Every finding on record at Maria Joseph Living Care Center

Based on record review, observation, staff interviews, policy review and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess a resident's skin and failed to timely identify the resident's pressure ulcers (injuries to skin and underlying tissue caused by prolonged pressure, friction, or shear, usually over bony areas like the hips, heels, or tailbone) until they had reached an advanced stage. Actual Harm occurred on 01/09/26 when Resident #209, who was risk for developing pressure ulcers, developed a facility acquired stage III pressure ulcer (full-thickness skin loss in which adipose [fat] is visible and granulation tissue [new tissue] and epibole [rolled wound edges] are often present. Slough [a soft, moist, yellow or white devitalized tissue comprised of dead cells, fibrin, and bacteria that forms in the wound bed, acting as a significant barrier to healing by stalling the inflammatory phase] and/or eschar [a thick, dry, black or brown layer of dead tissue that forms over deep wounds] may be visible along with undermining [tissue under the edges of the wound becomes eroded] and tunneling [narrow passageways or channels extending deep beneath the skin's surface into subcutaneous tissue or muscle may occur]) which was not identified until it had reached an advanced stage. On 02/10/26, Resident #209 developed an unstageable pressure ulcer (obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage III or Stage IV pressure injury will be revealed) wound on the right lateral heel which was not identified until it had reached an advanced stage. On 05/11/26, Resident #209 developed a facility acquired unstageable pressure ulcer on the left hip which was not identified until it had reached an advanced stage. On 05/14/26, Resident #209 developed a facility acquired Deep Tissue Injuries (DTI) (a localized damage to underlying soft tissue which appears as an area of persistent, non-blanchable deep red, maroon, or purple discolored intact skin or a blood-filled blister and underlying tissue is damaged before the skin breaks open) on bilateral feet and a stage III pressure ulcer on the left foot which was not identified until it had reached an advanced stage. Actual Harm occurred on 07/01/25 when Resident #2 who was at risk for developing pressure ulcers, developed a facility acquired stage III pressure on the residents sacrum which extended into the bilateral buttocks and was not identified until it had reached an advanced stage. Additionally, the resident was not timely assessed by the Wound Nurse Practitioner until 07/15/25. This affected two (Residents #209 and #2) of four residents reviewed for pressure ulcers. The facility census was 237.Findings include:1. Record review revealed Resident #209 was admitted on [DATE]. Diagnoses included Alzheimer's disease, type II diabetes mellitus (DM II), schizoaffective disorder, and major depressive disorder. The resident was transferred to the hospital on [DATE] and was still hospitalized at the time of the survey. Review of the Braden Scale for Predicting Pressure Sore Risk dated 11/07/25, revealed Resident #209 was at risk for developing pressure ulcers. Review of the shower sheets for Resident #209 dated 01/05/26 and 01/08/26, revealed no documented skin concerns.Review of the nurse's progress note for Resident #209 dated 01/09/26 at 11:20 P.M. and authored by Registered Nurse (RN) #910, revealed Resident #209 had an area to the right buttocks with bloody drainage. The area measured 8 centimeters (cm) in length by 4 cm in width. The area was cleansed with normal saline, calamine and zinc oxide cream applied, left open to air per the on-call Nurse Practitioner (NP) #999 and follow-up with wound care. The resident's daughter was notified of the skin concern.Review of the Skin Grid-Pressure Assessment for Resident #209 dated 01/13/26 and authored by Wound Registered Nurse (WRN) #938, revealed the resident was seen for a new pressure wound to the right buttock discovered on 01/09/26. Resident #209 had an in-house acquired stage III pressure ulcer to the right buttock that measured 8.5 cm in length by 5.5 cm in width by 0.2 cm in depth. The wound had 70 percent granulation tissue, 10 percent slough, 10 percent eschar and 10 percent epithelial (outer layer of skin) with a moderate amount of serous (clear, thin, and watery wound fluid composed primarily of blood plasma) drainage. Review of the physician order for Resident #209 dated 01/14/26, revealed the resident was ordered a low air loss mattress. Review of the physician orders for January 2026 revealed Resident #209 was ordered moisture barrier ointment after incontinent episode and as needed, assist with turning and repositioning as needed, and floating heels as tolerated. Review of care plan for Resident #209, dated January 2026, revealed Resident #209 was at risk for alteration in skin integrity related to dementia, diabetes, fragile skin, and edema. Interventions included skin checks weekly and as needed, provide dietary supplements per orders, encourage to turn and reposition as needed, notify the physician and family of changes, provide skin care as needed, provide assistance with activities of daily living (ADL) and positioning as needed. Review of the shower sheet dated 02/05/26, revealed Resident #209 had an area on her buttocks, but did not indicate any new skin concerns. There was no shower sheets recorded from 02/06/26 through 02/12/26. Review of the Skin Grid-Pressure Assessment for Resident #209 dated 02/10/26 authored by WRN #938, revealed the resident developed a new in-house unstageable pressure ulcer to the right lateral heel. The measurements were 3.4 cm in length by 2.5 cm in width and unable to determine (UTD) the depth with 40 percent eschar tissue and was 60 percent purple/maroon. Review of the nurse's progress note for Resident #209 dated 02/10/26, revealed no documentation of the resident having any new skin issues. Review of the shower sheet for Resident #209 dated 05/04/26, revealed the resident had no skin areas recorded on the shower sheet. There were no recorded shower sheets from 05/05/26 through 05/11/26. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #209 had severe cognitive impairment and was dependent on staff for ADL. Review of the nurse's progress note for Resident #209 dated 05/11/26 at 11:14 A.M. and authored by WRN #938, revealed she was notified of three new areas of concerns to resident's right ankle, left lateral foot, and left hip. New orders were received and implemented. Review of the Skin Grid-Pressure Assessment for Resident #209 dated 05/11/26 and authored by WRN #938, revealed the resident developed a new in-house acquired unstageable pressure to the left hip. Measurements were 8.6 cm in length by 7.2 cm in width by UTD the depth with 90 percent eschar and 10 percent granulation with moderate amount of bloody and clear drainage. The new wounds on the resident's right ankle and left lateral foot were not addressed in the assessment. Review of the shower sheet for Resident #209 dated 05/11/26, revealed a handwritten area that stated a bed sore on side.Review of the physician order dated 05/11/26, revealed Resident #209 was ordered to receive the left hip cleansed with 0.125 percent Dakins solution, then 0.125 percent Dakins-moistened gauze placed on the wound bed, covered with silicone foam dressing every night shift. Review of the physician order dated 05/12/26, revealed Resident #209 was ordered to receive the left lateral foot cleansed with wound cleanser, calcium alginate placed on the wound bed, covered with bordered foam dressing every Tuesday, Thursday, and Saturday. Orders also revealed the resident was ordered to receive right ankle cleansed with wound cleanser and covered with bordered foam dressing every day shift on Tuesday, Thursday, and Saturday. Review of the nurse's progress note dated 05/14/26 at 3:34 P.M. and authored WRN #938, revealed Resident #209 had new areas of concern to bilateral feet. There was new pressure areas discovered to right and left hallux areas (the outer area of the great toes), left lateral fifth toe, and an area between left fourth and fifth toe. Review of the Skin-Grid Pressure assessment dated [DATE] and authored by WRN #938, revealed Resident #209 developed a new in-house deep tissue injury (DTI) to the right hallux. Measurements were 2.2 cm in length by 1.1 cm in width and unable to determine depth. The wound had 100 percent purple/maroon granulation tissue. Review of the Skin-Grid Pressure Assessment for Resident #209 dated 05/14/26 and authored by WRN #938, revealed the resident developed an in-house acquired a deep tissue injury to the left dorsal great toe. Measurements were 1.7 cm in length by 1.4 cm in width and UTD the depth with 100percent purple/maroon. Review of the Skin-Grid Pressure Assessment for Resident #209 dated 05/14/26 and authored by WRN #938, revealed the resident developed a new in-house acquired stage III pressure ulcer to left lateral fifth toe. The measurements were 1.6 cm in length by 0.7 cm in width by 0.3 cm in depth with 100 percent granulation tissue and moderate amount of bloody and clear drainage.Review of the shower sheet for Resident #209 dated 05/14/26, revealed the resident had one area of concern noted on the left foot. There were no other areas noted.Review of the nurse's progress note dated 06/30/26 at 10:41 A.M. authored by RN #609, revealed Resident #209 was seen by Wound Nurse Practitioner (WNP) #998 for wound care evaluation. New orders received to send resident to the hospital for surgical debridement of the left fifth lateral toe. Review of the hospital paperwork dated 06/30/26, revealed Resident #209 was transferred to the hospital due to worsening wound in her left foot and small toe. The resident was admitted for osteomyelitis related to the wounds and never returned to the facility. During an interview on 07/08/26 at 10:50 A.M., WRN #938 stated she was the facility's wound nurse and once she was made aware of a new wound, she would assess, measure, and implement any new orders immediately. WRN #938 verified Resident #209 had wounds that were discovered at advanced stages on 01/09/26, 02/10/26, 05/11/26 and 05/14/26. During an interview on 07/08/26 at 1:50 P.M., the Director of Nursing (DON) stated weekly skin checks were documented in the treatment administration record (TAR) and a progress note should be completed in the resident's chart for any new skin areas including measurements, notification to the physician, family, and timely implementation of any new treatment orders. The DON deferred any wound questions to Unit Manager / License Practical Nurse (LPN) #810 and stated she would know more.During an interview on 07/08/26 at 3:49 P.M., Unit Manger /LPN #810 stated the expectation of staff was to find skin concerns before they were at an advanced stage and size. During an interview on 07/09/26 at 10:06 A.M., WNP #998 verified Resident #209's wounds on 01/09/26, 02/10/26, 05/11/26 and 05/14/26. were first discovered at advanced stages. WNP #998 stated Resident #209 had a decline and would be appropriate for hospice services. 2. Review of the medical record for Resident #2 revealed an admission date of 04/08/25. Diagnoses included end stage renal disease (ESRD), type II diabetes mellitus (DM II), and major depressive disorder.Review of the physician order for Resident #2 dated 04/08/25, revealed the resident was ordered to be assisted to turn and reposition as tolerated every shift. Review of the Braden Scale for Predicting Pressure Sore Risk for Resident #2 dated 04/15/25, revealed the resident was not at risk for developing pressures. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #2 had intact cognition. The resident required setup with eating, partial assistance with toileting, bathing, dressing, transfers and frequently incontinent of bowel and bladder. Review of the physician order dated 06/23/25, revealed Resident #2 was ordered a house supplement eight ounces a day. Review of the corresponding June 2025 MAR, revealed the resident was not given any of the house supplements during the month of June. Review of the shower sheet for Resident #2 dated 06/28/25, revealed the resident had no areas of concern recorded. Review of the nurse's progress note for 07/01/25 at 3:29 A.M. and created as a late entry on 07/16/25 at 3:31 A.M. and authored by LPN #963, revealed Resident #2 was noted to have a reddened open area to the buttocks. The area measured 6 cm in length by 7 cm in width. The area was cleansed with soap and water, calamine and zinc oxide ointment applied and left open to air and NP #999 was notified. Review of the Skin Grid-Pressure Assessment for Resident #2 dated 07/01/25 and authored by LPN #963, revealed, the resident developed an in-house acquired stage II pressure ulcer. The measurements were 6 cm in length by 7 cm in width and depth was unable to be determined. It had 100 percent pink/red granulation tissue. Review of dietary progress note for Resident #2 dated 07/01/26 and authored by Diet Tech #400, revealed the resident had a new pressure ulcer on buttock and nutritional needs reassessed. Recommend adding a protein supplement 30 ml twice daily. Review of the Skin Grid-Pressure Assessment for Resident #2 dated 07/15/25 and authored by WRN #938, revealed on 07/01/26 Resident #2 developed an in-house acquired stage III pressure ulcer to the sacrum extending to bilateral buttocks. The measurements were 4.5 cm in length by 6.6 cm in width by 0.2 cm in depth with 70 percent granulation and 30 percent epithelial tissue. During an interview on 07/08/26 at 11:23 A.M., WRN #938 stated she learned Resident #2 had a new pressure ulcer to the sacrum on 07/15/25 when she did rounds with WNP #998. WRN #938 stated it was assessed to be stage III and acquired on 07/01/25 per the note. WRN #938 stated she had been notified of Resident #2's wound prior to 07/15/25, she would have seen him sooner. Observation on 07/08/26 at 11:36 A.M., revealed wound care was completed to Resident #2 by WRN #938. Resident #2's wound was approximately the size of a baseball with moderate amount of clear and bloody drainage with undermining noted to the right upper corner of wound and it was classified as a Stage IV pressure ulcer. During an interview on 07/08/26 at 1:50 P.M., the DON stated weekly skin checks were documented in the TAR, and a progress note should be completed in the resident's chart for any new skin areas including measurements, notification to the physician, family, and implementation of any new treatment orders. The DON stated the staff just sign off on the TAR for weekly skin checks and if new skin areas are discovered, the staff are expected to create a progress note. The DON deferred any wound questions to Unit Manager / LPN #810. During an interview on 07/08/26 at 2:04 P.M., Unit Manager /LPN #810 stated the expectation of nurses were to complete a thorough skin assessment and for CNAs were to mark any areas of concern on the shower sheets. During an interview on 07/09/26 at 9:59 A.M., WNP #998 stated when she first assessed Resident #2 on 07/15/25, the wound was assessed to be stage III. WNP #998 stated Resident #2 had significant decline and would be appropriate for hospice services, but the resident did not want to stop dialysis. During an interview on 07/09/26 at 10:16 A.M., LPN #963 stated she discovered Resident #2's new wound on 07/01/26. LPN #963 stated she only marked the wound as a stage II because the note wouldn't let her complete the note without something marked. LPN #963 stated she couldn't stage a pressure ulcer due to her score of practice. LPN #963 verified she didn't document the wound until 07/15/26 and stated she was unsure why it was documented late. Review of facility policy titled Skin Assessment dated 12/02/15, revealed the facility would provide care to prevent the development of pressure injuries unless unavoidable. Residents with pressure injuries shall receive necessary treatment and services to promote healing, prevent infection, and prevent new injuries from developing consistent with the profession stands of practice. Nursing staff were to ensure skin assessments were completed timely, and document in the medical record.Review of the National Pressure Injury Advisory Panel (NPIAP) guidelines, dated 2014, pages 70-71, at (https://npiap.com/general/custom.asp?page=2014Guidelines), revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Unstageable pressure ulcer is defined as a depth unknown full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. The NPIAP Pressure Injury Stages, revealed if necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). This deficiency represents non-compliance investigated under Master Complaint Number 3068198 and Complaint Number 3068132.

