Every finding on record at Medilodge of Grand Rapids

This citation pertains to intake #3003696 Based on observation, interview and record review the facility failed to recognize a change in condition, ensure residents received care in accordance with professional standards and ensure resident's care choices were followed for 4 Residents (#60, #51, #3, and #30) of 24 reviewed for quality of care, resulting in a delay in treatment for an infection requiring hospitalization and toe amputation for Resident #3, delay in post fall nursing assessment and treatment for a closed nondisplaced oblique fracture of shaft of right femur and closed fracture of proximal end of right fibula for Resident #30, and a delay in treatment for an unrecognized hip fracture requiring surgical repair for Resident #60, and delay in specialized care for Resident #51 who experienced increased pain.Findings include: Resident #60 (R60) Review of a Face Sheet revealed R60 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: muscle weakness and cognitive communication deficit (difficulty with communication caused by decreased thinking skills). Review of a Minimum Data Set(MDS) assessment for R60 with a reference date of 3/18/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 13/15, which indicated the resident was cognitively intact. Section GG revealed R60 required moderate assistance to transfer to and from the toilet. Section J revealed R60 had falls in the last 90 days. Review of a Care Plan for R60 with a reference date of 6/19/24 revealed the following focus/goal/interventions: Focus: Resident is at risk for falls related to hx (history) of falls,.Resident frequently self-transfers and is non-compliant is asking nursing staff for assistance.Goal: Reduce the risk of injury.Interventions: Educate resident to look behind him prior to sitting.keep bed at lowest position.Resident educated on asking for assistance.Resident to use dycem (material that provides friction) in WC(wheelchair), discourage from wrapping self in blanket when up in his wheelchair.keep bed remote within reach. Review of a Fall Assessment for R60 with a reference date of 5/1/26 revealed Date of fall: 5/1/26.was in the bathroom and self-transferring from toilet to wheelchair.pain level: 3.Any injury or suspected injury: No. In an interview on 6/17/26 Licensed Practical Nurse (LPN) VV reported she was called to R60's around 5:20pm on 5/1/26 where she found him sitting on the floor with his back against a cupboard in his bathroom. LPN VV reported she completed a Fall Assessment for R60 and did not feel he had any injuries at that time, but he did require the use of mechanical lift to get him to bed. Of note, R60 was normally independent for walking short distances and out of bed multiple times throughout the day prior to the fall. In an interview on 6/23/26 at 9:58am, Certified Nursing Assistant (CNA) T reported she cared for R60 on the evening of 5/1/26 and he was not the same after the fall that occurred that day around 5:30pm. CNA T reported R60 complained of pain, would not get out of bed and required assistance of 2 staff for cares. CNA T reported prior to the fall, R60 did most cares without any assistance. CNA T reported she told the nurse on duty on 5/1/26 that R60 was having significant pain and that R60 told her he thought he broke his leg. In an interview on 6/18/26 at 9:28am, CNA I reported she cared for R60 on 5/2/26 and noticed around 6:30pm that the resident's leg was swollen, so she told the nurse on duty (LPN V) as well as the nurse coming in to work the night shift. CNA I stated I told them that I thought he needed an x-ray because R60 complained of more pain, said he thought he broke his hip, his leg was swollen, and he would not get out of bed. In an interview on 6/18/26 at 11:03am, LPN V, who cared for R60 on 5/2 and 5/3/26, reported the resident did not get out of bed all weekend and guarded his leg when she attempted to assess it. LPN V reported she could not recall if R60's leg appeared swollen or rotated. LPN V reported R60 was normally up and down all day and ate meals in the dining room. LPN V confirmed that CNA I told her R60 was in pain and his leg was swollen but she could not confirm that happened on 5/2/26. LPN V reported she contacted a provider on 5/3 for further direction and received an order for an x-ray. Review of Physician Orders for R60 with a reference date of 5/3/26 revealed the provider ordered a hip x-ray at 6:30am. Review of an Emergency Department Provider Note for R60 from a local hospital, with a reference date of 5/3/26 revealed Patient seen and evaluated. physical exam is notable for obvious deformity to the right femur (upper leg) with mild tenderness, right lower extremity shortened, externally (outward) rotated with decreased passive range of motion.Of note, I did speak with social work regarding concerns of the care patient received at (facility name omitted). He.has an obvious deformity of his right femur with fall 2 days ago. Resident #51 (R51) Review of an Face Sheet revealed R51 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: major depressive disorder(a serious mental health condition characterized by persistent feeling of sadness, hopelessness, and loss of interest in activities once enjoyed), pyoderma gangrenosum (rare skin condition that causes rapidly enlarging, extremely painful ulcers), thrombocytosis (condition in which the body produces too many platelets resulting in increased risk of blood clots), venous insufficiency (condition causing poor blood circulation) and hemiplegia (loss of movement on one side of the body). Review of a Minimum Data Set(MDS) assessment for R51 with a reference date of 6/2/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Section D of the MDS revealed R51 experienced little interest or pleasure in doing things during 12-14 days of the 14-day assessment period. Review of a Care Plan for R51 with a reference date of 9/25/25 revealed the following focus/goal/interventions: 1. Focus: Resident is at risk for an ADL self-care performance deficit related to depression, hemiplegia, history of falls, pain.Goal: Resident's Activities of Daily Living needs will be met.Interventions:.personal hygiene.offer set up help as needed toileting.offer set up help as needed., 2. Focus: Resident has an impaired circulatory status related to.chronic venous insufficiency, chronic venous hypertension of lower extremities. Goal: Resident will have reduced complications related to impaired circulatory status.Interventions: .diagnostic tests as ordered.3. Focus: Resident is at risk for impaired skin.Goal: Resident will have intact skin to extent allowed by resident.Interventions.Notify Physician/NP (Nurse Practitioner) of any new areas of skin impairment, preventative treatment per orders. In an interview on 6/16/26 at 9:50am, LPN (Licensed Practical Nurse) Q reported she spoke with Unit Manager (UM) S several weeks earlier about R51's need for a vascular specialist appointment due to the wounds and swelling in his lower legs. LPN Q reported she followed up with UM S about a week later at which time UM S confirmed she did not pursue making a vascular specialist appointment for R51. LPN Q reported she was very concerned about the condition of R51's legs, with open wounds, because he previously had severe wounds on both legs and amputation was recommended but he opted to have stents placed in his groin to try to increase his circulation, and his wounds resolved afterward. LPN Q reported R51's symptoms of new wounds, infection, increased swelling, and pain were indicative of a potential occlusion (blockage) in the stents in his groin, so he needed to be evaluated by a vascular specialist. When queried regarding when R51's wounds were treated for an infection, LPN Q reported she discovered one wound was filled with pus (a thick, milky, or yellowish fluid that accumulates at the site on an infection), about 3 weeks earlier and was treated with antibiotics at that time. LPN Q confirmed the facility still had not set up an appointment as of this date. LPN Q reported it was reasonable to expect appointments of this nature would be scheduled within 2 weeks after requested by a resident. LPN Q confirmed R51 had not received care from the wound clinic. LPN Q reported she was concerned about R51 because he was experiencing increased leg pain and swelling. In an interview on 6/17/26 at 2:08pm, UM S reported due to staffing issues, she worked as a floor nurse overnights 1-2 times per week. UM S confirmed it was her responsibility to ensure residents were scheduled for outpatient appointments as needed. UM S confirmed that regularly covering as a floor nurse interfered with her ability fulfil the responsibilities of her role, such as ensuring R51 was scheduled for an appointment with a vascular specialist. UM S confirmed R51 did not have an appointment to see a vascular specialist at this time and had not been to the wound clinic for his current wounds. When further queried, UM S confirmed LPN Q asked her several weeks earlier to coordinate a vascular specialist appointment for R51 but she (UM Q) was unaware the resident had previously been seen by a vascular specialist, so she did not follow up at that time. During an observation and interview on 6/17/26 at 2:23pm, as dressing were being changed, open wounds were noted on R51's right anterior (front) shin and posterior (back) shin. Both legs were swollen between the upper edge of the ace bandages that covered his lower legs and his kneecaps. R51 reported the first wound opened on 3/30/26 and since that time he had asked the nurses repeatedly to set up an appointment for him to see the vascular specialist. R51 reported he was very stressed and worried about his legs because a few years prior, he developed wounds on his lower legs, was recommended to have amputations but opted to have stents placed in the blood vessels in his groin to try to improve his circulation and thereby heal his wounds. R51 reported that he developed wounds again and was concerned his stents may be blocked. Review of a NP (Nurse Practitioner) Progress Note for R51 with a reference date of 4/15/26 at 10:22am revealed .Physical exam.Pyoderma gangrenosum.Coordinate with dermatology/wound clinic for ongoing management.venous insufficiency (poor blood flow causing swelling, wounds, poor healing in lower extremities). If ulcers fail to improve or there are signs of cellulitis (infection in the skin), consider vascular or wound clinic referral. In an interview on 6/18/26 at 11:29am Nurse Practitioner (NP) JJ confirmed R51 had not been evaluated by the wound clinic and that she had not ordered a referral for R51 to be evaluated by a vascular specialist until 6/16/26. NP JJ confirmed R51 had multiple wounds on both lower legs, had been treated with antibiotics for an infection and had a new wound develop in the last 30 days. Review of Wound and Skin documentation for R51 dated 6/2/26 revealed a new wound located on the right front lateral lower leg measuring 2.08cm x 1.69cm; further documentation on 6/9/26 indicated the wound had stalled (neither improving or worsening) and was measured to be 3.72 cm x 2.58cm. The comparison of the wound measurements indicated the wound increased in size. Review of the Wound and Skin documentation for R51 dated 6/2/26 revealed a wound located on the left lateral calf measured length 3.48cm x1.88cm, further documentation on 6/1/6/26 revealed the wound measured 3.1cm x 2.85 and was stalled with characteristics of plateauing, meaning the wound was unchanged. In a follow up interview on 6/23/26 at 9:11am, R51 reported growing concern about his health and the wounds he had on his lower legs. R51 stated I'm getting weaker, having more pain in my legs, and I'm afraid I'm going to relapse like I did a few years ago. R51 reported the staff did not seem to have time to follow up on his need to see a specialist, then stated I want to live so bad.I have to fight for what I need every day. I still don't have an appointment. Review of a Medication Administration Record (MAR) for R51 with a reference date of 5/2026 revealed the resident never rated his pain level above a 4 on the numeric pain scale of 0-10, throughout that entire month. Review of a Medication Administration Record (MAR) for R51 with a reference date of 6/2026 revealed the resident started taking Tramadol (synthetic opioid pain reliever prescribed to treat moderate to severe pain) on 6/18/26. R51 began experiencing increased pain on 6/8/26 with a rating of 6 on the numeric pain scale of 0-10, then continued to experience increased pain above a rating of 4 on at least 7 occasions between 6/8-6/17/26. In an interview on 6/23/26 at 9:20am, LPN Q reported R51 received a prescription for Tramadol for his leg pain. In an interview on 6/23/26 at 9:01am Medical Doctor (MD) XX reported a resident with a history of circulatory issues requiring stenting should be re-evaluated by a vascular specialist at the onset of new wounds. MD XX reported patients with certain circulatory issues requiring stenting can develop wounds that might rapidly deteriorate. MD XX confirmed additional symptoms such as swelling and pain would elevate his level of concern for a patient in this situation. MD XX reported NP JJ was responsible to monitor R51 for his care needs and consult with MD XX as needed. When further queried, MD XX reported he was not aware R60 had open wounds, and he felt the resident should be evaluated by a vascular specialist to ensure his stents had not become occluded (blocked). Resident #3 Review of a Face Sheet revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included assistance with personal care and type 2 diabetes mellitus without complications (elevated blood sugar due to insulin resistance or deficiency, but without any diabetes-related organ damage or secondary health problems) Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 5/29/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #3 was cognitively intact. During an interview on 6/16/2026 at 3:49 PM, Resident #3 reported that she had a diabetic ulcer on her toe that had gotten infected and required amputation. Resident #3 reported concerns with staff consistently completing wound care treatments as ordered. Review of Resident #3's Skin Issues note dated 3/25/26 revealed, Location: Right medial forefoot. Issue type: diabetic foot ulcer. Progress: deteriorating .Painful: Yes. wound pain (frequency): At dressing. Pain description: sharp. Wound pain interventions: change positions. Wound pain interventions: medicate after dressing change. Relief from interventions: yes. Length (cm-centimeters): 2.24. Width (cm): 2.47. Depth (cm) 0.2 . Eschar (necrotic tissue, meaning the skin cells underneath are dead and no longer viable, typically forming over full-thickness injuries such as third-degree burns, severe pressure ulcers, or deep infections): 100%. Exudate (fluid naturally produced by the body in response to tissue injury, beginning immediately after the skin barrier is compromised): moderate . Review of Resident #3's Progress note dated 3/26/26 and documented by Nurse Practitioner (NP) JJ revealed, .Assessment and plan . type 2 diabetes mellitus without complications: continue routine glucose monitoring and diabetes regimen as documented. Reinforce foot care and glycemic control to support wound healing and reduce infection risk . Noted that NP JJ did not address Resident #3's pain that was noted in her foot ulcer on 3/25/26. Review of Resident #3's Skin issue note dated 3/31/26 revealed, Location: Right medial forefoot. Issue type: Diabetic foot ulcer. Progress: Deteriorated. Wound acquired in house. Painful: Yes. Wound pain (frequency) at dressing. Pain description: sharp. Wound pain interventions: medicate prior to dressing change. Relief from interventions: Yes. Length (cm): 2.76. Width: 3.49. Depth (cm): 0.3 . Slough (non-viable, dead tissue in a wound, that can impede healing and harbor bacteria): 50%. Eschar: 50%. Exudate amount: moderate . Noted that the measurements in the wound increased in size from previous assessment. Review of Resident #3's Progress Note dated 4/1/26 and documented by NP JJ revealed, Chief complaint: low hemoglobin (protein in red blood cells that carries oxygen and carbon dioxide) level identified on recent labs Nursing reports no recent falls or change in wound drainage from the sacral pressure ulcer or the right knee prosthesis (artificial body part) site . Noted that NP JJ's note did not address Resident #3's diabetic ulcer or the change in condition to the ulcer (pain reported by Resident #3 and increase in wound size.) Review of Resident #3's Progress Note dated 4/3/26 revealed, dressing change done per order to right foot during this shift, strong odorous smell and large amount of serosanguinous (thin, watery, pink-tinged fluid that is a normal part of wound healing, composed of blood serum and a small number of red blood cells) drainage on old dressing . Review of Resident #3's Skin issues note dated 4/7/26 revealed, Location: right medial foot. Issue type: diabetic foot ulcer. Progress: stable. Previously deteriorating wound characteristics plateaued. Wound acquired in house . Painful: yes. length (cm): 2.73. Width (cm): 2.18. Depth (cm): 0.7 . 40% slough 60% eschar. Exudate amount: moderate .odor after cleansing: faint Noted that the measurements in the wound increased in size from previous assessment. Review of Resident #3's Progress Note dated 4/8/26 and documented by NP JJ revealed, Chief complaint: Follow up for anemia . Physical Exam: Skin: sacral pressure area and wound care documented in the chart . Noted that NP JJ's note did not address Resident #3's diabetic ulcer on her foot. Review of Resident #3's Skin issues note dated 4/14/26 revealed, Location: right medial foot. Issue type: diabetic foot ulcer. Progress: improving. overall wound characteristics improved. Wound acquired in house . Painful: No. length (cm): 3.05 Width (cm): 2.33 Depth (cm): 0.2 . 20 % slough . Noted that the measurements in the wound increased in size from previous assessment. Review of Resident #3's Skin issues note dated 4/21/26 revealed, Location: right medial foot. Issue type: diabetic foot ulcer. Progress: Stalled. Previously improving wound characteristics have plateaued. Wound acquired in house. Painful: No. length (cm): 3 Width (cm): 2 Depth (cm): 0.2 . Slough: 80%. Exudate amount: Moderate . Review of Resident #3's Skin issues note dated 4/28/26 revealed, Location: right medial foot. Issue type: diabetic foot ulcer. Progress: Stalled. Previously improving wound characteristics have plateaued. Wound acquired in house. Painful: Yes. Wound pain frequency: at dressings. Pain description: aching . length (cm): 3.17 Width (cm): 1.8 Depth (cm): 0.2 . Slough: 100%. Exudate amount: Moderate . Noted that the measurements in the wound increased in size from previous assessment. Review of Resident #3's Progress note dated 4/29/26 revealed, Dressing changed per order. Gauze saturated with brownish drainage. Foul odor from wound, painful to touch. Cleansed, patted dry, new dressing secured. Review of Resident #3's Progress note dated 5/1/26 and documented by Medical Doctor (MD) UU revealed, The patient (Resident #3) is seen today for evaluation of acute concern of right great toe diabetic ulcer. Patient states that the wound has been there for several weeks . Assessment and plan: Infected right great toe diabetic ulcer: patient has failed to improve with wound care by staff at the facility. Wound has now been present for several months. Will add ciprofloxacin (antibiotic) to address infection and cover pseudomonas (common opportunistic pathogen in wound infections). Will also have patient referred to formal wound care clinic . Review of Resident #3's Progress Note dated 5/3/26 revealed, Resident complains of malaise (fatigue) with nausea .pain to right foot noted with the highest pain during dressing change . Review of Resident #3's Progress Note dated 5/4/26 and documented by NP JJ revealed, Chief complaint: reported fever. History of present illness: patient seen today by this NP for a reported temperature . She is currently at increased risk of infection given a history of infection/inflammatory reaction related to internal right knee prosthesis and osteomyelitis involving the sacral region . I assessed for any concerning changes in mental status, pain, or wound appearance and will continue close monitoring given her high risk history . Physical exam . Skin: Known sacral stage 3 pressure ulcer in context of chronic wounds; no acute dramatic change documented today Assessment: 1. Fever- continue acetaminophen as ordered for fever and reassess temperature response . 2. If fever returns or clinical status worsens, consider further evaluation of infection source and sepsis risk based on symptoms and exam findings . Noted that NP JJ's visit did not address Resident #3's diabetic ulcer on her foot, or that she had recently been placed on an antibiotic for infection of 5/1/26 of the right toe. Review of Resident #3's Progress Note dated 5/4/26 revealed, Resident continues with malaise and mild nausea. She was afebrile (not feverish-sic) at 101.3 earlier this morning this shift. Tylenol was administered and effective . right foot wound remains very painful. Resident and her son are requesting to be sent to the hospital . Review of Resident #3's Progress Note dated 5/15/26 and documented by MD UU revealed, Patient seen today for re-admission to our subacute rehab . right foot with diabetic wound wrapped with bulky dressing. Wound without purulence (medical condition in which tissue or fluid contains or produces pus, a thick fluid made of dead white blood cells, bacteria, and tissue debris. It is commonly associated with bacterial infections) and has viable appearing tissue at this time. Assessment and plan: Infected right great toe diabetic foot ulcer: Patient has failed to improve with wound care at the facility. Wound has been present for several months. Culture grew Pseudomonas. Was placed on Bactrim and Amoxicillin (antibiotics) per ID (Infection Disease) inpatient. Continue wound care at clinic . Noted that MD UU did not address that Resident #3 toe was amputated due to infection when she was in the hospital. Review of Resident #3's Progress Note dated 6/19/26 and documented by MD UU revealed, Subjective: The patient (Resident #3) is seen today for evaluation of acute concern of sutures at right great toe amputation site still in place and need to be removed . Assessment and plan: Infected right great toe diabetic ulcer: Patient has failed to improve with wound care by staff at the facility . continue wound care at clinic . Sutures may now be removed . Review of Resident #3's Treatment Administration Record (TAR) for May 2026 revealed, Order: Refer to wound clinic for non-healing diabetic wound on right foot. Noted that this order did not contain a start date, or completion date to indicate if the order had been completed. During an interview on 6/23/2026 at 9:54 AM, Unit Manager (UM) S reported she was the staff member overseeing the facility's wound care program. UM S reported she would take photos and measurements of resident's wounds once a week and then would collaborate with NP JJ on wound care treatment orders. UM S was unable to report how often NP JJ or any other provider in the facility was assessing resident wounds. UM S was unable to report when the facility discovered Resident #3's diabetic foot ulcer. UM S reported that Resident #3's wound on her toe continued to decline, eventually became infected and needed to be amputated. UM S was unable to report if any provider had been notified when Resident #3 reported pain with dressing changes in March or when nursing staff noted strong odorous smell and large amount of serosanguinous drainage on old dressing on 4/3/26. UM S reported that she thought that Resident #3's diabetic wound on her foot had begun to improve in April but then declined again. UM Confirmed that Resident #3 had not been followed by a wound care clinic, and she did not know why NP JJ was documenting that she was followed by a wound care clinic. UM S confirmed that she was aware that nursing staff were not always completing wound care treatments as ordered. UM S confirmed that she had been working the floor a lot lately, and that was making it difficult for her to oversee the wound care program. During an interview on 6/23/2026 at 9:05 AM, Nurse Practitioner (NP) JJ was unable to report the current status of Resident #3's wounds and reported to this writer that she would need time to review her notes. When this writer queried as to when, if at all, was the last time that she had assessed Resident #3's wounds, NP JJ reported that she did not know. NP JJ was not able to report if Resident #3 had been followed at a wound care clinic as she had documented in her visit notes. NP JJ reported that she relied on the photos and assessment that UM S would complete weekly to determine treatment orders for Resident #3. NP JJ reported that she typically followed UM S recommendations for wound care treatments. NP JJ confirmed that UM S was a Licensed Practical Nurse, and therefore, was able to initiate treatment orders for wound care. On 6/23/26 at 9:51 AM, this writer requested via email to Nursing Home Administrator (NHA) A a list of dates where a Physician and/or Nurse Practitioner had assessed Resident #3's wounds since her admission to the facility. The facility did not provide the information requested prior to survey exit. Resident #30 Review of a Face Sheet revealed Resident #30 was originally admitted to the facility on [DATE] with pertinent diagnoses which included vascular dementia (cognitive decline caused by reduced blood flow to the brain, leading to memory, thinking, and behavioral changes), repeated falls and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 6/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #30 was moderately cognitively impaired. During an interview on 6/16/2026 at 2:03 PM, Family Member (FM) KK reported that she had concerns with the facility's fall prevention and supervision of Resident #30. FM KK reported that Resident #30 had fallen out of her bed in November and fractured her leg. FM KK reported that the details of Resident #30's fall did not make sense to her, and she was worried that Resident #30 would continue to fall and get injured again. Review of Resident #30's Incident Report dated 11/22/25 and documented by Licensed Practical Nurse (LPN) X revealed, Incident Description: Approximately at about 00:30 (12:30 AM) when this nurse came back from lunch break, resident's (Resident #30) CNA (Certified Nursing Assistant) reported that during her rounds, she caught resident self-transferring out of bed. CNA tried to help resident back into bed, but it was too late, and CNA assisted resident to the floor. When this nurse went to check on resident, res (resident) was asleep. Res woke up at around 3:10 AM screaming out in pain. Res right lower leg swollen, turned inward resident refused ROM (range of motion) stating, it hurts. On call provider notified, new order received to send resident to ER (emergency room) for evaluation . Review of Resident #30's Hospital Record dated 11/22/25 revealed, Chief Complaint Leg pain . Apparently, the patient has had multiple falls recently. Today, she was about to fall, and she was guided to the floor by staff. Patient has a severe right leg deformity. Medics are unsure when this injury occurred . Patient was given fentanyl (pain medication) for excruciating pain of the right leg and Zofran (nausea medicine) for nausea. Patient is unable to tell me what hurts other than her right leg . Physical exam: General: She is in acute distress (Patient in pain from right leg deformity). Appearance: She is ill-appearing . Muscoskeletal: swelling, tenderness, deformity, (Obvious right lower extremity deformity with bruising and swelling with malformation of the right lower leg .and signs of injury present. Right lower left leg: edema (swelling) present . X-ray tib-fib (two long bones of the lower leg) showed fracture of distal femoral meta diaphysis (distal femoral metaphysis is the region where the shaft widens and connects to the knee joint) and nondisplaced proximal fibular head/neck fracture. CT (Computed tomography) right lower extremity showed acute periprosthetic fracture of distal femoral metadiaphysis with no displacement, was unable to assess fibula fracture. Orthopedic surgery was consulted and recommended placing me immobilizer and 2 week outpatient follow up. Patient was admitted to medicine for sepsis secondary to UTI. She developed recurrent hypotension (low blood pressure) on the floor received additional IVF (intravenous fluids) and was transferred to ICU (intensive care unit) and started on norepi (norepinephrine- medication used to treat low blood pressure) She became more hypotensive and was found to have a hgb (hemoglobin) of 6.5 from 9.8 with significant ecchymosis(bruising) of her lower extremity to likely be the culprit. She required 2 units PRBC (packed red blood cells) the morning of 11/23 and ortho was contacted for reassessment . Patient family would like to discharge her back to her facility. Spoke with patient's son who said family plans to assign patient for hospice after discharge to the facility . During an interview on 6/18/2026 at 3:03 PM, LPN X reported on 11/22/25 she had been working overnight with CNA O and had returned from her break sometime around midnight when CNA O told her that she had had forgotten to tell her that she watched Resident #30 try to get out of bed and that she had to help lower her to the ground. LPN X reported that when she went into check on Resident #3, she was in her bed asleep, and she did not want to wake her up. LPN X confirmed that she did not assess Resident #3 when she found her asleep because Resident #3 could be behavioral when she was woken up. LPN X confirmed th[TRUNCATED]

Based on interview and record review, the facility failed to provide pressure ulcer care consistent with professional standards of practice for 1 (Resident #3) of 2 residents reviewed for pressure ulcer prevention and treatment, resulting in the worsening of a pressure ulcer and the potential of further worsening of and/or development of additional pressure ulcers and overall deterioration in health status. Findings include: Resident #3 Review of a Face Sheet revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included assistance with personal care and pressure ulcer of the sacral region (triangular area at the base of the spine that overlies the sacrum), stage 3 (pressure ulcer that involves full-thickness skin loss and require comprehensive management to promote healing and prevent complications.)Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 5/29/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #3 was cognitively intact. Review of Resident #3's Care Plan revealed, Focus: Resident has impaired skin integrity as evidenced by stage 3 on sacrum and stage 4 right hip (most severe form of pressure injuries, involving full-thickness tissue loss with exposure of muscle, tendon, or bone, also requiring comprehensive management to promote healing and prevent complications). Date initiated: 6/5/25. Last revised: 6/5/26. Interventions: Administer medications as ordered, administer treatments per orders, apply protective barrier cream after incontinent episodes, assist resident with turning and repositioning on or about every 2 hours as resident allows, consult dietitian as needed, encourage good nutrition and hydration as needed, encourage/assist as needed to elevate heels off the mattress as tolerated, labs as ordered, notify nurse of any new skin impairment noted during bathing or daily care (e.g., redness, bruises, discoloration, impairment related to medical device/tubing, Notify Physician of noted worsening skin condition or any new areas of skin impairment, notify Physician of signs/symptoms of infection (new or change in type/amount/color of drainage, bleeding, foul odor, pressure redistribution mattress to bed. Date initiated: 6/5/25. During an interview on 6/16/2026 at 3:49 PM, Resident #3 reported that staff were supposed to assist her with repositioning herself in bed and her wheelchair every two hours to assist with offloading pressure, but that the staff were not consistently repositioning her every two hours and she often went much longer without being repositioned. Resident #3 also reported concerns that nursing staff were not consistently changing her wound dressings as ordered. During an interview on 6/16/2026 at 10:53 AM, Certified Nursing Assistant (CNA) D reported that the CNAs at the facility were unable to complete two-hour reposition checks on residents that were at risk for skin breakdown because they were always working short staffed. CNA D reported she had reported her concerns with residents not receiving consistent and adequate care to Nursing Home Administrator (NHA) A and Director of Nursing (DON) B on several occasions, and she did not feel the concern had been addressed. CNA D reported that it was impossible for staff to even meet the basic care needs, and being able to reposition Resident #3 every two hours was getting missed often. Review of Resident #3's Progress Note dated 3/31/26 and documented by Nurse Practitioner (NP) JJ revealed, Chief complaint follow up of cerumen (ear wax) impaction . Physical exam . Skin/Wounds: sacral stage 3 pressure ulcer and other chronic wounds per wound care documentation; wound clinic referral remains active . Assessment and plan: Ongoing osteomyelitis is documented with associated sacral wound. Continue wound care measures and antimicrobial therapy as prescribed and maintain offloading and repositioning measures. Continue communication with wound clinic . Nursing to document wound measurements, drainage, and dressing integrity at each change and escalate concerns to wound clinic ., noted that NP JJ did not address Resident #3's right hip wound in this visit. Review of Resident #3's Progress Note dated 4/8/26 and documented by NP JJ revealed, Chief complaint follow up for anemia (condition in which the body does not have enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) . Physical exam . Skin: sacral pressure area and wound care documented in chart . Assessment and plan: Osteomyelitis of sacral region: active vertebral/sacral osteomyelitis is an additional possible contributor of anemia of chronic disease and ongoing inflammatory burden. Continue wound care and infection disease involvement as indicated; monitor clinical response to therapy and adjust management in coordination with specialists . noted that NP JJ did not address Resident #3's right hip wound in this visit. Review of Resident #3's Progress Note dated 4/23/26 and documented by Nurse Practitioner (NP) JJ revealed, Chief complain: 60-day follow up . The patient (Resident #3) reports overall steady status since the last hospitalization and procedures; she denies fevers, chills, new drainage from the right knee or sacral area, escalating pain, or new redness .Nursing notes document ongoing wound care for the sacral pressure ulcer and use of bilateral offloading boots in bed; wound clinic referral remains active . Review of symptoms denies new knee drainage or new erythema (redness of skin) . local sacral wound care ongoing without reported acute deterioration . Right knee: prosthesis site observed as per wound care notes with dressing in place; no gross active drainage reported at time of visit. Sacral region: stage 3 pressure injury documented in the chart; current dressing in place, no new large drainage or foul odor reported by nursing . Sacral osteomyelitis (bone infection) and associated stage 3 pressure ulcer remain under wound care surveillance. Continue current wound care regimen and offloading measures; wound clinic referral is active . Noted that visit did not address Resident #3's right hip wound. Review of Resident #3's Progress Note dated 5/4/26 and documented by NP JJ revealed, Chief complaint: reported fever . Physical exam Skin: known sacral stage 3 pressure ulcer in context of chronic wounds; no acute dramatic change documented today . Assessment and plan Osteomyelitis of vertebra, sacral region. Monitor pain levels and functional tolerance, as well as worsening of sacral region discomfort . Noted that NP JJ's progress note did not address Resident #3's right hip wound. Review of Resident #3's Progress Note dated 6/5/26 and documented by Medical Doctor (MD) UU revealed, Subjective: The patient (Resident #3) is seen today for evaluation of acute concern of fever of 101.7 of unknown origin. Physical examination . skin is warm, dry and intact aside from 2 stage 2 pressure wounds on the skin over left great trochanter (hip) and overlying sacrum . assessment and plan. 1. Acute fever. 2. Stage 2 pressure wound of sacrum. 3. Stage 2 pressure wound of left hip . noted that this note did not reflect the actual stages of Resident #3's sacral ulcer which was a stage 3 and her hip ulcer, which was a stage 4. Review of Resident #3's Progress Note dated 6/9/26 and documented by NP JJ revealed, Chief complaint: follow up after recent hospitalization for UTI (urinary tract infection) . Physical exam . skin: chronic sacral wound noted with dressing intact . Plan . pressure ulcer of sacral region, stage 3: continue wound care treatments as ordered . Noted that NP JJs note did not address Resident #3's right hip wound. During an interview on 6/18/2026 at 3:46 PM, Unit Manager (UM) S reported that Resident #3 was admitted to the facility with a pressure ulcer on her sacrum and her right hip. UM S reported that Resident #3's wounds had recently stalled with healing and had not improved since her last assessment of the wounds on 6/16/26. UM S reported that she would complete weekly photos and measurements of resident wounds and then she would collaborate with the facility's providers for treatment orders. UM S confirmed that the facility providers did not assess Resident #3's wounds with her, and she did not know how often Resident #3's wounds were assessed by a facility provider who was able to provide wound care orders. UM S reported that she was aware that staff had been missing wound care treatments and not repositioning Resident #3 every two hours. UM S reported that she had been working on the floor frequently, which made it harder for her to oversee the facility wound care program and follow up on missed treatments and care. UM S confirmed that Resident #4's right hip wound had declined from a stage 3 to a stage 4. UM S reported that Resident #3 was not followed by a wound clinic, and she did not know why NP JJ had documented that Resident #3 was being followed by a wound clinic. During an interview on 6/23/2026 at 9:05 AM, NP JJ was unable to report the current status of Resident #3's wounds on her coccyx and right hip and reported to this writer that she would need time to review her notes. NP JJ was unable to report if Resident #3 was receiving wound care at a wound clinic. When this writer queried as to when, if at all, was the last time that she had assessed Resident #3's wounds, NP JJ reported that she did not know. NP JJ reported that she relied on the photos and assessment that UM S completed weekly to determine treatment orders for Resident #3. NP JJ reported that she typically followed UM S recommendations for wound care treatments. NP JJ confirmed that UM S was a Licensed Practical Nurse, and therefore, was able to initiate treatment orders for wound care. On 6/23/26 at 9:51 AM, this writer requested via email to Nursing Home Administrator (NHA) A a list of dates where a Physician and/or Nurse Practitioner had assessed Resident #3's wounds since her admission to the facility. The facility did not provide the information requested prior to survey exit. Review of Resident #3's Treatment Administration Record (TAR) for May 2026 revealed, Order: Sacral wound: cleanse and pat dry .everyday shift for wound care. Start date: 5/15/26. Noted missing documentation to indicate if the treatment was completed on 5/20/26. Review of Resident #3's MDS assessment with a reference date of 9/15/25 revealed, Section M: Skin Conditions: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage: Number of Stage 3 pressure ulcers: 2. Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry: 2. Number of Stage 4 pressure ulcers: 0 . Review of Resident #3's MDS assessment with a reference date of 12/8/25 revealed, Section M: Skin Conditions: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage: Number of Stage 3 pressure ulcers: 1. Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry: 1. Number of Stage 4 pressure ulcers: 1 . Review of the facility's Pressure Ulcer/Skin Breakdown Policy last revised on 3/20/24 revealed, Policy: Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. Policy Explanation and Compliance Guidelines: . 10. The physician will help the staff define the type (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of an ulceration as needed. 11. 11. The physician will help clarify relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, the impact of comorbid conditions on wound healing, etc. as needed. 12. The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents .17. 17. During resident visits, the physician will evaluate and document the progress of wound healing- especially for those with complicated, extensive, or non-healing wounds.18. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions .

Based on observation, interview and record review, the facility failed to ensure a thorough medical evaluation of resident's condition, review the appropriateness of the resident's medical treatment, and implement orders for 2 (Resident #3 and Resident #51) of 24 residents reviewed for physician orders and treatment, resulting in resulting in the worsening of Resident #3 and Resident #51's wounds, lack of coordination of care and insufficient treatment for a resident's current condition and needs. Findings include: Resident #3 Review of a Face Sheet revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included assistance with personal care and type 2 diabetes mellitus without complications (elevated blood sugar due to insulin resistance or deficiency, but without any diabetes-related organ damage or secondary health problems) Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 5/29/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #3 was cognitively intact. During an interview on 6/16/2026 at 3:49 PM, Resident #3 reported that she had a diabetic ulcer on her toe that had gotten infected and required amputation, and a right hip wound that had also gotten worse since she had been admitted to the facility. Resident #3 reported concerns with staff consistently completing wound care treatments as ordered. Review of Resident #3's Skin Issues note dated 3/25/26 revealed, Location: Right medial forefoot. Issue type: diabetic foot ulcer. Progress: deteriorating .Painful: Yes. wound pain (frequency): At dressing. Pain description: sharp. Wound pain interventions: change positions. Wound pain interventions: medicate after dressing change. Relief from interventions: yes. Length (cm-centimeters): 2.24. Width (cm): 2.47. Depth (cm) 0.2 . Eschar (necrotic tissue, meaning the skin cells underneath are dead and no longer viable, typically forming over full-thickness injuries such as third-degree burns, severe pressure ulcers, or deep infections): 100%. Exudate (fluid naturally produced by the body in response to tissue injury, beginning immediately after the skin barrier is compromised): moderate . Wound location Front right trochanter (hip). Pressure ulcer staging: Stage 4 pressure injury- full thickness skin and tissue loss . length (cm) 2.31 Width (cm) 0.94 Depth (cm) 0.3. Granulation (specialized connective tissue that emerges during the proliferative phase of healing) 50%. Slough 50% . Review of Resident #3's Progress note dated 3/26/26 and documented by Nurse Practitioner (NP) JJ revealed, . Chief complain: Cerumen impaction (buildup of earwax (cerumen) that blocks or presses against the ear canal .Assessment and plan . type 2 diabetes mellitus without complications: continue routine glucose monitoring and diabetes regimen as documented. Reinforce foot care and glycemic control to support wound healing and reduce infection risk . Noted that NP JJ did not address Resident #3's pain that was noted in her foot ulcer on 3/25/26 or Resident #3's stage 4 pressure ulcer on her right hip. Review of Resident #3's Skin issue note dated 3/31/26 revealed, Location: Right medial forefoot. Issue type: Diabetic foot ulcer. Progress: Deteriorated. Wound acquired in house. Painful: Yes. Wound pain (frequency) at dressing. Pain description: sharp. Wound pain interventions: medicate prior to dressing change. Relief from interventions: Yes. Length (cm): 2.76. Width: 3.49. Depth (cm): 0.3 . Slough (non-viable, dead tissue is a wound, that can impede healing and harbor bacteria): 50%. Eschar: 50%. Exudate amount: moderate . Location: Wound location: Front right trochanter. Pressure ulcer staging: Stage 4 pressure injury- full thickness skin and tissue loss . length (cm) 1.34 Width (cm) 1.83 Depth (cm) 0. Granulation 50% Slough 50% .Noted that the measurements in the wound on Resident #3's foot had increased in size from previous assessment. Review of Resident #3's Progress Note dated 4/1/26 and documented by NP JJ revealed, Chief complaint: low hemoglobin (protein in red blood cells that carries oxygen and carbon dioxide) level identified on recent labs Nursing reports no recent falls or change in wound drainage from the sacral pressure ulcer or the right knee prosthesis (artificial body part) site . Noted that NP JJ's note did not address Resident #3's diabetic foot ulcer that she was reporting pain in, or the increase in the wound size. Noted that NP JJ's note did not address Resident #3's stage 4 pressure ulcer on her right hip. Review of Resident #3's Progress Note dated 4/3/26 revealed, dressing change done per order to right foot during this shift, strong odorous smell and large amount of serosanguinous (thin, watery, pink-tinged fluid that is a normal part of wound healing, composed of blood serum and a small number of red blood cells) drainage on old dressing . Review of Resident #3's Skin issues note dated 4/7/26 revealed, Location: right medial foot. Issue type: diabetic foot ulcer. Progress: stable. Previously deteriorating wound characteristics plateaued. Wound acquired in house . Painful: yes. length (cm): 2.73. Width (cm): 2.18. Depth (cm): 0.7 . 40% slough 60% eschar. Exudate amount: moderate .odor after cleansing: faint Noted that the measurements in the wound increased in size from previous assessment. Review of Resident #3's Progress Note dated 4/8/26 and documented by NP JJ revealed, Chief complaint: Follow up for anemia . Physical Exam: Skin: sacral pressure area and wound care documented in the chart . Noted that NP JJ's note did not address Resident #3's diabetic ulcer on her foot or Resident #3's stage 4 right hip pressure ulcer. Review of Resident #3's Skin issues note dated 4/14/26 revealed, Location: right medial foot. Issue type: diabetic foot ulcer. Progress: improving. overall wound characteristics improved. Wound acquired in house . Painful: No. length (cm): 3.05 Width (cm): 2.33 Depth (cm): 0.2 . 20 % slough . Noted that the measurements in the wound increased in size from previous assessment. Review of Resident #3's Skin issues note dated 4/21/26 revealed, Location: right medial foot. Issue type: diabetic foot ulcer. Progress: Stalled. Previously improving wound characteristics have plateaued. Wound acquired in house. Painful: No. length (cm): 3 Width (cm): 2 Depth (cm): 0.2 . Slough: 80%. Exudate amount: Moderate . Review of Resident #3's Skin issues note dated 4/28/26 revealed, Location: right medial foot. Issue type: diabetic foot ulcer. Progress: Stalled. Previously improving wound characteristics have plateaued. Wound acquired in house. Painful: Yes. Wound pain frequency: at dressings. Pain description: aching . length (cm): 3.17 Width (cm): 1.8 Depth (cm): 0.2 . Slough: 100%. Exudate amount: Moderate . Noted that the measurements in the wound increased in size from previous assessment. Review of Resident #3's Progress note dated 4/29/26 revealed, Dressing changed per order. Gauze saturated with brownish drainage. Foul odor from wound, painful to touch. Cleansed, patted dry, new dressing secured. Review of Resident #3's Progress note dated 5/1/26 and documented by Medical Doctor (MD) UU revealed, The patient (Resident #) is seen today for evaluation of acute concern of right great toe diabetic ulcer. Patient states that the wound has been there for several weeks . Assessment and plan: Infected right great toe diabetic ulcer: patient has failed to improve with wound care by staff at the facility. Wound has now been present for several months. Will add ciprofloxacin (antibiotic) to address infection and cover pseudomonas (common opportunistic pathogen in wound infections). Will also have patient referred to formal wound care clinic . Review of Resident #3's Progress Note dated 5/3/26 revealed, Resident complains of malaise (fatigue) with nausea .pain to right foot noted with the highest pain during dressing change . Review of Resident #3's Progress Note dated 5/4/26 and documented by NP JJ revealed, Chief complaint: reported fever. History of present illness: patient seen today by this NP for a reported temperature . She is currently at increased risk of infection given a history of infection/inflammatory reaction related to internal right knee prosthesis and osteomyelitis involving the sacral region . I assessed for any concerning changes in mental status, pain, or wound appearance and will continue close monitoring given her high risk history . Physical exam . Skin: Known sacral stage 3 pressure ulcer in context of chronic wounds; no acute dramatic change documented today Assessment: 1. Fever- continue acetaminophen as ordered for fever and reassess temperature response . 2. If fever returns or clinical status worsens, consider further evaluation of infection source and sepsis risk based on symptoms and exam findings . Noted that NP JJ's visit did not address Resident #3's diabetic ulcer on her foot, or that she had recently been placed on an antibiotic for infection of 5/1/26 of the right toe. NP JJ's note did not include any details of Resident #3's stage 4 right hip pressure ulcer. Review of Resident #3's Progress Note dated 5/4/26 revealed, Resident continues with malaise and mild nausea. She was afebrile (not feverish-sic) at 101.3 earlier this morning this shift. Tylenol was administered and effective . right foot wound remains very painful. Resident and her son are requesting to be sent to the hospital . Review of Resident #3's Progress Note dated 5/15/26 and documented by MD UU revealed, Patient seen today for re-admission to our subacute rehab . right foot with diabetic wound wrapped with bulky dressing. Wound without purulence (medical condition in which tissue or fluid contains or produces pus, a thick fluid made of dead white blood cells, bacteria, and tissue debris. It is commonly associated with bacterial infections) and has viable appearing tissue at this time. Assessment and plan: Infected right great toe diabetic foot ulcer: Patient has failed to improve with wound care at the facility. Wound has been present for several months. Culture grew Pseudomonas. Was placed on Bactrim and Amoxicillin (antibiotics) per ID (Infection Disease) inpatient. Continue wound care at clinic . Noted that MD UU did not address that Resident #3 toe was amputated due to infection when she was in the hospital. MD UU's note did not address Resident #3's stage 4 right hip pressure ulcer. Review of Resident #3's Progress Note dated 6/19/26 and documented by MD UU revealed, Subjective: The patient (Resident #3) is seen today for evaluation of acute concern of sutures at right great toe amputation site still in place and need to be removed . Assessment and plan: Infected right great toe diabetic ulcer: Patient has failed to improve with wound care by staff at the facility . continue wound care at clinic . Sutures may now be removed . Review of Resident #3's Treatment Administration Record (TAR) for May 2026 revealed, Order: Refer to wound clinic for non-healing diabetic wound on right foot. Noted that this order did not contain a start date, or completion date to indicate if the order had been completed. During an interview on 6/23/2026 at 9:54 AM, Unit Manager (UM) S reported she was the staff member overseeing the facility's wound care program. UM S reported she would take photos and measurements of resident's wounds once a week and then would collaborate with NP JJ on wound care treatment orders. UM S was unable to report how often NP JJ or any other provider in the facility was assessing resident wounds. UM S was unable to report when the facility discovered Resident #3's diabetic foot ulcer. UM S reported that Resident #3's wound on her toe continued to decline, eventually became infected and needed to be amputated. UM S was unable to report if any provider had been notified when Resident #3 reported pain with dressing changes in March or when nursing staff noted strong odorous smell and large amount of serosanguinous drainage on old dressing on 4/3/26. UM S reported that she thought that Resident #3's diabetic wound on her foot had begun to improve in April but then declined again. UM Confirmed that Resident #3 had not been followed by a wound care clinic, and she did not know why NP JJ was documenting that she was followed by a wound care clinic. UM S confirmed that she was aware that nursing staff were not always completing wound care treatments as ordered. UM S confirmed that she had been working the floor a lot lately, and that was making it difficult for her to oversee the wound care program. During an interview on 6/23/2026 at 9:05 AM, Nurse Practitioner (NP) JJ was unable to report the current status of Resident #3's wounds and reported to this writer that she would need time to review her notes. When this writer queried as to when, if at all, was the last time that she had assessed Resident #3's wounds, NP JJ reported that she did not know. NP JJ was not able to report if Resident #3 had been followed at a wound care clinic as she had documented in her visit notes. NP JJ reported that she relied on the photos and assessment that UM S completed weekly to determine treatment orders for Resident #3. NP JJ reported that she typically followed UM S recommendations for wound care treatments. NP JJ confirmed that UM S was a Licensed Practical Nurse, and therefore, was able to initiate treatment orders for wound care. On 6/23/26 at 9:51 AM, this writer requested via email to Nursing Home Administrator (NHA) A a list of dates where a Physician and/or Nurse Practitioner had assessed Resident #3's wounds since her admission to the facility. The facility did not provide the information requested prior to survey exit. Resident #51 (R51) Review of an Face Sheet revealed R51 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: major depressive disorder(a serious mental health condition characterized by persistent feeling of sadness, hopelessness, and loss of interest in activities once enjoyed),thrombocytosis (condition in which the body produces too many platelets causing an increased risk of blood clots), venous insufficiency (condition causing poor blood circulation) and pyoderma gangrenosum (rare skin condition that causes rapidly enlarging, extremely painful ulcers). Review of a Minimum Data Set(MDS) assessment for R51 with a reference date of 6/2/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Review of a Care Plan for R51 with a reference date of 9/25/25 revealed the following focus/goal/interventions: 1. Focus: Resident has an impaired circulatory status related to.chronic venous insufficiency, chronic venous hypertension of lower extremities. Goal: Resident will have reduced complications related to impaired circulatory status.Interventions: .diagnostic tests as ordered.2. Focus: Resident is at risk for impaired skin.Goal: Resident will have intact skin to extent allowed by resident.Interventions.Notify Physician/NP (Nurse Practitioner) of any new areas of skin impairment, preventative treatment per orders. In an interview on 6/16/26 at 9:50am, LPN (Licensed Practical Nurse) Q reported she spoke with Unit Manager (UM) S several weeks earlier about R51's need for a vascular specialist appointment due to the wounds and swelling in his lower legs. LPN Q reported she followed up with UM S about a week later at which time UM S confirmed she did not pursue making a vascular specialist appointment for R51. LPN Q reported she was very concerned about the condition of R51's legs, with open wounds, because he previously had severe wounds on both legs and amputation was recommended but he opted to have stents placed in his groin to try to increase his circulation, and his wounds resolved afterward. LPN Q reported R51's symptoms of new wounds, infection, increased swelling, and pain were indicative of a potential occlusion (blockage) in the stents in his groin, so he needed to be evaluated by a vascular specialist. When queried regarding when R51's wounds were treated for an infection, LPN Q reported she discovered one wound was filled with pus (a thick, milky, or yellowish fluid that accumulates at the site on an infection), about 3 weeks earlier and was treated with antibiotics at that time. LPN Q confirmed the facility still had not set up an appointment as of this date. LPN Q reported it was reasonable to expect appointments of this nature would be scheduled within 2 weeks after requested by a resident. LPN Q confirmed R51 had not received care from the wound clinic. LPN Q reported she was concerned about R51 because he was experiencing increased leg pain and swelling. In an interview on 6/17/26 at 2:08pm, UM S reported due to staffing issues, she worked as a floor nurse overnights 1-2 times per week. UM S confirmed it was her responsibility to ensure residents were scheduled for outpatient appointments as needed. UM S confirmed that regularly covering as a floor nurse interfered with her ability fulfil the responsibilities of her role, such as ensuring R51 was scheduled for an appointment with a vascular specialist. UM S confirmed R51 did not have an appointment to see a vascular specialist at this time and had not been to the wound clinic for his current wounds. When further queried, UM S confirmed LPN Q asked her several weeks earlier to coordinate a vascular specialist appointment for R51, but she (UM Q) was unaware the resident had previously been seen by a vascular specialist, so she did not follow up at that time. During an observation and interview on 6/17/26 at 2:23pm, as dressing were being changed, open wounds were noted on R51's right anterior (front) shin and posterior (back) shin. Both legs were swollen between the upper edge of the ace bandages that covered his lower legs and his kneecaps. R51 reported the first wound opened on 3/30/26 and since that time he had asked the nurses repeatedly to set up an appointment for him to see the vascular specialist. R51 reported he was very stressed and worried about his legs because a few years prior, he developed wounds on his lower legs, was recommended to have amputations but opted to have stents placed in the blood vessels in his groin to try to improve his circulation and thereby heal his wounds. R51 reported that he developed wounds again and was concerned his stents may be blocked. Review of a NP (Nurse Practitioner) Progress Note for R51 with a reference date of 4/15/26 at 10:22am revealed .Physical exam.Pyoderma gangrenosum.Coordinate with dermatology/wound clinic for ongoing management.venous insufficiency (poor blood flow causing swelling, wounds, poor healing in lower extremities). If ulcers fail to improve or there are signs of cellulitis (infection in the skin), consider vascular or wound clinic referral. Review of a NP Progress Note for R51 with reference date of 6/8/26 revealed Chief complaint: 60 day follow up.Patient appears at his baseline.no acute abnormalities.nursing staff report no acute concerns.Plan.Continue follow up with wound care specialists.monitor for.development of new wounds. Of note, NP JJ did not address Resident #51's new wound identified on 6/2/26. In an interview on 6/18/26 at 11:29am Nurse Practitioner (NP) JJ confirmed R51 had not been evaluated by the wound clinic and that she had not ordered a referral for R51 to be evaluated by a vascular specialist until 6/16/26. NP JJ confirmed R51 had multiple wounds on both lower legs, had been treated with antibiotics for an infection and had a new wound develop in the last 30 days. Review of Wound and Skin documentation for R51 dated 6/2/26 revealed a new wound located on the right front lateral lower leg measuring 2.08cm x 1.69cm; further documentation on 6/9/26 indicated the wound had stalled (neither improving or worsening) and was measured to be 3.72 cm x 2.58cm. The comparison of the wound measurements indicated the wound increased in size. Review of the Wound and Skin documentation for R51 dated 6/2/26 revealed a wound located on the left lateral calf measured length 3.48cm x1.88cm, further documentation on 6/1/6/26 revealed the wound measured 3.1cm x 2.85 and was stalled with characteristics of plateauing, meaning the wound was unchanged. In a follow up interview on 6/23/26 at 9:11am, R51 reported growing concern about his health and the wounds he had on his lower legs. R51 stated I'm getting weaker, having more pain in my legs, and I'm afraid I'm going to relapse like I did a few years ago. R51 reported the staff did not seem to have time to follow up on his need to see a specialist, then stated I want to live so bad.I have to fight for what I need every day. The NP never looks at my wounds. I still don't have an appointment. Review of a Medication Administration Record (MAR) for R51 with a reference date of 5/2026 revealed the resident never rated his pain level above a 4 on the numeric pain scale of 0-10, throughout that entire month. Review of a Medication Administration Record (MAR) for R51 with a reference date of 6/2026 revealed the resident started taking Tramadol (synthetic opioid pain reliever prescribed to treat moderate to severe pain) on 6/18/26. R51 began experiencing increased pain on 6/8/26 with a rating of 6 on the numeric pain scale of 0-10, then continued to experience increased pain above a rating of 4 on at least 7 occasions between 6/8-6/17/26. In an interview on 6/23/26 at 9:20am, LPN Q reported R51 received a prescription for Tramadol for his leg pain. In an interview on 6/23/26 at 9:01am Medical Doctor (MD) XX reported a resident with a history of circulatory issues requiring stenting should be re-evaluated by a vascular specialist at the onset of new wounds. MD XX reported patients with certain circulatory issues requiring stenting can develop wounds that might rapidly deteriorate. MD XX confirmed additional symptoms such as swelling and pain would elevate his level of concern for a patient in this situation. MD XX reported NP JJ was responsible to monitor R51 for his care needs and consult with MD XX as needed. When further queried, MD XX reported he was not aware R60 had open wounds, and he felt the resident should be evaluated by a vascular specialist to ensure his stents had not become occluded (blocked).

