Every finding on record at Medilodge of Portage

This citation pertains to intake #2968884, #3004071, and #3000720Based on observation, interview and record review the facility failed to ensure resident received appropriate care for skin breakdown and pressure ulcer development in 2 of 3 residents (Resident #119 and Resident #5) reviewed for pressure ulcers, resulting in Resident #119 developing a pressure ulcer infection and Resident #5 developing pressure ulcers.Findings include:Resident #119 Review of a Face Sheet revealed Resident #119 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: pressure ulcer of the sacral region (the lower part of the back, base of the spine just above the buttock) stage 4 (most severe form of the pressure ulcer, characterized by a deep, open wound that extends through the skin, underlying tissue, muscle, and bone), sepsis (a life-threatening condition caused by the body's extreme response to an infection), and paraplegia (paralysis of the legs and lower body). In an interview on 5/13/26 at 9:04 AM, Registered Nurse (RN) DD reported Resident #119 had orders for a wound vac (wound vacuum- a medical device that uses negative pressure to promote wound healing) when he was admitted to the facility. RN DD reported Resident #119's wound vac care was difficult on occasion and his wounds had so much drainage. RN DD reported Resident #119 had an order for a wet to dry dressing (involves placing a piece of gauze, moistened with sterile saline or water directly into the wound opening) when the wound vac was not working and he was waiting to be seen by the wound clinic. RN DD reported Resident #119's wound dressings were changed a couple of times a week. In a telephone interview on 5/13/26 at 9:14 AM, Family Member (FM) XX reported Resident #119 had a bad wound in his sacral area and had orders for a wound vac and the facility did not put the wound vac on as it should have been and Resident #119's wound was exposed to blood, pus, and urine when the facility did not have the wound vac in place. FM XX reported she had visited Resident #119, and the wound vac was not in place. FM XX reported Resident #119's wound was to be kept clean and dry. FM XX reported she was told by facility staff that the facility did not have the right staff to place a wound vac. FM XX stated if Resident #119's care was too complex for the facility to handle; they should have not accepted him. Review of Home Discharge Instructions for Resident #119 dated 2/16/26 revealed .Wound Care Discharge Instructions wound vac for sacral wounds x 4.change wound vac every Monday and Thursday.Nursing Notes History dated 2/12/26.all wounds have improved with this dressing change.R (right) trochanter (hip area/end of the femur near the hip joint) .no drainage with this assessment.R ischial (area of the hip/the curved bone forming the base of pelvis) wound. partially debrided (removal of dead tissue from wound bed).left side wound are all pink, clean, and granular (new tissue growth).will continue with NPWT (negative pressure wound therapy/wound vac) dressings biweekly (two times a week). Review of Braden Scale for Predicting Pressure Ulcer Risk Evaluation for Resident #119 from 2/16/26 revealed .Braden score 14. (13-14 moderate risk for the development of pressure ulcers). Review of Nursing Evaluation Summary for Resident #119 dated 2/16/26 at 15:49 (3:49 pm) revealed .Resident has wound vac on his coccyx. Review of Skin Issues for Resident #119 dated 2/16/26 at 16:23 (4:23pm) revealed .Skin issue #001.rear right trochanter.Stage 3(serious skin injury characterized by full thickness skin loss, exposing the fatty tissue beneath).no signs and symptoms of infection.painful yes.length 8.49 cm(centimeters) width 8.96 cm depth 2.8 cm.exudate (drainage) moderate amount, serosanguineous (drainage that is contains a mixture of clear and bloody) mixture of serous (clear watery fluid) and sanguineous (resembling/containing blood) fluid, typically pale, red, and watery.no odor after cleaning.primary dressing.negative pressure wound therapy.secondary dressing. no secondary dressing applied.Skin issue #002.rear left trochanter.Stage 3.no signs and symptoms of infection.painful yes.length 3.7 cm width 2.67 cm depth 0.2 cm.exudate (drainage) moderate amount, serosanguineous (drainage that is contains a mixture of clear and bloody) mixture of serous (clear watery fluid) and sanguineous (resembling/containing blood) fluid, typically pale, red, and watery.no odor after cleaning.primary dressing.negative pressure wound therapy.secondary dressing. no secondary dressing applied.Skin issue #003.Right gluteus (buttock).Stage 3.no signs and symptoms of infection.painful yes.length 6.26 cm width 7.61 cm depth 2.9.exudate (drainage) moderate amount, serosanguineous (drainage that is contains a mixture of clear and bloody) mixture of serous (clear watery fluid) and sanguineous (resembling/containing blood) fluid, typically pale, red, and watery.no odor after cleaning.primary dressing.negative pressure wound therapy.secondary dressing. no secondary dressing applied.Skin issue #004.Left gluteus.Stage 3.no signs and symptoms of infection. painful yes.length 6.41 cm width 4.37 cm depth 1.7 cm.exudate (drainage) moderate amount, serosanguineous (drainage that is contains a mixture of clear and bloody) mixture of serous (clear watery fluid) and sanguineous (resembling/containing blood) fluid, typically pale, red, and watery.no odor after cleaning.primary dressing.negative pressure wound therapy.secondary dressing. no secondary dressing applied. Review of Transcribed Physician Progress Note for Resident #119 dated 2/17/26 at 13:33 (1:55 pm) revealed .chief complaint Gluteal, lower extremity wounds.was transferred to this facility for continued physical rehab, has wound VAC in place. Review of Nurses' Notes for Resident #119 dated 2/18/26 at 03:50 (3:50 am) revealed .reinforcement successful. Wound vac running.No leaks. Review of Skin Issues for Resident #119 dated 2/18/26 at 22:11 (10:22 pm) revealed .Skin issue #002 has not been evaluated.location right gluteus.Skin issue #005 has not been evaluated.location rear left trochanter.Skin issue #009 has not been evaluated.location left gluteus.Skin issue #012 has not been evaluated. location rear right trochanter. Review of Nurses' Notes for Resident #119 dated 2/18/26 at 22:41 (10:22pm) revealed .Wound vac.was noted to be leaking.night shift nurse attempted to patch it but was unsuccessful.it began to leak after repositioning.order obtained to apply a wet-to dry dressing until tomorrow. Review of Nurses' Notes for Resident #119 dated 2/19/26 at 12:28 pm revealed .a voicemail was left with (Name Redacted) wound clinic to see if the resident is to follow-up with them for his multiple wounds; the resident is adamant he is seen by them. Review of Nurses' Notes for Resident #119 dated 2/20/26 13:18 (1:10 pm) revealed .due to the wound vac repeatedly not functioning properly due to the extent and location of his wound on his bilateral hips and ischium a seal cannot be maintained. Replacing and reinforcing the wound vac therapy has been attempted multiple times by multiple different people. Okay per (Name Redacted) NP to use a wet to dry dressing at this time. She is aware that we are waiting to get him into the wound clinic. Review of Skin Issues for Resident #119 dated 2/23/26 at 10:01 am revealed .Skin issue #002.right gluteus.progress: stable.previously deteriorating wound characteristics plateaued.unstageable ulcer due to slough (dead nonviable tissue in a wound, yellow or white that can impede healing) and/or eschar (a thick dry dead layer of tissues that forms over a wound often appearing black).no signs and symptoms of infection.painful no.length 6.97 cm width 7.76 cm depth 3 cm.exudate moderate amount, serosanguineous.no odor after cleaning.dressing saturation moderate 26-75% .primary dressing.wet soak.Other secondary dressing ABD (abdominal) pad tape.Skin issue #005.rear left trochanter. progress: stable.previously deteriorating wound characteristics plateaued.Stage 3.no signs and symptoms of infection.painful no.length 3.9 cm width 3.01 cm depth 0.2 cm.exudate moderate amount, serosanguineous.no odor after cleaning.dressing saturation moderate 26-75% .primary dressing.wet soak.Other secondary dressing ABD pad tape.Skin issue #009.Left gluteus. progress: stable.previously deteriorating wound characteristics plateaued.Stage 3.no signs and symptoms of infection.painful no.length 6.08 cm width 6.08 cm depth 1.5.exudate moderate amount, serosanguineous .no odor after cleaning. dressing saturation moderate 26-75% .primary dressing.wet soak.Other secondary dressing ABD pad tape.Skin issue #012.Rear right trochanter. progress: stable.previously deteriorating wound characteristics plateaued.unstageable ulcer due to slough and/or eschar.signs and symptoms of infection none.painful no.length 12.63 cm width 7.97 cm depth 2.1 cm.exudate moderate amount, serosanguineous.no odor after cleaning. dressing saturation moderate 26-75% .primary dressing.wet soak.Other secondary dressing ABD pad tape. Skin issues #002, #005, and #009 were noted documented with an increase in wound size indicating a decline not a stable plateau. Review of Appointment/Transportation Note for Resident #119 dated 2/24/26 at 13:47 (1:47pm) revealed .(Name Redacted) wound clinic resident scheduled for 3/3/26 at 1030. It was noted that the facility contacted (Name Redacted) wound clinic to schedule an appointment for Resident #119, seven (7) days after he admitted to the facility. Review of Skin Issues for Resident #119 dated 3/2/26 at 9:33 am revealed .Skin issue #008.rear left trochanter.progress: stable.previously deteriorating wound characteristics plateaued.stage 3.length 3.18 cm width 3.11 cm depth 0.2 cm.Other primary dressing calcium alginate.other secondary dressing applied super absorbent. frequency of dressing every day shift and PRN (as needed). Skin issue #012.left gluteus.progress: stable.previously deteriorating wound characteristics plateaued.Stage 3.length 4.09 cm width 5.04 cm depth 0 cm.exudate heavy amount, serosanguineous.Other primary dressing calcium alginate.other secondary dressing applied super absorbent. frequency of dressing every day shift and PRN .Skin issue #016.Right gluteus. progress: stable.previously deteriorating wound characteristics plateaued.Stage – unstageable.length 5.5 cm width 6.85 cm depth 0.exudate moderate amount, serosanguineous .Other primary dressing calcium alginate.other secondary dressing applied super absorbent. frequency of dressing every day shift and PRN.Skin issue #020.Rear right trochanter. progress: stable.previously deteriorating wound characteristics plateaued.unstageable ulcer.length 5.27 cm width 8.52 cm depth 0.5 cm.exudate heave amount, serosanguineous. Other primary dressing calcium alginate.other secondary dressing applied super absorbent. frequency of dressing every day shift and PRN. Skin issues #008 and #020 were noted documented with an increase in wound size indicating a decline not a stable plateau; and skin issues #008, #012, #016, and #020 were noted to have no documentation regarding an assessment for signs and symptoms of infection. Review of Nurses' Notes for Resident #119 dated 3/3/26 at 12:16pm revealed .(Name Redacted) wound clinic called and stated that they are sending resident (Resident #119) to the ED (emergency room) d/t (due to) fever and wounds needing to be debrided (removal of dead, damaged, or infected tissue to promote healing). Review of Progress Note Details for Resident #119 provided by wound clinic, dated 3/3/26 revealed .male.decreased mobility presents with multiple wounds from (Name Redacted) facility.was last seen on 1/15/26.was hospitalized 1/27-2/16/26 .while hospitalized he had an excisional debridement of.bilateral gluteal abscesses.was discharged to (Name Redacted) facility with a wound vac. However, he had no dressing on his wounds or wound vac supplies when he arrived at the wound clinic.He also had a 100.7 degree F temperature.Right hip wound with necrotic tissue draining copious amounts of purulent draining and probing down to the bone (a clinical tool used to diagnosis osteomyelitis (an infection of the bone) by detecting whether bone can be palpated through the wound with a sterile blunt metal probe). In a telephone interview on 5/14/26 at 8:49 AM, Wound Clinic Nurse Practitioner (WCNP) RR reported Resident #119 arrived at the clinic for his appointment on 3/3/26 with no dressings on his wounds and no wound vac or wound vac supplies. WCNP RR reported she would never recommend that a wound be left uncovered. WCNP RR reported Resident #119 had a low-grade fever and an infection in a wound and she sent him to the emergency room for treatment. WCNP RR reported Resident #119 was an established patient and the wound clinic should have been contacted by the facility regarding the difficulties experienced with Resident #119s wound vac. WCNP RR reported the facility had not contacted the wound clinic regarding Resident #119's wounds, dressing instructions, the wound vac malfunctioning, or for alternate treatment for his wounds. WCNP RR reported the facility had contacted the wound clinic via telephone on 2/23/26 regarding the need for a follow up appointment for Resident #119. Review of Treatment Administration Record (TAR) for Resident #119 for the month of February 2026 revealed .Bilateral hips/ischial wounds: cleanse & pat dry. Apply skin prep to surrounding tissue. Apply wound vac dressing, bridging all four wounds. Maintain continuous pressure at -125 mmhg (millimeters of mercury) every day shift every Mon, Thu for pressure wounds with a start date of 2/19/26 and a D/C (discontinue) date of 2/23/26. In a telephone interview on 5/14/26 at 2:41 PM, Wound Nurse/Registered Nurse (WN/RN) D reported Resident #119's wound vac was never discontinued. WN/RN D reported there was a time when the staff were struggling to get the dressing and the wound vac to seal, and they were given an OK to use a wet to dry dressing. WN/RN D reported she was able to get the wound vac to seal a couple of days at a time, and that her and Education Training Director/RN (ETD/RN) N were the two nurses managing Resident #119's wound care. WN/RN D reported she did not contact the wound clinic for alternate treatment options for Resident #119's wounds when the wound vac would not seal. WN/RN D reported she was on vacation from 2/24/26 and returned on 3/3/26 and when she is out of the building, ETD/RN N was the nurse who covered for her. In an interview on 5/14/26 at 3:08 PM, ETD/RN N reported she only covered for WN/RN D one day during her week vacations. ETD/RN N reported Resident #119 should have had dressings on his wound when he went to the wound clinic on 3/3/26, and she had no idea why they weren't covered. ETD/RN N reported Resident #119's wound vac was not discontinued; they were struggling to get it to seal correctly. ETD/RN N reported there was a day that she spent over an hour trying to secure the wound vac dressing for Resident #119 and was unsuccessful and had to contact the on call provider for an order to place a wet to dry dressing instead. ETD/RN N reported there should have been other nurses to assist with Resident #119's wounds, she was not the only one to cover when WN/RN D was off. ETD/RN N reported there was a standing order for a wet to dry dressing for wounds when they could not get a wound vac dressing secured. When queried, ETD/RN N reported she did not contact the wound clinic regarding alternate wound treatments for Resident #119's wounds when they experienced difficulties with the wound vac seal. In an interview on 5/14/26 at 3:15 PM, Director of Nursing (DON) B reported ETD/RN N was responsible for covering for WN/RN E when she was out of the building. In an interview on 5/14/26 at 3:21 PM, Nursing Home Administrator (NHA) A reported Resident #119's wound vac wound not seal and at one point Resident #119 had to be sent to the hospital for it to be placed. NHA A reported the wound vac was never discontinued, but it was placed on hold because it would not seal. In an interview on 5/14/26 at 3:22 PM, Corporate Clinical Nurse (CCN) E confirmed Resident #119's wound vac order was discontinued on 2/23/26. In an interview on 5/14/26 at 3:25 PM, NHA A reported she did not have documentation regarding the discontinuation of Resident #119's wound vac, continuation for the use of a wet to dry dressing in place of the wound vac, discussions with in house provider regarding Resident #119's wound care, nor discussions with wound clinic staff regarding Resident #119's wound care. Resident #5: Review of an admission Record revealed Resident #5 was a female with pertinent diagnoses which included heart failure, chronic pain, respiratory failure, peritoneal abscess (collection of infected fluid or pus in the abdominal cavity) JP drain infection (Jackson Pratt drain is a flexible, bulb-shaped surgical drain used to remove excess fluids (blood, serous fluid) from a wound site) and stroke. Review of Resident #5's activity of daily living (ADL) care plan included an intervention, revised 4/16/26, which stated, BED MOBILITY: 1 person assist; utilizes bilateral grab bars. Review of a current Care Plan for Resident #5 revised on revealed a focus .Resident is a risk for impaired skin integrity as evidenced by weakness, heart failure, chronic pain, impaired vision. Resident admitted with left arm skin tear, left buttock MASD (Moisture Associated Skin Damage-inflammation, softening, and erosion of the skin caused by prolonged exposure to bodily fluids), left flank indentation/redness, medial abdomen abscess (a walled-off pocket of pus and infection fluid inside the belly often caused by bacterial infections), bilateral feet dry skin, low back JP (drain) pain.New: Left heel pressure ulcer.Left calf red discoloration. with the intervention .APM (alternating pressure mattress) to bed; check for proper machine functioning & mattress inflation.Apply protective barrier cream after incontinent episodes.Encourage & assist resident to turn and reposition q (every) 2-3 h (hour) and PRN (as needed) .Encourage/assist as needed to elevate heels off the mattress as tolerated. Review of Braden Scale for Predicting Pressure Sore Risk dated 5/3/26 at 8:02 PM, revealed a BRADEN Score: 16.0 which indicated a mild risk for skin breakdown. Review of New Follow UP Note (Electronic Medical Record) dated 4/16/26 at 11:22 PM, revealed, .PLAN: 04/16/2026 - . Encourage out-of-bed activity multiple times per day. Requires ongoing skilled therapy progression and monitoring.Bowel and Bladder: Incontinent.The patient requires assistance with functional mobility and ADLs and has safety issues requiring further management. - Needs to continue intensive subacute rehabilitation therapy in order to ensure a safe discharge plan. Review of the document Skin Issue: #003 revealed Resident #5 had a new deep tissue pressure ulcer identified on the left heal, acquired 5/8/26 in house that was painful intermittently and burning. The wound measured Length (cm): 4.19 Width (cm): 3.89 Depth (cm): 0 Area (cm2): 13.36 Undermining: No. Tunneling: No. Epithelial: 100%. Exudate amount: None. Resident #5 was to have the wound cleaned and skin prep applied twice daily. Review of the document Skin Issue: #004 revealed Resident #5 had a new on the left lateral calf that was facility acquired and identified on 5/8/26. The wound measured Length (cm): 0.81 Width (cm): 4.89 Depth (cm): 0 with 100% epithelial tissue and no exudate. The wound was to be cleaned daily and as needed with skin prep applied. Review of Skin and Wound Note dated 5/11/26 at 4:21 PM, revealed Resident #5's wounds were .Left heel. Size: 5 cm x 4 cm x 0 cm (which was an increase in size) and the Left calf.Size: 8 cm x 1 cm x 0 cm. The treatment plan for the heel included: Treatment Recommendations: 1. Cleanse with wound cleanser.2. apply Skin Prep to base of the wound.3. leave open to air .4. apply skin prep every shift. The treatment plan for the left calf included Treatment Recommendations: 1. Cleanse with wound cleanser.2. apply Skin Prep to base of the wound.3. leave open to air 4. apply skin prep every shift.PREVENTATIVE MEASURES: Group 2 support surface - powered pressure reducing air mattress or non-powered advanced pressure reducing mattress, Offload heels per Facility Protocol, Offload pressure / reposition patient frequently.Additional Recommendations: Pain control: 30 min prior to wound treatment, please administer PRN pain medication and/or topical anesthetic. Pressure Relief: Repositioning, offloading, Specialty mattress.Dietary Interventions: protein supplement with meals twice daily until wound closure. Review of Order dated 5/8/26, revealed, .Encourage & assist resident to wear bilateral pressure redistribution boots at all times while in bed. every day and night shift. Review of Standard of Care Meeting dated 5/13/26 at 11:25 AM, revealed, .Reasons for Standards of Care review Wound: Reinforce current care plan updated: - APM to bed; check for proper machine functioning & mattress inflation.- Encourage & assist resident to turn and reposition q.2-3h and PRN.Assist as needed.- Encourage/assist as needed to elevate heels off the mattress as tolerated. During an observation on 05/12/2026 at 9:38 AM, Resident #5 was observed lying in her bed feet out in front of her, lying on her back, the head of her bed was at approximately 60 degrees, she did not have her feet on a pillow or bolster. No boots were noted on her feet. During an observation on 05/12/2026 at 10:04 AM, Resident #5 was observed lying in bed feet out in front of her, on her back and had the head of the bed at approximately 60 degrees. Review of Resident #5's medical record revealed no refusals noted for repositioning/turning and wearing pressure redistribution boots. In an interview on 05/14/2026 at 1:45 PM, Licensed Practical Nurse (LPN) W reported if a resident was susceptible to developing a pressure ulcer wound, and the resident refused turning and repositioning a progress note would be created in the medical record to document the refusal as well as the CNA (Certified Nursing Assistant) would document in their area in the medical record the refusal. In an interview on 05/14/2026 at 1:52 PM. Registered Nurse (RN) CCC reported if a resident was dependent for cares and the resident refused assistance with turning and re-positioning that as the nurse she would enter a note into the medical record to document any refusals of care. In an interview on 05/14/25 at 3:04 PM, Director of Nursing (DON) B reported staff should document in the medical record if a resident was refusing pressure ulcer interventions.