Based on observation and staff interviews, the facility failed to ensure residents ordered a pureed diet were served food in a form that met their needs. This affected all 12 residents (#2, #3, #7, #9, #17, #50, #53, #152, #153, #169, #180, and #213) who the facility identified as being ordered a pureed diet. The facility census was 237. Findings include: Observation on 07/09/2026 at 6:55 A.M. with Dietary Supervisor (DS) #407, revealed donuts had been pureed for the breakfast meal. A taste test of the pureed donuts revealed that the texture was sticky and with a pasty consistency that was difficult to clear from the mouth. Interview on 07/09/2026 at 6:57 A.M., DS #407 verified that the pureed donuts had a sticky texture and pasty consistency. Interview on 07/09/2026 at 7:05 A.M., Registered Dietician (RD) #965 verified that the pureed donuts had a sticky texture. RD #965 stated that ideally you would not want pureed food to have a sticky texture. Interview on 07/09/2026 at 7:08 A.M., RD #965 stated that grits were being served to the residents with a pureed diet order as a hot cereal option. Observation on 07/09/2026 at 7:09 A.M. with RD #965, revealed during a taste test the grits had a clumpy and uneven texture. Interview on 07/09/2026 at 7:10 A.M., RD #965 verified the grits had a clumpy and uneven texture and that pureed food should be smooth. Interview on 07/09/2026 at 7:46 A.M., DS #407 stated the oatmeal was pureed dry and then liquid was added to create pureed oatmeal. DS #507 stated this oatmeal was what she planned to serve to the residents who received a pureed diet. Observation on 07/09/2026 at 7:47 A.M. with RD #965, revealed during a taste test that the oatmeal had an uneven texture and was not smooth. Further observation of a cook stirring the oatmeal reveled that there was a visible uneven texture to the oatmeal. Interview on 07/09/2026 at 7:48 A.M., RD #965 stated her bite was smooth but verified that you could see the oatmeal had an uneven texture and was not smooth. RD #965 verified that pureed food should have a smooth consistency throughout the food. Interview on 07/09/2026 at 11:25 A.M., RD #965 stated the facility did not have a policy related to providing residents with pureed diets.

Based on observation, resident interview and staff interviews, the facility failed to ensure food served was palatable. This affected one (#12) but had the potential to affect 12 residents (#2, #3, #7, #9, #17, #50, #53, #152, #153, #169, #180, and #213) who the facility identified as being ordered a pureed diet. The facility census was 237. Findings include: Review of the medical record revealed Resident #180 was admitted to the facility on [DATE] with diagnoses of cerebral infarction with left (non-dominant) side hemiparesis and hemiplegia and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #180 was cognitively impaired and required supervision for eating. Observation on 07/06/2026 at 12:39 P.M. revealed Resident #180 was served a pureed diet, and the resident did not eat her meal. Interview with the resident at the same time revealed she did not like the pureed diet and referred to the food as slop. Interview on 07/06/2026 at 12:45 P.M. Certified Nursing Assistant (CNA) #709 stated Resident #180 had recently been changed to a pureed diet and had been refusing meals. CNA #709 stated that prior to the diet change Resident #180 did not refuse meals. Observation of a test tray on 07/08/2026 at 1:57 P.M. with Dietary Supervisor (DS) #407 revealed the facility uses premade puree chicken forms to serve to residents with a pureed diet. A taste test of the chicken revealed it had an unpalatable flavor and consistency. DS #407 was requested to participate with tasting the pureed test tray three different times and DS #407 refused. DS #407 stated that she already knew what the chicken tasted like and stated that it was dry. Interview on 07/08/26 at 2:00 P.M. Registered Dietician (RD) #965 stated she thought the premade pureed chicken was dry. Interview on 07/09/2026 at 11:25 A.M. RD #965 stated the facility did not have a policy related to serving palatable food to residents.

Based on observation and staff interview, the facility failed to maintain an effective pest control program. This had the potential to affect all residents residing in the facility with the exception of the three Residents (#11, #26, and #29) identified as having orders for nothing by mouth (NPO). The facility census was 237.Findings include: Review of the medical record revealed Resident #02 was admitted to the facility on [DATE] with diagnoses of end-stage renal disease (ESRD), diabetes mellitus type two, coronary artery disease and hypertension. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] revealed Resident #02 had intact cognition and required moderate assistance for eating, maximal assistance for oral and personal hygiene, and was dependent for toileting, bathing, dressing, bed mobility and transfers. Observation of the kitchen on 07/06/2026 at 9:55 A.M., with Dietary Supervisor (DS) #407, revealed gnats near the dry storage area in the main kitchen. Interview with DS #407 at the same time, verified the gnats in the kitchen. Observation of the kitchen on 07/09/2026 at 7:52 A.M., with Registered Dietitian (RD) #965, revealed gnats flying around a trash can in the food preparation area of the kitchen. Interview with RD #965 at the same time, verified the gnats. Interview on 07/09/2026 at 11:25 A.M. RD #965 stated the facility does not have a policy related to controlling insects /pests in the kitchen.

Based on observation, review of temperature logs, and staff interviews, the facility failed to store, serve, and prepare food in a safe and sanitary manner to prevent a foodborne illness. This had the potential to affect all residents residing in the facility except for three Residents (#11, #26, and #29) who had orders for nothing by mouth (NPO) and did not receive food from the kitchen. The facility census was 237. Findings include: Review of the medical record revealed Resident #02 was admitted to the facility on [DATE] with diagnoses of end-stage renal disease (ESRD), diabetes mellitus type two, coronary artery disease and hypertension. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] revealed Resident #02 had intact cognition and required moderate assistance for eating, maximal assistance for oral and personal hygiene, and was dependent for toileting, bathing, dressing, bed mobility and transfers. Observation of the kitchen on 07/06/26 at 9:47 A.M. with Maintenance Director #511, revealed a pallet of food and shelving of paper products stored in the basement directly under a sewage line. Maintenance Director #511 verified the findings at the time of the observation. Observation of the kitchen on 07/06/26 at 9:59 A.M. with Dietary Supervisor (DS) #407, revealed six strawberry mighty shakes with a use by date of December 2025, 17 chocolate mighty shakes with a use by date of January 2026, a box of chocolate magic cups with a used by date of June 2026, and a box of strawberry mighty shakes with a used by December 2025 stored in the reach in freezer. DS #407 verified the findings at the time of the observation. Observation of the kitchen on 07/06/26 at 10:03 A.M. with DS #4407, revealed the walk in refrigerator was 59 degrees Fahrenheit (F). Further observation of DS #407 taking the temperature of the food revealed a mixture of peas and carrots that were 49 degrees F and chicken noodles that were 53 degrees F. DS #407 verified the temperatures of the walk in cooler and the food. DS #407 stated the refrigerator temperature was last checked about 7:00 P.M. the night before and it was below 41 degrees F. DS #407 stated that she noticed the temperature of the refrigerator when she came in to work about 8:00 A.M. DS #407 started moving the food to a different refrigerator. DS #407 verified that she did not know the temperature of the food between 7:00 P.M. the night before and 8:00 A.M. that morning. Observation of the kitchen on 07/06/26 at 10:12 A.M. revealed a build-up of an unknown substance on can opener blade. DS #407 verified that the can opener was unclean. Observation of the kitchen on 07/06/26 at 10:15 A.M. with DS #407, revealed serving utensils stored plastic uncovered container on top of clean dish rack. Further observation revealed food debris in the bottom of the container. DS #407 verified that the utensils and storage container were unclean. During an interview on 07/06/26 at 3:32 P.M. DS #407 verified that when she arrived at the facility around 8:00 A.M. the walk in cooler was at about 50 degrees F and she started moving the contents of the refrigerator to a working refrigerator. DS #407 stated that she stopped transferring the food products to participate in the survey. DS #407 stated she did not instruct any kitchen staff to throw away the food that was stored in the broken refrigerator and she had moved food to a working refrigerator. DS #407 stated that she did not intend to serve the food; however, she did not trust her staff to throw away the food and did not ask them to discard it or label that the food was not to be used. DS #407 verified that she knew the food was at an unsafe temperature and left it in the broken refrigerator for hours and then transferred it to a working refrigerator. Observation of the dish machine temperature log on 07/06/26 at 3:45 P.M. with DS #407, revealed on 07/06/26 the wash temperature was listed as 155 degrees F and the chlorine parts per million (PPM) was documented as163. On 07/07/26 the was temperature was listed as 150 degrees F and chlorine was documented as 140 PPM. Further review of the logs revealed that rinse temperature was last documented on 03/31/26. Observation of the kitchen on 07/07/26 at 11:45 A.M., with DS #407, revealed two thermal plate lids were cracked and chipped and remained stored on the tray service line. DS #407 verified the findings at the time of the observation and stated the lids should have been discarded when damaged. During an interview on 07/07/26 at 1:17 P.M. Dietary Personnel (DP) #422 verified that he was the one that filled out the dish machine temperature log on 07/06/26 and 07/07/26. DP #422 verified that he did not complete the chlorine PPM but had instead documented the temperature of the wash and rinse gauge on the dish machine in place of the chlorine test. DP #422 stated the temperature gauge for the rinse cycle had been broken and the documented temperatures were a guess. During an interview on 07/07/26 at 1:24 P.M., DS #407 verified that the rinse temperature gauge on the dish machine has been broken for a few weeks and the temperature logs were inaccurate. DS #407 verified that the facility has been unable to accurately check the final rinse temperature of the dish machine. Observation of the kitchen on 07/08/26 at 11:48 A.M. revealed DP #335 was sitting at the service line with their elbow resting on the table next to them and their hand supporting their face while they waited for more plates of food to be prepared. Once the plates were ready, DP #335 began assembling the trays and without completing any hand hygiene. Interview at the same time, DP #335 verified that her hands were contaminated by touching her face and that she should have washed her hands before assembling the trays. During an interview on 07/08/26 at 11:52 A.M., with Registered Dietician (RD) #965 verified DP #335 should have washed her hands before starting to assemble food trays. Observation of the kitchen on 07/08/26 at 11:58 A.M., revealed DP #335 picked up a thermal lid to place over a plated meal. As the lid was inverted above the plate, liquid was observed leaking from the lid onto the meal and tray. DP #335 continued to place the lid on the plate and passed the tray down to DP #432 who finished the assembling the tray and placed it into the cart for service. During an interview on 07/08/26 at 12:00 P.M., DP #432 verified the trays in the cart were ready to be served to residents. Observation on 07/08/26 at 12:01 P.M. revealed RD #965 removed the tray from the cart. RD #965 removed the thermal lid and noticed it had a crack. A liquid was observed covering the surface of the tray and was visibly wet. Interview at the time of observation, RD #965 verified the tray was visibly wet. RD #965 stated that the liquid was probable from when it was washed and was trapped inside the lid due to the crack. She stated the liquid probably was a mixture of water and chemicals from the dish machine. RD #965 verified it was her expectation that staff assembled trays in a manner that prevented contamination and did not serve any items that have visibly been contaminated. Observation on 07/08/26 at 12:06 P.M. revealed DP #413 took chicken tenders from the food preparation area and placed them on a plate to be served. Review of the food temperature at the same time revealed the temperature of the chicken tenders was not recorded. During an interview on 07/08/26 at 12:08 P.M., RD #965 verified the temperature of the chicken was not recorded after it was done cooking. RD #965 verified that the chicken was stored in the hot holding cabinet. RD #965 tested two pieces of chicken, and they were 139 degrees F and 155 degrees F respectively. Observation on 07/08/26 at 12:12 P.M. revealed RD #965 removed the plate containing the chicken tenders from the food cart and took a temperature of the chicken tenders that measured 126 F. Observation on 07/08/26 at 12:24 P.M. revealed DP #413 standing with her hands on her hips while waiting for more food to be brought to the steam table. Once the food arrived, DP #413 began serving food without and hand hygiene. Interview with DP #413 at the same time, verified that she was touching her shirt and did not complete any hand hygiene. Observation on 07/08/26 at 12:39 P.M., revealed DP #427 had a beard and was in the food preparation area without a beard net in place. DP #427 stated at the same time, the facility had beard nets, and that DP #427 should have been wearing one. Observation on 07/09/26 at 7:10 A.M., with DS #433, revealed an out of order sign on the ice machine in the basement kitchen. DS #433 stated she placed the out of order sign on the ice machine because she was waiting for maintenance to clean it. DS #433 verified that the machine was last taken apart and cleaned around January 2026. DS #433 stated that she cleaned the parts that she could reach and found a black substance on the surfaces inside the ice machine while cleaning it this week. DS #433 stated that the ice was currently only being used to store a carton of liquid eggs to ensure they stay cold during breakfast service. During an interview on 07/09/26 at 7:16 A.M., RD #965 stated that due to the ice machine being unclean, the ice should not be used in any capacity. Observation on 07/09/26 at 7:19 A.M. with RD #965, revealed DP #330 walk into the kitchen, don gloves and begin plating food. RD #965 asked DP #330 if she had washed her hands when she entered the kitchen and donned gloves. DP #330 stated that she did not wash her hands. RD #965 verified that she had asked DP #330 if she had washed her hands and she had stated no. RD #965 verified staff should wash their hands when they enter the kitchen and prior to donning gloves. Observation on 07/09/26 at 7:25 A.M. with DP #330, revealed DP #330 brought a container of gravy to the steam table. Two plates of biscuits and gravy were made and sent out to the dining room. DP #330 verified she heated the gravy in the microwave and did not take a temperature of the gravy after heating it. During an interview on 07/09/26 at 7:30 A.M., RD #965 stated the temperature of foods should be taken prior to serving. Observation on 07/09/26 at 7:36 A.M. with RD #965, revealed DP #404 picked up the liquid eggs from the container containing contaminated ice, poured the eggs onto the griddle to make scrambles eggs, made toast and plated food. RD #965 verified that the liquid eggs were stored in a container of ice that came from the unclean ice machine. RD #965 stated DP #404 should have washed her hands after touching the carton of liquid eggs. RD #965 stated that the ice should not have been used. The ice was not discarded after it was discovered it was used, and that no one educated the kitchen workers that the ice was contaminated. During an interview on 07/09/26 at 11:25 A.M., RD #965 stated the facility did not have policies for maintaining the kitchen and equipment, food storage, food handling, food temperatures, or hand washing requirement.