Based on observation, interview, and record review, the facility failed to ensure adequate staffing to maintain the physical, mental, and psychosocial well-being in 8 of 24 residents (Residents #51, #21, #3,#17, #30, #45, #49 and #24) reviewed for staffing, resulting in feelings of worthlessness and frustration, missed wound care treatments, delayed follow up on resident concerns, delayed pain medication administration, long call light wait times, missed showers and resident preferences not being honored. Findings include: Resident #51(R51) Review of an Face Sheet revealed R51 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: major depressive disorder(a serious mental health condition characterized by persistent feeling of sadness, hopelessness, and loss of interest in activities once enjoyed), pyoderma gangrenosum (rare skin condition that causes rapidly enlarging, extremely painful ulcers) and hemiplegia (loss of movement on one side of the body). Review of a Minimum Data Set(MDS) assessment for R51 with a reference date of 6/2/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Section D of the MDS revealed R51 experienced little interest or pleasure in doing things during 12-14 days of the 14-day assessment period. Review of a MDS assessment for R51 with a reference date of 11/25/25 revealed the resident experienced little interest or pleasure in doing things during 2-6 days of the 14-day assessment period. Review of a Care Plan for R51 with a reference date of 9/25/25 revealed the following focus/goal/interventions: Focus: Resident is at risk for an ADL self-care performance deficit related to depression, hemiplegia, history of falls, pain.Goal: Resident's Activities of Daily Living needs will be met.Interventions:.personal hygiene.offer set up help as needed toileting.offer set up help as needed. In an interview on 6/16/26 at 11:07am, Resident #51 reported low staffing at the facility had been an ongoing issue. R51 reported he recently had an episode of bowel incontinence and managed to get himself to the bathroom where he activated the call light, but he waited on the toilet for more than an hour, and no one came to help him. R51 reported he was covered in stool, even into his shoes, and could not clean himself up. R51 reported he finally walked into the common area to find help, while still covered in feces. R51 reported he felt embarrassed and humiliated. R51 reported the staff were helping another resident who required the assist of multiple staff members, when he waited for more than an hour that day. R51 went on to say that the lack of response to his care needs was an ongoing situation that made him feel worthless. R51 stated There are days I don't feel like I'm treated like a human being here. R51 reported he felt he had to constantly fight to receive the care he needed because there was not adequate staff to meet his needs. Review of a Psychiatry Follow up Note for Resident #51 with a reference date of 5/6/26 revealed .Patient is.quite angry and frustrated as he had loose bowels and soiled himself on the floor, with BM (bowel movement) on his shoes.He states he is having difficulty getting assistance and is overall very frustrated and unhappy.previously he had been in good spirits.Patient distinguished frustration from depression, stating I am not suicidal but I feel just so very defeated.it is.frustration and unhappiness.Patient presents frustrated and angry today due to.practical stressors including.difficulty getting assistance at the facility . In an interview on 6/18/26 at 12:02pm, Nursing Home Administrator (NHA) A reported at the time of the incident in which R51 reported he did not get help after an episode of bowel incontinence, R51's unit had another resident that required the assistance of 4 staff members for cares. NHA A reported he told nursing staff to stay with the resident who needed assistance of 4 staff and wait for remaining staff members to arrive, because it took time for that many staff to gather. NHA A confirmed staff were frequently off the floor for an extended period when they assisted the resident who needed 4 staff members for cares. NHA A reported staff were assisting the other resident which caused a delay in R51 getting assistance. NHA A reported at times, the facility only had a total of 5 nursing staff members in the building and so if 1 resident needed the assistance of 4 staff members, that left only 1 staff member to care for the remaining residents throughout the building. NHA A confirmed in addition to one resident who required 4 staff for cares, R51's unit had a high number of residents who required assist of 2 staff members for cares. When queried about what steps were taken to ensure all resident needs would be met, after a resident who required assistance of 4 staff for cares was admitted , NHA A reported staff were provided with walkie talkies so they could gather 4 staff members to care for the resident who needed assist of 4 staff, but staffing levels were not increased. NHA A reported it was not feasible to add additional staff members due to the facility's high staff turnover rate. NHA A confirmed the unit was staffed with 1-2 nursing assistants, and 1 nurse who at times covered a portion of another unit as well. NHA A reported R51 was real frustrated and upset by the lack of care on 5/6/26 but had previously voiced frustration multiple times about long wait times and lack of care. In an interview on 6/16/26 at 9:50am, LPN (Licensed Practical Nurse) Q reported she spoke with Unit Manager (UM) S several weeks earlier about R51's need for a vascular specialist appointment due to the wounds and swelling in his lower legs. LPN Q reported she followed up with UM S about a week later at which time UM S confirmed she did not pursue making a vascular specialist appointment for R51. LPN Q reported she was very concerned about the condition of R51's legs, with open wounds, because he previously had severe wounds on both legs and amputation was recommended but he opted to have stents placed in his groin to try to increase his circulation, and his wounds resolved afterward. LPN Q reported R51's symptoms of new wounds, infection, increased swelling, and pain were indicative of a potential occlusion (blockage) in the stents in his groin, so he needed to be evaluated by a vascular specialist. When queried regarding when R51's wounds were treated for an infection, LPN Q reported she discovered one wound was filled with pus (a thick, milky, or yellowish fluid that accumulates at the site on an infection), about 3 weeks earlier and was treated with antibiotics at that time. LPN Q confirmed the facility still had not set up an appointment as of this date. LPN Q reported it was reasonable to expect appointments of this nature would be scheduled within 2 weeks after requested by a resident. LPN Q confirmed R51 had not received care from the wound clinic. In an interview on 6/17/26 at 2:08pm, UM S reported due to staffing issues, she worked as a floor nurse overnights 1-2 times per week. UM S confirmed it was her responsibility to ensure residents were scheduled for outpatient appointments as needed. UM S confirmed that regularly covering as a floor nurse interfered with her ability fulfil the responsibilities of her role, such as ensuring R51 was scheduled for an appointment with a vascular specialist. UM S confirmed R51 did not have an appointment to see a vascular specialist at this time and had not been to the wound clinic for his current wounds. When further queried, UM S confirmed LPN Q asked her several weeks earlier to coordinate a vascular specialist appointment for R51 but she (UM Q) was unaware the resident had previously been seen by a vascular specialist, so she did not follow up at that time. During an observation and interview on 6/17/26 at 2:23pm, as dressing were being changed, open wounds were noted on R51's right anterior (front) shin and posterior (back) shin. Both legs were swollen in the area between the leg wraps ended and the knee cap. R51 reported the first wound opened on 3/30/26 and since that time he had asked the nurses repeatedly to set up an appointment for him to see the vascular specialist. R51 reported he was very stressed and worried about his legs because a few years prior, he developed wounds on his lower legs, was recommended to have amputations but opted to have stents placed in the blood vessels in his groin to try to improve his circulation and thereby heal his wounds. R51 reported that he developed wounds again and was concerned his stents may be blocked. Review of a NP (Nurse Practitioner) Progress Note for R51 with a reference date of 4/15/26 at 10:22am revealed .Physical exam.Pyoderma gangrenosum.Coordinate with dermatology/wound clinic for ongoing management.venous insufficiency (poor blood flow causing swelling, wounds, poor healing in lower extremities). If ulcers fail to improve or there are signs of cellulitis (infection in the skin), consider vascular or wound clinic referral. In an interview on 6/18/26 at 11:29am Nurse Practitioner (NP) JJ confirmed R51 had not been evaluated by the wound clinic and that she had not ordered a referral for R51 to be evaluated by a vascular specialist until 6/16/26. NP JJ confirmed R51 had multiple wounds on both lower legs, had been treated with antibiotics for an infection and had a new wound develop in the last 30 days. In a follow up interview on 6/23/26 at 9:11am, R51 reported growing concern about his health and the wounds he had on his lower legs. R51 stated I'm getting weaker and I'm afraid I'm going to relapse like I did a few years ago. R51 reported the staff did not seem to have time to follow up on his need to see a specialist, then stated I want to live so bad.I have to fight for what I need every day. I still don't have an appointment. Review of a Psychology Follow-up Note for R51 with a reference date of 5/12/26 revealed (R51) presents for a psychology follow-up visit reporting.mounting frustration.with facility staff. He describes feeling depleted and states he cannot take another day.of the current situation.he describes having to fight for everything every morning and every day and states he is getting sick and tired of it.Interventions included.exploration of feelings of lack of autonomy. In an interview on 6/23/26 at 9:52am, Licensed Medical Social Worker (LMSW) LL reported R51 experienced emotional distress, feelings of worthlessness and hopelessness due to the lack of response to his care needs and requests. LMSW LL confirmed the lack of staff was detrimental to R51's psychosocial wellbeing. Resident #21 (R21) Review of an Face Sheet revealed R21 was originally admitted to the facility on with pertinent diagnoses which included: chronic pain syndrome (persistent pain lasting more than 3 months and causes other severe, non-pain symptoms like depression, anxiety, and insomnia (difficulty falling or staying asleep), major depressive disorder (a serious mental health condition characterized by persistent feeling of sadness, hopelessness, and loss of interest in activities once enjoyed) and radiculopathy (nerve root compression or irritation in the spinal column resulting in pain, numbness, weakness). Review of a Minimum Data Set(MDS) assessment for R21 with a reference date of 6/12/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Section GG revealed R21 required moderate (helper does less than half the effort) assistance for showering and toilet hygiene (the ability to maintain perineal {the region of the body between the genitals and the anus} hygiene). Section J of the MDS revealed R21 reported her pain level occasionally interfered with her sleep and she experienced moderate pain in the last five days. Review of a Care Plan for R21 with a reference date of 12/4/25 revealed the following focus/goal/interventions: 1. Focus: Resident has an ADL (activities of daily living) self-care deficit.Goal: Resident's ADL needs will be met. Interventions.bathing: 1 person assist.personal hygiene: 1 person assist 2. Focus: Resident is at risk for pain.Goal: Resident will not experience a decline in function related to pain.Interventions: Administer medications per orders. In an interview on 6/16/26 at 12:29pm, R21 reported due to staffing levels, she missed showers and received her pain medications late. R21 reported she felt embarrassed by her poor hygiene when she didn't get showers at least twice a week and recently had to go to a doctor's appointment with hair that was a grease ball and poor body hygiene. R21 reported she felt self-conscious at the appointment and wondered if she smelled. R21 reported she regularly transferred herself from toilet after waiting for more than 20 minutes for staff to respond to her call light but could not properly clean her perineal area so she felt unclean. R21 reported staff were delayed in providing her pain medications and the inconsistencies in timing caused her pain level to be unmanaged. R21 reported a manageable pain level was a 4 on the numeric pain scale of 0-10. Review of a Medication Administration Record (MAR) for R21 with a reference date of 6/1-6/21/26, revealed the resident reported her pain level was greater than a 4 on the numeric pain scale of 0-10, during 8 of 21 days. Review of Shower Records for R21 with a reference date of 4/20-6/20/26 revealed the resident received 10 showers total. If provided twice a week, the same reference period should have afforded R21 with 18 showers at a minimum. Resident #3 Review of a Face Sheet revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included assistance with personal care and pressure ulcer of the sacral region (triangular area at the base of the spine that overlies the sacrum), stage 3 (pressure ulcer that involves full-thickness skin loss and require comprehensive management to promote healing and prevent complications.) Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 5/29/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #3 was cognitively intact. During an interview on 6/16/2026 at 3:49 PM, Resident #3 reported that staff were supposed to assist her with repositioning herself in bed and her wheelchair every two hours to assist with offloading pressure, but that the staff were not consistently repositioning her every two hours and she often went much longer without being repositioned. Resident #3 also reported concerns that nursing staff were not consistently changing her wound dressings as ordered, and concerns that she was frequently missing showers/bed baths because the facility did not seem to have enough staff to complete resident care. Resident #3 reported that it was common to wait for over 30 minutes for her call light to be answered when she activated it to call for assistance. During an interview on 6/16/2026 at 10:53 AM, Certified Nursing Assistant (CNA) D reported that the CNAs at the facility were unable to complete two-hour reposition checks on residents that were at risk for skin breakdown because they were always working short staffed. CNA D reported she had reported her concerns with residents not receiving consistent and adequate care to Nursing Home Administrator (NHA) A and Director of Nursing (DON) B on several occasions, and she did not feel the concern had been addressed. CNA D reported that it was impossible for staff to even meet the basic care needs, and being able to reposition Resident #3 every two hours was getting missed often. During an interview on 6/18/2026 at 3:46 PM, Unit Manager (UM) S reported that Resident #3 was admitted to the facility with a pressure ulcer on her sacrum and her right hip. UM S reported that Resident #3's wounds had recently stalled with healing and had not improved since her last assessment of the wounds on 6/16/26. U. UM S reported that she was aware that staff had been missing wound care treatments and not repositioning Resident #3 every two hours. UM S reported that she had been working on the floor frequently, which made it harder for her to oversee the facility wound care program and follow up on missed treatments and care. UM S confirmed that Resident #4's right hip wound had declined from a stage 3 to a stage 4. Resident #17 Review of a Face Sheet revealed Resident #17 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #17, with a reference date of 6/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #17 was cognitively intact. During an interview on 6/16/2026 at 10:10 AM, Resident #17 reported that she felt the facility did not have enough staff to provide resident care. Resident #17 reported she frequently had to wait for over 30 minutes for her call light to be answered when she needed assistance, and that she had recently waited over 3 hours for staff to answer her call light. Resident #17 reported that she frequently had to lay in soiled briefs for extended periods of time because staff were not able to get to her timely. Resident #17 reported that she was soiled in urine up to my back on multiple occasions because staff could not change her brief for hours. Resident #17 reported that she often chose to just stay in bed all day because if she were to get out of bed, it would take staff too long to assist her back into bed and she did not want to be in pain from sitting in her chair for too long. Resident #17 reported that she was frequently missing showers and/or bed baths because the facility did not have enough staff to complete showers as scheduled. Resident #17 reported feeling frustrated and disappointed in the care that she was receiving at the facility and stated that It is shameful how little the facility cares about the residents here, we deserve so much better than this. Resident #17 reported that she had voiced her concerns to facility management several times, but nothing changes, they don't care. Review of Resident #17's Shower Tasks Review of Resident #3's Shower Tasks revealed that from 4/19/26-6/17/26 staff had documented that Resident #17 had received 10 showers in the 60-day time frame. Resident #30 Review of a Face Sheet revealed Resident #30 was originally admitted to the facility on [DATE] with pertinent diagnoses which included vascular dementia (cognitive decline caused by reduced blood flow to the brain, leading to memory, thinking, and behavioral changes), repeated falls and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 6/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #30 was moderately cognitively impaired. During an interview on 6/16/2026 at 2:03 PM, Family Member (FM) KK reported ongoing concerns with staffing at the facility. FM KK reported that she frequently visited Resident #30 at the facility, and she observed the staff working short nearly daily. FM KK reported that it was common for Resident #30 to wait for over an hour for assistance. FM KK reported that she and Resident #30 had been sitting at the unit's dining area since she had finished eating two hours prior because the facility did not have staff to take Resident #30 back to her bedroom to rest. FM KK reported that she knew Resident #30 was sitting in a soiled brief at the time and watching staff run around like crazy and still struggle to meet the basic needs of the residents at the facility was disheartening. FM KK reported she had witnessed Resident #30 wait for over two hours on multiple occasions. FM KK reported that Resident #30 had fallen on multiple occasions in the facility, with one fall that resulted in major injury, and she felt that the staffing at the facility contributed to Resident #30 falls. FM KK reported, They (The nursing staff) aren't even able to meet the basic care needs of residents, let alone monitor residents at an increased risk of falls. In an observation and interview on 6/17/26 at 8:23 AM, Licensed Practical Nurse (LPN) Q entered Resident #30's room, and then yelled out in the hallway, Where are the aides? I needed a hoyer (medical device designed to safely lift and transfer individuals with limited mobility from one surface to another using a sling and mechanical lifting system) like ten minutes ago! This writer followed LPN Q into Resident #30's room where she was laying on the floor next to her bed. LPN Q reported that one of the CNA's had found Resident #30 on the floor about 15 minutes prior, and that she had been waiting for the CNAs to come back with a hoyer so that they could get Resident #30 off the floor. Shortly after this writer entered Resident #30's room, CNA D and F entered Resident #30's room with a hoyer and assisted LPN Q in transferring Resident #30 back to her bed. CNA D reported that she had found Resident #30 on the floor again when she entered her room to get her ready for breakfast. CNA F reported that it was common for Resident #30 to fall out of bed. Resident #30 was noted to complain of pain when the staff were transferring her onto her bed. CNA D was unable to report the last time that Resident #30 had been checked on prior to when she found on the floor. Review of Resident #30's Incident Report dated 6/17/26 revealed, Incident Description: Resident found on fall mat in room. Resident Description: She was going to get up . level of pain: 4 . Suspected injury: Hand, finger . Resident #45 Review of a Minimum Data Set (MDS) assessment for Resident #45, originally admitted to the facility on [DATE] with pertinent diagnoses which included hypertension (high blood pressure) and depression. Review of Brief Interview for Mental Status (BIMS) with a reference date of 4/16/26 revealed a score of 15/15 which indicated Resident #45 was cognitively intact. Section GG: Functional abilities indicated that Resident #45 required partial/moderate assistance from staff for transfers. (Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.) During an interview on 6/16/2026 at 10:22 AM, Resident #45 reported concerns with staffing at the facility. Resident #45 reported that nurses were not always completing her wound care treatments as ordered because they did not have time to do them, and CNAs were missing her showers/bed baths because they also did not have time to complete them. Resident #45 reported that it was common to have to wait for over an hour for assistance when she used her call light. Resident #45 reported she gave up voicing her concerns to the facility, because nothing ever changed. During an observation and interview on 6/17/2026 at 1:14 PM, Resident #45 reported that she had turned her call light on at 6:15 AM to get help from staff to get up for the day. Resident #45 reported that a staff member came into her room and told her that she couldn't help her, but she would get someone to help her, and then she turned off her call light. Resident #45 reported that she made the decision at 7:20 AM to get up on her own even though she knew she was not supposed to because she didn't want to miss breakfast. Resident #45 was tearful during interview and stated, I try to be easy going, I try not to complain because I know it's not the girls (nurses and cnas) fault, they are always working short, but I feel like I deserve help getting up, and shouldn't have to risk my safety to make sure I can eat. Resident #24 Review of a Face sheet revealed Resident #24 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: dysphagia (difficulty swallowing), history of falling, and mild intellectual disabilities. Review of a Minimum Data Set (MDS) assessment for Resident #24, with a reference date of 6/2/26 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #24 was mildly cognitively impaired. Section GG, Self-Care Assessment, eating, supervision or touching assistance. On 6/18/26 at 1:12 pm, Resident #24 was observed sitting in her wheelchair, in the hallway of health center 3 unit, with her lunch meal in front of her and she was coughing. No nursing staff were observed in the hallway. When queried, Resident #24 stated I'm OK and continued to cough. The meal ticket present on Resident #24's meal tray which she was eating from, indicated Resident Notes: Supervision with meals. On 6/18/26 at 1:14 pm, Director of Nursing (DON) B was notified Resident #24 was in the hallway alone, with her meal, and coughing. DON B stated it was unacceptable that staff was not present and assisting Resident #24 with her meal. DON B assisted Resident #24 to finish her meal and removed her meal tray when Resident #24 was done eating. DON B reported she expected staff to follow protocol when a resident needed assistance with a meal. Review of an Order Summary for Resident #24 revealed .Resident is a 1:1 (one to one) feed- Ensure there is someone assisting resident with feeding at every meal with a start date of 6/5/26. Review of a Care Plan for Resident #24 revealed .Focus/Goal/Interventions: Resident has self-care performance deficient.ADL (activities of daily living) needs will be met.eating: 1:1 with ALL MEALS, Upright for meals, Cue to slow down and take small bites. Remain in Broda / Upright position for at least 30 minutes after meals with a revision date of 4/8/25. Resident #49 Review of a Face sheet revealed Resident #49 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: pressure ulcer of sacral region (area where the lower back and buttock meet) stage 4 (deep open wound that extends through the skin, underlying tissue, muscle and bone), neuromuscular dysfunction of bladder (inability to control bladder function) and paraplegia (paralysis of the legs and lower body). Review of a Minimum Data Set (MDS) assessment for Resident #49, with a reference date of 3/31/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #49 was cognitively intact. Section GG, Self-Care Assessment, shower, dependent, and mobility, roll left and right, and transfer chair/bed-to-chair transfer, Resident #49 was dependent on facility staff to complete the tasks. On 6/18/26 at 11:48 am, Resident #49 was heard yelling Somebody help me. There was no nursing staff present in the hallway. On 6/18/26 at 11:49 am, Resident #49 was observed lying flat in bed, on a wet blanket and mechanical lift shower sling, naked, covered by a wet towel. Resident #49 stated, I've been laying here for 55 minutes, I am wet, I am cold, and I am pissed. Resident #49 was observed to have wet disheveled hair and was visibly shivering. Resident #49 reported she was transferred into bed after a shower and the CNAs (Certified Nurse Assistant) said they were going to come back, and they haven't yet. Resident #49 stated I feel like I was forgotten. Resident #49 reported she had no bed control and no call light; both were noted to be lying on the floor under her bed. Resident #49 reported the only thing she could do was yell and she had been for almost an hour. In an interview on 6/18/26 at 11:55 am, Registered Nurse (RN) CC reported she would complete Resident #49's wound care after her shower and CNA Y had told her about an hour ago that Resident #49 was going for a shower. RN CC reported, they CNAs had not let her know she was done in the shower, and she had not completed her wound care yet. In an interview and observation on 6/18/26 at 12:02 pm, CNA Y was removing the wet blanket and mechanical lift sling from under Resident #49. CNA Y reported CNA K told her Resident #49 had been covered; and she thought that meant Resident #49 had been taken care of. In an interview on 6/18/26 at 12:02 pm, DON B reported her expectations were that residents were not left lying on wet items in bed and without call lights. DON B reported her expectations were that resident care was completed. DON B reported the CNAs should be working together, not pointing fingers at each other. In an interview on 6/18/26 at 1:15 pm, Resident #49 reported she felt like the staff had forgotten about her. Resident #49 reported she thought it was completely ridiculous that she was left without her call light, soaking wet and flat on the bed with her only option to scream out for help because she was cold and shivering. Resident #49 stated .I am mad. Very mad. You lay there for an hour and see how you feel; these people don't even care what happens to us. During an interview on 06/17/2026 at 8:16 AM, CNA D confirmed she had worked the day shift from 6:30 AM-2:45 PM on 6/10/2026, she had approximately 17-18 residents she was caring for that day, she couldn't remember how many staff (nurses/CNAs) worked but confirmed it wasn't enough to meet resident needs timely or adequately. CNA D reported she was supposed to have 8 residents to care for during that shift. CNA D confirmed several residents she was looking after required supervision so she couldn't pass meal trays timely as she was concerned about supervising residents' safety. CNA D reported if she needed help, she would need to go ask a CNA from another unit, and that would leave the unit with less staff or with no CNA while she looked for help. She reported when this happens it leaves it to the nurse to watch all the residents and she reported that doesn't seem safe and the nurse has other responsibilities like passing medications. CNA D stated, We've been short staffed every weekday and it had been like that for at least a month and a half to two months. CNA D stated, I don't think so, when asked if the staffing levels allowed staff to meet residents needs timely during that time frame. During an interview on 06/17/2026 at 11:11 AM, Scheduler AA reported

Based on observation, interview, and record review the facility failed to ensure foods were consistently served at a proper temperature for 6 Residents (#1, #3, #17, #29, #30, and #45) of 24 residents reviewed for dining and 1 of 1 resident from a confidential resident council meeting resulting in hot foods being served colder than desired, dissatisfaction with meal service, and the potential for decreased oral intake and/or unintended weight loss.Findings include: Resident #1 Review of a Minimum Data Set (MDS) assessment for Resident #1, revealed the resident originally admitted to the facility on [DATE] with pertinent diagnoses which included hypertension and diabetes mellitus (chronic condition affecting how your body regulates blood sugar.) Review of Brief Interview for Mental Status (BIMS) with a reference date of 5/22/26 revealed a score of 15/15 which indicated Resident #1 was cognitively intact. During an interview on 6/16/2026 at 11:32 AM, Resident #1 reported ongoing concerns with food at the facility. Resident #1 reported food was often served cold and was unappetizing. When asked if Resident #1 had discussed her concerns about cold food with the facility, Resident #1 reported It's pointless to try to tell them (Facility Management), they don't care about the residents here. Resident #3 Review of a Face Sheet revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included assistance with personal care and pressure ulcer of the sacral region, stage 3 (pressure ulcer that involves full-thickness skin loss and require comprehensive management to promote healing and prevent complications.) Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 5/29/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #3 was cognitively intact. During an interview on 6/16/2026 at 3:49 PM, Resident #3 reported ongoing concerns with cold food being served at the facility. Resident #3 reported she joined a few other residents and started going to the Assisted Living dining room to eat because the food was served warmer in that dining area. Resident #3 reported that she had voiced concerns about the food being served cold on multiple occasions. Resident #17 Review of a Face Sheet revealed Resident #17 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #17, with a reference date of 6/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #17 was cognitively intact. During an interview on 6/16/2026 at 10:10 AM, Resident #17 reported concerns with the food at the facility frequently being served cold. Resident #17 reported she had voiced concerns about the food being cold to the Nursing Home Administrator (NHA) A on several occasions, but the food temperatures had not improved. Resident #29 Review of a Face Sheet revealed Resident #29 was originally admitted to the facility on [DATE] with pertinent diagnoses which chronic kidney disease stage 4 (severe, irreversible kidney damage) and dependence on renal dialysis (procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions.) Review of a Minimum Data Set (MDS) assessment for Resident#29, with a reference date of 6/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #29 was cognitively intact. During an interview on 6/16/2026 at 11:20 AM, Resident #29 reported that the food at the facility was awful and was typically served too cold. Resident #29 reported that he wished the facility would try to make the food more edible. Resident #30 Review of a Face Sheet revealed Resident #30 was originally admitted to the facility on [DATE] with pertinent diagnoses which included vascular dementia (cognitive decline caused by reduced blood flow to the brain, leading to memory, thinking, and behavioral changes), repeated falls and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 6/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #30 was moderately cognitively impaired. During an interview on 6/16/2026 at 2:03 PM, Family Member (FM) KK reported she frequently visited Resident #30 at the facility, typically during lunch time. FM KK reported concerns with the food being served at the facility, noting that the food was frequently served cold. FM KK reported Resident #30 did not eat much of her lunch that day because it was cold. FM KK reported she often observed that the table of residents that Resident #30 ate lunch with every day had also frequently complained and skipped meals due to the food being served cold. Resident #45 Review of a Minimum Data Set (MDS) assessment for Resident #45, originally admitted to the facility on [DATE] with pertinent diagnoses which included hypertension (high blood pressure) and depression. Review of Brief Interview for Mental Status (BIMS) with a reference date of 4/16/26 revealed a score of 15/15 which indicated Resident #45 was cognitively intact. During an interview on 6/16/2026 at 10:22 AM, Resident #45 reported ongoing concerns with cold food being served at the facility. Resident #45 reported she recently started going to the Assisted Living dining for her meals because the food served in that dining room was a bit warmer, but still not as warm as she would prefer. Resident #45 reported she had given up on voicing concerns to the facility about cold food, because they never address concerns here. During an interview on 6/23/2026 at 10:13 AM, Unit Manager (UM) S reported that she was aware that residents in the facility had been reporting concerns with food at the facility. UM S was not able report what actions the facility had taken to address the food concerns in the facility. During an observation on 6/16/2026 at 11:44 AM, This writer intercepted a meal tray and checked the temperature of the food approximately 3 minutes after the tray was delivered to the unit. There was a rice mixture that was noted to be 120 degrees, and green beans were noted to be 110.5 degrees. During a confidential resident council meeting interview on 06/17/2026 at 1:18 PM, 1 of 1 resident in attendance reported foods intended to be served hot were often served cold and at times all three meals in a day were served cold. The resident reported when he told facility staff that the food was served to him cold, he was instructed to get the nurse aides to microwave the meal. On 6/16/26 at 12:08 PM, an interview with Regional Dietary Manager NN found that the plate warmer worked and was in good condition. At this time, the plate warmer was observed to be turned off with plate surfaces measuring 76F when assessed with an infra-red digital thermometer.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings Include:On 6/16/26 starting at 9:09 AM, an interview with Dietary Manger (DM) SS found that the dish machine was not reaching the required temperature this morning. At this time, kitchen staff were observed doing dishes and using the dish machine. When asked if the dish machine had been fixed yet (while staff were observed doing dishes), DM SS stated that maintenance knew about the concern and could have fixed it already. On 6/16/26 at 9:25 AM, observation of the two-door cooler found increased accumulation of crumbs and black spotted debris on the top portion of the gasket seals for the doors.On 6/16/26 at 9:27 AM, an interview with DM SS found that clean pots and pans are stored and stacked on the wire rack after they are dried. Observation of the clean pots and pans found two half pans and one quarter pan stacked and stored with moisture in between their surfaces.On 6/16/26 at 9:32 AM, observation of the back preparation table found a container of lemon juice, roughly two thirds full, stored underneath the preparation surface. A review of the manufacturer's directions found that the item states to Refrigerate After Opening.On 6/16/26 at 9:38 AM, observation of the dish machine area found staff placing dirty dishes on racks and running them through the conveyor dish machine. At this time, it was noted the dish machine required a minimum of 160F from the wash cycle, a minimum of 180F from the rinse cycle, and a minimum contact of 160F from the water rinsing surfaces in the machine. After watching three cycles of the machine, it was observed that the wash gauge was not reading higher than 120F. Three cycles of two dish plate thermometers were run through the machine and recorded contact temperatures ranging from 140F-145F from the internal rinse water. When asked if maintenance had fixed the machine or not, DM SS was unsure and stated it didn't appear to be working, and they would reach out to their vender. On 6/16/26 at 10:05 AM, observation of pantry two found dried food splatter accumulation on the inside ceiling of the microwave and crusted white debris on the inside spout of the ice machine. When asked about these areas, DM SS stated that staff sometimes use the microwave and that maintenance takes care of the ice machines. On 6/16/26 at 11:59 AM, observation and interview with the dish machine vendor found that the wash water tank was not reaching and holding temperature and that he believes some of the issue had to do with ensuring the inside of the machine is cleaned regularly so the wash tank heating element can work more effectively. The machine was left in working order.According to the 2022 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling.TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above.(2) At 5C (41F) or less. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. According to the 2022 FDA Food Code section 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than:.(3) For a single tank, conveyor, dual temperature machine, 71oC (160oF);. According to the 2022 FDA Food Code section 4-501.15 Warewashing Machines, Manufacturers' Operating Instructions. (A) A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions.According to the 2022 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD.

Based on observation, interview, and record review, the facility failed to administer its policies, practices and procedures in a manner that displayed effective and efficient use of its resources to ensure the achievement and maintenance of the highest practicable physical, mental and psychosocial well-being of each resident. This deficient practice resulted in staff shortages, missing medications and treatment orders, missing showers and assistance with other activities of daily living (ADL) care, missed assessments, failure to identify changes in condition, inadequate comprehensive care planning and revisions, inadequate infection control practices, inadequate food services, resident and staff concerns going unaddressed, increased risks of accidents and hazards at the facility and lack of support from the governing body. This deficient practice placed 49 residents that reside in the facility at risk for inadequate care and services with the potential for their health and safety to be compromised. Findings include: Resident #3 Review of a Face Sheet revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included assistance with personal care and pressure ulcer of the sacral region (triangular area at the base of the spine that overlies the sacrum), stage 3 (pressure ulcer that involves full-thickness skin loss and require comprehensive management to promote healing and prevent complications.)Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 5/29/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #3 was cognitively intact. During an interview on 6/16/2026 at 3:49 PM, Resident #3 reported that staff were supposed to assist her with repositioning herself in bed and her wheelchair every two hours to assist with offloading pressure, but that the staff were not consistently repositioning her every two hours and she often went much longer without being repositioned. Resident #3 also reported concerns that nursing staff were not consistently changing her wound dressings as ordered, and concerns that she was frequently missing showers/bed baths because the facility did not seem to have enough staff to complete resident care. Resident #3 reported that it was common to wait for over 30 minutes for her call light to be answered when she activated it to call for assistance. During an interview on 6/16/2026 at 10:53 AM, Certified Nursing Assistant (CNA) D reported that the CNAs at the facility were unable to complete two-hour reposition checks on residents that were at risk for skin breakdown because they were always working short staffed. CNA D reported she had reported her concerns with residents not receiving consistent and adequate care to Nursing Home Administrator (NHA) A and Director of Nursing (DON) B on several occasions, and she did not feel the concern had been addressed. CNA D reported that it was impossible for staff to even meet the basic care needs, and being able to reposition Resident #3 every two hours was getting missed often. During an interview on 6/18/2026 at 3:46 PM, Unit Manager (UM) S reported that she was aware that staff had been missing wound care treatments and not repositioning Resident #3 every two hours. UM S reported that she had been working on the floor frequently, which made it harder for her to oversee the facility wound care program and follow up on missed treatments and care. UM S confirmed that Resident #4's right hip wound had declined from a stage 3 to a stage 4. Resident #17Review of a Face Sheet revealed Resident #17 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #17, with a reference date of 6/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #17 was cognitively intact. During an interview on 6/16/2026 at 10:10 AM, Resident #17 reported that she felt the facility did not have enough staff to provide resident care. Resident #17 reported she frequently had to wait for over 30 minutes for her call light to be answered when she needed assistance, and that she had recently waited over 3 hours for staff to answer her call light. Resident #17 reported that she frequently had to lay in soiled briefs for extended periods of time because staff were not able to get to her timely. Resident #17 reported that she was soiled in urine up to my back on multiple occasions because staff could not change her brief for hours. Resident #17 reported that she often chose to just stay in bed all day because if she were to get out of bed, it would take staff too long to assist her back into bed and she did not want to be in pain from sitting in her chair for too long. Resident #17 reported that she was frequently missing showers and/or bed baths because the facility did not have enough staff to complete showers as scheduled. Resident #17 reported feeling frustrated and disappointed in the care that she was receiving at the facility and stated that It is shameful how little the facility cares about the residents here, we deserve so much better than this. Resident #17 reported that she had voiced her concerns to facility management several times, specifically Nursing Home Administrator (NHA) A but nothing changes, they don't care. During an interview on 6/16/2026 at 10:53 AM, CNA D reported that it was common for the CNAs to skip showers/bed baths for residents. CNA D reported that the facility was always short staffed and it was impossible for the CNA's to provide any additional resident care such as showers and bed baths because they did not have time to complete them. CNA D reported that she had voiced her concerns with residents missing care to the Director of Nursing (DON) B and Nursing Home Administrator (NHA) A, but residents were still missing showers often and care had not improved in the facility. During an interview on 6/23/2026 at 10:13 AM, Unit Manager (UM) S reported that she was aware that several residents in the facility were missing showers/bed baths and not getting assistance that they needed. Resident #30 Review of a Face Sheet revealed Resident #30 was originally admitted to the facility on [DATE] with pertinent diagnoses which included vascular dementia (cognitive decline caused by reduced blood flow to the brain, leading to memory, thinking, and behavioral changes), repeated falls and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 6/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #30 was moderately cognitively impaired. During an interview on 6/16/2026 at 2:03 PM, Family Member (FM) KK reported ongoing concerns with staffing at the facility. FM KK reported that she frequently visited Resident #30 at the facility, and she observed the staff working short nearly daily. FM KK reported that it was common for Resident #30 to wait for over an hour for assistance. FM KK reported that she and Resident #30 had been sitting at the unit's dining area since she had finished eating two hours prior because the facility did not have staff to take Resident #30 back to her bedroom to rest. FM KK reported that she knew Resident #30 was sitting in a soiled brief at the time and watching staff run around like crazy and still struggle to meet the basic needs of the residents at the facility was disheartening. FM KK reported she had witnessed Resident #30 wait for over two hours on multiple occasions. FM KK reported that Resident #30 had fallen on multiple occasions in the facility, with one fall that resulted in major injury, and she felt that the staffing at the facility contributed to Resident #30 falls. FM KK reported, They (The nursing staff) aren't even able to meet the basic care needs of residents, let alone monitor residents at an increased risk of falls. Resident #45 Review of a Minimum Data Set (MDS) assessment for Resident #45, originally admitted to the facility on [DATE] with pertinent diagnoses which included hypertension (high blood pressure) and depression. Review of Brief Interview for Mental Status (BIMS) with a reference date of 4/16/26 revealed a score of 15/15 which indicated Resident #45 was cognitively intact. Section GG: Functional abilities indicated that Resident #45 required partial/moderate assistance from staff for transfers. (Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.) During an interview on 6/16/2026 at 10:22 AM, Resident #45 reported concerns with staffing at the facility. Resident #45 reported that nurses were not always completing her wound care treatments as ordered because they did not have time to do them, and CNAs were missing her showers/bed baths because they also did not have time to complete them. Resident #45 reported that it was common to have to wait for over an hour for assistance when she used her call light. Resident #45 reported she gave up voicing her concerns to the facility, because nothing ever changed. During an observation and interview on 6/17/2026 at 1:14 PM, Resident #45 reported that she had turned her call light on at 6:15 AM to get help from staff to get up for the day. Resident #45 reported that a staff member came into her room and told her that she couldn't help her, but she would get someone to help her, and then she turned off her call light. Resident #45 reported that she made the decision at 7:20 AM to get up on her own even though she knew she was not supposed to because she didn't want to miss breakfast. Resident #45 was tearful during interview and stated, I try to be easy going, I try not to complain because I know it's not the girls (nurses and cnas) fault, they are always working short, but I feel like I deserve help getting up, and shouldn't have to risk my safety to make sure I can eat. During an interview on 6/18/2026 at 10:44 AM, CNA F reported that staff were frequently working short because of call ins or just not having the staff. CNA F reported that a lot of staff had left recently because they were getting burned out. CNA F reported that the Director of Nursing (DON) B had just started mandating CNAs to stay over when staff called in and would threaten to report our license for patient abandonment if they did not stay. CNA F reported it was impossible to keep up with the care of residents, and she felt that she could not provide care that the residents needed because there was not enough time. Review of Resident Council Meeting Minutes dated 3/20/26 indicated that resident council had voiced ongoing concerns related to call lights, dirty environment, food, and medications being administered late. Noted that NHA A attended this meeting. Review of Resident Council Meeting Minutes dated 4/14/26 indicated that the resident council had voiced ongoing concerns related to dirty environment, food, and medications being administered late. Noted that all of the concerns were discussed in the previous month. Noted that NHA A attended this meeting. Review of Resident Council Meeting Minutes dated 5/20/26 indicated that the resident council had voiced ongoing concerns related to dirty environment, food, and medications being administered late. Noted that all of the concerns were discussed in the previous two months. Noted that NHA A attended this meeting. During an interview on 6/23/26 at 11:11 AM, Nursing Home Administrator (NHA) A reported that the facility was not currently working on any performance improvement plan (PIP) for staffing, food, call lights, or the environment. NHA A reported that he did not feel that the facility had a Staffing issue, but that the facility had a turnover problem after hiring some bad apples and he felt like the concerns brought to him about staffing were because staff had poor attitudes. NHA A reported the facility staff frequently called in, which also caused the facility staff to work short often. NHA A confirmed that he was aware that several residents and staff members in the facility had voiced concerns related to call lights, staffing, food, and medications. NHA A was unable to report what the facility had done to try to resolve resident concerns. NHA A confirmed that he had been the administrator over the skilled nursing and Assisted living area of the facility until May 2026, which made it harder for him to monitor and work through the concerns in the skilled nursing facility. NHA A reported the facility had completed a mock survey in March 2026, and the mock survey had found many of the same concerns that the survey team had found during this survey, and that he was not surprised by the findings from this survey. When this writer queried as to what the facility had implemented since the Mock survey to improve care, NHA A reported that the facility was planning to work through the findings of the mock survey the week that the State Agency entered the facility for the recertification survey. NHA A did not provide further information as to what the facility (interdisciplinary team) had done to improve resident concerns. For further information please see, F584, F656, F657, F677, F684, F686, F689, F697, F698, F725, F759, F804, F806, F812, F867, and F880.