Based on observation, interview, and record review the facility failed to: 1.) ensure the safety of residents to prevent falls, 2) provide adequate supervision and assistance to prevent falls, and 3.) utilize footrests for wheelchair transport in 3 of 3 residents (Resident #40, #26, and #95) reviewed for accidents and hazards, resulting in Resident #40 having 22 falls over 2 months, Resident #40 and #95 being transferred without wheelchair footrests, and Resident #26 being improperly transferred. This deficient practice placed all 3 residents at risk for injury.Findings include: Resident #40: Review of an admission Record revealed Resident #40 was a male with pertinent diagnoses which included Alzheimer's disease, history of falling, dementia, insomnia, and kidney disease stage 3. Review of the medical record reviewed Resident #40 had 22 falls in two months between 3/11/26 and 5/12/26. Most of the falls indicated the root cause was the resident self-transferred and frequently needed toileting. During an observation on 05/12/2026 at 9:27 AM, Resident #40 was observed seated in his wheelchair in the doorway to his room. Resident #40 was observed to have a reddish/purple bruise directly under his middle left lower eyelid with a reddish-purple bruise that extended outward toward the corner of his left eye. During an observation on 05/13/2026 at 4:25 PM, Certified Nursing Assistant (CNA) Y was observed adjusting Resident #40 in his wheelchair, in front of him was the sit to stand transfer device. CNA Y had placed Resident #40 in the hallway and had him raise his legs while she pushed him out of the doorway into the hallway next to the rolling bedside table which was along the wall in the hallway. Resident #40 was observed attempting to prepare to stand up and CNA Y was able to intervene as she had been retrieving his foot pedals for his wheelchair in his room. CNA Y attached the foot pedals and was propelling Resident #40 down the hallway towards the dining room area as there was an activity occurring. Resident #40's right foot pedal fell off and CNA Y stopped and re-attached it, she continued down the hallway and Resident #40's left foot pedal fell off the wheelchair, and she continue to push him around the corner and into the dining room with the foot pedal being dragged under the wheelchair. In an interview on 05/14/2026 11:10 AM Unit Manager (UM) J reported Resident #40 has had a cognitive decline and when the falls began to happen, he was more higher functioning than he was now. UM J reported Resident #40 had had seizure activity and he had been receiving routine Busbar due to the chronic restlessness, but it was discontinued so she reported she wasn't sure if that correlated with the start of the falls Resident #40 had. UM J reported Resident #40 was able to stand and pivot and was now a hoyer transfer. UM J reported quite a few of Resident #40's falls revolved around him needing to use the bathroom and care plan interventions were developed to take him to the restroom prior to meals in the dining room and prior to placing him in bed. UM J reported the education provided to staff to follow the Kardex was provided verbally to the staff who were working the day it was determined education was needed. In an interview on 05/14/2026 at 2:52 PM, Nursing Home Administrator (NHA) A reviewed Resident #40's medical record and reported for transfers he was a hoyer lift with two staff assistance with transfers. NHA A reported it was not appropriate for Resident #40 to be transferred with a sit to stand and one person provided assistance. NHA A reported that when a resident had an incident involving a fall, the nurses were to implement an immediate intervention to keep the resident safe. NHA A reported the interdisciplinary team (IDT) reviewed the fall incidents and determined if the intervention initially implemented by the nurse was appropriate, if not, the intervention was revised in the incident report. NHA A reported this was not usually done on the day of the incident, especially if a fall incident happened over the weekend. NHA A reported a resident should not be transported in a wheelchair without foot pedals as the resident could place their feet down and create an injury. NHA A reported Resident #40 did not start restorative therapy until later due to falls that occurred after the fall where it was determined to start restorative therapy due to repeated falls and then eventual decline in resident's ability to self-ambulate. In an interview on 05/14/2026 at 1:33 PM, Licensed Practical Nurse (LPN) MM reported the nurse would develop and implement an immediate intervention following us fall to help prevent the next fall and provide for the safety for the resident. Review of the care plan for falls revealed Resident #40 was at risk for falls due to a history of falls, dementia, brain tumor and known to self-transfer/ambulate without asking for assistance. Interventions included: anti-roll backs to wheelchair Date Initiated: 11/21/2025 . Bed against wall to decrease environmental obstacles of room Date Initiated: 11/17/2025. Offer resident a HS snack at bedtime. Date Initiated: 01/21/2026 . Wheelchair to be locked at bedside when resident is in bed. Date Initiated: 11/17/2025 . Encourage & assist bed to remain at transfer height at all times. Date Initiated: 02/24/2026 Revision on: 03/11/2026 . No interventions were in place to prevent or mitigate risk for self-transfer/ambulation and toileting needs. Review of the incident/accident reports, care plans, and the initial fall evaluations revealed the following: 3/11/26 at 2:20 pm – fall out of bed. bed left high 3/30/26 at 00:00am- fall out of wheelchair. Self-transfer history and no toileting 5 hrs. Root cause: attempt to self-transfer. Review of Care Plan for Resident #40 revised on 5/1/26 revealed the added intervention of Resident to be referred to restorative program for strengthening. Date Initiated: 03/30/2026 . 4/4/26 at 3:50 am – fell from wheelchair. Not adequately monitored but had been redirected multiple times. Root cause: attempt to self-transfer. 4/4/26 at 8:20pm – fell in room on floor incontinent of urine. Wanted go to bathroom. Root cause: attempt to self-transfer. 4/10/26 at 4:37 am – fall in room. Was in bathroom, found vomit, stool and blood in bathroom. Root cause: attempt to self-transfer. 4/10/26 at 12:10pm – resident observed to stand up and walk unattended hitting his head. Root cause: attempt to self-transfer. Review of Transcribed NP/PA Progress Note dated 4/10/26 at 2:58 PM, revealed, .Service date/time: 4/9/26 at 10:51 PM, revealed, this is an [AGE] year-old male seen today at (Facility) .he has been vomiting and having seizure-like activity.he has been hypotensive today we will discontinue his dose of Norvasc. Will start low-dose lorazepam twice daily in the hopes to reduce his likelihood of breakthrough seizure. Orders given for Compazine for nausea .The patient has been up a lot at night or needing to monitor my hope is that Ativan will help settle him during his increased agitation in the evening hours. 4/11/26 at 8:15 pm – fell in visitor bathroom. Root cause: attempt to self-transfer. 4/11/26 at 11:40 pm – fell in hall after standing from wheelchair. Root cause: attempt to self-transfer. Review of Care Plan for Resident #40 revised on 5/1/26 revealed the added intervention of Encourage & assist the resident to use the toilet prior to bed. Date Initiated: 04/11/2026 . Review of Transcribed Physician Progress Note dated 4/14/26 at 1:42 PM, revealed, .it appears patient has been having frequent falls.It appears patient has had low sugars in the past and glipizide was held. Patient is poor historian, denies any dizziness, palpitations, sweating, medical staff does not report any change in mentation from baseline.Assessment/Plan 1. Type 2 diabetes mellitus: Patient currently on 10 units of Premeal insulin with Lunch, 28 units of Lantus twice daily, Sugars have been fluctuating will adjust dose of long-acting insulin to 25 units at bedtime, change Premeal insulin to 5 units, monitor sugars and adjust accordingly.2. Hypoglycemia: will make insulin adjustments as above he is asymptomatic unreliable historian due to cognitive impairment, unsure if he has hypoglycemia awareness, will have to be liberal with sugar control.3. Cerebral mass: on dexamethasone. Review of Nurses' Notes dated 4/17/26 at 11:44 AM, revealed, .New order to decrease the resident's bedtime Lantus to 10 units at HS (bedtime) per (Medical Doctor) due to hypoglycemic episode this morning. 4/12/26 at 3:55pm - resident found on floor in hallway. Root cause: fell asleep in wheelchair. Review of Care Plan for Resident #40 revised on 5/1/26 revealed the added intervention of If resident appears sleepy/sleeping in his wheelchair, encourage & assist resident to lay down in bed. Revision on: 04/13/2026 . Offer & assist to play music (county) when unable to sleep. Date Initiated: 04/13/2026 . 4/14/26 at 1:00pm – resident fell in dining room after attempt to stand or dislodge his wheelchair from current location. Root cause: attempts to stand, impulsiveness, poor safety awareness. Review of Care Plan for Resident #40 revised on 5/1/26 revealed the added intervention of Encourage & assist resident to wear hipsters at all times except bathing as tolerated. Date Initiated: 04/14/2026 . 4/17/26 at 1:00pm – resident fell, found lying in bathroom floor. Root cause: self-transfer to toilet independently. Interventions: toilet prior to meals and concave mattress. Review of Care Plan for Resident #40 revised on 5/1/26 revealed the added intervention of Assist resident to use the toilet then to the dining room for meals. Date Initiated: 04/17/2026 . During an observation on 05/13/26 at 4:00 PM, Resident #40 was propelled in his wheelchair by staff to the dining room without providing toileting prior to the meal after being transferred from his bed to the wheelchair. 4/18/26 at 00:50 am- resident found on floor sitting. Stated wanted to use restroom. Root cause: self-transfer to toilet independently. Intervention: fall mat to bedside. 4/18/26 at 9:10 am – resident sitting on floor in bathroom with soiled brief on. Root cause: self-transfer to toilet independently. Last toileted at 3:59 am. 4/18/26 at 12:00pm- resident found on floor in dining room after ambulating unassisted. Root cause: self-transfer Review of Care Plan for Resident #40 revised on 5/1/26 revealed the updated intervention of Educate staff to follow Kardex (care guide) to have resident toileted and then taken to dining room for meals Revision on: 04/20/2026 . 4/22/26 at 12:20 pm – resident found prone on bedroom floor. Had been waiting to be laid down. Root cause: self-transfer. Review of Care Plan for Resident #40 revised on 5/1/26 revealed the added intervention of Concave mattress to bed. Date Initiated: 04/22/2026 . 4/24/26 at 10:49am – found face down lying on bathroom floor. Skin tear observed. Root cause: self-transfer to bathroom. Intervention: continue current interventions. 4/26/26 at 11:50pm- resident observed lying on floor in room stated, trying to go to bathroom. Root cause: self-transfer to bathroom. 4/27/26 at 1:20am- resident found on floor in room with blood. Stated getting up to walk. Injury: skin tear left hand. Root cause: self-transfer/ambulate. Review of Care Plan for Resident #40 revised on 5/1/26 revealed the updated intervention of Bladder scan post void x3 with results to NP Date Initiated: 04/27/2026 . Fall mat to bedside floor when resident is in bed. Date Initiated: 04/27/2026 . 5/1/26 at 2:15am – resident found on floor in room. No new interventions. Root cause: self-transfer. 5/1/26 at 2:00pm – resident slid out of wheelchair in hallway and was lowered to floor by staff due to cushion being flat. Intervention: new cushion for chair. Review of Care Plan for Resident #40 revised on 5/1/26 revealed the updated intervention of Hospice contacted to order new pummel or anti-thrust cushion. Date Initiated: 05/01/2026 . 5/11/26 at 2:45pm – resident found on floor in doorway of room. No root cause identified. 5/12/26 at 9:10pm- resident found on floor inside doorway of room. No root cause identified. During an observation 05/14/2026 at 10:17 AM, Resident #40 was observed lying in his bed. Review of the incident/accident reports and the initial fall evaluations for these falls revealed the facility did not add any supervision interventions to Resident #40's care plan following each fall. Review of Resident #40's falls had revealed he had 8 incidents which resulted in skin tears on his arms and hands. Review of Resident #40s' falls had revealed he had 6 incidents which resulted in a bloody nose, 3 falls with abrasion injuries, an eyebrow laceration, and laceration to his right elbow. Review of policy, Accidents and Hazards revised on 12/27/23, revealed, .Each resident will be assessed for accident risk and will receive care and services in accordance with their individualized care plan. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring effectiveness and modifying interventions when necessary.5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility provides adequate supervision to prevent accidents. Adequacy of supervision is a. Defined by type and frequency .b. Based on the individual resident's assessed needs and identified hazards in their environment . Resident #26 Review of a Face Sheet revealed Resident #26 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: acute respiratory failure, malignant neoplasm of esophagus (cancer of the esophagus that has spread to other areas of the body) and sepsis (a life-threatening condition caused by the body's extreme response to an infection). Review of Care Plan for Resident #26 revealed focus/goal/interventions : Resident has an ADL (activities of daily living) self-care performance deficit.ADL needs will be met.toileting 1 person assist bedside commode.transfer 1 person stand and pivot assist.encourage resident to use call light when assistance is needed.with initiation dates of 2/20/2026. On 5/12/26 at 1:39 PM, Certified Nurse Assistant (CNA) NN was observed assisting Resident #26 from her bed onto her bedside commode. CNA NN was observed holding Resident #26 under both arms (armpit area) during the transfer. CNA NN did not use a gait belt during the transfer. On 5/12/26 at 1:42 PM, CNA NN was observed assisting Resident #26 up from the bedside commode. CNA NN was positioned in front of Resident #26 who was sitting on the commode, CNA NN used her right hand under Resident #26's left armpit and assisted Resident #26 into a partial standing position. Resident #26 sat back down abruptly onto the commode, and asked CNA NN can you hold me under both arms? CNA NN was observed placing a hand into each armpit of Resident #26 and lifting her from the commode into the bed. CNA NN did not use a gait belt for the transfer. In an interview on 5/12/26 at 1:48 PM, Resident #26 reported the staff did not use a gait belt when they assisted her onto the commode, or for any transfer. In an interview on 5/14/26 at 11:01 AM, CNA CC reported all transfers required the use of a gait belt. In an interview on 5/14/26 at 11:08 AM, CNA EE reported all transfers required the use of a gait belt. CNA EE reported gait belts offer safety and support for residents and staff when used during transfers. In an interview on 5/14/26 at 11:10 AM, Licensed Practical Nurse (LPN) MM reported Resident #26 was reevaluated on 5/12/26 after a difficult transfer to the commode and Resident #26's transfer status was downgraded for additional support. LPN MM reported that Resident #26 waxes and wanes with her strength, and staff should use a gait belt for safety during transfers. In an interview on 5/14/26 at 11:10 AM, CNA NN confirmed she did not use a gait belt when she transferred Resident #26 from bed to commode on 5/12/26 and said I should have especially with how weak she was the other day. Resident #95 Review of a Face Sheet revealed Resident #95 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: neurocognitive disorder with lewy bodies (a progressive brain disorder characterized by the presence of abnormal protein deposits called Lew bodies leading to cognitive decline and movement issues) and dementia (syndrome characterized by the decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities). Review of Care Plan for Resident #95 revealed focus/goal/interventions : Resident has an ADL (activities of daily living) self-care performance deficit.ADL needs will be met.transfer 2 person assist with Sara lift (a machine that assist an individual from a sitting to a stand position).impaired cognitive function.engage in simple, structured activities that avoid overly demanding tasks.with initiation dates of 4/28/2026. On 5/14/26 at 10:41 AM, Director of Nursing (DON) B was pushing Resident #95 in his wheelchair without footrests in place, down the B hall. DON B was observed standing behind and slightly to the side of the Resident #95's wheelchair, using her left hand on the right handle of Resident #95's wheelchair, and carrying a laptop in her right hand. DON B said pick your feet up to Resident #95 and as they passed this surveyor Resident #95's slippers could be heard scrapping on the floor as DON B continued to push Resident #95 in his wheelchair. DON B again reminded Resident #95 to pick your feet up. In an interview on 5/14/26 at 10:43 AM, DON B reported resident could be pushed without footrests as long as staff were walking beside them and could watch their feet and react if they put them down. DON B reported a resident could flip out of the wheelchair if they put their feet down while being pushed.

Based on observation and interview, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living.Findings Include:On 5/12/26 at 11:01 AM, observation of the D hall closet containing resident slings, found that the slings were hung up by one side on the hangers and left to drag onto the floor. When asked if this is how the slings are normally kept, Housekeeping Manager M stated that it happens all the time and that staff need to hang both sides of the sling up to keep it off the floor. On 5/13/26 at 9:47 AM, observation of the love seat and chair, located on the far side of the dining room, were found with increased accumulation of debris, sand, wrappers, paper trash and a yellow push pin. Further review of the chair found a sheet of paper with resident's names and rooms numbers for the D hall and an intact plastic vile of Albuterol Sulfate. On 5/13/26 at 10:15 AM, an interview with Housekeeping Manager M found that the furniture in the dining room gets cleaned daily and that they get a lot of use from residents in that area. On 5/13/26 at 10:17 AM, observation of the B hall spa room found slings hung up on one side with the bottoms of the slings hanging on the floor of the shower room. On 5/13/26 at 10:25 AM, observation of the sling closet on B hall found slings hung up on one side leaving the bottom portions of the slings laying on the floor. On 5/13/26 at 2:03 PM, a perimeter tour of the facility observed numerous discharge pipes, for diverting rainwater from the roof away from the building, found broken at the bottom where water would exit away from the building. This was allowing diverted rainwater to consistently run down the brick outer layer causing added deterioration and erosion of the building in these areas. During an observation on 05/13/26 at 10:39 AM, observed Room A-05's bathroom floor, which had dirt and debris scattered across the floor, needed to be mopped, and the toilet had a black coating on the caulking around it which appeared to be mold/mildew. The bathroom walls on each side of the toilet had black marks on the walls, the doorframe had scrapes in the paint, black marks on the door frames and baseboards. The bathroom door thresholds leading to Room A-05 and A-03 appeared to be dirty needing to be mopped. In Room A-05 behind the bathroom door had dried liquid material. The shared floor space in Room A-05 needed to be swept and mopped, there were black scuff marks covering the floor. During an observation on 05/12/2026 at 10:50 AM, observed in Room D-01, Bed 2 had a grey fall mat next to the bed which was encrusted with what appeared to be dirt and had various splatters across the mat of dried brown liquid material. During an observation on 05/13/2026 at 12:40 PM, observed in Room C3, the wall on the right-hand side had scrapes and black streaks on the wall, the entry doorway frame had built up dirt and debris/ marks on the doorway, and the doorway had paint scrapped off the doorframe. During an observation on 05/13/2026 at 12:43 PM, observed in Room C5, the wall on the left as entered the room had black streaks on the wall, the bathroom door, and baseboards as well. There were a couple of quarter size paint chips on the wall by the bathroom door. The door to the room had black marks and streaks on the bottom quarter of the door. During an observation on 05/13/2026 at 12:44 PM, observed in Room C8, there were black streaks and scrapes on the entry door, there was broken and missing piece of a tile at the transition from the hallway tile to the room tile near the door jamb. The hallway tile at the threshold had various cracks across them. During an observation on 05/13/2026 at 12:48 PM, observed in Room C8, the threshold from the room to the bathroom marble transition piece which would be under the bathroom door had the width of a door an area of dried liquid dirt where it would be under the door when closed. The door frame at the entry to the room had built up dirt and debris. The door to the room had black streaks/scrapes, and the door frame had missing paint/black scrapes. During an observation on 05/13/2026 at 1:01 PM, observed in Room C2 behind the entry door had the missing metal door stopper which was embedded in the floor and this created divot in the floor as well as appeared to be metal sticking up from the piece being broken off. During an observation on 05/14/2026 at 1:38 PM, observed on C Hallway outside of the Activity Supplies room door, there was a triangular piece of tile missing from the tile embedded there. Observed outside of the Personal Linens room door near Room C3, there was a half dollar size missing tile with cracks extending out from it. In an interview on 05/14/26 at 1:39 PM, Manager, Housekeeping M reported when the housekeeping staff observed broken items the housekeeping staff submitted a maintenance request in the facility maintenance request system. Manager, Housekeeping M reported the broken and missing tile in the hallway had been entered in the facility maintenance request system prior, but maintenance had not been able to complete the request yet.

This citation pertains to intake # 2790303 & 2968884.Based on interview, and record review, the facility failed to ensure timely response to call lights to meet resident needs in 4 of 5 residents (Resident #8, #14, #58, & #119) reviewed for dignity, and 6 of 13 residents from the confidential group interview, resulting in long call light wait times for incontinence care, frustration, and impaired self-worth.Findings include:Resident #8 Review of a Face Sheet revealed Resident #8 was a female, with pertinent diagnoses which included heart failure, obstructive lung disease, morbid obesity, diabetes, high blood pressure, depression, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 3/6/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15, indicating she was cognitively intact. Further review revealed Resident #8 was always incontinent of bowel and bladder. In an interview on 5/12/26 at 9:49 AM, Resident #8 reported concerns with long call light wait times, and staff coming to the room and turning off her call light before her need was met. Resident #8 reported call light response times on first shift are generally between 20-30 minutes but sometimes .it takes them (the staff) an hour . to respond to her call light and assist her with incontinence care. Resident #8 reported call light response times on second shift (in the afternoon) were generally longer, and she had to wait approximately 45 minutes at times for incontinence care and to get her brief changed. Resident #8 reported waiting a long period of time for incontinence care .Makes you feel like (expletive) .(Like) you are not worth anything. You don't mean anything . Resident #14 Review of a Face Sheet revealed Resident #14 was a female, with pertinent diagnoses which included heart failure, heart disease, obstructive lung disease, morbid obesity, chronic pain, anxiety, high blood pressure, muscle weakness, reduced mobility, diabetes, and a history of falls. Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 4/28/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15, indicating she was cognitively intact. Further review revealed Resident #14 was always incontinent of bowel and bladder. In an interview on 5/14/26 at 11:43 AM, Resident #14 reported concerns with long call light wait times. Resident #14 reported she experienced a call light wait time of approximately two hours last week for incontinence care during the morning shift. Resident #14 stated .I was soaked and it was burning my behind . Resident #14 reported waiting for an extended period of time for incontinence care makes her feel .bad . Review of the policy/procedure Call Lights: Accessibility and Timely Response, dated 1/1/2022, revealed .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response .All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified . Resident #58 Review of a Face Sheet revealed Resident #58 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: muscle weakness, history of falling, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness or paralysis of the right side of the body following a stroke). Review of Care Plan for Resident #58 revealed focus/goal/interventions : Resident has an ADL (activities of daily living) self-care performance deficit.ADL needs will be met.dressing 1 person assist.personal hygiene 1 person assist.toileting 1 person assist.transfer 1 person assist.encourage resident to use call light when assistance is needed.with initiation dates of 9/26/2023. In an interview on 5/12/26 at 9:45 AM, Resident #58 reported third shift staff would take over an hour to answer his call light. Resident #58 reported last week he had an accident, he urinated on himself, when he was waiting for the call light to be answered by the third shift staff. Resident #58 reported he was mad, frustrated, and embarrassed when that happened. Resident #58 stated The wait is ridiculous and it shouldn't happen.Someone could be dying waiting for them to answer the call light. Resident #119 Review of a Face Sheet revealed Resident #119 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: pressure ulcer of the sacral region stage 4 (most severe form of the pressure ulcer, characterized by a deep, open wound that extends through the skin, underlying tissue, muscle, and bone), sepsis (a life-threatening condition caused by the body's extreme response to an infection), and paraplegia (paralysis of the legs and lower body). Review of Care Plan for Resident #119 revealed focus/goal/interventions : Resident has an ADL (activities of daily living) self-care performance deficit.ADL needs will be met.dressing 1 person assist.personal hygiene 1 person assist.bed mobility 1 person assist.eating 1 person assist.transfer Hoyer lift x 2 staff assistance.encourage resident to use call light when assistance is needed.prefers to have call light attached to his wrist with a rubber band.with initiation dates of 2/16/26. In a telephone call on 5/13/26 at 9:41 AM, Family Member (FM) XX reported Resident #119 waited a long time for his call light to be answered. FM XX reported she witnessed Resident #119's call light on for over 20 minutes when she was visiting before staff responded. FM XX reported staff would turn off the call light, ask Resident #119 what he needed, and then they would not come back. FM XX reported Resident #119 would call her in the middle of the night, tell her his call light had been on for a long time, and no one would answer it. FM XX reported she would then call the facility and ask for the staff to check on Resident #119. FM XX reported her and another family member had to call the facility to get their attention several times. FM XX reported Resident #119 was bed bound and required a lift for transfers; he was unable to get out of bed on his own. In an interview on 05/13/2026 at 10:20 AM, 6 out of 13 participants from a confidential group meeting reported staff members were turning off call light before their needs were met, turning off the call light and not returning to complete the residents request, and long call light wait times for resident assistance.

Based on observation, interview, and record review the facility failed to ensure accurate medical records for 1 (Resident #77) of 21 residents reviewed for accurate medical records, resulting in an inaccurate representation of Resident #77's current care needs and the potential for unmet care needs.Findings include:Resident #77Review of a Face Sheet revealed Resident #77 was a female who originally admitted to the facility on [DATE] and had pertinent diagnosis which included: syndrome of inappropriate secretion of antidiuretic hormone (SIADH- a condition in which excessive antidiuretic hormone causes water retention and low blood sodium).Review of a Minimum Data Set (MDS) assessment for Resident #77, with a reference date of 4/25/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #77 was cognitively intact.On 5/12/26 at 9:15 AM, Resident #77 was in her room, sitting at the bedside, with her breakfast tray in front of her. Noted on the meal tray ticket present on Resident #77's breakfast was instructions for fluid restriction. Observed on Resident #77's breakfast tray was a 4-ounce glass of water and a cup of coffee. Resident #77 was drinking from the coffee cup. Observed on Resident #77's over the bed table was an empty coffee cup, a partially consumed 4-ounce glass of water, 3 Styrofoam cups approximately 480 mL in size, all partially consumed, with varying levels of water, and a partially drank (Brand Redacted) soda pop bottle.Review of Medication Administration Record for Resident #77 for May 1 to May 13, 2026, revealed .Fluid Restriction 1000 mL/24hr (hours) 540 mL from dietary and 460 mL from nursing every day and night shift for hyponatremia (low blood sodium) start date 4/21/26.Review of Care Plan for Resident #77 revealed focus/goal/interventions : Resident is at risk for altered nutritional status.will have adequate nutrition to meet nutritional needs.fluid intake restriction as ordered 1000mL (milliliters) (540 mL from dietary, 460 ML from nursing with an initiated date 4/21/26.On 5/13/26 at 10:36 AM, a 480 mL cup of water with the date 5/12, partially consumed, a 4-ounce cup of water, partially consumed, two 12-ounce cans of soda pop, unopened, and a large metal cup with a handle, lid, and straw was observed in Resident #77's room.In an interview on 5/13/26 at 10:50 AM, Resident #77 reported occasionally my sodium gets low and they put me on a fluid restriction; I might even have to go to the hospital for salty fluids. Resident #77 reported she was not on a fluid restriction now since her salt was fine. Observed a partially consumed 16-ounce bottle of soda, and Resident #77 reported she had acquired it that morning, and she was drinking it. Resident #77 stated I am not retaining fluid right now, I can drink what I want, and I do.In an interview on 5/13/26 at 10:59 AM, Certified Nurse Assistant (CNA) AA Resident #77 was on a fluid restriction, and it was the responsibility of all the staff to monitor her compliance with the fluid restriction.In an interview on 5/13/26 at 11:18 AM, CNA X reported she was not familiar with Resident #77 but knew she was on a fluid restriction. CNA X reported she did not believe Resident #77 was compliant with following her fluid restriction considering the large number of cups she removed from her room that morning.Review of Medication Administration Record for Resident #77 for May 1 to May 13, 2026, revealed .Fluid Restriction 1000 mL/24hr (hours) 540 mL from dietary and 460 mL from nursing every day and night shift for hyponatremia, start date 4/21/26. 23/25 documented entries indicated staff acknowledged and followed the ordered fluid restriction for Resident #77.In an interview on 5/13/26 at 2:20 PM, Licensed Practical Nurse (LPN) MM reported Resident #77 was on a fluid restriction. LPN MM reported when she documented in the MAR regarding Resident #77's fluid restriction, she was documenting her acknowledgment that Resident #77 was on a fluid restriction, not if she was compliant with her fluid restriction.In an interview on 5/13/26 at 2:31 PM, Registered Dietitian (RD) L confirmed Resident #77 was ordered to be on a fluid restriction.In an interview on 5/13/26 at 2:39 PM, Nurse Practitioner (NP) YY reported Resident #77 should be on a fluid restriction, but she knew she would not be compliant, so she didn't order one. NP YY reported if Resident #77 was on a fluid restriction and was not compliant the nursing staff needed to document that. NP YY stated, Yes, she should be on one, but it won't make a difference, she won't follow it, it will just fail.