Based on medical record review and staff interview, the facility failed to ensure a resident who consented to the influenza (flu) vaccine received the influenza vaccine. This affected one (#02) of the five residents reviewed for vaccines The facility census was 237 residentsFindings include: Review of the medical record revealed Resident #02 was admitted to the facility on [DATE] with diagnoses of end-stage renal disease (ESRD), diabetes mellitus type two, coronary artery disease and hypertension. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] revealed Resident #02 had intact cognition and required moderate assistance for eating, maximal assistance for oral and personal hygiene, and was dependent for toileting, bathing, dressing, bed mobility and transfers. Review of the flu Vaccine Informed Consent Form for Resident #02 dated 09/18/25, revealed Resident #02 's representative specified consent for Resident #02 to receive an annual flu vaccine. Review of the Immunization Record for Resident #02 revealed no documented evidence Resident #02 received the influenza vaccine. During interview on 07/09/26 at 12:26 P.M. Infection Control Preventionist verified the facility did not provide Resident #02 the flu vaccine after a consent was provided on 09/18/25.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff followed appropriate infection control practices. The affected one (#17) of two residents reviewed for infection control precautions. The facility census was 237 residents.Findings include: Review of medical record for Resident #17 revealed an admission dated 10/04/24 . Diagnoses included Alzheimer's disease, and anxiety. Review of physician order dated 03/21/26, revealed Resident #17 had an order to be housed in enhanced barrier precautions (EBP) related to having a gastric tube. Observation of Resident #17's room on 07/06/26 at 11:41 A.M. revealed the resident was in EBP by the signage near the resident's room. Speech Therapist #980 was in the resident's room providing treatment wearing a gown and a mask. Speech Therapist #980 left Resident #17's room with her gown and mask still in place and walked down to the next hall. Interview on 07/06/26 at 11:48 A.M., Speech Therapist #980 verified she never took her gown off, nor completed any hand hygiene after finishing Resident #17's treatment and exiting the room. Speech Therapist #980 stated she should have discarded her personal protective equipment (PPE), then completed hand hygiene, and exited Resident #17's room. Review of facility document titled, Contact Isolation Precautions Best Practice, revised November 2017, revealed contact isolation is implemented for a resident suspected or confirmed to be infected with microorganisms transmitted by contact with the resident, environmental surfaces inside the resident's room, or care items in the resident's environment (main source for spreading the infection). PPE worn as needed for contact with contaminated surfaces or items inside the resident's room and remove PPE and perform hand hygiene before leaving the room.

Based on observation, interviews, and review of facility policy, revealed the facility failed to provide timely incontinence care for one (#50) out of the three residents reviewed for incontinence. The facility census was 237. Findings include: Review of medical records for Resident #50 revealed an admission date of 06/09/23. Diagnoses included hypertension, dementia, peripheral vascular diseases, benign prostatic hyperplasia and bilateral cataracts. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had Brief Interview of Mental Status (BIMS) of 04 which indicated he was severely cognitively impaired. Resident #50 was dependent on staff for activities of daily living (ADL). Review of plan of care dated 05/06/26 revealed Resident #50 had an alteration in elimination and was occasionally incontinent of bowel and bladder. Interventions included monitoring for signs and symptoms of urinary tract infection (UTI), assessing bowel sounds, monitoring and recording bowel movements every shift, monitoring and providing hydration as prescribed and providing incontinence care as needed. Review of Bowel and or Bladder assessment dated [DATE] revealed Resident #50 was incontinent for bowel and bladder incontinence. Observation of the main television room on 07/06/26 from 10:27 A.M. revealed Resident #50 was sitting in his wheelchair and dressed for the day and had heavy odor of urine. Observation on 07/06/26 at 3:00 P.M. revealed Resident #50 was moved from the television room to his room for care by Certified Nursing Assistant (CNA) #722. Observation on 07/06/26 from 3:00 P.M. to 3:05 P.M. revealed Resident #50 was provided with incontinence care by CNA #722. Observation revealed the resident's had a strong odor of urine and the incontinence brief was heavily saturated with urine and bowel. CNA #722 verified the findings at the time of the observation. CNA #722 stated she was tasked with caring for Resident #50 and the resident today and he was already up when she arrived at the facility at 7:00 A.M. CNA #722 stated she had not provided any incontinence care to Resident #50 today. CNA #722 stated Resident #50 was supposed to be checked and changed every two hours. Interview on 07/06/26 at 3:13 P.M., CNA #957 stated she had not provided incontinence care for Resident #50 today. Interview on 07/06/26 at 3:14 P.M., Registered Nurse (RN) #725 stated she had not provided incontinence care for Resident #50 today. Interview on 07/06/26 at 3:15 P.M. with Licensed Practical Nurse (LPN) #712 stated she had not provided incontinence care for Resident #50 today. Interview on 07/07/26 at 3:11 P.M. with CNA #701 stated he worked on 07/06/26 and last provided incontinence care for Resident #50 at 9:30 A.M. Interview on 07/08/26 at 2:00 P.M. with Regional Nurse #976 who stated that the facility did not have an incontinence program at the facility. Review of the facility document titled Skin Incontinence Care Protocol dated 01/14/2005 revealed that the facility will provide incontinence care for the resident to assist in maintaining skin integrity, preventing skin breakdown, controlling odor and providing comfort and self-esteem for the resident. This deficiency represents non-compliance investigated under Master Complaint Number 3068198 and Complaint Number 3068132.

Based on record review, observation, and interviews, the facility failed to ensure care plans were accurate and interventions were implemented. This affected two Residents (Resident #75 and #50) of 35 the residents reviewed. The facility census was 237. Findings include: 1) Review of the medical record for Resident #75 revealed an admissions date of 03/06/26 with a diagnosis that included binocular dysfunction. Review of the physician order dated 05/16/26 revealed Resident #75 had an order for an eye patch to right eye while awake. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 was cognitively impaired. Interview on 07/06/2026 at 12:12 P.M. with Resident #75 stated her left eye was a lazy eye and would be corrected when she covered the right eye. Resident #75 stated that her left eye caused her discomfort. Observations throughout the survey on 07/06/26 and 07/07/26 revealed Resident #75 was not wearing an eye patch. Interview on 07/07/2026 at 4:14 P.M. with Registered Nurse (RN) #919 revealed Resident #75 kept the eye patches in her room and applied them herself. Observation on 07/08/2026 at 4:50 P.M. of Resident #75 revealed that she had a piece of gauze over her right eye that was being held up by a pair of glasses. Interview on 07/08/2026 at 4:53 P.M. with Certified Nursing Assistant #709 verified that she worked from 7:00 A.M. to 7:00 P.M. on 07/06/26 and 07/07/26 and she did not see Resident #75 wearing an eye patch. She also verified that Resident #75 currently had a piece of gauze covering her eye. Review of the physician orders for Resident #75 revealed an active order dated 07/08/26 for Resident #75 to have a covering to right eye while awake. Interview on 07/09/26 at 9:48 A.M. with Director of Nursing #821 revealed she would expect nursing staff to apply eye patches and that the resident should not be keeping her own eye patches. She also verified that the facility did not have a care plan for Resident #75's vision or use of an eye patch. Interview on 07/09/2026 at 11:49 A.M. with Resident #75 stated on 07/08/26 was the first time the facility staff covered her right eye, and it helped. Resident #75 stated that the gauze they are using was uncomfortable because it required her to always keep her reading glasses on to keep the eye cover in place. Resident #75 stated that she would prefer for it to be an eye patch that was taped to her eye. Interview on 07/09/26 at 11:52 P.M. with RN #919 stated she contacted the nurse practitioner (NP) to get the order changed due to the facility not having eye patches in stock. Interview on 07/09/26 at 12:02 P.M. with Central Supply #314 stated she had a full box of eye pads in the supply room that was ordered over eight months ago. She stated that no one has requested any eye patches from her. Review of the July 2026 active care plan revealed Resident #75 did not have a care plan for vision, use of an eye patch, or a diagnosis of binocular dysfunction. 2) Review of medical records for Resident #50 revealed an admission date of 06/09/23. Diagnoses included dementia, osteopenia, and hypertension. Review of the Plan of Care date 06/20/23 revealed Resident #50 was at risk for falls related to weakness, impaired balance, and cognitive impairment with wandering behavior at times. Interventions include two-person assist with showers, antiroll back brakes to wheelchair, assist resident to television room, bed stabilizers and ensure call light was in reach. Review of MDS Quarterly assessment dated [DATE] revealed Resident #50 had Brief Interview Mental Status (BIMS) of 04 which indicated he was severely cognitively impaired. Resident #50 required partial to moderate assistance for eating, personal hygiene, dressing upper body, and oral care. Resident #50 required substantial to maximal assistance putting on and off shoes, dressing lower body, bathing, and toileting. Observation of Resident #50 sitting in a wheelchair on 07/06/26 at 2:01 P.M. with Unit Manager #812, revealed there were no anti-rollbacks on the resident's wheelchair and the rubber treads on the wheels were coming off. Unit Manager #812 stated the resident was supposed to have anti-rollbacks on the wheelchair and verified none were in place and verified the rubber was coming off the wheels. Interview on 07/06/26 at 2:20 P.M. with Physical Therapist #981 who verified there was no anti-roll back system on Resident #50's wheelchair and there should be in place. Physical Therapist #981 also verified that both the wheelchair rubber tires rubber were falling off the wheels.

Based on record review and staff interviews, the facility failed to ensure Beneficiary Notifications - Notice of Medicare Non-Coverage (NOMNC) were issued in a timely manner. This affected one (#11) out of the six residents reviewed for Beneficiary Notifications. The facility census was 237.Findings include: Review of the medical record revealed Resident #11 was admitted on [DATE] with medical diagnoses of hypertensive heart disease without failure, aphasia following cerebral infarction, essential hypertension, hyperlipidemia, and Type II Diabetes. Review of Resident #11's NOMNC revealed Medicare coverage of skilled services ended on 06/05/26. Resident #11's guardian was informed on 06/05/26. Review of Resident #11's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 2. Resident #11 required maximal assistance with oral hygiene and was dependent on staff for all other Activities of Daily Living (ADL) and bed mobility. Interview on 07/08/26 at 10:01 A.M. with SSD # 318 confirmed the NOMNC was presented to Resident #11's guardian on the same day coverage ended. SSD #318 confirmed notice should have been given 48 hours prior to services ending. Interview on 07/08/26 at 12:17 P.M. with Regional Nurse #976 stated the facility did not have a policy regarding Beneficiary Notices - NOMNC issuance.

Based on record review, resident interview and staff interview, the facility failed to ensure resident rights were maintained. This affected three Residents (#220, #62, and #75) of the three residents reviewed for resident rights. The facility census was 237. Findings include: Review of the medical record revealed Resident #244 had an admissions date of 08/24/18 with diagnoses of bipolar disorder, schizoaffective disorder, mood disorder, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #244 was cognitively intact. Resident #244 had delusions and verbal behavior symptoms occurring one to three days during the assessment period. During an interview with Resident #220 on 07/06/26 at 11:20 A.M. revealed the surveyor and Resident #220 were in the hallway when Resident #244 exited his room and began yelling at Resident #220. Resident #244 was observed making comments about Resident #220 playing a guitar and it needing to be taken away from him. Resident #220 did not have a guitar at the time. Surveyor and Resident #220 had to move further down the hall to finish their conversation. Resident #220 stated Resident #224 was frequently verbally aggressive to other residents, and it made for an uncomfortable environment. Observation of lunch service on 07/06/2026 at 12:35 P.M. revealed Resident #244 was repeatedly yelling after staff refused to provide him with salt packets due to a recent diet order change to no added salt. Resident #244 remained verbally disruptive throughout the meal, resulting in other residents appearing visibly uncomfortable. Resident #244 also directed comments at other residents and made statements about how no one in the facility helped anyone. The resident also attempted to involve other residents in the disagreement. The other residents were observed to be quiet and visibly uncomfortable throughout the incident. Interview on 07/06/2026 at 12:43 P.M. with Certified Nursing Assistant (CNA) #709 revealed there had been attempts to have Resident #244 eat in his room, but his preference was to eat in the dining room. CNA #709 stated Resident #244 has had these behaviors for a while and residents had started to grow tired of it. Interview on 07/06/26 at 12:47 P.M., Resident #62 stated he sat at the same table as Resident #244 and was uncomfortable by Resident #244's verbally aggressive behaviors. Resident #62 revealed that the behavior was frequent and made it difficult for him to enjoy his meals. Interview on 07/07/2026 at 2:24 P.M. CNA #602 stated Resident #244 had always been verbally aggressive to staff and other residents. CNA #602 stated the resident was on the men's behavior unit before and had to be moved due to behavior problems with the other residents. CNA #602 stated she was about to take the residents down to the facility store to buy snacks; however, Resident #244 was not allowed to go due to his behavior. Observation on 07/07/2026 at 2:31 P.M. revealed CNA #602 gathered residents to take them to the store. Resident #244 was instructed that he was unable to go. After CNA #602 gathered the residents permitted to go to the store and placed them in the elevator, Resident #244 was observed near the elevator doors yelling and swearing. Observation on 07/07/2026 at 2:33 P.M. revealed Resident #244 came to the smoking room for a smoke break. Throughout the smoke break, Resident #244 shouted about not being permitted to go to the store and how his rights were taken away. All other residents were observed to be quiet and proceeded to quickly finish their cigarette and leave the smoking area. Interview on 07/07/2026 at 2:42 P.M. CNA #709 verified Resident #244 shouted throughout the smoke break. CNA #709 stated the staff tried to get him to go to his room when he was having his behaviors. CNA #709 also stated she was unsure of what the facility was doing to manage his behaviors. Interview on 07/07/2026 at 4:15 P.M. Registered Nurse (RN) #919 stated staff would try to keep Resident #244 in his room, but he would refuse. RN #919 stated If the resident was in common areas and became verbally aggressive, they would attempt to redirect him but normally he would refuse and they would have to ask the other residents to leave the area. RN #919 stated that Resident #244 had always been verbally aggressive. Interview on 07/08/2026 at 4:17 P.M. Resident #75 stated during the observed smoke break on 07/07/26, she was uncomfortable due to the behaviors of Resident #244 and that it made it difficult for her to enjoy her smoke break. Resident #75 stated Resident #244 was frequently verbally aggressive towards residents and the staff. Interview on 07/13/2026 at 10:10 A.M. the Administrator stated the facility did not have a policy for addressing the resident rights.