Based on interview and record review, the facility failed to ensure that the facility-wide assessment accurately reflected the facility's resident population, care required by the resident population, and staffing decisions to ensure there was an sufficient number of staff to care for all residents residing in the facility, resulting in insufficient staffing to meet the needs of the residents, inadequate knowledge of the facility population, and inadequate resources to care for residents and unmet care needs for all 49 residents that reside in the facility. Findings include: Review of the Facility assessment dated [DATE] revealed, Person (names/titles) involved in completing assessment: Nursing Home Administrator (NHA) A, Director of Nursing (DON) B Average daily census: 50 . Individual staff assignment: Facility uses consistent assignments, specialty trainings for IV Mastery (Intravenous medications), wound care, dementia training, reviewing resident care assignments to determine load of halls. Review of resident preferences for types of caregivers .Staffing Plan: Position: Licensed nurses providing direct care: RN (Registered Nurse) 0.36 PPD (Patient per day-PPD stands for Patients Per Day, which is a measure used in healthcare to assess the average number of patients that a facility cares for on a daily basis. This metric is essential for understanding staffing needs and ensuring that adequate resources are allocated to provide quality care)-0.55 PPD. LPN (Licensed Practical Nurse) 0.39 PPD-0.48 PPD. Nurs aides: 1.50 PPD-2.45 PPD . Contingency plan . Facility uses (messaging application) to send mass messages to staff. Nursing managers are on call 24/7. Pick up bonuses are offered as needed. Facility will mandate, if necessary, in an emergency, facility will ask for assistance from other sister facilities if needed. Staffing levels will be evaluated as to whether it is conventional, contingency, or crisis daily. Decision will be made after evaluation of OT (over time), open shifts, administrative staff working as direct care, current staff burnout level. Documentation of factors effecting decisions, efforts being made to improve staffing. Factors may affect staffing include census, open positions, infectious outbreak, pandemic for a few examples . Noted that the facility assessment did not include documentation of involvement or input from residents or resident representatives. Noted that the facility assessment did not consider specific staffing needs for each unit, or specific staffing needs based on shifts. Noted that the facility assessment did not include an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet each resident's needs. Noted that the facility assessment listed the former medical services provider and former Medical Director and had not been revised to include the facility's current Medical Director. During an interview on 6/23/2026 at 11:11 AM, Nursing Home Administrator (NHA) A reported that he could not recall the last time that the facility had reviewed and revised the facility assessment and reported that he knew the facility assessment was due soon and that his regional staff were going to help him complete it. NHA A was unable to report how the facility had incorporated the facility assessment into staffing decisions at the facility. NHA A then reported to this writer that the facility assessment should be pretty accurate as to what the staffing needs on the floor were at the facility, but that some of the resident population contributed to staffing concerns reported by staff. NHA A reported that the facility currently had a resident that required four staff members to complete all of her activities of daily (ADL) care, so anytime staff were caring for that resident, they had the potential to get behind on other care. When this writer queried NHA A had incorporated the high acuity needs of the resident that required four staff for all care, NHA A reported that he did not know. NHA A then reported that he felt another struggle the building had with staffing was the layout of the facility, and how the layout made it hard for the aides to see all the call lights and resident rooms that they were assigned. When this writer further queried NHA A about the building layout concerns and if that had been incorporated into the facility assessment, NHA A did not know. NHA A was unable to report how the facility had incorporated residents and resident representatives into the facility assessment. For further information, please see F725.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for 5 (Resident #3, #29, #49, #19, and #24) of 24 residents reviewed for reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents. Findings include: Resident #3 Review of a Face Sheet revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included assistance with personal care and pressure ulcer of the sacral region, stage 3 (pressure ulcer that involves full-thickness skin loss and require comprehensive management to promote healing and prevent complications.) Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 5/29/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #3 was cognitively intact. During an interview on 6/16/2026 at 3:49 PM, Resident #3 reported concerns with the facility staff not consistently completing her care treatments. Review of Resident #3 Treatment Administration Record (TAR) for April 2026 revealed, Order: Wound to right big toe: Cleanse with wound . start date 3/28/26. Noted missing documentation to indicate if this treatment was completed on 4/27/26. Order: Catheter (flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid )-Anchor secured in place every day and night shift. Start date: 12/10/25. Noted missing documentation to indicate if this treatment was completed on 4/27/26. Order: Monitor DTI (deep tissue injury) right ankle BID (two times a day). Start date: 12/10/25. Noted missing documentation to indicate if this treatment was completed on 4/27/26. Order: Vital signs two times day. Start date: 12/10/25. Noted missing documentation to indicate if this treatment was completed on 4/27/26. Order: Apply bilateral offloading boots . Start date: 12/10/25. Noted missing documentation to indicate if this treatment was completed on 4/27/26. Order: Ensure repositioning on or about every two hours every shift. Start date: 12/10/25. Noted missing documentation to indicate if this treatment was completed on 4/27/26. Order: observe resident closely for signs and symptoms of hypoglycemia (low blood sugar) . Start date: 12/10/25. Noted missing documentation to indicate if this treatment was completed on 4/26/26. Review of Resident #3's TAR for May 2026 revealed, Order: Sacral (large, triangular bone at the base of your spine) wound: cleanse and apt dry . Start date: 5/15/26. Noted missing documentation to indicate if this treatment was completed on 5/20/26. Order: Vital signs two times a day . Start date: 5/15/26. Noted missing documentation to indicate if this treatment was completed on 5/28/26. Review of Resident #3's TAR for June 2026 revealed, Order: Cleanse area with soap and H20, rinse, pat dry . Start date: 6/9/26. Noted missing documentation to indicate if this treatment was completed on 6/10/26. Order: flush foley catheter . start date: 6/9/26. Noted missing documentation to indicate if this treatment was completed on 6/10/26. Order: Weight 4 weeks, then monthly, weight one time a day every month starting on the 1st . Start date: 5/21/26. Noted missing documentation to indicate if this treatment was completed on 6/1/26. Resident #29 Review of a Face Sheet revealed Resident #29 was originally admitted to the facility on [DATE] with pertinent diagnoses which chronic kidney disease stage 4 (severe, irreversible kidney damage) and dependence on renal dialysis (procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions.) Review of a Minimum Data Set (MDS) assessment for Resident#29, with a reference date of 6/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #29 was cognitively intact. Review of Resident #29's TAR for June 2026 revealed, Order: Milk of magnesia (medication used as a laxative) . give 30 ml (milliliters) one time a day for constipation. Order start date: 6/2/26. Noted missing documentation to indicate if this medication was administered on 6/21/26. Order: Carvedilol (medication used to treat heart failure and high blood pressure) tablet . Give 1 tablet by mouth two times a day . start date: 6/1/26. Noted missing documentation to indicate if this medication was administered on 6/11/26. Order: Miralax (laxative)oral powder . give 1 scoop by mouth two times a day . start date: 6/2/26. Noted missing documentation to indicate if this medication was administered on 6/21/26. Order: Oxycodone (pain medication) . give 1 tablet by mouth every 8 hours for pain. Start date: 6/5/26. Noted missing documentation to indicate if the medication was administered on 6/13/26, and 6/14/26. Order: AV shunt (surgically created connection between an artery and a vein, designed to allow repeated access for hemodialysis treatments) site left forearm. Monitor for bruit and thrill every shift. Start date: 6/2/26. Noted missing documentation to indicate if this treatment was completed on 6/9/26. Order: BID (twice daily) vital signs . start date: 6/2/26. Noted missing documentation to indicate if treatment was completed on 6/10/26. During an interview on 6/23/26 at 10:13 AM, Unit Manager (UM) S reported that nurses were required to document on all medication and treatment orders to indicate if they were completed or missed, and if the treatment or medication was missed, they should also document the rationale for why the medication or treatment was missed. R49 According to the Minimum Data Set (MDS) dated [DATE], R49 was cognitively intact as indicated by a score of 15/15 on her BIMS (Brief Interview Mental Status). Section O-Special Treatments, Procedures, and Programs revealed as of 3/24/26, R49's Covid-19 vaccination was up-to-date (UTD). Review of R49's medical records regarding immunization tab indicated the resident last received the Covid-19 vaccine on 10/25/2024. Review of R49's consent for the covid-19 vaccine was dated 12/15/25 and signed by her. Review of R49 Medication/Treatment Administration Record (MAR/TAR) dated 12/1/2025-12/32/2025 indicated an order had been placed for R49 that included, .dated 12/18/25 Comirnaty Intramuscular Suspension Prefilled Syringe 30 MCG/0. 3ML (COVID-19 (SARS-CoV-2) mRNA Virus Vaccine) Inject 0.3 milliliter intramuscularly one time only for Covid 19 prophylaxis for 1 Day-Start Date 12/18/2025 1404 (2:04 PM). Further review of R49's MAR TAR for 12/1/25-12/31/25 did not have documentation the covid vaccine was given as ordered on 12/18-12/19/25. Review of R49's Progress Notes did not have documentation regarding the administration status of the Covid-19 vaccine on 12/18/25 or 12/19/25. During an interview and record review on 6/23/26 at 10:44 AM, RCC OO stated while reviewing R49's medical records, (R49's) immunization tab indicated Covid-19 immunization was completed 12/20/25. (R49's) MAR/TAR dated 12/1/2025-12/31/2025 indicated Cormiaty (brand name of Covid-19 vaccine) was not administered, as 12/18 and 12/19 date slots for acknowledging treatment completed was left blank. My expectation of the clinical nurse is to administer the ordered vaccine, document on the MAR/TAR when it was administered and then document in immunizations tab (located in the resident's medical records) as well. In (R49's) immunization tab, the lot number, expiration date, location (thigh), date/time (12/20/25) administered is there but the nurse did not document in (R49's) MAR/TAR. Not documenting in the MAR/TAR indicates the treatment was not done and the vaccine could be given a second time unknowingly and cause adverse side effects. R19 According to R19's MDS dated [DATE], she was unable to complete the BIMS with a score of 99. Section O- Special Treatments, Procedures, Programs did not indicate the use of antibiotics. Review of R19's Diagnoses tab did not indicate UTI (urinary tract infection). Review of R19's Order Summary dated 4/16/26, revealed, Nitrofurantoln microcrystal (antibiotic) capsule 50 mg give 1 capsule by mouth in the morning for UTI prophylaxis. It was noted there was no stop date to assess its effectiveness and continuation. Review of R19's MAR/TAR dated 6/1/26-6/30/26 indicated Nitrofurantoln microcrystal (antibiotic) capsule 50 mg give 1 capsule by mouth in the morning for UTI prophylaxis start date 4/17/26 had been administered each AM (morning) from 6/1/26 to 6/23/26 (survey end date 6/23/26). Review of R19's Progress Notes dated 6/1/26-6/23/26 did not have documentation pertaining to the monitoring and assessment of effectiveness of a prophylactic antibiotic. During an interview and record review on 6/23/26 at 10:44 AM RCC OO stated while reviewing R19's medical records, A care conference (a scheduled, interdisciplinary (IDT) meeting involving facility staff, the resident, and their family/representative/guardian) is held quarterly for each resident. In that meeting, the residents' medication is extensively discussed. Prophylactic antibiotics would be a medication that would be discussed regarding its effectiveness and if it should be continued. That would be a part of antibiotic stewardship. (R19) has received a prophylactic antibiotic for UTI beginning 4/17/26. (R19's) quarterly care conference was held 5/22/26. The notes from that meeting did not discuss the continuation of the prophylactic antibiotic. I do not find an assessment regarding the use and administration of the prophylactic antibiotic in (R19's) medical records either. There is an assessment called Pertinent Charting and Follow up that should be done for prophylactic antibiotics upon the start and during the use of and it was not done for (R19). R24 According to R24's MDS dated [DATE], the resident was moderately cognitively impaired as indicated by a score of 9/15 on her BIMS. Section O- Special Treatments, Procedures, Programs did not indicate the use of antibiotics. Review of R24's Order Summary dated 12/7/2025, revealed, Bactrim DS oral tablet 800-160 mg (Sulfamethoxazol-Trimethoprim) give 1 tablet by mouth one time a day for prophylaxis. It was noted there was no indication of use for the antibiotic nor was there a stop date to assess its effectiveness and continuation. Review of R24's MAR/TAR dated 6/1/26-6/30/16 indicated Bactrim DS oral tablet 800-160 mg (Sulfamethoxazol-Trimethoprim) give 1 tablet by mouth one time a day for prophylaxis start date 5/19/26, had been administered each AM (morning) from 6/1/26 to 6/23/26 (survey end date 6/23/26). It was noted there was no indication for use of a prophylactic antibiotic. During an interview and record review on 6/23/26 at 10:44 AM, RCC OO stated while reviewing R24's Physician Progress Note dated 4/24/26, 5/7/26, and 6/17/26, Bactrim DS was mentioned but did not state indication of use. My expectation is the physician states why the antibiotic is being used and why it is prophylactic. The nursing staff should double-check the physician's orders for rights of medication administration (right medication, right route, right dose, right time, right resident, right reason). RCC OO reviewed R24's medical chart for form, Pertinent Charting Follow-up. RCC OO stated, There is no form for the beginning of the Bactrim or any follow-up forms while the resident has been on the prophylactic antibiotic. There is no indication for the use of the prophylactic antibiotic.

Based on interview and record review, the facility failed to: 1) effectively identify quality deficiencies, develop, and implement appropriate action to correct deficiencies; and 2) sustain a system to ensure corrective measures related to staffing, food procurement and storage, care plans, activities of daily living care (ADL), quality of care, accidents and hazards, tube feeding, complete and accurate medical records and infection control as evidenced by repeated deficiencies on the past three surveys. This deficient practice has the potential to affect all residents that reside in the facility. Findings Include During an interview on 6/23/26 at 11:11 AM, Nursing Home Administrator (NHA) A reported that the facility's interdisciplinary team (IDT) team met monthly for QAPI. NHA A reported that the facility's current performance improvement plans (PIP) that the facility was working on included monitoring linen use, monitoring blank tags on oxygen concentrators and equipment being in rooms for new admissions. NHA A reported that the facility was collecting data and monitoring for feedback during monthly town hall meetings, and that the facility utilized an excel sheet for high care areas like dietary, housekeeping, nursing care, showers, and returns to the hospitals. NHA 'A confirmed that the facility QAPI was not currently working on PIPS for showers, nursing care, housekeeping, and nursing care. NHA A' reported that he was aware that residents in resident council brought forth concerns with all of those areas for the last three months. NHA A reported that the facility was incorporating floor staff into QAPI by discussing it in huddles, but when the former Director of Nursing (DON) left the facility, that fell by the wayside. NHA A confirmed that the facility did not have a current PIP for staffing. NHA A reported that he did not feel that staffing was an issue at the facility, but that high turnover, and hiring some bad apples with poor attitudes were the issue. NHA A was unable to report any further ways that the facility QAPI was incorporating resident and staff feedback into the QAPI program. NHA A was unable to report if the facility had utilized the facility assessment for QAPI and reported that he had not yet completed a facility assessment and that his Regional Director was planning to help him do that soon. NHA A confirmed that the facility did not have current PIPS for staffing, food procurement and storage, care plans, ADL care, quality of care, accidents and hazards, tube feeding, complete and accurate medical records and infection control, which were all noted repeat deficiencies. NHA A reported that the facility had conducted a mock survey in March 2026, and that survey had found several of the same concerns that the survey team found during the recertification survey, so he was not surprised by the survey findings. Review of the facility's QAPI Plan dated 10/24/22 revealed, Purpose: It is the policy of this facility to systematically collect data as part of the QAPI program to ensure the care and services it delivers meet acceptable standards of quality in accordance with recognized standards of practice. In addition the purpose of this document is to serve as a plan to assist the facility in development, implementation, and maintenance of an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The goal is to create a process that ensures care and services delivered meet accepted standards of quality Prioritization of program activities that focus on high-risk, high-volume, or problem- prone areas as identified in the facility assessment that reflects the specific units, programs, departments and unique population the facility serves.

Based on observation, interview, and record review the facility failed to: 1. Ensure the use of personal protective equipment (PPE) for 2 residents (Resident #47 and Resident #49) during high contact care activities while in enhanced barrier precautions; 2. properly clean and store resident shared equipment for 1 resident (Resident #3); and 3. Maintain an active an ongoing water management plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP) for 3 of 49 residents reviewed for infection control, resulting in the increased potential for the spread of infection, cross-contamination, disease transmission and the development of water borne pathogens and/or respiratory infections to exist and spread in the facility's plumbing system affecting all residents in the facility.Findings include: Resident #47 Review of a Minimum Data Set (MDS) assessment for Resident #47, with a reference date of 4/8/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #47 was cognitively intact. Section GG, Self-Care Assessment, mobility, roll left and right, and transfer chair/bed-to-chair transfer, Resident #47 was dependent on facility staff to complete the task. Review of an Order Summary for Resident #47 revealed .Use enhanced barrier precautions while performing high-contact activity with the resident with a start date of 4/16/2026. Review of a Care Plan for Resident #47 revealed .Focus/Goal/Interventions.Resident requires enhanced barrier precautions related to supra pubic catheter, wounds.use gown and gloves when providing direct care.use enhanced barrier precautions when providing high contact resident care activities (dressing, bathing, transferring, personal hygiene, changing linens, changing briefs/assisting with toileting, device care urinary catheters. all initiated on 4/8/2024. On 6/18/26 at 11:46 am, Certified Nurse Assistant (CNA) Y and CNA K were observed transferring Resident #47 from a shower gurney into her bed via a mechanical lift. Neither CNA was wearing PPE, a gown. Signage observed posted outside of the resident's room indicated enhanced barrier precautions were in place for Resident #47. Resident #49 Review of a Face sheet revealed Resident #49 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: pressure ulcer of sacral region (area where the lower back and buttock meet) stage 4 (deep open wound that extends through the skin, underlying tissue and muscle to the bone), neuromuscular dysfunction of bladder (inability to control bladder function) and paraplegia (paralysis of the legs and lower body). Review of a Minimum Data Set (MDS) assessment for Resident #49, with a reference date of 3/31/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #49 was cognitively intact. Section GG, Self-Care Assessment, mobility, roll left and right, and transfer chair/bed-to-chair transfer, Resident #49 was dependent on facility staff to complete the task. Review of an Order Summary for Resident #49 revealed .Use enhanced barrier precautions while performing high-contact activity with the resident with a start date of 2/13/2026. Review of a Care Plan for Resident #49 revealed .Focus/Goal/Interventions.Resident requires enhanced barrier precautions related to supra pubic catheter, wounds.use gown and gloves when providing direct care.use enhanced barrier precautions when providing high contact resident care activities (dressing, bathing, transferring, personal hygiene, changing linens, changing briefs/assisting with toileting, device care urinary catheters. all initiated on 4/8/2024. On 6/16/26 at 10:55 am, CNA Y and CNA K were observed using a mechanical lift to transfer Resident #49 from her bed to her wheelchair. CNA Y assisted Resident #49 with removing her gown and putting on a bra and shirt. CNA K was observed assisting with positioning Resident #49 into her wheelchair and was then observed collecting soiled linen and placing it into a plastic bag. CNA Y was further observed removing soiled linen from Resident #49's bed. Neither CNA Y nor CNA K were wearing gowns during care. Signage indicating Resident #49 was in enhanced barrier precautions was noted on the door upon entry into her room. In an interview on 6/16/26 at 11:03 am, Resident #49 reported staff never wear the gowns unless they were doing her wound care. In an interview on 6/16/26 at 11:24 am, CNA Y reported the signage indicated enhanced barrier precautions was to be used during wound care for Resident #49. CNA Y reported she did not need to wear PPE during transfers of residents in EBP it was only for wound care. In an interview on 6/17/26 at 2:55 pm, CNA K reported the signage outside of Resident #49's room indicated a gown and gloves needed to be worn during cares, and she did not have an understanding of the signage earlier today when she was observed not wearing PPE during a transfer, but she now understood. CNA K confirmed she did not wear PPE when providing high contact care to Resident #49. In an interview on 6/23/26 at 10:44 am, Regional Clinical Consultant (RCC) OO reported enhanced barrier precautions should be implemented and PPE should be worn when residents' had a foley catheter and chronic wounds. Review of facility policy Enhanced Barrier Precautions (EBP) with a revision date of 3/26/24 revealed .designed to reduce the transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high contact resident care activities.staff receive training on high risk activities.initiation of enhanced barrier precautions.indwelling medical devices.urinary catheters.high-contact resident care activities to consider include: dressing bathing, transferring, providing personal hygiene, changing linens, changing briefs or assisting with toileting, device care or use.wound care. Review of Centers for Disease Control and Prevention (CDC) dated March 20, 2024, revealed, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .EBP are indicated for residents with any of the following: 1. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or 2. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .Effective Date: April 1, 2024 . Resident #3 Review of a Face Sheet revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included assistance with personal care and pressure ulcer of the sacral region, stage 3 (pressure ulcer that involves full-thickness skin loss and require comprehensive management to promote healing and prevent complications.) Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 5/29/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #3 was cognitively intact. During a care observation on 6/18/2026 at 10:44 AM, Resident #3 was lying in her bed as Certified Nursing Assistant (CNA) D and CNA F got her dressed for the day. Noted that Resident #3 was lying on top of hoyer (medical device designed to safely lift and transfer individuals with limited mobility from one surface to another using a sling and mechanical lifting system) sling (a fabric support device used with a Hoyer lift to safely lift and transfer patients between surfaces like beds, chairs, or commodes) in her bed which was visibly soiled with some kind of brown liquid and several food crumbs and dried skin on the sling. CNA D and CNA F were noted to use the soiled sling on Resident #3 during a transfer to her wheelchair. During a subsequent observation on 6/18/2026 at 1:48 PM, Resident #3 was noted to be sitting in her wheelchair in her room. Noted that Resident #3 was still sitting on the soiled hoyer sling. On 6/16/26 at 9:43 am, a shower gurney was observed parked in the hallway on the health center 3 unit. The shower gurney was noted to be soiled with debris, hair, and what appeared to be a white cream smeared on the removable pad. The mesh netting under the removable pad was noted to contain smeared white substances and a white powder. The vinyl catch material under the shower gurney bed was noted to be discolored orange, had standing water present, and had dirt, debris, and hairs present. A sit to stand lift present in the same hallway was noted to be soiled with dirt and debris. On 6/16/26 at 9:53 am, two over the bed tables were observed in the hallway on health center 3 unit and both tabletops were soiled with debris and appeared sticky. One table was noted to have a white substance smeared on the top surface. On 6/17/26 at 11:27 am, two over the bed tables were observed in the hallway on health center 3 unit and both tabletops were soiled with debris and appeared sticky. On 6/16/26 at 10:05 am, an unknown resident was heard yelling and asking to have a mechanical lift removed from her room. On 6/16/26 at 10:10 am, DON B was observed removing a mechanical lift from the unknown resident room and placing it into the hallway. There was a plastic bag with a spray bottle of cleaning solution noted on the lift handle. No rags/towels were observed. DON B parked the lift in the hallway and did not clean it. On 6/17/26 at 10:55 am, CNA Y and CNA K were observed using the mechanical lift to transfer a resident. Following the transfer CNA Y placed the mechanical lift in the hallway and did not clean it after use. In an interview on 6/17/26 at 11:24 am CNA Y reported mechanical lifts were cleaned by third shift, and she had no idea what the schedule was for cleaning. In an interview on 6/17/26 at 11:25 am, Registered Nurse (RN) G reported the lifts were cleaned by third shift and there was probably a book somewhere that listed the cleaning schedules for wheelchairs, walkers, and the lifts. In an interview on 6/23/26 at 10:44 am, RCC OO reported resident shared equipment. should be cleaned between each use and blue liquid in spray bottles, a mixed disinfectant, should be on each piece of resident-shared equipment for immediate cleaning after each use. On 6/16/26 at 9:56 AM, observation of the pantry in health center one found disposable gloves and a new filter for the ice machine stored underneath the wastewater line of the sink. On 6/16/26 at 11:06 AM, observation of the wall hung storage cabinet, in the health center one spa room, found a bottle of spray disinfectant mixed with bottles of personal hygiene products such as body wash and shampoo. On 6/16/26 at 11:20 AM, observation of the Ridgewood spa room found a shower bed with heavy accumulation of debris between the padded mattress and the structural netting of the bed. Accumulations of hair and crusted white debris was evident in the folds of the netting with numerous discolored stains on the top portion of the netting. On 6/16/26 at 9:20 AM, observation of the wall to the right of the two-door cooler in the kitchen, found two sets of unused hot and cold-water hook ups not in use indicating stagnant water. No set up for easy flushing was observed and Dietary Manager SS was not familiar with staff flushing these water lines. Further reviews on the outside beverage station found a cold-water line not in use. On 6/16/26 at 11:05 AM, observation of the health center one spa tub found accumulation of dust and debris inside of the tub area, indicating the tub is not used or flushed regularly. On 6/16/26 at 11:15 AM, observation of the Ridgewood clean utility room found a sink connection on the back left portion of the wall with the water lines capped indicating stagnant water. On 6/16/26 at 11:22 AM, observation of the Ridgewood soiled utility room found that the hot water handle was turned off and was unable to be flushed, indicating a stagnant water line. On 6/16/26 at 1:46 PM, a phone interview with Maintenance Director P found that he regularly flushes hoppers, but the fixtures found in the kitchen and the clean utility room he was unaware of and are not currently on a regular flushing schedule. A record review of the facility provided document entitled Operation, Maintenance, and Control Limits, not dated, states to Flush low-flow pipe runs, dead legs and infrequently used fixtures weekly.

Based on observation, interview, and record review, the facility failed to maintain a clean and homelike environment for 6 (Resident #3, #17, #10, #13, #47 and #51) of 24 residents reviewed for clean environment resulting in resident dissatisfaction with their living environment. Findings include: Resident #3 Review of a Minimum Data Set (MDS) assessment for Resident#3, with a reference date of 5/29/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #3 was cognitively intact. During an interview and observation on 6/18/2026 at 10:44 AM, Resident #3 was lying in her bed. Several pieces of trash, paper and food crumbs were noted on Resident #3's floor around and underneath her bed. There were two soiled pillows, soiled bed linens, and soiled clothing protectors sitting on the floor next to resident's bed. Resident #3 reported that she did not know how long the soiled items had been in her room and she did not know how often the facility cleaned her room, but she wished that staff were cleaning her room more often. Resident #3 reported she preferred for her room to be picked up after staff completed care with her, or if they saw trash items on the floor. During an observation on 6/18/2026 at 1:48 PM it was noted that Resident #3's room remained in the same condition as previous observation. Resident #17 Review of a Minimum Data Set (MDS) assessment for Resident #17, with a reference date of 6/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #17 was cognitively intact. During an interview and observation on 6/17/2026 at 8:46 AM, Resident #17 reported concerns related to the cleanliness of her room. Resident #17 reported she had voiced concerns related to the smell of the bathroom in her room to facility staff on multiple occasions, but the facility had not yet addressed her concern. At the time of the interview a strong odor of bowel movement was noted in addition to several pieces of trash on the floor around Resident #17's bed and near the entrance to the shared bathroom. Resident #10 (R#10):Review of R#10's brief interview for mental status, dated 6/12/2026, was scored 8 which suggested moderately impaired cognition.During an observation 06/16/2026 at 9:46 AM, R#10 was lying in bed, appeared confused, and his floor, wall, and bedding were soiled. Between the bed and the wall, stretching from the corner of the floor up past the head of the bed down to the foot of the bed, there was an accumulation of dust and debris. The accumulation of unknown debris was variable in size and various colors which included orange, brown, gray, and white. The orange debris appeared to be dried food material. The decorative wood molding on the midway point of the wall next to the bed had dried brown splatter. The bedside table was covered in dust and debris. 17 of the slats of his window blinds were bent and in disrepair. The top sheet of his bedding had what appeared to be dried food stains on the area near his chin, upper corners, and knee area. During an observation on 06/17/2026 at 8:29 AM, R#10 was lying in bed, and his bedding, floor, and wall were unclean and/or soiled as they had been observed on 06/16/2026 at 9:46 AM. During a phone interview on 06/17/2026 at 10:04 AM, R#10's Family Member (FM) DD expressed a concern over the cleanliness of R#10's room during previous visits. FM DD reported cleaning R#10's room during visits and had brought a personal dustpan and broom from home to clean the debris from the floor between the bed and wall as well as under the bed. FM DD confirmed the issue of cleanliness in R#10's room had been ongoing for approximately a year. Review of R#10's Quality Assurance Form (grievance/concern form), dated 3/2/26, stated, .Communicated by: Family/RP (Responsible Party) .Communicated to: Staff Name: Staff/nurses.Assistance Needed.Other.Details.Lack of housekeeping in . (R#10's) room.Findings.Room needs cleaned. Resident #13 Review of a Face sheet revealed Resident #13 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: dementia unspecified severity, with agitation and cognitive communication deficit. On 6/16/26 at 11:35 am, a strong odor of urine was noted in the hallway outside of and in Resident #13's room. On 6/17/26 at 8:32 am, a strong odor of urine was noted in the hallway outside of and in Resident #13's room. On 6/17/26 at 11:32 am, a strong odor of urine was noted in the hallway outside of and in Resident #13's room. Resident #47 Review of a Minimum Data Set (MDS) assessment for Resident #47, with a reference date of 4/8/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #47 was cognitively intact. In an observation on 6/16/26 at 10:10 am, the personal refrigerator in Resident #47's room was noted to be soiled with crumbs, spillage, and debris inside, and noted dust on the top. In an observation and interview on 6/16/26 at 12:15 pm, the personal refrigerator in Resident #47's room was noted to be soiled with crumbs, spillage, and debris inside. Resident #47 stated don't judge, my husband tries to keep the fridge clean. When queried, Resident #47 reported facility staff did not clean her refrigerator. In an observation on 6/17/26 at 8:45 am and 11:34 am, the personal refrigerator in Resident #47's room was noted to be soiled with crumbs, spillage, and debris inside. In an interview on 6/17/26 at 11:40 am, Housekeeper (HSK) FF reported she had never been instructed to clean resident refrigerators, she did not clean them, and housekeeping was not responsible to clean resident refrigerators. In an interview on 6/17/26 at 1:10 pm, Housekeeping Director (HSKD) GG reported the housekeeping department was not responsible for cleaning resident refrigerators. HSKD GG stated it could be maintenance, could be nursing, I don't know, but it wasn't us. In an interview on 6/17/26 at 5:06 pm, Maintenance Director (MD) P reported his department had nothing to do with cleaning resident refrigerators. MD P reported he thought housekeeping was responsible for cleaning resident refrigerators. On 6/18/26 at 12:30 pm, an unknown housekeeping staff member was observed cleaning the refrigerator in Resident #47's room. In an interview on 6/18/26 at 12:48 pm, Resident #47 reported until today, housekeeping had not cleaned her refrigerator before. Review of facility policy Resident Refrigerators' with a revision date of 1/1/2022 revealed .to ensure safe and sanitary use of any resident-owned refrigerators.Housekeeping staff (or department assigned) shall clean the refrigerator daily and discard any food that are out of compliance. Nursing staff shall clean up spills as needed, or refer to housekeeping staff. Resident #51 (R51) Review of a Minimum Data Set(MDS) assessment for R51 with a reference date of 6/2/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. During an observation and interview on 6/16/26 at 12:02pm, assorted food crumbs were noted on the floor next to R51's bed, where he would place his feet when he got up, across the surface of his bedside table and along the wall next to his bed, on the opposite side. The surface of his bedside table appeared sticky. A large slightly yellowed stain with brown edges was present on the bed sheets in the area where R51's legs would be while he was in bed. An empty medication cup was under the bed. The privacy curtain was soiled with several spots of dried brown substance. R51 reported housekeeping did not clean his room every day and even when they did come, they were not thorough when cleaning. R51 reported he often had crumbs on his bedside table, on the floor where he rested his feet and, on the floor, next to the wall/under his bed. R51 reported he asked to have his sheets changed the day prior because he noticed dried drainage from his leg wounds on the sheets, but no one had changed them yet. During an observation on 6/17/26 at 2:23pm, the pill cup and assorted crumbs remained under R51's bed. On 6/16/26 at 11:14 AM, observation of the Ridgewood Hall found a noticeable odor of urine as the surveyor walked past the first few resident rooms on the hall. On 6/16/26 at 12:31 PM, observation of resident room [ROOM NUMBER] found that the wall boards were removed from the wall and instead of a bumper board present, just the fasteners for the bumper board were observed on the wall. The window blinds to bed two were found disheveled with pieces of plastic blinds broke and on the floor. On 6/16/26 at 12:35 PM, observation of resident room [ROOM NUMBER] found accumulation of dirt and crumb debris evident in between furnishings in the room such as the nightstand and the dresser. An interview with R47 at this time found that staff do not clean their room as thoroughly as she would like. When asked about the presence of pests in the room, R47 stated that the room gets ants and that there have been times where she has woken up to ants on her while in bed. On 6/16/26 at 1:17 PM, an interview with Housekeeping Director GG found that the odor on Ridgewood comes from R13 who is newer to the facility and has a history of urinating in his room and not in the commode. On 6/16/26 at 1:47 PM, a phone interview with Maintenance Director (MD) P found that the wall boards in room [ROOM NUMBER] were removed after bed one broke the wall boards adjusting the bed height. MD P stated that he didn't realize that just the fasteners were left on the wall. When asked about pests in the facility, MD P stated that they keep a log for their pest control operator and that he uses traps and spray when he gets a concern about ants. A record review of the facility provided Service Request Log for their pest control vendor, found a report on 4/28/26 that states room [ROOM NUMBER]-2 ants around bed. Review of the facility's Safe and Homelike environment policy last revised 1/1/22 revealed, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk . Policy Explanation and Compliance Guidelines: . 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment .

Based on observation, interview, and record review, the facility failed to provide timely and consistent ADL (activities of daily living) care to 5 (#3, #8, #17, #21, and #49) of 6 residents reviewed for ADL's, resulting in residents not receiving proper assistance and supervision with eating, being un-bathed for extended periods, and feeling embarrassed about their body hygiene.Findings include: Resident #3 Review of a Face Sheet revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included assistance with personal care and pressure ulcer of the sacral region, stage 3 (pressure ulcer that involves full-thickness skin loss and require comprehensive management to promote healing and prevent complications.) Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 5/29/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #3 was cognitively intact. During an interview on 6/16/2026 at 3:49 PM, Resident #3 reported she was frequently missing showers at the facility. Resident #3 reported that she was supposed to get showers twice a week, but she often only would get one shower a week. Resident #3's hair was noted to be disheveled. Review of Resident #3's Shower Tasks revealed that from 4/19/26-6/18/26 staff had documented that Resident #3 had received 8 showers in the 60-day time frame. Resident #8 Review of a Face Sheet revealed Resident #8 was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes mellitus without complications (elevated blood sugar due to insulin resistance or deficiency, but without any diabetes-related organ damage or secondary health problems) and lymphedema (tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system.) Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 4/22/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #8 was cognitively intact. Review of Resident #8's Care Plan revealed, Resident has an ADL self-care deficit performance . Start date: 3/18/26. Interventions . Eating: Supervision. Offer assistance with meal set up as needed. Date initiated: 3/18/26. During an observation on 6/16/2026 at 12:32 PM, Resident #8 was sitting at a table in the dining area with a full milk carton in his hand and an untouched meal tray sitting in front of him. Resident #8 was noted to be falling in and out of sleep as he sat in front of his meal tray. Noted there was 1 staff member (Registered Nurse (RN) G sitting at another table in the dining area providing assistance to another resident. During an interview on 6/16/2026 at 12:42 PM, Registered Nurse (RN) G reported that Resident #8 needed staff supervision during meals because he needed queuing reminders from staff to eat. RN G reported that she was the only staff member available to assist in the unit dining room, and that she would assist Resident #8 when she was done assisting another resident in the dining area. During an observation on 6/16/2026 at 12:44 PM, Nursing Home Administrator (NHA) A approached the table that Resident #8 was sitting at and attempted to talk to Resident #8 and que him to eat his food. Resident #8 woke up and began to take bites of his sandwich. Noted that NHA A stopped interacting with Resident #8 and began looking at his phone. Resident began to close his eyes and rest again. At 12:48 PM NHA A left Resident #8's table, and he was noted to be resting his eyes at the table with his sandwich in his hands. Review of Resident #8's ADL-Eating Tasks dated 6/16/26 revealed, Eating performance: How resident eats and drinks, regardless of skill . It was noted that staff had documented that Resident #8 was independent with eating his lunch on 6/16/26 at 1:21 PM, which indicated that Resident #8 did not require supervision, oversight, encouragement, or cueing with eating . During an interview and observation on 6/17/2026 at 8:50 AM, Resident #8 was sitting at a table in the unit dining area with an untouched plate of sausage and toast in front of him. Noted that there were not any staff members present in the area to supervise or que resident to eat. Resident #8 reported that he was hungry and wanted to eat, but he was too weak to feed himself and he was waiting for someone to help him. Resident #17 Review of a Face Sheet revealed Resident #17 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #17, with a reference date of 6/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #17 was cognitively intact. During an interview on 6/16/2026 at 10:10 AM, Resident #17 was lying in bed in her room. Resident #17 reported concerns with the care she was receiving at the facility, especially with missing showers. Resident #17 reported it was common to miss one or both of her scheduled showers each week because the facility staff did not seem to have the time to complete showers or bed baths. During an interview on 6/18/2026 at 1:14 PM, Resident #17 was lying in bed. Noted that Resident #17 was wearing the same outfit as previous observation on 6/16/26 (two days prior). Resident #17 reported that she was wearing the same clothing, which was common for her because staff were not always able to get her up and dressed into new clothes daily, which was her preference. Resident #17 voiced frustration over the care at the facility and reported feeling like staff just don't care about the residents at the facility. Review of Resident #17's Shower Tasks Review of Resident #3's Shower Tasks revealed that from 4/19/26-6/17/26 staff had documented that Resident #17 had received 10 showers in the 60-day time frame. During an interview on 6/16/2026 at 10:53 AM, Certified Nursing Assistant (CNA) D reported that it was common for the CNAs to skip showers/bed baths for residents. CNA D reported that the facility was always short staffed and it was impossible for the CNA's to provide any additional resident care such as showers and bed baths because they did not have time to complete them. CNA D reported that she had voiced her concerns with residents missing care to the Director of Nursing (DON) B and Nursing Home Administrator (NHA) A, but residents were still missing showers often and care had not improved in the facility. During an interview on 6/23/2026 at 10:13 AM, Unit Manager (UM) S reported that she was aware that several residents in the facility were missing showers/bed baths and not getting assistance that they needed, and that the facility had been trying to work on that. When this writer queried as to what the facility interdisciplinary (IDT) team had done to work on the concern of residents not receiving adequate ADL care, UM S was unable to provide an answer. Review of the facility's ADL policy last revised 12/28/23 revealed, Policy: The facility takes measures to minimize the loss of resident's functional abilities, including activities of daily living (ADLs). Activities of Daily Living include the ability to: 1. bathe, dress, and groom. 2. transfer and ambulate. 3. toilet 4. eat and 5. use speech, language, or other functional communication systems. Policy explanation and guidance: . 3. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 4. The facility identifies resident triggers through the Care Area Assessment (CAA) process to assess causal factors for decline, potential decline, or lack of improvement Resident #21 (R21) Review of an Face Sheet revealed R21 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic pain syndrome (persistent pain lasting more than 3 months and causes other severe, non-pain symptoms like depression, anxiety, and insomnia (difficulty falling or staying asleep), major depressive disorder (a serious mental health condition characterized by persistent feeling of sadness, hopelessness, and loss of interest in activities once enjoyed) and radiculopathy (nerve root compression or irritation in the spinal column resulting in pain, numbness, weakness). Review of a Minimum Data Set(MDS) assessment for R21 with a reference date of 6/12/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Section GG revealed R21 required moderate (helper does less than half the effort) assistance for showering and toilet hygiene (the ability to maintain perineal {the region of the body between the genitals and the anus} hygiene). Review of a Care Plan for R21 with a reference date of 12/4/25 revealed the following focus/goal/interventions: Focus: Resident has an ADL (activities of daily living) self-care deficit.Goal: Resident's ADL needs will be met. Interventions.bathing: 1 person assist.personal hygiene: 1 person assist. In an interview on 6/16/26 at 12:29pm, R21 reported due to staffing levels, she frequently was not offered showers at least twice a week. R21 reported she felt embarrassed about her poor hygiene when she didn't get showers at least twice a week and recently had to go to a doctor's appointment with hair that was a grease ball and poor body hygiene. R21 reported she felt self-conscious at the appointment and wondered if she smelled. R21 reported she regularly transferred herself from toilet after waiting for more than 20 minutes for staff to respond to her call light but could not properly clean her perineal area so she felt unclean Review of Shower Records for R21 with a reference date of 4/20-6/20/26 revealed the resident received 10 showers total. If provided twice a week, the same reference period should have afforded R21 with 18 showers at a minimum. In an interview on 6/17/26 at 12:26pm, CNA F reported the facility frequently did not have enough nursing staff and as a result, resident showers were not offered, residents who needed 2 staff for cares waited long periods of time, and other residents were not properly supervised. Resident #49 Review of a Face sheet revealed Resident #49 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: pressure ulcer of sacral region (area where the lower back and buttock meet) stage 4 (deep open wound that extends through the skin, underlying tissue, muscle and bone), neuromuscular dysfunction of bladder (inability to control bladder function) and paraplegia (paralysis of the legs and lower body). Review of a Minimum Data Set (MDS) assessment for Resident #49, with a reference date of 3/31/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #49 was cognitively intact. Section GG: Self-Care Assessment, indicated Resident #49 was dependent on facility staff to complete ADL tasks of showers, bed mobility, and transfers. In an interview on 6/16/26 at 9:46 am, Resident #49 reported she had received one shower last week and had not yet received a shower this week. In a subsequent interview on 6/16/26 at 11:03 am, Resident #49 reported her scheduled shower days were Monday and Thursday. Resident #49 stated If I don't get a shower tomorrow, you won't need to talk to me, you will hear me, I will be very angry, and I will make it known. I have things to do this weekend, and I need to be cleaned up for them. Review of POC (point of care) Response History-Task GG Shower/Bathe Monday/Thursday first shift for Resident #24, with a 30 day look back from 6/16/26 revealed documentation indicating Resident #49 received a shower on 5/28/26 and 6/7/26. 2 documented showers out of 9 scheduled opportunities for a shower for Resident #49. Review of Shower/bathe Monday/Thursday first shift for Resident #49 documentation provided by the facility revealed Resident #49 received a shower 7 times in a 60-day period. On 6/18/26 at 11:48 am, Resident #49 was heard yelling Somebody help me. There were no nursing staff present in the hallway. On 6/18/26 at 11:49 am, Resident #49 was observed lying flat in bed, naked, on a wet blanket and mechanical lift shower sling, covered in a wet towel. Resident #49 stated, I've been laying here for 55 minutes, I am wet, I am cold, and I am pissed. Resident #49's hair was wet and disheveled and she was visibly shivering. Resident #49 reported she was transferred into bed after a shower and the CNAs (Certified Nurse Assistant) said they were going to come back, and they hadn't yet. Resident #49 stated I feel like I was forgotten. Resident #49 reported she had no bed control and no call light; both were noted to be lying on the floor under her bed. Resident #49 reported the only thing she could do was yell and she had been for almost an hour. In an interview on 6/18/26 at 11:55 am, Registered Nurse (RN) CC reported she would complete Resident #49's wound care after her shower and CNA Y had told her about an hour ago that Resident #49 was going for a shower. RN CC reported, the CNAs had not let her know she was done in the shower, and she had not completed her wound care yet. In an interview on 6/18/26 at 12:02 pm, DON B reported her expectations were that residents were not left lying on wet items in bed and without call lights. DON B reported her expectations were that resident care was completed. In an interview on 6/18/26 at 1:15 pm, Resident #49 reported she felt like the staff had forgotten about her. Resident #49 reported she thought it was completely ridiculous that she was left without her call light, soaking wet and flat on the bed with her only option to scream out for help because she was cold and shivering. Resident #49 stated .I am mad. Very mad. You lay there for an hour and see how you feel; these people don't even care what happens to us.

