended PT/OT, for pain, ROM and modification of restorative program. There aren't any orders yet. There is a referral out there. I don't know why it hasn't started yet. She has increased pain. I put her in the doctor's book awhile back. The Restorative CNA told me last week she was having increased pain, shooting with ROM, it's like a lightning bolt. On 7/18/18 at 9:20 AM, during an interview with OTR O, she was queried about the lack of documentation of the Restorative Nursing services for Resident #69 and stated, She is at risk of contractures and the plan should always be continued. Resident #111 On 7/17 18 at 8:44 AM, Resident #111 was observed sitting in a chair in her room and stated, Restorative is to come in daily at 2:00 PM to apply my left arm brace. An arm brace was lying on the resident's bed. A record review of the Face Sheet and MDS dated [DATE] indicated the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS indicated the resident had full cognitive abilities and needed assistance with all ADL's except for eating. The resident was ambulating with 2 -person assistance and Restorative Nursing services for ROM, splints and walking was provided. A review of the ADL Care Plan, date initiated 12/22/15 and revised 7/2/18, Interventions: Restorative: (strengthening/ambulation), LUE (Left Upper Extremity: hand, wrist, and elbow) extensions. Shoulder extensions. Complete 2 sets x10 reps once daily. LUE elbow splint to be worn every other day, wearing wrist splint on opposite day (only one splint to be worn at a time). Total wear time of 8 hours for each splint daily as tolerated. Report redness or open areas to underlying skin daily. RUE exercises in all planes of motion with 1-2 lb. weight as desired by resident. Complete 2 sets x 15 reps daily as tolerated. LLE (left lower extremity) Passive ROM in all planes of motion prior to donning of AFO brace. Complete 2 sets x 10 reps once daily as tolerated. Ambulation with x1 person assist and quad base cane. Walk 50-100 feet with left ankle AFO once daily as tolerated. Wheelchair to follow, Date Initiated: 01/22/2018. A review of the Restorative Documentation for (MONTH) and (MONTH) (YEAR): June: ROM was only documented 4 times: 6/19, 6/25, 6/27 and 6/28/18. (MONTH) ROM documented 5 times: 7/2, 7/11, 7/12, 7/15 and 7/17/18. Walking for (MONTH) (YEAR) documented once on 7/6/18. On 7/17/18 at 8:40 AM, an interview with Restorative CNA (RCNA) II revealed, Each nurses station has their own (Restorative CNA's). We ambulate, range (ROM), splints, bike, hand bike and sit to stands. When queried where the Restorative services were documented, the Restorative CNA stated, On the computer under Restorative. The Restorative CNA demonstrated the documentation in the electronic medical record. Restorative CNA II was queried on what Restorative services were provided to Resident #111 and replied, Restorative splints, ROM and walking, but (the resident) has not been walking, because her brace needs help, therapy is working on that. A review of the Restorative walking documentation with RCNA II revealed the last documentation of Ambulation was 7/6/18 for 180 feet. The RCNA stated, She usually walks far, when she walks. When further queried if there was a reason it wouldn't be charted, the RCNA stated, No, it should be charted. On 7/17/18 at 1:42 PM, an interview with CCC GG revealed, The Restorative Plan for (Resident #111) is-Left upper extremity elbow splint every other day, wrist splint on the opposite day, total wear time 8 hours/day. She has extensive wrist contractures, but she hasn't had the wrist and elbow splint on for 3 days. She is extensive assist to walk. The Ambulation Plan is ambulate (walk) with quad cane and 1 person assist, walk 50-100 feet with left ankle AFO brace. She's having a little more contracture with that left ankle. On 7/12/18 a nursing to therapy recommended referral was sent. Nothing has been done yet, her insurance takes forever to authorize. The last 3 days she hasn't had any walking. The Therapy screen was completed on 7/12/18, but they're waiting for insurance to get a new brace. Therapy recommends a new left ankle brace due to increased contractures. The ROM Plan is left upper extremity hand wrist and elbow extensions, 2 sets once daily, right upper extremity exercises, daily as tolerated x2 reps. and left upper extremity PROM 2 sets once daily. She's really not doing any of that ROM, this month. A quarterly therapy screen is completed, but no one is reviewing the Restorative documentation. If the Restorative aide notices a decline, then I would contact therapy. When