Based on observation, interview, and record review, the facility failed to provide individualized activities designed to support the psychosocial well-being of 1 of 1 resident (R65) reviewed for activities, resulting in a potential for feelings of social isolation, loneliness, boredom, and depressed mood.Findings include:Review of R65's Minimum Data Set (MDS) dated [DATE], revealed the resident was unable to complete the BIMS (Brief Interview Mental Status) with a score of 99. Section B- Hearing, Speech, and Vision, stated R65 was absent of spoken words and rarely/never understood. Section GG-Functional Abilities revealed R65 was dependent on staff to provide ADLs (activities of daily living) including positioning and sensory stimulation. Section I-Active Diagnoses indicated R65's active diagnoses included stroke and traumatic brain injury.Review of R65's Care Plan, At Risk for Altered Activity Patterns/Pursuits related to cerebral infarction was dated 9/22/2023. The goal for the resident was revised on 3/17/2026 and included R65 accepting/interacting with others during 1:1 visit. To meet this goal, interventions included visiting with his son, listening to music-R&B (rhythm and blues), and short room visits. It was noted this intervention had not been revised since 12/17/2023 and there were no other activities listed to offer R65 including gardening and being outdoors. Review of R65's Activities Evaluation dated 3/2/26, indicated the resident was evaluated for activities he enjoyed which included family/friend visits, gardening/outdoor activities, movies/TV, and music/talk radio. A television was listed as needed for self-recreation material. A music machine was not listed as needed. R65 was indicated to have activities in his own room [ROOM NUMBER] on 1 throughout the day. R65 was stated to be rarely/never understood due to being unable to speak. As well as rarely/never understanding others. Special considerations to provide R65 with preferred activities indicated a television and radio were needed in his room.Review of R65's Activities Quarterly Progress Note dated 4/10/26, revealed, .needs assistance for most activities and transport.Resident enjoys music, watching sports and spending time with family, per son and observation. Will continue to assist resident with activities of interest and stimulation.Review of R65's Activities 1:1 Program dated 4/16/26 through 5/13/26 documented the resident listened/participated to music 7 times, refused once, and 12 times activities were not applicable to R65. It was noted not once during this period was R65 assisted in an outdoor activity that was previously stated he enjoyed. It was noted, R65's Care Plan did not have documentation that supported charting that the resident refused to participate in activities. Observed on 5/12/2026 at 2:44 PM, R65 was lying supine (on back) in bed staring at the privacy curtain to his left. To his right, the television was on. Behind R65 was a dresser with a stack of photographs out of his sight. No music machine was visible. There were no pictures or photographs on the walls in R65's bed area. It was noted that R65 was dependent on staff to turn, position him, and provide him with sensory stimulation.Observed on 5/12/26 at 1:05 PM, R65 lying supine in bed staring at a blank white ceiling. The television was tuned to a sitcom rerun. No music machine was visible in room. Observed on 5/12/26 at 3:00 PM, R65 was supine in bed staring at a blank white ceiling while a musical activity was being held in the main dining/common area. There was no music machine visible in resident's room. During an interview on 5/13/26 at 9:30 AM, Activity Director O stated, (R65) is unable to respond verbally to staff. He is unable to refuse activities because he cannot communicate. I bought a music machine for (R65) to listen to in his room. His short 1:1 visits are the music machine I got him. I don't know if staff turns it on for him or not. (R65's) brother has said he enjoys music. He likes R&B (rhythm and blues) per his brother. I have not been following CNAs (certified nursing assistant) charting about (R65). I did not know they were charting he was refusing activities because he cannot. I did not know (R65) was not up and listening to the music program yesterday. I dropped the ball on that.Review of R65's Care Plan indicated the resident enjoys listening to music, specifically R&B. Care plan interventions did not include the music machine Activities Director O obtained for him. Interventions do not include to keep television on, nor that R65 would enjoy listening to music programs offered by the facility as indicated by the Activities Director. During an observation on 5/13/26 at 9:45 AM, R65 was lying supine staring at the blank ceiling. A stack of family photographs was on the bedside dresser unable to be viewed by R65. Framed family photographs were lined up on furniture behind R65 and not within sight of resident. No music machine was visible in R65's bed area. A handwritten sign on the wall by the television was a request by family to always keep the television on. During an interview on 5/13/26 at 9:50 AM, Licensed Practical Nurse (LPN) W stated, (R65) does not have a music machine that I know of. His family has a sign on the wall to keep his television on.During an interview on 5/14/26 at 12:10 PM, CNA BB and LL stated R65 was unable to communicate his needs or wants. R65 could not refuse cares or what he wanted to do because he could not communicate. He does not have a choice in the music he listens to because his roommate listens to loud music all the time. R65 did not have a music machine they were aware of. They do not assist R65 in getting up for activities unless activities ask them to which was rare. According to nih.gov, Activities are vital for stroke residents in nursing homes, serving as a continuation of rehabilitation rather than just a way to pass the time. They prevent physical and mental decline, boost brain neuroplasticity, enhance everyday independence, and significantly reduce social isolation, depression, and fall risks.Call placed to R65's guardian, WW on 5/13/26 8:52 AM with a message left to call surveyor by end of survey 5/14/26. A call back was not received by end of survey 5/14/26 at 5:30 PM.

Based on observation, interview, and record review the facility failed to ensure a urinary catheter (tube placed in the body to drain and collect urine from the bladder) was maintained in a sanitary manner for 1 (Resident #122) of 2 residents reviewed for urinary catheters, resulting in the urinary catheter bag lying on the floor creating an opportunity for contamination and the potential for urinary tract infection. Findings include: Review of a current Care Plan for Resident #122 reflected a need for an indwelling catheter related to urine retention with interventions to change catheter and drainage system as clinically indicated per order(s). Observe for signs/symptoms of obstruction (leakage, increased sediment, etc.), infection, or if closed system was compromised.Irrigate foley catheter as indicated .Maintain drainage bag below the bladder level .Privacy cover to catheter drainage bag. During an observation on 05/12/2026 at 10:12 AM, outside of Resident #122's door was a sign for enhanced barrier precautions (EBP). Resident #122 was observed seated in his wheelchair located in the hallway across from his room's doorway. Resident #122 had a catheter bag hanging under his wheelchair and the catheter bag was partially lying on the floor Resident #122 began to self-propel into his room and the catheter bag was dragging along on the floor. Licensed Practical Nurse (LPN) ZZ informed Resident #122 she had another attachment for him and she had him go into his room and she shut the door. LPN ZZ reported she replaced Resident #122's catheter tubing securement device.Review of Centers for Disease Control (CDC) poster for Enhanced Barrier Precautions, revealed, .Enhanced Barrier Precautions: Everyone Must .Clean Their Hands, including before entering and when leaving a room .Providers and Staff Must Also .Wear Gown and Gloves for the following High Contact Resident Care Activities .Device care or use: urinary catheter . Review of Nursing Evaluation Summary dated 5/7/2026 at 3:08 PM, revealed, .arrived at facility via ambulance. transferred to bed form (sic) wheelchair x 1 assist. recent hospital for stroke. has left side weakness in upper extremity. able to lift extremities away form (sic) body. unable to straighten arm completely .foley catheter in place 16 French (catheter sizing measurement) flexible medical tube with 10 ml (milliliters) balloon. was straight cath (catheter) at home independently prior to stroke .During an observation on 05/13/2026 at 12:08 PM, Resident #122 was self-propelling down the hallway, the catheter bag was observed to be under his wheelchair, and the bottom of the catheter bag was dragging on the floor.During an observation on 05/13/2026 at 12:54 PM, Resident #122 was seated in his wheelchair in the doorway to his room. The catheter bag was hanging under the wheelchair, the bottom of the catheter bag was dragging on the floor, and he was moving back and forth in the doorway. In an interview on 05/14/2026 at 11:15 AM, Unit Manager (UM) J reported Resident #122's catheter bag shouldn't be on the floor as that was an infection control issue and would contaminate the catheter bag. In an interview on 05/14/26 at 3:00 PM, Director of Nursing (DON) B reported Resident #122's catheter bag should not be on the floor as it is an infection control concern.

Based on observation, interview, and record review, the facility failed to ensure residents received oxygen as ordered in 1 resident of 1 resident (R9) reviewed for oxygen administration, resulting in the potential of respiratory health complications including exacerbation of COPD (chronic obstructive pulmonary disease) and/or retention of carbon dioxide (gas produced by cellular respiration in humans).Findings include:According to R9's Minimum Data Set (MDS) dated [DATE], she was cognitively impaired indicated by a BIMS (Brief Interview Mental Status) score of 8/15. Section GG-Functional Abilities indicated R9 was dependent on staff for transferring and mobility. Section I-Active Diagnoses stated debility due to cardiorespiratory conditions that included heart failure, respiratory failure with hypercapnia, Section O-indicated R9 used oxygen therapy continuously while a resident in the facility. Review of R9's Order Summary dated 3/29/2023, indicated oxygen rate was ordered to run at 2.5 lpm (liters per minute (amount of oxygen delivered via tubing)). Review of R9's Medication/Treatment Administration Record dated 5/1/26-5/31/26 revealed, 2.5L (liter) oxygen via nasal cannula (2-prongs that deliver oxygen via a tube into the resident's nose) continuous every day and night shift related to chronic respiratory failure whether with hypoxia (low oxygenation) or hypercapnia. Start date 3/29/2023. It was noted the night shift nurse documented R9's pulse oxygenation had been assessed at 94% and the resident was receiving 2.5 lpm.Review of R9's Care Plan, dated 9/12/2024, focused on altered respiratory status/difficulty breathing related to chronic respiratory failure with hypoxia, CHF, history of pleural effusion, current O2 dependence, SOB (shortness of breath). The goal for this specific focus centered on maintaining a normal breathing pattern by using interventions that included Oxygen use: continuous O2 (oxygen) via NC as ordered by MD/NP, see MAR. Observed on 5/12/2026 at 2:03 PM, R9's oxygen to be running at 3.5 lpm.Observed on 5/13/26 at 9:45 AM, R9's oxygen to be running at 3.5 lpm.During an observation and interview on 5/14/26 at 10:00 AM, Licensed Practical Nurse (LPN) W reviewed R9's physician order stating (R9) oxygen is ordered to be set at 2.5 lpm. LPN W observed R9's oxygen concentrator to be set at 4 lpm stating, Oh, I did not know it was set at that. If the night nurse changed the oxygen flow during the night with a new order, I should have been told when coming on shift. (R9) should not have been left at 4 lpm. It's not good for her to be left that high (concentration) for a long period of time.During an interview on 5/14/26 at 11:00 AM, Nursing Home Administration (NHA) A stated, Oxygen is a medication order.Review of the National Institute of Health (NIH.gov) revealed COPD (Chronic Obstructive Pulmonary Disease) is a progressive inflammatory lung disease that blocks airflow, making it hard to breathe. For residents with COPD, over-oxygenation occurs when supplemental oxygen raises blood saturation above safe levels, leading to dangerous carbon dioxide (CO2) retention (hypercapnia). Hypercapnia is an unhealthy buildup of CO2 in the bloodstream. It occurs when the body is unable to effectively expel XO2 through normal breathing.

Based on observation, interview, and record review, the facility failed to (1) ensure medications labeled/dated for 1 resident of 1 resident (R84) reviewed for medication labeling/dating, (2) ensure medications were stored in a secure manner in 2 of 2 treatment carts and 1 medication room/refrigerator (A Hall), resulting in the potential for residents to receive expired medications with altered potency and decreased efficacy, and residents, visitors, and/or staff access the medications, including narcotics, in the facility. Findings include: According to R84's Minimum Data Set (MDS) dated [DATE], the resident's BIMS (Brief Interview Mental Status) was 13/15 (cognitively intact). Section I-Active Diagnoses stated medically complex conditions including heart failure, arthritis (painful joints), non-Alzheimer's dementia (loss of memory), and bipolar disorder (recurring shifts in mood). During an observation, interview, and record review on 5/12/26 at 11:04 AM, R84 was awake in her bed. On a dresser next to R84's bed, was a tube of zinc oxide dated 3/16/26. The cap was off the tube with small particles of debris sticking to the white ointment around the brim of the opening. The top of the dresser was also covered in food crumbs, dirt, dust, and debris. R84 reported staff had used the zinc ointment on her bottom earlier that day and had left it on the dresser stating, Staff leave it there all the time. Antifungal powder was in a basin on the bedside table in front of R84 with no labeling or dating. Bio Freeze gel was on a shelf of a bookcase with no labeling or dating. On another bookcase shelf was a pair of clear disposable gloves. R84 stated, The powder goes under my boobs and belly. The green gel, I think it is bio something, goes on my knees when they hurt. Observed on 5/13/26 at 9:50 AM, R84 to have antifungal powder in a basin on a bedside table with no labeling or dating and a tube of Bio Freeze gel on a shelf of the bookcase with no labeling or dating. Review of R84's Order Summary, dated 6/25/25, revealed, Bio Freeze Cool the Pain External Gel 4% (Menthol (topical analgesic)). Apply to Bilateral knees topically three times a day related to PAIN. Review of R84's Order Summary, dated 11/3/25, revealed Zinc Oxide Bilateral buttocks: Apply Zinc. every day and night shift for blanchable redness AND as needed. Review of R84's Order Summary did not include an order for anti-fungal powder. Review of R84's Medication/Treatment Administration Record (MAR/TAR) dated 5/1/26-5/31/26, revealed from 5/1-5/14/26: - Bio Freeze Cool the Pain External Gel 4% (Menthol (topical analgesic)). Apply to Bilateral knees topically three times a day related to PAIN was applied as ordered. - Bilateral buttocks: Apply Zinc every day and night shift for blanchable redness. Start date: 11/3/25 was applied as ordered. It was noted; there was no documentation the antifungal powder had been applied. Review of R84's Care Plan, revision date of 3/24/26, Focus Resident is at risk for impaired skin integrity related to (r/t) . history (hx) of excoriation to bilateral buttocks. Recurrent open wound r/t MASD/IAD (moisture associated skin disorder) to buttock. Hx stage III pressure ulcer to right gluteus. A goal of Resident will have intact skin . met by interventions that included Apply protective barrier cream after incontinent episodes (8/22/23). Further review of R84's care plan did not include a focus, goal, or interventions that contained antifungal cream or bio freeze gel. During an interview on 5/14/26 at 12:00 PM, Licensed Practical Nurse (LPN) W reported that no resident on A hall, including R84, self-administered medications. During an interview on 5/14/26 at 12:05 PM, Certified Nursing Assistants (CNAs) (BB and LL) reported R84 did not self-administer ointments, lotions, or powders on her own. CNA BB reported powders, ointments, or lotions should not be kept in resident rooms and should be kept in a medication cart. Neither CNA answered when asked if they had administered the zinc oxide ointment, Bio Freeze, or antifungal powder to R84. Observed on5/14/26 at 12:05 PM, antifungal powder on the top shelf of a bookcase in R84's room. The container was not labeled or dated. On the second to bottom shelf of the same bookcase, was a tube of Bio Freeze gel. Next to the tube of gel was a pair of clear disposable gloves. The gloves were in the exact place as they had been when first seen on 5/12/26 at 11:04 AM. During an interview and record review on 5/14/26 at 12:45 PM, Infection Control Preventionist (ICP) C reviewed R84's medical chart while reporting medications including tubes of ointments and gels along with containers of antifungal powder should be labeled and dated for infection control purposes and their efficacy. Also, labeling ensures the correct resident receives the correct medication. ICP C stated after reviewing R84's medical chart that the resident was not assessed to nor could she administer ointments to her buttocks, or gel to her knees. R84 did not have an order for antifungal powder and should not have had it in her room nor applied to her skin. On 5/13/26 at 8:03 AM the refrigerator on the counter closest to the door, in the medication room on the A hall was observed unlocked. In an interview on 5/13/26 at 8:03 AM, Registered Nurse (RN) R reported the refrigerator, she gestured to while standing with this surveyor in the medication room, were used to store medications including narcotic medications. RN R made no attempt to secure the lock on the refrigerator. In an interview and observation on 5/13/26 at 8:23 AM, RN P reported there were narcotic medications stored in both refrigerators in the medication room on A hall. RN P entered the medication room with this surveyor and removed a plastic storage container from the refrigerator on the counter closest to the door. The plastic storage container was noted to be secured with a red plastic seal. RN P displayed the label on the box and indicated it contained a narcotic. RN P reported the refrigerators should be kept locked. In an interview and observation on 5/14/26 at 10:31 AM, RN T reported the refrigerator in the medication room on A hall should be kept locked. RN T reported narcotic medications were stored in the refrigerator and displaced the same plastic storage container with the red plastic seal and RN T reported the red plastic seal was removed with a pair of scissors when the medications stored inside it were accessed. In an interview on 5/14/26 at 10:40 AM, Director of Nursing (DON) B reported the refrigerators in the medication room on A hall should be locked at all times, there was no reason for the refrigerators to be left unlocked. DON B confirmed narcotic medications were stored in the refrigerators. Review of facility policy Medication Storage with a revision date of 1/30/2024 revealed .2. Narcotics and Controlled Substances.are stored under double lock and key.