Based on observation, interview and record review the facility failed to 1.) implement fall interventions to prevent falls in 1 resident (Resident #22); 2.) investigate a fall for 1 resident (Resident #30); 3.) securely store smoking paraphilia for 1 resident (Resident #14); and 4.) provide adequate supervision during meals for 1 resident (Resident #24) of 4 residents reviewed for accidents and hazards, resulting in the potential of injury to residents.Findings include: Resident #22 Review of a Face sheet revealed Resident #22 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: repeated falls, protein calorie malnutrition, and schizoaffective disorder (chronic mental health condition with coexistence of psychotic symptoms and mood disturbances, such as hallucinations and delusions, and/or depression and mania). Review of a Minimum Data Set (MDS) assessment for Resident #22, with a reference date of 6/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #22 was severely cognitively impaired. Section GG, Self-Care Assessment, eating, supervision or touching assistance and mobility chair/bed-to-chair transfer dependent, indicating helper does all of the effort. On 6/16/26 at 12:21 pm, Resident #22 was in bed, with his bed against the wall of the room and a styrofoam cup of water, with a lid and straw was observed on the bedside dresser out of the resident's reach. Resident #22's over the bed table was observed to be across the room, against the curtain with the television remote attached by a coiled cord well out of reach of Resident #22. Review of an Order Summary for Resident #22 revealed .regular diet, regular texture, regular/Thin – NO STRAW consistency, Kennedy cup (a lightweight, easy-to-grip, spill-proof, drinking cup), finger foods assist as resident will allow. with a start date of 6/5/2026. Review of a Care Plan for Resident #22 revealed .Focus: Resident is at risk for falls/injury related to chronic pain syndrome, weakness, hx (history) of falls.revised on 6/17/26. Goal: reduce the risk of injury: Interventions: ensure that resident has water at bedside before he goes to bed.initiated 11/4/25.keep bedside table within reach. TV remote attached to bedside table. initiated on 6/4/26.Provide food and fluids within reach while resident is in bed.revised on 10/20/2025. In an interview on 6/17/26 at 11:15 am, Registered Nurse (RN) G reported Resident #24 had experienced a fall earlier in the shift. RN G stated he was yelling out and I found him on his fall mat. When queried, RN G reported he (Resident #22) said he was reaching for something. RN G reported Resident #22 was a high fall risk and staff needed to check on him frequently. RN G reported Resident #22 was able to hold a cup, drink from a straw and that he had 'polydipsia', which RN G further explained to mean Resident #22 experienced excessive thirst. RN G reported Resident #22 had tremors in his hands, and they shook a lot. RN G reported Resident #22 needed to have a lid on his drinks or he spilled them. RN G reported Resident #22 was probably reaching for his drink when he fell that morning, and RN G stated he (Resident #22) drinks a lot. In an interview on 6/18/26 at 11:27 am, Unit Manager (UM) S reported Resident #22 was a high fall risk and a 'frequent faller' and some of the interventions to help prevent falls were to keep his over the bed table, water, and TV remote within reach. In an interview on 6/18/26 at 1:43 pm, Certified Nurse Assistant (CNA) K reported she had no idea what Resident #22 needed, but she knew he fell all the time. In serial observations on 6/16/26 at 1:14pm, 6/17/26 at 8:14 am & 11:10 am, and 6/18/26 at 9:25 am, Resident #22 was observed in bed, and his over the bed table with the remote attached and a styrofoam cup of water, with a lid and straw was noted to be out of reach. Resident #24 Review of a Face sheet revealed Resident #24 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: dysphagia (difficulty swallowing), history of falling, and mild intellectual disabilities. Review of a Minimum Data Set (MDS) assessment for Resident #24, with a reference date of 6/2/26 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #24 was mildly cognitively impaired. Section GG, Self-Care Assessment, eating, supervision or touching assistance. On 6/18/26 at 1:12 pm, Resident #24 was observed sitting in her wheelchair, in the hallway of health center 3 unit, with her lunch meal in front of her and she was coughing. No nursing staff were observed in the hallway. When queried, Resident #24 stated I'm OK and continued to cough. The meal ticket present on Resident #24's meal tray which she was eating from, indicated Resident Notes: Supervision with meals. On 6/18/26 at 1:14 pm, Director of Nursing (DON) B was notified Resident #24 was in the hallway alone, with her meal, and coughing. DON B stated it was unacceptable that staff was not present and assisting Resident #24 with her meal. DON B assisted Resident #24 to finish her meal and removed her meal tray when Resident #24 was done eating. DON B reported she expected staff to follow protocol when a resident needed assistance with a meal. Review of an Order Summary for Resident #24 revealed .Resident is a 1:1 (one to one) feed- Ensure there is someone assisting resident with feeding at every meal with a start date of 6/5/26. Review of a Care Plan for Resident #24 revealed .Focus/Goal/Interventions: Resident has self-care performance deficient.ADL (activities of daily living) needs will be met.eating: 1:1 with ALL MEALS, Upright for meals, Cue to slow down and take small bites. Remain in Broda / Upright position for at least 30 minutes after meals with a revision date of 4/8/25. Resident #30 Review of a Face Sheet revealed Resident #30 was originally admitted to the facility on [DATE] with pertinent diagnoses which included vascular dementia (cognitive decline caused by reduced blood flow to the brain, leading to memory, thinking, and behavioral changes), repeated falls and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 6/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #30 was moderately cognitively impaired. During an interview on 6/16/2026 at 2:03 PM, Family Member (FM) KK reported that she had concerns with the facility's fall prevention and supervision of Resident #30. FM KK reported that Resident #30 had fallen out of her bed in November and fractured her leg. FM KK reported that the details of Resident #30's fall did not make sense to her, and she was worried that Resident #30 would continue to fall and get injured again. FM KK reported she had voiced her concerns to the facility management about Resident #30 frequently falling out of bed and had asked them multiple times to consider new interventions and/or monitoring of Resident #30, but she felt that her concerns had not been addressed. Review of Resident #30's Incident Report dated 11/22/25 and documented by Licensed Practical Nurse (LPN) X revealed, Incident Description: Approximately at about 00:30 (12:30 AM) when this nurse came back from lunch break, resident's (Resident #30) CNA (Certified Nursing Assistant) reported that during her rounds, she caught resident self-transferring out of bed. CNA tried to help resident back into bed, but it was too late, and CNA assisted resident to the floor. When this nurse went to check on resident, res (resident) was asleep. Res woke up at around 3:10 AM screaming out in pain. Res right lower leg swollen, turned inward resident refused ROM (range of motion) stating, it hurts. On call provider notified, new order received to send resident to ER (emergency room) for evaluation . Review of Resident #30's Hospital Record dated 11/22/25 revealed, Chief Complaint Leg pain . Apparently, the patient has had multiple falls recently. Today, she was about to fall, and she was guided to the floor by staff. Patient has a severe right leg deformity. Medics are unsure when this injury occurred . Patient was given fentanyl (pain medication) for excruciating pain of the right leg and Zofran (nausea medicine) for nausea. Patient is unable to tell me what hurts other than her right leg . Physical exam: General: She is in acute distress (Patient in pain from right leg deformity). Appearance: She is ill-appearing .Musculoskeletal:swelling, tenderness, deformity, (Obvious right lower extremity deformity with bruising and swelling with malformation of the right lower leg .and signs of injury present. Right lower left leg: edema (swelling) present . X-ray tib-fib (two long bones of the lower leg) showed fracture of distal femoral meta diaphysis (distal femoral metaphysis is the region where the shaft widens and connects to the knee joint) and nondisplaced proximal fibular head/neck fracture. CT (Computed tomography) right lower extremity showed acute periprosthetic fracture of distal femoral metadiaphysis with no displacement, was unable to assess fibula fracture. Orthopedic surgery was consulted and recommended placing me immobilizer and 2 week outpatient follow up. Patient was admitted to medicine for sepsis secondary to UTI. She developed recurrent hypotension (low blood pressure) on the floor received additional IVF (intravenous fluids) and was transferred to ICU (intensive care unit) and started on norepi (norepinephrine- medication used to treat low blood pressure) She became more hypotensive and was found to have a hgb (hemoglobin) of 6.5 from 9.8 with significant ecchymosis(bruising) of her lower extremity to likely be the culprit. She required 2 units PRBC (packed red blood cells) the morning of 11/23 and ortho was contacted for reassessment . Patient family would like to discharge her back to her facility. Spoke with patient's son who said family plans to assign patient for hospice after discharge to the facility . During an interview on 6/18/2026 at 3:03 PM, LPN X reported on 11/22/25 she had been working overnight with CNA O and had returned from her break sometime around midnight when CNA O told her that she had had forgotten to tell her that she watched Resident #30 try to get out of bed and that she had to help lower her to the ground. LPN X reported that when she went into check on Resident #3, she was in her bed asleep, and she did not want to wake her up. LPN X confirmed that she did not assess Resident #3 when she found her asleep because Resident #3 could be behavioral when she was woken up. LPN X confirmed that she did not complete range of motion or assess Resident #3's leg until 3 hours later when Resident #3 woke up screaming out in bed from pain. LPN X reported that Resident #3's leg was clearly deformed when she assessed it at 3:00 AM, so she called the provider on call and sent Resident #30 to the hospital. LPN X confirmed that nurses were supposed to assess a resident after a fall prior to the resident being moved in case of injury. LPN X confirmed that Resident #3 was dependent on staff for transfers and required a hoyer lift (mechanical device used to assist in transferring patients with limited mobility) to transfer. LPN X confirmed that she did not know how CNA O put Resident #30 back to bed. LPN X reported that CNA O made it seem like Resident #30's fall was not a big deal, so she was not worried about her until she woke up three hours later screaming out in pain. LPN X confirmed that Resident #30 had frequent falls, and tried to get out of bed often. Review of an MDS assessment for Resident #30, with a reference date of 9/15/25 revealed, Section GG: Functional abilities and goals indicated that Resident #30 was dependent for transfers. (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.) This writer attempted to reach CNA O via telephone on 6/18/2026 at 3:21 PM and 6/23/2026 at 7:51 AM. CNA O did not return this writer's calls prior to survey exit. In an observation and interview on 6/17/26 at 8:23 AM, LPN Q entered Resident #30's room, and then yelled out in the hallway, Where are the aides? I needed a hoyer like ten minutes ago! This writer followed LPN Q into Resident #30's room where she was laying on the floor next to her bed. LPN Q reported that one of the CNA's had found Resident #30 on the floor about 15 minutes prior, and that she had been waiting for the CNA's to come back with a hoyer so that they could get Resident #30 off the floor. Shortly after this writer entered Resident #30's room, CNA D and F entered Resident #30's room with a hoyer and assisted LPN Q in transferring Resident #30 back to her bed. CNA D reported that she had found Resident #30 on the floor again when she entered her room to get her ready for breakfast. CNA F reported that it was common for Resident #30 to fall out of bed. Resident #30 was noted to complain of pain when the staff were transferring her onto her bed. During an observation on 6/18/2026 at 8:21 AM, Resident #30 was lying in her bed sleeping. It was noted that the fall mat that was supposed to be next to her bed was folded up and lying next to her bed. During an interview on 6/23/2026 at 10:09 AM, Unit Manager (UM) S reported that she did not think the facility investigated Resident #30's fall because it was witnessed. When asked if she knew how CNA O put Resident #30 back in bed after her fall, UM S reported that she thought that the facility had looked into that, but she was unable to find any information about it to provide further details. UM S was unable to report if there was a delay in the post fall assessment and transfer to the emergency room after Resident #30 fell. UM S reported that the facility IDT (interdisciplinary team) investigated every fall to determine a root cause analysis to prevent further falls from occurring. When this writer queried as to what new intervention had been put in place to prevent Resident #30 from continuing to fall out of bed after her fall with injury on 11/22/25, UM S reported that the intervention was to send Resident #30 to the hospital. UM S confirmed that Resident #30 had experienced 5 documented falls at the facility since 9/9/25. UM S then reviewed Resident #30's care plan with this writer and confirmed that Resident #30's Fall care plan had been revised with one new intervention to prevent further falls since 2024. On 6/18/2026 at 3:17 PM, this writer requested the facility's fall investigation report for Resident #30's fall on 11/22/25 to Nursing Home Administrator (NHA) A. The facility did not provide this information prior to survey exit. During an interview on 6/23/2026 at 11:11 AM, NHA A reported that he did not think that the facility had investigated how Resident #30 fell, how she was placed back into bed by CNA O, or the delay in transfer to the hospital for Resident #30. Review of the facility's Fall Prevention policy last revised 10/26/23 revealed, Policy: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls . A near miss, also considered a fall, is when a resident would have fallen if someone else had not caught the resident from doing so. Policy Explanation and Compliance Guidelines . 6. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury . Resident #14(R14) Review of a Face Sheet revealed R14 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cognitive communication deficit (disruption in brain function and thinking skills causing difficulty with communication) and dementia (umbrella term for loss of memory, language, problem-solving, and other thinking abilities). Review of a Minimum Data Set(MDS) assessment for R14 with a reference date of 4/29/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Review of a Care Plan for R14 with a reference date of 4/8/26 revealed the following focus/goal/interventions: Focus: Resident chooses to smoke. Goal: Resident will follow and verbalize understanding regarding facility rules for.smoking materials.Interventions: Inform resident regarding.storage of smoking materials. In an interview on 6/16/26 at 3:51pm, R14 reported he always kept his cigarettes and lighter in the unlocked basket of his wheeled walker. When queried, R14 reported he did not know what the facility policy was regarding storage of smoking materials. R14 reported he was aware he had to smoke in a designated location outdoors and did so but had witnessed other residents not complying with smoking in the designated location. R14 reported sometimes other residents smoked under the awning at the front entrance, less than 25 feet from the building. During an observation and interview on 6/17/26 at 12:37pm, R14 exited his room, ambulated with his walker across the common area, into the hallway toward the front exit. When queried, R14 reported he had his smoking materials with him as he always did and was going outdoors to smoke. In an interview on 6/18/26 at 12:26pm, Nursing Home Administrator (NHA) A reported it was the expectation that all resident smoking materials (lighters, matches, electronic cigarettes and traditional cigarettes) were stored in a locked drawer at the nurse's station. NHA A reported the floor nurse was responsible for ensuring residents turned in their smoking materials immediately upon returning to the unit and that the materials were stored safely. NHA A confirmed the facility had not recently monitored where residents were storing their smoking materials. Review of a Smoking Policy Non-Smoking Campus with a reference date of 5/31/23 revealed Policy: It is the policy of this facility to establish and maintain safe resident smoking practices .use this policy for education with the resident.Residents.shall not be permitted to retain any types of smoking articles, to include cigarettes, tobacco, etc., either on his or her person or within his/her living or sleeping area, at any time.

Based on observation, interview, and record review the facility failed to ensure enteral feeding (tube feeding: the delivery of nutrition directly into the GI (gastrointestinal) tract through a feeding tube when oral intake is insufficient or unsafe) was administered per manufacture recommended expiration date for 1 (Resident #50) of 2 residents reviewed for enteral feedings resulting in the potential for bacterial contamination, nutrient degradation, and an increase risk for GI upset, infection, and/or foodborne illness when Resident #50 was administered expired tube feeding.Findings include:Resident #50Review of a Face sheet revealed Resident #50 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: dysphagia (difficulty swallowing) following cerebral infarct (stroke), type 2 diabetes mellitus with hyperglycemia, (metabolic disorder that occurs when the body becomes resistant to insulin or when the pancreases fails to produce enough insulin resulting in high blood sugar), and impaired cognitive function following cerebral infarction.On 6/16/26 at 10:15 am, a bottle of Glucerna 1.5 Cal tube feeding formula with approximately 400 ml (milliliters) of the 1000 ml bottle remaining was observed hanging from a pole with the administration tubing loaded into the tube feeding pump positioned next to Resident #50's bed. The tube feeding bottle was noted to have Resident #50's name printed in ink on the label and dated 6/16/26. There was no time noted on the bottle. The bottle was noted to be coated on the inside with feeding, while the formula still present appeared to be 'separated'. Further observation of the bottle revealed a noted manufactured expiration date of 6/1/2026. A second Glucerna 1.5 Cal bottle with the tubing connected, Resident #50's name printed in ink on the label, dated 6/14/26 and a time of 12:00 am, appeared to be mostly empty, with thick chunks, congealed and spoiled feeding in the bottle was observed on the floor under the head of the bed. Additionally, this bottle was noted to have manufactured expiration date of 6/1/2026 as well.In an interview and observation on 6/16/26 at 10:21 am, Licensed Practical Nurse (LPN) L reported she had disconnected Resident #50's tube feeding this morning, and it needed to be discarded as the bottle of tube feeding did not have a date on it. LPN L entered Resident #50's room, reviewed the bottle of tube feeding hanging from the pole and loaded it into the tube feeding pump, and confirmed that this bottle was the one she disconnected from Resident #50. LPN L observed the bottle, noted it was dated, and stated, it does have a date, but it still needs to be discarded. When queried about why it needed to be discarded, LPN L reported the label did not have an administration start time, and open tube feeding was only good for 24 hours.In an interview and observation on 6/16/26 at 10:27 am, 5 unopened bottles of Glucerna 1.5 Cal were present in the medication room, and all 5 bottles had a manufacturer expiration date of 6/1/26. LPN L reported the 5 bottles present in the medication room were the supply that was available for Resident #50 and that was the supply staff were using. LPN L reviewed all 5 bottles and confirmed they had a manufacturer expiration date of 6/1/26. LPN L stated I wouldn't think to look at the expiration date, I never do. LPN L reported Scheduler/Central Supply (S/CS) AA was responsible for stocking tube feeding in the medication room.In an interview and observation on 6/16/26 at 10:30 am, Director of Nursing (DON) B stated Oh, nice when she was informed Resident #50 had received expired tube feeding. DON B accessed the storage room in the lower level of the building and retrieved a case of Glucerna 1.5 Cal with a manufacturer expiration date of March 2027. DON B reported her expectations were that nurses were reviewing tube feeding expiration dates and not administering expired tube feeding to residents.In an interview on 6/17/26 at 1:13 pm, Registered Dietitian (RD) HH reported most tube feeding was lactose free, but contained milk, and was only good for 24 hours once opened. RD HH reported the mineral and vitamins in the tube feeding could degrade when the tube feeding was beyond the manufacturer's expiration date. RD HH reported administration of expired tube feeding could lead to infection, bacterial growth, GI upset/issues, and the resident could possibly not receive adequate nutrients. RD HH reported the tube feeding in the bottle could congeal (solidify) if it was open longer than 24 hours, or expired, and the discoloration of the bottle and the appearance that the tube feeding had separated would be an indication of the breakdown of the mineral and vitamins and the diminished nutrient value. RD HH stated tube feeding does not 'stick' to the inside of the bottle. RD HH reported the administration of expired tube feeding could be distressful to a resident's GI system and would not be sufficient nutrients.In an interview on 6/17/26 at 2:41 pm, S/CS AA reported tube feeding was ordered once a month and the facility had received a skid of over 40 cases of tube feeding, different brands, a few days ago. S/CS AA reported she had not ordered, stocked, or done anything with Glucerna 1.5 Cal tube feeding since starting in the position a few weeks ago. S/CS AA reported she was made aware a resident was receiving expired tube feeding, and she reviewed the facility tube feeding stock and found an additional 5 bottles of tube feeding that had expired and she discarded them. Review of Medication Administration Record (MAR) for Resident #50 for the month of June 2026 revealed .Enteral Feed Order Two times a day Glucerna 1.5 @ (at) 70ml/hr (milliliters per hour) x 12 hours for total volume infused of 840 ml on at 8 pm and off at 8am with a start date of 6/10/26. Documentation indicated that the tube feeding was administered as ordered 7 of 7 days from the start of the order.Review of Care Plan for Resident #50 revealed .Resident has an ADL self-care performance deficit related to CVA (cerebral vascular accident- stroke).ADL needs will be met.Eating NPO (nothing by mouth).initiated 6/12/26.Review of facility policy Feeding Tubes with a revision date of 10/15/2024 revealed .Feeding tubes will be maintained in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.Directions for staff regarding nutritional products and meeting the resident's nutritional needs will be provided to include.ensuring that the selection and use of enteral nutrition is consistent with manufacturer's recommendations.ensuring that the product has not exceeded the expiration date.

Based on observation, interview, and record review the facility failed to ensure resident food preferences were honored consistently for 6 (Residents #6, 21, 14, 10, 12, and 17) of 24 residents reviewed for dining and 1 of 1 resident from a confidential resident council meeting resulting in not receiving desired food and beverages, dissatisfaction with meal service, and the potential for decreased oral intake and/or unintended weight loss. Findings include:Review of the facility's resident council's (independent group of residents who meet to discuss concerns/suggestions and various other topics) most recent three months of resident council minutes, dated 3/20-5/20/26, indicated resident food preference issues each month.- Review of the facility's Resident Council Minutes, dated 3/20/26, stated, .New Business Review/Action Plan.Current Situation/Concern.Food missing.Outcome. (Two options were noted with a check box next to them but neither were selected; Resolved - Still Monitoring or Not Resolved - Action Needed) .- Review of the facility's Resident Council Minutes, dated 4/14/26, stated, .Old Business Review: (List unresolved old business from last meeting's minutes, status of the concern.Move unresolved issues to New Business).Issue.Food Missing.Status Update.Ongoing.New Business Review/Action Plan.Current Situation/Concern.Food received inaccurate.Outcome.(Two options were noted with a check box next to them but neither were selected; Resolved - Still Monitoring or Not Resolved - Action Needed).- Review of the facility's Resident Council Minutes, dated 5/20/26, stated, .Old Business Review.Issue.Wrong Food.Status Update.Ongoing.New Business Review/Action Plan.Current Situation/Concern.Food received inaccurate.Outcome.(Two options were noted with a check box next to them but neither were selected; Resolved - Still Monitoring or Not Resolved - Action Needed).During a confidential resident council meeting interview on 06/17/2026 at 1:18 PM, 1 of 1 resident in attendance reported food preference issues were an ongoing issue, the issue might go away for a few days, but then it was a problem again. The resident confirmed the past three months of resident council minutes that addressed food concerns were all about residents not receiving their food preferences consistently. The resident reported this issue affected lots of residents and it wasn't just him. The resident reported he had had to go down to the kitchen several times to show them the meal ticket and request his missing items. The resident reported his nutrition was important to him, his food preferences not being honored made him upset, and felt he shouldn't have to go ask for food items that are on his ticket.Resident #6 (R#6):Review of R#6's brief interview for mental status, dated 5/22/2026, was scored 9 which reflected he had moderate cognitive impairment. Review of R#6's nutrition care plan, revised 10/27/2025, stated, .Interventions.Provide meals/fluids based on resident food preferences and as ordered.Update and honor resident's food preferences on tray ticket.During an interview on 06/16/26 at 12:09 PM, Regional Dietary Manager NN, reported staff had developed a blue and white meal service ticket system, with blue tickets to help stick out/show staff when a resident had a special request or preference on their meal ticket.During an observation and interview on 06/16/2026 at 12:51 PM, R#6 was eating lunch independently in the dining area just outside his room. R#6 had a blue colored meal ticket on the table next to his meal that indicated he was to receive a Cheeseburger and Chocolate Milk - 8 oz (ounces). R#6 received a hamburger with no cheese and a carton of 2% white milk. R#6 reported he wanted a cheeseburger, he received no cheese for his hamburger, and he specifically asked for a cheeseburger because he liked them a lot. The meal ticket stated (in bold font), Chocolate Milk - 8 oz (ounces), and he was served a carton of regular 2% white milk. R#6 reported his food preferences weren't consistently followed.Resident #21 (R#21):Review of R#21's brief interview for mental status 6/12/2026, was scored 15 which reflected she was cognitively intact.Review of R#21's Quality Assurance Form, dated 4/14/2026, stated, Assistance Needed .Details .not receiving condiments from aides for meals .Findings: Residents were not always getting condiments .During an interview on 06/16/2026 at 1:36 PM, R#21 reported she consistently didn't get the food she ordered on her meal ticket. Resident #14 (R#14): Review of R#14's brief interview for mental status, dated 4/29/2026, was scored 15 which reflected he was cognitively intact.During an interview on 06/16/2026 at 3:47 PM, R#14 reported receiving incorrect food items happened daily. R#14 reported previously having to go down to the kitchen to request missing meal items when he didn't get served what was on his meal ticket.Resident #10 (R#10):Review of R#10's brief interview for mental status, dated 6/12/2026, was scored 8 which suggested moderately impaired cognition.Review of R#10's nutrition care plan, revised 3/27/2026, stated, .Interventions.Provide meals/fluids based on resident food preferences and as ordered.Update and honor resident's food preferences on tray ticket. R#10's cognitive function care plan, dated 8/21/2023, stated, .has impaired cognitive function.disorganized thinking.During an observation and interview on 06/17/2026 at 8:32 AM, R#10 was served breakfast in his room, appeared to be confused, and was unable to answer questions regarding his food preferences. R#10's meal ticket indicated to provide Milk - 8 Oz but the only drink served to him was orange juice. Applying the reasonable person concept, for those with cognitive impairments who were unable to answer questions appropriately, a resident would desire to be served what was on their meal ticket/food preferences and likely would be dissatisfied with meal service if they were to receive incorrect items.Resident #12 (R#12):Review of R#12's brief interview for mental status, dated 6/3/2026, was scored 15 which reflected he was cognitively intact.Review of R#12's nutrition care plan, dated 11/17/2025, stated, .Interventions.Provide meals/fluids based on resident food preferences and as ordered.Update and honor resident's food preferences on tray ticket.During an interview on 06/18/2026 at 8:35 AM, Nursing Home Administrator (NHA) A confirmed residents' food preferences not being followed had been an issue the past few months and reported he received two grievances yesterday about food preferences.During an observation and interview on 06/18/2026 at 12:07 PM, R#12 was eating lunch independently in the dining area across from the therapy room. R#12 reported he didn't like to complain, but his meals were often missing something. R#12's blue colored meal ticket was on the table next to his meal. R#12's meal ticket indicated to provide Lettuce & Tomato - 1 Plate, it was not anywhere on the table, and he reported he wanted the lettuce and tomato for his sandwich. Review of R#12's Quality Assurance Form (grievance/concern form), dated 3/20/2026, stated, .Assistance Needed .Food .Details: Food missing from his tray consistently .Updated his preferences to avoid future issues. Discussed new changes being implemented to avoid items missing from trays .Review of R#12's Quality Assurance Form, dated 5/6/2026, stated, .Assistance Needed .Other .Details: Receives French dressing at every meal, does not know why. Does not get salads near as much as supposed to .Resident #17 (R#17):Review of R#17's brief interview for mental status, dated 6/5/2026, was scored 15 which reflected she was cognitively intact.During an interview on 06/18/2026 at 1:14 PM, R#17 reported she had received gravy on her lunch that day, her meal ticket had indicated no gravy, and she had not asked for gravy. R#17 reported staff often don't follow her meal ticket.Review of R#17's Quality Assurance Form, dated 4/2/2026, stated, .Assistance Needed .Dietary Complaints .Details.she (R#17) rarely gets the banana that is listed on her ticket - she didn't get a banana today. Her ticket reads .3 brown sugars - she didn't get any of these items.Review of the facility's Resident Food Preferences policy, dated 7/1/2025, stated, .Upon the resident's admission Dietary Manager or designee will identify a resident's food preferences.The resident's clinical record (orders, care plan, or other appropriate locations) will document the resident's likes and dislikes and special dietary instructions or limitations.

Based on observation, interview, and record review, the facility failed ensure residents did not self-administer medications that were not assessed as safe in 1 (Resident #49) of 1 resident, reviewed for self-administration, resulting in the potential for overmedication of a resident and medication errors, and medical complications. Findings include:Resident #49Review of a Face sheet revealed Resident #49 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included paraplegia (paralysis of the legs and lower body).Review of a Minimum Data Set (MDS) assessment for Resident #49, with a reference date of 3/31/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #49 was cognitively intact.In an observation and interview on 6/16/26 at 9:46 am, 3 tubes of green pain relief gel and two tubs of lidocaine cream were observed on Resident #49's over the bed table and in a storage, compartment attached to the bedrail of her bed. Resident #49 reported she used pain creams on her shoulders, legs, and her forehead. Resident #49 reported she applied it to her forehead when she needed it, and the staff applied it everywhere else she needed it when she asked. Review of an Order Summary for Resident #49 revealed .Bio freeze Professional External Gel 5% (menthol (Topical Analgesic)) Apply to neck, shoulder, back topically every 6 hours as needed for muscle soreness with an order date of 2/12/26.Review of Resident #49's medical record revealed no noted assessment for self-administration of medications.Review of a Care Plan for Resident #49 revealed no noted documentation regarding self-administration of medications.In an interview on 6/17/26 at 2:15 pm, Registered Nurse (RN) G reported no residents were allowed to self-administer medications.In an interview on 6/17/26 at 2:17 pm, Licensed Practical Nurse (LPN) Q reported no residents were allowed to self-administer medications. LPN Q reported a resident needed to be assessed and an order from the provider needed to be in place for a resident to self-administer medications. LPN Q reported that a resident who self-administered medications also needed a lock box to store medications at the bedside. LPN Q reported tubes of pain gel were stored in the locked treatment carts and one tube was used for several residents, as the pain gel was dispensed into disposable plastic cups when being administered. Review of a list of residents approved for self-administration of medications, provided by Nursing Home Administrator (NHA) A on 6/17/26 revealed one resident was listed, and Resident #49 was not on the list as assessed and/or approved for self-administration of medications.In an interview on 6/18/26 at 3:35 pm, Director of Nursing (DON) B reported pain gel is a medication, requiring a prescription, and should not be left at the bedside. DON B reported pain gel needed to be kept in the locked treatment cart. DON B reported an assessment needed to be completed and provider approval with an order was needed for a resident to self-administer medications. DON B reported no residents were allowed to self-administer medications.Review of facility policy Medication- Resident Self-Administration of with a revision date of 1/30/2024 revealed .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered.the results of the interdisciplinary team assessment are recorded in the resident's medical record.conditions are met for bedside storage to occur: the manner of storage prevents access by other residents.the care plan must reflect resident self-administration and storage arrangements for such medications.

Based on interview, and record review, the facility failed to provide rationale and documented monitoring for the continued use of a chemical restraint medication for 1 (Resident #30) of 6 residents reviewed for unnecessary medications, resulting in continued administration of a psychotropic medication with a lack of monitoring for effectiveness and an increased risk for potential adverse reactions Findings include:Resident #30 Review of a Face Sheet revealed Resident #30 was originally admitted to the facility on [DATE] with pertinent diagnoses which included repeated falls and vascular dementia (dementia caused by reduced blood flow to the brain, leading to cognitive decline and memory issues). Review of Resident #30's Orders revealed, Lorazepam (medication used to treat anxiety) tablet 0.5 mg (milligrams). Give 1 tablet by mouth every six hours as needed for anxiety and restlessness. Start date: 5/15/26. Noted that the order did not have an end date. During an interview on 6/23/2026 10:13 AM, Unit Manager (UM) S reported that she assumed that the facility had reviewed Resident #30's need for the PRN lorazepam order and determined that the benefits outweighed the risks of continuing the medication for Resident #30. This writer asked UM S to provide verification that the facility had reviewed the PRN lorazepam order, and UM S reported that she would need to review Resident #30's record to find the requested information. The facility did not provide any verification or further information that Resident #30's lorazepam order had been reviewed prior to survey exit.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive resident focused care plan based on a comprehensive assessment for 2 (Resident #29 and Resident #22) of 24 residents reviewed for care plans, resulting in the potential for unidentified care needs and inadequate provision of care according to standards of practice. Findings include: Resident #29 Review of a Face Sheet revealed Resident #29 was originally admitted to the facility on [DATE] with pertinent diagnoses which chronic kidney disease stage 4 (severe, irreversible kidney damage) and dependence on renal dialysis (procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions.) Review of Resident #29's Care Plan did not reveal a care plan focus for dialysis services. During an interview on 6/18/2026 at 4:04 PM, Unit Manager (UM) S reported care plans were created and updated by the interdisciplinary team (IDT) and that it was a group effort to ensure care plans reflected the resident's care needs. UM S reported every resident that received dialysis services should have a care plan with a focus on dialysis care. UM S reviewed Resident #29's care plan with this writer and confirmed that Resident #29's care plan did not contain information related to dialysis, and that the facility had missed this. Resident #22 Review of a Face sheet revealed Resident #22 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: repeated falls, protein calorie malnutrition, and schizoaffective disorder (chronic mental health condition with coexistence of psychotic symptoms and mood disturbances, such as hallucinations and delusions, and/or depression and mania). Review of a Minimum Data Set (MDS) assessment for Resident #22, with a reference date of 6/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #22 was severely cognitively impaired. Section GG, Self-Care Assessment, eating, supervision or touching assistance and mobility chair/bed-to-chair transfer dependent, indicating helper does all of the effort. On 6/16/26 at 12:21 pm, Resident #22 was in bed, with his bed against the wall of the room and a styrofoam cup of water, with a lid and straw was observed on the bedside dresser out of the resident's reach. Resident #22's over the bed table was observed to be across the room, against the curtain with the television remote attached by a coiled cord well out of reach of Resident #22. Review of a Care Plan for Resident #22 revealed .Focus: Resident is at risk for falls/injury related to chronic pain syndrome, weakness, hx (history) of falls.revised on 6/17/26. Goal: reduce the risk of injury: Interventions: ensure that resident has water at bedside before he goes to bed.initiated 11/4/25.keep bedside table within reach. TV remote attached to bedside table. initiated on 6/4/26.Provide food and fluids within reach while resident is in bed.revised on 10/20/2025. In an interview on 6/17/26 at 11:15 am, Registered Nurse (RN) G reported she found Resident #22 this morning, he was yelling out and I found him on his fall mat. When queried, RN G reported he (Resident #22) said he was reaching for something. RN G reported Resident #22 was a high fall risk and staff needed to check on him frequently. RN G reported Resident #22 was probably reaching for his drink when he fell that morning, and RN G stated he (Resident #22) drinks a lot. In an interview on 6/18/26 at 11:27 am, Unit Manager (UM) S reported Resident #22 was a high fall risk and a 'frequent faller' and some of the interventions to help prevent falls were to keep his over the bed table, water, and TV remote within reach. In an interview on 6/18/26 at 1:43 pm, Certified Nurse Assistant (CNA) K reported she had no idea what Resident #22 needed, but she knew he fell all the time. In serial observations on 6/16/26 at 1:14pm, 6/17/26 at 8:14 am & 11:10 am, and 6/18/26 at 9:25 am, Resident #22 was observed in bed, and his over the bed table with the remote attached and a styrofoam cup of water, with a lid and straw was noted to be out of reach.

Based on interview and record review, the facility failed to review and revise a comprehensive, individualized plan of care for 2 (Resident #3 and Resident #50) of 24 residents reviewed for care plan revisions, resulting in the potential for unmet care needs and impaired physical, mental, and psychosocial well-being. Findings include: Resident #3 Review of a Face Sheet revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included assistance with personal care and pressure ulcer of the sacral region, stage 3 (pressure ulcer that involves full-thickness skin loss and require comprehensive management to promote healing and prevent complications.) Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 5/29/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #3 was cognitively intact. Review of Resident #3's Care Plan revealed, Focus: Resident has impaired skin integrity as evidenced by stage 3 on sacrum and stage 4 right hip (most severe form of pressure injuries, involving full-thickness tissue loss with exposure of muscle, tendon, or bone, also requiring comprehensive management to promote healing and prevent complications). Date initiated: 6/5/25. Noted that all interventions listed in the care plan were dated 6/5/25. Review of Resident #3's Standards of Care meeting notes dated 6/16/26 revealed, . Wound review: Wound type: Pressure injury. Wound location: Coccyx (tailbone) . Wound status considering observation, measurements, and PUSH (Pressure Ulcer Scale for Healing) tool is a standardized instrument used to monitor the healing progress of pressure ulcers by evaluating wound size, exudate, and tissue type) tool of the wound: stalled . Wound type: pressure injury. Wound location: Right trochanter (bony bump on the outer side of your upper thigh, near the hip) . Wound status . Stalled . During the meeting the care plan was reviewed for resident's current status/condition, and it was determined: No care plan updates were needed; it reflected current status/condition . During an interview on 6/18/2026 at 3:46 PM, Unit Manager (UM) S reported that Resident #3 had admitted to the facility with pressure ulcers on her sacrum and right hip. UM S reported that the facility had struggled with healing Resident #3's pressure ulcers. UM S reported Resident #3 had periods where her pressure ulcers would improve, but also frequent periods where the healing progress of the wounds would stall, and the facility would review resident orders and care plans to implement new interventions to assist in healing Resident #3's wounds. UM S reviewed Resident #3's care plan with this writer and confirmed that Resident #3's care plan had not been revised since 6/5/25, and the facility had missed this. Resident #50 Review of a Face sheet revealed Resident #50 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: dysphagia (difficulty swallowing) following cerebral infarct (stroke), type 2 diabetes mellitus with hyperglycemia, (metabolic disorder that occurs when the body becomes resistant to insulin or when the pancreases fails to produce enough insulin resulting in high blood sugar), and impaired cognitive function following cerebral infarction. Review of Care Plan for Resident #50 revealed Focus/Goal/Interventions.Resident has an ADL self-care performance deficit related to CVA (cerebral vascular accident- stroke).ADL needs will be met.Eating NPO (nothing by mouth).initiated 6/12/26.Resident is at risk for fluid volume deficit related to PEG tube (feeding tube).Encourage resident to drink fluids unless contraindicated (i.e. fluid restrictions) assist as needed.Offer fluids during activities. Offer fluids of choice. Ensure all beverages offered comply with diet/fluid restrictions and consistency requirements. initiated 5/30/26.Resident has an impaired gastrointestinal status.administer enteral nutrition per orders.flush feeding tube per orders. initiated 6/12/26.Resident at risk for altered nutritional status related to tube feeding.administer nutrition per orders . flush feeding tube per order. Resident is NPO.all initiated on 6/1/26. Resident is at risk for malnutrition. monitor tube feeding tolerance.obtain food preferences. initiated 6/1/2026. Resident #50's care plan was reviewed and noted to include NPO, nothing by mouth, encourage fluids, offer fluids during activities, offer fluids of choice, and obtain food preferences. Review of Order Summary for Resident #50 revealed .NPO diet, NPO texture, NPO consistency, NPO with a start date of 6/9/26. In an interview on 6/16/26 at 1021 am, Licensed Practical Nurse (LPN) L reported Resident #50 could have nothing by mouth and only received fluid and nutrition via her feeding tube. In an interview on 6/17/26 at 2:75 pm, Registered Nurse (RN) G reported Resident #50 was NPO and could have nothing by mouth. RN G reported staff used the care plan for resident care and care plan updates were not part of her responsibilities as a floor nurse. In an interview on 6/18/26 at 11:46 am, Certified Nurse Assistant (CNA) Y reported Resident #50 was NPO, I think; it's whatever is in her care plan.

This citation pertains to Intake 2718302.Based on interview and record review the facility failed to honor a residents choice for do not resuscitate (DNR; no CPR to be performed) and ensure cardiopulmonary resuscitation (CPR) was not performed on a resident who was a DNR in 1 (Resident #1) of 8 residents reviewed for CPR, resulting in Resident #1 being subjected to dehumanization and unavoidable pain when facility staff initiated CPR and contacted Emergency Medical Services (EMS) and then performed unwanted life sustaining efforts (cardiopulmonary resuscitation (CPR), automated external defibrillation (AED; delivers electric shock to attempt to restore normal heart rhythm), and insertion of an intraosseous venous access (inserting a specialized needle into the bone marrow cavity to provide immediate vascular (bloodstream) access) of the tibia (shinbone)) causing the likelihood for serious psychosocial and bodily harm. Findings include:The Immediate Jeopardy began on [DATE] when the facility failed to honor Resident #1's do not resuscitate order and subjected the resident to CPR, automated external defibrillation, and insertion of an intraosseous venous access against her wishes. Nursing Home Administrator A was notified of the Immediate Jeopardy on [DATE] at 12:23 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed, and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore past noncompliance.Review of Resident #1's census page indicated Resident #1 was admitted to the facility on [DATE] on hospice services with a diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery (condition of plaque buildup) With Unstable Angina Pectoris(chest pain)).During an interview on [DATE] at 10:13 AM, when discussing Resident #1 having a medical code event (life threatening emergency) on [DATE], Nursing Home Administrator (NHA) A confirmed Resident #1's do not resuscitate (DNR) order had not been signed by a physician and/or received back from the physician before the code ([DATE] at approximately 10:35 PM), the facility was aware of the resident's wishes for DNR but they provided CPR as they hadn't received the DNR order signed by the physician yet, and it had not been updated to DNR to reflect Resident #1's wishes. Review of Resident #1's #2204 Code Blue (alert signaling someone is experiencing a life-threatening medical emergency) document, dated [DATE], stated, .At around 10:30pm when the nurse (Licensed Practical Nurse (LPN) G) was doing her rounds she observed resident lying on the bathroom floor, face down. The nurse called resident's name and resident did not respond. The nurse tried to find a pulse on resident's neck but could not feel a pulse. The nurse yelled to the CNA (certified nurse aide M) to grab the other nurse (Registered Nurse O) and this nurse verified code status and started CPR (cardiopulmonary resuscitation) immediately. Crash cart and AED (automated external defibrillator; can deliver electric shock to restore normal heartbeat) machine were brought by CNA and other nurse. EMS (emergency medical services) was called around 10:35 PM while CPR continued for resident. When EMS arrived, they started CPR immediately. EMS performed CPR x (for) 30 minutes and were unsuccessful in retrieving a pulse.pronounced resident deceased at 2316 (11:16 PM) .Statements.Staff (LPN G) .This nurse checked the code status, and it reads FULL CODE and CPR Started.Review of Resident #1's emergency medical services call sheet, dated [DATE], stated, Complaint Type.Cardiac arrest.Duration of Complaint.20 Minutes.Date/Time of Symptom Onset: [DATE] 22:36:00 (10:36 PM).Primary Symptom: Cardiac arrest .The pt (patient) was in a nursing home.She had just been signed up with hospice and they were still working on getting DNR paperwork set up. Staff stated the paperwork was started but not signed.They (facility staff) started CPR and called 911. They also placed the pt (patient) on an AED (automated external defibrillator) .The fire department stated they arrived at 2238 (10:38 PM) and took over CPR (cardiopulmonary resuscitation) for nursing home staff.They placed an I-GEL (airway device), and ventilated the pt with high flow oxygen. Once the I-GEL was placed they switched from 30:2 CPR (give two breaths after every 30 chest compressions) to continuous CPR.The paramedic started administering EPI (epinephrine) every 3-5 min, and he started the pt on fluids (intravenous therapy).EMS defibrillated and immediately continued CPR.called TOD (time of death) at 23:16 (11:16 PM).Resuscitation Attempted by EMS: Defibrillation (electrical shock to heart in an attempt to restore normal heartbeat); Ventilation (moving air into and out of the lungs); Chest Compressions (lifesaving manual technique used in CPR to restore blood circulation during cardiac arrest).XXX[DATE] 22:47:00.Procedure.Venous Access - Intraosseous (IO; inserting a specialized needle into the bone marrow cavity to provide vascular access).Vascular Access Location .IO-Tibia (shin bone)-Left.IV(intravenous; within a vein) Flushed Easily.Yes.Review of Resident #1's Quality Assurance Form, dated [DATE], stated, .Communicated by: Family/RP (responsible party) .Name: (Resident #1) .Details: Resident recently admitted 12/22 (2025). Code status not completed prior to resident coding. CPR performed on resident .Findings: DNR (do not resuscitate) paperwork not complete at time of code. Code done, resident was supposed to be DNR.Reporter Satisfied.No.Describe: Family still very upset that loved one had to go through a code .Review of Resident #1's level of care determination assessment, dated [DATE], noted Resident #1's cognitive skills were Independent: The applicant's decisions were consistent and reasonable.the applicant organized daily routine and made decisions in a consistent, reasonable, and organized fashion.Review of Resident #1's facility's DNR (do not resuscitate form) form, dated [DATE], stated, .I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me.Being of sound mind, I voluntarily execute this order, and I understand its full Import. This form was signed and dated by Resident #1 and two witnesses on [DATE]. The physician signature was noted to be on [DATE]. The DNR order was received by the facility signed and completed approximately 7 hours before Resident #1 experienced a code event but was never updated in the resident's record.Review of Resident #1's physician orders, print date [DATE], included an order of FULL CODE that was started on [DATE] with an end date of [DATE]. This order was never updated to Do Not Resuscitate upon receipt of Resident #1's signed and completed DNR form on [DATE].During an interview on [DATE] at 1:43 PM, Director of Nursing (DON) B reported Resident #1 was admitted to the facility on [DATE] and the facility discovered they didn't have any consent forms which included advanced directives and the DNR form during an admission audit on [DATE], and confirmed this indicated the DNR form had not been completed on day 1 of admission with Resident #1. DON B reported normal routine was to use an audit tool the day after admission to ensure specific things were completed, such as the DNR form. DON B confirmed the facility could not find the consent forms or the DNR form by the end of the day on [DATE]. DON B reported on [DATE] she got Licensed Practical Nurse (LPN) F to work with Resident #1 to sign consents (which included the DNR form) and Resident #1 was her own person (responsible for herself; no power of attorney or guardian). DON B reported Resident #1's DNR form was completed with herself (DON B), Resident #1, and LPN F on [DATE] and as soon as it was signed, she emailed the DNR form to Medical Doctor/Medical Director K to have it signed/finalized by a doctor. DON B confirmed the DNR form signed and emailed back to the facility from the physician on [DATE] at 3:37 PM was not received by anyone at the facility before the code event at approximately 10:30 PM on [DATE]. DON B confirmed the returned signed DNR form for Resident #1 came back to her own individual email inbox, she was the only one who had access to this inbox, she wasn't working on [DATE], and therefore she didn't check the inbox to be able to receive the signed and completed DNR for Resident #1. DON B confirmed Resident #1's DNR status wasn't updated in the resident record prior to the code event. DON B reported LPN G found Resident #1 unresponsive and checked the code status order in her physician's orders which indicated full code as it hadn't been updated to show the DNR order. DON B reported it is the facility and the corporate policy that the DNR must be signed by the physician before being changed in the system (physician's orders). DON B reported the DNR form should have been completed with Resident #1 on day 1 ([DATE]) of admission. DON B reported the DNR form should be completed on day 1 or day 2 and confirmed this didn't' happen for Resident #1's admission.On [DATE] at 2:15 PM, LPN G was attempted to be contacted, but no response was received before the end of survey.During an interview on [DATE] at 2:27 PM, Resident #1's Family Member J confirmed Resident #1 completed a DNR form and returned it to the facility on the day she admitted to the facility, [DATE]. Family Member J confirmed a completed DNR form signed by Resident #1 was returned to the facility and given to the nurse on duty. Family Member J reported Resident #1 was on hospice services prior to and upon entering the facility, Resident #1 did not want CPR but rather wanted to be a do not resuscitate, and confirmed Resident #1 would have never wanted her body to be subjected to CPR and/or other life sustaining measures. Family Member J reported he was unhappy that Resident #1's wishes were not honored and didn't want this situation to occur to anyone else at the facility.During an interview and record review on [DATE] at 2:55 PM, Regional Registered Nurse (RRN) N confirmed completing and updating Resident #1's advanced directive (DNR code status) was not completed timely. RRN N confirmed it was an issue of timeliness, and it shouldn't have taken until [DATE] to receive Resident #1's completed (physician signed) DNR form. When asked if Resident #1's hospice team had sent over a DNR order or documentation addressing advanced directive/code status to the facility, RRN N reported there were documents in Resident #1's electronic medical record that were from Resident #1's hospice company that were received and put into the medical record prior to her [DATE] admission. These documents reviewed were titled (Resident #1) REF (1).pdf (file format) Pre-admission Documentation and (Resident #1) REF cont. (continued) (1).pdf Pre-admission Documentation, both with an uploaded date of [DATE]. These hospice documents were reviewed briefly with RRN N and RRN N confirmed the documents included a form that displayed verbiage that stated, DO NOT RESUSCITATE. During an interview on [DATE] at 4:15 PM, DON B reported Admissions staff L or LPN N would have been the staff member responsible to complete the DNR form/advanced directives form with Resident #1 on [DATE]. DON B could not confirm if staff forgot to complete the DNR form with Resident #1 on admission or if the form was completed and then lost. DON B confirmed the facility was unable to find any advanced directive/DNR forms on [DATE] for Resident #1, the staff didn't begin working on the DNR form again until [DATE], and it wasn't completed and signed by a physician until [DATE].During an interview on [DATE] at 4:28 PM, LPN N reported she remembered Resident #1 vaguely and doing her admission paperwork. LPN N reported any paperwork including a DNR form from Resident #1 she would have put in the doctor's book to be signed. LPN N reported she wasn't sure if Resident #1 completed a DNR form on [DATE] (day of Resident #1's admission) but thought she initiated the DNR form with Resident #1. LPN N reported she remembered Resident #1 was accompanied by Family Member I on the day of her admission. Any advanced directive/DNR Forms from the doctor's book were requested from Nursing Home Administrator A on [DATE] at 4:34 PM. No documents were provided back by the end of survey that showed LPN N had placed DNR forms for Resident #1 in the physician's book.During an interview on [DATE] at 8:24 AM, Resident #1's Family Member I confirmed she was present onsite at the facility with Resident #1 on day 1 of admission; [DATE]. Family Member I confirmed Resident #1 was her own responsible party and completed facility DNR paperwork (to show her wishes to be a DNR) and returned it to the nurse doing the admission paperwork. Family Member I reported on [DATE] she was on the phone talking with Resident #1 when Resident #1 was asking why she was having to refill out DNR paperwork again at the facility. Family Member I confirmed hospice had sent the facility preadmission screening documents on [DATE] that indicated Resident #1 desired to be a do not resuscitate. Family Member I reported she visited Resident #1 approximately 3 hours after she passed away and Resident #1 had an airway device in her throat (a supraglottic airway device; provide a secure airway), IV (intravenous) catheter drilled into her shin, and showed burn marks from the use of automated external defibrillation (AED; delivers electric shock to attempt to restore normal heart rhythm). Family Member I expressed concern that Resident #1's advanced directives and end of life care were not honored, her body was subjected to life saving measures and voiced concern that it could happen to someone else at the facility.During an interview on [DATE] at 8:49 AM, DON B confirmed consent forms which included advanced directive/code status (DNR) were supposed to be completed on day 1 (Resident #1 was admitted on [DATE]), but not later than day 2 of admission (This would have been [DATE] for Resident #1). When asked why Resident #1's DNR wasn't completed until [DATE] when the facility found it wasn't completed on [DATE] DON B reported they were still looking for the missing DNR form. DON B confirmed the original DNR forms/consents were never found. DON B reported Admissions staff L would have been the staff that reviewed the hospice preadmission documentation that was faxed to the facility on [DATE].During an interview on [DATE] at 10:10 AM, Admissions staff L confirmed Resident #1 was admitted to the facility on [DATE] at 4:29 PM from the community. Admissions staff L reported advanced directive forms should be completed with the resident on day 1 of admission. Admissions staff L reported she gave the admission documents which included advanced directive/DNR forms to nursing staff to complete with Resident #1 on [DATE]. Admissions staff L reported when she returned to Resident #1's room on [DATE] she observed Licensed Practical Nurse F completing a DNR form with Resident #1. Admissions staff L confirmed it was unusual for the DNR form to be completed with a newly admitted resident on the third day after admission as it was usually completed on day 1 of admissionReview of Resident #1's progress note, dated [DATE], stated, .Resident arrived at facility at 1630 (4:30 PM). Daughter-in-law in attendance. Admitting diagnosis is lung cancer. Resident is also patient of [Hospice Company Name] .Review of Resident #1's hospice care plan, initiated date [DATE], stated, Resident has a terminal prognosis with [Hospice Company Name] related to end of life diagnosis Lung Cancer.Goal.Resident's end-of-life wishes will be honored through next review.Review of Resident #1's pre-admission hospice documentation, fax (from hospice company to long term care facility) date of [DATE] and uploaded into electronic medical record date of [DATE], stated, Care Type.HOSPICE.Clinical Info (information).Type.DO NOT RESUSCITATE.Location.CHART.Diagnoses.HEART DISEASE.HRT FAIL (heart failure).PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BRONCHUS (passage in respiratory tract) AND LUNG.Review of the Facility Past Non-compliance Checklist, dated [DATE], stated, Was the resident injured? Resident expired (passed away) .Description of deficient practice (why and how did it happen): Resident admitted without proper code status paperwork completed by admission nurse. DON (Director of Nursing) completed appropriate paperwork with resident. Paperwork was sent to Medical Director for signature on [DATE]. DON was out of facility for holiday weekend, signed code status was sent back to DON's email. Resident coded prior to code status being entered into the medical record. Plan of Correction: In-depth analysis of how the deficiency occurred: (RCA (root cause analysis)) Staff did not obtain and complete code status documentation paperwork with resident upon admission.Review of a One-on-one in-service record pertaining to Resident #1, dated [DATE], stated, Employee Name: (Director of Nursing B).Inservice Topic/Title: DNR/Code Status.If emailing code status info (information) for physician signature ensure you are frequently checking email for completed documents to avoid any delay in care.Review of the facility's Do Not Resuscitate Order policy, reviewed/revised date [DATE], stated, .A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident.placed in the front of the resident's medical record and scanned into the electronic medical record.Review of the facility's Residents' Rights Regarding Treatment and Advance Directives policy, reviewed/revised date [DATE], stated, .It is the policy of this facility to support and facilitate a resident's rights to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive.On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive.Review of the facility's Cardiopulmonary Resuscitation (CPR) & Basic Life Support (BLS) policy, reviewed/revised date [DATE], stated, .Do Not Resuscitate (DNR) Order refers to a medical order issued by a physician.that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest.If a resident experiences a cardiac arrest or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition)., facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services.in accordance with the resident's advance directives .In the absence of advance directives or a DNR order.Review of the facility's Admissions to the Facility policy, reviewed/revised date [DATE], stated, .Prior to or at the time of admission, the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least:.Care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment.Assure that the facility receives appropriate medical records.prior to or upon the resident's admission.Applying the reasonable person concept, one who wished to be do not resuscitate would not want CPR performed to save their life. These lifesaving acts would be in direct contradiction of medical care and life wishes and would have both physical and psychosocial harm.The Immediate Jeopardy that began on [DATE] was removed and the deficient practice corrected on [DATE] when the facility took the following actions to remove the Immediacy and correct the noncompliance: 1. Identification of residents affected or likely to be affected: -Blanket audit completed for 50/50 facility residents on [DATE] to ensure medical record accurately reflects residents code status and a signed copy of advanced directive has been uploaded into PCC (electronic health record). There were no noted concerns or required corrections at this time.2. Actions to prevent occurrence/Reoccurrence:-CPR and Advanced Directive policy reviewed by NHA and DON on [DATE] and remains appropriate. The social service director audited all residents in the facility 50/50 to ensure proper code status were in place. 50/50 residents reviewed on [DATE] to ensure medical record accurately reflects residents code status and a signed copy of advanced directive has been uploaded into PCC and no changes required at that time. Additionally, The DON completed a separate Audit on last 14 days of admissions on [DATE] to ensure proper code status in place for all new admissions during this timeframe, this was completed as an additional audit as the resident noted in the PNC (past non-compliance) was a new admission to the facility in the past 14-day timeframe. On the audit looking at the last 14 days of admissions completed by the DON 7/50 residents were reviewed on this audit on [DATE], there were no discrepancies noted and no corrections made.-Additionally, the admission policy was reviewed [DATE] and deemed appropriate.-All Licensed Nurses 22/22 educated on [DATE]. 18/22 educated in person face to face, 4 educated verbally via phone on completing advanced directives paperwork on admission with designated responsible party and notifying physician to obtain orders and place into PCC.-Process: Nurse educated on [DATE] that they will meet with resident/Responsible party immediately upon admission to address code status wishes. Appropriate paperwork will be completed addressing residents' wishes and immediately communicated to the physician to obtain orders to be placed in PCC (facility's electronic medical record system).-The new facility process for immediate action regarding code status is that the admitting nurse will fax the document to a preprogramed number on the facility fax machine that transmits the document to the provider email and the document can be signed and returned via provider phone to facility fax. Nurses will also contact provider via phone to ensure they are aware of the incoming document. This process was initiated, educated and in place by the DOC (date of correction) for the PNC [DATE]-Audits started on [DATE] and will be completed by DON weekly x 12 weeks to ensure any new admissions code status documentation is obtained and completed by admitting nurse and facility procedure and policy is being followed. Audits will continue until the QAPI (quality assurance and performance improvement) committee deems facility has achieved substantial compliance.