the CCC was further queried if the only time a review of the Restorative services was completed was with a decline in condition, she stated, I don't document a summary of the resident's response to the plan unless there is a problem. A review of an Interdisciplinary Note dated 7/12/18, Restorative therapy is reporting increased difficulty with ROM of the LLE. During assessment she presents with more pronounced contracture of the left foot/ankle towards midline which causes increased difficulty donning her AFO brace for ambulation tasks. (The resident) reports no increase in pain or discomfort, however, states I don't want it to get any worse where I can't walk at all. Refer to physical therapy for evaluation and possible treatment. A review of an Interdisciplinary Note dated 7/17/18 revealed, Restorative program discontinued until resident's left AFO brace can be evaluated and refitted by therapy services. Writer spoke with (resident) to notify her of this change. She expresses understanding at this time. On 7/18/18 at 9:45 am, an interview with OTR/Program Manager O provided, When the resident finishes therapy an FMP is sent to the unit for the CCC Nurse Manager, it goes in a book for the restorative aides to look at. The only other thing they would come to us for is if it isn't working out, change in ROM, splint isn't working or something like that, we might pick them back up in therapy to address the decline. If there is a need, or a decline is noted, we would screen them. There is no review of progress unless staff says there is a decline. We do a quarterly screen. We look at everything, but Restorative documentation. I can only look back for 30 days. I will ask them if there is a change. They came to me recently about a change in her. We did notice increased in stiffness in the lower extremity left ankle. We notified (the Durable Medical Equipment company) to adjust her splint. We are going to pick her up. I was waiting for her insurance to approve that. On 7/18/18 at 10:25 AM, during an interview with the Director of Nursing (DON), she was queried why there was no ongoing evaluation, including a summary of the resident's response to the Restorative program, for each resident receiving those services and stated, Each CCC oversees restorative on their unit. The Restorative aides are supposed to document in the electronic medical record under Tasks. There are three Restorative CNA's on days and three on afternoons. My expectation is the CCC/Restorative Nurse completes a monthly restorative assessment for each resident. The CCC's are supposed to document a monthly Restorative Summary. They are responsible for that. We used to have it on paper, but now we use the computer. A review of the facility policy titled, Restorative Nursing Program, dated (MONTH) (YEAR) provided, It is the policy of this facility .to assist the resident to attain or maintain their highest possible functional level .to support enhanced self-esteem, deter loss of avoidable function, and improve a residents Quality of Life .The Clinical Care Coordinator will assess and document as indicated on the progress or lack of progress and make recommendations for further intervention or discontinuation of a restorative program .Restorative programs are documented in the (electronic medical record). Resident #27 According to admission face sheet, Resident #27 was a [AGE] year old female admitted to the facility on [DATE], readmitted [DATE], with [DIAGNOSES REDACTED]. Review of Resident #27's Activities of Daily Living (ADL) Care Plan dated as initiated 6/21/18, revised on 6/21/18, documented under 'Restorative' (strengthening/ambulation) documented BUE (bilateral upper extremity) ROM in all planes using 2 lb weight. Complete 2 sets x 15 reps once daily as tolerated, 3-5 times/week. Ambulate using FWW (front wheeled walker) and x 1 person, contact guard assistance with distance up to 90 feet. Complete once daily, 3-5/week as tolerated. Review was done of previous 14 day documentation for 'Restorative-Ambulation'' from look back period of 6/22/18, through 7/8/18, revealing lack of documentation that Restorative services for ambulation were being completed. 30 days were requested but was only provided with 14 day look-back. There was no documentation noted on 6/23/18, related to ambulation assistance. On 6/24/18, until 6/29/18, ( 6 days) as completion of the task was left undocumented that the services were being completed On 6/30/18, was left blank. On 7/4/18 was left blank. 8 days out of 14 revealed undocumented services for ambulation from Restorative for services provided.