This citation pertains to intake #2709386.Based on observation, interview, and record review, the facility failed to provide adequate supervision with hot liquids for 1 resident (Resident #101) of 5 residents reviewed for accidents and safety resulting in Resident #101 receiving a second degree burn (causes pain and damages the outer and second layer of the skin) on her left arm on 12/27/2025 and a burn on her left hand on 12/30/2025 and the fear of receiving another burn. Findings include:Resident #101 (R101)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R101 originally admitted to the facility on [DATE] with pertinent diagnoses including nontraumatic intracerebral hemorrhage (serious stroke where bleeding occurs inside the brain), flaccid (lacking firmness, strength or stiffness; limp and flabby) hemiplegia (paralysis of one side) affecting left dominant side, chronic pain and depression. Brief Interview for Mental Status (BIMS) on 1/12/2026 reflected a score of 13 out of 15 which indicated R101 cognition was intact. R101 went to the hospital on [DATE] and returned on 1/6/2026. In an email correspondence on 1/13/2026 at 10:20 AM, Family Member (FM) K stated on 12/27/2026 at 3 PM she found R101 was covered in dried coffee and it was all over her bed and she had a burn from the coffee on her left forearm. FM K said R101's burn was red, swollen, skin peeled off in areas and she was complaining of pain. FM K stated that R101 had another burn on 12/30/2025 and she was notified about it when Unit Manager (UM) S called her and said R101 spilled coffee on her arm and all over the bed. FM K said R101 had a stroke, has left side paralysis and has only the use of her right arm which is her non-dominant hand. FM K stated that R101 needed assistance at meals and with drinks and she told staff that. Review of R101's Nursing admission Evaluation-Part -V9 dated 12/18/2025 indicated she was at risk of hot liquid spills due to weakness/paresis in upper extremities and loss of mobility/reduced movement in upper extremities. Review of R101's Care Plan revealed Focus: Resident has an ADL (Activities of Daily Living) self-care performance deficit related to intracerebral hemorrhage (bleeding inside the skull), major depressive disorder, multiple intracranial aneurysms (a weak, bulging spot on a blood vessel in the brain, often forming at artery junctions, that can leak or burst, causing a life threatening stroke) Left sided weakness . Date initiated 12/18/2025. Interventions. Eating: 1 person assist. Date initiated 12/18/2025. There was no information on R101 being at risk for hot liquid spills or any special equipment needed to help diminish the risk of spills. Review of R101's Kardex (where staff can get information about the resident such as assistance levels) revealed .Eating: 1 person assist. Created date: 12/18/2025. There was no information on R101 being at risk for hot liquid spills or any special equipment needed to help diminish the risk of spills. Review of R101's MDS Section GG-Functional Abilities dated 12/24/2025 revealed . Eating: the ability to use suitable utensils to bring food and or liquid to the mouth and swallow food and or liquid once the meal is placed before the resident: Partial/Moderate assistance.During an interview on 1/13/2026 at 11:05 AM, Registered Nurse (RN) O stated that R101 needed assistance with meals and lids and straws for drinks because she spilled her drinks.During an observation and interview on 1/13/2026 at 12:00 PM, R101 was sitting in the main dining room in a Broda chair (specialized wheelchair for limited mobility and to increase comfort and support) waiting for lunch. R101 stated that she had 2 burns on her left arm/hand and the first burn was bad and almost a 3rd degree burn. R101 reported that she had blisters with the first burn and it was so painful. R101 said that the coffee lid was on the coffee cup both times but it fell off when she took a drink. R101 stated that she was left-handed and due to her left side neglect, she had to eat and drink with her right hand. R101 stated that she needed help with meals and drinks. R101 said she loved coffee but she only drank chocolate milk now because she feared getting burned again. Review of R101's Progress Note dated 12/27/2025 revealed Skin Issues: Skin Issue: #001: New skin Issue. Location: Left inner forearm. Issue type: Burn. Progress: New: new wound. Wound acquired in-house. Painful: Yes. Wound pain (Frequency): Continuous. Pain description: Burning. Length (cm-centimeters): 4.77 Width (cm): 3.98 Depth (cm): 0 Area (cm2): 14.78.Review of R101's Progress Note dated 12/27/2025 revealed Nurses' Notes: New skin issues noted to the left lower forearm. resident c/o (complained of) pain Tylenol not effective on call provider notified who ordered 400mg TID (three times a day) for 2 days. The name of the medication ordered was not indicated in the progress note. Review of R101's Progress Note dated 12/30/2025 revealed Nurses' Notes: Late Entry: This DON{(Director of Nursing B} and Administrator {Nursing Home Administrator (NHA) A}met with resident after the spill and burn from hot liquid, to discuss with resident how we can prevent this from occurring again. Resident stated she actually preferred chocolate milk over coffee. We also discussed with resident using a sipper cup for hot liquids. Resident was in agreement with this, and (NHA A) and I updated the unit managers (UM S and UM MM) requesting to update her care plan to reflect these preferences.Review of R101's Incident Report dated 12/27/2025 which was completed by Licensed Practical Nurse (LPN) I revealed .Nursing Description: This nurse was notified by staff that resident had spilled her coffee and burned herself. Upon assessments this nurse observed a skin injury to left lower forearm open skin with surrounding redness. Daughter was present during injury who stated, she was not supposed to be left alone with hot drinks. Resident stated, I was drinking my coffee and it spilled and it hurts. This nurse completed a skin assessment, notified appropriate parties, cleansed pat dry, applied triple antibiotic ointment, applied tefla (non stick wrap) and wrapped in stretch gauze.Level of Pain: 5.During an interview on 1/13/2026 at 2:42 PM, Wound Nurse (WN) Y stated that LPN I saw R101's wound after the burn on 12/27/2025, took a picture of it and started treatment. WN Y said she saw the first wound on 12/30/2025 and took a picture of it and UM S saw the second burn which occurred later, on 12/30/2025. WN Y reported that the first burn that she looked at on 12/30/2025 had granulation tissue, no blisters, was not raised and had a yellow appearance. WN Y stated that R101 needed assistance with meals since she couldn't use her left arm. During an interview on 1/14/2026 at 9:24 AM, LPN I stated that she completed the incident report on 12/27/2025 after the first burn. LPN I stated that a CNA (Certified Nursing Assistant) told her that R101 had a burn to her arm from spilling coffee. LPN I' stated that she saw redness with open skin and said some skin flapped over like the skin peels away during a skin tear. LPN I said she called the doctor and got an order for triple antibiotic cream and non-adherent pad (non-sticking) and to wrap it in in stretch gauze. During a second interview on 1/15/2026 at 9:21 AM, LPN I reported that she did not put cold water on R101's burn on 12/27/2026. She also stated that triple antibiotic ointment sounded like a good choice for treating a burn and the on-call provider {Nurse Practitioner (NP) JJ} said it was okay. According to the Burn Institute, first aid for burns includes the following steps, stop the burning process, remove the source of heat .remove all burned clothing .pour cool water over burned area, keep pouring the cool water for at least 3-5 minutes, never put ice or cold water on a burn as it lowers the body temperature and can make the burn worse .do not apply ointments, creams, or salves to wound .cover burn with a soft, clean, dry dressing, bandage or sheet. Seek medical attention as soon as possible. (www.burninstitue.org/fbp/factsheets/firstaid.html).According to the Mayo Foundation for Medical Education and Research, 1998-2012, when the first layer of skin has been burned through and the second layer of skin (dermis) also is burned, the injury is called a second-degree burn, blisters develop, skin takes on an intensely reddened, splotchy appearance and there is severe pain and swelling. If the second-degree burn area is no larger than 3 inches (7.6 centimeters) in diameter, treat it as a minor burn. If the burned area is larger or if the burn is on the hands, feet, face, groin or buttocks, or over a major joint, treat it as a major burn and get medical help immediately. (www.mayoclinic.com/health/first-aid-burns)During an interview on 1/15/2026 at 8:56 AM, Nurse Practitioner (NP) JJ stated that she didn't see R101's burn and that NP KK was on call on 12/27/2025 when the first burn occurred. NP JJ stated that the standard of care for a burn would be to get something cold on it right away and to start Silvadene cream if skin was peeled or there were blisters. During an interview on 1/15/2026 at 9:29 AM, NP KK stated that the nurse (LPN I) called her on 12/27/2025 after she found R101 had a burn. NP KK said LPN I put R101's arm under cold water and put triple antibiotic ointment cream on it since it was a brand-new burn, there were no blisters and the skin was intact, then it was covered with a non-stick pad. When discussing the standards of care for a burn, NP KK stated to run the burn under cold water for 15 minutes, wash with soap and water, cover with dry nonstick pad to keep infection out. NP KK said if the skin was open then Silvadene should be applied.Review of R101's burn photograph dated 12/27/2025 revealed Length (cm-centimeters): 4.77. Width (cm): 3.98. Depth (cm): 0. Area (cm2): 14.78. The picture showed the area on her left arm area was red, shiny, and open.Review of R101's burn photograph dated 12/30/2025 from the burn on 12/27/2025 revealed Length (cm-centimeters): 4.27. Width (cm): 3.56. Depth (cm): .1. Area (cm2): 12.34. The picture showed the left arm area was blistered as evidenced by raised skin, yellow exudate (discharged fluid substance), red exposed skin in middle of blistered area and it was red around the edges. Review of hospital notes on 12/31/2025 revealed .Type-Wound 1: Blister, Location: Wrist, Left, Description: Blistered, Surrounding tissue: Red, Drainage: Serosanguinous (fluid from wound), Drainage Amount : Scant (a little bit). Review of the 2022 Cleveland Clinic Guidelines revealed . Second degree burns cause skin discoloration: deep red to dark brown, blisters, shiny and moist skin, pain or discomfort, swelling, layers of skin peeling away. A common prescription cream to treat second-degree burns is silver sulfadiazine (Silvadene).During an interview on 1/15/2026 at 12:30 PM, UM S stated for a burn, staff should get ice water and dump it on the burn and then call the doctor. UM S stated that triple antibiotic cream should not be used, Silvadene should be used instead. During an interview on 1/15/2026 at 1 PM, Director of Nursing (DON) B stated her expectation for a burn was to put cool water on it, not ice and use Silvadene cream. She stated that triple antibiotic cream shouldn't be used because it was petroleum based and held heat in.Review of R101's Medication Administration Record (MAR) for December 2025 revealed Left Lower Forearm: Cleanse, Pat Dry, apply triple antibiotic ointment, apply tefla (telfa-sterile, non-adherent wound pad with a perforated film on both sides that prevents it from sticking to healing tissue), wrap with stretch gauze. every day shift. Start date 12/28/2025. D/C date (discontinued date) 12/29/2025. The MAR showed it was applied on 12/28/2025 and 12/29/2025 and LPN I applied it on 12/27/2025 right after the burn.Review of the 2024 American Heart Association Guidelines revealed Burns can come from a variety of sources such as hot water (scalds).It is known that applying ice directly to a burn can cause tissue ischemia (restricted blood supply leading to shortage of oxygen which can lead to tissue damage). Don't apply ice directly to a burn, it can produce tissue ischemia. Cool thermal burns with cool or cold water potable water as soon as possible and for at least 10 minutes. If cool or cold water is not available a clean cool or cold, but not freezing compress can be useful as a substitute for cooling burns.Review of the 2026 American Burn Association Guidelines revealed .First aid facts.Don't apply ice-it can worsen damage, don't use butter, oils or ointments-they trap heat.During an interview on 1/14/2026 at 11:25 AM, CNA H stated that she worked on 12/27/2025 when R101 got her first burn. CNA H said that R101 was a one-to-one assist with meals because her right hand got shaky when drinking and feeding herself. During an interview on 1/14/2026 at 10:30 AM, CNA U stated on 12/27/2025 she asked RN T if R101 could have coffee because she noticed that R101 spilled soda all over herself and the bed over the weekend and RN T said R101 could have it. CNA U said she gave her the cup of coffee with a lid and set it on R101's bedside table and R101 said she would let it cool before drinking it. CNA U indicated that the Kardex should indicate if R101 needed assistance with hot beverages. During an interview on 1/14/2026 at 10:43 AM, RN T stated that R101 loved coffee and was always asking for it. RN T stated on 12/27/2025 she couldn't remember if a CNA asked her if R101 could have coffee and then she was notified R101 had a burn. RN T said she looked at the burn briefly and only noticed red areas but LPN I completed the incident report and treatment. Review of R101's Incident Report dated 12/30/2025 (date of R101's second burn incident) which was completed by UM S revealed Nursing Description: CNA went to resident's room because the resident's call light was on and resident informed CNA that she spilled her coffee. CNA came to my office to notify me of the incident. Went into resident's room and there was spilled coffee on the bed and the floor all over with the cup on the floor resident left hand noted to be red, blanching (white/pale). Resident description: I spilled my coffee. Staff poured cool water on area immediately after seeing the spill. Care plan updated: Encourage and assist resident to the dining room for meals. Sippy cups with lids and straws for all liquids, divided plate. Statements: (CNA J): I went into resident's room to answer call light and resident informed me that she spilled her coffee. I poured water on area and got nurse to assess area.During an interview on 1/13/2026 at 3:00 PM, UM S stated that on 12/30/2025 CNA J got her when she noticed R101 had another burn on her left hand by her knuckles. UM S said that CNA J put water on it and got her. UM S stated that R101 had red knuckles and coffee was spilled on her bed and mostly on the floor. UM S said that the hot liquid safety assessment was completed upon admission which indicated that she was at risk for hot liquid spills and they didn't know R101 needed help with eating at first. UM S confirmed that the care plan and Kardex dated 12/18/2025 upon admission indicated R101 was an assist at meals and the CNAs would know that looking at the Kardex and it should be followed. UM S stated that she did not get a therapy to nursing communication form regarding any assisted devices for R101 from her first admission or after the first burn. During an interview on 1/14/2026 at 9:55 AM, RN Q stated that R101 needed assistance with meals due to left sided weakness. RN Q stated that CNA P took R101 coffee on 12/30/2025 when she was on lunch and when she got back, she was told that R101 received a burn. During an interview on 1/14/2026 at 10:02 AM, CNA P stated on 12/30/2025 R101 got her attention when she was in the hallway and asked her for a cup of coffee. CNA P stated that she didn't know R101 had a burn a few days before. CNA P indicated that the Kardex would have if assistance was needed by a resident.During an interview on 1/14/2026 at 12:37 PM, CNA J stated on 12/30/2025 she answered R101's call light and noticed she spilled her lunch plate and coffee on her and the floor. CNA J said R101's hand was red and she got UM S and UM S put cold water on R101's hand. CNA J reported that she was aware that R101 was a 1:1 assist at meals and that UM S said that R101 shouldn't have been eating and drinking by herself due to having a burn before. CNA J stated she was unaware of the first burn until UM S told her after she received the second burn. During an observation on 1/15/2026 at 12:00 noon, R101 received her lunch tray in the main dining room, was eating with her right hand and shaking. She had a cup with a plastic lid for her drink and staff was nearby to assist her.During an interview on 1/13/2026 at 11:40 AM, Occupational Therapist (OT) AA stated that she saw R101 on 12/30/2025 after her second burn before she went to the hospital from a fall. OT AA said that she did a full feeding assessment and filled out a communication form for nursing related to R101 needing a Kennedy cup (adaptive, spill-proof drinking cup with a secure lid), divided plate and lids on hot liquids and for her to go to the dining room for meals. OT AA stated that R101 needed assistance with food and fluids. During a phone interview on 1/13/2026 at 2:31 PM, Therapy Rehabilitation Director (TRD) Z stated that he thought nursing completed the hot liquid safety assessment and then the speech therapist or OT would look at the resident if a referral was made. During an interview on 1/13/2026 at 3:20 PM, OT CC and this surveyor could not locate the therapy to nursing communication form in the therapy department for when R101 was first admitted on [DATE] until her second burn occurred on 12/30/2025 when OT AA assessed her. During an interview on 1/13/2026 at 4:20 PM, Dietary Account Manager (DAM) D stated that the kitchen staff checked the temperature of hot coffee but not hot water before it left the kitchen at meals and it was documented on the log and that lids were put on all hot liquids. DAM D said she would let therapy know if she thought a resident needed assistive devices with eating/drinking or they would let her know. DAM D stated that therapy ordered sippy cups for R101 because she got burned.Review of the Service Line Checklist for December revealed that breakfast, lunch and dinner only had 1 line for hot beverages and the staff checked coffee temperatures before serving the meal and did not have a line for other hot beverages such as hot water for tea and hot chocolate. During an interview on 1/14/2026 at 7:50 AM, Assistant Manager (AM) E checked the temperature of the coffee pot for the main dining room and it was at 164.2 degrees Fahrenheit. During an interview on 1/14/2026 at 9:15 AM, DAM D said the temperature of the coffee that came off of the coffee machine was usually around 180 degrees Fahrenheit, then the dietary staff put the coffee in pots which was usually around 160 degrees Fahrenheit, and when it was poured into cups for the dining room it was around 140 degrees Fahrenheit.The temperature of room tray coffee was 99.8 degrees Fahrenheit and the hot water temperature was 152 degrees Fahrenheit.During an interview on 1/14/2026 at 9:34 AM, Director of Clinical Operations (DCO) L who is also a Registered Dietitian stated IDT can determine who needs assistive devices. When a resident was at risk for hot liquid spills, DCO L said that OT would evaluate for specialty equipment and put an order in. DCO L stated that the dietary staff makes sure hot liquids aren't too hot and to minimize risk for burns they like to maintain hot liquids at or below 165 degrees Fahrenheit when serving. During an interview on 1/14/2026 at 3:19 PM, UM S stated that the facility didn't do anything with hot liquid safety assessments when a resident was at risk for spills since all residents received a plastic lid (used to keep heat in) with hot liquids. UM S said they wouldn't have done anything different with R101. When discussing how staff would be aware if a resident was at risk for a hot liquid spill and how this would be communicated, UM S said this wouldn't be communicated. When discussing interventions after R101's burn on 12/27/2025, UM S said that the nurse and on call manager should have put interventions in place initially and then it should have been discussed at the next IDT. UM S stated OT saw R101 after the second burn on 12/30/2025 and interventions were put in place at that time. UM S stated that she did not get a therapy to nursing communication form regarding any assisted devices for R101 from her admission on [DATE] or after the first burn on 12/27/2025. UM S said that facility staff weren't educated after either burn. UM S also stated that the nurses interchanged the location of where the first burn was and said either left forearm/left wrist. During an interview on 1/14/2026 at 3:39 PM, Nursing Home Administrator (NHA) A stated that R101's burn was an isolated incident and they didn't think there was a systemic issue so they didn't do full staff education. NHA A stated that the hot liquid safety assessment was completed on all residents and they didn't do anything for high-risk residents since every resident received lids on their cups and OT would see them if a referral was made. NHA A also stated that there were no interventions put in place after R101's first burn on 12/27/2025. NHA said that it was her expectation that staff followed the Kardex.Review of the Hot Liquids/Food Assessment Policy with a revision date of 10/26/2023 revealed Policy: Hot Liquids will be provided to residents as indicated on the facility menu, resident preference and to meet the individualized needs of each resident, while providing safety. Hot liquid assessments will be completed on admission, quarterly and with acute change of condition. Policy Explanation and Compliance Guidelines: Fluids will be served to residents per the physician order(s).1. If the resident is identified as having concerns regarding the ability to handle hot liquids, a hot liquids safety evaluation should be completed to determine if the resident is at higher risk for spills.assistance with meals, weakness, shaking. 2. If a resident is identified with any of the above or other symptoms that would warrant further evaluation the following actions should be conducted as applicable; Immediate interventions to prevent spills such as; Lids, Cooling of liquids before served (adding ice, letting set (sit) 10 minutes before serving, or avoidance of hot liquids until formal evaluation complete: Therapy evaluation, Interdisciplinary team review, Immediate plan of care. 5. All interventions should be added to the plan of care and Kardex/nurse aide plan of care. 6. The care plan should be reviewed and updated at least quarterly and with significant change in status.Review of the Use of Assistive Devices Policy with a revision date of 10/26/2023 revealed Policy: The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity. Policy Explanation and Compliance Guidelines: 1. Assistive devices are tools, products, types of equipment, or technology that help individuals perform tasks and activities. They may help the individual move around, see, communicate, eat, or get dressed. Assistive devices include: .g. eating utensils. The facility will provide assistive devices for residents who need them. Nursing, dietary, social services, and therapy departments will work together to ensure availability of devices, such as for ordering and/or replacement. 4. Facility staff will provide appropriate assistance to ensure that the resident can use the assistive devices. This may include education or therapy sessions for training on the use of the device, set up assistance, supervision, or physical assistance as needed. 5. Direct care staff will be trained on the use of the devices as needed to carry out their roles and responsibilities regarding the devices. Training will also include when to refer to other departments for changes in condition or problems with the device. 6. The resident's assigned nurse will monitor for the consistent use of the device and safety in the use of the device. Refusals of use, or problems with the device, will be documented in the medical record. Modifications to the plan of care will be made as needed.

This citation pertains to intake #2709386.Based on observation, interview and record review, the facility failed to report an incident of neglect (a hot liquid burn) for 1 resident (Resident #101) of 5 residents reviewed for accidents/safety when Resident #101 did not have appropriate interventions in place based on an assessment related to hot liquid spills and did not receive the help she needed resulting in a second burn causing Resident #101 pain, distress and fear of getting burned again. Findings include:Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R101 originally admitted to the facility on [DATE] with pertinent diagnoses including nontraumatic intracerebral hemorrhage (serious stroke where bleeding occurs inside the brain and flaccid (lacking firmness, strength or stiffness; limp and flabby) hemiplegia (paralysis of one side) affecting left dominant side. Brief Interview for Mental Status (BIMS) on 1/12/2026 reflected a score of 13 out of 15 which indicated R101 cognition was intact. R101 went to the hospital on [DATE] and returned on 1/6/2026. In an email correspondence on 1/13/2026 at 10:20 AM, Family Member (FM) K stated on 12/27/2026 at 3 PM she found R101 was covered in dried coffee, and it was all over her bed and she had a burn from the coffee on her left forearm. FM K said R101's burn was red, swollen, skin peeled off in areas and she was complaining of pain. FM K stated that R101 had another burn on 12/30/2025 and she was notified about it when Unit Manager (UM) S called her and said R101 spilled coffee on her arm and all over the bed. FM K said R101 had a stroke, has left side paralysis and has only the use of her right arm which is her non-dominant hand. FM K stated that R101 needed assistance at meals and with drinks and she told staff that. Review of R101's Nursing admission Evaluation-Part -V9 dated 12/18/2025 indicated she was at risk from hot liquid spills due to weakness/paresis in upper extremities and loss of mobility/reduced movement in upper extremities. Review of R101's Care Plan revealed Focus: Resident has an ADL (Activities of Daily Living) self-care performance deficit related to intracerebral hemorrhage (bleeding inside the skull), major depressive disorder, multiple intracranial aneurysms (a weak, bulging spot on a blood vessel in the brain, often forming at artery junctions, that can leak or burst, causing a life threatening stroke) Left sided weakness . Date initiated 12/18/2025. Interventions. Eating: 1 person assist. Date initiated 12/18/2025. There was no information on R101 being at risk for hot liquid spills or any special equipment needed to diminish the risk of spills.Review of R101's Kardex (where staff can get information about the resident such as assistance levels) revealed .Eating: 1 person assist. Created date: 12/18/2025. There was no information on R101 being at risk for hot liquid spills or any special equipment needed to diminish the risk of spills. During an interview on 1/13/2026 at 11:05 AM, Registered Nurse (RN) O stated that R101 needed assistance with meals and lids and straws for drinks because she spilled her drinks.During an observation and interview on 1/13/2026 at 12:00 PM, R101 was sitting in the main dining room in a Broda chair (specialized wheelchair for limited mobility and to increase comfort and support) waiting for lunch. R101 stated that she had 2 burns on her left arm/hand and the first burn was bad and almost a 3rd degree burn. R101 reported that she had blisters with the first burn and it was so painful. R101 said that the coffee lid was on the coffee cup both times but it fell off when she took a drink. R101 stated that she was left-handed and due to her left side neglect, she had to eat and drink with her right hand. R101 stated that she needed help with meals and drinks.Review of R101's Incident Report dated 12/27/2025 which was completed by Licensed Practical Nurse (LPN) I revealed .Nursing Description: This nurse was notified by staff that resident had spilled her coffee and burned herself. Upon assessments this nurse observed a skin injury to left lower forearm open skin with surrounding redness. Daughter was present during injury who stated she was not supposed to be left alone with hot drinks. Resident stated, I was drinking my coffee and it spilled and it hurts. During an interview on 1/14/2026 at 11:25 AM, CNA H stated that she worked on 12/27/2025 when R101 got her first burn. CNA H said that R101 was a one-to-one assist with meals because her right hand got shaky when drinking and feeding herself. CNA H stated that CNA U asked RN T if R101 could have coffee before giving it to her and then they left for the day. CNA H stated that she knew R101 needed assistance with meals/liquids. During an interview on 1/14/2026 at 10:30 AM, CNA U stated on 12/27/2025 she asked RN T if R101 could have coffee because she noticed that R101 spilled soda all over herself and the bed over the weekend and RN T said R101 could have it. CNA U said she gave her the cup of coffee with a lid and set it on R101's bedside table and R101 said she would let it cool before drinking it. CNA U indicated that the Kardex should indicate if R101 needed assistance with hot beverages. During an interview on 1/14/2026 at 10:43 AM, RN T stated on 12/27/2025 she couldn't remember if a CNA asked her if R101 could have coffee and then she was notified R101 had a burn. Review of R101's Incident Report (for second hot liquid spill) dated 12/30/2025 which was completed by UM S revealed Nursing Description: CNA went to resident's room because the resident's call light was on and resident informed CNA that she spilled her coffee. CNA came to my office to notify me of the incident. Went into resident's room and there was spilled coffee on the bed and the floor all over with the cup on the floor resident left hand noted to be red, blanching (white/pale). Resident description: I spilled my coffee. During an interview on 1/13/2026 at 3:00 PM, UM S stated that the hot liquid safety assessment was completed upon admission which indicated that she was at risk for hot liquid spills. UM S confirmed that the care plan and Kardex dated 12/18/2025 upon admission indicated R101 was an assist at meals and the CNAs would know that looking at the Kardex. UM S stated that she did not get a therapy to nursing communication form regarding any assisted devices for R101 from her first admission or after the first burn. During an interview on 1/14/2026 at 3:19 PM, UM S stated that the facility didn't do anything with hot liquid safety assessments when a resident was at risk for spills since all residents received a lid with hot liquids. When discussing how staff would be aware if a resident was at risk for a hot liquid spill and how this would be communicated, UM S said this wouldn't be communicated. When discussing interventions after R101's burn on 12/27/2025, UM S said that the nurse and on call manager should have put interventions in place initially and then it should have been discussed at the next IDT. UM S stated OT saw R101 after the second burn on 12/30/2025 and interventions were put in place at that time. UM S stated that the Kardex had whether resident needed assistance with meals/liquids and should be followed. UM S said that facility staff weren't educated after either burn. During an interview on 1/14/2026 at 3:39 PM, Nursing Home Administrator (NHA) A stated that the burn on 12/27/2025 wasn't reported since it wasn't an injury of unknown origin. This surveyor discussed reporting for neglect, when the care plan wasn't followed and interventions and education weren't in place after the first burn on 12/27/2025. NHA A stated that the hot liquid safety assessment was completed on all residents and they didn't do anything for high-risk residents since every resident received lids on their cups and OT would see them if a referral was made. NHA A stated that she expected the Kardex would be followed by staff.Review of the Abuse, Neglect and Exploitation Policy with a revision date of 1/10/2024 revealed . Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.III. Prevention of Abuse, Neglect and Exploitation.D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.IV. Identification of Abuse, Neglect and Exploitation.B. Possible indicators of abuse include but are not limited to.8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & positioning.VII. Reporting/Response.5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following. b. Defining how care provision will be changed and/or improved to protect residents receiving services.