This citation pertains to Intake 2718302.Based on interview and record review the facility failed to obtain and put into place an advance directive (legal documents that provide instructions for medical care to ensure healthcare preferences are honored) in a timely manner and failed to honor the residents do not resuscitate (DNR) order for 1 (Resident #1) of 8 residents reviewed for advanced directives resulting in a resident who did not want life sustaining services to endure painful lifesaving activities that included cardiopulmonary resuscitation (CPR), receiving automated external defibrillation (AED; delivers electric shock to attempt to restore normal heart rhythm), and insertion of an intraosseous venous access (inserting a specialize needle into the bone marrow cavity to provide immediate vascular (bloodstream) access) of the tibia (shinbone).Findings include:Review of Resident #1's census page indicated Resident #1 was admitted to the facility on [DATE] on hospice services with a diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery (condition of plaque buildup) With Unstable Angina Pectoris (chest pain)).Review of Resident #1's level of care determination assessment, dated [DATE], noted Resident #1's cognitive skills were Independent: The applicant's decisions were consistent and reasonable.the applicant organized daily routine and made decisions in a consistent, reasonable, and organized fashion.Review of Resident #1's facility's DNR (do not resuscitate form) form, dated [DATE], stated, .I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me.Being of sound mind, I voluntarily execute this order, and I understand its full Import. This form was signed and dated by Resident #1 and two witnesses on [DATE]. The physician signature was noted to be on [DATE].Review of Resident #1's physician orders, print date [DATE], included an order of FULL CODE that was started on [DATE] with an end date of [DATE].This order was not updated to Do Not Resuscitate upon receipt of Resident #1's signed and completed DNR form received by the facility on [DATE].During an interview on [DATE] at 1:43 PM, Director of Nursing (DON) B reported Resident #1 was admitted to the facility on [DATE] and the facility discovered they didn't have any consent forms which included advanced directives and the DNR form during an admission audit on [DATE], and confirmed this indicated the DNR form had not been completed on day 1 of admission with Resident #1. DON B reported on [DATE] she got Licensed Practical Nurse (LPN) F to work with Resident #1 to sign consents (which included the DNR form) and Resident #1 was her own person (responsible for herself; no power of attorney or guardian). DON B reported Resident #1's DNR form was completed with herself (DON B), Resident #1, and LPN F on [DATE] and as soon as it was signed she emailed the DNR form to Medical Doctor/Medical Director K to have it signed/finalized by a doctor. DON B confirmed the DNR form signed and emailed back to the facility from the physician on [DATE] at 3:37 PM was not received by anyone at the facility before the code event at approximately 10:30 PM on [DATE]. DON B confirmed the returned signed DNR form for Resident #1 came back to her own individual email inbox, she was the only one who had access to this inbox, she wasn't working on [DATE], and therefore she didn't check the inbox to be able to receive the signed and completed DNR for Resident #1. DON B confirmed Resident #1's DNR status wasn't updated in the resident record prior to the code event. DON B reported LPN G found Resident #1 unresponsive and checked the code status order in her physician's orders which indicated full code as it hadn't been updated to show the DNR order. DON B reported the DNR form should have been completed with Resident #1 on day 1 ([DATE]) of admission.On [DATE] at 2:15 PM, LPN G was attempted to be contacted, but no response was received before the end of survey.During an interview on [DATE] at 8:24 AM, Resident #1's Family Member I confirmed she was present onsite at the facility with Resident #1 on day 1 of admission; [DATE]. Family Member I confirmed Resident #1 was her own responsible party and completed facility DNR paperwork (to show her wishes to be a DNR) and returned it to the nurse doing the admission paperwork. Family Member I reported on [DATE] she was on the phone talking with Resident #1 when Resident #1 was asking why she was having to refill out DNR paperwork again at the facility. Family Member I confirmed hospice had sent the facility preadmission screening documents on [DATE] that indicated Resident #1 desired to be a do not resuscitate. Family Member I expressed concern that Resident #1's advanced directives and end of life care were not honored, her body was subjected to life saving measures and voiced concern that it could happen to someone else at the facility.Review of Resident #1's #2204 Code Blue (alert signaling someone is experiencing a life-threatening medical emergency) document, dated [DATE], stated, .At around 10:30pm when the nurse (LPN G) was doing her rounds she observed resident lying on the bathroom floor, face down. The nurse called resident's name and resident did not respond. The nurse tried to find a pulse on resident's neck but could not feel a pulse. The nurse yelled to the CNA (Certified Nurse Aide M) to grab the other nurse (Registered Nurse O) and this nurse verified code status and started CPR immediately. Crash cart and AED machine were brought by CNA and other nurse. EMS (emergency medical services) was called around 10:35 PM while CPR continued for resident. When EMS arrived, they started CPR immediately. EMS performed CPR x (for) 30 minutes and were unsuccessful in retrieving a pulse.pronounced resident deceased at 2316 (11:16 PM).Statements.Staff (LPN G).This nurse checked the code status, and it reads FULL CODE and CPR Started.Review of Resident #1's emergency medical services call sheet, dated [DATE], stated, Complaint Type.Cardiac arrest.Duration of Complaint.20 Minutes.Date/Time of Symptom Onset: [DATE] 22:36:00 (10:36 PM).Primary Symptom: Cardiac arrest .The pt (patient) was in a nursing home.She had just been signed up with hospice and they were still working on getting DNR paperwork set up. Staff stated the paperwork was started but not signed.They (facility staff) started CPR and called 911. They also placed the pt (patient) on an AED.The fire department stated they arrived at 2238 (10:38 PM) and took over CPR for nursing home staff.They placed an I-GEL (airway device) and ventilated the pt with high flow oxygen. Once the I-GEL was placed they switched from 30:2 CPR (give two breaths after every 30 chest compressions) to continuous CPR.The paramedic started administering EPI (epinephrine) every 3-5 min, and he started the pt on fluids (intravenous therapy).EMS defibrillated and immediately continued CPR.called TOD (time of death) at 23:16 (11:16 PM).Resuscitation Attempted by EMS: Defibrillation (electrical shock to heart in an attempt to restore normal heartbeat); Ventilation (moving air into and out of the lungs); Chest Compressions (lifesaving manual technique used in CPR to restore blood circulation during cardiac arrest).XXX[DATE] 22:47:00.Procedure.Venous Access - Intraosseous (IO; inserting a specialized needle into the bone marrow cavity to provide vascular access).Vascular Access Location .IO-Tibia (shin bone)-Left.IV(intravenous; within a vein) Flushed Easily.Yes.Review of Resident #1's Quality Assurance Form, dated [DATE], stated, .Communicated by: Family/RP (responsible party) .Name: (Resident #1) .Details: Resident recently admitted 12/22 (2025). Code status not completed prior to resident coding. CPR performed on resident .Findings: DNR (do not resuscitate) paperwork not complete at time of code. Code done, resident was supposed to be DNR.Reporter Satisfied.No.Describe: Family still very upset that loved one had to go through a code .Review of the facility's Do Not Resuscitate Order policy, reviewed/revised date [DATE], stated, .A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident.placed in the front of the resident's medical record and scanned into the electronic medical record.Review of the facility's Residents' Rights Regarding Treatment and Advance Directives policy, reviewed/revised date [DATE], stated, .It is the policy of this facility to support and facilitate a resident's rights to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive.On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive.Review of the facility's Admissions to the Facility policy, reviewed/revised date [DATE], stated, .Prior to or at the time of admission, the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least:.Care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment.Assure that the facility receives appropriate medical records.prior to or upon the resident's admission.Applying the reasonable person concept, one who wished to be do not resuscitate would not want CPR performed to save their life. These lifesaving acts would be in direct contradiction of medical care and life wishes and would have both physical and psychosocial harm as possible outcomes.Review of the Facility Past Non-compliance Checklist, dated [DATE], stated, Was the resident injured? Resident expired (passed away) .Description of deficient practice (why and how did it happen): Resident admitted without proper code status paperwork completed by admission nurse. DON (Director of Nursing) completed appropriate paperwork with resident. Paperwork was sent to Medical Director for signature on [DATE]. DON was out of facility for holiday weekend, signed code status was sent back to DON's email. Resident coded prior to code status being entered into the medical record. Plan of Correction: In-depth analysis of how the deficiency occurred: (RCA (root cause analysis)) Staff did not obtain and complete code status documentation paperwork with resident upon admission.Review of a One-on-one in-service record pertaining to Resident #1, dated [DATE], stated, Employee Name: (Director of Nursing B) . Inservice Topic/Title: DNR/Code Status. If emailing code status info (information) for physician signature, ensure you are frequently checking email for completed documents to avoid any delay in care.Please see F678 for additional information.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: 1. Identification of residents affected or likely to be affected:-Blanket audit completed for 50/50 facility residents on [DATE] to ensure medical record accurately reflects residents code status and a signed copy of advanced directive has been uploaded into PCC (electronic health record). There were no noted concerns or required corrections at this time.2. Actions to prevent occurrence/Reoccurrence -CPR and Advanced Directive policy reviewed by NHA and DON on [DATE] and remains appropriate. The social service director audited all residents in the facility 50/50 to ensure proper code status were in place. 50/50 residents reviewed on [DATE] to ensure medical record accurately reflects residents code status and a signed copy of advanced directive has been uploaded into PCC and no changes required at that time. Additionally, The DON completed a separate Audit on last 14 days of admissions on [DATE] to ensure proper code status in place for all new admissions during this timeframe, this was completed as an additional audit as the resident noted in the PNC (past non-compliance) was a new admission to the facility in the past 14-day timeframe. On the audit looking at the last 14 days of admissions completed by the DON 7/50 residents were reviewed on this audit on [DATE], there were no discrepancies noted and no corrections made.-Additionally, the admission policy was reviewed [DATE] and deemed appropriate.-All Licensed Nurses 22/22 educated on [DATE]. 18/22 educated in person face to face, 4 educated verbally via phone on completing advanced directives paperwork on admission with designated responsible party and notifying physician to obtain orders and place into PCC.-Process: Nurse educated on [DATE] that they will meet with resident/Responsible party immediately upon admission to address code status wishes. Appropriate paperwork will be completed addressing residents' wishes and immediately communicated to the physician to obtain orders to be placed in PCC.-The new facility process for immediate action regarding code status is that the admitting nurse will fax the document to a preprogramed number on the facility fax machine that transmits the document to the provider email and the document can be signed and returned via provider phone to facility fax. Nurses will also contact provider via phone to ensure they are aware of the incoming document. This process was initiated, educated and in place by the DOC for the PNC [DATE]-Audits started on [DATE] and will be completed by DON weekly x 12 weeks to ensure any new admissions code status documentation is obtained and completed by admitting nurse and facility procedure and policy is being followed. Audits will continue until the QAPI committee deems facility has achieved substantial compliance.The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake #MI00148777 Based on interview and record review, the facility failed to implement treatment measures when a change in condition was identified (acute stroke) in 1 (Resident #100) of 2 residents reviewed for change in condition, resulting in an Immediate Jeopary when on 1014/24, Resident #100 had sign and symptoms of a stroke and facility staff did not identify them resulting in the diagnosis of a cerebral infarction due to occlusion (Stroke caused by a blockage in a blood vessel) and a 27-day hospitalization . Findings include: The immediate jeopardy began on 10/14/2024 and was identified on 12/27/2024 due to the facility's failure to implement treatment measures when a change in condition was identified resulting in Resident #100 being hospitalized for 27 days and diagnosed with a cerebral infarction due to an occlusion (Stroke). On 12/27/24 at 4:06 PM., the Nursing Home Administrator was verbally notified and received written notification of the Immediate Jeopardy. The surveyor confirmed that the immediate Jeopardy was removed on 12/27/24 but noncompliance remains at the scope of isolated and severity of actual harm due to not all staff had not received the education and sustained compliance has not been verified by the State Agency. Resident #100 Review of an Admission Record revealed Resident #100 had pertinent diagnoses which included: Cerebral infarction due to occlusion, epilepsy with simple partial seizures, (abnormal electrical impulses in the brain, seizure disorder), spastic diplegic cerebral palsy (neurological condition that causes disruption to normal movements and causes stiffness to arms and legs), and hydrocephalus (buildup of fluid in the cavities around the brain). Review of Nurses' Notes for Resident #100 dated 10/14/24 at 10:34 AM., authored by Registered Nurse (RN) N revealed Upon entering room to administer meds resident was noted to have eyes open with no tracking; looking straight forward. Vitals are WNL (within normal limits). When given heavy stimulation such as sternal rub and speaking very loudly; her eyes tracked. She is not speaking or answering questions at this time. No meds administered at this time. (Name Omitted) Medical Doctor (MD) and (Name Omitted) ADON (Assistant Director of Nursing) made aware of presentation. Review of Nurses' Notes for Resident #100 dated 10/14/24 at 19:01 (7:01 PM) authored by RN N revealed .no meals taken today. Resident more alert, but slow to respond. Review of Nurses' Note dated 10/14/24 at 20:48 (8:48 PM) authored by RN J revealed Resident continues to present as lethargic, and LOC (level of consciousness) decreased from baseline. Resident will track with eyes momentarily, and then continue to stare past writer; continues to not be willing or able to swallow medications . Review of Nurses' Note dated 10/14/24 at 6:11 AM authored by RN J revealed .has not voided (urinated) throughout shift, has had no oral intake in over 24 hours . During an observation on 12/26/24 at 9:54 AM., Resident #100 was noted lying in her bed with her eyes open, unfocused, and staring towards the television in the room. Resident #100 did not respond in any way (verbal or physical movement) when this surveyor spoke to her. In an interview on 12/26/24 at 11:15 AM., Certified Nurse Assistant (CNA) H reported Resident #100 was now non-verbal, and that she did talk before her stroke in October (2024). In an interview on 12/26/24 at 11:45 AM., Director of Nursing (DON) B reported Resident #100 was now non-verbal and was dependent on staff for all cares, including continuous tube feeding for nutrition and hydration needs. In an interview on 12/26/24 at 2:11 PM., RN N reported she thought that Resident #100's change in condition on 10/14/24 was a seizure, or that her shunt (a tube in the brain that redirects fluid) was malfunctioning. RN N reported she mentioned to the provider and the DON that Resident #100 was experiencing a change in condition, but she did not send her to the emergency room . RN N reported Resident #100 was sent frequently to the emergency room and the emergency room would do nothing and just send her back. RN N was asked if she contacted Resident #100's family when she noted the change in condition, and RN N stated I do not believe I contacted the family. RN N reported the process for a resident change in condition included a complete assessment, full vital signs, completion of the changed in condition assessment form, and a progress note needs to be completed. Also notify the provider, guardian/family/decision maker/ and then transfer to the emergency room . RN N reported she does not do the progress notes all the time due to things getting busy on the unit. RN N reported that both Medical Doctor (MD) Y and ADON C assessed Resident #100 on 10/14/24 and Resident #100 was not sent to the emergency room until the next day. In an interview on 12/26/24 at 2:35 PM., ADON C reported she was notified of Resident #100's change in condition and was asked to assess Resident #100. ADON C reported she was not aware of Resident #100's baseline status and was only advisory to RN N at the time. ADON C confirmed she did not document anything regarding Resident #100's condition on 10/14/24. In an interview on 12/27/24 11:37 AM., MD Y reported a couple of days before Resident #100 was sent to the emergency room , she assessed her, and nothing indicated that anything was different, there was nothing concrete that indicated Resident #100 needed to be seen by the ER (emergency room ). MD Y reported she expected the nurses to monitor the resident and confirmed that she had not provided specifically what to monitor the resident for. MD Y reported she did not order Resident #100 be sent to the hospital; her family requested she be sent to the hospital. The MD Y was asked if she contacted the family to discuss Resident #100's condition and she replied she did not contact the family the nurse did. This surveyor asked MD Y about her documentation regarding assessment and visit to Resident #100 on 10/14/24 and MD Y stated I didn't document the visit. In an interview on 12/27/24 at 2:33 PM., DON B reported her expectations for a change in condition for a resident included the nurses performing a nursing assessment, vital signs, communication with the provider, contact family regarding the resident's condition, send the resident to the emergency room if indicated and that it be documented in the Resident's medical record. DON B stated If it wasn't documented it didn't happen. In a telephone interview on 12/27/24 at 2:07 PM., RN J reported she was told in shift-to-shift report on 10/14/24 about Resident #100 change in condition and that the provider was aware of the change, and she was to monitor Resident #100's condition. RN J reported that she documented Resident #100's condition during her shift and was concerned with Resident #100 ability to swallow and she did not provide anything to her orally during her shift. RN J reported there was no protocol in place for what to do if a resident has no noted oral intake for 24 hours. RN J reported she did not contact the provider during her shift. In a telephone interview on 12/27/24 at 5:48 PM., Licensed Practical Nurse (LPN) R reported she sent Resident #100 to the emergency roiagnom on [DATE]. LPN R reported she noticed something was wrong with Resident #100 and had been told in shift-to-shift report that the provider was aware, and the staff was to monitor Resident #100's condition. LPN R reported when Resident #100's family arrived at the facility on 10/15/24 in the evening and they reported something was clearly wrong with Resident #100 and asked for her to be sent to the emergency room . LPN R reported she called the provider on call for a verbal order and transferred Resident #100 to the emergency room . In an interview on 12/26/24 at 12:28 PM., Family Member (FM) Z reported Resident #100 was sent to the hospital per family request in October where the hospital determined Resident #100 had suffered a stroke. FM Z reported that he visited the resident on 10/15/24 in the evening after work, and noticed Resident #100 was not herself. FM Z reported he went to DON B and told her something was wrong with Resident #100 and DON B told him they we're monitoring Resident #100. FM Z reported he requested that Resident #100 be sent to the emergency room immediately. FM Z reported he was angry that the facility staff was aware that something was wrong with Resident #100 and had done nothing for her. FM Z reported he had not been made aware of the change in condition of Resident #100 until he arrived to see her on the same day she was transferred to the emergency room . Review of Resident #100's medical record revealed no noted documentation from MD Y, ADON C, nor DON B regarding any assessment of Resident #100's change in condition, any specific monitoring or follow up, or any treatment measures for Resident #100's condition, nor any noted documentation regarding Resident #100's transfer to the emergency room during the dates of 10/14/24 and 10/15/24. Review of facility policy titled Notification of Changes implemented on 10/30/2020 with a revision date of 8/29/24 revealed the purpose of this policy is to ensure that facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification. Definitions: life-threatening conditions example-heart attack or stroke .circumstances requiring notification include .significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental, or psychosocial status this may include a. life-threatening conditions . According to the Mayo Foundation for Medical Education and Research, 1998-2010, retrieved online on 10/22/10, It should be noted when signs and symptoms of a stroke begin, because the length of time they have been present may guide treatment decisions. Seek immediate medical attention if you notice any signs or symptoms of a stroke, even if they seem to fluctuate or disappear. Call 911 or your local emergency number right away. Every minute counts. Don't wait to see if symptoms go away. The longer a stroke goes untreated, the greater the potential for brain damage and disability. To maximize the effectiveness of evaluation and treatment, it's best that you get to the emergency room within 60 minutes of your first symptoms. The immediate Jeopardy that began on 10/14/2024 was removed on 12/27/2024 when the facility took the following actions to remove the immediacy: On October 14, 2024, the facility identified that the resident had a change in condition. The resident was transferred to the emergency room for evaluation on October 15, 2024. On December 27, 2024, the facility identified treatment was not implemented for a change in condition for Resident #100. On December 27, 2024, the Director of Nursing and/or designee began education of the facility staff on signs and symptoms of a stroke, to include specifically decreased oral intake, unresponsiveness, inability to take medications and decreased level of consciousness. How to seek medical direction and treatment for urgent levels of care. Notification of family of change in condition. Physician/provider notification of change in condition. Documentation of notifications and assessments. How to identify acute changes in condition. No staff will not be permitted to work prior to receiving the education. The DON and/or designee completed a chart audit of all residents on 12/27/24 to determine if any other residents had sustained an acute change of condition. No others were found. The QAPI committee had reviewed the change in condition policy on 12/27/24 and deemed it appropriate. The facility had an Ad Hoc QAPI Meeting, including the Medical Director on December 27, 2024, and deemed this removal plan appropriate.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent falls with injury in 1 (Resident #102) of 3 residents reviewed for accident hazards and supervision, resulting in Resident #102 suffering pain, a head laceration which required stitches, and a hematoma on his forehead. Findings include: Review of an Admission Record revealed Resident #102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: muscle weakness, unsteadiness on feet, other abnormalities of gait (manner of walking) and mobility, disorientation, cognitive communication deficit, restlessness and agitation, and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 12/11/24 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #102 was moderately cognitively impaired. Section GG of the MDS revealed Resident #102 required moderate (helper does less than half the effort) to transfer from bed to chair, transfer to the toilet, and to ambulate 10'. Section J revealed Resident #102 had a history of falls prior to his admission and had suffered a fall with injury since his admission to the facility. Review of a Care Plan for Resident # 102, with a reference date of 12/5/24, revealed a focus/goal/interventions of: Resident is at risk for falls .Goal: reduce the risk of injury through the next review. Interventions: .educate resident on safety interventions, encourage resident to keep needed items within reach, encourage resident to use call light . Review of an Incident Report dated 12/11/24 revealed Resident #102 was found lying on the floor of his room at 2:45pm. Resident #102 was bleeding from the right side of his head. A statement from a staff member who cared for Resident #102 on 12/11/24 indicated the resident had tried to stand and transfer on his own throughout the shift and multiple reminders were given to him. Review of an Initial Fall Evaluation for Resident #102, with a reference date of 12/11/24, revealed: pain evaluation: right side of head, pain level 5 .physical evaluation: right side head injury with bleeding .plan of care review .describe other interventions: constant reminders to use call light and to not self-transfer . Review of an After Visit Summary for Resident #102, with a reference date of 12/11/24 revealed the resident was diagnosed with: ground level fall, injury of head, laceration of scalp, at a local emergency roiagnom on this date. Review of an Interdisciplinary Progress Note for Resident #102, with a reference date of 12/12/24 revealed: Resident told staff he stood up from his wheelchair, did not use his call light and tipped over. Resident had laceration to right side of head and was sent to ER (emergency room ) .upon return, staff determined a good intervention would be to provide more frequent checks on him . Review of an Incident Report dated 12/12/24, revealed Resident #102 was found lying on the floor in the common area after an unwitnessed fall. Review of an Initial Fall Evaluation for Resident #102, with a reference date of 12/12/24, revealed: Describe other interventions: Resident to be in common areas of staff .Resident is impulsive. Needs constant reminders and monitoring. Review of an Incident Report dated 12/13/24, revealed Resident #102 had an unwitnessed fall in his room at 4:34pm. Review of an Incident Report dated 12/15/24, revealed Resident #102 was found on the floor in the common area after an unwitnessed fall. Review of an Incident Report dated 12/16/24, revealed Resident #102 was found on the floor in his room after an unwitnessed fall. Review of an After Visit Summary dated 12/19/24, revealed Resident #102 was diagnosed with ground level fall, closed head injury, traumatic hematoma of forehead at a local emergency roiagnom on this date. During an observation on 12/26/24 at 9:07am, Resident #102 sat fully reclined in a recliner chair outside his room. A large hematoma with bruising surrounding it, was present on the right side of Resident #102's forehead. No staff were present during the 5-minute observation. In an interview on 12/26/24, at 12:03pm, Family Member (FM) CC reported Resident #102 needed more supervision to remain safe at the facility. FM CC reported she visited the resident daily and often times did not see any staff while she was visiting. FM CC stated He is falling more here than he did at home, because he's getting less supervision. FM CC reported she requested the resident get more supervision during his care conference because she was worried about his safety, and she was told the facility was in the process of hiring additional staff. FM CC reported Resident #102 had been sent to the emergency room twice in recent weeks because he fell and hit his head. The resident received stitches to his right forehead during both visits to the emergency room . FM CC stated They just need more staff to give him the supervision he needs. In an interview on 12/26/24, at 3:19pm, Registered Nurse (RN) W reported Resident #102 needed constant supervision to avoid falling. RN W reported she cared for Resident #102 on 12/19/24 and he fell after being left unsupervised. RN W reported although Resident #102 needed constant supervision to remain safe, the facility did not have enough staff to provide the supervision he needed. In an interview on 12/26/24 at 3:25pm, Registered Nurse (RN) N reported she had cared for Resident #102 in recent weeks and felt the facility did not provide the amount of supervision the resident needed to remain safe. RN N reported Resident #102 constantly attempted to stand up and when he did so, the resident would stand up and fall on his head. RN N reported the facility had provided Resident #102 with 1:1 supervision at times but did not have enough staff to always do so. In an interview on 12/27/24 at 9:19am, Certified Nursing Assistant (CNA) L reported on 12/19/24 while she was in another resident's room, she was alerted by Resident #102's roommate that he had fallen. CNA L reported she and another CNA found Resident #102 actively bleeding, lying on the floor in his room. CNA L reported she was aware Resident #102 was unsafe to be alone, but the staffing level did not allow for a staff member to always be with Resident #102 and she and the other CNA were caring for a resident that needed the assistance of 2 staff members, when Resident #102 fell . CNA K reported Resident #102's unit only had 2 CNA's at the time, one of which was a trainee, who could not be left alone with Resident #102. During an observation on 12/27/24 at 9:24am, Medical Records Coordinator (MR) I sat next to Resident #102 as he slept in a recliner chair in the common area of the facility. In an interview on 12/27/24 at 9:27sm, MR I reported she was providing supervision to Resident #102 as she sat with him on this date. MR I reported she was asked to provide supervision to Resident #102 for the first time on 12/26/24, was happy to help, but had not been asked previously. In an interview on 12/26/24 at 1:22pm, CNA V reported Resident #102 was supposed to be checked on frequently, but she was unsure exactly how often staff were expected to check on him. CNA V added, He moves so fast, unless you're right there, he will fall. In an interview on 12/26/24 at 2:29pm, Director of Nursing (DON) B reported Resident #102 required a lot of supervision to remain safe. DON B reported the resident was placed on frequent checks which meant he could not be expected to ask for help before attempting to get up and should be within line of sight of staff when he was awake. DON B reported the expectation was for Resident #102 to always be with staff when he was awake. When further queried about the amount of supervision the facility had provided to Resident #102, DON B became tearful and reported the facility had done what it could to provide the level of supervision Resident #102 needed and had been successful with providing supervision while the resident was awake in the last few days. No additional interventions beside supervision were discussed or considered. In an interview on 12/27/24 at 1:35pm, Registered Nurse (RN) W reported the facility recognized Resident #102 needed constant 1:1 supervision to remain safe at times, but there was not enough staff to provide that level of supervision. In an interview on 12/27/24 at 1:43pm, Confidential Informant (CI) DD reported Resident #102 needed 1:1 supervision to maintain his safety when he was restless. CI DD reported the facility staffing had suffered through a perfect storm in recent weeks due to open nursing positions, staff illness, and the recent holidays. When queried about the facility's ability to meet the supervision needs of Resident #102, CI DD stated All I can say is look at the nursing schedules. Review of the nursing schedules for (12/11, 12/12, 12/13, 12/15, 12/16, 12/19), each day/shift on which Resident #102 had a fall, revealed the facility was operating with less nursing staff than it deemed necessary for Resident #102's unit. Review of a facility policy, Fall Prevention Program with a reference date of 10/26/23 revealed Policy: Each resident will .receive care and services in accordance with the level of risk to minimize the likelihood of falls.

This citation pertains to Intake: MI00149223 Based on interview and record review, the facility failed to ensure 1 of 1 residents (Resident #100) reviewed for safety, received the correct food tray and assistance with eating on [DATE], resulting in an Immediate Jeopardy when Resident #100 choked on a piece of cauliflower and subsequently died . Findings include: The immediate jeopardy began on [DATE] and was identified on [DATE] due to the facility's failure to provide the correct diet tray and no assistance when eating resulting in Resident #100 choking on a piece of cauliflower and subsequent death. On [DATE] at 12:00 PM, the Nursing Home Administrator was verbally notified and received written notification of the Immediate Jeopardy. The surveyor confirmed by observation, interview, and record review that the Immediate jeopardy was removed on [DATE] but noncompliance remains at the scope of isolated and severity of actual harm due to not all staff had received the education and sustained compliance has not been verified by the State Agency. Dysphagia refers to difficulty swallowing. The causes and complications of dysphagia vary. Complications include aspiration pneumonia, dehydration, decreased nutritional status, and weight loss. [NAME], [NAME] A.; [NAME], [NAME]: Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations ,d+[DATE]). Elsevier Health Sciences. Kindle Edition. Resident #100: Review of an Admission Record revealed Resident #100 was a male with pertinent diagnoses which included paralysis on right dominant side, aphasia (loss of the ability to understand or express speech caused by brain damage, like with a stroke), cognitive communication deficit (progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language), dysphagia (damage to the brain responsible for production and comprehension of speech), need for assistance with personal care, intellectual disabilities, and cerebral infarction affecting right dominant side (blood flow to the brain is blocked, causing an area of tissue death in the brain . Review of Care Plan with [DATE], revealed the focus, .Resident has an ADL (Activities of daily living) self-care performance deficit related to CVA (cerebral vascular accident), epilepsy, dysphagia (damage to the brain responsible for production and comprehension of speech), pulmonary vascular congestion, hemiplegia . with the intervention .EATING: 1 person assist. Uses divided plate, built up utensils, and clothing protector as resident allows . Review of Order dated [DATE], revealed, .NDD (National Dysphagia Diet) Level 1 diet, Pureed Texture, Honey/Moderately Thick Consistency (a liquid that pours slowly, similar to honey, where it is thick enough to not easily flow out of a cup but can still be sipped from a spoon), oral care before and after each meal. No straws. Upright in wheelchair in dining room for all meals. DOUBLE PORTIONS . Review of Level 1 Dysphagia Puree received on [DATE], revealed, .ALL FOODS PUREED smooth without lumps and seeds .Cream of Wheat needs to be lump free, and oatmeal pureed .Cannot puree bacon or pepperoni unless stated otherwise .No pureed fruits with skim, pulp, or seeds .Sandwiches pureed as separate components .No sticky or chewy foods . Review of Summary of Daily Skilled Services dated [DATE], revealed, .Precautions: Fall risk, aphasia, PEG tube, low vision, NDD level 1 textures, honey-thick liquids, no straws .Pt (Patient) alert/awake in dining room. Pt cooperative with treatment session, in which recertification was completed. Pt continues on a NDD level 1 texture diet honey-thick liquids. Pt has been safely tolerating therapeutic trials of NDD level 2 textures, however, pt continues to require max cueing for implementation of safe swallowing strategies. Recommend continued education in strategies, including small bites/sips, alternate bites/sips, and eat slowly. No therapeutic trials of upgraded liquids have been trialed d/t (due to) no upgrade recommended until f/u VFSS. Pt implementing safe swallowing strategies with 75% accuracy given max verbal cues. Pt agreeable to continue to participate in skilled SLP (Speech Language Pathologist) services ,d+[DATE]x/week for 30 days to continue to complete pharyngeal strengthening exercises and facilitate diet advancement as appropriate . Review of Incident Report dated [DATE], revealed, .Incident Description: Resident sitting in dining room on (Unit). New employee CENA delivered resident tray. Resident .diet/honey thick liquids but was served a regular tray accidentally by CENA. Was noted to be choking .nurse .Immediate Action Taken: RN immediately attempted Heimlich x3, resident turning blue and no air exchange noted, placed on floor, Heimlich .CPR initiated, [DATE] called. AED attached -no shock needed. No food noted in mouth. EMS arrived and took over .(Local Hospital) via EMS who were continuing to work on resident .Other Info: New CENA in orientation provided wrong diet to resident. Preceptor was assisting another resident and was not aware of wrong tray .noted resident in choking position with hands at throat . Review of Nurse's Notes dated [DATE] at 8:51 PM, revealed, .Witnessed choking event occurred. Approximately 1730 dinner trays passed by CNA's. Resident sitting in dining area on (Unit) in wheelchair. At 1735 RN (Registered Nurse) who was passing meds on (Unit) was alerted by CNA (Certified Nursing Assistant) F that resident was choking as resident put hands over throat and signaled to help. After rapidly attending to resident, this RN attempted Heimlich multiple times while in wheelchair without success. Resident rapidly turned blue in lips and gasping without any air exchange. Unable to visualize any food in mouth. Resident then assisted to floor and positioned supine. Heimlich reattempted without any success. 911 called after establishing no pulse. CPR started by this RN and assisted by CNA. After approximately 3 rounds of CPR EMS arrived. LMA (laryngeal mask airway) and IO (Intraosseous- procedure that involves injecting fluids, medications, or blood products directly into the bone marrow. This done when intravenous access (IV) is not available or feasible, such as in cardiac arrest or decompensated shock) iv placed per EMS and AED applied. Resident eventually transported to (Local Hospital) with no spontaneous pulse . Review of IDT-Interdisciplinary Progress Note dated [DATE] at 2:38 PM, revealed, .IDT (Interdisciplinary Team), including RDC met to review choking incident. Resident on puree diet received the wrong tray of a regular diet that belonged to his roommate. (CNA G), CNA orientee, had mistakenly given (Resident #100) the dinner tray that should have gone to his roommate. (CNA F) was supervising the dining room when she noted that (Resident #100) had placed his hands at his throat indicating he was choking. She called for the nurse who immediately attended to the resident and performed the Heimlich maneuver with no results and called 911 and began CPR. Paramedics arrived and took over; he was then transported to (Local hospital) where he was later deceased . In an interview on [DATE] at 12:27, Registered Nurse (RN) E reported she was on a different hallway administering medications. RN E reported the facility only had two nurses on shift and when that happened, the unit Resident #100 was on was split between the nurses. RN E reported the incident occurred at dinner time and there was not a nurse down on that unit at that time. CNA F was the only CNA on the unit, and she had a trainee with her, CNA G who was employed by the facility but was orienting. CNA F yelled to me loudly (Resident #100) was choking, sprinted down there and he was sitting at the table in the dining room area. Resident #100 was seated in his wheelchair, he was trying to breath, he was gasping and totally occluded. He was starting to turn blue. RN E reported CNA F had been in that area, he raised his hand and grabbed his throat, she quickly yelled to me. RN E reported she tried Heimlich on him, he was a bigger guy, tall and heavier set guy. RN E reported she tried multiple times, and nothing was happening. He slumped over, RN E reported he was not ambulatory person, and he was in his wheelchair, she was behind him trying the Heimlich maneuver doing the best she could. RN E reported he had lost consciousness not sure how long it had been by the time she called me to come down to assist Resident #100. RN E reported she had to get him to the floor. CNA F and her got him to the floor and tried abdominal thrusts on him, looked in his airway and there was nothing there. RN E reported they had him on the floor in the middle of the dining room and she couldn't feel a pulse, she called 911 and then started cardiopulmonary resuscitation (CPR). RN E reported CNA H came down from another unit and grabbed the crash cart. RN E had called 911 and they told the staff to start CPR, and she was doing ,d+[DATE], 911 told her to stay on the phone and someone would be there right away, and then Fires rescue arrived, not sure how many rounds of CPR she had performed on Resident #100. RN E reported when Fire Rescue got there, they began running the code and soon after EMS arrived. CNA F had been assisting the other residents out of the dining room and back to their rooms. RN E reported the responders tried putting an oral airway in him but were unsuccessful and they ended up intubating him. RN E reported the AED reported a shock was not advised, and the code was ran for a good ,d+[DATE] minutes. RN E reported the incident happened at like 5:35 PM and the responders took him sometime after 6:00 PM. RN E reported it wasn't until she took a look at his tray, she realized the CNA had delivered the wrong tray to Resident #100. RN E reported there were chunks of cauliflower and penne pasta roasted on the tray. RN E reported had decompensated in the ICU (Intensive Care Unit) that night and had died . RN E' reported she was informed by the hospital it was the cauliflower caught in his throat. RN E reported CNA G didn't know the residents well and she fell apart when she realized she had given Resident #100 the wrong diet tray. Review of Risk Management Statement dated [DATE], revealed, CNA G wrote .Began passing trays, I delivered a tray to (Resident #100) that belonged to his roommate by mistake. (Resident #100) was seated at the table in the dining room. I then went to another unit to assist another resident with their meal. I returned to (Unit) to see the staff providing CPR to (Resident #100) . In an interview on [DATE] at 1:06 PM, CNA G reported she was training on (Unit) when it was dinner time, reported we were passing the trays out. CNA G reported she was told to pass out trays for Resident #100 and his roommate. CNA G reported she dropped the trays off and was to go to another hall and feed another resident. When CNA G came out of the room, she saw EMS giving him (Resident #100) CPR. CNA G reported she had only worked at the facility for approximately two weeks prior to this incident and she was still in training. CNA G reported she didn't' know who the residents were on that unit as she had only worked over there one other time. CNA G reported the staff were to check the meal ticket and she had mixed them up. CNA G reported she was supposed to check the kiosk if she did not know who the resident was and/or to verify the resident's diet order was correct, but she didn't have access to the charting system but if had access she could have checked the charting system. CNA G reported they were working short staffed and CNA F had other things to do and she told me here the tray go ahead and pass it. She had pointed the trays out to me and told me they went to the residents in Resident #100's room. CNA G reported she did not verify who she gave the meal tray too was correct as she had to go assist another resident with eating. CNA G stated, she felt, .Terrible for his family because of my mistake . Review of Risk Management Statement dated [DATE], revealed, .I, (CNA F), CNA was supervising the dining room when I saw and heard the resident placed his hand to his chest and give the sign that he was choking. I went right over to him, asked him if he was ok, he shook his head no, I immediately called out for the nurse, (RN E) ran to the resident and began the Heimlich maneuver. That was unsuccessful. 911 was called and we laid the resident to the floor and began CPR until paramedics arrived and they took over . This writer attempted to contact CNA F on [DATE] at 2:35 PM and [DATE] at 10:39 AM and was unable to reach her prior to the end of survey. Review of Risk Management Statement dated [DATE], revealed, .I, (CNA H), was in another room assisting a resident to eat their meal. I exited the room and walked to dining room area to see (RN E), RN and (CNA F), CNA performing the Heimlich maneuver on resident (Resident #100). I then went for emergency cart/AED and brought to the nurse. Paramedics then arrived as (RN E) and (CNA F) were performing CPR . In an interview on [DATE] at 12:16 PM, Family Member (FM) K reported they were in the building frequently and stated, .You don't know how many times the wrong trays are given to the wrong people, see it quite a bit . In an interview on [DATE] at 2:31 PM, CNA J reported Resident #100 was one person assist, and he needed to be watched when he ate as he ate too fast, he had built up silverware and he was getting better, but he was still on a pureed diet. In an interview on [DATE] at 4:17 PM, Director of Nursing (DON) C reported there were two residents who needed assistance on [DATE] and Resident #100 would have been one of them. In an interview on [DATE] at 2:07 PM, Director of Rehabilitation, Speech Language Pathologist (SLP) I reported Resident #100 admitted to the facility in [DATE], he was originally NPO (nothing by mouth) with a peg tube. SLP I reported she saw him from August to October and he had a swallow study done on [DATE] and was upgraded to a Level I Pureed diet, thick liquids via cup only no straws. SLP I reported she had done some trials with Resident #100 with a Level II diet, mechanical soft and pretty mushy. SLP I reported she had only given him a little bite and she never felt comfortable upgrading his diet to Level II because he ate super, super fast and she wanted to do another swallow study before any upgrades. SLP I reported for the trails she used a very small piece of oatmeal cream pie cookie, didn't do a ton of trials as he ate too fast. SLP I reported she was working with Resident #100 4 days a week when he had dies. SLP I reported he was a new stroke still and that was part of what brought him here in [DATE]. SLP I reported on [DATE] note it was written, Resident #100 was safely tolerating of level textures, max cueing safe swallowing not recommended to upgrade. SLP I reported she saw Resident #100 for aphasia as well. Review of ED to Hosp-Admission note dated [DATE] at 7:37 PM, revealed, .HISTORY OF PRESENT ILLNESS: 75 yo M (male) who presents via EMS from (Long Term Care Facility) after he went down. Patient was eating dinner when he suddenly choked on his food. Patient was supposed to be eating a pureed diet but had solid food. He went down, lost pulses and CPR was started. EMS attempted to intubate however there was a food bolus passed the vocal cords they were unable to remove. I gel (airway device used to manage airway during resuscitation or anesthesia) was placed. They continued CPR and did get return of spontaneous circulation at 1 point. Estimated downtime of approximately ,d+[DATE] minutes. They did give 4 rounds of epinephrine .75 yo male with cardiac arrest due to acute airway obstruction after aspirating (inhalation of a foreign object into the lungs) on a piece of cauliflower. Downtime at least 40 minutes. Neurologic assessment unable to be obtained due to severe shock and hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). Chest imaging with evidence of severe aspiration pneumonitis. Bronchoscopy (procedure that allows the doctor to examine the inside of the lungs, trachea, and bronchi using a thin, lighted tube called a bronchoscope) done at bedside with pulmonary hemorrhage, presuming due to trauma from CPR done while aspirated food content was lodged in airway. Etiology (cause or manner for a disease or condition) of shock likely due to severe acute lung injury and impending ARDS (acute respiratory distress syndrome). Review of policy, .Resident Meal Service reviewed/revised on [DATE], revealed, .Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance .2. Nursing personnel will ensure that residents ware served the correct food tray .3. Prior to service the food tray, the Nurse Aide/Feeding Assistant must check the tray card to ensure that the correct food tray is being served to the resident. IF there is doubt, the nurse supervisor will check the written physician's order . Review of policy, Tray Identification reviewed/revised on [DATE], revealed, .3. Nursing staff shall check each food tray for the correct diet before serving the residents . The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: On [DATE], the facility identified that a resident was given a regular diet instead of his ordered puree honey thick liquid diet. The resident began choking and ultimately requiring CPR. The facility identified that the CENA in orientation did not have her preceptor with her and did not know how to identify residents. On [DATE], the Director of Nursing and/or designee began education of facility staff on providing accurate diet, not providing care without preceptor/Nurse in attendance until relieved from Orientation, and that preceptors will not leave or allow new employees to provide care until they are deemed competent to provide care without preceptor. Staff were also educated on utilizing the kiosk when needing to identify residents. NHA and DON were educated on [DATE] on orientation process and preceptor expectations as well as the policy for orientation. On [DATE] the facility implemented resident diet info binders to include diet terminology conversion, pictures of diets and allowable foods for texture, resident pictures who have altered diets. The facility implemented re-education on [DATE], upon identification that staff were unable to verbalize use of resident diet info binders. The facility has 15 Licensed Nurses and 27 C.E.N.A.'s As of [DATE], the facility had educated 6 of the 15 Licensed Nurses and 14 of the 27 C.E.N.A/s. Any staff not educated at the time would not be permitted to work a shift until education had been completed. The facility Medical Director was notified on [DATE], at 1:55pm. The Director of Nursing and/or designee completed an audit on all residents with an altered diets to ensure orders are entered correctly and match the binders. This audit for accuracy was completed on [DATE] and no concerns notes. The QAPI committee has reviewed the Orientation policy, therapeutic diet orders and ADLs and has deemed them appropriate [DATE]. The facility had an Ad hoc QAPI meeting including the Medical Director (via phone) on [DATE] and deemed this removal plan appropriate. The Administrator and Director of Nursing are responsible for continued compliance.