This citation pertains to intake number MI 772. Based on interview and record review, the facility failed to prevent falls in 1 of 4 sampled residents (Resident #101), from a total of 4 residents reviewed for fall risks, resulting in Resident #101 experiencing a fall with fracture and surgery of her left hip. Findings include: The face sheet revealed Resident #101 was a [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Sets ((MDS) dated [DATE], revealed Resident #101 was moderately to severely cognitively impaired, experienced both long- and short term memory loss, required minimum assistance (staff- provided guidance by a staff person) to perform activities of daily living (ADL'S), was assessed with [REDACTED]. Fall assessments dated 5/31/2012 and 8/23/2012, identified Resident #101 at risk for falls. The Falls Care Plan initiated 3/9/2012, and reviewed August 2012, identified Resident #101 at risk for falls "related to confusion and poor safety awareness." Specified as interventions to her care, Resident #101 was to utilize "safety devices as indicated on the ADL care guidelines." The ADL care guideline initiated 3/9/2012, and reviewed August 2012, specified Resident #101 was to utilize sensor alarms in bed and while up in her wheelchair. Record review of the facility "Incident/Accident Report" dated 9/26/12 (no time indicated) revealed that Resident #101 was observed on the floor on 9/25/12 at 1820. The report further revealed that Resident #101 was transferred to the emergency department for evaluation and treatment of [REDACTED]. An unsuccessful attempt was made on 11/5/2012 at 12:45 P.M. to interview Resident #101, secondary to mental status changes. During an interview on 11/5/2012 at 1:45 P.M., Certified Nursing Assistant (CNA) #3 said, "I was working on the evening shift on 9/25/2012 as the activities aide. Resident #101's roommate called out that they needed a nurse. I ran to the room, saw the resident (#101) on the floor next to her bed, on her left side between the bedside table and her bed. I don't remember if any alarms were sounding. The call light was not on. I saw the resident about 10 to 15 minutes before the fall; she was in bed, sleeping." During an interview on 11/5/2012 at 2:05 P.M., RN #4 said, "I was assigned to Resident #101's care on 9/25/2012, evening shift. She didn't use the call light consistently; don't think she ever really used it. An aide (CNA # 3) called out for help. Me and another nurse (RN #7) went to the resident's room, we ran. She (Resident #101) was supposed to have an alarm on her bed, a sensor alarm. It wasn't reactivated 'cause we all wondered why her alarm didn't go off. We checked it after the fall and it was working, and it was on her bed. The last person who did care with her obviously hadn't listened to make sure the sensor was functioning. It should've sounded, it didn't. It was dangerous for that resident to be put back to bed after care, and the sensor alarm not used properly. She wasn't sat properly on that sensor. With this resident, who repeatedly self-transferred, it doesn't surprise me that if the alarm wasn't used properly, that she fell ." During an interview on 11/5/2012 at 2:25 P.M., Physical Therapist #5 said Resident #101 was a fall risk secondary to her dementia and safety awareness, and loss of balance. During an interview on 11/5/2012 at 2:40 P.M., Occupational Therapist #6 said Resident #101 was at risk for falls and "absolutely, a sensor alarm that wasn't used properly was dangerous for her due to her cognition, it was a safety issue. Safety carry over was decreased due to her cognition and memory." During a phone interview on 11/15/2012 at 2:20 P.M., RN #7 said she was not assigned to Resident #101 on 9/25/2012 at the time of the fall at 6:20 P.M., but was called to the room by CNA #3. She said the resident had a sensor on her bed, but does not recall if the alarm was sounding. The RN said she had been in the Resident's room previous to the fall, and that the Resident did have a functioning bed sensor alarm. During an interview on 11/5/2012 at 2:55 P.M., Director of Nursing #2 said she took part in the post-fall investigation for Resident #101, and could find no reason that the alarm didn't function. Record review of the radiology report dated 9/25/12 at 11:25 PM revealed an "acute complete femoral neck fracture with partial displacement...". Record review of the hospital "History and Physical" dated 9/26/12 at 3:30 AM revealed "Multiple views of the patient's left hip and pelvis have been assessed that show a left femoral neck fracture that is displaced...". "Left femoral neck fracture. The patient will be admitted . She (Resident #101) will be n.p.o. (nothing by mouth) after midnight on 9/26/12 for surgery on 9/27/12."