Based on record review, observation and staff interview, the facility failed to ensure infection control measures were followed during incontinence care. This affected (#11) out of three residents reviewed for infection control. The facility census was 245. Findings include:Review of medical record for Resident #11 revealed admission date of 04/08/25. The resident was admitted with diagnoses including end stage renal disease, diabetes mellitus, depression, gout, and anxiety. The significant change Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 13 indicating intact cognition. He required supervision with eating, maximum assistance with dependent for toileting hygiene, bed mobility and transfers. Observation on 09/08/25 at 3:52 P.M. revealed Certified Nursing Assistant (CNA) #31 was assisted by CNA #10 in providing incontinence care for Resident #11. Both CNA's donned Personal Protective Equipment (PPE) for enhanced barrier precautions without concern. CNA #31 was observed to perform thorough peri care using two washcloths, one soapy to cleanse and the other wet to rinse. When peri care was completed, CNA #31 placed both soiled wash clothes on the bedside table and used a towel to pat dry and place it on the bed. CNA #10 assisted CNA #31 to place a clean incontinent product, redress and reposition Resident #11. CNA #31 removed the soiled washcloths and entered Resident #11's restroom without disinfecting Resident #11's bedside table. CNA #31 returned with soiled items in a clear plastic bag having doffed her PPE and washed her hands. Interview on 09/08/25 at 4:09 P.M. directly following observed incontinence care for Resident #11, CNA #31 verified she place soiled wash clothes on the bedside table and stated she should have brought a bag with her to place the soiled items at bedside. CNA #31 acknowledged placing the soiled washcloths on the bedside table presented an infection control concern. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review and staff interviews, the facility failed to ensure accurate documentation of medication administration. This affected one (#10) out of three residents reviewed for medication administration. The facility census was 245. Findings include: Review of medical record for Resident #10 revealed admission date of 05/22/25. The resident was admitted with diagnoses including end stage renal disease, type two diabetes mellitus, depression and hypertension. The resident was hospitalized on [DATE] and did not return. The admission Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. He required supervision for eating, extensive two-person assistance for bed mobility, toileting and dependence for transfers. Review of the physician orders revealed an order for Coreg (blood pressure) 6.25 milligrams (mg) one tablet twice daily. Hold for Systolic Blood Pressure (SBP) less than 110 millimeters of mercury (mm Hg). Review of the June Medication Administration Record (MAR) revealed on 06/28/25 at 9:00 the blood pressure was SBP was documented as 96 mm HG. The medication was signed as given. Review of the July MAR revealed on 07/06/25 the 9:00 A.M. SBP was 100 mm Hg and on 07/12/25 the 9:00 A.M. SBP was 96. Each day the medication was documented as given. Interview on 09/11/25 at 12:30 P.M. with Registered Nurse (RN) #22 revealed she was Resident #10's nurse on 06/28/25, 07/06/25 and 07/12/25. RN #22 stated she did not give the Coreg as the MAR indicated. RN #22 explained she believed because she documented the blood pressure was outside of the parameters, it meant she did not give it. RN #22 denied knowledge electronic charting offered a code to indicate a medication was outside of parameters, or to see the nurses' notes. Interview on 09/11/25 at 1:17 P.M. with the Director of Nursing acknowledged Resident #10's MAR documentation on 06/28/25, 07/06/25 and 07/12/25 did not reflect the medication had been held per parameters. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observations, staff interviews, and policy review, the facility failed to ensure appropriate infection control measures were completed during incontinence care. This affected one (#47) resident of three residents reviewed for incontinence care. The facility census was 234. Findings include: Review of the medical record for Resident #47 revealed an admitted [DATE]. Diagnoses included anxiety disorder, major depressive disorder, and chronic obstructive pulmonary disease (COPD). Review of the Annual Minim Data Set (MDS) assessment dated [DATE] revealed Resident #47 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. This resident was assessed to require setup with eating, dependent with toileting and dressing, and substantial assistance with bathing and transfers. Observation on 03/20/25 at 11:10 A.M. revealed Certified Nursing Assistant (CNA) #13 performed incontinence care to Resident #47. Hand hygiene was performed, and gloves were applied prior to providing care. CNA #13 cleaned Resident #47's perineal (peri) area in the front with a clean washcloth. CNA #13 placed the soiled washcloth back into water basin. CNA #13 cleaned Resident #47's back side with the same washcloth. CNA #13 did not change her gloves during care and touched the clean incontinence brief with her soiled gloves. Interview on 03/20/25 with CNA #13 verified she used the same washcloths to clean Resident #47's front and back side. CNA #13 also verified that she did not change her gloves or complete hand hygiene. Review of the facility policy titled, Infection Control Policy/Procedure Manual, revised 11/28/17 revealed staff performed hand hygiene even if gloves were used in the following situations: before and after contact with the resident, after contact with blood, body fluids, or visibly contaminated surfaces or other objects and surfaces in the resident's environment, and after removing personal protective equipment (PPE).

Based on observation, menu review, and staff interview, the facility failed to ensure the planned menu was followed. This affected 32 (#22, #35, #38, #52, #78, #88, #94, #96, #102, #111, #118, #119, #136, #137, #141, #142, #149, #152, #161, #162, #170, #174, #181, #182, #186, #193, #204, #205, #206, #208, #225, and #450) of 32 residents who resided on the [NAME] Four unit. All 32 residents on the [NAME] Four unit were identified by the facility to received food by mouth. The census was 235. Findings included: Review of the planned breakfast menu for 06/06/23 revealed items consisting of a choice of juices, sausage links, choice of cereal, pancakes, hash browns, water, margarine, and syrup. Observation of the breakfast tray line on 06/06/23 at 9:00 A.M. on the [NAME] Four unit revealed there were no hash brown potatoes being served as indicated on the menu. Interview with Dietary Aide (DA) #158 on 06/06/23 at 9:03 A.M. stated she did not notice there were no hash browns to serve to the residents, and confirmed the menu indicated hash browns were to be served for the breakfast meal on 06/06/23. DA #158 stated there was not a substitute for the hash browns, and she did not know why hash browns were not prepared or why a substitution was not provided.

Based on personal funds account review and staff interview, the facility failed to notify residents or their representatives of the need to spend down personal funds once the account reached $200 less than the Supplemental Security Income (SSI) resource limit of one person. This affected 19 (#3, #15, #20, #37, #41, #43, #44, #45, #54, #101, #111, #124, #127, #158, #183, #195, #198, #227, and #448) of 19 residents reviewed for personal funds. The census was 235. Findings included: 1. Review of Resident #3's personal funds account revealed a balance as of 06/07/23 of $20,424.70. 2. Review of Resident #15's personal funds account revealed a balance as of 06/08/23 of $2,534.72. 3. Review of Resident #20's personal funds account revealed a balance as of 06/01/23 of $2,366.34. 4. Review of Resident #37's personal funds account revealed a balance as of 06/05/23 of $22,686.10. 5. Review of Resident #41's personal funds account revealed a balance as of 06/02/23 of $4,664.31. 6. Review of Resident #43's personal funds account revealed a balance as of 06/08/23 of $5,835.42. 7. Review of Resident #44's personal funds account revealed a balance as of 06/02/23 of $2,399.76. 8. Review of Resident #45's personal funds account revealed a balance as of 06/02/23 of $6,641.78. 9. Review of Resident #54's personal funds account revealed a balance as of 06/07/23 of $3,694.30. 10. Review of Resident #101's personal funds account revealed a balance as of 06/01/23 of $3,728.40. 11. Review of Resident #111's personal funds account revealed a balance as of 06/07/23 of $3,583.82. 12. Review of Resident #124's personal funds account revealed a balance as of 06/02/23 of $6,223.07. 13. Review of Resident #127's personal funds account revealed a balance as of 06/07/23 of $5,198.70. 14. Review of Resident #158's personal funds account revealed a balance as of 06/07/23 of $8,656.77. 15. Review of Resident #183's personal funds account revealed a balance as of 06/07/23 of $8,069.18. 16. Review of Resident #195's personal funds account revealed a balance as of 06/07/23 of $6,069.32. 17. Review of Resident #198's personal funds account revealed a balance as of 06/08/23 of $2,510.67. 18. Review of Resident #227's personal funds account revealed a balance as of 06/02/23 of $2,244.31. 19. Review of Resident #448's personal funds account revealed a balance as of 06/08/23 of $2,225.77. Interview with Business Office Manager (BOM) #49 on 06/08/23 at 12:15 P.M. stated the staff who previously worked for her were not notifying residents or representatives of a need to spend down resident's personal funds accounts. BOM #49 stated the staff no longer worked at the facility, and the new staff she had were working to get the spend down notifications sent out. BOM #49 confirmed Resident #3, Resident #15, Resident #20, Resident #37, Resident #41, Resident #43, Resident #44, Resident #45, Resident #54, Resident #101, Resident #111, Resident #124, Resident #127, Resident #158, Resident #183, Resident #195, Resident #198, Resident #227, and Resident #448 all should have been notified to spend down their personal funds accounts.

Based on medical record review and staff interview, the facility failed to ensure physician orders for a referral to a gynecologist were processed timely. This affected one (#184) of one residents reviewed for referrals to outside providers. The facility census was 235. Findings include: Medical record review for Resident #184 revealed an admission of 01/24/23 with diagnoses including but not limited to bipolar disorder with severe psychotic features, diabetes, chronic obstructive pulmonary disease, anemia, morbid obesity, heart failure, mastitis without abscess, chronic pain syndrome, pulmonary embolism, major depressive disorder, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #184 had an intact cognition. Review of the physicians order for Resident #184 revealed an order for a referral to a gynecologist dated 05/07/23. Review of a progress note dated 05/07/23 at 4:27 P.M. revealed a new order given by the nurse practitioner to obtain a urinalysis and consult with a gynecologist due to Resident #184 complaining of pain in vaginal area. Interview on 06/06/23 at 10:50 A.M. with Resident #184 stated she was supposed to go to a gynecologist and she had not seen a gynecologist yet. Interview on 06/09/23 at 10:20 A.M. with Unit Manager Licensed Practical Nurse (LPN) #124 verified the referral for Resident #184 to see a gynecologist was not processed for Resident #184 to be seen in a timely manner, and an appointment was just scheduled on 06/08/23.

Based on observation, medical record review, menu review, and staff and resident interview, the facility failed to ensure food choices were provided for resident meals. This affected one (#348) of one residents reviewed for choices. The census was 235. Findings included: Medical record review for Resident #348 revealed an admitted [DATE]. Medical diagnoses included peripheral vascular disease, heart failure, and non-Alzheimer's dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #348 was severely cognitively impaired and his functional status was extensive assistance for bed mobility, transfers, and toileting. The resident required limited assistance for eating. Review of the breakfast menu on 06/06/23 revealed there was choice of juices, sausage links, choice of cereal, pancakes, hash browns, water, margarine, and syrup. Review of the breakfast menu on 06/07/23 revealed choice of juices, ham and cheese pocket, hash browns, choice of cereal, choice of milk, and water. There was no choices listed on the menu referring to mechanical soft diets. Observation and interview at the same time on 06/06/23 at 9:05 A.M. revealed Resident #348 was sitting in the dining room at the table with his breakfast meal in front of him. State tested Nurse Aide (STNA) #154 delivered the meal to Resident #348, and when asked if the resident was given a choice of cereal, STNA #154 stated Resident #348 was not asked if he wanted cereal. Observation of the breakfast meal for Resident #348 and interview on 06/07/23 at 9:14 A.M. revealed the resident had scrambled eggs, two sausage links, one slice of toast, milk, orange juice, and water. Resident #348 stated at that time he would like some cereal if the staff would give it to him, and verified he did not get a choice of what he wanted to eat for his meals. Interview with STNA #241 on 06/07/23 at 9:17 A.M. stated in the month she had been at the facility, the staff did not ask the residents what they want for breakfast. STNA #241 stated Resident #348 was on a mechanical soft diet, but when asked if he could have oatmeal with his breakfast she went over to the servery and got Resident #348 oatmeal. Interview with Dietary Manager #86 on 06/07/23 at 12:54 P.M. indicated residents on a mechanical soft diet could have cereal.

39702 Based on observation, medical record review, and resident and staff interview, the facility failed to assist dependent residents with activities of daily living (ADLs). This affected two (#103 and #110) of six residents reviewed for ADLs. The facility census was 235. Findings include: 1. Review of Resident #103's medical record revealed admission to the facility on [DATE] with diagnoses of cerebral infarction, need for assistance with personal care, diabetes mellitus type II, dysphagia, repeated falls, and aphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #103 had moderate cognitive impairment. Resident #103's functional status was assessed as one to two person extensive assist with ADLs. The MDS assessment also revealed Resident #103 was frequently incontinent of urine and always incontinent of bowel. Review of the care plan dated 04/04/23 revealed Resident #103 may require assistance with ADLs and may be at risk for developing complications associated with decreased ADL self-performance. An intervention included in the care plan revealed Resident #103 needed assistance with grooming including nail care, shaving, and hair care. Review of state tested nurse aide (STNA) resident task documentation dated 05/25/23 through 06/07/23 revealed nail care was not provided for Resident #103 except on 06/05/23 at 2:59 P.M. and the resident refused care. Further review of the STNA task sheet documentation dated 06/07/23 at 6:59 A.M. revealed no nail care was provided and was marked as not applicable. Observation of Resident #103 on 06/05/23 at 2:30 P.M. and on 06/07/23 at 11:48 A.M. revealed Resident #103 had long finger nails with a black substance under all finger nails on both hands. Interview with Resident #103 on 06/07/23 at 11:48 A.M. state he received a shower the morning of 06/07/23 the nurse aide did not ask to cut or clean his finger nails. Interview with Registered Nurse (RN) #176 at 11:49 A.M. confirmed Resident #103's finger nails should have been cleaned and trimmed after his showers. 2. Review of the medical record for Resident #110 revealed an admitted [DATE] with diagnoses including but not limited to type two diabetes, atherosclerotic heart disease, migraines, atrial fibrillation, supraventricular tachycardia, anxiety disorder, depressive disorder, diverticulosis of large intestine, anemia, myocardial infarction, cystitis, partial intestinal obstruction, and colostomy. Review of the quarterly MDS assessment date 04/15/23 revealed a cognitive assessment was not completed, and Resident #110 required extensive assistance with two staff members for bed mobility, transferred with assistance of one staff member, required limited assistance for eating, and extensive assistance for toileting. Review of the plan of care revealed Resident #110 may require assistance with ADLs and may be at risk for developing complications associated with decreased ADL self-performance. Interventions included bathing assistance was needed, encourage resident participation while performing ADLs, and grooming (nails/shave/hair) assistance was needed. Review of STNA resident tasks documentation for Resident #110 dated 05/08/23 through 06/08/23 was silent for any documentation related to hair shampooing. Observation on 06/08/23 at 10:40 A.M. of Resident #110 revealed the resident had long facial hair on the [NAME] and neck. Resident #110's hair on the head was long and scraggly with an excessive oily appearance. Resident #110 had white flakes noted throughout the hair close to the scalp. Interview on 06/08/23 at 10:40 A.M. with Resident #110 states she had not had her hair washed for a long time, and was not able to remember when her hair was washed last. Resident #110 stated the staff used a waterless cap to wash her hair. Resident #110 stated she was able to shave her facial hair, but she no longer had the razor she used to keep in her cup on her bedside table, and she was not able to complete that task for an undetermined time. Interview on 06/08/23 at 10:45 A.M. with Director of Nursing (DON) #176 verified Resident #110's hair on her head appeared to be unwashed, and stated Resident #110's scheduled bathing days were Monday and Thursday on second shift. DON #176 further verified Resident #110's facial hair was longer than expected if it would have been shaved on her bathing days.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure residents were treated with dignity and respect. This affected one (#348) of three residents reviewed for dignity and respect. The census was 235. Findings included: Medical record review for Resident #348 revealed an admitted [DATE]. Diagnoses included peripheral vascular disease, heart failure, and non-Alzheimer's dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #348 was assessed with severely impaired cognition. Observation and interview on 06/06/23 at 9:05 A.M. revealed Resident #348 was sitting in the dining room at the table with his breakfast meal in front of him that State tested Nurse Aide (STNA) #154 delivered to him. STNA #154 was asked if the resident was given a choice of cereal, and STNA #154 replied in front of Resident #348, He (Resident #348) was not asked if he wanted cereal and he got what he got. Further interview with STNA #154 confirmed her statement in reply to the question about Resident #348's choice of cereal was not respectful to the resident. Review of the undated policy titled, Resident [NAME] of Rights, revealed the residents would be treated with the courtesy and respect in full recognition of dignity and individuality.