This citation pertains to intake: MI00138818. Based on interview and record review, the facility failed to ensure the safety and prevent elopement in 1 (Resident #100) of 5 residents reviewed for accidents/hazards, resulting in an Immediate Jeopardy when Resident #100, who had been assessed as an elopement risk and fall risk, had made multiple prior attempts to exit the facility, and had a Brief Interview for Mental Status (BIMS) of 3, exited the facility unbeknownst to facility staff and was located on 7/24/23 at 7:30 PM down the hill of the facility driveway on the sidewalk, located along a 35 mph, 4-lane divided road. Findings include: Resident #100 Review of an Admission Record revealed Resident #100 was a female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's Disease (a form of dementia), unspecified mental disorder due to known physiological condition, major depressive disorder, and generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 7/19/23 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #100 was severely cognitively impaired. Review of a Facility Reported Incident (FRI) report revealed, Incident Summary: (Certified Nursing Assistant (CENA) R) walked by the patio off of (nursing unit name omitted) and noted (Resident #100) was on the patio. When she realized there was no staff with the resident staff exited the center and returned with (Resident #100) . Review of a Facility Investigation Report revealed, .On 7/24/23 at approximately 1930 (7:30 PM) (CENA R) walked past the patio off of (nursing unit name omitted) and noted (Resident #100) was outside. (CENA R) continued to walk past the patio to a resident room as she assumed (Hospitality Aide (HA) Q) had taken (Resident #100) outside for a walk as the alarm on the door had not sounded and he had been with her earlier. (CENA R) entered (resident room number omitted), which is directly next to the exit to the patio, assessed each resident and (sic) not having any needs and exited the room .Upon exiting the room (CENA R) saw (HA Q) inside the center but did not see (Resident #100) with him. When questioned as to where (Resident #100) was (HA Q) did not know. A missing resident code was announced and staff began searching the facility, including staff exiting the center from different exits. Once (CENA R) exited the center from the (nursing unit name omitted) exit she observed (Resident #100) on the sidewalk along the facility driveway. (Resident #100) walked back inside of the center with staff without any issues at 1934 (7:34 PM) . Review of Resident #100's Care Plan in place on at the time of the elopement on 7/24/23 revealed a focus of The resident is at risk for falls related Anxiety, receipt of to (sic) Alzheimer's with compromised safety awareness, OA (osteoarthritis), receipt of antidepressant medications with a date initiated of 7/13/23. Further review of said Care Plan revealed a focus of Resident has behaviors related to Alzheimer's with exit seeking, refuses medications, wandering throughout facility with no sense of direction with a date initiated of 7/19/23. Further review of said Care Plan revealed a focus of Resident is at risk for elopement related to exit seeking behavior, unsafe wandering with a date initiated of 7/19/23. Review of Resident #100's Behavior Tracking documentation for the period 7/17/23 (when tracking began) to 7/24/23 (when Resident #100 eloped) revealed 5 Yes responses for the question, TARGET BEHAVIOR 1: attempting to leave facility .Did Resident exhibit target behavior? indicating Resident #100 had made multiple attempts to exit the facility prior to 7/24/23. Review of CENA R's Witness Statement dated 7/24/23 at 10:19 PM revealed, I saw (Resident #100) on the patio outside of (nursing unit name omitted) door. I thought (HA Q) had been with her. I went to do a round in a room and when I walked back by, I didn't see her outside and I didn't see her inside so I told the other aide I couldn't find (Resident #100). That's when we started looking inside and outside and found her out front. I never heard the alarm go off. In an interview on 8/28/23 at 1:01 PM, Registered Nurse (RN) K reported was the nurse for Resident #100 on 7/24/23. RN K reported had just started her shift and it was the first time having met (Resident #100) before she eloped. RN K reported before Resident #100 got out of the building, she had been wandering and was thinking she needed to go pick up her son or somebody was going to pick her up. In an interview on 8/28/23 at 2:10 PM, CENA S reported Resident #100 was known to be an elopement risk before she eloped. CENA S stated she (referring to Resident #100) would never settle down .she would constantly try to escape .this was from the very first day she came to us. In an interview on 8/28/23 at 2:42 PM, Social Worker (SW) P reported Resident #100 exhibited severe sundowning (confusion that occurs late afternoon into the night) when she first admitted to the facility and would say that she had to go see her sister or her son. SW P reported Resident #100 would ask where the exit doors were because she said she needed to go out and that she would look for an exit. In an interview on 8/29/23 at 1:04 PM, HA Q reported Resident #100 had been trying to get out of the facility prior to her elopement on 7/24/23. HA Q reported earlier in the day on 7/24/23 Resident #100 had been asking what door she needed to go to in order to get out of the facility and that staff had redirected her as a preventative measure. HA Q recalled at one point earlier in the day on 7/24/23 having to stand between Resident #100 and the exit door and Resident #100 pushing on HA Q's arm thinking it was the door. When queried as to whether or not Resident #100 was put on increased supervision after that, HA Q reported did not believe so. HA Q reported had redirected Resident #100 at that time and continued with other work responsibilities. On 8/29/23 at 9:30 AM, Nursing Home Administrator (NHA) A was verbally notified and received written notification of the Immediate Jeopardy that began on 7/24/23 at approximately 7:30 PM due to the facility's failure to prevent the elopement of Resident #100. A written plan for removal for the Immediate Jeopardy was received on 8/29/23 and the following was verified on 8/29/23: * On 7/24/2023, The Hospitality aide was assigned to provide one to one support for the resident. She was assessed by the nurse for pain and skin concerns. All were within normal limits. * The facility provider, NHA and responsible party were notified on 7/24/2023. The NHA came back to the facility. * Additional interventions put in place at that time including initiating investigation and interviews, checking all doors and confirming they were in working order and reviewing the residents care plan on 7-24-23. * 7/26/2023 NHA provided supportive visit to the resident who was pleasant and cooperative and remained on one to one supervision. * A head count was completed on 7/24/2023 and no other residents were identified as unaccounted for. Door checks were completed on 7/24/2023 and no other door alarm issues were identified. * An Ad Hoc QAPI was held on 7/25/2023 to initiate a root cause analysis: Per investigation it was noted that the current alarm on the door out to the courtyard was not loud enough to hear if staff were in resident rooms. * Staffing was reviewed by the Administrator on 7/24/2023 and found not to be an issue. * All residents with a BIMS score of less than 10 were reassessed for elopement risk on 7/25/2023. The facility conducted an audit of all residents in the facility regarding their Elopement Risk assessments. Elopement Risk assessments/residents deemed to be at high risk were listed, care plans were updated accordingly and all high-risk residents were cross-referenced with the facility elopement books. * Elopement books found at the nurses' station and receptionist desk as well as the emergency tri folds were checked to ensure they included all the required information and were updated accordingly on 7/24/2023. * A padlock placed on the gate where resident was wandering 7/25/2023. This gives the appearance of the gate being locked however you are able to lift the handle and open the gate. * A perimeter walk through was completed; all doors were noted to be secured on 7/25/2023. * The volume on the enunciator was increased on the door that the resident exited on 7/25/2023. Additional enunciator was also installed for the door on 7/25/2023. All other doors enunciator's volumes were checked to ensure they were sufficient on 7/25/2023. * Doors were checked and working properly on 7/25/2023. * Resident continued on one to one. Resident had a skin assessment and pain assessment completed on 7/24/2023 by the licensed nurses on duty. No adverse effects were noted from any of the assessments. * Physician notified and assessed resident at next visit to the facility on [DATE]. * Family notified 7-24-23 by (name omitted) RN and agreed to allow facility to find a dementia unit for resident. * Care plan was reviewed and updated 7/25/2023. * Door codes were changed 7/25/2023. Staff educated to not give families the codes and only Health Center staff were to let residents/families out of the unit. * Education was to continue on elopement. Staff elopement quizzes were re-implemented on 7/25/2023 and continue to be completed. 70 out of 70 employees were educated on the new exit door codes and not to share with any non-employees on 7-25-23. * Daily monitoring of doors to continue. * Elopement policy reviewed and deemed appropriately followed by NHA on 7/24/2023. * Education completed by Administrator/designee to the facility staff on (topics): a. Elopement Policies and Procedures b.Changes in resident behaviors/notification of Supervisor when changes are identified. c. Elopement Books d. Enunciator Board * The facility will conduct the following audits to ensure the deficient practice does not recur: a. Daily audit of all exterior doors b. Audit of Elopement books weekly for accuracy During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included those items verified on the approved IJ removal plan dated 8/29/23 above. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake MI00132704. Based on interview and record review, the facility failured to monitor and care for nephrostomy tubes consistent with professional standards of practice, in one of one resident reviewed for nephrostomy care and services (Resident #10), resulting in an Immediate Jeopardy due to the likelihood for serious harm and/or death when Resident #10 required an emergency transfer to the hospital for appropriate care with intravenous fluids, replacement of nephrostomy tubes and antibiotic treatment for a serious infection. Findings include: Hospital Discharge Summary with admitted [DATE] and discharge date of [DATE], indicated R10 was admitted for a urinary tract infection (UTI) and had two nephrostomy tubes (small catheter placed through the skin of the lower back into the kidney to drain urine; a portion of the catheter was connected on the outside to a drainage bag and secured with an adhesive clip to secure the catheter) placed approximately one month prior to admission. R10 had a past history of metastatic prostate cancer, obstructive uropathy (urine cannot drain through the urinary tract), diabetes mellitus, history of deep vein thrombosis (DVT, blood clot in a deep vein) in the right lower extremity in June 2022; and swelling and pain in lower extremities for two weeks prior to admission. Urine samples were obtained from both nephrostomy tubes and R10 received intravenous (IV) antibiotics to treat the infection during hospital stay. In review of R10's Hospital Medication Administration Report dated 10/25/22 through 10/27/22, Cephalexin (Keflex) (antibiotic) was ordered starting 10/24/22, 250 milligrams (mg) every 6 hours, until 11/02/22. The same report indicated R10 received one dose of Keflex in the hospital prior to discharge on 10/27/22; and was to receive the next 3 doses at the nursing home on 10/27/22. R10 was to receive a total of 36 doses of Keflex, 11 doses while at the hospital, and 25 doses at the nursing home. R10's Nursing Admission Evaluation dated 10/28/22, under urinary continence, indicated he was continent of bladder, and urine was yellow without odor. Urinary care plan was blank, and there was no documentation that R10 had nephrostomy tubes. UTI in last 30 days box was not checked as a potential problem. R10's Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/02/22 revealed he was [AGE] years old, admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a brief performance-based cognitive screener for nursing home residents, score of 13 (13-15 Cognitively Intact). R10 required extensive physical assistive of 2 plus persons in toilet use (how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes, not including emptying of the catheter bag). The same MDS indicated R10 was frequently incontinent of bowel (2 or more episodes of bowel incontinence, but at least one continent bowel movement during the 7-day look-back period). In review of R10's October 2022 Medication Administration Record (MAR), he did not receive 3 doses of antibiotic on 10/27/22 at the nursing home. On 10/28/22 there was no documentation of R10 receiving Keflex on 10/28/22 at 6:00 PM. R10's record indicated he refused Keflex two times in October, on 10/29/22 and 10/31/22. In review of R10's October 2022 and November 2022 MAR, he received 20 out of 25 doses of the ordered Keflex. Nursing Home Administrator (NHA) A was interviewed on 2/27/23 at 10:22 AM and stated she did not know why Keflex wasn't started on day of admission for R10, and confirmed it was available to administer on the day of admission. On 2/27/23 at 11:45 AM Nurse Consultant (NC) C was interviewed and confirmed Nephrostomy Tube education did not occur prior or during R10's admission. Nephrostomy Care education was started after surveyor interviews that occurred on 2/16/23. NC C stated a resident's vital signs would be included on a Transfer Form from facility to the hospital. The Nephrostomy and Cystostomy (surgically inserted into bladder to divert urine from urethra) Tube Care and Maintenance Policy date reviewed/revised 1/01/22, indicated residents with nephrostomy tubes would receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The same policy revealed the care and maintenance of nephrostomy tubes would be in accordance with physician orders; the order would specify the type and frequency of dressing changes and emptying of collection bags along with any special instructions. The residents goals and preferences for care and treatment of the tubes would be used to formulate a plan of care, including, but not limited to: 1. Frequency of dressing changes and emptying of collection bags. 2. Self/family care instructions. 3. Monitoring for and responding to any signs of resident's discomfort associated with the tubes. 4. Interventions to prevent complications included: a. Fluid preferences and need for increased fluid intake. b. Monitoring for symptoms of blockage (reduced or absent urinary output), urinary tract infection (fever, chills, back pain, new onset of confusion, foul smelling or cloudy urine), or dislodgement (tube falls out, leaking urine around tube, increase in tube length). c. Monitoring for skin breakdown or signs of infections (redness, warmth, swelling, abnormal drainage) around the insertion sites. d. Physical management of tubing and collection bags to prevent infection or dislodgement. 5. Procedure for irrigation if ordered by physician. Hospice Note dated 10/27/22 indicated R10 was admitted to hospice and the nursing home on 10/27/22 at 2:30 PM. Per Physician Narrative Notes R10's nephrostomy tubes were observed without dressings covering insertion sites; orders were left for dressings and securement devices per family request. The same note indicated family also requested drainage bags be changed as they had been in place for over a month. Communication Sheet dated 10/27/22 at 3:40 PM, revealed a physician's telephone order, signed by a Registered Nurse (RN), to cleanse both nephrostomy sites with alcohol or chlorhexidine (topical antiseptic), allow to air dry, cover with split gauze and transparent dressing (clear sterile dressing that keeps out water, dirt and germs) weekly. Secure both nephrostomy tubes to skin with stat lock (stabilization device) or similar device. Change both nephrostomy bags every other week with dressing change. In review of R10's Physician Order Summary Report, admitted [DATE], and Medication/Treatment records, there were no orders for frequency of nephrostomy dressing changes, emptying of collection bag, irrigation, or any special instructions for care. The nephrostomy tube orders were not transcribed. Regional Director of Operations J was interviewed on 2/16/23 at 1:20 PM and indicated the facility did not complete skills checks/competencies of Agency staff; and they did not know what the agency checked, they no longer used agency staff. RDO J stated in the same interview, if agency staff had issues, they would ask them not to send them back to our facility. Facility Progress Note dated 10/31/22 at 1:33PM indicated family concern of decreased urine output from R10's nephrostomy tubes. Facility Progress Note dated 10/31/22 at 3:15 PM indicated Hospice nurse and facility nurse both attempted to flush R10's nephrostomy tubes and the right nephrostomy tube flushed easily, the left nephrostomy did not flush. There was no mention the physician was notified. There were no physician orders to flush the tubes. Hospice Note dated 10/31/22 at 10:00 PM indicated under nephrostomy tube care the facility staff were to weekly remove old dressings and cleanse site with alcohol or chlorhexidine, cover with gauze and transparent dressing. The same note under narrative notes revealed R10's family reported he had not been eating or drinking much and staff reported same. Facility nurse reported to hospice Registered Nurse (RN) that the right nephrostomy tube was flushed, and they were not able to flush the left nephrostomy tube. The same note indicated the hospice RN attempted to flush R10's left nephrostomy tube without success. The same note revealed family member reported R10's nephrostomy bag was cut or tore and requested a new one, the RN gave suggestions for that night and would try to find one the next day. The same note indicated the family asked about in-house hospice placement and the noted indicated it would be looked into. The note did not indicate a physician was notified. Facility Progress Note dated 10/31/22 at 4:45 PM indicated R10's glucose level was 251 and he was not eating or drinking at the time, orders were obtained to hold insulin. Hospice invoice dated 11/01/22 revealed drainage bags were ordered on 11/01/22 and shipped to the hospice nurse on 11/02/22. Hospice Narrative note dated 11/03/22 indicated the hospice nurse visited and reported to family R10 received the nephrostomy drainage bags. Physician Progress note dated 11/04/22 at 1:40 PM revealed it was reported by facility R10 was painful, had severe swelling, refused medications, and was hitting staff. The same note indicated R10 was unable to take pills because they were hard to swallow; pain medication was changed to liquid form. There were no mention nephrostomy tubes were assessed. Hospice note dated 11/04/22 at 5:15 PM indicated hospice RN spoke with facility nurse and aide and instructed to remove and replace catheter secure devices the next time R10 got up. In review of R10's medical record, there was no documentation of output from each catheter during R10's stay, there were no VS documented in the VS summary on 11/06/22 and 11/07/22. In review of R10's medical record under task charting, R10 refused all meals and liquids on 11/06/22, there was no indication the nurse was notified. Facility Progress Notes dated 11/07/22 at 5:03 AM indicated R10 slid down in his recliner chair when the Licensed Practical Nurse (LPN) G attempted to administer his scheduled medications. His weight was much for me so I let him slide on my feet and then yelled for help. R10 was put into bed with a total lift transfer device. LPN G was interviewed on 2/16/23 at 12:50 PM and stated on 11/07/22 when R10 slid from his chair she did not notice anything with his nephrostomy tubes, she was aware he had nephrostomy tubes, and did not check if he had dressings on sites and did not observe sites. LPN G stated in the same interview R10 rarely had drainage in bag. In review of NP note dated 11/07/22 at 1:35 PM indicated nursing reported increased pain and agitation that morning. The same note indicated R10's nephrostomy tubes were dislodged. VS were documented indicated R10's temperature was 97.7 degrees Fahrenheit, pulse was 52, respirations was 14, blood pressure was 116/48, and pulse oximetry was 94 percent (%) on room air. The VS were exactly the same on 11/05/22 at 10:09 PM. The same note indicated R10 was taking Lasix, a diuretic, 40 milligrams daily, for 5 days for leg swelling. In review of R10's November 2022 Medication Administration Record (MAR) Lasix was ordered on 11/05/22, the medication was documented as refused for 3 days. Nurse Practitioner (NP) H was interviewed on 2/16/23 at 11:50 AM and stated R10's nephrostomy tubes were dislodged and she did not assess if the tubes secured in place. NP H stated in the same interview she did not recall looking at the nephrostomy sites. NP H was interviewed 2/27/23 at 12:11 PM regarding R10's VS documented in her note on 11/07/22; NP H stated if the VS were exactly the same as on 11/05/22, then his VS were from 11/05/22 and not 11/07/22. NP H did not recall if she was notified that R10 did not receive the complete course of Keflex and no intake on 11/06/22; and if notified of such things, they would included in her progress note. RN F was interviewed on 2/27/23 at 12:48 PM and stated she was working on 11/07/22 when R10 was transferred to the hospital. RN F stated she didn't recall why VS were not taken that day (11/07/22), and thought there could have been only one nurse assistant working with her, as there usually was only one nurse assistant scheduled on the unit. RN F stated R10's nephrostomy catheter care orders did not show up on the MAR or Treatment Administration Record (TAR). RN F stated she wasn't aware the facility had a Transfer Form, that she gave a verbal report to Emergency Medical Services (EMS). RN F added staffing really was not safe for residents at the facility. In review of R10's hospice note dated 11/07/22 at 2:10 PM indicated R10 had reported a lot of pain and anxiety to staff prior to hospice visit and was given morphine (pain medication) and Ativan (anti-anxiety medication). The same note indicated the RN had spoke to R10's family member several times on this same day; before, after, and during the visit to update them on his nephrostomy tubes. The same note indicated it was reported to her R10's nephrostomy tubes were clogged or dislodged, they wanted them replaced. R10 was transferred to the hospital for nephrostomy tube assessment/placement. In review of R10's care plan, date initiated 11/08/22 (was discharged from facility before care plan was initiated) revealed I have nephrostomy catheter for prostate cancer, obstructive uropathy. I am at risk for complications related to urinary catheter use, including: Increased risk for urinary tract infection, sepsis, accidental dislodgement of my catheter, pain/irritation, trauma to insertion site, urethral injury, skin breakdown, and loss of dignity. The same care plan included intervention to monitor and document intake and output. Emergency Department note dated 11/07/22 revealed R10 received a total of 2 liters of IV normal saline. The same note indicated a family member reported she had been communicating with staff and the hospice nurse about the need to flush out the nephrostomy tubes and the hospice nurse did do that but then his other nephrostomy tube became plugged; he had been leaking around the tube and so they placed some type of garbage bag around the collection material and remained in place for several days. The same note indicated a concern about potential neglect at nursing home. R10 was ultimately admitted for IV antibiotic treatment. 11/07/22 at 8:30 PM social worker note revealed they met with R10 and his spouse in the emergency room (ER) due to plan to replace nephrostomy tubes due to leakage. Once at the ER R10 was found to have a significant amount of pus blocking the tubing with severe infection and high potassium levels. The same note indicated R10 would be admitted to the hospital and immediately started on IV antibiotics. The same note indicated R10's spouse was very upset and expressed he was not getting the care he needed and did not want R10 to return to the nursing home. On 2/27/23 at 2:00 PM, Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy, that was identified on 2/27/23 and determined beginning on 10/27/22, when the facility failed to educate facility/agency nursing staff and ensure competency in nephrostomy tubes consistent with standards of practice. On 2/28/23 the facility provided an acceptable plan to remove the Immediate Jeopardy as follows: 1. Identification of Residents Affected or Likely to be Affected: There have been no further admissions and no current residents with Nephrostomy tubes since 10/27/22. 2. Nurse Practitioner was notified on 2/16/23 that there was a concern related to nephrostomy tube care. 3. An audit was completed on all residents with indwelling catheters and/or IV sites on 2/16/23. Orders were reviewed for complete and accuracy. There have been no admissions with Nephrostomy tubes since 10/27/22, and no current residents with Nephrostomy tubes. 4. Residents with Indwelling Catheters and/or IV's had an assessment completed to ensure urine did not have S/S of infection, IV site was without S/S of infection. Vital signs were reviewed with no signs or symptoms of infection on 2/16/23. 5. A progress note was placed in the residents record 2/16/23 related to signs and symptoms of infection. 6. Care plans were reviewed on 2/16/23 for residents with indwelling catheters and/or IVs to ensure monitoring of catheter, care of catheter was care planned. 7. Director of Nursing (DON) or designee will complete education with licensed staff by 2/16/23 or next scheduled shift related to Nephrostomy tube care, indwelling catheter care and IV site care. 25 out of 32 nursing staff educated. Remaining staff to be educated prior to working. 8. Education was completed on 11/17/22 and 11/20/22 on new admission orders or new orders and the expectation that medications will be pulled from the automated dispensing machine and administer medication, if medication is not available, will call pharmacy and have medication drop shipped. 9 of 11 licensed nurses educated at this time. All licensed staff receive education on automated dispensing machine and electronic medical record program including physician orders on day 2 of general orientation. 9. The policy for nephrostomy tubes was reviewed by the DON and NHA and deemed appropriate on 2/16/23. 10. Ad Hoc Quality Assurance/Performance Improvement (QAPI) was completed to review action plan on 2/16/23. 11. DON will review findings in QAPI monthly for 3 months or until substantial compliance is maintained. 12. Facility was no longer utilizing agency staff as of 2/01/23. 13. All admissions will be reviewed for accuracy related to orders and necessary treatments for monitoring by IDT. 14. DON or designee will review all new admissions for accuracy related to orders ongoing 5 times a week. 15. DON or designee will complete audit with staff for return demonstration of care of indwelling tubing for infection control practices weekly for one month and then bi-monthly for one month and then monthly until substantial compliance was maintained. Although the Immediate Jeopardy was removed on 11/07/22, the facility remained out of compliance at a scope of isolated and severity of actual harm that is not Immediate Jeopardy due to sustained compliance had not been verified by the State Agency (SA).

This citation pertains to intake numbers MI00130859, MI00131145 Based on interview and record review the facility's pharmace failed to dispense pain medicine in a timely manner for one (#16) of three residents assessed for pain for one of one resident (#6) with congestive heart failure (CHF) resulting in increased pain, stress and anger for #16 and difficulty breathing, reoccurrence of CHF symptoms and hospitalization . Findings include: Resident (R)16 R16 was admitted to the facility on [DATE] with diagnoses that included fall with fractured right femur and knee, history of left hip and knee replacements, osteoarthritis, fibromyalgia, anxiety and depression. R16 had no cognitive impairment. A review of physician's orders reflected R16 was prescribed oxycodone-acetamenophen (opioid with Tylenol) 5 milligram (mg)-325 mg, one to two tablets every four hours as needed for pain. A review of R16's Controlled Substance Proof of Use documents reflected the following: On 8/23/22 at approximately 4:00 am, R16 wrote that they were given two oxycodone/Tylenol, and advised there was only one pill left. R16 requested more pills be ordered and the physician notified. On 8/23/22 at approximately 10:00 am, the last oxycodone/Tylenol was given to R16. The next two tablets were given to R16 on 8/24/22 at 2:15 am, a gap of 16 hours without pain medication and 22 hours without receiving both tablets as ordered. A review of R16's Medication Administration Record reflected sixteen doses of oxycodone/Tylenol were given between 8/20/22 and 8/24/22. R16's Based on interview and record review the facility failed to ensure one (#16) of three residents assessed for pain received pain medication in a timely manner resulting in continued pain, increased stress and anger. A review of R16's care plan for pain, dated 8/1/23, stated: I have or have potential for pain related to chronic pain, post-operative status, right femur fracture, right knee replacement, left hip replacement, fibromyalgia, varicose veins. I will verbalize satisfaction with my pain control regimen through the review date. Interventions were: Assess for cause of pain. Assist with mobility as needed. I will be assessed and/or asked every shift about my pain level. ;Pan care to give me adequate rest. Position for comfort. PT/OT [physical and occupational therapies]. On 2/14/23 at 1:30 pm, a message was left with R16 to call. R16 failed to return my call. A progress note in the facility's EMR reflected on 8/23/22 at 5:00 am reflected Registered Nurse M called the pharmacy for a refill of R16's oxycodone/Tylenol. There was no other documentation or reason to explain why the delivery failed to arrive at the facility until 8/24/22 at 2:00 am. There was no documentation of other calls made to the pharmacy due to delayed delivery of this medication. On 2/16/23 at 2:15 pm, Omni pharmacist Z was interviewed via phone. When asked if oxycodone/Tylenol 5-325 mg was kept in the facility's back-up medication supply, Pharmacist Z thought the medication was part of the back-up supply. Omni pharmacy provided pharmacy services to the facility during August 2022. To access this, facility staff had to fax a request to us and we would provide a number to access the back-up box. Deliveries left the pharmacy at 1:00 am and were at the facility around 2:00 am Monday through Friday. R16's prescription was initially written for 360 tablets and the pharmacy dispensed 30 tablets at a time to the facility. Pharmacy records reflected the following: On 8/11/22, thirty tablets were dispensed to the facility. On 8/19/22 a note reflected a facility nurse called for a refill of tablets just in time for the night delivery. On 8/23/22, records reflect a facility nurse called for a refill of R16's oxycodon/Tylenol around 5:00 am. There was no documentation after that. Pharmacist Z could think of no reason for the delay in delivery of the tablets to the facility until 5:00 am on 8/24/22. On 2/16/23 during the afternoon, Unit Manager Aa was interviewed as followed: they said pharmacy deliveries were early morning around 2:00 am. They believed oxycodone/Tylenol 5/325 mg was in the facility's back-up supply. On medication cards there was a line drawn across the card to tell the nurse to reorder the drug. I believe it's four days before the medication runs out. Someone missed that reminder. for R16, UM Aa said. When requested, Administrator A reported the facility does not have policies for management of controlled substances and/or reordering medications. R6 R6 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, chronic renal failure stage 4, anemia, edema, diabetes and hypo-osmolality (leads to edema) and hyponatremia (low blood sodium). R6 had mild cognitive impairment. TR6 was admitted to the facility on [DATE] and discharged to the emergency department (ED) on 9/12/22. On 2/14/23 at 1:35 pm, the complainant was interviewed was follows: [R6] was short of breath the day before they were sent to the ED. [R6] would always say the compression socks were not on correctly, but staff would ignore them if they mentioned it. Or staff would attempt to rotate and adjust the socks while they were still on [R6]. Wrinkles in the socks caused pain and more swelling. [R6] legs were always huge and swollen. The complainant called on the day they were sent to the ED, but they never mentioned [R6] was short of breath. On 2/15/23 at 1:15 pm. Registered Dietician (RD) D was interviewed as follows: No added sodium means we don't give them a salt packet. If highly needed, the resident was educated and foods to avoid are added to the dislikes list. RD D was unsure if the facility could serve a low sodium diet and would get back to me. If a low sodium diet was felt to be necessary, the interdisciplinary team would meet and discuss it. RD D stated the hospital discharge instructions ordered no added salt diet, not low sodium diet. After three more inquiries, RD D failed to provide any information about a low sodium diet at the facility. When interviewed, a nursing staff reported the following: R6 would say they were okay but would admit to difficulty breathing if asked directly. They had [NAME] the last night, they were panting. The compression stockings were hard to get on. On 12/16/23 at 11:50 am, Nurse Practitioner (NP) H was interviewed. When asked if the facility staff followed any current guidelines for CHF, NP H said no. [R6] was sent to the ED for significant difficulty breathing and significant edema. Weights were not done. Her kidney function and CHF were worsening. R6's Lasix was held for three days due to increasing kidney failure, but was resumed the day before R6 went to the ED. All the weights done for R6 were as follows: 9/2/22 @ 2:00 pm. 143.4 pounds (lb). 9/3/22 @ 1:30 pm. 146.4 lb. standing (double checked). 2 lb gain from admission weight. 9/5/22 @ 9:20 pm. 144 lb. chair. (chair scale or wheel chair?) 2 lb lost. 9/10/22 @ 1:20 pm. 146 lb standing. 2 lb gain. 9/11/23 @ 1:00 pm. 150.2 lb. standing 7 lb gain. On admission, 8/31/22, the nursing assessment reflected 1+ pitting edema and clear lung sounds. On 9/12/22 at approximately 6:00 am, R6 activated her call light and was observed sitting in bed at a 90-degree angle with difficulty breathing. R6 told the aide that they were having a hard time breathing and had called family to come and take them to the hospital. The aide told R6 that they had to get the nurse. The nurse went into the room and observed R6 sitting on the toilet. She told the nurse that they were sitting on the bed when they started having difficulty breathing and this was how it started when they had fluid in their lungs. The nurse assessed lung sounds as crackles in the bases of the lung sounds. Family arrived and took R6 to the ED. A review of a facility policy titled Weight Monitoring, revision date1/2/22, reflected: 5. A weight monitoring schedule will be developed upon admission for all residents: a. weights should be recorded at the time obtained. b. Newly admitted residents - monitor weight weekly for 4 weeks .d. If clinically indicated - monitor weight daily . CHF guidelines for weights was not mentioned in the policy. The facility does not have a policy for CHF. A review of a hospital document for R6 titled Discharge Instructions, printed on 8/31/22, reflected: This is a heart failure patient. Order: standing daily weights first thing in the morning after patient empties bladder . Please be sure weights are consistent in terms of shoes, clothes, prosthetic etc .Monitor the patient daily and notify facility provider for the following: Weight gain of 2-3 pounds in 1 day of 5 pounds in 1 week. Increased shortness of breath with activity, sleeping, [sic] or at rest. Unable to lay flat at night. Complaints of abdominal fullness, nausea, [sic] or change in appetite, increase swelling. Increased O2 needs from baseline or new oxygen requirement. Unable to tolerate medications (beta-blockers, diuretics, ACE/ARB/ARNI-enestro). Systolic blood pressure of less than 90 or over 140 for more than three consecutive readings .For any of these concerns, please notify the facility provider. A review of an article found online at aahfn.org/mpage/dailyweights (American Association of Heart Failure Nurses), Checking your weight is key to keeping an eye on your symptoms. Weight gain is one of the first signs of retaining fluid. Contact your doctor with weight gain or loss as directed .Changes in your weight may be a sign of fluid retention.

This citation pertains to intake #MI 312. Based on interview and record review the facility failed to assess and monitor for abdominal distention and follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of an Admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 8/16/22 revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated Resident #101 was cognitively severely impaired. Review of the Functional Status revealed that Resident #101 was completely dependent on staff for toileting. In an interview on 8/23/22 at 8:28 A.M., Responsible Party (RP) L reported that Resident #101 was hospitalized and had to have surgery due to a bowel obstruction. RP L reported that she had concerns about Resident #101's abdomen being enlarged and her constipation medications not being adequately administered for several weeks and stated, .I talked to people there everyday .I asked them to please help her .the doctor never even looked at her .we went to an appointment on 7/28/22 and that doctor was shocked with how big her abdomen was and sent a note to the facility .I told the DON .the DON said that as long as there were bowel sounds and any amount of poop .that there was not a problem . In an interview on 8/23/22 at 4:33 P.M., DON reported that Resident #101's mother has ongoing concerns with her bowel care and had came to her approximately 2 weeks before she was hospitalized , with concerns about Resident #101's abdominal distention and not receiving her full dose of [MEDICATION(S)] (medicated drink to prevent constipation). DON reported that she reviewed Resident #101's bowel movement records recorded by the staff, reviewed the medication record, ordered an abdominal x-ray and stated, .I did not do an assessment .there was no record of an assessment for bowels . Review of Resident #101's Hospital Records dated 8/3/22 through 8/8/22 revealed, .Hospital Course: .Pt appeared uncomfortable with significant abdominal distention. CT (cat scan: image) Abd (abdomen)/Pelvis done showed severely dilated rectum due to large amount of fecal material with rectal distention of 12 cm this raises suspicion for mild stercoral colitits (an [CONDITION(S)] condition caused by increased pressure from impacted feces in the bowels) .admitted for further management. She was continued on IVF (intravenous fluids), IV [MEDICATION(S)] (antibiotic)and kept NPO (nothing by mouth) .Colorectal surgery did disimpaction (removal of feces) on 8/5 with favorable response up to the day of discharge on 8/8/2022 .Patient is also eating well with assist and is on empiric antibiotics to complete outpatient for a 7 day course total . In an interview on 8/23/22 at 3:25 P.M., Medical Doctor (MD) K reported that Resident #101 had chronic issues with constipation. MD K reported that the nurses are supposed to be doing bowel assessments as part of the basic nursing care. Review of Resident #101's Physical Medicine & Rehabilitation Visit Note (outside of the facility) dated 7/28/22 revealed, .Additional Notes: Patient has significant abdominal distention. Her mother believes long term care facility is not aggressive enough with a bowel program . In an interview on 8/24/22 at 9:15 A.M., DON reported that she had not seen a note from the Physical Medicine & Rehabilitation visit on 7/28/22 and when Resident #101's mother reported that the doctor was concerned about abdominal distention, there was no physical examine performed by the facility. DON reported that Resident #101 did not have any documentation of a physical assessment of her abdominal distention until 8/3/22. In an interview on 8/24/22 at 11:31 P.M. Unit Manager (UM) D reported that she had not been notified about Resident #101's Physical Medicine & Rehabilitation doctor's concerns about abdominal distention and stated, .the DON called me and asked me to contact (NP E) and ask for a KUB (abdominal x-ray) to be ordered .I did not do an assessment .I thought that (DON) did an assessment . In an interview on 8/24/22 at 11:58 A.M., NP E reported that she was not notified that Resident #101's Physical Medicine & Rehabilitation doctor had reported concerns about abdominal distention when she ordered the KUB on 7/29/22 and stated, .it was my understanding that this was a chronic concern, not acute .I did not see her .it was not communicated that this was a change . In an interview on 8/24/22 at 1:08 P.M. LPN-Agency (LPNA) H reported that Resident #101's abdomen was distended on 7/29/22 when she came to in at approximately 6:30 P.M., and that the doctor had ordered 2 enemas 12 hours apart and stated, .I gave the first one early in the morning around 4:30 A.M. (7/30/22) .I don't know why the computer says that (Registered Nurse (RN) G) gave the first one at 9 . There was no documentation for the enema that LPNA H reported to have administered on 7/30/22 at 4:30 A.M. In an interview on 8/24/22 at 2:52 P.M., RN G reported that on 7/30/22 the third shift nurse LPNA H reported that she had given Resident #101 an enema on her shift, therefore he gave another enema around 9:00 A.M. and stated, .her abdomen was hard .she had a BM after the enema .it was still hard after that .it was solid .it seems like she was having bowel sounds . RN G reported that he did not notify the physician regarding Resident #101 abdominal distention. Resident #101 had 2 enema's administered approximately 5 hours apart. Review of Resident #101's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Fleet Enema Enema (Sodium Phosphates) Insert 4 ounce rectally one time only for constipation for 1 Day -Start Date- 07/30/2022 0600 (6:00 A.M.), administered on 7/30/22 at 9:44 A.M. by RN G. Fleet Enema Enema (Sodium Phosphates) Insert 4 ounce rectally one time only for constipation for 1 Day -Start Date- 07/30/2022 1550 (3:50 P.M.), administered on 7/30/22 at 8:26 P.M. by LPN R. Fleet Enema Enema (Sodium Phosphates) Insert 4 ounce rectally one time only for constipation for 1 Day -Start Date- 07/30/2022 1800 (6:00 P.M.), administered on 7/30/22 at 8:26 P.M. by LPN R. In an interview on 8/24/22 at 1:54 P.M., DON reported that LPNA H must have forgotten to chart that she gave Resident #101 an enema at 4:30 A.M. and stated, .so then (RN G) did another one . In addition, the DON reported that Resident #101 was only supposed to have a total of 2 enemas ordered 12 hours apart and stated, .the second one must have gotten duplicated .she could not have gotten 2 enema's at the same time .that is a mistake in the MAR . DON reported that the bowel protocol is not always followed and stated, .especially by agency staff .about 50% of our nurses are agency . DON reported that the facility held a full staff meeting 8/23/22 and the bowel protocol was discussed during the meeting.