Applies to MI 586 & MI 688 Based on observation, interview, and record review, the facility failed to ensure a mechanical lift sling strap was properly attached to the lift hanger bar hook in 1 of 4 sampled residents Resident (#101), from a total sample of 4 residents, resulting in Resident #101 sustaining bruising to the top of head, face area and complaint of headache when a strap detached from the hanger bar during a transfer and Resident #101 fell to floor. Findings include: Review of MDS (Minimum Data Set) dated 11/3/10 revealed Resident # 101 had [DIAGNOSES REDACTED]. Review of ADL (Activities of Daily Living) RAP (Resident Assessment Protocol) dated 11/3/10 revealed Resident #101 was dependent on staff "for all ADL cares". Review of "Safety" care plan (no date) revealed Resident #101 was "high risk" for falls. Numerous interventions were in place including, "TRANSFER: Full Mechanical Lift and (2 person assist) with full sling." Review of I/A (Incident Accident Report) dated 7/30/11 at 7:20 pm revealed the following: "(Resident #101) was being transferred from wheelchair to the bed using 2 person mechanical lift. In mid transfer (Resident #101) fell out of the sling approximately 2 feet to the ground." I/A revealed Resident #101 sustained "large hematoma (collection of blood in tissue) to top of the head", "large hematoma...to the right lower extremity" and "left side of forehead and eye area bruised". Review of "ED (Emergency Department) Clinical Report" dated 7/31/11 at 1:25 am revealed "Minor closed head injury without loss of consciousness". The Mechanical lift (Invacare Relient 450 Power Lift) and sling attachment was observed on 8/25/11 at 9:15 am in hall near Resident #101's room accompanied by RN (Registered Nurse) #5. Observation revealed both sides of hanger bar had a combination of 3 open hooks bent (curved) in a manor that sling loops slide across from open hook end around a curved area to a seat area. Applying force to the sling caused sling loops to tighten on the hook seat area and curve prevents slipping of sling loops. RN #5 said, "They think the sling strap was not secured around the hook and slipped off (the hook) when (Resident #101) was lifted, resulting in the fall." CNA (Certified Nursing Assistant) #3 was interviewed by telephone on 8/25/11 at 10:20 am. CNA #3 said she did not set Resident #101's sling up; CNA #4 set the sling up. She said she was behind the wheelchair and pulled the wheelchair out as CNA #4 lifted Resident #101. CNA #3 said, "...the sling hooked on front left side of mast came out and (Resident #101) fell ...(Resident #101) hit her head on the leg of the lift with wheels...I guess the sling strap just slipped...I did not check the (sling)sic strap attachments (to hooks on hanger bar)sic prior to lifting..." Attempts were made to contact CNA #4 but failed. DON (Director of Nurses) #2 said CNA #4 no longer worked at facility. RN #6 was interviewed on 8/25/11 at 2:30 pm in a conference room. RN #6 said she observed Resident #101 on the floor "sort of between the legs of the lift". RN #6 said she felt a "bump" on top of Resident #101's head and Resident #101 complained intermittently of pain. RN #6 stated, "She complained of a headache intermittently and that she was cold..." LPN (Licensed Practical Nurse) #7 was interviewed on 8/25/11 at 10:50 am in a conference room. LPN #7 said, "...RN #6 was already in the room...(Resident #101)sic was complaining of being cold...(Resident #101) didn't state she was in pain but was moaning and groaning that she was in pain...She probably was in pain. She fell 3 feet out of the air." Review of the Nurse's Note dated 7/30/11 at 11:30 pm written by LPN #7 revealed, " (Resident #101)sic was complaining headache and complaining of being very cold. Resident #101 was observed and interviewed on 8/25/11 at 9:15 am in resident room. Resident #101 did not provide any information related to fall or observed injury. Resident #101 had discoloration on the left side of her face near the forehead and down the side of her face to the ear lobe level. There was discoloration observed around her left eye as well. Resident #101 was wearing hair net that secured a dressing to top of head. Review of treatment record dated 8/23/11 revealed "open area to top of skull measuring 2.0 cm (centimeter) x 1.5 cm x 0.25 cm.."