Based on observations, medical record review, review of the facility investigation, staff interview, review of police reports, review of the local fire department (paramedic) report and policy review, the facility failed to provide adequate supervision to prevent a cognitively impaired resident from eloping from a secured dementia unit. This resulted in Immediate Jeopardy and subsequent death when one resident (Resident #300) eloped from the secured unit on the fourth floor (Emma 4) through the stairwell exit door located at the southernmost point of the secured unit. The resident was found on the second floor of the(NAME)building (Emma 2) in the kitchen, inside of walk-in cooler #17, deceased . This affected one (Resident #300) of eighteen residents assessed at risk for elopement on the(NAME)4 unit. The facility identified 40 residents at risk for elopement throughout the facility. The facility census was 255. On [DATE] at 2:39 P.M., the Administrator, the Director of Nursing (DON), Facility Consultant #275, Manager of Clinical Services, Registered Nurse (RN) #273 and President of Clinical Services RN #274 were notified Immediate Jeopardy began on [DATE] at 9:35 P.M. when State tested Nurse Aide (STNA) #201 silenced the stairwell exit door alarm at the southernmost point of the(NAME)4 unit and failed to ensure no residents had exited the secured unit. The facility was unaware Resident #300 had eloped from(NAME)4 until STNA #218 entered the resident's room on [DATE] at approximately 12:30 A.M. and discovered her missing. Resident #300 had exited the(NAME)4 unit via the stairwell and was subsequently discovered on [DATE] at 3:55 A.M. by the DON in the kitchen on(NAME)2, lying on the floor of walk-in cooler #17, deceased . Review of the local Fire Department Report dated [DATE] revealed Paramedic #140 documented Resident #300 was found on the floor of the walk-in cooler unresponsive, pulseless, not breathing, cold to the touch with her pupils fixed and unresponsive. The resident was pronounced dead on site at 4:22 A.M. The walk-in cooler had a temperature of 37 degrees Fahrenheit (F). The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 1:00 A.M., the Nursing Supervisor #119 and designee checked on and accounted for all other residents in the facility. No negative findings were noted. · On [DATE] at approximately 2:55 A.M., Maintenance Director #208 and Assistant Maintenance Director #271 immediately checked all exit doors and alarms for function and a dedicated hall monitor was assigned to supervise the corridors on each of the three secured units. · On [DATE], Maintenance Director #208 and designees inspected and tested all exterior exit egress doors for proper function. · On [DATE], the door contractor serviced the exit doors from each of the three secured units to meet the requirements of NFPA 101 for door locking arrangements where clinical needs of the patients require specialized security measures. · On [DATE], the Maintenance Director #208 secured the walk-in cooler doors. · On [DATE], the DON, Assistant Director of Nursing (ADON), and designees began all-staff in-services on the Elopement Policy and Best Practice, Abuse Prevention Policy and Procedures, Rounding every two hours, Search Procedures and door security. By [DATE], all staff had been provided in-service content. · On [DATE], Regional Dietitian #400 and facility Dietary Manager #246 provided in-service education to all dietary staff regarding after hours security (e.g., door locking, walk-in cooler security ). The walk in coolers and freezers now have a padlock on the outside requiring a key for entry. · On [DATE], the DON and/or designees reviewed and updated all elopement books. The elopement books contain information on residents at risk for elopement; photos, diagnoses, and emergency contact information. A copy is kept on each unit in the facility. · On [DATE], the Administrator, Maintenance Director #208 and/or designees completed elopement drills on each shift . The elopement drills were successful with no negative outcomes. · On [DATE] and [DATE], the MDS Nurse #207 audited all residents' elopement risk assessments, applicable care plans, and physician orders relative to elopement risk to validate accuracy. · On [DATE], a Quality Assurance (QA) committee meeting was held to review the incident investigation, internal action plan and audit plan. The second shift nursing supervisor will check the locks on the cooler and freezer doors and ensure the kitchen is locked. Maintenance personnel are responsible for checking every exit door in the facility to ensure proper function. · On [DATE], STNA #201 was suspended pending investigation and terminated on [DATE] for deactivation of a door alarm on the secured unit without notifying anyone or ensuring that all residents were present and accounted for. · On [DATE] between 1:05 P.M. and 3:55 P.M., Alarm System Technician #200 bypassed the egress delay on(NAME)4 unit exit doors requiring codes to enter and exit the unit from the stairwell. · On [DATE] between 1:08 P.M. and 3:08 P.M., Alarm Systems Technicians #200 and #210 bypassed the egress delay on the stairwells for additional secured units' stairwells on Lordes 2 and Lordes 4 units requiring codes to enter or exit the units from the stairwell. · On [DATE], Alarm Systems Technicians #200, #210 and #215 added badge readers to the entry doors to the kitchen. · On [DATE] and [DATE], interviews were conducted with Licensed Practical Nurses (LPN) #20, #133 and #206, STNA's #57, #103, #215, #247 and #268, Dietary Personnel #246 and #270 and verified they had attended the in-services for elopement, search procedures, door security, and rounding, and verbalized the correct procedures to follow in the event of an elopement and door alarm activation. · On [DATE] record reviews and observations for Residents #16, #26, #28, #34, #47, #81, #83, #85, #87, #92, #108, #132, #168, #173, #189, #249 and #256, identified as being at risk for elopement, who reside on the(NAME)4 unit, had appropriate interventions in place in accordance with the facility's corrective actions taken. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #300's medical record revealed a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's elopement risk assessment, dated [DATE], revealed she was at risk for elopement because she was confused to time and place and wanders, roams and paces. A nursing care plan was revised on [DATE] to address the resident's risk of elopement. Interventions included one-on-one care when necessary, provide redirection and diversional activities as needed and report changes in behavior to the physician. Review of the comprehensive Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had severely impaired cognition and required limited assistance with ambulation. On [DATE], a secured unit placement was ordered by the physician as a necessary form of treatment to maintain safety of self and others. Review of the nursing note dated [DATE] at 6:15 A.M. revealed LPN #206 documented the nurse was charting when at approximately 9:00 P.M., Resident #108 reported to her that Resident #300 was in her bed. The nurse redirected Resident #300 to her own bed. At approximately 12:45 A.M., STNA #218 reported to the nurse that Resident #300 was not in her room. After searching the unit, the supervisor was notified. Staff continued to search and called a code Brown for a missing resident and the police were notified. Several attempts were made to contact the resident's son and voice messages were left to contact the facility. Review of the facility's investigation, initiated on [DATE] at 4:27 P.M. revealed on [DATE] at approximately 12:45 A.M., facility staff were unable to locate Resident #300 on the(NAME)4 secured unit. At approximately 3:45 A.M., with the assistance of the local law enforcement and emergency personnel, Resident #300 was located inside the walk-in cooler in the kitchen on the second floor of the(NAME)building, deceased . It was determined STNA #201 cancelled the door alarm on [DATE] at 9:35 P.M. and did not check the south stairwell where Resident #300 exited the unit. Review of the local Fire Department Report dated [DATE] revealed Paramedic #140 documented Resident #300 was found on the floor of the walk-in cooler unresponsive, pulseless, not breathing, cold to the touch with her pupils fixed and unresponsive. The resident was pronounced dead on site at 4:22 A.M. The walk-in cooler had a temperature of 37 degrees Fahrenheit (F). Review of Police Chief #500's report revealed he was dispatched to the facility on [DATE] at approximately 4:30 A.M. Upon arrival he conferred with the officers on site. He was advised a female resident had been located within the refrigeration unit used by the kitchen staff. The resident was found lying on her side in the corner of the walk-in cooler. Photographs were taken of the resident and the surrounding area. The surrounding area showed signs of distress. Several food trays had been knocked over and food spilled on the floor. Police Chief #500 was led up to the living quarters of the resident and retraced her steps leading to the kitchen. The first doorway into the stairwell was key coded and alarmed, which required a 15 second push in order to release the locking mechanism. From that point, the resident traveled down two flights of stairs, eventually going into the walk-in cooler. Upon inspection of the cooler door, there was no locking mechanisms on either side and no external lock on the door. During an interview on [DATE] at 8:37 A.M., the Administrator and DON revealed on [DATE] at approximately 1:20 A.M., the DON received a telephone call from Nursing Supervisor RN #119 that Resident #300 was missing and a code Brown had been initiated. The DON stated Nursing Supervisor RN #119 called again at 1:30 A.M. to inform her the resident had not been found. The DON instructed the nurse to notify the police immediately. The DON arrived at the facility at approximately 1:50 A.M. and several police were searching inside and outside the facility. The DON stated staff and police continued to search. The DON stated at approximately 2:30 A.M., she sent a text to all available employees to report to the facility to assist in the search. The DON further stated at approximately 2:45 A.M., she realized Maintenance Director #208 was probably sleeping and did not get the text so she called him and asked him to come to the facility immediately to review the camera footage. The DON stated the camera footage was viewed by her with the police and MD #208 and showed the resident exiting the south stairwell located on the second floor near the kitchen. The DON notified staff to check the kitchen and the coolers. The DON stated she went to the kitchen and checked the area again. She checked the walk-in coolers and at 3:55 A.M. observed Resident #300 lying on the floor of walk-in cooler #17. The resident's skin was pale and her lips were bluish. The DON stated the paramedics were already in the building and assessed the resident. The paramedics did not attempt to resuscitate Resident #300 and determined she was deceased . The DON stated she was not aware STNA #201 had cancelled the exit door alarm on(NAME)4 until her interview on [DATE]. The Administrator stated the kitchen doors and walk-in cooler #17 were not locked. The cooler doors can be locked on the outside with a padlock and can be pushed open from the inside. The Administrator stated Dietary Worker #23 had failed to lock the kitchen door when leaving the night of [DATE]. The security camera footage was viewed on [DATE] at 10:00 A.M. with Maintenance Director #208 and Clinical Service Manager RN #273. The camera footage revealed on [DATE] at 9:27 P.M., Resident #300 was dressed in a white gown with a pink undershirt, ambulating independently down the south stairwell from(NAME)3 to(NAME)2. The resident went through the door to the(NAME)2 unit. At 9:31 P.M., the resident comes back through the door from(NAME)2 and walks back up the stairs to(NAME)3. At 9:36 P.M., Resident #300 comes back down the stairs for the last time from(NAME)3 to(NAME)2, goes through the door again and turns right toward the kitchen. Maintenance Director #208 revealed there are cameras at the exits of the facility but not on the units. On [DATE] between 3:00 P.M. and 4:00 P.M., observations were made of the kitchen doors and revealed a badge reader requiring staff to open doors with identification badges. Observation of the south stairwell exit door of the secured unit(NAME)4 revealed the door will not open when pushed and staff must enter a code to silence the alarm and to enter or exit the unit. On [DATE] at 12:56 P.M. during a telephone interview, STNA #247 stated she was Resident #300's assigned aide on [DATE] for the second shift, 3:00 P.M. to 11:00 P.M. STNA #247 stated she had put the resident to bed at approximately 9:00 P.M. and continued to assist other residents. STNA #247 stated when she was exiting another resident's room, she observed Resident #300 and the nurse walking toward the resident's room at approximately 9:30 P.M. STNA #247 stated she did not hear any alarms on the unit during her shift. She stated STNA #201 was the other assigned aide and she never mentioned an alarm sounding. STNA #247 stated never saw Resident #300 after that. She assumed everyone was in bed because there were no residents up or in the hallway. She left the facility at the end of her shift. On [DATE] at 1:17 P.M. during a telephone interview, LPN #206 stated between 9:00 P.M. and 9:30 P.M., Resident #108 informed her resident #300 was in her bed. LPN #206 stated she returned Resident #300 to her bed, which was located beside Resident #108's room. LPN #206 stated that was the last time she saw Resident #300. LPN #206 stated at approximately 12:30 P.M., STNA #218 notified her that she could not find Resident #300. The nurse and the STNA's searched the unit again because Resident #300 had a history of [REDACTED]. LPN #206 stated she notified Nursing Supervisor RN #119 and the code Brown was initiated. The local police were notified. LPN #206 stated she did not hear any alarms that night, which is why she thought the door alarms were not working. On [DATE] at 1:51 P.M. during a telephone interview with STNA #218, she stated she was Resident #300's assigned aide the night of [DATE]. STNA #218 stated when she started her shift at 11:00 P.M., she did not do rounds. She started going from room to room checking and changing residents that needed care. STNA #218 stated when she came to Resident #300's room, she was not in her bed. STNA #218 stated she started checking every room because the resident had a history of [REDACTED]. STNA #218 stated after looking into the other rooms, she notified LPN #206 on [DATE] at 12:45 A.M. that she couldn't find Resident #300. On [DATE] at 8:15 A.M. during a telephone interview, Dietary Porter #23 stated he left the facility at approximately 7:10 P.M. and did not lock the kitchen doors. On [DATE] at 3:32 P.M. during a telephone interview, STNA #201 stated she had returned from lunch at approximately 9:35 P.M. She was at the opposite end of the hall from the southernmost stairwell exit when she heard the exit door alarm. STNA #201 stated she had seen STNA #247 coming down the hall and assumed she had triggered the alarm. That is why she didn't check the stairwell before silencing the alarm. Review of the facility policy titled Elopements and Wandering Residents, dated [DATE], revealed the facility ensures that residents who exhibit wandering behaviors and/or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement. 4 a.) Adequate supervision will be provided to help prevent accidents or elopements. This deficiency substantiates Complaint Numbers OH 866 and OH 828.