This citation pertains to intake MI 312. Based on interview and record review the facility failed to maintain professional standards of care when facility staff did not adequately assess and coordinate care to identify a change of condition in 1 of 3 sampled residents (Resident #101) reviewed for quality of care, resulting in a delay in a delay in treatment, and pain from abdominal distention related to bowel impaction, requiring hospitalization and surgical intervention, and the potential for bowel perforation due to retained feces. Findings include: Review of an Admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 8/16/22 revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated Resident #101 was cognitively severely impaired. Review of the Functional Status revealed that Resident #101 was completely dependent on staff for toileting. Review of Resident #101's Care Plan revealed, no care plan for bowel incontinence or constipation. In an interview on 8/23/22 at 8:28 A.M., Responsible Party (RP) L reported that Resident #101 was hospitalized and had to have surgery due to a bowel obstruction. RP L reported that she had concerns about Resident #101's abdomen being enlarged and her constipation medications not being adequately administered for several weeks and stated, .I talked to people there everyday .I asked them to please help her .the doctor never even looked at her .we went to an appointment on 7/28/22 and that doctor was shocked with how big her abdomen was and sent a note to the facility .I told the DON .the DON said that as long as there were bowel sounds and any amount of poop .that there was not a problem . In an interview on 8/23/22 at 4:33 P.M., DON reported that Resident #101's mother has ongoing concerns with her bowel care and had came to her approximately 2 weeks before she was hospitalized , with concerns about Resident #101's abdominal distention and not receiving her full dose of [MEDICATION(S)] (medicated drink to prevent constipation). DON reported that she reviewed Resident #101's bowel movement records recorded by the staff, reviewed the medication record, ordered an abdominal x-ray and stated, .we were doing everything that we could .I did not do an assessment .there was no record of an assessment for bowels . Review of Resident #101's Hospital Records dated 8/3/22 through 8/8/22 revealed, .Hospital Course: .Pt appeared uncomfortable with significant abdominal distention. CT (cat scan: image) Abd (abdomen)/Pelvis done showed severely dilated rectum due to large amount of fecal material with rectal distention of 12 cm this raises suspicion for mild stercoral colitits (an [CONDITION(S)] condition caused by increased pressure from impacted feces in the bowels) .admitted for further management. She was continued on IVF (intravenous fluids), IV [MEDICATION(S)] (antibiotic)and kept NPO (nothing by mouth) .Colorectal surgery did disimpaction (removal of feces) on 8/5 with favorable response up to the day of discharge on 8/8/2022 .Patient is also eating well with assist and is on empiric antibiotics to complete outpatient for a 7 day course total . In an interview on 8/23/22 at 3:03 P.M., LPN F reported that Resident #101 was having issues with abdominal distention after meals and stated, .but that day (8/3/22) her abdomen was extremely distended and firm .it was very obvious that she was in pain .the on-call provider ordered a suppository .when that didn't work her mom wanted her sent to the ER . LPN F reported that she had not received any previous report that Resident #101 had abdominal distention. LPN F reported that with Resident #101's history of constipation, she would not normally be concerned, but she had never seen an abdomen as distended as Resident #101's was that day. In an interview on 8/23/22 at 3:25 P.M., Medical Doctor (MD) K reported that Resident #101 had chronic issues with constipation and when Resident #101 was seen on 7/27/22, the nursing staff had not reported a concern about abdominal distention, it was a routine visit. MD K reported that the nurses are supposed to be doing bowel assessments as part of the basic nursing care. MD K reported that someone dropped the ball and stated, .(Resident #101's) mother knows her best .when the x-ray was negative .I would have expected someone to be more aggressive .it's easy to grab us and have us look if there is an issue .I am not pleased with the situation . Review of Resident #101's Physical Medicine & Rehabilitation Visit Note (outside of the facility) dated 7/28/22 revealed, .Additional Notes: Patient has significant abdominal distention. Her mother believes long term care facility is not aggressive enough with a bowel program. Constipation will worsen all aspects of patients including pain and [CONDITION(S)] (stiffness of muscles). Recommend an enema verse manual disimpaction to clear the patient out. It is possible to have large stool burden with continuation of small BM's (bowel movements) .Adequate hydration will be critical. In an interview on 8/24/22 at 9:15 A.M., DON reported that she had not seen a note from the Physical Medicine & Rehabilitation visit on 7/28/22 and when Resident #101's mother reported that the doctor was concerned about abdominal distention, there was no physical examine performed by the facility. DON reported that Nurse Practitioner (NP) E had ordered the abdominal x-ray in response to the concern, and that was performed on 7/29/22 and stated, .that was normal .then orders for an enema were put in the computer . DON reported that Resident #101 did not have any documentation of a physical assessment of her abdominal distention until 8/3/22. In an interview on 8/24/22 at 11:31 P.M. Unit Manager (UM) D reported that she had not been notified about Resident #101's Physical Medicine & Rehabilitation doctor's concerns about abdominal distention and stated, .the DON called me and asked me to contact (NP E) and ask for a KUB (abdominal x-ray) to be ordered .I did not do an assessment .I thought that (DON) did an assessment . UM D reported that the facility has multiple agency nurses and stated, .we have not done any review of the policy or procedures for bowel assessments . In an interview on 8/24/22 at 11:58 A.M., NP E reported that she was not notified that Resident #101's Physical Medicine & Rehabilitation doctor had reported concerns about abdominal distention when she ordered the KUB on 7/29/22 and stated, .it was my understanding that this was a chronic concern, not acute .I did not see her .it was not communicated that this was a change . NP E reported that she was physically present in the facility on 8/1/22 and was not notified of any concerns. In an interview on 8/24/22 at 1:08 P.M. LPN-Agency (LPNA) H reported that Resident #101's abdomen was distended on 7/29/22 when she came to in at approximately 6:30 P.M., and that the doctor had ordered 2 enemas 12 hours apart and stated, .I gave the first one early in the morning around 4:30 A.M. (7/30/22) .I don't know why the computer says that (Registered Nurse (RN) G) gave the first one at 9 . LPNA H reported that the DON has not discussed Resident #101 with her at all and stated, .I don't think anyone has talked to us about bowel assessments . There was no documentation for the enema that LPNA H reported to have administered on 7/30/22 at 4:30 A.M. In an interview on 8/24/22 at 2:52 P.M., RN G reported that Resident #101 had abdominal distention at least a couple days prior to her hospitalization on [DATE]. RN G reported that on 7/30/22 the third shift nurse LPNA H reported that she had given Resident #101 an enema on her shift, therefore he gave another enema around 9:00 A.M. and stated, .her abdomen was hard .she had a BM after the enema .it was still hard after that .it was solid .it seems like she was having bowel sounds . RN G reported that he did not notify the physician regarding Resident #101 abdominal distention. RN G reported that he attended a full staff meeting on 8/23/22 and stated, .they did not talk about the bowel protocol .they talked about CNA charting . Resident #101 had 2 enema's administered approximately 5 hours apart. Review of Resident #101's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Fleet Enema Enema (Sodium Phosphates) Insert 4 ounce rectally one time only for constipation for 1 Day -Start Date- 07/30/2022 0600 (6:00 A.M.), administered on 7/30/22 at 9:44 A.M. by RN G. Fleet Enema Enema (Sodium Phosphates) Insert 4 ounce rectally one time only for constipation for 1 Day -Start Date- 07/30/2022 1550 (3:50 P.M.), administered on 7/30/22 at 8:26 P.M. by LPN R. Fleet Enema Enema (Sodium Phosphates) Insert 4 ounce rectally one time only for constipation for 1 Day -Start Date- 07/30/2022 1800 (6:00 P.M.), administered on 7/30/22 at 8:26 P.M. by LPN R. In an interview on 8/24/22 at 1:54 P.M., DON reported that LPNA H must have forgotten to chart that she gave Resident #101 an enema at 4:30 A.M. and stated, .so then (RN G) did another one . In addition, the DON reported that Resident #101 was only supposed to have a total of 2 enemas ordered 12 hours apart and stated, .the second one must have gotten duplicated .she could not have gotten 2 enema's at the same time .that is a mistake in the MAR . DON reported that the bowel protocol is not always followed and stated, .especially by agency staff .about 50% of our nurses are agency . DON reported that the facility held a full staff meeting 8/23/22 and the bowel protocol was discussed during the meeting. In an interview on 8/24/22 at 10:39 A.M., Certified Nursing Assistant (CNA) J reported that Resident #101 had frequent small soft BM's and stated, .her belly was getting really big .really hard . In an interview on 8/23/22 at 2:08 P.M., LPN M reported that Resident #101 was recently hospitalized for bowel impaction and stated, .her abdomen was distended .it had been getting worse .but the KUB (abdominal x-ray) was negative . In an interview on 8/24/22 at 11:51 A.M., CNA I reported that she had notified a nurse about Resident #101's abdomen being distended a few days before she went to the hospital and stated, .I didn't know she was constipated .I just noticed that her abdomen was hard . In an interview on 8/24/22 at 10:49 A.M., MDS Nurse (MDS) C reported that she was not working when Resident #101 was admitted to the hospital on 8/3/22, but that there was a big meeting about it after she came back. MDS C reported that there are a lot of agency nurses working in the facility, and Resident #101's caregivers frequently changed and stated, .we are trying to keep our own staff over there now . Review of Resident #101's Nurses Note dated 8/3/2022 at 16:37 (4:37 P.M.) revealed, Resident was transferred by (name omitted) EMS (emergency medical services) to (name omitted) hospital around 1630 (4:30 P.M.) on 08/03/2022. At 1400 (2:00 P.M.), resident was in her room with her mom, then she came out to tell me that the resident's abdomen was distended and firm and the resident was in distress. The resident had already had several stool softeners/medications for constipation, but the mom asked the nurse to administer more. The nurse contacted the on call physician .who instructed the nurse to administer a suppository, then order a STAT (immediate) repeat abdominal x-ray if the distention did not go down. 1 hour after the suppository was passed, the resident had still not had a BM (bowel movement) and her abdomen showed no improvement. The nurse told the resident's mom that she was going to order a repeat abdominal x-ray, but she was not happy with this and wanted something to be done immediately. The on call physician then instructed the nurse to send the patient to the ER (emergency room ) . Review of Resident #101 Nurse's Note dated 8/3/2022 at 14:26 (2:26 P.M.) revealed, Resident's mother told the nurse that the resident's abdomen was distended and firm. The nurse osculated bowel sounds in all 4quadrants and listened to breathsounds. Bowel sounder (sic) were normal . Review of Resident #101's Nurse Practitioner Note dated 8/3/2022 at 13:56 (1:56 P.M.) revealed, .Nursing reports abdominal distension. Mom concerned with constipation. Order given to give suppository and check KUB if abdominal distension not resolved . Review of Resident #101's Nurse's Note dated 8/3/2022 12:19 P.M. revealed, Wound rounding completed with wound specialist . There was no documentation of abdominal distention. Review of Resident #101's Abdominal X-Ray dated 7/29/22 at 16:10 (4:10 P.M.) revealed, Reason for Study: ABDOMINAL DISTENSION .FINDINGS: .Colonic fecal residual (an incomplete elimination of BM in the intestines) is noted .Modest colonic fecal residual may correlate with clinical constipation. CONCLUSION: Nonobstructive bowel gas pattern . Review of Resident #101's Nurse Practitioner Note dated 8/1/2022 at 13:36 (1:36 P.M.) revealed, .Xray-KUB c/w non-obstructive bowel gas. A/P (assessment/plan): Constipation. -No obstruction on KUB. -Current regimen: prn (as needed) enema/d (daily),sennas 2 po (by mouth) bid (twice a day), [MEDICATION(S)]/d (daily) prn. mom (milk of magnisia) 30mg/d (daily) prn, [MEDICATION(S)] 17gm daily and daily prn, -Add [MEDICATION(S)] 30GM daily. This note was entered remotely related to x-ray results. Review of Resident #101's Nurse's Note dated 8/1/2022 at 00:17 (12:17 A.M.) revealed, (Resident #101) yelled out 1x at 11:00 pm . Review of Resident #101's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M.) revealed, Seen for follow up visit GI: Abd s/nt/nd (soft/non-tender/no distention) . Review of Resident #101's Nurse's Note dated 7/12/2022 at 14:07 (2:07 P.M.) revealed, Mother thinks that her belly is distended with BM, needed to know if there is something that can be done . There was no documentation of physical assessment findings. The quality of patient care depends on your ability to communicate with other members of the health care team. Regardless of whether documentation is entered electronically or on paper, each member of the health care team needs to document patient information in an accurate, timely, concise, and effective manner to develop and maintain an effective, organized, and comprehensive plan of care. When a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, and delays or omissions in care often occur. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review the facility failed to ensure infection control practices per CDC (Centers for Disease Control) recommendations for COVID-19 of hand hygiene and proper PPE (personal protection equipment) implementation for 9 of 9 residents, (Resident #102, #103, #105, #106, #107, #108, #109, #110, and #111) reviewed for infection control, resulting in an immediate jeopardy when, while not following contact and droplet precautions to prevent the spread of respiratory illness, COVID-19, beginning on 6/18/20, facility staff did not perform surveillance or follow the CDC guidance to prevent the spread of Covid-19 to residents in the facility This deficient practice placed all residents residing in the facility at risk for serious harm and/or death. On 7/8/2020 at 2:31 PM, the Nursing Home Administrator was verbally notified and received written notification of the immediate jeopardy that began on 6/18/2020 due to the facility's failure to implement infection control in the designated COVID-19 unit. A written plan for removal for the immediate jeopardy was received on 7/8/2020 and the following was verified on 7/14/2020. 1. Staff that were observed and/or identified during the observations have been in serviced on maintaining infection control standards which included Hand Hygiene and proper use of PPE. 4 of the 6 involved have received in service training as of July 9, 2020 by the Director, Nursing Services. The remaining 2 will be in service trained before the start of the next assigned shift. 2. As of July 10, 2020, Residents on the Covid 19 unit will have a daily respiratory assessment completed as recommended by the CDC. If a resident becomes symptomatic the medical director will be notified for treatment/testing orders and identified as possibly COVID-19 positive. 3. Initial testing of residents to meet the baseline testing was completed June 20, 2020 with no subsequent positive results being identified. Additionally, all residents in the community are tested based on the June 15, 2020 (state name) Department of Health and Human Services communication, which currently recommends weekly testing for COVID 19. Weekly testing of residents began July 10, 2020 in which all residents tested negative. Staff testing was initially completed on June 26, 2020 followed by July 1, 2020 and last tested on [DATE] with all staff testing negative. Next weekly testing of Staff is July 15, 2020. 4. The County Health Department has been consulted with to obtain input on its layout and development on 7/13/2020. All guidance from the County Health Department has been incorporated into the COVID unit plan. Based on recommendations as indicated by the CDC, a temporary barrier will be installed on 7/13/2020 in the area encompassing rooms [ROOM NUMBERS] to contain COVID 19 positive residents as well as persons under investigation. This temporary barrier physically separates these rooms from the rest of the community and will be staffed with a dedicated staff member to provide care to these residents when these rooms are occupied or in use. Signage will be installed on this physical barrier to indicate positive COVID-19 residents are within. 5. Appropriate signage which consists of a STOP sign, a droplet isolation indication sign, and PPE use sign has been affixed to all resident room doors as of 7/10/2020. 6. Staff will be in serviced by Director, Nursing Services or designee on the following policies and procedures: -Hand Hygiene / Handwashing (Staff who are assigned to the Covid 19 Unit will be in serviced prior to their next scheduled shift.) 30 of the 99 staff have been in serviced as of July 9, 2020. As of July 13, 2020, 91 of 103 community staff members and providers have been in serviced. For all remaining, none will be allowed to work without receiving the necessary education. -Proper selection and use of PPE (Staff who are assigned to the Covid 19 Unit will be in serviced prior to their next scheduled shift.) 30 of the 99 staff have been in serviced as of July 9, 2020 As of July 13, 2020, 91 of 103 community staff members and providers have been in serviced. For all remaining, none will be allowed to work without receiving the necessary education. -Inservice of the facility policy and procedure for the Covid 19 unit. (Staff who are assigned to the Covid 19 Unit will be in serviced prior to their next scheduled led shift.) 30 of the 99 staff have been in serviced as of July 9, 2020 As of July 13, 2020, 91 of 103 community staff members and providers have been in serviced. For all remaining, none will be allowed to work without receiving the necessary education. 7. Effective July 11, 2020 Director of Nursing, or designee, will complete routine audits of hand hygiene, PPE usage, and general infection control practices with a frequency of 2 times a shift, every shift, ongoing until otherwise directed by the QA/QAPI committee. Audits will be reviewed with QA/QAPI to determine need of audit modification and further interventions to improve and maintain infection control processes. Although the immediate jeopardy was removed as of 7/13/2020, the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the fact that not all facility staff have received education and sustained compliance had not been verified by the State Agency. Findings include: According to CDC (Centers for Disease Control) https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fprevent-spread-in-long-term-care-facilities.html, .Identify Space in the Facility that Could be Dedicated to Monitor and Care for Residents with COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Identify HCP (health-care professional) who will be assigned to work only on the COVID-19 care unit when it is in use. Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive). Residents in the facility who develop symptoms consistent with COVID-19 could be moved to a single room pending results of [DIAGNOSES REDACTED]-CoV-2 testing. They should not be placed in a room with a new admission nor should they be moved to the COVID-19 care unit unless they are confirmed to have COVID-19 by testing. While awaiting results of testing, HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents . According to CDC https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, .Resident Cohorting: Considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19: -Determine the location of the COVID-19 care unit and create a staffing plan before residents or HCP with COVID-19 are identified in the facility. This will allow time for residents to be relocated to create space for the unit and to identify HCP to work on this unit -Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19 -Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) (identified as CNA (certified nursing assistant in the facility) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility . -Place signage at the entrance to the COVID-19 care unit that instructs HCP they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms -Ensure that HCP have been trained on infection prevention measures, including the use of and steps to properly put on and remove recommended personal protective equipment (PPE) . According to https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html, Cohorting is the practice of grouping residents infected or colonized with the same infectious agent together to confine their care to one area and prevent contact twith susceptible residents (cohorting residents). During outbreaks, healthcare staff may be assigned to a specific cohort of residents to further limit opportunities for transmission (cohorting staff). The terms cohort or cohorting is standardized language used in the practice of infection prevention and control; the use of this terminology is not intended to offend residents or staff. According to CDC https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf, . I.B.3.b. Droplet transmission. Droplet transmission is, technically, a form of contact transmission, and some infectious agents transmitted by the droplet route also may be transmitted by the direct and indirect contact routes .in contrast to contact transmission, respiratory droplets carrying infectious pathogens transmit infection when they travel directly from the respiratory tract of the infectious individual to susceptible mucosal surfaces of the recipient, generally over short distances, necessitating facial protection. Respiratory droplets are generated when an infected person coughs, sneezes, or talks .Examples of infectious agents that are transmitted via the droplet route include .[DIAGNOSES REDACTED]-associated coronavirus ([DIAGNOSES REDACTED]-CoV) . Although respiratory [MEDICAL CONDITION] may be transmitted by the droplet route, direct contact with infected respiratory secretions is the most important determinant of transmission and consistent adherence to Standard plus Contact Precautions prevents transmission in healthcare settings .I.B.3.d.i. Transmission from patients .Although [DIAGNOSES REDACTED]-CoV is transmitted primarily by contact and/or droplet routes, airborne transmission over a limited distance (e.g., within a room) . I.D.2.a. Long-term care. The designation LTCF applies to a diverse group of residential settings, ranging from institutions for the developmentally disabled to nursing homes for the elderly .LCTFs are different from other healthcare settings in that elderly patients at increased risk for infection are brought together in one setting and remain in the facility for extended periods of time; for most residents, it is their home .Risk factors for infection are prevalent among LTCF residents .Upon identification of a potentially infectious patient, implementation of prevention measures, including prompt separation of potentially infectious patients and implementation of appropriate control measures (e.g., .Respiratory Hygiene/Cough Etiquette and Transmission-Based Precautions) can decrease transmission risks .I.E.1. Immunocompromised patients. Patients who have congenital primary immune deficiencies or acquired disease (eg. treatment-induced immune deficiencies) are at increased risk for numerous types of infections while receiving healthcare and may be located throughout the healthcare facility. II.A.3. Adherence of healthcare personnel to recommended guidelines. Adherence to recommended infection control practices decreases transmission of infectious agents in healthcare settings .II.E. Personal Protective Equipment (PPE) for Healthcare Personnel .PPE refers to a variety of barriers and respirators used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents. The selection of PPE is based on the nature of the patient interaction and/or the likely mode(s) of transmission .II.E.2. Isolation gowns. Isolation gowns are used as specified by Standard and Transmission-Based Precautions, to protect the HCW's (health-care worker) arms and exposed body areas and prevent contamination of clothing with .potentially infectious material .Isolation gowns should be removed before leaving the patient care area to prevent possible contamination of the environment outside the patient's room . According to https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html Contact precautions are measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Droplet precautions are actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. According to CDC (Centers for Disease Control) at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, revealed, Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 .As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). Facilities should assign at least one individual with training in IPC to provide on-site management of their COVID-19 prevention and response activities because of the breadth of activities for which an IPC program is responsible, including developing IPC policies and procedures, performing infection surveillance, providing competency-based training of HCP (health care professional), and auditing adherence to recommended IPC practices . Core Practices These practices should remain in place even as nursing homes resume normal activities. Assign One or More Individuals with Training in Infection Control to Provide On-Site Management of the IPC Program .Smaller facilities should consider staffing the IPC program based on the resident population and facility service needs . Review of facility policy (Facility Name) COVID-19 PROCEDURE POLICY date not known, revealed, TRANSMISSION-BASED PRECAUTIONS 1. Follow recommendations of CDC. 2. Follow recommendations of CMS. 3. Follow recommendations of Health Department .9. For a resident with known or suspected COVID-19 .E. Signage will be posted outside of Residents room with use of specific PPE . Review of facility policy, Infection Control Approved/Origination Date: 03/26/2018, revealed, Position Statement (facility name) has established and will maintain an ongoing facility-wide infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment that promotes the prevention of development and transmission of communicable diseases and infections. The IPCP will include an ongoing system of surveillance designed to identify possible communicable disease or infections to prevent the spread to other persons in the facility. Rationale: Healthcare associated infections (HAIs) can cause significant pain and discomfort for residents in long-term care facilities (LTCFs) and can have significant adverse consequences. Serious infections are a major cause of hospitalization and death annually. Infection prevention and control practices are important in maintaining a safe environment by reducing the risk of the potential spread of disease from person to person. These practices are designed to reduce the risk of HAIs and to ensure a safe and healthy environment for residents, .and healthcare staff .Infection Prevention and Control Policies and Procedures (facility name) has developed and implemented written policies and procedures for the provision of infection prevention and control. The facility .Infection Preventionist will ensure that current standards of practice based on recognized guidelines and best evidence are incorporated in the policies and procedures. Policies and procedures will guide nursing .practices .Surveillance (facility name) has established a system for surveillance based upon national standards of practice and the facility assessment, including the resident population and the services and care provided. Surveillance encompasses routine, ongoing, and systematic collection, analyses, interpretation, and dissemination of surveillance data to identify infections, infection risks, communicable disease outbreaks to maintain or improve resident health status. Staff Education and Competency with IPCP (facility name) will ensure that staff will follow the IPCP and all standards, policies, and procedures. Therefore, staff will be informed and competent. Education and training of staff will promote knowledge and skills pertaining to the IPCP and infection control practices . RESIDENT 102 Review of a Face Sheet revealed Resident #102 was a [AGE] year-old female, originally admitted to the facility on [DATE] and had a positive Covid-19 test on 6/18/20 and 7/2/20. RESIDENT 103 Review of a Face Sheet revealed Resident #103 was an [AGE] year-old female, originally admitted to the facility on [DATE] and had a positive Covid-19 test on 6/18/20. During an interview on 7/7/2020 at 9:40 AM Director of Nursing (DON) B stated, There are 2 (two) residents in the facility that are COVID-19 positive. (Resident #102 and Resident #103). (Resident #103) was put on hospice after the [DIAGNOSES REDACTED]. I do not know how they got [MEDICAL CONDITION]. (Resident #102 and Resident #103) were roommates. They are now on the designated COVID-19 isolation unit. All residents on that unit are on droplet precautions. There are signs on the unit to tell staff what PPE (personal protection equipment) is required when entering the unit. Staff enters a vestibule and is required to don a N95 mask (tight-fitting respirators that filter out at least 95% of particles in the air, including large and small particles) and eye covering before entering the unit. Both quarantined, and positive COVID-19 residents are in the unit. There is no plastic wall or anything that separates the quarantined residents from the positive COVID-19 resident rooms. Staff takes care of the two (2) positive COVID-19 residents and the seven (7) quarantined residents. During the pandemic, the facility works with the local health department, CDC (Centers for Disease Control), and Region 6. During an observation and interview on 7/7/2020 at 1:40 PM, toured with DON B the identified designated COVID-19 isolation unit. Upon entering the vestibule between 2 (two) zip-walls (plastic wall with zippers), there were tables that held gloves, masks, goggles, hand sanitizer, and disinfectant wipes. Under the tables were boxes of gowns. On the zip-wall leading directly into the COVID unit were signage explaining what PPE was required to enter the unit, what PPE was required when coming into direct contact with the residents on contact and droplet isolation, and directions for dining, laundry, and housekeeping staff. On the vestibule walls hung plastic bags for each employee to hold employee specific N95 masks and face shields. To enter directly into the designated COVID-19-unit signage stated STOP stating that a N95 mask and eye-covering was were required. DON B stated, The vestibule leading into the COVID unit between the 2-zipwalls is where staff puts on PPE before entering The Nest. The Nest is what the facility calls the designated COVID-19 unit. There is signage indicating a N95 respirator mask and face shield or eye covering is required to enter the unit. On each resident door you will see there is signage telling staff to not enter a room without first talking to a nurse and stating the resident is on droplet precautions. There is no signage to designate which resident is COVID-19 positive and which resident is on quarantine. I set-up the COVID-19 unit. The quarantined residents are either new or re-admit residents and are on the unit for 14-days. All but one of the current quarantine residents were tested for COVID-19 with negative results at the hospital before coming into the facility. One resident, (Resident # 107), was not tested for COVID-19 before she was readmitted to the facility. She is immunocompromised (impaired immune system). After acquiring required PPE, surveyor entered COVID unit with DON B into a staging-unit where N95 mask and face-shield were donned. The unit main area was an open concept with resident rooms circling on 3 (three) sides with a total of 9 (nine) resident rooms. The nursing station and utility rooms were to the left of the entrance. To the right of the entrance, beyond the common area, were 2 (two) rooms with doors closed. All other resident rooms had doors open into the common area. DON B stated, These 2 (rooms) are where the COVID-positive residents, (Resident #102 and #103) are at. Their doors are always to be closed. All resident doors on this unit should always be closed. Observed on Resident #102 and Resident #103 doors were signage directing people to STOP and see the nurse before entering the room. The other sign on the doors designated the resident in the room was on droplet precautions. DON B stated, I set-up this area. I did not have any more zip-walls to put around the positive COVID residents. The facility was trying to keep the cost down. Resident #108 Review of a Face Sheet revealed Resident #108 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. During an observation and interview on 7/7/2020 at 1:40 PM while with DON B on the COVID unit, next to Resident #102's room was Resident #108's room. The resident's door was open with Physician H and Unit Manager (UM) F in with him. Physician H was wearing a dark colored gown, gloves, mask, and face shield. Unit Manager (UM) F wore similar PPE as Physician H, with her gown a light blue. DON B stated, (Resident #108) is a new admit. (Physician H and UM F) are evaluating him. The door should be closed. Gowns are assigned to each staff for each resident room daily. The gown is to be kept in the resident room and disposed of at the end of the staff's shift. You will not see any staff enter a room without or this unit without a N95 (mask) or face shield. It is automatic staff wear one. Resident #111 Review of a Face Sheet revealed Resident #111 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. During an observation and interview on 7/7/2020 at 1:45 PM, while on COVID unit with DON B, Central Supply Assistant (CSA) P was outside of Resident #111's door shaking open a red biological-hazard (bio-hazard) bag. Admissions Coordinator (AC) Q was inside resident's room wearing a N95 mask, face shield, gloves, and a light blue plastic-like gown. DON B stated, The bags should not be shaken open even clean, it could spread [MEDICAL CONDITION] particles. During an observation on 7/7/2020 at 2:10 PM while on the COVID unit, Admissions Coordinator (AC) Q exited Resident #111's room while wearing gloves, gown, face shield, and N95 mask and not performing hand hygiene. She gathered up clean linen from across the unit's common area and re-entered the room with the same gloves and gown on and did not perform hand hygiene. AC Q could not answer surveyor's question on why it was important to change gown and gloves before exiting an isolation room and perform hand hygiene when entering or exiting a resident's room. During an interview on 7/7/2020 at 2:12 PM, LPN R stated, Staff should take off gown and gloves and do hand hygiene before entering and upon exiting a resident's room because of infection control risk. During an interview on 7/7/2020 at 2:10 PM, CSA P while on the COVID unit stated, I've had training on droplet precautions. The facility's corporate office sent over aerosol training. Staff was told breathing treatments is high-flow and can spread [MEDICAL CONDITION]. Shaking out a bag is in the facility's general infection control training. I should not have shook the bag out; it could spread the infection. Resident #110 Review of a Face Sheet revealed Resident #110 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. During an observation and interview on 7/7/2020 at 1:50 PM while on the COVID unit with DON B, Licensed Practical Nurse (LPN) R entered Resident #110's room wearing only a N95 mask and face shield. On the resident's door was signage designating the resident as a droplet precaution. It is noted that in the vestibule before entering the COVID unit, signage directs staff that before entering any room, staff should wear the N95 mask, face shield, perform hand hygiene, and don gown and gloves. LPN R stated, I just gave her the phone and threw away her lunch stuff. Resident #106 Review of a Face Sheet revealed Resident #106 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. During observation and interview on 7/7/2020 at 1:55 PM, Physician H exited Resident #108's room without doffing gown and wearing gloves then enter Resident #106's room without closing the door behind her. Surveyor was able to observe Physician H from hallway with Resident #106. Physician H removed resident's socks, touched her lower legs and feet, and replaced the socks. Physician H then pushed up resident's shirt sleeves and examined lower arms and hands. Physician H came to door after being in room with resident for approximately 10 minutes and said to surveyor, This is a COVID room and I am supposed to close the door. Physician H partially shut the door, leaving an estimated 6 (six) inch gap between the door and frame. During an observation and interview on 7/7/2020 at 2:15 PM while on the COVID unit, Physician H exited Resident #106's room without doffing the gown she wore from Resident #108's to Resident #106's room, and went across the hall and entered Resident #107's room. Observed Physician H removing gloves while crossing hall with another pair of gloves underneath them and not performing hand hygiene upon entering Resident #107's room. Resident #107 Review of a Face Sheet revealed Resident #107 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. During an observation and interview on 7/7/2020 at 2:00 PM, Social Worker (SW) S entered Resident #107's room without performing hand hygiene. After speaking with resident, SW S exited the room without performing hand hygiene. SW S stated, I did not do hand hygiene before entering or exiting (Resident #107's) room. Hand hygiene is very important to stop the spread of infection. There is hand sanitizer in the vestibule we can keep with us while on the COVID unit. I've had infection control education and training for COVID. During an interview on 7/7/2020 at 2:10 PM, LPN R stated, Resident doors on this unit (COVID unit) should remain closed at all times. It lessens the risk of air flow and spread of infection. The infection could spread by droplet, fecal, contact and aerosol, especially nebulizer treatments. There should be no fans on in this area and no shaking of bags because [MEDICAL CONDITION] could get on you. During an observation and interview on 7/7/2020 at 2:25 PM while on the COVID unit, Physician H exited Resident #107's room wearing the same gown she had worn in Resident #108's and Resident #106's rooms. Physician H stated, It is important to wear PPE on this unit because there is COVID here. When surveyor asked why she did not change gowns after exiting resident rooms, Physician H stated, I don't have time to answer any more questions and walked away to the nursing station. It was noted that on all resident room doors on the COVID unit signage identifying the resident as a droplet precaution. It was further noted that the zip-wall before entering the COVID unit notified staff to wear N95, face shield, and to don gown, and gloves upon entering a resident room and to leave the gown in the room, remove gloves and perform hand hygiene before exiting the room. During an observation and interview on 7/7/2020 at 2:30 PM while in the COVID vestibule, Registered Nurse (RN) E entered the COVID unit via the vestibule without donning any type of face covering or N95 mask or face shield. At the nursing station RN E donned a surgical paper mask and stated, It is my understanding staff does not have to wear the face shield, eye coverings, or N95 unless going into a resident's room. Surveyor asked RN E to view the notices on the zip-wall with her. Noted that RN E at this time had donned a N95 mask while at the nursing station but did not have on a face shield. Review of signage with RN E revealed two of the facility notices stated, STOP - Know Your PPE stated, To Enter This Unit N95 and Face Shield Are Required. N95s and Face Shields are issued from the med room by the nurse . and NEST UNIT GENERAL INFORMATION .while on the nest unit you must wear eye protection and your N95 mask . RN E stated, My supervisor (UM F) told me I did not have to wear that PPE (N95 and face shield) unless in a resident's room. During an interview on 7/7/2020 at 2:45 PM, DON B stated, Any staff while on the Nest or any room that is isolation precautions should remove gown when exiting the room. When staff go through the zip-wall into the Nest they are expected to wear a N95 mask and face shield/eye protection. All staff education on COVID-19 PPE use has been verbal. There has been staff education online as well. Even (Physician H) has been education numerous times. During an interview on 7/8/2020 at 10:25 AM UM F stated, When staff enter the COVID unit they should have on a N95 mask and either goggles or a face shield. They should have it on to protect themselves from COVID-19. Staff knows it is in that area. The signage at the opening of the unit on the zip-wall notifies staff what PPE to have on before entering that area. Resident doors should be closed to prevent the airflow of [MEDICAL CONDITION]. Besides the PPE signage on the zip-wall, staff has been verbally told and during Huddle (meeting), donning and doffing demonstrations have been done. (Registered Nurse (RN) E) is a RN and has received education and training on COVID-19. They are currently a PRN (as needed) employee. The signage was there for they to know what to wear. During an interview on 7/7/2020 at 9:40 AM, Director of Nursing (DON) B stated, I am in charge of the facility's infection control program. I am the Infection Preventionist. During an interview on 7/9/2020 at 1:00 PM, Nursing Home Administrator (NHA) A stated, (DON B) is the facility Infection Preventionist. She is not certified through the CDC (Centers of Disease Control). During an interview on 7/9/2020 at 1:00 PM, DON B stated, I am the Infection Preventionist for the facility. I am not certified. I have not taken the ICP (Infection Control Preventionist) class online through the CDC website. During a telephone interview on 7/9/2020 at 2:25 PM local health department employee (LHD) M stated, I have 2 (two) cases of COVID-19 on my list dated the week of June 15th for the facility. The facility sent me notification on June 19, 2020 of the positive cases. The facility had been trying to stay in touch but not recently. Resident doors on the designated COVID-19 unit should be shut. The facility should be considering test status results of positive and negative and there should be a separate area for positive residents from the new/re-admits. Residents should be tested before coming into a facilit (TRUNCATED)

This citation pertains to intake MI 141 Based on observation, interview, and record review, the facility failed to implement safety interventions and adequate supervision to prevent a fall with injury for 1 resident (Resident #101) of 11 sampled residents reviewed for falls, resulting in a fall with femur fracture and the decreased potential to preventing further falls with injuries. Findings include: Review of facility policy Fall Management Reviewed Date: Reviewed Date: 3/3/2017, revealed, Policy: This community is dedicated to providing the best possible care to our residents. Safety is a priority to our mission. All residents admitted to our community are considered at risk for falls. Our efforts are focused on minimizing fall risk and fall related injuries, while maximizing individual dignity freedom and quality of life. Procedure: A fall risk assessment will be completed on all residents on . following each fall .Fall management interventions are based on the overall assessment, history and physical examination [REDACTED]. Interventions are monitored for effectiveness .and following each fall .If a resident falls, despite interventions, the following will occur . The new intervention will be implemented by the unit staff as soon as possible . An acute fall care plan will be completed to include the new preventative measures. If an acute fall care plan is already in place, the care plan will be updated with new preventive measures . Review of intake MI 141 indicated on 4/22/2020 at 8:42 AM, Resident #101 fell and sustained an injury. Review of Resident #101's Unusual Incident Report #988 dated 4/16/2020 10:30 indicated the resident going over to help her roommate . stated she fell on her butt. The Immediate Action Taken revealed .educated on call-light use. Resident placed on 30-minute checks. Further review of the report revealed Resident #101 had predisposing psychological risk factor of confused gait imbalance and impaired memory. Noted that a Fall Risk Assessment was not completed for this fall. Review of Resident #101's Progress Note dated 4/16/2020 at 11:05 revealed, Resident found on the floor .Resident placed on 30-minute checks Will continue to monitor . Noted that Resident #101's Care Plan and Kardex did not reflect the intervention of 30-minute checks was added. Review of Resident #101 Unusual Incident Report #992 dated 4/22/2020 at 09:32 (9:32 AM) indicated the resident was in her room and used her 4 WW to get up to get a cup of coffee and fell while sustaining a right hip/leg injury. Further review of the report revealed Resident #101 had predisposing psychological risk factor of impaired memory and was aware this was her third fall recently. Noted that a Fall Risk Assessment was not completed for this fall. Review of witness statement dated 4/24/2020 at 8:42 AM from Housekeeping C revealed, I saw her fall. She was sitting on the edge of her bed and she got up to walk. She twisted her feet, I think she was trying to turn around, her ankles crossed over each other and she fell right over. She landed with her walker under her shoulder. I ran to try and catch her, but I didn't get there in time. Review of a Face Sheet revealed Resident #101 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 4/22/2020, revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated Resident #101 was cognitively impaired. Further review of the MDS revealed Resident #101 was at risk for falls and required a walker to assist with mobility. Review of Resident #101's Care Plans revealed, Focus: risk for falls related to history of falling, impaired mobility, positive Fall Risk Assessment and confusion and impulsivity. Date Initiated: 2/27/2020 .Goal: I will have no falls and/or fall related injuries through the review date Date Initiated: 2/27/2020 .Interventions . OT screen for room set up/clear pathways Date Initiated: 04/10/2020 . PT/OT referral Date Initiated: 03/10/2020 .Focus . ADL self-care performance deficit related to altered respiratory status, decreased endurance, generalized weakness/deconditioning Date Initiated: 02/27/2020 .Goal .I will improve level of function through the review date. Date Initiated: 2/27/2020 .Interventions .AMBULATION: I walk with minimum assist with 4 WW (wheeled walker) short distances due to impulsivity. Date Initiated: 03/10/2020 . Noted Resident #101 fell on [DATE] resulting in a fracture and did not return to the facility. Review of Resident #101's Kardex Report as of 7/12/2020 (certified nursing assistant (CNA)) care guide to direct resident care) revealed, .ADL's (activities of daily living) AMBULATION . walk with minimum assist with 4 WW (4 wheeled-walker) for short distances due to impulsivity . TRANSFER . require minimal staff assistance with transfers . MONITORING Assist with mobility as needed . SAFETY Keep frequent needed items within reach, Keep my call light within reach and remind me to use it .OT screen for room set up/clear pathways . MISCELLANEOUS .Avoid Clutter During an interview on 7/7/2020 at 9:40 AM, Director of Nursing (DON) B stated, (Resident #101) fell in her room and broke her leg. A housekeeper was in the room and could not get to her in time to avoid the fall. During an interview on 7/8/2020 at 10:04 AM Unit Manager (UM) F stated, (Resident #101) fall on April 22 (2020) got up to talk to her roommate and forget to use her walker. She would use her walker 75% of the time and would have to be reminded. (Resident #101) had a history of [REDACTED]. During an interview on 7/8/2020 at 11:59 PM CNA D stated, (Resident #101) The housekeeping staff was already in her room when she fell in April (4/22/2020). I was the room next door coming towards (Resident #101) room. The housekeeper told me (Resident #101) had just fallen. CNA staff knew (Resident #101) was a fall risk but I do not know if housekeeping was told. During an interview on 7/8/2020 at 1:10 PM, Housekeeping C stated, I do not work at the facility anymore. I do not want to talk about what happened. During an interview and record review on 7/14/2020 at 10:10 AM with Registered Nurse (RN) U stated, (Resident #101) did not use her call-light like she should and would just get up off her bed and walk. She fell a few times in a row and did not use her call-light each time. She was put on 30-minute checks for closer monitoring. CNAs were told she was on fall report. Fall Report is when vital signs are done for 3-days along with neurological checks. Review of Resident #101's Care Plans with RN U revealed the intervention of 30-minute checks was not added after stated in Unusual Incident Report #988 and Progress Note dated 4/16/2020 11:05.

This citation pertains to MI 558. Based on observation interview and record review the facility failed to provide a safety device (gait belt) to prevent falls for 2 of 3 residents (Resident #101 and Resident #103) reviewed for falls with major injury, resulting in the fall with femur (long bone in leg) fracture (broken bone) for Resident #101 and the potential for injury for Resident #103. Findings include: Review of the Policy Gait Belt Use dated 12/18/18 revealed, It is the policy to utilize gait belts to assist with resident transfers and ambulation. A gait belt provides a secure grasping surface to aid with resident transfers and ambulation. A gait belt may be safely used to lower a resident to the ground if the resident begins to fall. Resident #101: Review of the Face Sheet revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 had a brief interview for mental status (BIMS) score of 13 out of 15 which indicated she was cognitively intact. Review of the Fall Risk assessment dated [DATE] revealed Resident #101 was a High Risk for falls. Review of the Care Plan .ADL (activities of daily living) self performance deficit related to generalized weakness, decreased endurance dated 12/28/18 revealed Resident #101 had an intervention of Extensive assist of 1, gait belt and grab bars for transfers/toileting dated 1/29/19. Review of the Facility Reported Incident (FRI) dated 3/31/19 revealed Resident #101 on 3/31/19 at approximately 5:45 PM, CNA (Certified Nurse Aide, CNA H) states that resident (Resident #101) had her call light on and requested to go to the bathroom. CNA H then set up a recliner to wheelchair transfer for Resident #101. CNA H .states she assisted (Resident #101) to standing position and the resident went to take a step forward with her walker .(Resident #101's) foot got caught behind her causing her to stumble and .that the resident began to fall to the floor. In an observation on 4/18/19 at 9:48 am, Resident #101 was noted to be in her wheelchair in her room. In an interview on 4/18/19 at 9:48 am, Resident #101 stated her broken leg (fractured femur) happened when the aide (CNA H) was transferring me on 3/31/19. Resident #101 stated, I went down and I broke my leg. Resident #101 further stated, they (CNA H) didn't have a belt (gait belt) on me that day, they (CNA H) should have had a gait belt and Therapy says they (staff) should always use a belt (gait belt) when they (staff) transfer me. In an interview on 4/18/19 at 10:52 am, Licensed Practical Nurse (LPN) I stated, on 3/31/19, CNA H notified me Resident #101 had fallen. LPN I stated she found Resident #101 on the floor of her room. LPN I stated Resident #101 told her 'my leg is broke, I heard it pop.' LPN I stated Resident #101 did not have a gait belt on and stated with transfers you would expect a belt (gait belt). LPN I stated, (CNA H) told me she did not use a gait belt during the transfer of Resident #101 on 3/31/19. In an interview on 4/18/19 at 1:50 PM, CNA J stated, on 3/31/19, CNA H came out and told us she (Resident #101) fell . CNA J stated she entered Resident #101's room and observed Resident #101 laying on the floor and Resident #101 stated 'her leg hurt, she thought it (leg) was broken.' CNA J stated there was no gait belt on Resident #101 or visible in Resident #101's room. In an interview on 4/18/19 at 12:00 PM, CNA H stated, on 3/31/19, during the transfer, Resident #101 .lost her (Resident #101) balance and went over. CNA H stated, I couldn't stop her (Resident #101) from falling to the floor. CNA H stated, she (Resident #101) said she heard a pop in her leg after she struck the floor. CNA H stated she did not use a gait belt because she (Resident #101) doesn't (sic) have one (gait belt) available to use during the transfer. In an interview on 4/18/19 at 8:38 am, Physical Therapy Assistant (PTA) E stated gait belts were to be used any time staff .transfer a resident it's the policy for safety. In an interview on 4/18/19 at 12:14 PM, Nursing Home Administrator (NHA) A stated, yes staff were to use a gait belt per policy for safe transfers. Review of the Emergency Department discharge summary dated 3/31/19 revealed, today they (facility) attempted a transfer her (Resident #101) .her (Resident #101) leg twisted with a sudden pop and acute onset of pain and swelling .X-rays were obtained showing an acute oblique fracture (broken bone) of the left distal femur (large bone in leg) and injury occurred during transfer at care facility. Review of the Orthopedic Trauma Consult dated 4/1/19 revealed Resident #101 .presents today after a fall while being transferred at adult living facility. Review of the Radiology results dated 3/31/19 revealed Resident #101 had a Closed fracture of distal end of left femur. Review of the HOSPITAL COURSE dated 4/6/19 revealed Resident #101 .who presented after a fall. In the emergency department .X-rays were obtained and showed an acute oblique [MEDICAL CONDITION] distal femur with extension inferiorly to the femoral component of the patient's knee prosthesis. Orthopedic surgery was consulted and they recommended non operative management with non-weight bearing in a knee immobilizer and eventual transition to a hinged brace .The patient continued to complain of left lower extremity pain. After discussion with the patient, family and orthopedic surgery, the decision was made to perform ORIF (open reduction internal fixation, surgical repair of broken leg) .On 4/3/19, ORIF of the left distal femur was performed. Review of the Resident Care Guide dated 4/6/19 revealed Resident #101 was a Hoyer (a machine used for resident transfer) with 2 assist (indicated a decrease in resident ability to transfer to toilet) after she returned to facility post surgery. Review of the Care Plan .ADL (activities of daily living) self performance deficit related to generalized weakness, decreased endurance dated 4/8/19 revealed Resident #101 was a Hoyer with 2 assist to bedside commode (indicated a decrease in resident ability to transfer to toilet). Review of the Occupational Therapy .Plan & Treatment dated 4/8/19 revealed Resident #101 was .recently admitted to hospital on 3/31 (2019) with dx (diagnosis) of distal L (left) femur during a transfer from bed to w/c (wheelchair) .Pt (patient) is currently NWB (non weight bearing) LLE (left lower extremity). She presents with decreased indpe (independence) with ADL (activities of daily living) transfers, generalized weakness, and decreased activity tolerance. In an interview on 4/18/19 at 1:44 PM, Medical Doctor (MD) K stated after the surgical repair Resident #101's broken leg she was less active because of the fracture and definitely (had a) decreased level of function. Resident #103: Review of the Face Sheet revealed Resident #103 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #103 had a brief interview for mental status (BIMS) score of 15 out of 15 which indicated she was cognitively intact. Review of the Fall Risk assessment dated [DATE] revealed Resident #103 was a High Risk for falls. In an observation on 4/18/19 at 8:38 am, Resident #103 was noted to be in her wheelchair in her room with CNA D. Resident #103 stood from the wheelchair and performed a pivot turn to her bed without CNA D using a gait belt. In an interview on 4/18/19 at 1:16 PM, Resident #103 stated, no a gait belt was not used during the transfer this morning. Resident #103 stated a gait belt was used in case I would fall. In an interview on 4/18/19 at 2:00 PM, CNA D stated, typically we do use a gait belt during transfers but a gait belt was not used this morning to transfer Resident #103.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopement and ensure safety in 1 of 14 residents (Resident #20) reviewed for safety/supervision, from a total sample of 14, resulting in an Immediate Jeopardy when on [DATE] at approximately 5:28 p.m., Resident #20 exited the facility, unbeknownst to facility staff, and was found approximately 0.4 miles away in a dollar store by a customer. Resident #20 was returned to the facility lobby by the customer at 6:26 p.m. This deficient practice placed 5 residents, identified as risk for elopement, at risk for serious harm, injury, and/or death. Resident #20 Review of an Admission Record revealed Resident # 20 was an [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #101 with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of a total possible score of 15, which indicated Resident #20 was cognitively intact. Review of the MDS reference date of [DATE], section G revealed, Resident # 20 was able to walk in her room independently and could be independent with no physical help from staff locomotion on unit and off the unit. Review of the ADL care plan interventions dated [DATE] revealed, AMBULATION: I may ambulate within my room independently with walker. I require 1 assist outside my room. DRESSING: Independent. Review of a facility wander/elopement assessment for Resident # 20 dated [DATE] revealed she maintains watch of exit and repeatedly tries to leave. Has history of exit seeking behavior. Denies need for protected environment. Has delusions, suspiciousness, anxiety related to loss or short term memory causing misperceptions. The assessment concluded that Resident # 20 was at risk for elopement but was physically or mentally unable. Review of a care conference note dated [DATE] at 10:57 revealed, She displayed disorganized and delusional thinking during care conference per her baseline; She was unable to recall incident of smoking in her room, nor having multiple conversations with SW/nursing regarding facility's smoking policy. She stated her son is continuing to pay rent on her apartment at (former home), but later confirmed that her belongings were removed from the property as she no longer has an active lease . Review of a Care Coordinator Progress note from [DATE] at 15:39 revealed, Note Text: Writer had conversation with resident in regards to history of smoking and desire to smoke while residing here at pilgrim manor. Resident was educated that d/t State, City and facility policy that staff cannot take her to smoke on or off the property and that her family may take her pending they travel at least 100 feet away from the building. She was also informed that failure to comply with this policy could result in her being asked to evacuate. She verbalized understanding of instructions as evidenced by her statement that's fine honey, it's no bother I'm moving in two weeks anyways and when writer asked if she had anymore cigarettes or lighters she replied no honey you have them, keep them, I'll get more when I get out of this loon bin. Review of a Nurse's progress note from [DATE] at 17:14 revealed, Resident # 20 continued to make statements about how (another resident) should stay on her hall and how she, (Resident # 20) pays rent here and also voiced her frustrations about she was supposed to go home. I tried to reason with (Resident # 20) for a short period of time about how she shouldn't take her frustrations out on another resident and make others feel bad . I stated that (the other resident) has the right to wheel herself anywhere in the halls she would like . (Resident # 20) did not agree. She did not show remorse, understanding, or sympathy for her feelings and we were not able to redirect (Resident # 20) so I removed (the other resident) from the area so she was not near (Resident # 20) . Interventions: tried to talk out issues and feelings and point out what was wrong with the rude behavior and taking out her frustrations on another resident. Effectiveness of Intervention: Reasoning with (Resident # 20) was not effective. Review of a progress note from [DATE] at 13:15 by social worker M revealed, Staff informed SW that Ms. Groves wants to visit the dollar store. Staff not sure if Ms. Groves can go, due to having Influenza A. SW followed up with Ms. Groves. SW encouraged Ms. Groves to stay inside the community, due to her being positive for Influenza A; to prevent further exposure and exposing others. Resident # 20 responded by stating, I have a mask and no longer have Influenza A. (Resident # 20) asked SW M Are you a cop?. SW M said no, to which Resident # 20 said then you can leave now. SW M left the room. SW M notified DON B of impulsive decision making and lack of understanding as to what effect leaving the community can have on her health and other's health. Review of the facility investigation revealed, review of camera showed Resident #20 left the building (on [DATE]) at 5:28 p.m. Review of the facility investigation note signed by SW M and dated [DATE] revealed, DON B and SW M met with Resident #20 to discuss recent trip outside of community. Resident #20 reports that she used her wheelchair to get to the handicap accessible door on health center 1. She reports standing up and entering the code to the secure door, which she reported to be 1478. Resident #20 reports that after leaving the health center she went to the front desk to get $20. She reports that the blonde lady gave it to her. She showed a receipt for [DATE] for $20. After getting her money she reports exiting the front door in her wheelchair. She showed that she left her wheelchair by the emergency exit on health center 1; outside. She said she walked down the hill and then up the road two traffic lights to the road where you can see the fire station across the street. She stated once she got by the fire station she did not know where she was at, what she was doing or how to get back. She said she tried to cross the street, which she said was hard. She said when she crossed, cars were honking at her. She reports that she then went to a dollar store where she sat on a display of toilet paper that collapsed, causing her to fall backwards. Resident #20 reported that a male and female brought her back to the facility. Review of an AccuWeather report revealed the temperature on [DATE] experienced a high of 17 degrees and low of 10 degrees. Review of an Informed Consent for Medical Decisions revealed Physician L deemed Resident Not Capable of making informed consent for medical choices on [DATE]. And Physician K deemed Resident # 20 Not Capable of making informed consent for medical choices on [DATE]. Review of the entire care plan for Resident #20 provided by the facility revealed no care plan focus was in place for the risk of wandering/elopement until [DATE] after the resident had eloped. In an observation on [DATE] 10:40 AM Resident # 20 was sitting in the common area at the table nearest the nurses station outside of room [ROOM NUMBER]. Restorative Certified Nurse Aide (CNA) P greeted resident. Resident # 20 stated, I'm going to Denny's Licensed Practical Nurse (LPN) J reported her friend takes her out occasionally. Friend Q was inside resident's room (16). Resident # 20 got up and started walking down the hallway toward the automated door in health center 1. CNA P followed her. Where are you going? I'm going to Denny's LPN J asked, did she sign out? CNA P redirected Resident # 20 to the nurse's station and facilitated her signing out. Then friend Q exited room [ROOM NUMBER], came to Resident # 20's side and then CNA P guided them out a different exit. In an observation on [DATE] at approximately 2:20 p.m., 1 staff member entered health center 1 via the coded, automated door near the administrator's office and kept walking without turning around to visualize the closure of the door. In an interview on [DATE] 08:58 AM Resident # 20 stated my roommate asked me to get her some cigarettes. but I didn't have any. So I got out and went down to the store to get some for her. Boy was I cold. It was really hard walking up that hill. At one point I forgot what I was doing or where I was. But I made it to the store and fell into some toilet paper or something. And this nice guy brought me home. I was absolutely freezing. This place has too many rules. I was a single mom after my husband died . I did everything on my own. I had no one telling me what to do. And I'm not even supposed to be here. My doctor said I should be here 2 weeks. It's been over 6 months! I don't understand, I can walk, make my bed. I need to get out of here. In an interview on [DATE] 10:20 AM, Licensed Practical Nurse (LPN) J stated, (Resident # 20) is opinionated, she likes things done her way. She's had no significant change in condition. She has been here since before I started. I've worked here since august. She always talks about wanting to go back to the place she came from. She gets restorative therapy right now, and ever since I've been here. For a while she didn't even ask to go smoke. We then started taking her out every so often to smoke . that ended then soon after we found her in her room smoking one time. When we did bring her out to smoke, she was supervised, she wasn't allowed to, couldn't go out on her own. I'm not sure why she couldn't go out on her own, maybe due to the elopement risk. Last time she went out to smoke was ,[DATE] months ago. You could tell she was an elopement risk because she would watch us put the numbers in the key pad. We have to guard our fingers when we punch in the code. She would always talk about leaving. I'm pretty sure she (social worker M) knew about her spying on the key pad. That was going on before the elopement. We don't use wander guards here. We have a Have you seen me book. She has been in the book as long as I've been here as far as I know. We are not allowed to give the code out anymore, and we changed the code. It was common practice to let visitors and vendors know what the code was. In an observation on [DATE] at 10:55 a.m., at the nurses' station, the coded, automated door on health center 1 was in sight down the hallway. It had a 15 second lag time from opening to closing securely. Noted that while open, no staff were visible on either side of the door. In an interview on [DATE] at 2:14 p.m., Store Manager O from the Dollar General reported she recalled the incident, but needed to return my call shortly after she assisted some customers. In an interview on [DATE] at 2:44 p.m., Resident # 20's family member O stated, She has never been happy there. She's delusional that she can live independently. And even though that's the case, she's got a fair amount of ninja in her. She's no dummy, she entered the code after the front desk staff left. She will wait, and wait, and wait. In an observation on [DATE] at approximately 1:45 p.m., 2 staff members exited health center 1 via the coded, automated door near the administrator's office and kept walking without turning around to visualize the closure of the door. In an interview on [DATE] at 1:50 p.m., Receptionist R reported that she leaves for the day at 5 p.m. In an interview on [DATE] at 10:33 AM, Social Worker M stated, (Resident # 20) is very outspoken. In the beginning she was understanding of why she was here (because of the fall). Over time she started to really not demonstrate an understanding of why she needed to stay here, even after multiple follow-ups. She was active, would move about the community. She would visit other residents. She likes to say all the other residents have issues (goofy, looney) but that she's fine. She wants to be back at her old home. I knew that she would try to leave with her friend when he was here. She was in our Have you seen me book. I knew that she would go down to the door and wait. She is very smart and very impulsive. She cannot rationalize. She was always mobile. If she wants something, she'll find a way to get it. She has always been in the wander book ever since she came to long term care. I'm the one that updates the book. The MDS nurse is the one who care plans residents for elopement risk. In an interview on [DATE] at 11:01 AM, MDS Coordinator T stated, At the time of the (MONTH) assessment, she was unable to walk more than a few feet, She was unsteady and I truly didn't think she was physically able to exit the building. She was dealing with significant pain from her previous [MEDICAL CONDITION]. She ended up improving and we got her pain under control. Pain was ,[DATE] per assessment in October. The wander/elopement assessment is triggered by the quarterly MDS assessment. I'm honestly not sure how I would've known that she physically improved unless staff told me. She didn't trigger automatically for a significant change from certified nurse aide (CNA) documentation. Unfortunately, staff are more trained to notice declines. Rarely do improvements lead to higher risks. Usually improvements are celebrated. On [DATE], Administrator A was notified of an identified Immediate Jeopardy that began on [DATE] when Resident #20, who was identified as an elopement risk, eloped from the facility, unbeknownst to facility staff. On [DATE], this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. On [DATE], Resident #20 was assessed for injury with no abnormal findings noted. NHA A, DON B and the family were notified of the incident. 2. On [DATE], the codes to the health center doors were changed. 3. On [DATE], Resident put on 30 minute checks right after the incident on [DATE] and documented started [DATE]. 4. On [DATE], Resident # 20 was educated by DON B on the potential risks of leaving the building and that she needs to be supervised according to her leave of absence order if she chooses to. 5. From [DATE]-[DATE], Staff and residents were interviewed regarding the incident and statements gathered to determine root cause of the elopement. 6. On [DATE], Resident #20 was updated to the Have You Seen Me? book due to her risk for elopement. 7. On [DATE], the Physician was contacted. 8. On [DATE], Resident #20 was moved to a private room for additional monitoring and placed on 30 minute checks. 9. On [DATE] Visitor of Resident #20 educated by MDS Coordinator T on not sharing the door code with Resident # 20. 10. On [DATE], Resident # 20 was re-assessed for elopement risk, and care plan and kardex updated. 11. On [DATE] Admissions Director, FF met with Resident # 20 and let her know that if she would like to leave the facility to go shopping or meet some other need she would arrange it for her. 12. On [DATE], All residents identified as at risk for elopement, based on elopement assessment score, were re-assessed for their risk of elopement and care plans and kardexes were updated. 13. On [DATE], Resident # 20 was educated by NHA A to utilize the community store located on the campus. NHA A provided resident #20 with his personal cell phone so she can call him at any time if she needs something. 14. On [DATE], the Elopement policy was updated to ensure no visitors or vendors will be provided with the door codes, and all staff associated with the health center were educated. 15. On [DATE], review of all incident/accident reports and progress notes from [DATE] to [DATE] revealed that Resident #20 has not attempted to exit building since incident. 16. On [DATE], the automatic door opener has been shut off and is no longer in operation. 17. On [DATE], all staff associated with the health center on duty have been educated by NHA A and DON B on [DATE] on the importance of observing and monitoring any door with a keypad to ensure proper closure. 18. On [DATE] a plan of action was put in place to educate staff in departments associated with the health center over the phone and in person over the weekend and moving forward to ensure staff are educated prior to their next shift. Staff to sign off on education sheet to demonstrate understanding and staff will not work prior to receiving education. 19. On [DATE] verified that all staff associated with the health center signed off on education prior to their next shift. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance with a scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to sustained compliance could not be verified by the state agency.