BASED ON RECORD REVIEW AND INTERVIEW, THE FACILITY FAILED TO KEEP ONE OF 16 COGNITIVELY IMPAIRED RESIDENTS OUT OF 24 SAMPLED RESIDENTS (#715) FREE FROM PHYSICAL AND MENTAL ABUSE , RESULTING IN THE RESIDENT BEING PHYSICALLY AND MENTALLY ABUSED BY STAFF. FINDINGS INCLUDE: THIS IS RELATED TO FACILITY REPORTED INCIDENT (FRI) MI 703. REVIEW OF THE FACILITY INTAKE INFORMATION SHEET FOR INTAKE #MI 703; FACILITY INVESTIGATION REPORT, (NO DATE); AND AN INTERVIEW WITH THE DIRECTOR OF NURSING ON 9/23/10 REVEALED THE FOLLOWING INFORMATION: 1. ON 8/03/10 AT 2230 (10:30 P.M.) STAFF "A" (CERTIFIED NURSING ASSISTANT AND ALLEGED PERPETRATOR) ASKED STAFF "B" (CERTIFIED NURSING ASSISTANT AND WITNESS) TO ASSIST WITH PERSONAL CARE FOR RESIDENT #715. THE RESIDENT WAS SOILED WITH FECES AND "UPSET" AND DID NOT WANT CARE PROVIDED. STAFF "A" WAS POSITIONED ON THE RESIDENT'S LEFT SIDE AND STAFF "B" WAS POSITIONED ON THE RIGHT SIDE OF RESIDENT #714. 2. DURING THE PROVISION OF CARE, RESIDENT #715 "MADE QUICK OPEN-HANDED CONTACT ON TOP OF (NAME OF STAFF "A'S") HAND. (NAME OF CNA--"A") TOOK HER OPEN HAND AND MADE CONTACT WITH (RESIDENT'S NAME) HAND." 3. STAFF "B" NOTICED FECAL MATERIAL ON THE CATHETER STRAP AND TOLD STAFF "A" SHE (STAFF "B") WOULD PROVIDE CATHETER CARE. A TOWELETTE WAS USED TO REMOVE STOOL FROM THE RESIDENT'S BODY. STAFF "A" TOOK THE TOWELETTE SOILED WITH STOOL AND PLACED IT NEAR RESIDENT #715'S FACE IN WHAT WAS BELIEVED TO BE AN EFFORT TO DEMONSTRATE TO THE RESIDENT SHE WAS SOILED AND GET HER TO COMPLY WITH CARE--THE REPORT WAS AS FOLLOWS: "MAYBE SHE WOULD STOP RESISTING CARE IF SHE COULD SEE THAT SHE WAS SOILED." 4. CNA "A" POSITIONED HER LEFT LEG ON RESIDENT #715'S BED AND "POSITIONED (RESIDENT'S NAME) ARMS OVER (RESIDENT'S NAME) HEAD." CATHETER CARE CONTINUED AND THE RESIDENT WAS LEFT TO REST IN BED. RESIDENT #715 SAID, "[***] ! I AM GOING TO TELL." CNA'S "A" AND "B" LEFT THE RESIDENT'S ROOM AND DID NOT RE-ENTER. CNA "B" WAS INTERVIEWED ON 9/23/10 AT 2:00 P.M. AND REPORTED SHE WITNESSED CNA "A" AND OBSERVED CNA "A" MISTREAT RESIDENT #715 ON 8/03/10 AT APPROXIMATELY 10:30 P.M. CNA "B" REPORTED CNA "A" HAD ASKED HER TO ASSIST WITH RESIDENT #715'S INCONTINENCE CARE AND DESCRIBED CNA "A" AS "FRUSTRATED". CNA "B" DESCRIBED THE SITUATION AS FOLLOWS: CNA "A" ASKED CNA "B" TO ASSIST WITH CARE. BOTH CNA'S ENTERED RESIDENT #715'S ROOM. RESIDENT #715 WAS ASLEEP IN BED. CNA "A" "RIPPED THE COVERS OFF OF (RESIDENT #715) AND BEGAN DOING INCONTINENCE CARE." CNA "A" WAS ON THE LEFT SIDE OF THE RESIDENT AND CNA "B" WAS ON THE RIGHT SIDE OF THE RESIDENT. RESIDENT #715 WAS TURNED FACING RIGHT. RESIDENT #715 HIT CNA "A" AND CNA "A" "HIT HER BACK" (CNA "B" DEMONSTRATED A FIRM OPEN-HANDED SLAP ON THE TOP OF THE HAND) CNA "A" REMOVED STOOL FROM THE RESIDENT USING A TOWELETTE. CNA "A" PLACED THE TOWELETTE CLOSE TO RESIDENT #715'S FACE (DEMONSTRATED TO BE APPROXIMATELY 6 INCHES FROM HER FACE). CNA "B" REPORTED THAT SHE TRIED TO REASSURE RESIDENT #715 DURING THE CARE EXPERIENCE. WHEN THE RESIDENT WAS PLACED ON HER BACK, STOOL WAS NOTICED ON THE CATHETER STRAP. CNA "B" STATED SHE TOLD CNA "A" THAT SHE WOULD DO CATHETER CARE. CNA "B" THEN PLACED HER LEFT KNEE/THIGH OVER RESIDENT #715'S LEFT LEG AND HELD BOTH OF THE RESIDENT'S HAND'S STRAIGHT OVER THE RESIDENT'S HEAD AND ON THE BED. CNA "B" REPORTED CNA "A" USED HER KNEE "TO HOLD THE LEFT LEG OPEN." CARE WAS COMPLETED AND RESIDENT #715 CALLED CNA "A" A "[***] ." IT WAS REPORTED THAT CNA "A" "TAUNTED" THE RESIDENT...SAYING "WHAT" (LIKE SHE COULDN'T HEAR HER (RESIDENT #715) "SO SHE (RESIDENT) WOULD SAY IT AGAIN ([***] )." BOTH CNA'S LEFT THE ROOM WHEN CARE WAS COMPLETED AND DID NOT RETURN. ATTEMPTS TO CONTACT CNA "A" WERE MADE ON 9/23/10 AT 2:30 P.M. AND 9/24/10 AT APPROXIMATELY 10:30 A.M. A VOICE-MAIL MESSAGE WAS LEFT. THE CALLS WERE NOT RETURNED. CNA "A'S" PERSONNEL RECORD WAS REVIEWED WITH THE DIRECTOR OF NURSING ON 9/24/10. A "DISCIPLINARY ACTION FORM", DATED 8/03/10 AT 1700 (5:00 P.M.) REVEALED THE CNA WAS PROVIDED "ONE-TO-ONE EDUCATION BECAUSE SHE DID NOT REAPPROACH A RESIDENT FOR CARE (DIFFERENT RESIDENT) WHO WAS DISPLAYING BEHAVIOR." INTERVIEW WITH THE DIRECTOR OF NURSING REVEALED CNA "A" WAS TRYING TO "TURN" A RESIDENT WHO USUALLY ASSISTED WITH TURNING. THE RESIDENT WAS UNABLE TO DO SO DUE TO EXACERBATED SYMPTOMS OF [MEDICAL CONDITION] AND CNA "A" CONTINUED TO TRY TO TURN THE RESIDENT BY HERSELF INSTEAD OF GETTING ASSISTANCE FROM ANOTHER STAFF MEMBER. RESIDENT #715 WAS INTERVIEWED ON 9/23/10 AT 11:30 A.M. THE RESIDENT WAS ALERT AND OBSERVED IN HER WHEELCHAIR. THE RESIDENT WAS ASKED ABOUT HOW SHE WAS TREATED BY STAFF MEMBERS AND SHE VOICED NO COMPLAINTS. RESIDENT #715 STATED THAT IF ANYONE WAS