This citation pertains to Intake: 2575789, 2567564Based on interview and record review, the facility failed to prevent resident to resident sexual abuse in 1 of 3 sampled residents (Resident #102) reviewed for abuse, resulting in the potential for a decline in mental and psychosocial well-being.Findings include: Resident #102: Review of an admission Record revealed Resident #102 was a female with pertinent diagnoses which included major depressive disorder, reduced mobility, hemiplegia and hemiparesis (paralysis) following cerebral infarction affecting left non dominant side, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 6/20/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #102 was cognitively intact. Review of current Care Plan for Resident #102, revised on 3/19/2025, revealed the focus, .Resident has an impaired mood/psychiatric status related to major depressive do (disorder), anxiety. Has depression r/t (related to) stroke dx (diagnosis). Resident chooses to keep concern forms in her room to use as notes rather than share them with staff. with the interventions .Periodically complete the PHQ-9 (questionnaire used to screen, diagnosis, and monitor depression severity).Provide resident with quality listening time and encourage expressions of feelings.Encourage resident to share her concerns so that we can assist her. Review of Order dated 7/17/25, revealed, .Ensure stop sign is hung across bedroom doorway at night at bedtime. Review of Nurses' Notes dated 7/17/2025 at 04:15 AM, revealed, .Resident reported to nurse that resident (Resident #103) in room (Room Hallway and Number) was in her room and she called the police, asked what happened and resident states I woke up because I felt someone touching me and it was him! Then she states that he was touching her in her breasts and vaginal area so she screamed for him to leave and he did and so she called the police, the police arrived and spoke with resident who does want to press charges, writer called and notified administrator who is also the abuse coordinator, writer had seen both residents asleep in their rooms after midnight med pass. The CNA (Certified nursing assistant) reports they were both sleeping in their beds at 0300 rounds.Review of Social Services Progress Notes dated 7/17/2025 at 3:39 PM, revealed, .SS (social services) followed up with resident r/t (related to) recent incident that occurred with another resident.SS did voice that she wants to press charges in which she has been in communication with the police. Resident has a stop sign located outside her door in which order is being put in to ensure that it is put up over doorway during the night. Resident voiced that she is happy that the resident that the incident occurred with has been moved to another hall. Resident was seen by the psych NP (nurse practitioner) today 7/17 and continues to be followed by services for continued support. Review of Social Services Progress Notes dated 7/18/2025 at 3:16 PM, revealed, .SS (social services) visited with resident to see how she is doing. Resident stated I'm good and I'm feeling safer now that that guy is not on the hall anymore. Resident is referring to (Resident #103) who has entered her room the other day while she was sleeping. Resident #103: Review of an admission Record revealed Resident # 103 was a male with pertinent diagnoses which included dementia with other behavioral disturbance, major depressive disorder, and insomnia. Review of Care Plan for Resident #103, revised on 6/30/25, revealed the focus, .Resident has behaviors of sexual comments, gestures towards staff. May become intimate with other residents such as kissing. Physical and verbal aggression toward staff. Exit seeking behaviors. with the interventions .Observe and document episodes of inappropriate behaviors, explain that behavior is inappropriate.Revision on: 04/22/2025. Offer/provide activities of interest to keep resident engaged in positive interactions.Date Initiated: 04/22/2025.Review of Care Plan for Resident #103, revised on 7/25/25, revealed the focus, .Resident has behaviors of sexual comments, gestures towards staff such as grabbing at inappropriate areas. May become intimate with other residents such as kissing. At times prefers to lay naked in his bed, declining to put clothing on. Physical and verbal aggression toward staff. Exit seeking behaviors. with the interventions .1:1 at all times until further notice.Observe and document episodes of inappropriate behaviors, explain that behavior is inappropriate.Offer/provide activities of interest to keep resident engaged in positive interactions.Redirect to activity of interest- Watching Westerns, baseball games and boxing, listening to country music.Review of Nurses' Notes dated 6/22/2025 at 11:09 PM, revealed, .observed resident walking down the hallway without wheelchair multiple times during shift. redirected resident multiple times. redirection effective for a short period of times, repeated getting up ambulating down the hall. resident noted having hallucinations of seeing a person and dog in room. Resident redirected to wheelchair, spent time with nurse at nurse cart during med (medication) pass for safety, then assisted to bed. Resident denies anything wrong.message left for NP in communication book.Review of Nurses' Notes dated 6/25/2025 at 3:10 PM, revealed, .Resident noted with increase confusion, hallucination of seeing people in his room, he had attempted to pick up stuff of floor that was (sic) there, very restless today. NP wants to check UA (urinalysis) with CNS (culture and sensitivity) d/t (due to) hallucinations, increase confusion, dysuria, and urgency. Called and reported to (name of daughter) the POA of new orders as well. Resident did have recent GDR (gradual dose reduction) in Lexapro but resident was over the recommended dose. Nurse (first name) notified of the new orders. Review of Pertinent Charting-Behavior dated 6/30/2025 at 1:57 PM, revealed, .Event date: 06/25/2025: resident calm and cooperative throughout morning, blowing kisses at staff and trying to grab butts, easy to redirect, ate meals in room independently with set up assist only, appetite good, denies SOB (short of breath), prn (as needed) pain medication given and effective.Review of Nurses' Notes dated 6/30/2025 at 07:04 AM, revealed, .CNA also reported after this that CNA was trying to get him to the bathroom and he took out his penis and started goes towards her, CNA was able to redirect will continue to monitor for this behavior. Review of Pertinent Charting-Behavior dated 7/1/2025 at 06:23 AM, revealed, .Event date: 06/30/2025: Resident had quiet night. When woke up this morning for his Synthroid, became touchy wanting to hug this nurse saying, I love you, give me a hug. Was educated that this behavior was inappropriate. Seemed to accept this without any aggression.Review of Pertinent Charting-Behavior dated 7/4/2025 at 04:09 AM, revealed, .Event date: 06/30/2025.resident up ambulating on own in hallways, somewhat compliant with redirection. continues with slightly sexual inappropriate gestures.Review of Pertinent Charting-Behavior dated 7/4/2025 at 5:43 PM, revealed, .Event date: 06/30/2025:.resident restless on and off throughout shift, has intermittent episodes of exit seeking, difficult to redirect. Review of Pertinent Charting-Behavior dated 7/13/2025 at 7:37 PM, revealed, .Event Date: 07/13/2025.Behavior Displayed: resident speaking inappropriately to staff. stated you have a nice butt. when was the last time you had a blow job to male housekeeper. housekeeper reported to nurse.Precipitating factors/events: housekeeper greeted resident upon entering room for daily cleaning.Intervention(s) attempted: educated resident on appropriate conversation topics.Intervention results: no comments of sexual nature reported following intervention.Review of Nurses' Notes dated 7/17/2025 at 04:15 AM, revealed, .This resident was in resident (Hallway/Room number), the resident in her room woke to him touching her breasts and vaginal area she then started screaming and this resident then left her room and went back to his room.Review of Social Services Progress Notes dated 7/17/2025 at 3:11 PM, revealed, .SS (Social Services) followed up with resident r/t (related to) incident he had with a female resident that recently occurred. Resident had no recollection of incident during visit. Resident was seen today by (Name of Mental Health Services Provider) psych NP today 7/17. Resident has had a room move today to (Hallway/Room number) bed1in which he seems to be adjusting fine at this time. Review of Pertinent Charting-Behavior dated 7/18/2025 at 2:37 PM, revealed, .Event Date: 07/18/2025.Behavior Displayed: Increase behaviors; new orders to start zoloft and discontinue Lexapro.Precipitating factors/events: increase behaviors/agitation at times.Intervention(s) attempted: Redirection, snacks, activities.Pharmacologic Intervention required: Zoloft 50mg.Comments: Discontinue lexapro and start zoloft 50mg for depression and increase agitation and behaviors at times with increase difficulty redirecting resident. Dtr (daughter) consented to medication. Monitor for adverse effects of medication. Monitor resident's behaviors.Review of Transcribed NP/PA Progress Note dated 7/18/25 at 6:53 PM revealed, .HISTORY OF PRESENT ILLNESS: This is an [AGE] year-old male who is being seen for follow-up after patient apparently was found in a residence [sic] room and was touching her trunk area in the middle of the night-the pt's (patient's) room he was in stated that he was touching her trunk area starting from her peri-area up to her breast. Review of Pertinent Charting-Behavior dated 7/19/2025 at 4:38 PM, revealed, .Resident told cna that cna has nice breasts. Resident attempting to hug staff members while sitting in WC (wheelchair) in hallway. No aggressive behaviors observed during shift.Review of Pertinent Charting-Behavior dated 7/20/2025 at 2:40 PM, revealed, .Resident calm during shift. Attempting to hug staff members throughout day. Resident states that resident enjoys looking at CNA's breasts. Review of Nurses' Notes dated 7/20/2025 at 2:42 PM, revealed, .Nurse and staff members educated resident multiple times during day shift regarding inappropriate statements made towards staff.Review of Nurses' Notes dated 7/21/2025 at 1:19 PM, revealed, .Resident still exhibiting sexual behaviors. Resident was asking multiple staff members to allow him to perform oral sex on them. Staff members redirected resident stating this is inappropriate behavior and he needs to respect people's boundaries after staff members had told him no to holding his hand, or hugging him. Resident became frustrated and verbally aggressive after this conversation. Another staff member reports him talking about sexual interactions with other people, reportedly making the staff members feel uncomfortable.This RN reiterated that these topics are not appropriate to discuss with staff members and that he is making people uncomfortable. I requested the resident to change the topic. Able to redirect at this time. Review of Progress Note-General dated 7/22/2025 at 5:34 PM, revealed, .This writer was asked to go to the room as (Resident #103) was sexually touching the aide in his room. The aide asked him multiple times to stop, and he wouldn't. When walking into the room the nurse was standing in front of the aide, and (Resident #103) reached out and grabbed the nurse's breasts. The aide left the room, the nurse and I stayed in the room with (Resident #103). While he continued to make sexually inappropriate states including If you didn't want your p**** touched you wouldn't have come in here.Review of Nurses' Notes dated 7/22/2025 at 6:35 PM, revealed, .Entered the resident's room around lunch time to give him his meds and he grabbed my arm and pulled me to him and grabbed my vagina and told me How sweet my p**** was I told him to stop and he then grabbed my breast. I pulled away.Review of Nurses' Notes dated 7/22/2025 at 7:32 PM, revealed, .Was called into the residents room d/t (due to) him lying his head into the CNAs breast. I entered the room and the resident put his fist in my face and stated he wanted to hit the black bastard behind me and then put both hands on my breast and I told him to stop and then he grabbed my vagina. The resident then grabs my face with both hands and tells me how good my p**** is' Admin entered the room and other staff left and then he grabbed my vagina again. Stayed with the resident and the admin until he was picked up. Sent resident to (Local Hospital).Review of Pertinent Charting-Behavior dated 7/23/2025 at 4:19 PM, revealed, .Event date: 07/18/2025: Stated to the staff today.Are you sure you don't want to suck your c***, i can make your [NAME] feel real good.I really like that and I want to suck it It looks really nice please let me suck it i wish you would let me suck it.hey son I'm glad you didn't get mad and tell that i wanted to suck your d***. If you change your mind let me know.Review of Nurses' Notes 7/24/2025 at 11:56 AM, revealed, .Attempted to obtain UAx2, resident states he doesn't have to pee at this time.Resident also began pleasuring himself while staff on 1:1 was in the room. Advised staff to sit outside of resident's room to maintain the 1:1 status and pull the curtain for resident's privacy.Review of Pertinent Charting-Behavior dated 7/24/2025 at 7:46 PM, revealed, .Event date: 07/18/2025: Resident had inappropriate moments throughout the day. He at one point began to self pleasure-move 1:1 to hallway and allowed for privacy in which he stopped after staff left the room. A CNA later reported that the resident groped her butt and attempted to grab at her vagina when resident was receiving dinner tray.Review of Nurses' Notes dated 7/26/2025 at 6:50 PM, revealed, .Resident stated to this nurse the only way I would touch your butt is if I was making love to you and resident also talked about touching nurse's nipples. Resident reached at nurse attempting to touch this nurse's butt. Nurse moved away from resident and resident touched just below the butt. Resident stated, I missed I almost got your butt. Resident also kept trying to touch this nurse's face.Review of Pertinent Charting-Behavior dated 7/30/2025 at 12:30 PM, revealed, .Event date: 07/18/2025: Resident remains a 1-1. Resident making sexual comments and trying to touch staff. Education to stop this behavior was provided but resident continues. Resident noted to be masturbating this morning in his room. Privacy was provided by pulling the curtain.Review of Nurses' Notes dated 7/30/2025 at 09:16 AM, revealed, .The resident was wheeling around the hallway yelling I want fu***** pus**. The resident's eyebrows were furrowed, and he said he was fu***** angry that no one would give him pus**.He continued to ask for the person who runs this joint.He then asked 2 female staff to give him what he wants.The 1:1 sitter, (Hallway) nurse.were present.Staff were able to deescalate the resident and bring him back into his room. The resident continues to be a 1:1. The sitter is currently sitting outside the resident's room (while the resident is in sight) due to his frequent, inappropriate comments and requests. Review of Nurses' Notes dated 7/31/2025 at 06:50 AM, revealed, .resident was observed by 1:1 staff masturbating for 10 minutes in bed. privacy curtain pulled for privacy.Review of Pertinent Charting-Behavior dated 7/31/2025 at 03:17 AM, revealed, .Event date: 07/18/2025: resident continues on 1:1, resident making inappropriate comments to nurse giving resident HS (night time) meds, no further behaviors.In an interview on 08/04/25 at 2:23 PM, Resident #102 reported Resident #103 had said to her a few days prior to him coming to her room, Wouldn't it be nice if you had a blow job, she told him, No. Resident #102 reported this happened in the hallway outside of her room. Resident #102 reported a few days later she had woken up to someone touching her, she opened her eyes and saw a shadow, and then she turned on the light and it was Resident #103. Resident #102 reported she turned on the call light but no one came so she called 911 and the police came and talked to him, twice she said. Resident #102 reported he (Resident #103) had touched her in her vaginal area and moved up to her breasts. Resident #102 reported she was very frightened of him, the incident was scary to her. Resident #102 reported Resident #103 was moved to another hallway, and she was glad he was moved. Resident #102 reported the facility placed the Stop sign banner on her door after this happened. Resident #102 reported she reported it to the police so it would not happen to anyone else again and she was happy he was moved to another hallway.In an interview on 08/04/25 at 3:25 PM, Ombudsman DD reported Resident #102 was pretty upset. Ombudsman DD reported the situation had rattled Resident #102 pretty good and she expressed to her that she felt violated and the wondered if it would happen again to her. Ombudsman DD reported it was better Resident #103 had been moved from the same hallway as she was self-isolating, not wanting to leave her room, and was unsure if Resident #102 was fearful of seeing Resident #103 again. Ombudsman DD reported the staff knew Resident #103 had sexual acting out behaviors and was not managing them prior to this incident. In an interview on 08/06/25 at 4:16 PM, CNA J reported Resident #103 was a very touchy person, sexually attracted to men and women and had made sexual comments to both. CNA J reported when it came to females he had a tendency of inappropriate touching. CNA J reported she was pretty sure she was not the only person. CNA J reported it was normal for Resident #103 to ask to have kids with you and at some point, his behaviors intensified. CNA J reported Resident #103 had always acted this way since she started to work with him.In an interview on 08/06/25 at 09:15 AM, CNA R reported she had worked with Resident #103 as a one to one and noted he could not be around other residents, and staff were told to keep a close eye on him. In an interview on 08/06/25 at 09:17 AM, CNA Q reported before she became a CNA, she was a resident assistant, and she reported she worked on the hall where Resident #103 originally resided. CNA Q reported he was touchy, hugs, hold your hand, touch you in some way, tell her she was beautiful, shared he said he wanted to marry her and other staff informed her to be careful around him as he could be touchy and informed her if there was any inappropriate behavior to chart it and let someone know. CNA Q reported she did work with him on a one to one and she was surprised by his very inappropriate comments and behavior. In an interview on 08/06/25 at 09:34 AM, CNA U reported Resident #103 was touchy, he would grab your hand and hurry up and kiss it. CNA U reported he would say things like you look nice, wished he was younger, different phrases like those. CNA U reported he was flirty and then he became aggressive and would grab you in inappropriate areas on your body. CNA U reported when a resident had behaviors the staff were to document in his medical record. CNA U reported there was also paper documentation the staff could complete. CNA U reported in the medical record staff could also create an Alert for Resident #103's behaviors. In an interview on 08/06/25 at 09:59 AM, Registered Nurse (RN) BB reported she had worked with Resident #103 when he was in his previous room prior to the incident with Resident #102. RN BB reported Resident #103 was confused, alert to self and there were times he could say inappropriate things and they were graphic. In an interview on 08/06/25 at 10:11 AM, Social Services Director (SSD) CC reported the behavior management team met weekly to review residents who were on antipsychotics. SSD CC reported typically, the team would review a few residents at a time to discuss the medications, behaviors, what needs the resident may have, and whether a gradual dose reduction (GDR) was needed. SSD CC reported for those residents who were not on an antipsychotic medication and had behaviors, the clinical staff would discuss the needs in the morning meeting. As the clinical staff would be flagged when reviewing the behavior tasks, 24 hour reports, and alerts to see what the clinical staff as a team could develop for the resident as far as interventions. SSD CC reported Resident #103 was not someone the behavior management team was following. In an interview on 08/04/25 at 08:30 AM, Nursing Home Administrator (NHA) A reported Resident #103 had been on one to one since the incident on 7/17/25. NHA A reported he became more agitated, sent him to a psychiatric facility for evaluation last week (7/31/25). NHA A reported she was informed the resident had been at a local skilled nursing facility from a staff member, who had reported to the NHA the resident had been on a one to one during his stay there for inappropriate sexual behavior. NHA A reported Resident #103 did have a history of sexual crimes from 20+ years ago. NHA A reported the facility did complete a background check that doesn't prevent us from taking them as they would look at the whole person in the present. On 08/06/25 at 3:05 PM, NHA A reported when a resident was on one to one monitoring all the blanks on the 15 minute check sheet should be completed. This writer requested all behavior documentation for Resident #103 from admission. The documentation received was from 7/6/25 -7/21/25 prior to his discharge to a psychiatric facility on 7/31/25.Review of .Targeted behavior: Hallucinations such as seeing people/dogs in his room.7/17/25 Yes at 2:01 PM.Behavior: dated 7/21/25, indicated Yes.sexually inappropriate. Review of Resident #103's one to one documentation revealed, he was noted to not be monitored the following days and times, .7/20/25: 12:00 AM - 06:15 AM.7/21/25 08:30 AM - 11:45 PM.7/22/25: 12:00 AM - 07:45 AM.7/22/25: 09:00 PM to 10:15 PM.7/23/25: 1:15 PM - 2:15 PM.7/24/25: 07:00 AM - 07:45 AM.7/24/25: 2:45 PM - 3:15 PM.7/26/25: 12:00 AM - 02:15 AM.7/31/25 12:00 AM - 06:15 AM.Review of policy, Abuse, Neglect and Exploitation revised on 1/10/24, revealed, . Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual Abuse is non-consensual sexual contact of any type with a resident. B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms.

Based on observation, interview and record review, the facility failed to ensure that a urinary drainage bag was not resting on the floor to prevent the risk of urinary tract infection for 1 (Resident #101) of 3 residents reviewed for urinary catheter use, resulting in the potential for infection. Findings include:A urinary catheter is a tube placed in the body to drain and collect urine from the bladder .An indwelling catheter collects urine by attaching it to a drainage bag. The bag has a valve that can be opened to allow urine to flow out. Some of these bags can be secured to your leg. This allows you to wear the bag under your clothes. An indwelling catheter may be inserted into the bladder in 2 ways: Most often, the catheter is inserted through the urethra. This is the tube that carries urine from the bladder to the outside of the body. Sometimes, the provider will insert a catheter into your bladder through a small hole in your belly. This is done at a hospital or provider's office . A catheter is most often attached to a drainage bag. Keep the drainage bag lower than your bladder so that urine does not flow back up into your bladder. (https://medlineplus.gov > Medical Encyclopedia)Resident #101: Review of an admission Record revealed Resident #101 was a male with pertinent diagnoses which included acute kidney failure, kidney disease, retention (holding back of substances in the body that are normally excreted) of urine, and benign prostatic hyperplasia (enlarged prostate gland) with lower urinary tract symptoms. Review of current Care Plan for Resident #103, revised on 5/15/2025, revealed the focus, .Resident has a need for an indwelling catheter related to: urinary retention, mechanical complication of foley cath. with the intervention .Observe for signs and symptoms of UTI (Urinary Tract Infection) and report to the Physician: blood in urine, cloudiness, foul smell, fever, change in mental status.Document output.Report signs of peri-area redness, irritation, skin excoriation/breakdown to the Nurse.Report signs of peri-area redness, irritation, skin excoriation/breakdown to Physician/NP/PA.Assist resident with indwelling catheter care.Change catheter and drainage system as clinically indicated per order(s). Observe for signs/symptoms of obstruction (leakage, increased sediment, etc.), infection, or if closed system was compromised.Irrigate foley catheter as indicated.Maintain drainage bag below the bladder level.Privacy cover to catheter drainage bag.Review of Order dated 4/28/25 revealed, .Monitor urine from indwelling catheter for color, cloudiness, odor, and decreased output. Notify provider as needed of any changes.every day and night shift. Review of Order dated 4/28/25, revealed, .Catheter: ensure anchor secured in place.every day and night shift. Review of Order dated 4/28/25, revealed, .Change indwelling Foley catheter 16Fr; balloon 10cc as clinically indicated: s/s (signs/symptoms) of obstruction (leakage, increased sediment, etc.), infection, or if closed system was compromised.as needed.Review of Order dated 4/28/25, revealed, .Maintain indwelling foley catheter every day and night shift related to OTHER RETENTION OF URINE (R33.8).During an observation on 08/05/25 at 8:50 AM, Resident #101 was observed lying sideways in his bed. Noted his catheter bag was hanging from the left side of the bed, there was not a privacy bag which covered it, and it was lying on the floor. During an observation on 08/05/25 at 09:50 AM, Resident #101 was observed lying in his bed, his catheter bag was placed on the floor on the left side of the foot of the bed. No privacy bag/cover was over it. During an observation on 08/05/25 at 11:42 AM, Resident #101 was observed lying in his bed, his catheter bag was lying on the floor next to the right side by the privacy curtain side. During an observation on 08/05/25 at 12:58 PM, Resident #101 was observed lying in his bed. His catheter bag was lying flat on the floor, the connection to the bag/tube area was not on the floor. During an observation on 08/05/25 at 2:19 PM, Resident #101 was seated upright, and he was eating his lunch. Resident #101's catheter bag was hung at the left side of his bed, but it did not have a privacy bag/cover over it. During an observation on 08/06/2025 at 09:00 AM, Resident #101 was observed in his room, lying in his bed, he had his breakfast tray but had not begun to eat it yet. The catheter bag was hung at the side of the bed, but it did not have a privacy bag. Review of Nurse's Notes dated 7/4/2025 at 10:19 PM, revealed, .Note Text: Foley bag had milky/green foul odor urine, reported to NP (Nurse Practitioner) (Name of NP) who ordered UA C&S (culture and sensitivity).Review of Pertinent Charting-Infections/Signs Symptoms dated 7/7/2025 at 4:59 PM, revealed, .Event Date: 07/04/2025.Site of infection: UTI .Reason on antibiotics/new signs & symptoms: Foley bag had milky/green foul odor urine, reported to NP (Name of NP) who ordered UA C&S.Intervention(s): Administer medications and treatments to treat infection and/or symptoms as ordered; observe for adverse effects.Encourage fluids unless contraindicated. Observe and report to Physician/NP/PA signs/symptoms of dehydration (poor skin turgor, dry mucous membranes, increased heart rate, sunken eyes, decreased urinary output, difficulty breathing, hypotension).Evaluate for verbal and non-verbal signs of pain. Administer pain meds as ordered.Notify Physician/NP/PA of change in mentation, increased pain, decreased urinary output, sign/symptoms of infection.Observe for psychosocial changes and offer emotional support when needed.Enhanced barrier precautions.Clean peri-area well after BM (bowel movement) in order to help prevent bacteria in the urinary tract.Consult with urinary specialist as ordered.Review of Nurses' Notes dated 7/7/2025 at 5:14 PM, revealed, .New orders obtained by NP for positive UTI; Cipro 250mg BID for 7 days.In an interview on 08/06/25 at 09:36 AM, Certified Nursing Assistant (CNA) U reported for a resident who had a catheter ensure the catheter bag was closed and wear personal protective equipment (PPE) when providing care to Resident #101. CNA U reported the catheter bag should be hung on the bed rail or on the hook, should not be on the floor and should have a privacy bag. CNA U reported if the catheter bag was on the floor that could cause infection, and it would be contaminated. In an interview on 9:59 AM, Registered Nurse (RN) BB reported ensure the catheter was cleaned daily, make sure it is patent (open), draining, and with peri care it was emptied. Staff would ensure the catheter bag was secured to prevent pulling, and either a leg bag or hung on the bed below the bladder so that the urine emptied into the bag. RN BB reported the catheter bag should not be placed on the floor as this was not safe and would allow infection to get into the catheter. RN BB reported the catheter bag should've been covered with a privacy bag for the resident's dignity. In an interview on 08/06/25 at 10:25 AM, Infection Preventionist (IFP) EE reported the CNAs should ensure the catheter bag was down the line from the bladder, no loops or back up as it can grow bacteria. IFP EE reported staff should ensure the catheter drainage bag was attached to the side of the bed, beneath the catheter and secured with the securement device. IFP EE reported the catheter bag should never be on the floor as bacteria could be introduced in the bag, tubing, and up into the catheter causing a catheter associated urinary tract infection (CAUTI). IFP EE reported the catheter bag should be covered with a fig leaf bag and if the facility doesn't have any, a privacy cover bag should be used.A CAUTI (Catheter associated urinary tract infection), or a UTI associated with a catheter, is common if you have an indwelling catheter inside your urethra.Symptoms are similar to a general UTI and include bloody or cloudy urine, gritty particles or mucus in your urine, urine with a strong odor, pain in your lower back, chills and fever. (https://www.healthline.com/health/sediment-in-urine)In an interview on 08/06/25 at 3:01 PM, Unit Manager (UM) D reported the catheter bag should never be on the floor as it opened the portal for infection. Review of Resident #101's chart with UM D revealed he had a recent UTI and reported would like to prevent another one for him. Review of policy, Catheter Care Procedure - Urinary revised on 12/28/23, revealed, .It is the policy of this facility to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections, while maintaining their dignity and privacy. Catheter care may be provided by the nursing assistant and/or licensed nurse. 2. Privacy bags are used to cover catheter drainage bags while in use.