Based on observation interview, and record review the facility failed to prevent and properly treat pressure ulcers in 3 out of 5 residents (Residents #33, #40, and #493) reviewed for pressure ulcers, out of a total sample of 14 residents, resulting in the potential for worsen of pressure ulcers, infection, and hospitalization . Findings include: Review of the publication Prevention and treatment of [REDACTED]. .2. Continue to turn and reposition the individual regardless of the support surface in use. Establish turning frequency based on the characteristics of the support surface and the individual's response . No support surface provides complete pressure relief. Mobilization 1. Develop a schedule for progressive sitting according to the individual's tolerance and pressure ulcer response . .Repositioning Documentation 1. Record repositioning regimes, specifying frequency and position adopted, and include an evaluation of the outcome of the repositioning regime .Documentation provides a written record of care delivery and, as such, serves as evidence that repositioning has occurred . National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [REDACTED]. EmilyHaesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014. Review of the facility's policy and procedure, Skin Care and Prevention of Skin Issues, dated 3/1/18, revealed, Health maintenance vastly correlates to the integrity of skin as a vital role in health and wellbeing. Proper care and planning requires a collaborative approach to minimize the risks and prevent the occurrence of skin breakdown; to provide early detection an intervention of all breakdown of skin both on admission and through disease pathophysiology and progression .Inspections. 1. C.N.A. (Certified Nursing Assistant) will inspect all skin areas during routine cares and document in P(NAME) (Point Click Care) .Pressure Relief: 1. Resident will be turned and repositioned at least every two hours. Turn time may be shortened as deemed appropriate for the individual resident .6. If the resident sits in a wheel chair for more than one hour, the resident will be repositioned with side to side relief or complete lifting of the buttocks for the chair . Review of the facility's policy and procedure, Wound Care, dated 3/1/18, revealed 5. Stage I Pressure Ulcer, a. Identify and relieve pressure source, b. Establish turn schedule and pressure relief .Wound Nurse .to .reevaluate pressure relief and update Care Plan/Kardex as needed . Resident #33 Review of a facility Admissions Record revealed Resident #33 was an [AGE] year-old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#33 was an extensive assist with 2 staff for transfers, dressing, ambulation, and eating. Brief Interview for Mental Status (BIMS), on 10/31/17, revealed Resident #33 was cognitively impaired. Review of Resident #33's Medication Review Report revealed, Cleanse wound coccyx with spray wound cleanser, apply medi-honey to wound and cover with [MEDICATION NAME] foam dressing and silicone adhesive every day shift every 2 days, start date 11/20/17. During an observation on 3/1/18 2:25 PM, Charge Nurse AA (CN) went into Resident #33's room to change the Stage III pressure ulcer dressing to the coccyx. No hand hygiene was observed. CN AA moved Resident #33's body pillow and rolled Resident #33 on the left side. CN AA washed hands, pulled down Resident #33'a brief to expose the dressed coccyx wound and stool. CN AA removed the dressing to the Stage III coccyx ulcer. CN AA used Resident #33's soiled brief to wipe the stool off Resident #33's buttocks, wiping vulnerable tissue surrounding the ulcer. CN AA rolled the brief down into a ball containing the stool. The brief was wedged under Resident #33's buttocks between Resident #33's legs. No hand wash was observed. CN AA donned new gloves. CN AA cleansed Resident #33's Stage III coccyx ulcer and applied the [MEDICATION NAME] foam dressing. CN AA placed the silicone tape on Resident #33's visibly soiled incontinence pad and adhered the dressing. CN AA rolled Resident #33 flat on the visibly soiled incontinence pad with the rolled-up brief balled between Resident #33's legs. In an interview on 3/1/18 at 2:32 PM, CN AA indicated wound go ahead with the dressing change and then call the Certified Nurse Assistants (CNA) in to change Resident #33's brief after the dressing change. In an interview on 3/1/18 at 2:40 PM, CNA EE indicated saw stool on the dressing but was not allowed to remove a soiled dressing; only the nurse can do that. CNA EE indicated wondered why CN AA asked to have Resident #33's brief changed if there was stool on the dressing but did not question CN AA request. CNA EE did not know why CN AA' would change the dressing before provinding incontinence care, normally we would clean up the stool first and then the nurse would change the dressing. CNA EE indicated would normally tell the nurse there was stool on a dressing right away. In an interview on 3/6/18 at 11:35 AM, Unit Manager S (UM) indicated was the certified wound nurse in the facility. UM S would reeducate CN AA on dressing change technique and resident care. UM S indicated CN AA should have performed Resident #33's incontinence care first and then changed the dressing. Resident #33's pressure ulcer has improved but stool in the wound could impede healing progress. Resident #493 Review of a facility Admissions Record revealed Resident #493 was an [AGE] year-old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#493 was an extensive assist with 2 staff for transfers, dressing, ambulation and toileting, and setup and assistance for eating. Brief Interview for Mental Status (BIMS), on 1/9/18, revealed Resident #493 was cognitively impaired. Review of Resident #493's care plan revealed: Focus: I have a hx (history) of incontinence and am at risk for impaired skin integrity related to: declined cognitive abilities, pain, decline functional abilities, Multiple Comorbidities, depression, .dated initiated 4/5/16 .Goal: To maintain proper hygiene and intact skin integrity, date initiated 4/5/16 . Interventions: Monitor skin daily with toileting and routine care. Report any abnormalities to charge nurse and wound nurse .Check and change at least every 2 hours to avoid episodes of incontinence and reduce prolonged moisture, dated 4/5/16. Review of Resident #493's October 2017 Certified Nursing Assistant (CNA) care documentation, revealed: 1st shift (6:30 AM-2:30 PM), 2nd shift (2:30 PM-10:30 PM) and 3rd shift (10:30 PM-6:30 AM). Head to Toe skin observation: 10/2/17, 10/3/17, 10/4/17- 3rd shift, no documentation of skin assessment 10/5/17- 2nd shift, no documentation of skin assessment 10/6/17- 3rd shift, no documentation of skin assessment Turn and Repositioned: Did you turn and reposition? Y- Yes N-No 10/1/17- 1st shift and 2nd shift, no documentation of position change (no position change from 6:30 AM to 10:30 PM) 10/2/17, 10/3/17- 3rd shift, no documentation of position change 10/4/17 - 2nd shift, documentation of N or no turn and reposition done 10/4/17 - 3rd shift, no documentation of position change (position change from 2:30 PM-6:30 AM) 10/5/17- 2nd shift, no documentation of position change 10/6/17- 3rd shift, no documentation of position change Review of Ulcer Tracking Tool dated 10/7/17, revealed Resident #493 had developed a new stage I (coccyx pressure ulcer) .G. Program Review: 1. Turning/Positioning Program Review, yes, 2a. Turn every 1-2 hrs (hours) .2d. Position devices as needed, 2e. Pressure reducing mattress .2i. Pressure reducing device to chair . Review of Resident #493's .at risk for impaired skin integrity . care plan revealed, no new care plan interventions related to the discovery of the 10/7/17, Stage I ulcer pressure ulcer noted. No pressure ulcer care plans initiated after discovery of the 10/7/17, Stage I ulcer pressure ulcer. Review of Resident #493's October 2017 Certified Nursing Assistant (CNA) care documentation, revealed: 1st shift (6:30 AM-2:30 PM), 2nd shift (2:30 PM-10:30 PM) and 3rd shift (10:30 PM-6:30 AM). Head to Toe skin observation: 10/7/17, 10/8/17, 10/9/17, 10/10/17- 3rd shift, no documentation of skin assessment 10/12/17- 2nd and 3rd shift, no documentation of skin assessment (2:30 PM-6:30 AM) 10/13/17, 10/14/17- 3rd shift, no documentation of skin assessment 10/15/17- 2nd shift resident refusal of skin assessment and 3rd shift no documentation of skin assessment (2:30 PM-6:30 AM) 10/16/17- 2nd shift resident refusal of skin assessment and 3rd shift no documentation of skin assessment (2:30 PM-6:30 AM) Turn and Repositioned: Did you turn and reposition? Y- Yes N-No 10/9/17, 10/10/17, 10/11/17- 3rd shift, no documentation of position change 10/12/17- 2nd and 3rd shift, no documentation of position change (2:30PM-6:30 AM) 10/13/17, 10/14/17- 3rd shift, no documentation of position change 10/15/17 - 2nd shift, resident refusal and 3nd shift, no documentation of position change from 2:30PM-6:30 AM 10/16/17- 2nd shift, resident refusal and 3nd shift, no documentation of position change from 2:30PM-6:30 AM 10/17/17- 1st shift, N documentation, or did not reposition, (no documentation of repositioning from 10/16/17 at 2:30 PM to 10/17/17 at 2:30 PM) Review of Ulcer Tracking Tool dated 10/17/17, revealed Resident #493 Stage I coccyx pressure ulcer had developed to a Stage II, new Stage II pressure ulcers developed to the left buttock, right buttock, left heel, and a new Stage I pressure had developed to left ischium. Ulcer Tracking Tool revealed, G. Program Review: 1. Turning/Positioning Program Review, yes, 2a. Turn every 1-2 hrs (hours) .2d. Position devices as needed, 2h. Float heels/heels up, 2i. Pressure reducing device to chair, 2j. Alternating pressure/low air loss mattress . Review of Resident #493's .at risk for impaired skin integrity . care plan revealed, new care plan interventions related to the discovery of the 10/17/17, ulcer pressure ulcer were APM (alternating pressure mattress) . No pressure ulcer care plans initiated after the discovery of the worsening Stage II ulcer pressure ulcer and development of the new Stage II and Stage I pressure ulcers. In an interview on 3/7/18 at 10:37 AM, Unit Manager (UM) and Wound Nurse S indicated does not believe an APM bed alone would prevent pressure ulcers. UM S indicated an APM does not replace the need for off loading and reposition residents who have pressure ulcers. UM S indicated residents at risk for pressure ulcer or have pressure ulcers need to reposition every 2 hours. UM S indicated if CNA's did not document repostitioning of skin checks, then those task are considered not done. Review of Ulcer Tracking Tool, dated 11/1/17, revealed Resident #493's coccyx, right buttock, left buttock and left ischium healed, left heel closed. Review of Resident #493's care plan, revealed a new care plan focus, I have a .Stage II to my right ischium related to pressure ., initiated 11/2/17 .Goal: Blisters will show signs of healing and remain free from infection .Interventions: Alternating pressure mattress, dated initiated 11/2/17 Follow facility policies/protocols for the treatment/prevention of skin breakdown, date initiated 11/2/17 . Review of Resident #493's November 2017 Certified Nursing Assistant (CNA) care documentation, revealed: 1st shift (6:30 AM-2:30 PM), 2nd shift (2:30 PM-10:30 PM) and 3rd shift (10:30 PM-6:30 AM). Head to Toe skin observation: 11/1/17, 11/4/17-3rd shift, no documentation of skin assessment 11/6/17, 11/7/17, 11/8/17- 3rd shift, no documentation of skin assessment 11/9/17- 2nd and 3rd shift, no documentation of skin assessment (2:30 PM-6:30 AM) Turn and Repositioned: Did you turn and reposition? Y- Yes N-No 11/1/17- 3rd shift, no documentation of position change 11/4/17- 2nd shift refusal and 3rd shift, no documentation of position change (2:30 PM-6:30 AM) 11/6/17, 11/7/17- 2nd shift resident refusal and 3rd shift, no documentation of position change (2:30 PM-6:30 AM) 11/8/17- 3rd shift, no documented position change 11/9/17 - 2rd shift, resident refusal and 3nd shift, no documentation of position change (2:30 PM-6:30 AM) Review of Ulcer Tracking Tool dated 11/9/17, revealed Resident #493 left heel pressure ulcer and left medial metatarsal from 10/17/17 had worsened and were reclassified as Suspected Deep Tissue Injuries (SDTI). Ulcer Tracking Tool revealed, G. Program Review: 1. Turning/Positioning Program Review, yes, 2a. Turn every 1-2 hrs (hours) .2d. Position devices as needed .2i. Pressure reducing device to chair, 2h. Alternating pressure/low air loss mattress . Review of Resident #493's .at risk for impaired skin integrity . care plan revealed, no new care plan interventions related to the development of the 11/9/17, worsen pressure ulcers to the left heel and medial metatarsal. Review of Resident #493's I have a .Stage II to my right ischium related to pressure . care plan revealed, no new care plan interventions related to the development of the 11/9/17, worsen pressure ulcers to the left heel and medial metatarsal. Review of Resident #493's December 2017 Certified Nursing Assistant (CNA) care documentation, revealed: 1st shift (6:30 AM-2:30 PM), 2nd shift (2:30 PM-10:30 PM) and 3rd shift (10:30 PM-6:30 AM). Head to Toe skin observation: 12/1/17- 1st and 3rd shift, no documentation of skin assessment 12/4/17- 1st and 3rd shift, no documentation of skin assessment 12/5/17- 1st and 3rd shift, no documentation of skin assessment 12/6/17- 3rd shift, no documentation of skin assessment Turn and Repositioned: Did you turn and reposition? Y- Yes N-No 12/1/17- 1st and 3rd shift, no documentation of position change 12/4/17- 1st, 2nd shift and 3rd shift, no documentation of position change (6:30 AM-6:30 AM) 12/5/17- 1st and 3rd shift, no documentation of position change 12/6/17- 3rd shift, no documentation of position change Review of Ulcer Tracking Tool dated 12/7/17, revealed Resident #493 left heel and left medial metatarsal SDTIs both measured slightly smaller, and had developed a new bilateral Stage I gluteal folds pressure ulcers. Ulcer Tracking Tool revealed, G. Program Review: 1. Turning/Positioning Program Review, yes, 2a. Turn every 1-2 hrs (hours), .2d. Position devices as needed, 2h. Float heels/heels up, 2i. Pressure reducing device to chair, 2j. Alternating pressure/low air loss mattress . Review of Resident #493's .at risk for impaired skin integrity . care plan revealed, no new care plan interventions related to the new development of the 12/7/17, bilateral Stage I pressure ulcer to the gluteal folds. Review of Resident #493's I have a .Stage II to my right ischium related to pressure . care plan revealed, no new care plan interventions related to the new development of the 12/7/17, bilateral Stage I pressure ulcer to the gluteal folds. Review of Resident #493's December 2017 Certified Nursing Assistant (CNA) care documentation, revealed: 1st shift (6:30 AM-2:30 PM), 2nd shift (2:30 PM-10:30 PM) and 3rd shift (10:30 PM-6:30 AM). Head to Toe skin observation: 12/7/17- 3rd shift, no documentation of skin assessment 12/10/17- 3rd shift, no documentation of skin assessment 12/12/17- 1st shift, no documentation of skin assessment 12/16/17- 2rd shift no documentation of skin assessment 12/18/17- 2nd shift, no documentation of skin assessment Turn and Repositioned: Did you turn and reposition? Y- Yes N-No 12/10/17-3rd shift, no documentation of position change 12/12/17- 1stshift, no documentation of position change 12/16/17- 2nd shift, no documentation of position change Review of Ulcer Tracking Tool dated 12/15/17, revealed Resident #493 left heel and left medial metatarsal SDTIs resolved, and bilateral Stage I gluteal folds pressure ulcers resolved . Review of Ulcer Tracking Tool dated 12/19/17, revealed Resident #493 left medial metatarsal SDTI was reclassified as unstageable, open with slough. Ulcer Tracking Tool revealed, G. Program Review: 1. Turning/Positioning Program Review, yes, 2a. Turn every 1-2 hrs (hours) .2d. Position devices as needed, 2h. Float heels/heels up, 2i. Pressure reducing device to chair, 2j. Alternating pressure/low air loss mattress . Review of Resident #493's .at risk for impaired skin integrity . care plan revealed, the new care plan intervention, Turning Program: Assist to reposition every 1 to 1.5 hours while in bed or wheelchair ., date initiated 12/14/17 and Foot protectors on at all times, dated 12/14/17 . Review of Resident #493's I have a Unstageable wound to my left inner first metatarsal and Sage II to my right ischium related to pressure . care plan revealed, no new care plan interventions related to the new worsening of the 12/19/17, left medial metatarsal SDTI to unstageable, open with slough. Review of Resident #493's December 2017 Certified Nursing Assistant (CNA) care documentation, revealed: 1st shift (6:30 AM-2:30 PM), 2nd shift (2:30 PM-10:30 PM) and 3rd shift (10:30 PM-6:30 AM). Head to Toe skin observation: 12/19/17- 3rd shift, no documentation of skin assessment 12/21/17- 2nd shift, no documentation of skin assessment 12/24/17- 2nd shift, no documentation of skin assessment Turn and Repositioned: Did you turn and reposition? Y- Yes N-No 12/19/17-3rd shift, no documentation of position change 12/21/17- 2nd shift, no documentation of position change 12/24/17- 2nd shift, no documentation of position change Review of Ulcer Tracking Tool dated 12/26/17, revealed Resident #493 left medial metatarsal unstageable was larger and a new Stage II pressure ulcer developed on right ischium, with slough. Ulcer Tracking Tool revealed, G. Program Review: 1. Turning/Positioning Program Review, yes, 2a. Turn every 1-2 hrs (hours) .2d. Position devices as needed, 2h. Float heels/heels up, 2i. Pressure reducing device to chair, 2j. Alternating pressure/low air loss mattress . Review of Resident #493's .at risk for impaired skin integrity . care plan revealed, no new care plan interventions related to the 12/26/17, worsened unstageable left medial metatarsal and new Stage II right ischium pressure ulcer. Review of Resident #493's I have a Unstageable wound to my left inner first metatarsal and Sage II to my right ischium related to pressure . care plan revealed, no new care plan interventions related to the 12/26/17 worsened unstageable left medial metatarsal and new Stage II right ischium pressure ulcer. Review of untitled document, missing 1st page, dated 12/28/17 revealed, 6) The pressure ulcer identified above has been determined to be clinically unavoidable due to the indicated circumstances: yes, 6) Additional comments: Resident (#493) has recently had increased energy and has been up in w/c (wheelchair) self-propelling which has been a goal to aid in contracture reduction. This has subsequently created additional pressure to R (right) ischial area. Review of Resident #493 care plans revealed, no new care plan interventions implemented regarding additional pressure to R (right) ischial area. In an interview on 3/6/18 at 10:20 AM, UM S indicated Resident #493's contractures had improved so much Resident #493 was up in the wheel for up to 3 hours at a time, which improved appetite and social life but exerted pressure on the ischial area. Review of Resident #493's January 2017 Certified Nursing Assistant (CNA) care documentation, revealed: 1st shift (6:30 AM-2:30 PM), 2nd shift (2:30 PM-10:30 PM) and 3rd shift (10:30 PM-6:30 AM). Head to Toe skin observation: 1/2/18- 3rd shift, no documentation of skin assessment 1/3/18- 2nd shift, no documentation of skin assessment 1/6/18, 1/7/18- 3rd shift, no documentation of skin assessment 1/8/18- 1st shift, no documentation of skin assessment 1/10/18- 3rd shift, no documentation of skin assessment Turn and Repositioned: Did you turn and reposition? Y- Yes N-No 1/2/18-3rd shift, no documentation of position change 1/6/18 and 1/7/18- 3rd shift, no documentation of position change 1/8/18- 1st shift, no documentation of position change Review of Ulcer Tracking Tool dated 1/11/18, revealed Resident #493 left medial metatarsal unstageable was stable and the Stage II pressure ulcer on the right ischium worsened to unstageable due to slough. Ulcer Tracking Tool revealed, G. Program Review: 1. Turning/Positioning Program Review, yes, 2a. Turn every 1-2 hrs (hours) .2d. Position devices as needed, 2h. Float heels/heels up, 2i. Pressure reducing device to chair, 2j. Alternating pressure/low air loss mattress . Review of Resident #493's .at risk for impaired skin integrity . care plan revealed, no new care plan interventions related to the 1/11/18, unstageable left medial metatarsal and worsened right ischium pressure ulcer. Review of Resident #493's I have a Unstageable wound to my left inner first metatarsal and Sage II to my right ischium related to pressure . care plan revealed, no new care plan interventions related to the 1/11/18 unstageable left medial metatarsal and worsened right ischium pressure ulcer. Review of Resident #493's January 2017 Certified Nursing Assistant (CNA) care documentation, revealed: 1st shift (6:30 AM-2:30 PM), 2nd shift (2:30 PM-10:30 PM) and 3rd shift (10:30 PM-6:30 AM). Head to Toe skin observation: 1/13/18- 3rd shift, no documentation of skin assessment 1/15/18- 3rd shift, no documentation of skin assessment Turn and Repositioned: Did you turn and reposition? Y- Yes N-No 1/13/18-3rd shift, no documentation of position change 1/15/18- 3rd shift, no documentation of position change Review of Ulcer Tracking Tool dated 1/19/18, revealed Resident #493 left medial metatarsal unstageable was stable and the unstageable pressure ulcer to the right ischium had worsen, measuring on 1/11/18, 3.0cm X 2.0cm X 0cm (depth), to measuring on 1/19/18, 6.0 cm X 3.8 cm X 2.0 cm. New Stage II pressure ulcers to bilateral sacral region. Ulcer Tracking Tool revealed, G. Program Review: 1. Turning/Positioning Program Review, yes, 2a. Turn every 1-2 hrs (hours) .2d. Position devices as needed, 2h. Float heels/heels up, 2i. Pressure reducing device to chair, 2j. Alternating pressure/low air loss mattress . Review of Resident #493's .at risk for impaired skin integrity . care plan revealed, the new care plan interventions related to the 1/19/18, worsen, unstageable right ischium pressure ulcer, Pommel cushion to wheelchair, check placement q (every) shift, date initiated 1/23/18. Review of Resident #493's I have a Unstageable wound to my left inner first metatarsal and Sage II to my right ischium related to pressure . care plan revealed, new care plan interventions related to the 1/19/18 worsened, unstageable right ischium pressure ulcer Li (TRUNCATED)

This refers to MI 822 and MI 863. Based on observation, interview, and record review, the facility failed to prevent neglect for 1 of 10 residents (Resident #10) reviewed for abuse and neglect from a total sample of 11 residents, resulting in Resident #10 developing bruising to the right side of the body and bilateral lower extremity contractures. Findings include: A review of Resident #10's admission record, dated 12/19/17, revealed Resident #10 was an [AGE] year old resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #10's Minimum Data Set (MDS- a tool used for assessing a resident's care needs), dated 10/9/17, revealed Resident #10 had a Brief Interview for Mental Status (BIMS- a tool used to determine a resident's cognitive status) score of 10 which indicated Resident #10 had moderate cognitive impairment. In addition, Resident #10's MDS revealed Resident #10 had physical behaviors directed toward others and rejected care most days of the week and verbal behaviors directed toward others at least 1 to 3 times a week. Resident #10's MDS revealed Resident #10 needed extensive assistance (resident involved in activity, staff providing weight bearing assistance) with one person for transferring from one surface to another (e.g. wheelchair to bed) and bathing. During an interview on 12/19/17 at 11:15 a.m., Resident #10's Power of Attorney (POA H) stated Resident #10 had developed contractures at the facility. POA H stated, They say they are rare, but occur. I know a resident can refuse to get up and all, but at a certain point, they (the facility staff) have to look at what is best for the resident. POA H indicated he believed Resident #10 developed the contractures as a result of facility staff leaving Resident #10 in bed all the time and not providing care. POA H stated, She (Resident #10) had a bruise on the right side of her body-on her arm, her breast, her side, all the way down. She even had a bruise the size of a man's hand on her right hip. They (the facility) said the bruising is from a transfer, but they don't know for sure. A review of Resident #10's incident report for a bruise discovered on 12/4/17, dated 12/4/17, revealed the nursing assistants were getting the resident (Resident #10) ready for bed. Resident #10 had a bruise that was found on the resident's (Resident #10) right upper arm, under her armpit, and on the left (right?) breast. The bruise on the (right) upper arm measures 9 in. (inches) x (by) 4.5 in. All of the bruising is dark purple in color . The bruising goes from the right upper arm, under the right armpit, and onto the right breast. During an interview on 12/19/17 at 12:50 p.m., unit manager (UM) K stated, She (Resident #10) had bruising to the right side of her body. It was extensive. It just showed up one day. It was to her (Resident #10's) right arm, right side, and the side of her body. We think it was from not using a gait belt during a transfer. The bruising was heaviest under her arms and on her side. She is now a hoyer (a mechanical lift device used with a sling) transfer. During an observation on 12/19/17 at 2:00 p.m. with UM K, Resident #10 was observed in bed with bilateral (both sides) lower extremities contracted into a fetal position and lying on her left side. Resident #10's upper right arm had dark purple bruising from her shoulder to her elbow, dark purple bruising extending continuously from Resident #10's right armpit to Resident #10's right hip with yellow bruising along the top of her right hip, dark purple bruising from Resident #10's armpit across her right breast to approximately mid-chest, and dark purple bruising under Resident #10's left arm from approximately mid-armpit to lower armpit extending towards the left breast (but not on Resident #10's left breast). In addition, Resident #10 had a raised area (bump) over her right collar bone. Resident 10 shook her head no when asked if she had any pain. A review of Resident #10's skin assessments, dated 12/1/17 to 12/19/17 revealed the following: - 12/1/17= Resident had weekly shower and skin check. No new issues noted. Continues with heel and metatarsal (foot bone) treatments. - 12/5/17= right dorsal (top) wrist bruising 1.8 centimeters (cm) by 1.5 cm; right breast bruising 10.5 cm by 9 cm; right ribs bruising 12 cm by 7 cm; right dorsal wrist bruising 2.4 cm by 1 cm; right inner humerus (upper arm) bruising 22 cm by 10 cm; right thumb webbing bruising 3.5 cm by 3 cm; left posterior (back) axilla (armpit) bruising 5 cm by 2.5 cm; right bicep bruising 7 cm by 4 cm; and right lateral chest swelling 4 cm depth. Multiple areas of bruising reported with farthest lateral right side being darkest in color and fading medially (towards the center of the body). Areas of welling noted extending from right axilla through approximately 7 cm towards medial pectoralis major (chest). - 12/8/17= right antecubital (where arm bends) bruising, right elbow bruising, right hand (back) bruising, right shoulder (front) bruising, and right wrist bruising. Resident (Resident #10) did not tolerate measuring of multiple bruises. Bruises are purple to yellowing in color. Appear to be healing. - 12/19/17= left wrist abrasion 0.4 cm by 0.3 cm by 0.1 cm; right dorsal wrist lateral fading bruising 0.8 cm by 0.6 cm; right dorsal wrist medial fading bruising 1 cm by 1 cm; right lateral chest swelling/nodule 11 cm by 10 cm by 3 cm; right bicep fading bruise 12 cm by 4.5 cm; right breast fading bruising 12 cm by 7.5 cm; left posterior axilla faint bruising 2.5 cm by 2.3 cm; right inner humerus fading bruising 20 cm by 7.5 cm; right ribs fading bruising 23.5 cm by 23 cm; and right thumb webbing faint bruising. These measurements were made during the observation on 12/19/17 at 2:00 p.m. During an interview on 12/19/17 at 3:35 p.m., certified nursing assistant (CNA) S stated, I was working with (name of CNA T) (on 12/4/17). (Name of CNA T) got her (Resident #10) ready and gave her a shower. I saw (heard) (name of CNA T) calling for someone to help her with a transfer. I went in the shower room. The resident (Resident #10) had her brief and pants on as much as she could in the sitting position and her top was completely on. She (CNA T) told me we would do a stand pivot (a type of transfer method in which the resident stands up and the staff help to pivot the resident from one surface to another). She (CNA T) told me she needed help to stand her (Resident #10) up and get her in the chair (wheelchair). We grabbed her (Resident #10) under the arms and grabbed her waistband (to assist with standing). We each had one arm under her arms and the other hands were pulling up her pants. We didn't use a gait belt. I was on the resident's (Resident #10) right side. I felt like I was supporting her weight. I didn't feel right about it. I wasn't sure how she (Resident #10) transferred when I helped (name of CNA T). I just didn't feel right because I needed to support her (Resident #10) weight and I'm used to residents standing on their own with a stand pivot (transfer) and me just guiding them. The transfer was fine. The resident (Resident #10) didn't seem agitated when I was in there (the shower room). I don't recall seeing any bruises or marks. After lunch I helped to transfer her (Resident #10) to the recliner with (name of CNA T) from the wheelchair. We did a stand pivot (transfer) then, too. We didn't use a gait belt then either. We supported her (Resident #10) under the arm and by her waistband. I talked to (name of Director of Nursing (DON) B) after (name of DON B) talked to me about this (the bruises). I asked her why aides don't use gait belts (when transferring a resident ). She said they should. During an interview on 12/20/17 at 8:40 a.m., CNA R stated, I was called by (name of CNA T) to help her put her (Resident #10) in her shower chair (on 12/4/17). I carried her from the bed to the shower chair. She went very smoothly and I sat her straight up. I didn't see any bruising. She didn't have any bruising before that. It appeared the day after I put her in the shower chair. I don't know how she got the bruising. I know she wasn't bruised when I put her in the chair. It could have happened in the shower or on another shift. She can cuss (swear) at you. But since she's been taking the meds (medications) she's been a lot better. I can't think of anyone I work with that would intentionally hurt her. She's (Resident #10) had little bruises before, but not anything big. A review of CNA R's written and signed statement, dated 12/5/17, revealed, on 12/4/17 I (CNA R) told (name of CNA T) to stand behind the shower chair while I transferred (name of Resident #10) to the shower chair. (Name of Resident #10) was still lying in her bed on her right side. I (CNA R) placed my right arm under her (Resident #10) back and right hand (CNA R's) on the outside of her right shoulder. I then placed my right hand down to top part of her pajama pants and gripped her wrist band with my right hand. I then placed my left arm under her legs by the back of the knee caps, rolled her towards my torso, and (name of Resident #10) put her right arm around my neck and I proceeded to lift her and place her in a straight position in the shower chair, not leaning to the left or leaning to the right. CNA R's statement is consistent with the interview on 12/20/17 at 8:40 a.m., in which CNA R stated he carried Resident #10 from her bed to the shower chair. On 12/20/17 at 9:20 a.m., a voicemail message was left for CNA U requesting a call back. However at the time of exit from the facility and the conclusion of the investigation, CNA U failed to return the phone call. A review of CNA U's written and signed statement, dated 12/5/17, revealed, On 12/4/17 myself (CNA U) and (name of CNA V) helped (name of Resident #10) to bed. We transferred her to her w/c (wheelchair) from the recliner in the hall using a 2-person transfer w/o (without) a gait belt. When we were in her (Resident #10) room, we took off her sweater to put her nightgown on. This is when we discovered an extremely large deep purple bruise covering the entire inside of her (R) (right) upper arm, armpit, and across her chest . (Name of CNA V) and I questioned (name of Resident #10) about what happened to which she (Resident #10) said she did not know. We then continued to put a gown on her and transferred her to bed, this time using a gait belt as to not cause her pain. During an interview on 12/20/17 at 10:00 a.m., CNA T stated, On the morning of 12/4/17, I was with her (Resident #10). I offered to do her shower. I got (name of CNA R) to transfer her (Resident #10) to the shower chair. I think (name of CNA R) put his arm around her like a baby cradle. I was holding the (shower) chair when he (CNA R) put her in the (shower) chair. She (Resident #10) didn't hit anything when her put her in the shower chair. We usually use a 2-person transfer. But I got (name of CNA R) to pick her up. We would do a pivot turn (transfer) before this (discovery of bruises). Now she's a hoyer lift (transfer). After (name of CNA R) got her in the shower chair, I took her into the shower. I got her dressed as I could after the shower and then I got the other girl (CNA S) to help me to transfer her to the wheelchair from the shower chair after we pulled up her (Resident #10) pants. We each put an arm under her and we each grabbed her pants to pull them up because they were mid-thigh. We didn't use a gait belt because she's (Resident #10) so small and I didn't want to bruise her. I normally 1-person (transfer) her, but I needed to pull up her pants, so I used 2-people (transfer). If I was by myself, I would have transferred her (Resident #10) by hugging her from the front and put her in the chair. She (Resident #10) didn't slip or fall when I gave her a shower (on 12/4/17). After lunch, I brought her (Resident #10) to the nurse's station and we put her in the recliner. We pivot turned (transfer) her when we transferred her. We didn't use a gait belt. We put an arm under each arm and grabbed the back of her pants (waistband). We didn't have any problems getting her in there recliner. I didn't see any bruising or anything when I gave her a shower (on 12/4/17). I didn't even see the start of anything. I've never noticed any big bruises on her before. I think her bruise may have been caused by her sweater because it was a little tight (when CNA R put it on Resident #10 the morning of 10/4/17). It was a new and fitted sweater, so it was a bit tight around the cuff. It may have been hard to get off if she (Resident #10) was struggling. During an interview on 12/20/17 at 12:30 p.m., CNA V stated, It was toward the end of my shift (on 12/4/17). I was working with (name of CNA U). I was assigned to her (Resident #10) or (name of CNA U) was. We went in the room to get her (Resident #10) ready for bed. I took off her shirt and noticed she had bruises. It came off (Resident #10's) top) easily. She was in her wheelchair and we put her in the bed. (Name of CNA U) held her legs and I had her arms. We lifted her from the wheelchair and put her in bed. She can't stand up. I was behind her and (name of CNA U) was in front of her. That day, as far as I know, (name of CNA U) said she (Resident #10) was a 2-person transfer. (Name of CNA U) wanted to lift her up and put her in bed. We did the best we could. We found the bruises when she was in her chair and I took her top off. The bruises were under her right arm, above the elbow, and across to her right breast. I took care of her (Resident #10) a week before and that (the bruises) was not there. Most of the time I've had (taken care of) her, she's in bed. I've not had to transfer her before. She can't use a sit-to-stand because her legs are contracted. I don't know anything about her contractures. If I don't know how to transfer someone, I look at the kardex (a form used to describe how to care for a resident- e.g. how to transfer them). They can change a lot. CNA V was asked if it was possible her and CNA U may have dropped Resident #10 while transferring her from the wheelchair to the bed. CNA V stated, The only way she (Resident #10) could have been dropped is if someone was transferring her by themselves. A review of Resident #10's care plans revealed Resident #10 was a total assist (staff providing full weight bearing) of 2 staff members for transferring (dated 11/2/17) and bathing (dated 11/27/17) at the time Resident #10's bruises were observed (12/4/17). A review of the facility's investigative summary for the incident on 12/4/17, dated 12/8/17, revealed Bruising is located in common contact areas associated with transfers. Resident (Resident #10) is a two person extensive transfer assist. Resident (Resident #10) was transferred five times throughout the day with extensive assist of 2 CNA's. DON (DON B) interviewed CNA 's involved in the transfers and a gait belt was used during one transfer. It was determined that the bruising was the result of multiple transfers without a gait belt . (initials of CNA T) provided resident (Resident #10) with a shower the morning of the observed bruising (12/4/17) at which time no bruising was noted. Resident (Resident #10) is not ambulatory and is fully dependent on nursing staff to meet all care needs Staff educated regarding gait belt use for transfers. A review of the facility's transfer and gait belt use education, dated 12/13/17 to 12/19/17 (state on-site investigation began on 12/15/17), revealed, Why do we use gait belts? Staff are required to use a gait belt with all transfers (unless a mechanical lift) and ambulation, unless the resident is SBA (stand-by assist- staff stand by the resident with hands off in case they are needed) or independent. A review of the facility's transfer and gait belt use education sign in sheet, dated 12/13/17 to 12/19/17 (state on-site investigation began on 12/15/17), revealed CNA R, CNA S, CNA V, and 17 other staff members were not educated on the use of gait belts after the incident on 12/4/17. Therefore, during the time of the state on-site investigation, 12/15/17 to 12/20/17, the facility continued to remain in non-compliance for gait belt use during transfers. The facility's sign in education sheet for gait belt use also revealed education was not started until 12/13/17, even thought the facility's investigative summary (five day report to the state survey agency) indicated the training had been completed by 12/8/17. During a second interview on 12/19/17 at 4:35 p.m., UM K stated, She (Resident #10) got contractures around September or October (2017). She likes to lie in the fetal position. I'm not sure how they developed. I don't know if she refused to be taken care of and they just left her alone or if she developed them because she likes to lie in that position (fetal) and will go back to it (when staff repositioned her). She will strike out at people. She says no a lot. Requested all documentation related to Resident #10's contractures from UM K. A review of Resident #10's clinical records and progress notes, dated 8/1/17 to 9/19/17, failed to reveal documentation about Resident #10's lower extremity contractures (e.g. when they occurred, why they occurred, interventions to treat them or keep them from getting worse). During a third interview on 12/19/17 at 5:10 p.m., UM K stated, There isn't any documentation on her (Resident #10) contractures. Just what therapy documents on their log. UM K presented Resident #10's service log matrix, dated 10/1/17 to 12/19/17, to this Surveyor. A review of Resident #10's service log matrix, dated 10/1/17 to 12/19/17, revealed Resident #10 started to receive physical therapy on 10/18/17 for generalized muscle weakness and had received it 2 to 3 times a week from 10/18/17 to 12/13/17. However, Resident #10's service log matrix does not indicate Resident #10 has lower extremity contractures or receives therapy for those contractures. During an interview on 12/20/17 at 10:00 a.m., CNA T stated, Her (Resident #10) legs got constricted about 3 to 4 months ago (August or September 2017). (Name of CNA Q) and I were the only ones to get her (Resident #10) out of bed. At the time, people (staff) didn't want to get her out of bed because she was combative. They could just leave her alone and if she refused they'd leave it at that. (Name of CNA Q) and I would tell her (Resident #10) we were getting her up and we would do it. She was ok with it (getting out of bed). Other people would just leave her and say she refused to get up instead of really trying to get her up.

This citation pertains to intake MI 632 Based on observation, interview, and record review the facility failed to ensure the safety and prevent a fall with injury for 1 Resident #1) of 3 residents ( Residents #1, #4, #5 ) reviewed for falls in a total sample of 6 residents, resulting in a fall with a fracture. Findings include: On 8/19/2015, The facility identified an incident resulting in an injury to a resident. The facility reported the incident within 24 hours to the State Agency and initiated an investigation. On 8/25/15, an unannounced on site investigation was initiated. Review of the medical record revealed Resident #1 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS)dated 6/1/15, revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated Resident #1 had moderate cognitive impairment. Review of MDS section G (functional status) revealed Resident #1 required assistance for transfers. Review of the Fall Care Plan revealed Resident #1 was At Risk for Falls. Information and interventions to protect Resident #1 included: required assistance with transfers, a history of attempting self-transfers despite reminders, poor judgement, and lacked insight. 20-40 minutes checks for safety, Do not leave unattended in the bathroom, sensor alarm, and an alarming seat belt. The documentation of the Fall Care Plan revealed the alarms were to be, appropriately placed , and checked regularly to ensure the device was functioning. Review of the Incident Report dated 8/19/15, completed by Licensed Practical Nurse (LPN) H revealed during the evening meal in the Health Center (HC) #2 Dining Room Resident # 1 fell . The report indicated the fall was not witnessed by the 5 staff members present. The documentation by LPN H indicated the alarm did not activate prior to the fall. The report indicated the Resident was evaluated and returned to her room. The documentation of the incident indicated the Resident later complained of pain, was re-evaluated and transported to the hospital where it was determined a fractured hip was sustained in the fall. Review of the facility report to the state agency dated 8/21/15, revealed, it was determined resident (Resident #1) was in dining room chair without alarm as care planned . Care plan was followed . Review of the statement dated 8/19/15, revealed LPN H documented she did not hear an alarm prior to the fall of Resident #1. On 8/26/15, at 3:23 PM, a telephone Interview was conducted with LPN H. LPN H reported she was unsure if an alarm was on the dining chair of Resident #1. LPN H reported she did not hear an alarm prior to fall. LPN H reported she did not hook up or reset an alarm after assisting Resident #1 back into the dining chair. Review of the statement dated 8/19/15, revealed Certified Nurse Aide (CNA) G documented no alarm was heard prior to the fall of Resident #1. On 8/26/15, 3:05 PM, an interview was conducted with CNA G who reported no alarm was heard prior to the fall of Resident #1 on 8/19/15. Review of the statement dated 8/19/15, revealed Dietary Personal (DP) K reported no alarm was heard prior to the fall of Resident #1. On 8/26/2015, 9:50 AM, an interview was conducted with CNA D. CNA D reported a sensor alarm would be moved with the resident to whatever chair the resident would sit in. CNA D reported the facility kept a log of alarm checks that were completed every 2 hours for function and placement by the staff assigned to the care of resident with the alarm. Review of the Alarm Check Log dated 8/19/15, for Resident #1 revealed alarms were not documented for 7 am-3pm shift, but alarm checks were documented for the 3pm-11pm shift during which time Resident #1 fell and was transported to the hospital. Review of Alarm Check Logs for 2 days prior to the fall of Resident #1 revealed alarm checks were not documented for 7 am-3pm shifts, 3pm-11pm shifts, and 11pm-7am shifts. Review of the facility report to the state agency dated 8/21/15, revealed, Care plan was followed and it was an isolated incident for the resident (Resident #1). Review of the medical record revealed Resident #1 had prior falls on 9/16/14, 4/4/15, 6/11/15, and 8/9/15. Review of the facility Incident Report Check List dated 9/16/14, revealed Resident #1 fell and fractured her wrist. Review of the Fall Care did not reveal new interventions were implemented following the fall of 4/4/15. Review of the facility Incident Report Check List dated 6/11/15, at 8:00 AM, revealed Resident #1 fell in her room. The report indicated an alarm was in place but was disconnected. Review of the facility Incident Report Check List dated 8/9/15, at 8:05 AM, revealed Resident #1 fell in her room. The report indicated an alarm was in place but battery dead. On 8/26/15, 10:10 AM, an interview was conducted with CNA D. CNA D revealed the facility used a Care Guide which is the communication between CNA's and Nursing, and includes how residents were assisted, transferred, ambulated, dining needs, toileted, and showers. CNA D had a current Care Guide for Resident #1. Review of the Care Guide provided by the facility 8/26/15, revealed Resident #1 required a sensor alarm and, 20 - 40 min checks. In an interview conducted 8/26/15, at 12:40 PM Director of Nursing (DON) C revealed the facility did not have a record or log of completed checks of the Care Guide instruction and Fall Care Plan intervention implemented 6/11/15, that directed, Check on me at least every 20 -40 minutes to be sure I am safe.