MEAN TO HER, SHE WOULD REPORT IT TO HER NURSE. WHEN ASKED IF SHE EVER REPORTED ANYONE BEING MEAN TO HER, SHE SAID "NO". RESIDENT #715'S CLINICAL RECORD WAS REVIEWED ON 9/23/10 AT 10:30 A.M. ACCORDING TO THE PHYSICIAN'S HISTORY AND PHYSICAL, DATED 3/18/10, THE RESIDENT WAS diagnosed with [REDACTED]. THE MOST RECENT Minimum Data Set, dated dated [DATE] DESCRIBED THE RESIDENT WITH LONG AND SHORT-TERM MEMORY IMPAIRMENT AND MODERATELY IMPAIRED COGNITIVE SKILLS FOR DAILY DECISION-MAKING. THE RESIDENT DISPLAYED ANGER EVERY DAY WHICH WAS NOT EASILY REDIRECTED. THE RESIDENT DISPLAYED BEHAVIORS OF VERBAL ABUSE, PHYSICAL ABUSE, AND RESISTING CARE WHICH WERE NOT EASILY ALTERED BY STAFF RE-DIRECTION. REVIEW OF THE COGNITIVE SKILLS RESIDENT ASSESSMENT PROTOCOL (RAP) COMPLETED DURING THE ANNUAL RESIDENT ASSESSMENT ON 5/10/10 DESCRIBED THE RESIDENT WITH "...INCREASED BEHAVIORS AND CHANGES IN MOOD RELATED TO MEDICAL CONDITION AND INFECTION CAUSING [MEDICAL CONDITION] AND PARANOID...RESISTANT TO CARE...RESIDENT YELLING AND HITTING...EPISODES OCCUR ON SECOND SHIFT (3-11 P.M.)" THE FACILITY'S POLICY AND PROCEDURE "ABUSE PREVENTION OVERVIEW", REVISED 7/10, THAT IT WAS THE POLICY OF THE FACILITY TO "PROVIDE THE HIGHEST QUALITY OF CARE POSSIBLE..." EMPLOYEES WOULD RECEIVE ORIENTATION, TRAINING, AND EDUCATION RELATED TO: "APPROPRIATE INTERVENTIONS TO DEAL WITH AGGRESSIVE AND CATASTROPHIC REACTIONS OF RESIDENTS;... HOW TO RECOGNIZE BURNOUT, FRUSTRATIONS, AND STRESS THAT MAY LEAD TO ABUSE; WHAT CONSTITUTES ABUSE, NEGLECT, AND MISAPPROPRIATION OF RESIDENT PROPERTY; TECHNIQUES FOR MANAGEMENT OF CHALLENGING RESIDENT BEHAVIORS; AND ASSESSMENT OF PERSONAL RESPONSES TO AND IDENTIFICATION OF FACTORS THAT LEAD TO OR ESCALATE AGGRESSIVE BEHAVIOR." THE DIRECTOR OF NURSING PROVIDED EVIDENCE CNA "A" RECEIVED INSERVICE EDUCATION ON ABUSE ON 1/20/09, 7/23/09, AND 3/31/10; DEALING WITH COMBATIVE RESIDENTS ON 3/04/09 AND 3/11/10; AND RESIDENT RIGHTS ON 3/26/09, 7/23/09 AND 3/31/10. INSERVICE EDUCATION OUTLINE AND SIGN-IN SHEETS PROVIDED BY THE DIRECTOR OF NURSING REVEALED ALL FACILITY STAFF RECEIVED INSERVICE EDUCATION ON ABUSE AND RESIDENT RIGHTS ON 8/05 AND 8/10/10. GOALS OF THE INSERVICES WERE LISTED AS FOLLOWS: "DEFINE RESIDENT RIGHTS; RESPECT AND DIGNITY ISSUES; ABUSE POLICY AND DUTY TO REPORT; AND RESPONDING TO RESISTIVE/COMBATIVE RESIDENTS."