Based on medical record review, review of hospital documentation, staff interview, and review of a facility policy, the facility failed to ensure Resident #1 was adequately and timely assessed when the resident experienced with a change in condition. This resulted in actual harm when Resident #1 experienced a change in condition, the resident was subsequently hospitalized and received intravenous (IV) antibiotic treatment for [REDACTED].#1) of three residents reviewed for hospitalization s and. The facility census was 231. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE]. The resident was transferred to the hospital on [DATE] and was hospitalized until 10/25/17, when she returned to the facility. Medical [DIAGNOSES REDACTED]. The resident had a quarterly Minimum Data Set (MDS) assessment completed on 10/03/17 which indicated she had a brief interview for mental status (BIMS) score of 12 out of 15, indicating moderate impairment in cognition. The resident was receiving [MEDICAL TREATMENT] treatments. Review of the resident's nursing notes revealed an entry on 10/18/17 at 1:04 P.M. by Registered Nurse (RN) Unit Manager #53 indicating Resident #1's family was requesting the resident be sent to the hospital due to a change in mental status. A physician's orders [REDACTED]. There were no additional nursing notes on 10/18/17 indicating a change in condition for the resident. Review of the resident's transfer form dated 10/18/17 at 12:55 P.M. completed by Licensed Practical Nurse (LPN) #54 revealed the resident was transferred to the hospital for abnormal laboratory values and assessment. Vital signs were documented as follows: 10/18/17 at 8:47 A.M. blood pressure was 178/120, blood sugar was 147 at 5:57 A.M. on 10/18/17; 10/16/17 at 9:18 A.M. pulse was 69; 09/22/17 at 2:13 P.M. respirations were 18, temperature was 98.0 degrees Fahrenheit (F), and oxygen saturation was 99.0 percent (%). The resident's pain level was documented as a seven on 10/17/17 at 11:05 P.M. The transfer form indicated the resident was not alert and was not ambulatory. Review of the resident's Situation, Background, Assessment/Appearance and Request (SBAR) form dated 10/18/17 at 12:54 P.M. completed by LPN #54 revealed the resident was unresponsive since 10/18/17 (no time indicated) and had gotten worse. It was documented the resident was in and out of consciousness, not eating, and not responding to speaking or touching. The resident was experiencing pain with movement. The resident's vital signs were documented as they were on the 10/18/17 transfer form. The resident's family requested a transfer to the hospital. Review of the resident's vital sign records revealed the resident's blood pressure was 156/84 on 10/17/17 at 11:04 P.M. The next documented blood pressure was on 10/18/17 at 8:47 A.M. of 178/120. At 1:16 P.M. on 10/18/17, a blood pressure of 156/71 was documented. The most recent pulse was 69 on 10/16/17. The most recent respirations were 18 on 09/22/17. The most recent temperature was 98.0 degrees F on 09/22/17. Interview with State tested Nursing Assistant (STNA) #62 on 10/30/17 at 10:45 A.M. revealed she was the STNA scheduled to care for Resident #1 on 10/18/17. She stated the resident was not acting right at breakfast on 10/18/17 and spit out some of her breakfast. She notified LPN #54 the resident was not responding in her normal manner and the nurse came in to check her. She was not sure what the nurse had determined. The resident's family came in around lunch time and requested the resident be given a supplement instead of a lunch tray as she was not responding normally to them. The resident did not want to eat. The resident would respond with yes, ma'am only with much prompting and rubbing her arm by the STNA. She stated the resident would not respond to her family. The family was very upset and requested the resident be sent to the hospital. Interview with RN Unit Manager #53 on 10/30/17 at 1:55 P.M. revealed she was not aware of Resident #1's elevated blood pressure at 8:47 A.M. on 10/18/17. She stated she was not aware that LPN #54 did not document an updated set of vital signs or assessment when the resident's experienced an alteration in her level of consciousness on 10/18/17, which resulted in a transfer to the hospital. Interview with LPN #54 on 10/31/17 at 9:51 A.M. revealed she notified RN Unit Manager #53 of Resident #1's elevated blood pressure of 178/120 on 10/18/17 at 8:47 A.M. She stated RN Unit Manager #53 instructed her to give the resident her routine blood pressure medications and recheck the blood pressure. She verified she did not review the resident's previous vital signs to see if this was the normal range for her. She did not recheck the resident's blood pressure until lunch time when she was sending her to the hospital. She stated she asked the resident if she was in any pain and she denied pain at 8:45 A.M. on 10/18/17. At lunch time on 10/18/17, the resident's family was visiting and requested she be transferred to the hospital. LPN #54 stated she went in to assess the resident at that time. She verified she did not document any further assessment of the resident between 8:45 A.M. and the time the resident was sent out around 1:00 P.M. She stated 10/18/17 was her first day off orientation and she did not know the charting system well. She thought she had obtained a full set of vital signs prior to sending the resident to the hospital, however, she was not sure where they were documented. She verified she did not document a current set of vital signs on the SBAR or transfer form on 10/18/17. Further interview with RN Unit Manager #53 on 10/31/17 at 10:25 A.M. revealed she did not recall LPN #54 informing her of Resident #1's blood pressure being elevated on 10/18/17. She stated she would have had her call the physician for further direction with a blood pressure of 178/120. Review of the resident's discharge hospital documentation dated 10/18/17 through 10/25/17 revealed the resident had a temperature of 100.2 degrees F on admission to the hospital and was admitted due to altered mental status. The resident received [MEDICATION NAME] and [MEDICATION NAME] antibiotics IV during her admission to the hospital. Cultures of her blood, urine, and peritoneal fluid showed no growth. The hospital physician diagnosed the resident as having failure to thrive and suggested percutaneous endoscopic gastrostomy (PEG) tube placement. Upon discharge, the physician indicated the resident's leukocytosis (increased white blood cell count) was likely secondary to an infection and had improved. He indicated the resident's acute [MEDICAL CONDITION] was likely secondary [MEDICAL CONDITION], however there was no clear infectious source. The resident was diagnosed with [REDACTED]. Review of a facility policy titled Change of Condition dated 10/18/01 revealed a change of condition is defined as deterioration in the health, mental, or psychosocial status of a resident related to a) a life-threatening condition, b) a significant alteration in treatment, or c) a significant change in the resident's clinical condition or status. Life threatening conditions may include any of the following, depending on severity: cardiovascular or respiratory changes, broken bones, semi or unconsciousness, choking, dehydration, infection, or impaction. Significant alteration in treatment is defined as a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new treatment, or the decision to transfer a resident to a hospital. Significant changes in resident's clinical condition or status include improvement or decline in the following: to include emergence of unstable condition or disease. The unit supervisor or charge nurse will notify the resident, physician and guardian/interested family member of all changes. The person doing the notification will document all notification in the medical record. This deficiency substantiates Complaint Number OH 153.

Based on record review, staff and family interviews, the facility failed to ensure a care planned fall intervention was in place and activated for a resident identified at risk for falls. This resulted in actual harm when Resident #29's alarming seatbelt was not activated, the resident fell , which resulted in abrasions, a subdural hematoma and subsequent hospitalization with monitoring. This affected one (Resident #29) of three residents reviewed for falls. The facility census was 238. Findings included: Record review for Resident #29 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #29's fall risk care plan revealed the resident had a history of [REDACTED]. Review of Resident #29's use/application of an external device for prevention of injury care plan revealed the resident was as risk for falls/injury. Interventions included to apply the self-releasing alarming seatbelt and to use the safety device when in wheelchair. Review of Resident #29's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition as interview for cognitive status could not be conducted. She had daily behaviors directed towards others and wandering which had increased. The resident required extensive assistance of two or more staff for bed mobility. She required extensive assistance of one staff for transfers, toilet, and personal hygiene. The resident did not walk in her room or corridor. Regarding balance the resident was not steady, only able to stabilize with human assistance with moving from a seated to standing position, moving on and off toilet and surface-to surface transfers (transfer between bed and chair or wheelchair). The resident used a wheelchair and was receiving hospice services due to end stage Alzheimer's disease. The resident triggered a fall care area assessment and a fall care plan was implemented. Review of a nursing progress note, dated 08/29/17 at 3:15 P.M., revealed the resident was removing the self releasing alarm seatbelt several times and grabbing tightly with attempts to re-apply. There was no documentation noted of a re-evaluation of the effectiveness of the intervention. Review of the nursing progress notes, dated 09/23/17 at 10:44 A.M. revealed the resident was found to be laying prone on the floor in the hallway. Resident #29 was noted to be bleeding from her nose. The wheelchair was noted near the resident. The seatbelt wasn't activated at the time of the fall. A full body skin assessment was completed. The resident was found to have a 3.5 centimeter (cm) by 2 cm abrasion on the forehead and a 2 cm by 1.0 cm abrasion on bridge of nose. Resident #29's nose was bleeding and her top lip was swollen. The physician was notified and ordered the resident sent to the emergency room . The family was notified as well. Review of the nursing progress note dated 09/23/17 at 7:28 P.M. revealed the resident was admitted to the hospital intensive care unit for subdural bleeding. Review of the radiology report of the computerized tomography (CT) scan dated 09/23/17 at 2:57 P.M. revealed the scan showed a thin parafalcine subdural hematoma. Review of the hospital progress notes dated 09/24/17 revealed the CT scan in the emergency room showed a possible subdural hematoma, she was admitted to Intensive Care Unit (ICU) where she was observed for any neurological worsening. A repeat CT scan on 09/24/17 did not show any bleeding. the resident was transferred from the ICU to the floor. The assessment/plan revealed the resident had a subdural hemorrhage that was small and stable overnight. An interview with the family of Resident #29 revealed the resident wore a seat belt with an alarm and there was an alarm on the bed. The family stated the resident on fell on [DATE] out of her wheelchair. The staff stated the alarm was not on. She was sent to the hospital where a CT scan showed a brain bleed and she was admitted to the ICU. During an interview with the Regional Nurse (RN) #222 on 09/27/17 at 5:15 P.M. verified Resident #29 had a fall from her wheelchair and the seatbelt was not activated at the time of the fall.