Based on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: During the initial tour of the kitchen, at 10:10 AM on 4/7/25, it was observed that the kitchens only hand sink was being blocked by a large dietary cart full of dirty dishes from breakfast. With no other hand sink in the kitchen, the cart had to be repositioned and moved over so that the hand sink could be accessible. An interview with Regional Dietitian VV found that facility staff have thought about adding another hand sink in the kitchen but are not sure of the best location. An interview with Maintenance Director Z, at 11:20 AM on 4/7/25, found that the original location suggested for an additional hand sink was too close to an electrical panel. When asked about adding a sink between the cook line and the three compartment sink, Maintenance Director Z stated one could possibly fit and more easily tie into the plumbing. An interview with Director of Operations WW, at 4:02 PM on 4/7/25, found that where its easiest to place the dietary carts for dishes is not convenient for regular access to the only hand sink. According to the 2022 FDA Food Code section 5-203.11 Handwashing Sinks. (A) Except as specified in (B) and (C) of this section, at least 1 HANDWASHING SINK, a number of HANDWASHING SINKS necessary for their convenient use by EMPLOYEES in areas specified under S 5-204.11, and not fewer than the number of HANDWASHING SINKS required by LAW shall be provided. According to the 2022 FDA Food Code section 5-204.11 Handwashing Sinks. A HANDWASHING SINK shall be located: (A) To allow convenient use by EMPLOYEES in FOOD preparation, FOOD dispensing, and WAREWASHING areas . According to the 2022 FDA Food Code section 5-205.11 Using a Handwashing Sink. (A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use . During a tour of lunch service, starting at 12:08 PM on 4/7/25, it was observed that Dietary Aide TT and Dietary Aide UU were found with artificial fingernails on the service-line. The dietary aids were helping add drinks, silverware, desserts, and plates of food to trays. At this time, no gloves were observed being worn by staff with artificial fingernails and Dietary Aide TT was observed wearing four bracelets. According to the 2022 FDA Food Code section 2-302.11 Maintenance of Fingernails (A) FOOD EMPLOYEES shall keep their fingernails trimmed, filed, and maintained so the edges and surfaces are cleanable and not rough. (B) Unless wearing intact gloves in good repair, a FOOD EMPLOYEE may not wear fingernail polish or artificial fingernails when working with exposed FOOD. According to the 2022 FDA Food Code section 2-303.11 Prohibition Jewelry Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry including medical information jewelry on their arms and hands. During an observation of lunch service, at 12:31 PM on 4/7/25, it was observed that Certified Dietary Manager (CDM) RR was helping check resident meal tickets and completed trays before being delivered. [NAME] SS stated she needed assistance with a food item. CDM RR was observed coming into the kitchen from outside the service window and assisting [NAME] SS with getting what looked to be parmesan cheese and then going back outside of the service window to continue her work with the trays. No hand washing was observed upon entering the kitchen and working with food. During an observation of lunch service, at 12:35 PM on 4/7/25, was observed that Dietary Aid UU, was placing utensils, desserts, and drinks onto resident trays. At this time, Dietary Aide UU was observed stepping off the tray line and exiting the kitchen to grab the next halls meal tickets located in the dining room. Dietary Aide UU was observed checking her phone upon leaving the kitchen and before grabbing the next halls meal tickets. After getting the meal tickets, Dietary Aid UU walked back into the kitchen and got back onto the service-line without washing her hands. During an observation of lunch service, at 12:43 PM on 4/7/25, it was observed that CDM RR was helping check resident meal tickets and completed trays before being delivered to residents. [NAME] SS stated she needed assistance with a food item. CDM RR was observed coming into the kitchen and getting chips for [NAME] SS without washing her hands. According to the 2022 FDA Food Code section 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and:(A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands.

Based on observation, interview, and record review, the facility failed to serve food at a palatable temperature in 2 of 4 residents (Resident #66 & #91) reviewed for food palatability, and 9 of 9 residents from the confidential group interview, resulting in dissatisfaction with meals and the potential for nutritional decline. Findings include: Resident #66 Review of an Admission Record revealed Resident #66 was a female with pertinent diagnoses which included anemia, diabetes, depression, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #66, with a reference date of 2/22/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated she was cognitively intact. In an interview on 4/7/25 at 11:49 AM, Resident #66 reported she eats her meals in her room, and hot foods at the facility are often cold by the time they are served. In an interview on 4/8/25 at 3:48 PM, Registered Dietitian (RD) M reported they have talked with Resident #66 about her food concerns, which include hot foods being served cold. In an interview on 4/8/25 at 3:58 PM, Resident #66 reported the dinner served last night (pork chop) was cold by the time it was delivered to her room. 27306 During the RC meeting on 4/8/25 at 10:00 am, 9 of the 9 participants reported the food was always , always cold with overcooked vegetables that were mushy. The RC participants reported items were missing of trays at every meal either a tea bag, salad, bread, dessert, food requests/preferences not honored. RC participants stated the facility had food committee in place, but all 9 RC participants unanimously agreed there had been no improvement. Resident 91 Review of the clinical record including the Minimum Data Set (MDS) dated [DATE], reflected Resident 91 (R91) was admitted to the facility with diagnoses that included sepsis due to escherichia Coli (E. Coli). R91 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 04/07/25 at 02:27 PM during an interview R91 reported food was terrible, had no flavor and always cold. R91 reported making multiple complaints to staff and had missed several meals due to palatability. 38905 An interview with [NAME] SS, at 11:59 AM on 4/7/25, found that she likes hot food on the steam table to be around 175F. At this time, temperatures of hot food items were taken and found to be over 175F. An interview with Certified Dietary Manager RR at 12:21 PM on 4/7/25, found that the order of food being delivered goes C hall cart, B hall cart , Dining room service , A hall cart, and then D hall cart. During lunch service, at 1:15 PM on 4/7/25, a test tray was plated and placed as the first meal tray on the D hall cart. No observations of additional food temperatures were found to have been taken since the start of service. At 1:29 PM on 4/7/25, the D hall cart, with the test tray and roughly 16 resident trays, was delivered to D hall. At 1:35 PM on 4/7/25, all of the resident trays on D hall had been delivered and the test tray was back in the conference room. The following temperatures were found with a rapid read digital thermometer: Mash potatoes 119F, Salisbury steak 109F, and carrots 118F.

Based on interview and record review the facility failed to ensure that grievances were promptly documented, investigated and resolved for 9 of 9 residents that participated in the Resident Council (RC) meeting. Findings include: Review of RC minutes dated 3/14/25 revealed old business included a concern that call lights on 3 rd shift were not answered timely and light turned off before need was met and that water was not passed consistently. The section of Actions taken was left blank. RC minutes dated 2/7/25 RC revealed old business that call light response time on 3rd shift slow to respond, and water pass was not consistent. New business identified concerns of 1. Call light on 3rd shift long wait time. 2. Turning off call light before addressing issues. 3. Ice water not passed out consistently Action taken changing hours to support third shift RC minutes dated 1/10/25 reflected under old business that call light response time was ongoing actions taken section of the minutes was left blank. New Business concerns were 1. Water not passed consistently 2. Call light response time 3rd shift weekends RC minutes dated 12/06/24 identified old business as call light response time status update ongoing Action taken will be added to all shift. New business call lights not being answered timely on 3rd shift will be added to all staff RC minutes dated 11/08/24 identified old business was call light response time Status update ongoing New Business - Call light response time early morning/night Action taken was ongoing. RC minutes dated 10/11/24 revealed new Business was a concern with call light response time- Action taken Was that the Director of Nursing would do spot checks on 2nd and 3rd shift. During the RC meeting on 4/8/25 at 10:00 am, 9 of the 9 participants reported they do not receive assistance in a timely manner on third shift. One participant reported he turned on his call light last night at 3:30 am and did not receive assistance until the day shift came in at 7:00 am. All 9 participants stated they complain about call light response time, staff turning off the call light prior to meeting their need and staff not consistently passing out water. RC participants stated these issues come up every month and will get better for a few days, then revert back. Five of the 9 RC participants reported they no longer voice concerns to Nursing Home Administrator A or Director of Nursing (DON) Bbecause they felt like their concerns were not taken seriously and fall on deaf ears. Three participants stated there was a canned response of We will take care of it. or Will see. On 04/09/25 at 10:10 AM, during an interview with NHA A she reported she stated she was aware of the concerns and had altered the staff development nurses schedule to work 4 -10 hour days in attempts to correct issues. When queried what time the staff development nurse got off duty , NHA A stated 9:00 pm.

Based on interview and record review, the facility failed to implement ordered restorative program services provided to maintain, increase, or improve range of motion for 1 resident (Resident #41) of 2 residents reviewed for positioning/mobility, resulting in the potential for decreased range of motion and related complications such as development/worsening of contractures (shortening and hardening of muscles, tendons or tissue leading to deformity and rigidity of joints) and pain. Findings include: Resident #41(R41) Review of the Admission Record and Minimum Data Set (MDS) dated [DATE] revealed R41 originally admitted to the facility on [DATE] with diagnoses including type 2 diabetes (body has trouble controlling blood sugar and using it for energy), reduced mobility, depression and anxiety. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R41 was cognitively intact (13 to 15 cognitively intact). During an interview on 4/7/2025 at 11:02 AM, R41 stated that he was supposed to be on a restorative program for range of motion and the facility staff hadn't done anything with him. R41 said he was on a restorative program in the past and really liked it and would like to receive it again. Review of R41's physician order revealed an order date of 3/11/2025 and Resident will benefit from level 2 restorative ADL (Activities of Daily Living)/HYGIENE and ROM (Range of Motion) program as resident tolerates and is willing. During an interview on 4/8/2025 at 9:42 AM, Restorative Aide (RA) LL stated that he worked with R41 in the past and he was on the caseload again. RA LL said that that he should work with R41 2-3 times a week if R41 was available since he likes to go outside a lot. RA LL stated that he was just on vacation for 10 days and he wasn't sure if the other RA (RA KK) saw him when he was on vacation. During an interview on 4/8/2025 at 9:47 AM, Minimum Data Set (MDS) Licensed Practical Nurse (LPN) who was also the Restorative Director (RD) II stated that R41 was on restorative caseload for ROM and hygiene but he hasn't really been seen since he spends a lot of time outside. RD II said they like to see residents 2-3 times a week but the time isn't set since it's PRN (as needed). Review of R41's care plan revealed Focus: Resident would benefit from a restorative range of motion program related to decreased strength in lower extremities, decreased strength in upper extremities. Date initiated 1/24/2024, Revision on 3/11/2025 Review of R41's task documentation revealed the following restorative tasks: Right upper extremity active Range of Motion, shoulder and elbow all planes, manual resistance 2-3 sets/15-20 reps (repetitions); Restorative Nursing: Dressing/Grooming: Hand hygiene- Set up soapy water with washcloth and orange sticks; set up/supervision assist. The questions How well did resident tolerate, amount of minutes spent proving range of motion and why did the restorative program not occur? each area displayed no data found for the last 30 days. When discussing the lack of restorative documentation on 4/8/2025 at 10:00 AM, RD II stated that she doesn't do a good job documenting for the restorative program and making sure the RA's document under the task tab. RD II said that she doesn't have any other documentation anywhere and it's my fault. Review of the Restorative Nursing Programs Policy with an implementation date of 10/30/2020 and a review date of 1/1/2022 revealed Level II Restorative Nursing - A reasonable expectation that improvement will continue to occur with resident participation and goal setting . The following types of residents could benefit from a Restorative Program(s) but limited to: Contracture prevention and/or management . Skills practice/training in Activities of Daily Living Contracture Prevention and Management . Once determined that the resident would benefit from a restorative nursing program, implement the following: Determine if the resident is willing and able to participate. Document refusal in the medical record with education regarding risks and benefits. Re-visit at least quarterly to determine if the resident would still benefit. Determine willingness and ability and document refusals as previously completed Each facility should establish a monitoring program to assure success. The following have been identified as best practices . Establishment of a daily review of rehabilitation documentation to discern delivery of care or need to schedule on another shift .Implementation of program review by nursing staff, therapy, and others as appropriate to monitor program including additions of new residents and removal of programs Documentation of implementation should be completed on the Restorative Service Delivery Record or EMR as applicable. This includes each description of the intervention or modality to be provided, Time in minutes each time provided, Staff initials each time provided

Based on observation, interview, and record review, the facility failed to protect the resident's right to dignity with grooming of facial hair in 1 resident (Resident #101) of 5 residents reviewed for dignity resulting in the potential for feelings of diminished self-worth, sadness, and frustration. Findings include: Resident #101(R101) Review of the Admission Record and Minimum Data Set (MDS) dated [DATE] revealed R101 admitted to the facility on [DATE] with diagnoses including type 2 diabetes (body has trouble controlling blood sugar and using it for energy) and muscle weakness. Brief Interview for Mental Status (BIMS) reflected a score of 11 out of 15 which indicated R101's cognition was moderately impaired (8-12 moderately impaired). During an observation and interview on 4/7/2025 at 11:36 AM, R101 was observed to have approximately 10 long gray facial hairs on her chin. R101 stated that they used to shave her chin in the group home before she came to the facility. R101 said that she hasn't had her facial hair shaved here since she was admitted to the facility and would like it to be done. During an interview on 4/8/2025 at 9:28 AM, Resident Assistant (RA) O stated that it is standard for staff to pluck or shave residents on shower days or if they request it to be done. During an interview on 4/8/2025 at 9:31 AM, Certified Nursing Assistant (CNA) C stated that residents should be shaved on shower days. CNA C said when she notices facial hair she asks residents if they want to be shaved or they will ask her to be shaved. During an interview on 4/8/2025 at 3:49 PM, CNA S stated that on shower or bed bath days she asks residents if they want to be shaved or have hair plucked if she notices facial hair on them. During another observation and interview on 4/8/2025 at 9:39 AM, R101 was observed to still have gray facial hair on her chin. R101 stated that she had a shower the day before (4/7/2025) and the staff were supposed to shave her chin but they didn't. R101 said she would still like it done. Review of the task list for staff revealed that R101's bathing schedule was on Mondays and Thursday on 1st shift. It was noted that R101 received a bed bath or shower 9 times since admission. The shower sheets only indicated whether skin checks were done and did not display any grooming check off. During an interview on 4/8/2025 at 3:56 PM, Nursing Home Administrator A stated that it is an expectation for staff to groom and ask residents if they want facial hair removed on their shower days. Review of the Expectation and Documentation of Resident's Shower sheet in each hall's CNA book revealed .4. Facial hair for both men and women need to be attended to with each shower. If facial hair is present, please shave. If the resident refuses to allow shaving, please inform the nurse responsible for that resident

Based on observation, interview, and record review the facility failed to revise a person-centered care plan for 1 (Resident #106) of 7 residents reviewed for person-centered care plan revisions resulting in an inaccurate reflection of the resident's current care needs. Findings include: Review of an Admission Record revealed Resident #106 had pertinent diagnoses which included: adult failure to thrive, restlessness and agitation, and severe protein calorie malnutrition. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 12/20/2024 revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident #106 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment). Review of Order Summary for Resident #106 revealed Adaptive equipment: plate guard, built-up utensils (a piece of foam with a slit in the center for the handle of eating utensils to be inserted to create a greater gripping surface area), 2-handled cup with straw with a start date of 8/26/2024. Review of Care Plan for Resident #106 revealed Focus/Interventions Resident has an ADL (activity of daily living) self-care performance deficit related to physical debility, generalized muscle weakness .adult failure to thrive; Intervention eating: 1 person assist; utilize plate guard, built-up utensils, 2-handled cup with straw with meals with an initiation date of 8/26/2024. Review of Therapy to Nursing Communication Form for Resident #106 dated 8/26/24 revealed plate guard, built-up utensils, 2-handled cup w/ straw (with). During an observation on 2/5/25 at 8:40 AM Resident #106 was sitting his high back wheelchair, in the dining room, with his legs pulled up and his knees bent. Resident #106 had a breakfast tray on the table in front of him, that included 2 coffee cups with lids and straws and Resident #106 was holding and drinking from a coffee cup with a lid and a straw in it. Restorative Aide (RA) AA was observed scraping Resident #106's scrambled eggs into a bowl and handing the bowl and a built-up utensil to Resident #106 to eat. In an interview on 2/5/25 at 10:20 AM, Occupational Therapist (OT) GG reported Resident #106 did not use built up utensils anymore. OT GG reported she had upgraded Resident #106 to regular silverware, and she had communicated the changes to nursing and dietary departments. OT GG reported that Resident #106 did not always need a 2-handeld cup, but she had not changed that yet. OT GG reviewed the care plan for Resident #106 with this surveyor and confirmed the care plan indicated plate guard, built-up utensils, and 2-handled cups for liquids and it had not been revised to reflect the changed OT GG had communicated. Review of Therapy to Nursing Communication Form for Resident #106 dated 12/11/24 revealed Return to regular utensils-D/C (discontinue) built-up. The form was signed by nursing and dated 12/11/24 as acknowledged. In an interview on 2/5/25 at 10:31 AM, Dietary Manager (DM) JJ reported that Resident #106 was to have coffee cups with lids and straws, built up utensils, and a plate guard. DM JJreported that dietary staff knew the resident's needs because they were listed on the Resident's meal ticket. Review of meal tickets for Resident #106 dated 2/5/25 revealed Breakfast- Coffee cups w/lids for all liquids, built up utensils, plate guard; Lunch - built up utensils, coffee cups w/lids for all liquids, plate guard; Dinner- Built up utensils, coffee cup w/lids for all liquids, plate guard. During an observation on 2/5/25 at 12:40 PM Resident #106 was sitting in his wheelchair in the dining room, up to a table, drinking from a coffee cup with a lid and a straw that he was holding. Review of Order Summary for Resident #106 dated 2/5/25 at 11:02 AM, revealed adaptive equipment: plate guard, 2-handled cup with straw In an interview on 2/5/25 at 12:43 PM, Unit Manager/Licensed Practical Nurse (UM/LPN) O reported she had made updates today to Resident #106's orders for adaptive equipment because she was given a communication that was signed in December and the changes had not yet been made. UM/LPN O reported the nursing department communicates changes to the dietary department. UM/LPN reported when the changes did not happen in the nursing department, they did not happen in the dietary department either. In an observation on 2/5/25 at 12:53 PM, Resident #106 was sitting in his wheelchair, in the dining room, drinking from a coffee cup with a lid and straw that he was holding. OT GG was present, observing and interacting with Resident #106. In an observation on 2/5/25 at 12:56 PM, Resident #106 was sitting in his wheelchair, in the dining room, up to the table, with his meal tray present in front of him. Resident #106 meal tray included built-up utensils, a plate guard, and 3 2-handled cups of liquids. OT GG joined Resident #106 and replaced his built-up utensils with regular ones.

This citation pertains to intake #MI00146503 Based on interview and record review the facility failed to ensure that professional standards of nursing practice were maintained related to physician orders for 1 (Resident #100) of 1 resident reviewed for professional nursing standards and physician orders resulting in inaccurate physician orders and the potential for medication error. Findings include: Review of an Admission Record revealed Resident #100 had pertinent diagnoses which included: pain, muscle spasm, contracture of the left foot, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 12/16/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #100 was cognitively intact. (BIMS score 12-15 indicates little or no cognitive impairment). Review of Medication Administration Record (MAR) for Resident #100 for the month of December 2024 revealed Oxycodone-acetaminophen (Percocet) Oral Tablet 10-325 mg (milligrams) (Oxycodone w/ (with) acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain until 12/11/24 at 23:59 (11:59pm) with a start date of 12/10/2024 at 17:30 (5:30 pm). Documentation was noted on the MAR indicating at 17:30 pm on 12/10/24 this medication was administered to Resident #100. In a telephone interview on 1/30/25 at 2:25 PM, Family Member (FM) DD reported the facility did not dispense Resident #100's pain medication as her physician was ordering/prescribing it. FM DD reported the facility had given Resident #100 Percocet, and Resident #100 never had an order for Percocet. FM DD reported Resident #100 should have had an order for Norco. FM DD reported he was told this was a near miss (a serious error or mishap that has the potential to cause an adverse event but fails to do so because of chance or because it is intercepted) and not a medication error. Review of Nurses' Notes for Resident #100 dated 12/10/2024 at 19:20 (7:20 PM) and authored by Registered Nurse/Supervisor (RN/S) K revealed Resident's PCP (primary care physician) was in to visit resident and gave verbal order for Norco 10-325mg q8 (every 8 hours) PRN (as needed) until 12-11 at 23:59 . In a telephone interview on 1/30/25 at 3:33 PM., Resident #100 reported she remembered she was supposed to take Norco for pain and the facility tried to give her something else. In an interview on 2/4/25 at 12:10 PM., Director of Nursing (DON) B reported the order for Percocet was entered inaccurately, the order should have been for Norco. In an interview on 2/4/25 at 12:10 PM., Nursing Home Administrator (NHA) A reported the order for Percocet for Resident #100 was entered into the computer (Electronic Health Record/EHR) inaccurately, it should have been an order for Norco. In an interview on 2/4/25 at 3:24 PM., Education Training Director/RN (ETD/RN) W reported Resident #100's order for Percocet was a clerical error, the order was inputted into the EHR wrong. ETD/RN W reported there was no written prescription and no verbal order for Resident #100 to have Percocet. ETD/RN W reported there was never a delivery of Percocet for Resident #100 to the facility. In an interview on 2/5/25 at 10:49 AM., RN/S K reported on 12/10/24 Resident #100's doctor gave her a verbal order and she wrote it down wrong. RN/S K reported the actual verbal order was for hydrocodone (Norco), not Percocet. RN/S K reported she entered the order into Resident #100's EHR as Percocet. RN/S K did not recall if she documented she had administered Percocet to Resident #100 on that day. RN/S K reported Percocet was never available in the medication cart for Resident #100 and she did not administer Percocet to Resident #100 when her doctor gave her a verbal order. RN/S K stated I gave her what was available in the medication cart and that was Norco. Review of Controlled Substance Record for Resident #100 revealed Hydrocodone-APAP (acetaminophen) (Norco) 10-325 mg tab (tablet). On 12/10/24 at 17:30 (5:30pm) RN/S K initialed for the removal of one tablet for administration to Resident #100. Review of MAR for Resident #100 for the month of December revealed no active order for Hydrocodone-Acetaminophen (Norco) Tablet 10-325 mg give one tablet by mouth every 8 hours as needed for pain on 12/10/2024. Review of Quality Assistance Form dated 1/16/25, completed by NHA A and reviewed by DON B, concerning Resident #100 revealed The order for Norco (hydrocodone) was written for oxycodone (Percocet). Findings: orders only written for Norco; Plan/Action: reordered the next day; resolved, yes, correct order written. In an interview on 2/5/25 at 12:16 PM., RN Q reported the medication given should match the order in the EHR. In an interview on 2/5/25 at 12:18 PM., Licensed Practical Nurse (LPN) BB reported verifying the medication order and the medication available was part of the 5 rights to medication administration. In an interview on 2/5/25 at 12:36 PM., DON B reported her expectations were when a medication was administred the order EHR and the medication given should match.