Based on observations, staff interviews, review of the steam table owner's manual, and review of documentation from the American Burn Association, the facility failed to provide a safe environment free from accident hazards when steam tables were observed unattended in three of six serveries in the facility. This resulted in Immediate Jeopardy for 53 cognitively impaired mobile residents (#30, #34, #35, #37, #54, #64, #72, #87, #89, #103, #114, #116, #117, #123, #124, #125, #131, #135, #142 ,#156, #160, #165, #180, #182, #188, #192, #202, #208, #218, #225, #232, #245, #246, #251, #260, #261, #267, #271, #278, #282, #285, #294, #299, #300, #309, #323, #330, #375, #381, #395, #399, #500 and #501) who reside on the locked dementia units, Lourdes 4 (L4) unit and Emma 4 (E4) unit, and 18 additional cognitively impaired mobile residents (#10, #24, #31, #40, #65, #74, #122, #146, #152, #181, #222, #224, #274, #296, #301, #307, #358 and #384) who reside on the Brunner 4 (B4) unit. Additionally, the facility failed to ensure a resident at high risk for falls had his fall prevention intervention correctly in place. This involved a self releasing seat belt which was not properly secured around one resident (#130) which allowed the resident to fall forward in his wheelchair and hit his head on the ground sustaining three abrasions. This affected one of four resident's reviewed for accidents of 64 residents who had falls in the past 60 days. The facility census was 253. On 09/18/12 at 3:50 P.M., the Administrator was notified Immediate Jeopardy began on 09/17/12 at 12:49 P.M. when a steam table in the servery on the B4 unit was observed unattended with hot water visibly boiling in it. The boiling point of water is 212 degrees Fahrenheit (F). Additionally, observations on 09/17/12 at 2:25 P.M. and 2:46 P.M., revealed the L4 servery was left unattended when the steam tables were on and contained hot water which measured 150 degrees F and the E4 servery also had unattended steam tables with hot water that measured 135 degrees F. This placed all 71 residents at risk for third degree burns which penetrates the entire thickness of the skin and destroys the skin tissue. The Immediate Jeopardy was removed on 09/23/12 at 11:00 A.M. when the facility implemented the following corrective actions: ? On 09/17/12 at 4:15 P.M. when the B4 servery steam table was off and cool to touch and the L4 and E4 steam tables were secured by locked doors. ? On 09/18/12, the steam tables on B4 and L4 serveries were removed to a non-resident area between meals. ? On 09/19/12, the facility developed a policy regarding the use of portable steam tables. The new procedure directed all steam tables will be kept in a locked area when not in use, removed to a non-resident area or monitored by a staff member while on, heating up or cooling down. ? On 09/19/12, the supervisors of each department began inservicing all staff on the new steam table policy and procedure and in-servicing was to be completed by 09/23/12 at 11:00 A.M. ? On 09/19/12 between 1:10 P.M. and 2:06 P.M., Dietary Aide (DA) #16, DA #18, DA #20 and Licensed Practical Nurse (LPN) #22, LPN #24, State tested Nurse Aide (STNA) # 2, STNA #4, STNA #6, STNA #8, STNA #10, STNA #12 and STNA #14 all verbalized knowledge of the new servery procedures during staff interviews. Although the Immediate Jeopardy was removed when the facility secured the steam tables in a manner to prevent resident access, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) because the facility failed to ensure the environment was free of accident and hazards by failing to ensure fall prevention interventions were correctly placed. Findings include: 1. Observations on 09/17/12 at 12:49 P.M. of the B4 dining/activity room (off the resident hallway) revealed there were 11 residents in the dining room, sitting at tables, waiting on lunch to be served. The steam table located in the dining room was plugged in and turned on. Observation of the steam table revealed there were three heated wells for food each containing water with lids in place. The lids to the three wells were hot to touch. Removal of the lids revealed boiling water in each of the three wells. There was no staff present in the dining room with the 11 residents. The dining/activity room was in an open area, beside the resident hallway, with no doors. Observations on 09/17/12 at 12:58 P.M. revealed DA #50 in the dining room placing food on the steam table. Interview with DA #50 at that time confirmed when she placed the food on the steam table the water was boiling and the lids were very hot to touch. Further interview with DA # 50 revealed she turns the steam tables on in the morning by 7:00 A.M. and then goes back to the kitchen to allow the steam table time to get hot. She stated she returns to the dining room around 8:00 A.M. to place the hot food into the steam table and during that time frame the steam table is left unattended. DA #50 stated after breakfast, the steam table is turned down; however, remains on, until lunch is brought to the dining room around 12:45 P.M. After lunch, the steam table is turned off and then turned back on at 4:00 P.M. to allow the steam table time to get hot. Dinner is then brought to the steam table around 5:45 P.M. The steam table is left unattended from the time it is turned on until the food is brought in. On 09/17/12 at 1:48 P.M. DA #50 left the B4 dining area. Residents were still in the dining room, without staff present, and other residents were observed independently going up and down the hallway in front of the open dining area. Interview on 09/17/12 at 2:10 P.M. with Registered Nurse (RN) #99, who is the unit manager of the B4 unit, confirmed the lids on the three wells of the steam table were still very hot to touch. RN #99 stated, to her knowledge, no resident has been burned due to the steam tables being left on. On 09/17/12 at 2:27 P.M. (39 minutes after the steam table was turned off), the temperature of the hot water in the three wells on the steam table was taken and measured 122 degrees F per the facility's thermometer. This was verified by DA #50. Observations made on 09/17/12 at 2:35 P.M. revealed two doors leading to the steam table on the E4 kitchenette were wide open. The E4 kitchenette was at one end of the residents' dining room and was enclosed from the dining room by two parallel walls and a counter top facing the dining room. Next to the counter was a door that led to a hallway, and immediately behind that door was another door that led to the kitchenette where the steam table was located. The steam table was located across from the door, along the opposite wall and perpendicular to the kitchen counter. The steam table was accessible to residents through the two open doors. The door leading directly into the kitchenette had a sign which read "Please keep door locked when kitchen is unattended." Resident #124 was observed standing in front of the counter near the first open door. There was no staff observed in the area at this time. When touched, the stainless steel dome lids covering the hot water in the steam table were hot. At 2:46 P.M., STNA #30 measured the temperature of the water in the steam table with a facility thermometer and the temperature was 135 degrees F. She verified the door leading directly into the kitchenette should have been closed and locked. At 2:48 P.M., RN #85 also confirmed the door to the kitchenette should have been closed and locked and that Resident #124 was cognitively impaired and ambulatory. Observations made of the L4 dining/activity room on 09/17/12 at 1:56 P.M. revealed the entrance door was opened and a steam table located in the dining room was plugged in and turned on. There were four hot wells on the steam table with metal lids covering the wells. The four lids were hot to touch and steam was observed rising from around the lids. When the lids were lifted hot water was observed inside the four wells. The observation further revealed no staff was present in the dining room. During an observation on 09/17/12 at 2:00 P.M., the L4 Nurse Manager (#121) touched one of the lids on the steam table with her bare hand, then immediately withdrew her hand and stated she was unable to keep her hand on the lids because they were too hot. The nurse manager (#121) verified the door to the dining room was opened and no staff was present in the dining room. She further stated residents of L4 unit were cognitively impaired and mobile. The Nurse Manager (#121) revealed the door to the dining room should always be closed and locked when staff is not present. During interview on 09/17/12 at 2:37 P.M., Registered Dietitian (RD) #100 confirmed the steam table was on and verified the lids felt hot. RD #100 explained that the dietary aides were instructed to turn off the steam table after each meal service and again affirmed the steam table was on. RD #100 was observed to turn off the steam table by rotating four dials located on the steam table. At 3:05 P.M., 28 minutes after the steam table was turned off, RD #100 stated the surface temperature of each lid was unable to be measured. RD #100 was observed to measure the temperature of the water in each well and reported the temperature of the water in Well #1 was 150 degrees F, Well #2 was 140 degrees F, Well #3 was 120 degrees F, and Well #4 was 120 degrees F. RD #100 confirmed steam tables were used on six different units in the facility and stated "we need to rethink this process." Review of the operator's manual for the steam tables used in the serveries indicated all units should be turned off when not in use and the unit should be set at the highest setting to maintain a minimum hot water temperature of 185 degrees F. The manual further stated the equipment is designed for use only by trained and experienced personnel. During an interview on 09/19/12 at 1:45 P.M., the Administrator stated the facility had no written policy and procedure related to the operation of the steam tables. Interview on 09/20/12 at 9:37 A.M. with RD #100 revealed the six steam tables were obtained and added to the units at different times. She stated the first of the six steam tables was placed in operation about 2 years ago. RD #100 stated there was no formalized training given to any of the staff. The staff was verbally in-serviced during their initial training. The staff are expected to turn the steam tables on in advance in order to preheat them. The staff then leave the steam tables unattended while they are in the kitchen getting the food. At the end of the meal they are to turn the steam tables off and remove the food. Dietary staff are expected to turn the steam tables on to the highest temperature in order for the water to get hot enough to maintain the appropriate food temperatures. According to the American Burn Association, the severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. The most common regulatory standard for the maximum temperature of water delivered by residential water heaters to the tap is 120 degrees Fahrenheit. At this temperature, the skin of adults requires an average of five minutes of exposure for a full thickness burn to occur. When the temperature of a hot liquid is increased to 140 degrees F, it takes only five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 degrees F, resulting in almost instantaneous burns that will require surgery. Since immediate removal of the hot liquid from the skin may lessen severity, splash and spill burns may not be as deep as burns suffered in a bathtub. Review of the facility's incident and accident logs dated 03/20/12 to present (09/20/12), indicated no incidents of residents being burned due the steam tables. 2. Review of Resident #130's medical record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #130's fall assessment dated [DATE] documented the resident was at high risk for falls. On 08/14/12 the physician wrote an order for [REDACTED]. According to the computerized nurses notes on 08/18/12 at 9:24 P.M. Resident #130 was found slumped in the wheelchair leaning forward with the top of head on the floor in the doorway of room. Resident #130 was secured in place by a self-releasing seat belt on his wheelchair and all four wheels of the wheelchair were on the floor. The resident sustained [REDACTED]. On 09/27/12 at 11:47 A.M. the nurse (Licensed Practical Nurse #110) that found Resident #130 after his fall on 08/18/12 was interviewed. LPN #110 stated when the resident was found he was still in his wheelchair with his seatbelt on and his head was on the ground. LPN #110 stated the resident's seatbelt was loose around the resident's waist. LPN #110 further stated on 08/19/12 the resident was "not eating and not right" so the doctor was notified and the resident was sent to the hospital. When interviewed on 09/27/12 at 10:00 A.M. the DON verified Resident #130 had a seatbelt in his wheelchair for safety and that on 08/18/12 the seatbelt was not applied correctly which permitted the resident to slump forward so much his head hit the floor causing abrasions. This citation substantiates allegations in Complaint Number OH 351.

Based on observation, record review and interview, the facility did not attempt to prevent or control pain for one resident (#153) who received treatments of recently debrided (dead tissue removed by scalpel) bed sores. This deficient practice resulted in actual harm for one (#153) of two residents observed during treatment of [REDACTED]. Findings include: Review of medical record revealed Resident #153 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #153 was admitted to hospice for palliative care, was totally dependant on staff for all care and received treatments for pressure ulcers. Further record review revealed Resident #153 was prescribed [MEDICATION NAME] (pain medication) on 03/30/12 as needed for pain, on 07/08/12 was prescribed [MEDICATION NAME] (narcotic pain medication) routinely every four hours, and on 09/10/12, active treatment to pressure sores began. On 09/20/12 at 6:50 A.M., Resident #153 was observed during wound care treatment to the right lateral foot. During the treatment, Resident #153 was observed withdrawing her foot from the nurse, frowning, wincing, and raising her left arm and hand. Resident #153 was also heard whimpering. Resident #153 was aphasic and unable to state her needs to staff. During interview immediately following the treatment, Licensed Practical Nurse (LPN) #11 confirmed Resident #153 displayed signs and symptoms of pain. LPN #11 also confirmed the resident was not administered pain medication for the specific purpose of preventing possible pain during the treatment and confirmed the treatment was continued while the resident displayed signs of pain. LPN #11 explained that Resident #153 was prescribed [MEDICATION NAME], a pain medication, routinely and it was not yet time for Resident #153 to get the scheduled [MEDICATION NAME]. During treatment to a pressure ulcer located on the left hip on 09/21/12 at 3:45 P.M., Resident #153 was observed raising her left arm and hand, wincing and frowning, and was heard moaning and crying. During interview immediately following the treatment, LPN #112 confirmed Resident #153 displayed signs and symptoms of pain and indicated Resident #153 was medicated with the regularly scheduled [MEDICATION NAME] before the treatment was performed. Review of facility nursing policy and procedures related to pressure ulcers dated 10/18/01 and revised 11/06, indicated residents with pressure ulcers were assessed for pain daily and if pain was not adequately controlled, nurses would intervene as needed. Interview with the Director of Nursing (DON) on 09/28/12 at 12:30 p.m. confirmed attempt to prevent or control pain to the extent possible should have been done for Resident #153. This certification deficiency is an example of continued noncompliance from the complaint investigation of 09/04/12.

Based on closed medical record review, review of hospital documentation, review of the facility policy regarding neglect, and interview with facility staff, including the attending physician, the facility failed to prevent resident neglect when staff did not assess and provide physician ordered care and services to a newly admitted resident for 12 hours. This resulted in Immediate Jeopardy for one (Resident #268) of 14 newly admitted /readmitted sampled residents. The total facility census was 265 residents. On [DATE] at 5:45 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at approximately 3:42 P.M. when Resident #268 arrived at the facility from a local hospital after having a pancreatectomy due [MEDICAL CONDITION]. The resident was not assessed upon admission or periodically during the next two shifts. The hospital physician orders were not clarified with the physician and the resident did not receive blood glucose monitoring, medications to include insulin and continuous tube feeding. On [DATE] at 2:30 A.M., the resident was found unresponsive with labored breathing with a large amount of coffee ground emesis on his mouth and chest. The emergency medical service (EMS) reported Resident #268 ' s blood sugar was 27 on their arrival to the nursing facility. Resident #268 was transferred to the hospital via emergency transport on [DATE] at 2:45 A.M. where he subsequently expired in on [DATE]. The Immediate Jeopardy was removed and corrected on [DATE] when the facility took the following actions: - On [DATE] the DON instituted a new " triple check " admission procedure for the staff to follow for all newly admitted residents. The new admission procedure requires two nurses to check all admissions to ensure resident admission assessments are completed. Upon admission a nurse must write a narrative admission note to include time of admission, mode of arrival to the nursing facility and a summary of pertinent assessment findings. Additionally, one nurse is required to transcribe the admitting physician ' s orders and a second nurse is required to confirm and check the admitting orders with the attending physicians. In order to monitor the process the day after admission, the physician ' s orders are to be verified a third time by the DON, Unit Managers, or Supervisors. Any special care required for a newly admitted resident was to be initiated upon their arrival. - On [DATE] all staff involved in the admission process were in-serviced on the new Triple Check Admission Policy and Procedure. - Review of 13 residents admitted in [DATE] revealed nursing staff completed admission assessments, verified admitting physician orders and verified care. - Review of medical records for five residents after the implementation of the new facility policy and procedures revealed all were assessed upon admission. Physician orders were verified and documented as administered as ordered. Care was documented as provided according to the physician orders. - On [DATE], Licensed Practical Nurse #1 (LPN #1) received a final written warning regarding failure to provide nourishment, medication and tube feeding to Resident #268 and failure to provide a report to the oncoming nurse regarding the care. - On [DATE] and [DATE] interviews with four nursing staff revealed they were retrained in the admission process and knew the current admission process. Findings include: A review of the hospital Discharge Summary dated [DATE] revealed the resident was admitted to the hospital for a total pancreatectomy (excision of the pancreas which will cause diabetes because of a lack of insulin) and splenectomy (surgical excision of the spleen) due to [MEDICAL CONDITION]. The Discharge Summary dated [DATE] documented [DIAGNOSES REDACTED]. Review of the hospital Medical Staff Progress Notes dated [DATE] at 7:22 A.M. revealed Resident #268 ' s discharge examination indicated his pain was minimal and controlled, he denied nausea and vomiting, chest pain or shortness of breath. The resident was documented as alert and oriented to person, place and time, pleasant and comfortable; his heart had a regular rate and rhythm; he was breathing comfortably; his abdomen was soft, without tenderness or distention and his incision was clean, dry and intact with staples. The Progress Notes included the resident had a continuous tube feeding of [MEDICATION NAME] at 70 cubic centimeters (cc) per hour and his glucose was 134 on [DATE] at 5:28 A.M. Physician #10 stated the resident was doing well overall and he would need an appropriate outpatient regimen for his diabetes that was secondary to his pancreatectomy. The physician further stated " Nutrition-tolerating tube feeds. Not much po (oral) intake. Hopefully this will improve. Until then, continue tube feeds. " The hospital Discharge Summary dated [DATE] stated the resident was discharged from the hospital to the facility on [DATE] at 3:03 P.M. Further review of the Discharge Summary dated [DATE] from the hospital revealed Resident #268 was to receive tube feedings via jejunostomy tube, as well as a regular diet by mouth. A review of the facility ' s All Active Orders for [DATE] dated [DATE] documented Resident #268 was to receive Fibersource HN (a type of tube feeding) at 60 milliliters and hour continuous. The first entry in the facility ' s nurses ' notes by LPN #2 was dated [DATE] at 3:26 A.M., 12 hours after admission. LPN #2 documented the resident was observed " awake and alert at 12:30 A.M., talking clearly and precisely with respirations even and unlabored. Resident at 2:30 A.M. was observed with large amount of coffee ground emesis and undigested food particles coming from mouth and running down chest with labored breathing and gurgles. Resident was observed to be unresponsive with several attempts made with verbal, touch and pain stimuli to arouse resident ...all attempts were unsuccessful. R.N. (Registered Nurse) supervisor notified of change in resident ' s condition. R.N. supervisor arrived to unit, attempt made to notify P.A. (physician assistant #5) for Dr. (resident ' s attending physician #9) was unsuccessful. 911 immediately called. " The resident ' s vital signs were also documented. Respirations were 30 per minute, blood pressure was ,[DATE] and the oxygen saturation level was only 86% on room air. Oxygen was applied per nasal cannula at four liters, but when rechecked, the oxygen saturation level remained at 86%. The notes further indicated the " resident remains unresponsive with gurgles noted and labored breathing. Squad arrived at 2:45 A.M., assessed resident, and proceeded to transport out of facility " . Review of emergency room Triage Notes dated [DATE] at 6:09 A.M. revealed the resident arrived to the emergency department from the nursing home via emergency medical services (EMS) with a complaint of shortness of breath. The notes stated EMS reported the resident ' s blood sugar was 27 on their arrival to the facility. The resident was documented as nonverbal and on a non-rebreather mask. The resident was given 2 [MEDICATION NAME] of glucose (D50). During an interview with Registered Nurse #2 (RN #2) on [DATE] at 4:15 P.M. she stated she was the unit manager on [DATE] when Resident #268 was admitted . RN #2 stated she was not certain what time Resident #268 arrived at the facility, as there was no documentation in the medical record of when he arrived or his condition. RN #2 stated she thought he had been admitted sometime in the afternoon on [DATE]. RN #2 confirmed there were no nurses ' notes indicating the resident ' s condition prior to him being found unresponsive at 2:30 A.M. on [DATE]. RN #2 stated an initial admission assessment of the resident had not been completed prior to his discharge on [DATE]. RN #2 stated she had transferred the physician ' s orders from the hospital discharge instructions over to the attending physician ' s order. She stated she had left a message at the physician #9 ' s office to call the facility to confirm the resident ' s orders. She stated when she left the facility in the evening, the physician had not called to confirm the orders and she was not aware if he had called back to confirm the orders later. The DON stated the facility had an admission checklist that the staff was to follow and that all of the items were to be marked as completed within 24 hours of a resident ' s admission and returned to her. She stated she did not receive the admission checklist for Resident #268, indicating any type of assessment of the resident had ever been conducted. Review of the admission checklist (undated) revealed that after the resident was admitted , vital signs were to be obtained and entered into the electronic medical record (EMR). The continuity information from the admitting hospital was to be entered into the EMR. The physician ' s orders were then to be printed and verified with the attending physician, as well as any pertinent lab required. Documentation of the physician ' s approval was to be documented. If any labs were required, the lab requisition was to be completed. The physician ' s orders should then be faxed to the pharmacy so that the medications for the resident could be obtained. Interview with Licensed Practical Nurse #1 (LPN #1) on [DATE] at 5:00 P.M revealed she did not normally work on the unit on which Resident #268 resided. She stated during the afternoon of [DATE], she was " pulled " off of her unit and transferred to Resident #268 ' s unit to work. She stated she advised the nursing supervisor that she was not familiar with the residents on that unit and did not feel comfortable working on the unit, but stated she was mandated to stay and work on the unit anyway. LPN#1 stated she arrived on the unit at approximately 3:30 P.M. She stated as she was administering medications to residents in their rooms, she noticed there was a resident sitting up in the bed in the room where Resident #268 resided. She stated she had no idea who the resident was. She stated she had not received a report on Resident #268 or any of the other residents on the unit prior to beginning her medication administration. She stated when she asked RN #3 about Resident #268, she was advised that she didn ' t have to worry about doing anything with him or administering him any medications. She stated she was not advised to complete any part of the admission assessment. An interview with RN #3, the second shift supervisor for the facility was conducted on [DATE] at 5:15 P.M. RN #3 stated she came on duty at 3:00 P.M on [DATE]. When she made her rounds on the unit, Resident #268 was already in his room. RN #3 stated she was not told the physician had not called back to confirm the orders for the resident ' s medication and treatments. RN #3 stated she was not aware of Resident #268 ' s diagnoses, that he was to have a tube feeding administered, and stated she was not aware that his blood glucose should be monitored. During the interview with the DON and RN #2 on [DATE] at 4:17 P.M., they both stated there were no dietary intake records for the evening meal on [DATE] and there was no evidence that Resident #268 received a tray of regular food for the evening meal. The DON and RN #2 also confirmed the jejunostomy tube feedings had never been started for Resident #268, since the physician had never called back to confirm the orders. RN #2 stated there was no order to monitor the resident ' s blood glucose level on the discharge instructions from the hospital. RN #2 confirmed that a resident who had recently had their pancreas removed (as insulin is produced by the pancreas) and was receiving insulin injections four times per day may be at risk of fluctuating blood glucose levels and should have a physician ' s order to monitor the blood glucose levels. Review of the medication administration records for Resident #268 confirmed the resident did not receive any of his medications from the time of admission on [DATE] at 3:42 P.M. until he was transferred via emergency squad to the hospital at 2:45 A.M. on [DATE]. Interview with LPN #2 on [DATE] at 3:45 P.M. revealed she wrote the nurse ' s note dated [DATE] at 2:30 A.M. regarding the significant change in Resident #268 ' s condition. LPN #2 stated she came in late for her night shift on [DATE] and met with LPN #4 (had worked the 2nd half of the ,[DATE] shift ). LPN #4 and LPN #2 counted narcotics for verification of correct amounts. LPN #2 stated LPN #4 did not provide any report on the condition of any of the residents. LPN #2 stated LPN #4 told her " things have been crazy around here " and pointed to the nurses ' station. LPN #2 stated LPN #4 told her there had been three new admissions and she had not had time to take care of anything with any of them. LPN #2 stated after she counted narcotics, she did go to the rooms of all three newly admitted residents, just to see them and to introduce herself. She confirmed that Resident #268 did not have a feeding pump in his room and was not receiving any type of tube feeding. She stated at that time, which was approximately 12:00 A.M.; the resident was in his bed, awake, talking, and appeared to be oriented. LPN #2 stated that none of Resident #268 ' s information had been placed in the medication or treatment administration records since his admission. She stated she did not administer any medications or treatments to Resident #268. LPN #2 stated that at approximately 2:30 A.M. State tested Nurse ' s Aide (STNA) #8 told her she had seen him Resident #268 earlier when she had passed the room and he " seemed fine " , but when she went back in at 2:30 A.M. to check on him, he seemed like he " was out of it " . LPN #2 stated when she entered the room; Resident #268 had vomited coffee ground emesis and was unresponsive. She contacted the nursing supervisor. LPN #2 stated she thought she had checked the resident ' s blood glucose level at that time, but confirmed there was nothing documented. She stated she did not remember what his blood glucose level was at the time. An interview with the resident ' s attending physician ' s assistant #5 on [DATE] on [DATE] at 3:20 P.M. revealed he did not remember anyone from the facility contacting him the afternoon of [DATE] to verify physician orders for resident #268 but stated if he had given a verbal approval he does not keep documentation of that. During an interview with STNA #8 on [DATE] at 4:20 P.M. she stated she was not assigned to Resident #268 that night. When she had walked by his room, unsure exact time but it was before 2:30 A.M., she glanced in and he was sleeping. About five minutes later, after answering a few call lights, she walked back and saw something black around his mouth. Upon entering his room, she noted he had emesis and was not responsive she immediately summoned LPN #2. Review of the facility Nursing Policy/Procedure Manual Subject: Abuse: Abuse Prevention dated [DATE], revealed the facility identified neglect as " the failure to provide goods and services necessary to avoid physical harm, mental anguish, and mental illness. " The policy stated Resident care and treatment are monitored by all staff, on ongoing bases to assure residents are free from abuse, neglect or mistreatment. It is the responsibility of all staff to provide a safe environment for the residents " . An interview with the DON on [DATE] at 12:50 P.M. affirmed the staff did not complete assessments and did not provide medications and tube feedings to Resident #268. This allegation substantiated Complaint Number OH 355.

Based on record review, review of facility documentation regarding new admissions, and staff interview, the facility failed to ensure appropriate care and services were provided to three of nine residents reviewed (Residents #268, #220, and #233), by failing to provide adequate enteral tube feedings and by failing to monitor blood glucose levels. This resulted in harm for one resident (#268) who was found unresponsive and admitted to the hospital with [REDACTED]. Findings include: 1. Record review for Resident #268 was completed during the afternoon of 07/05/11. Review of the record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed the first entry in the nurses' notes was dated 06/25/11 at 3:26 A.M. The note indicated the resident was observed "awake and alert at 12:30 A.M., talking clearly and precisely with respiration even and unlabored. Resident at 2:30 A.M. was observed with large amount of coffee ground emesis and undigested food particles coming from mouth and running down chest with labored breathing and gurgles. Resident was observed to be unresponsive with several attempts made with verbal, touch and pain stimuli to arouse resident...all attempts were unsuccessful. R.N. supervisor notified of change in resident's condition. R.N. supervisor arrived to unit, attempt made to notify P.A. (physician assistant) for Dr. (residents' attending physician) was unsuccessful. 911 immediately called." The resident's vital signs were also documented. Respirations were 30 per minute, blood pressure was 110/56 and the resident's oxygen saturation level was only 86% on room air. Oxygen was applied per nasal cannula at four liters, but when rechecked, the oxygen saturation level remained at 86%. The notes further indicated the "resident remains unresponsive with gurgles noted and labored breathing,. Squad arrived at 2:45 A.M., assessed resident, and proceeded to transport out of facility". An interview was conducted with the Director of Nursing (DON) and Registered Nurse #2 (RN#2), the unit manager for the unit on which Resident #268 was admitted , on 07/05/11 at 4:15 P.M. During the interview, RN#2 stated she was not certain what time Resident #268 entered the facility, as there was no documentation in the medical record of when he arrived or what condition he was in when he arrived. However, RN#2 stated she thought he had been admitted sometime in the middle of the afternoon on 06/24/11. RN#2 confirmed that there were no nurses' notes indicating the resident's condition prior to him being found unresponsive at 2:30 A.M. RN#2 stated an initial admission assessment of the resident had not been completed prior to his discharge from the facility during the night. RN#2 stated she had transferred the physician's orders [REDACTED]., but she stated when she left the building in the evening, the physician had not called to confirm the orders and she was not aware if he had called back to confirm the orders later. The DON stated the facility had an admission checklist that the staff were to follow and that all of the items were to be marked as completed within 24 hours of a resident's admission and returned to her. She stated she did not ever receive the admission checklist for Resident #268, indicating any type of assessment of the resident had ever been conducted. An interview was conducted with Licensed Practical Nurse #1 (LPN#1) on 07/05/11 at 5:00 P.M. LPN #1 stated she did not normally work on the unit on which Resident #268 resided, but that during the afternoon of 06/24/11, she was "pulled" off of her unit and transferred to Resident #268's unit to work. She stated she advised the nursing supervisor that she was not familiar with the residents on that unit and did not feel comfortable working on the unit, but stated she was mandated to stay and work on the unit anyway. LPN#1 stated she arrived on the unit at approximately 3:30 P.M. She stated as she was administering medications to residents in their rooms, she noticed there was a resident sitting in the bed in the room where Resident #268 resided, but she stated she had no idea who the resident was. She stated she had not received a report on Resident #268 or any of the other residents on the unit prior to beginning her medication administration. She stated when she asked the nursing supervisor about Resident #268, she was advised that she didn't have to worry about doing anything with him or administering him any medications. She stated she was not advised to complete any part of the admission assessment. An interview with RN#3, the second shift supervisor for the facility, was conducted on 07/05/11 at 5:15 P.M. RN#3 stated when she came on duty at 3:00 P.M. on 06/24/11, Resident #268 had already arrived at the facility. RN#3 stated she was not told that the admission assessment for Resident #268 had not been started and she was not told that the physician had not called back to confirm the orders for the resident's medications and treatments. RN#3 stated she was not aware of Resident #268's diagnoses, that he was to have a tube feeding administered, and stated she was not aware that his blood glucose level should be monitored. Further review of the discharge instructions from the hospital revealed Resident #268 was to receive tube feedings via jejunostomy tube, as well as a regular diet by mouth. During the interview with the DON and RN#2, they both stated there were no dietary intake records for the evening meal on 06/24/11 and there was no evidence that Resident #268 received a tray of regular food for the evening meal. The DON and RN#2 also confirmed that the jejunostomy tube feedings had never been started for Resident #268, since the physician had never called back to confirm the orders. RN#2 stated there was no order to monitor the resident's blood glucose level on the discharge instructions from the hospital. RN#2 confirmed that a resident who had recently had their pancreas removed (as insulin is produced by the pancreas) and was receiving insulin injections four times per day may be at risk of fluctuating blood glucose levels and should have a physician's orders [REDACTED]. Review of the medication administration records in the medical record for Resident #268 confirmed the resident did not receive any of his medications from the time of admission approximately 3:42 P.M. until he was transferred via emergency squad to the hospital at 2:45 A.M. Review of emergency room Triage Notes dated 06/25/11 at 6:09 A.M. revealed the resident arrived to the emergency department from the nursing home via emergency medical services (EMS) with a complaint of shortness of breath. The notes stated EMS reported the resident ' s blood sugar was 27 on their arrival to the facility. The resident was documented as nonverbal and on a non-rebreather mask. The resident was given 2 [MEDICATION NAME] of glucose (D50). An interview with the DON on 07/05/11 at 5:45 P.M. revealed she had identified the admission process as a problem and was taking steps to implement a new procedure in which the admission paperwork would be triple checked by the nursing staff to ensure each resident's needs were met. 2. Record review for Resident #233 was completed during the afternoon of 07/05/11. Review of the record revealed the resident was originally admitted to the facility on [DATE] and the readmitted after a hospitalization on [DATE] with [DIAGNOSES REDACTED]. The medical record further revealed the resident was discharged to the hospital on [DATE] due to respiratory distress and had not returned to the facility. Further review of the record revealed Resident #233 had a physician's orders [REDACTED]. Her plan of care, dated 12/10/10, revealed she was at risk of hypo and [MEDICAL CONDITION] and required sliding scale insulin. Review of the physician's orders [REDACTED]. Review of the medication administration records back to 06/01/11 revealed no documentation to indicate Resident #233's blood glucose level had been monitored or that she had received any insulin. Further review of the physician's orders [REDACTED].M. each afternoon until 12:00 P.M. the next day. The tube feeding was then ordered to be disconnected from 12:00 P.M. to 2:00 P.M. and the resident was to be provided a regular diet to eat by mouth. Review of the medication administration records revealed the resident's tube feeding was not administered on the following dates: 06/04/11, 06/05/11, 06/18/11, 06/19/11, and 06/25/11. An interview with the DON and RN#2, the unit manager for the unit on which Resident #233 resided, was conducted on 07/05/11 at 4:15 P.M. Both of the nurses confirmed the above findings. RN#2 stated she thought the resident's insulin and blood glucose monitoring had been discontinued, but she could not find evidence of any physician's orders [REDACTED]. 3. Record review for Resident #220 was completed during the morning of 07/06/11. Review of the record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed Resident #220 had a physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. and 6:00 A.M., 06/04/11 at 12:00 P.M., 06/05/11 at 12:00 P.M., 06/06/11 at 6:00 A.M. and 6:00 P.M., 06/08/11 at 6:00 P.M., 06/10/11 at 12:00 A.M. and 6:00 A.M., 06/11/11 at 6:00 A.M., 06/12/11 at 12:00 P.M., 06/18/11 at 12:00 A.M. and 6:00 A.M., and on 06/24/11 at 12:00 P.M. and 6:00 P.M. Further review of the physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED], 06/21/11 (night shift), 06/22/11 (night shift), 06/23/11 (night shift), 06/24/11 (night shift), and 06/25/11 (evening shift). An interview with the DON and RN#2, who was the unit manager for the unit on which Resident #220 resided, confirmed there was no evidence to indicate Resident #220 received his blood glucose monitoring, his insulin injections or his enteral tube feedings as ordered by the physician. This deficiency substantiates Complaint Number OH 355.