This citation has two Deficient Practice Statements (DPS). DPS 1 Based on observation, interview, and record review, the facility failed to ensure a safe environment and adequate safety measures for one resident (R9) of 22 residents reviewed for accidents and hazards, resulting in a fall with injury and the potential of additional falls with injuries. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R9 scored 2/15 on her BIMS (Brief Interview Mental Status) indicating the resident was severely cognitively impaired, experienced bowel/bladder incontinence. The resident had no impairment in her arms or legs, high-risk medications included antianxiety, antidepressant and sedative medications. Section J1900- two or more falls since admission. Review of R9's Diagnoses included dementia, diastolic congestive heart failure, hypertension, anxiety, major depressive disorder recurrent mild, urinary tract infection (1/15/2024), repeated falls (1/9/2024), pain in left leg, developmental disorders of speech and language, dependence on wheelchair, generalized muscle weakness, and insomnia. During an observation and interview on 2/27/24 at 11:38 AM, R9 was in her room awake and supine (positioned on back) sitting up in bed. On the middle of her forehead were two scabbed over lacerations, with her left cheek and eye having multiple shades of bruising. The resident's bed was positioned with the head-of-bed (HOB) against wall and both sides open. A fall mat was on the floor to the right side of the bed. There was no fall mat to the left side of the bed. The resident reported she liked to drink water as she tried twice to drink from her empty drinking cup. Resident asked surveyor to have her brief changed because she was soiled. Review of R9's Incident Report (IR) #771 dated 1/3/2024 20:50 (8:50 PM) reported the resident had an unwitnessed fall in her room. She was found laying on the floor beside her bed. R9 told staff she was getting up to go downstairs. The resident's care plan had been updated to include encourage and assist resident up in her wheelchair when anxious/restless and calling out. Staff had last seen the resident at 2040 (8:40 PM) in bed. Staff statements included resident was laying under her bed laughing was on the floor with her head under the foot of the bed closest to the door last checked at 8:30 (PM). Was told by co-worker resident was on the floor, was happy, smiling, saying she was going out. It was noted that the side of the bed the resident was found was not indicated. Review of R9's Fall Initial Report 1/3/2024 reported the resident had fallen on this date while trying to go out. Interventions were updated in care plan included frequent observations. Review of R9's Care Plan 1/3/2024 Risk of falls/injury Revision 12/26/2023. Focus was related to unsteadiness on feet, dementia, congestive heart failure, hypertension, anxiety, generalized muscle weakness, reduced mobility, pain, neuropathy, constipation, insomnia, and depression. The resident chooses not to use her call light and attempts to self-transfer/ambulate at times. It was noted the resident could not complete her BIMS due to severely impaired cognition. The goal was to reduce the risk of injury through the next review. Frequent observations as reported in the Fall Initial Report 1/3/2024 was not an updated intervention after R9's fall on 1/3/2024. Review of R9's IR #777 dated 1/8/2024 00:30 (AM) reported the resident had an unwitnessed fall in her room. She was heard calling out and observed laying on the right bedside floor with her head towards the foot of the bed. The resident had been incontinent of diarrhea. The resident's care plan had been updated to include a medication review for bowel medications. The resident was receiving a constipation medication with a history of bowel obstruction. Staff statements included The resident was incontinent of bowel and bladder the resident was on her back lying on the floor with her head toward the foot of bed .had previously last seen by this nurse at 2300 (11 PM) saw her on the floor on the opposite side of the bed with head toward the door. It was noted the side of the bed the resident was found was not indicated. However, the last witness statement saw her on the floor on the opposite side of the bed with head toward the door indicates the resident was on the left side of the bed. Review of R9's Fall Initial Report 1/8/2024 reported the resident had fallen on this date. The resident was laying in bed sleeping prior to the fall. Interventions were updated in care plan included floor mat on right side of bed. Review of R9's Care Plan 1/8/2024 Risk for Falls/Injury updated interventions did not include Fall mat to right bedside floor when resident is in bed as reported in the Fall Initial Report 1/3/2024 until 2/19/2024 when the resident fell and sustained lacerations to her forehead that required medical attention. Review of R9's IR #864 dated 2/18/2024 19:30 (7:30 PM) reported the resident had an unwitnessed fall in her room. The resident could be heard calling out from the hallway. She was found resting supine of the floor next to her bed bleeding from her forehead. An assessment presented with impairment to R9's forehead and arm. The resident was sent to the ER (emergency room ) for evaluation. R9's care plan was updated to include referral to therapy for evaluation of side rails, discontinue wheelchair at bedside, and fall mat to right bedside floor when resident in bed. Staff statements included resident was put to bed around 1920 (7:20 PM). Resident was checked and changed during this time. It was noted the side of the bed R9 was found not indicated. Review of R9's Fall Initial Report 2/18/2024 reported the resident had fallen on this date and was sent to the ER for further evaluation of a forehead injury. The resident was laying in bed and was toileted at 7 PM prior to the fall. Interventions updated in the care plan included vital sign monitoring may include orthostatic (laying/sitting/standing blood pressure). Review of R9's Care Plan 2/19/2024, Risk for Impaired Skin Integrity -Left forearm skin tear 2/15/2024 -Left eyebrow laceration with 2 staples -Forehead laceration with 3 staples The goal was for the resident was to have intact skin. No interventions were documented for the lacerations. Review of R9's Care Plan Risk of falls/injury updated interventions did not include vital sign monitoring may include orthostatic (laying/sitting/standing blood pressure) as reported in the Fall Initial Report 2/18/2024. Review of R9's Order Summary revealed: -2/19/2024 Fall mat to right bedside floor when resident is in bed every day and night shift. -2/26/2024 Forehead laceration: Cleanse and pat dry. Apply A&D ointment to scab area and cover with a large bandage every day shift for wound care. -2/26/2024 Forehead laceration: Cleanse and pat dry. Apply A&D ointment to scab area and cover with a large bandage as needed. -2/26/2024 left eyebrow laceration/scab: Leave OTA (open to air). Notify MD/NP of any negative changes every day shift for wound care. -2/26/2024 left forearm scab: Apply skin prep. -2/21/2024 Monitor bruising to face: notify MD/NP of abnormal changes every day and night shift DC (discontinue) upon completion. Observed on 2/27/24 at 1:27 PM, on the floor to R9's right side was a fall mat. No fall mat was on the floor to the resident's left side. Observed on 2/28/24 at 9:05 AM, on the floor to R9's right side was a fall mat. No fall mat was on the floor to the resident's left side. During an observation, interview, and record review on 2/28/24 at 1:27 PM, Licensed Practical Nurse (LPN) N stated, (R9) falls out of bed. Staff cannot figure out what she is doing. One time she was screaming before she fell . She was referred to therapy. She always falls to the right that is why the fall mat is only to her right side. She panics when being moved in bed, even when she is turned by staff. She has never been seen to fall to the left. She initially had a perimeter standard sized mattress so staff got her a bariatric bed to see if that would help her. Grab bars were tried but she did not use them, so they were removed. She was sent to the emergency room (ER) after her last fall and has a few staples in the laceration. During an observation and interview on 2/29/24 at 8:30 AM, LPN CC with surveyor toured R9's bed area. A fall mat was on the floor to the right side of the resident. There was no fall mat to the left side of the bed. LPN stated, I do not know why there is not a fall mat on the left side of her (R9's) bed. During an interview and record review on 2/29/24 at 11:00 AM, Therapy R stated, (R9) crosses her left leg over right leg and leans more to the right. She is inconsistent with her body position but mostly it is to her right side. I do not know if she would fall to the left because she mainly leans to the right. Review of R9's Nursing Quarterly/Significant Change Evaluation 2/29/2024 reported the resident scored 16.0 (Falls-High Risk). The resident had had 1-2 falls in the last 90 days with the most recent fall on 2/18/2024. Her mobility was described as confined to chair. Balance while standing, sitting, and during transitions was not able to attempt without physical help. Review of R9's Progress Note 2/19/2024 16:36 (4:36 PM) IDT-Interdisciplinary reported the clinical team reviewed the resident's fall report from 02/18/24 at 1930 (7:30 PM). The report stated This resident was observed resting supine on the floor next to her bed. Neurochecks and vital signs were completed, a head-to-toe assessment was completed with impairment noted to forehead and arm. Notifications made per facility protocol and order obtained from (name of Nurse Practitioner) to send the resident to the ER for evaluation. This resident was also referred to therapy to assess her grab bars because she is using them to self-transfer out of bed. A fall mat was then placed to the right, bedside floor (while the resident is in bed.) Staff will continue to monitor these new interventions for efficacy. Review of R9's NP Progress Note 2/19/2024 09:29 (AM) reported as a hospital extended care note, the resident had been seen in the ER after a fall and had a laceration on the forehead. The note indicated R9 had received staples that would require removal in approximately seven days. The diagnosis after evaluation indicated the resident received a concussion and two lacerations to the forehead, one that measured 2.5 cm (centimeters) and required stitches. Bruising was present on the resident's face. Review of R9's Progress Note 2/22/2024 10:19 (AM) reported occupational therapy had assessed the resident and at that time did not require bilateral grab bars. Review of R9's Progress Note 2/25/2024 14:31 (2:31 PM) reported the skin tear to the resident's left forearm was healing. No dressing was applied at that time. A scabbed area was OTA. Review of facility policy Fall Prevention Program revised 1/1/2022, revealed, .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 . Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care . Interventions will be monitored for effectiveness .The plan of care will be revised as needed . When any resident experiences a fall, the facility will . Review the resident's care plan and update as indicated . 38905 DPS 2 Based on observation and interview, the facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120 F. This resulted in an increased risk of injury among residents who are ambulatory. Findings Include: During a tour of the B hall shower room, at 3:18 PM on 2/27/24, it was observed that no shower head was located on the shower. When asked if this room was still used for given resident showers, Maintenance Director (MD) S stated yes, but he wasn't sure where the shower head has gone or when it was used last. During a tour of the facility, with MD S, at 3:30 PM on 2/27/24, observation of empty resident rooms B-9 and B-11 found that the shared bathroom sink reached 136F when tested with a rapid read thermometer. At this time, an interview with MD S found that each hall has its own hot water supply. When asked why the water temperature would be so high, MD S stated the lack of hot water usage on this hall might have helped stack the hot water and deliver high temperatures. During a tour of the facility, at 3:36 PM on 2/27/24, observation of the B hall soiled utility room found that hot water reached 135F after running for one minute and sustained the temperature. During a revisit to the B hall spa room, at 3:39 PM on 2/27/24, found the hot water from the sink reached 133F while running while MD S was actively flushing hot water from the system to help decrease the temperature. During a revisit to the D-hall spa room, at 4:50 PM on 2/27/24, it was observed that the spa room sink reached a hot water temperature of 127F. During a tour of resident room C-2, at 4:55 PM on 2/27/24, it was observed that the bathroom sink was found to reach 126F. During a tour of resident room A-1, at 4:58 PM on 2/27/24, it was observed that the bathroom sink was found to reach 123F. During an interview with MD S at 8:15 AM on 2/28/24, in the B hall boiler room, found that the their plumbing vendor came yesterday and discovered that the mixing valve was not working properly as it dispensed hot water to resident care areas and will need to be repaired. When asked about the about the excess hot water in the other hallways, MD S stated the water heaters have been readjusted to maintain hot water levels below 120F. During an interview with MD S, at 10:40 AM on 2/28/24, the surveyor asked if the facility kept track of the hot water temperatures and if they could provide a log of temperatures for the domestic hot water. MD S stated his staff performs the logs and he could get them. During an interview with MD S at 11:10 AM it was found that he can't find the book used to document hot water temperatures. No documentation was provided.

Based on observation, interview and record review the facility failed to accurately assess a resident's skin integrity, and update interventions to prevent the development and worsening of a medical device related pressure ulcers for 1 (Resident #100) of 4 residents reviewed for pressure wounds, resulting in Resident #100 developing unstageable/non-healing pressure ulcers after a cast like boot (for leg fracture) had not been removed for assessment of skin integrity by nursing staff in accordance with physicians orders. Findings include: Review of an Admission Record revealed Resident #100, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic respiratory failure. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 11/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #100 was cognitively intact. Further review of Resident #100's MDS assessment revealed Resident #100 was a 2 person (staff) assist with a hoyer lift. Review of Resident #100's Nursing Progress Note dated 8/28/23 revealed: Note Text: significant findings of oblique fracture of left tibia received from STAT (immediate/ASAP) x-ray ordered for increased pain, on-call provider notified Review of Resident #100's Incident/Accident: report dated 8/29/23 at 10:00 AM., revealed: Nursing Description: Resident complained of left leg pain On 08/28/23 a tib/fib x-ray was ordered with results noting Obliquely oriented fracture through the mid distal tibial shaft Resident Description: -Do you remember anything happening to your leg? No-Did something hurt your leg? No Do someone hurt your leg? No, .It hurts when they turn me. Injuries Observed at Time of Incident . Location Injury Left lower leg (front) . Type Injury Bruise Fracture .Location Left lower leg (front) Review of Resident 100's physicians orders dated 8/29/23 revealed: Order Summary: Fracture boot to left lower extremity at all times except bathing; monitor skin under and surrounding boot & notify MD/NP (medical doctor/nurse practitioner) of any changes . Every day and night shift related to unspecified fracture of shaft of left tibia .initial encounter for closed fracture . Review of Resident #100's Care Plan revealed: Focus: (Resident#100) is at risk for impaired skin integrity related to impaired cognition, incontinent of bladder, incontinent of bowel, neuropathy, impaired mobility . hx of open sores between buttocks . Current: Left heel, Left anterior ankle, & Left dorsal foot, (medical device related pressure sores) 09/09/23 Date Initiated: 08/29/2023 In an interview on 12/5/23 at 12:10 PM., Resident #100 reported she broke her left leg a few months ago, and after wearing a boot like cast for over a week she (Resident #100) developed some sores on her left foot, which have gotten worse Resident #100 reported when the boot was on her left leg, it was on there at least a week, and it (the boot) was not taken off during that time. In an interview on 12/5/23 at 12:35 PM., Certified Nurse Aide (CNA) G reported (Resident #100) had an injury to her left leg about 3-4 months ago. CNA G reported she had an X-ray done,and had a fracture of her lower left leg. CNA G reported (Resident #100) had to wear a hard boot for a while. CNA G reported it was her (CNA G's) understanding that the boot was left on for quite a while before it was noticed that no one had assess her skin under the boot. In an interview/record review on 12/5/23 at 1:30 PM., Registered Nurse (RN) D reported Resident #100 developed facility acquired pressure ulcers on her left foot due to a medical device (hard fracture boot-not full cast). RN D reported according to (Resident #100's) physicians orders the fracture boot was ordered to be put on her on 8/28/23. RN D reported to fracture boot came in on 8/29/23 and was put on (Resident #100) that evening. RN D and this surveyor reviewed Resident #100's physicians orders, wound evaluations and progress notes at this time. RN D reported the fracture boot was placed on (Resident #100's) left foot on 8/29/23. RN D reported according to (Resident #100's) progress notes it wasn't until 9/8/23 that is was noted there were 2 new acquired wounds on (Resident #100's) left foot. Review of Resident #100's Progress Note dated 9/06/2023 revealed: NP/PA (Nurse Practitioner/Physician's Assistant) Progress Note Text: (Resident #100) is Associated Diagnoses: Debility; Left leg pain; Unspecified fracture of shaft of unspecified tibia, initial encounter for closed fracture; Immobility .(Resident #100) is being seen for concern by the nursing staff that pt (Patient) .(Resident #100) is having uncontrolled pain at times- pt with recent dx of a tibial fx (fracture) and is currently wearing a fracture boot Musculoskeletal pt has a fracture boot in place on the left lower leg/foot- pt's toes were warm to touch- skin pink in color- pt was unable to wiggle her left toes for me today . Further review of this progress note revealed no indication the NP/PA removed the boot and assess Resident #100's left wounds/foot. Review of Resident #100's Progress Note dated 9/8/2023 revealed: Nurses Notes Late Entry: Note Text: The resident (Resident #100) was observed with two new wounds to her (Left Lower Extremity)-LLE. The left top of the ankle crease wound measures 10 cm x 6 cm and is more rectangular shaped that correlates with the plastic buckle where the velcro strap is laced through. This wound is not open and is pink/purple in color and is indented. There are red abrasions/scratches surrounding this area as well (this is within the measured area). On the left lateral heel/foot an intact blister is noted measuring 10 cm x 8 cm; clear fluid is observed within the blister Review of Resident #100's Wound Evaluation dated 9/11/23 revealed: (Resident 100) Rear Left Malleolus, Pressure Sore: Resident acquired this wound from her medical device/fracture boot. Epithelium is red and non-blanching. There also is an open blister/area. The open area is filled with pink granulation tissue. Skin flap from blister is still attached. Peri wound is dry & flaky . Review of Resident #100's Wound Evaluation dated 9/19/23 revealed: (Resident 100) shows with a pressure wound to her left heel. This wound was captured in two photos. This portion of the wound is on the medial side. Area measures 10.3 x 6.2 cm. The blister is no longer intact & the wound now shows with necrotic tissue. A portion of the wound shows with purple, non-blanchable tissue. Body Location: Rear Left Malleolus Deteriorating - 11 days old Acquired: In-House Acquired . Review of Resident #100's Wound Evaluation dated 12/5/23 revealed: (Resident 100) Unstageable pressure, Rear left malleolus/heel: Wound bed covered with brown, dry, gangrene/eschar . During an observation/interview on 12/6/23 at 1:30 PM., observed Resident #100's left foot wounds. large area of dark brown, scabbed/dry area covering entire heel, eschar (dead dark tissue covering wound, difficult to view wound bed for infection due to dry/dark scab like appearance) of 100% noted. Review of Fundamentals of Nursing ([NAME] and [NAME]) 8th edition revealed: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 20717-20719). Elsevier Health Sciences. Kindle Edition.The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient . Review of Kaiser Permanente-Boot and Skin Care-Wearing a Walking Boot: Care Instructions revealed: If you're allowed to take your boot off, be sure your skin is dry before you put the boot back on. Be careful not to put the boot on too tightly .Check the skin under the boot every day. If you are not supposed to remove the boot, check the skin around the edges .https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.wearing-a-walking-boot-care-instructions .

This citation pertains to Intake #MI00133261. Based on observation, interview and record review, the facility failed to provided adequate supervision to prevent accidents and falls, identify hazards, and follow professional standards of care after a fall for two residents (Resident #304 and #63) of 7 residents reviewed for accidents, resulting in a thoracic spine (mid-back) fracture repeated falls and skin lacerations. Findings Include: Resident #304 Review of an Admission Record revealed Resident #304 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: history of falling and fracture of left femur (upper leg). Resident #304 discharged on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #304, with a reference date of 11/16/22 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #304 was cognitively intact. Review of the Functional Status revealed that Resident #304 was coded 2 (NOT steady, only stable with staff assist) for balance during all transitions and walking and required extensive assistance of 2 people with transfers. Review of Resident #304's Care Plan revealed, The resident needs activities of daily living assistance .Date initiated 11/12/22. INTERVENTIONS: .Transfers: The resident requires 1 staff assistance with the steady lift (mechanical lift) to move between surfaces .The resident is at risk for falls related to .history of falling .Date initiated 11/12/22. INTERVENTIONS: .Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed. Date initiated 11/12/22 .Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date initiated 11/12/22. Encourage resident to not attempt to stand or transfer self without staff assistance. Date initiated 11/29/22 .Reeducate resident to use call light when she needs assistance and to wait for staff to be present and assist prior to getting up. Date initiated 12/5/22 . Review of Resident #304's Fall Risk assessment dated [DATE] indicated that the resident was at high risk for falling. In an interview on 2/27/22 at 10:02 A.M., Family Member (FM) IIII reported that Resident #304 sustained a fall with major injury on 11/28/22, and the facility failed to notify her of the fall. FM IIII reported that she was told by the Director of Nursing (DON) that Resident #304 was aware and therefore FM IIII did not need to be contacted. FM IIII was frustrated because the facility required her to sign all the paperwork upon admission, and require her authorization about immunizations, but yet the facility didn't notify her about Resident #304's fall. Review of Nurse's Note dated 11/29/2022 at 13:54 (1:54 P.M.) revealed, resident awoke for breakfast and stated she has severe pain in left ribs, reported to (Nurse Practitioner) NP YYY who ordered chest x ray, (MD XXX) saw resident this shift, prn (as needed) pain medication given and effective, daughter here visiting during Dr. visit. Review of Resident #304's Physician Progress Note dated 11/29/2022 14:09 (2:09 P.M.) revealed, .experienced last night (sic) a fall in the shower with subsequent rib injury as well as back injury. Also daughter is present at bedside .Back pain: Bilaterally, The pain is moderate .Plan: Recent mechanical fall with rib and back pain going to do an x-ray of both areas at present time . Review of Resident #304's X-Ray of Spine exam date 11/29/22 at 11:08 P.M. revealed, .T9 (thoracic spine) vertebral body fracture . In an interview on 03/06/23 at 12:28 P.M., Certified Nursing Assistant (CNA) X reported that she was assisting Resident #304 in the shower room when Resident #304 fell on [DATE] some time during first shift and stated, .it was her normal time for a shower . CNA X reported that she had stepped away for a moment to a grab towel and that was when Resident #304 stood up from the shower chair, slipped on the wet floor and fell back onto the chair, pushing it into the wall of the shower. CNA X reported that Resident #304 was complaining of back pain, but was able to stand up and sit down on the chair. CNA X reported that she then left the shower room to inform Registered Nurse (RN) DD of the fall. CNA X reported that RN DD did not assess Resident #304 or the situation, but requested that CNA X obtain vital signs and transfer Resident #304 into bed. CNA X reported that Resident #304 did not require a 2 person assist and stated, .she was a stand, pivot and needed stand by assistance . CNA X reported that the day following the fall, Resident #304 was in so much pain, that she could not even move in her bed. Attempt to interview RN DD on 03/07/23 at 11:24 A.M., but did not receive a return call. In an interview on 03/07/23 at 11:28 A.M., RN D reported that she was not working on the day that Resident #304 fell and broke her back, but that RN DD was the nurse assigned to Resident #304 that day. RN D reported that on 11/29/22 when she started work, she was not informed that Resident #304 had fallen the day prior, until Resident #304 was complaining of severe pain, and CNA X explained that Resident #304 had fallen back really hard onto the shower chair the day before. RN D reported that she assessed Resident #304 and she was in a lot of pain and stated, .I think there was a bruise on her side . RN D reported that she notified the doctor immediately and he went into Resident #304's room right away. RN D reported that Resident #304's daughter was very upset because she had not been informed of the fall. In an interview on 03/07/23 at 11:52 A.M., DON reported that when an fall occurs the nurse is expected to perform a full assessment on the resident and the environment prior to moving the resident, and obtain vital signs every shift, along with documentation of the fall and notification to the doctor and family. DON reported that the nurse did not document a progress note or an assessment on Resident #304 on 11/28/22. DON reported that based on the documentation charted by RN D (that worked with the resident the day after the fall) the fall occurred on 11/28/22 at 10:45 A.M., but the doctors note from 11/29/22 refers to a fall last night. DON reported that the only vitals signs documented on 11/28/22 were from 9:10 A.M. DON was unable to definitively say when the fall had occurred, was unable to provide a root cause analysis, and reported that according to Resident #304's care plan she required a steady lift (mechanical lift) for transfers. Review of Initial Fall Document dated 11/28/22 at 10:45 A.M., created by RN D on 11/29/22 revealed, .Date of fall 11/28/22 .Most recent Blood pressure: .Date 11/29/22 at 8:08 A.M What was resident doing prior to the fall: Shower .Describe pain: ribs .Pain level: 6 .11/29/22 at 13:47 (1:47 P.M.) .Resident educated related to asking for assistance and waiting for help . This initial fall report was created the day after Resident #304's fall, by RN D who was not present at the time of the fall. Review of Resident #304's Witnessed Fall Report dated 11/28/22 at 10:45 A.M., created by RN D revealed, .Injuries Reported Post Incident: Fracture Vertebrae .Witnesses: (CNA X): I just finished showering resident and went to grab a towel to dry her off, as I was grabbing towel I hear a loud bang and found resident laying with her back against the chair seat and holding on so she wouldn't fall all the way, I grabbed her and helped her stand back up, I asked resident what happened and she said, I was standing up to come out of the shower to get to my chair and slipped and hit my back. People Notified: DON 11/29/22 at 13:54 (1:54 P.M.) .Family Member (FM III) 11/28/22 at 11:50 A.M., Physician 11/29/22 at 13:53 (1:53 P.M.). This report was created after Resident #304's fall, by RN D, who was not working at the time of the fall. The report does not include a statement or assessment notes from RN DD, who was responsible for Resident #304 at the time of the fall. Review of Resident #304's Un-Witnessed Fall Report dated 12/3/22 at 02:57 A.M. revealed, .Writer walked into residents room and found resident on the floor. Resident states she was trying to get in her chair when she fell . Resident assessed and no new injury noted. Resident was taken off the ground and into her chair .Fracture T9 from previous fall .People Notified: (FM IIII) on 12/4/22 at 10:30 A.M., NP YYY on 12/5/22 at 10:41 A.M. Review of Resident #304's Nurse's Notes dated 12/3/2022 at 16:13 (4:13 P.M.) revealed, Resident showing increased weakness, confusion, and poor appetite. Resident has not been eating well for a several days and confusion has increased. Resident family would like her to be sent to hospital. NP and management notified. (EMS) transported resident to (hospital) via stretcher. Family took most of her belongings with them. 46999 Resident #63 A review of a Face Sheet dated 2/1/22 for Resident #63 revealed pertinent diagnoses that included: Alzheimer's Disease (progressive mental deterioration), age-related physical debility (deconditioning), muscle weakness, dizziness, history of falling, other reduced mobility and chronic pain syndrome. A review of Minimum Data Set (MDS) assessment revealed a Brief Inventory of Mental Status (BIMS) score of 6 which indicated Resident #63 was severely cognitively impaired, Resident #63 required extensive assistance to transfer (move from one surface to another) and was non-ambulatory(did not walk). A review of a Care Plan dated 2/1/22 revealed a focus of .at risk for falls ., a goal stated, minimize risk of serious injury, decrease fall risk . and interventions that include ensure wheelchair is locked at bedside (initiated 2/18/23), Resident to wear gripper socks at all times except bathing (initiated 12/28/22). A review of Fall Reports for Resident #63 revealed falls on 9/22/22, 12/2/22/ 12/24/22 and 2/18/23. 2 falls occurred prior to evening meal, 1 upon waking up in the morning and 1 during the night when Resident #63 awoke and thought it was time to get up. Resident #63 suffered a skin tear to the right elbow and lateral left knee on 12/2/22 and skin tear to the left side of forehead (2x4 cm) that required steri-strips for closure on 2/18/23. During an observation on 02/27/23 at 01:55 pm, Resident #63 was observed sitting in his wheelchair, dressed in daytime attire, wearing patriotic dress socks and black, soft vinyl, clog style, slip on shoes. During on observation on 3/1/23 at 11:05 am, Resident #63 was observed propelling his wheelchair, wearing daytime attire, patriotic dress socks, and black, soft viny,l clog style slip on shoes. Resident noted to self-propel slowly. During on observation on 3/6/23 at 1:23pm, Resident # 63 was observed self-propelling his wheelchair, moving toward his room, wearing daytime attire, patriotic socks, soft vinyl, clog style slip on shoes. Resident #63's feet were slipping on the floor as he attempted to move his wheelchair. Resident #63 stated These shoes slide. In an interview on 03/07/23 at 9:23 am, Certified Nursing Assistant (CENA) SSS reported she responded when Resident #63 fell on [DATE] and saw the Resident sitting on the floor, against the bed, facing the doorway with the wheelchair next to the head of the bed and the bedside table near the foot of his bed. CENA SSS reported Resident #63 normally wakes up around 7:00 am every morning and puts his call light on when he is ready to get up. CENA SSS reported Resident #63 thought he was going to church on that day; time was shortly before 7am, Resident #63 does normally go to church every Sunday with his son. In an interview on 03/07/23 09:23 am, Certified Nursing Assistant (CENA) FFF reported Resident #63 refused to wear gripper socks, and would only wear patriotic socks and his soft vinyl, clog style slip on shoes. CENA FFF reported no other fall prevention interventions had been attempted. In an interview on 03/07/23 09:30 am, Licensed Practical Nurse (LPN) G explained that Resident #63's son normally visited daily, assisted him at mealtime, reminded him not to attempt to transfer alone, took Resident #63 to church each week but had been unable to visit for several weeks because the son was hospitalized . LPN G reported that the son's absence had changed Resident #63's routine which was difficult for the Resident. LPN G described Resident #63 as impatient, mobile in his wheelchair and unaware of his physical limitations. LPN G stated We're trying to keep 32 Resident's safe and sometimes we cannot be with them. LPN G reported Resident #63 refused to wear gripper socks when they were offered and will only wear soft vinyl, clog style shoes and patriotic dress socks. In an interview on 03/07/23 at 10:14 am, Registered Nurse, Unit Manager, Infection Preventionist (RN-Unit Manager, ICP) BBB reported resident falls are discussed by the Interdisciplinary Team and new fall prevention interventions are developed at that time. RN-Unit Manager ICP BBB reported floor staff that witnessed a fall are interviewed for input, but other floor staff are not involved in fall intervention development. RN-Unit Manager ICP was not aware that Resident #63's son had not been able to offer social support in several weeks or that Resident #63 refused to wear gripper socks. In an interview on 03/07/23 at 11:49 am, Interim Director of Nursing (IDON) B confirmed that the fall interventions added for Resident #63 since 9/22/22 were: items within reach, wheelchair next to bed with breaks locked, gripper socks at all times except when showering. IDON B reported the Interdisciplinary Team (IDT) discussed each fall and added the interventions. IDON B reported that input from floor staff was solicited as needed when fall interventions are developed and family members were educated about new interventions after they are put in place. IDON reported that Resident #63's has strong social support from his son who visits daily. IDON B was unaware that Resident #63's son had not been able to visit in recent weeks or that Resident #63 refused to wear gripper socks. When told this information, IDON B stated (Resident # 63's) son not being here might really throw (Resident #63) off and I didn't know he wouldn't wear the gripper socks. People don't tell me everything. IDON B stated that's good to know because maybe we could do something to improve the traction on the shoes he likes, referring to Resident #63's preference to wear own shoes.

This citation pertains to intake #MI 9804. Based on observation, interview and record review the facility failed to provide quality care and prevention and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of a facility Policy titled Pressure Injury Prevention and Management with a revision date of 01/01/2022 revealed: Policy: This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. Definitions: Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Review of a facility Policy titled Turning and Repositioning) with a revision date of 01/01/2022 revealed: Policy: It is our policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols for turning and repositioning Policy Explanation and Compliance Guidelines: .1. All residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition. In this case, small shifts in repositioning will be employed 2. Turning and repositioning is a primary responsibility of nursing assistants. However, all nursing staff are expected to assist with turning and repositioning 3. The facility has established routine turning and repositioning schedules consisting of every 2-4 hours, 4. A routine turn schedule includes using both side-lying and back positions, alternating from the right, back, and left side. It also includes assisting the resident to stand, or making small shifts of position, if in chair. A resident's condition will determine whether or not a specialized turn schedule is warranted 5. The frequency of turning and repositioning will be documented in the residents plan of care, and will be determined by the residents: a. Level of activity and mobility .b. Skin condition .c. Overall medical condition .d. Treatment goals .e. Type of pressure redistribution support surface in use (turning and positioning is still require don specialty surfaces, but frequency may be reduced) .f. Comfort levels .6. Use the appropriate number of staff to perform the tasks safely Resident #100 Review of an Admission Record revealed Resident #100, 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 #100, with a reference date of 6/30/22 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #100 was mildly cognitively impaired. Further review of Resident #100's MDS revealed: Section E-Did the resident (Resident #100) reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? Do not include behaviors that have already been addressed (e.g., by discussion or care-planning with the resident or family), and determined to be consistent with resident values, preferences, or goals. The answer to Section E Behavior on the MDS for Resident #100 was 0 indicating he did not have any rejection of care. Section G Functional Status Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. was coded 2. Limited assistance -(with 1 staff assist) resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance. Section J Pain Effect on Function .B. Ask resident: Over the past 5 days, have you limited your day-to-day activities because of pain? the answer to this question was coded 1-(Yes) During an observation on 8/9/22 at 2:27 PM., observed Resident #100 asleep in his bed laying on his left side. The head of bed (HOB) was slightly elevated. Resident #100 noted to be wearing a local college sports T-shirt. During an observation on 8/9/22 at 3:20 PM., observed Resident #100 asleep in his bed laying on his left side. The head of bed (HOB) was slightly elevated. Resident #100 noted to be wearing a local college sports T-shirt. During an observation on 8/10/22 at 2:05 PM., observed Resident #100 asleep in his bed laying on his left side with his bed side table next to him. Resident #100's lunch tray (including a covered plate of food untouched-drinks full, ice cream melted -Magic Cup). Residents meal ticket was noted on his lunch tray. The meal ticket noted to say Standing Order- Magic Cup (ice cream) 290 calories 9 grams of protein. During an interview on 8/10/22 at 2:15 PM., Resident #100's Family Member (FM) TT reported she comes in daily and Resident #100's clothing was often the same as the previous day. FM TT reported staff does not help Resident #100 reposition himself or turn him to prevent pressure ulcers. FM TT reported Resident #100 needs someone to approach with compassion and patience due to his condition, and pain level. FM TT reported she was taking Resident #100 home today to care for him due to the poor care he (Resident #100) was receiving at the facility. FM TT reported she informed staff nurses and CNA's about her concerns repeatedly and nothing has been done to remedy the lack of grooming, help with eating meals and repositioning. FM TT reported there are plenty of staff that she sees around, but they do not do their jobs. During an observation on 8/10/22 at 2:25 PM., observed Resident #100's wound dressing change on his coccyx. Resident #100 was in bed laying on his left side, with the HOB slightly elevated. FM TT present at bedside. Nurse Practitioner (NP) XX reported Resident #100 admitted to 2 open areas on his buttocks which now have merged into a stage 4 coccyx pressure ulcer. NP XX reported he also has a Deep Tissue Injury (DTI) to his left hip which was noted to be new on 8/8/22. NP XX reported she was unsure if Resident #100 has lost weight. Registered Nurse (RN) Y completed the wound dressing change the coccyx wound was observed to be a large area on coccyx which was open with a foul. odor, a large area of slough, red granulation tissue 50-75 % slough and actively bleeding. Noted while Resident #100 was being repositioned a large reddened area on his right hip non-blanching approximately 3 inches in diameter (circular in shape). Once the dressing was changed on the coccyx, RN Y and NP XX repositioned Resident #100 onto his right side from left side lying position he had been in. Noted a large reddened area on Resident #100's left hip approximate size length 17 cm x width 10 cm wide. Resident #100 had no behaviors, no rejection of care, no agitation during the dressing change, repositioning and lifting of legs to view heels. Resident #100 did moan and wince when moved and appeared to be in some pain. Review of Resident #100's Skin Evaluation dated 8/8/22 revealed: Left trochanter (hip) deep tissue injury, non-blanchable, deep red-purple discoloration .Area size 4.6 cm .length 3.7 cm .width 1.9 cm . During an interview on 8/10/22 at 3:30 PM., Hospice Social Worker (HSW) SS reported she had wipe his face off. HSW SS reported over the last couple weeks he has been seen in the same clothing, laying on his left side when she has been there, and also his meal trays have been sitting on his bedside table hours after lunch. HSW SS reported the meal trays did not appear to be in a position that he could reach, nor was he positioned to sit up with the bedside table in front of him. In an interview on 8/12/22 at 8:30 AM., LPN K reported Resident #100 has recently been put on Hospice Care (end of life). LPN K reported Resident declined very rapidly since admission. LPN K reported she worked with Resident #100 often, and he was discussed a lot due to his wife's (FM TT) concerns with his pressure ulcers. LPN K reported Resident #100 was pleasant but at times could be agitated due to pain. LPN K reported to her knowledge on a regular basis Resident #100 did not refuse meals and repositioning. LPN K reported he needed a gentle approach, and reassurance because while turning he would become fearful of falling. LPN K reported she thinks that was because of his fall resulting in a broken left hip. LPN K reported the unit/hall Resident #100 resided on was a heavy hall, and difficulty for staff to keep with a lot of 2 person assists for repositioning and assistance with eating. LPN K reported there are a lot of residents with weight loss and pressure ulcers. Review of a facility document requested for a list of residents with pressure ulcers revealed 5 out of 11 residents with pressure ulcers resided on the A hall. Review of Resident #100's EMR revealed: Progress Note 7/27/22: hospice MD (Hospice Medical Director (HMD) YY) in and assessed wound. (HMD YY) wound will likely not heal due to current state and poor PO (by mouth) intake. Will come back to debrided wound. Review of Resident #100's EMR revealed: Progress Note 7/29/22: wound to be debrided by (HMD YY) Review of Resident #100's EMR revealed: Progress Note 8/1/22: Hospice doc (HMD YY) talks to (family members -FM TT) informing very little chance of healing of wound. Resident (Resident #100) needs good nutrition, repositioning .Laying on left side with family at bedside. Review of Resident #100's Electronic Medical Record (EMR) revealed: Resident #100 had a significant change completed on his MDS assessment on 7/23/22 indicating Resident #100 was coded as 1 staff physical assist with eating Resident #100's weights were: On 6/24/22 (admission) 214.4 pounds, on 7/2/22 205.8 pounds and on 8/2/22 181.4 pounds Review of Resident #100 EMR totaled a weight loss of 33 pounds in just under 6 weeks. Further review of Resident #100's EMR of documentation of weights, food acceptance logs and staff task (assist with feeding) many discrepancies were noted from 7/14/22-8/10/22. Review of Resident #100's EMR focusing on food acceptance logs and staff task-eating (staff helping Resident #100 eat). revealed the following documentation discrepancies from 7/14/22-8/10/22 . Documented On 7/23 all 3 meals eaten independently at 100% On 7/25 2 meals eaten independently both documented at 12:30 pm at 50% .On 7/26 2 meals eaten independently at 50%, 100% and 1 meal extensive assist staff providing the assist at 25% .On 7/27 2 meals eaten with supervision at 50% On 7/28 1 meal (dinner) eaten independently at 10% .on 7/29 2 meals eaten independently at 25% & 15% On 7/30 3 meals eaten independently at 0%, 0% & 50% .On 7/31 3 meals eaten independently at 0%, 0%, and 10% .On 8/1 2 meals eaten with supervision both at 100% On 8/2 2 meals eaten independently at 25% both meals On 8/3 2 meals eaten independently, both documented at the time of 12:11 at 0% for both meals On 8/4 2 meals eaten with supervision at 100% & 50% and 1 meal eaten independently at 25% On 8/5 3 meals eaten with supervision at 8:40 am 120% eaten, at 1:30 pm refused-, and no documentation at all for % eaten on the 3rd meal .On 8/6 2 meals eaten independently at 100% & 75% .On 8/7 3 meals eaten independently at 100%, 0% & 0% .On 8/8 only 2 meals documented as refused at 0% and 5% .On 8/9 1 meal eaten independently at 50% (dinner) On 8/10 2 meals eaten with limited assist resident highly involved at 40% & 30 % . (this surveyor noted that the lunch meal charted with limited assist at 30% was charted at 12:38 PM in the earlier observation made by this surveyor, the meal was untouched at 1:45 PM, and again until 2:30 PM In a Phone interview on 8/12/22 at 4:24 PM., Hospice Medical Director (HMD) YY reported he had recently been in the facility due to his hospice nurses request with concerns about Resident #100's pressure ulcer (PU) on his coccyx. HMD YY reported it (coccyx PU) was extensive it wasn't going to heal. HMD YY reported he just took off the skin that was superficial. HMD YY reported Resident #100 did not have any rejection or refusal for the procedure but did have pain mostly when positioning him for the procedure. HMD YY reported after looking at it I spoke with it the family (FM TT and son) who were present for the procedure about the importance of nutrition and and positioning. HMD YY reported he (Resident #100) had to roll over away form him (HMD YY) which made him uncomfortable, and he was given an additional dose of [MEDICATION(S)] (pain medication) it help. HMD YY reported on July 29th was the first time he had visited Resident #100 and he (Resident #100) was very pleasant and could answer questions hungry, pain, he could give you basic answers he (Resident #100) was alert and oriented to family and what we were going to do. HMD YY reported when he spoke with FM TT he (HMD YY) expressed the importance of would healing, and it is is all based on nutrition, increased mobility and repositioning. HMD YY reported if Resident #100 was not eating, and or being assisted to eat, not repositioned along with being less mobile puts (Resident #100) at risk then it can go downhill very fast, if (Resident #100) was not getting nutritional intake that absolutely would have contribute to the situation. HMD YY stated Ill be honest the 2 visits the nurses assisting with the procedure were supportive they responded to him, and he was cooperative with them, Resident #100 did not have any behaviors, rejection or hesitation to anything we were doing. During an interview on 8/16/22 at 1:38 PM., CNA G reported Resident #100 reported the hall that Resident #100 was a heavy hall with a lot of 2 person assists for transfers, and a lot of residents who need assistance with eating. CNA G reported at times residents don't get their cares completed, and it's nearly impossible to turn and reposition all the residents every 2 hours. CNA G reported Resident #100 was agitated at times, but typically if you prompted him and told him how important it was to eat, and turn he would would allow us to do cares. CNA G reported a lot of new staff on the unit makes it difficulty to know if residents are actually getting turned and being fed. CNA G' reported she picks up a lot of meal trays and Resident #100's was barely touched a lot of the time. CNA G reported he needed a staff to help him (provide actual physical help with utensils and/or feed him) During an interview on 8/12/22 at 1:50 PM., RN S reported when Resident #100 originally admitted to the facility on isolation it deterred staff from going in there because they had to fully don/doff Personal Protective Equipment (PPE). RN S reported this has been an ongoing issue with Covid#19. RN S reported another factor Resident #100 developed/worse PU's was because in the isolation room his bed was against the wall which makes it difficult for staff to turn/reposition, and that means 2 staff would have to fully don PPE. RN S reported we don't have a good process of repositioning of residents. RN S reported there is no direction on who and when they should be turned. RN S reported there is no determination, at some point every one that worked with him should have known what to do with him. RN S reported it is obvious that seasoned CNAs and nurses will do proper care, assistance and repositioning, but not everyone that works here is on the the same pace, page and ethical understanding of the care these residents need. RN S reported many staff do not do what they are suppose to do with their assigned residents, and when we (nurses) delegate, or request something at time we are told flat out No. During an interview on 8/16/22 at 2:00 PM., Registered Nurse (RN) O reported Resident #100 did not refuse care while she cared for him. RN O reported he would say No at first when care needed to be provided, especially when turning, but he had pain due to a broken hip upon admission at the end of June (2022). the 2 he had they were superficial and non-blanching .when he didn't want to be messed with he would be possum .he would pretend he would sleep he could talk RN O reported Resident #100 could no feed himself any longer, and didn't do a good job when he first arrived as he had very shaky hands. RN O reported he had weighted utensils to assist when he was able at times to eat his ice cream. RN O reported Resident #100 was unable to dress himself, turn himself and or clean himself up. RN O reported with residents such as Resident #100 a lot of patience is needed and trying different techniques to assist with his care needs. RN O reported residents should be weighed on admission, weekly for 1 month and then monthly or as needed depending on the individual and their nutritional/medical conditions. RN O' reported this past weekend she tried to get staff to get up and do stuff for their residents and staff literally told me no and they just sat around the desk and didn't do it. RN O reported she has brought this up in meetings, and to the Director of Nursing (DON) B but DON B is brand new so nothing has changes as of yet. During an interview on 8/16/22 at 2:55 PM., CNA P reported CNA's working with Resident #100 should know he cannot feed himself. CNA P reported Resident #100 has declined very quickly over the last month. CNA P reported Resident #100 would at times be difficult to arouse, but if you approached him patiently and slowly he would comply with whatever care he needed. CNA P reported Resident #100 was in a lot of pain which may have contributed to staff not wanting to assist him due to him saying No at times. CNA P reported there are a lot of new staff CNA's and not all of them re-approach and/or ask for help when a resident refuses cares/medications/repositioning and meals. CNA P reported any refusal should be documented correctly and reported to the nurse to ensure the resident gets the proper care. During an interview on 8/16/22 at 1:00 PM., Nursing Home Administrator (NHA) A reported staff should be informing the nurses on the units whenever there are any refusals for any resident cares, meals, ADL's. NHA A reported resident refusals should always be documented correctly in all areas of the EMR. NHA A reported staff should not be documenting they completed a task such as assisting with feeding if the staff member did not complete the task.

This citation pertains to intakes: MI 806 & MI 84 Based on observation, interview, and record review, the facility failed to implement safety interventions to prevent a fall with injury for 3 (Resident #101, Resident #102, & Resident #104) of 4 residents reviewed for falls, resulting in a fall with a facial laceration that required sutures for Resident #101, falls with fracture for Resident #103 & Resident #104, falls with bruising for Resident #102, and the increased potential for preventing further falls with injuries. Findings include: Review of facility policy Falls - Clinical Protocol dated 6/2018, revealed, Assessment and Recognition: 1. As part of an initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling. This will be accomplished by the following task; a. The Falls Risk Evaluation is completed upon admission, quarterly, and with significant change in status. 1.(sic) Based on the assessment a care plan will be developed and implemented to address identified risk. This will be revised as necessary . 3. Goals of the plan of care may include the interdisciplinary team, physician, resident and responsible party when possible. a. Goals may include, but not limited to reduction of falls, minimize injury from falls, and/or prevent falls while maintaining and/or improving resident abilities and quality of life. 4. Interventions should be developed and implemented per the assessed needs. 5. In addition, interventions for direct care givers should be placed on the KARDEX or similar format. Comprehensive Care Plan 6. The care plan and KARDEX should be updated as interventions change . Post Fall Analysis/Treatment/Management . 3. Update the plan of care with the new or revised interventions. 4. Update the KARDEX or similar format with new or revised interventions. 5. Provide ongoing report at shift change regarding updates to the plan/s of care . Monitoring and Follow-Up . 1. The staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. 2. Residents will be reviewed through Standards of Care at a determined time frame after new interventions are implemented to determine if effective or revision is necessary. 3. If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention (for example, dizziness or musculoskeletal pain) has resolved . If the individual continues to fall, the interdisciplinary team should re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions . Resident #101 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 7/16/2020, revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #101 was severely cognitively impaired. Further review of the MDS indicated Resident #101 used a walker as an aide for walking. Review of Resident #101's Incidents dated 7/25/2020 at 0230 (2:30 AM) indicate the resident had memory, physical, and decision-making impairment. The fall occurred in the resident's room unobserved. When found, the resident was said to be in a sitting position with her walker in front of her, confused and unable to tell staff what happened. Review of Resident #101's Fall Investigation Report date of 7/25/2020 at 0230 indicated the factors contributing to the fall with the root cause being lost of balance and alone and unattended. Review of Resident #101's Incidents dated 7/31/2020 at 0815 (8:15 AM) indicate the resident had memory, physical, hearing/vision, and decision-making impairments. The fall occurred in the resident's room unobserved. The resident when found was said to be confused, disoriented and with her pants down to her thighs. Further review of the report revealed the resident's blood pressure was 184/100 with a laceration over her left eyebrow. Review of Resident #101's Fall Investigation Report date of 7/31/2020 at 0815 indicated the factors contributing to the fall with the root cause being loss of strength, appeared to get weak, bed height not appropriate, soiled, and was alone and unattended while trying to self-transfer. Review of Resident #101's Care Plans revealed, Focus .at risk for falls r/t (related to) pain, .difficulty walking .resident refuses to ask or wait for assistance with transfers and ambulation, history of falls, removed 4WW (four-wheeled walker) from room on 7/27/2020 .initiated on 9/7/2018 Revision on 7/27/2020 .Goal .will not sustain serious injury through the review date. Date Initiated 1/29/2016 .Interventions .Anticipate and meet the resident's needs. Date Initiated 1/29/2016 .Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed date initiated 1/29/2016 .Encourage .to wear non slip footwear or gripper socks for ambulation revision on: 10/10/2018 .Review information on past falls and attempt to determine source of falls. Record possible root causes. Remove any potential causes if possible. Educate resident/family/caregivers as to causes. Date initiated 9/7/2018 . Wheelchair to be locked at bedside when resident in bed. Date initiated 7/27/2020 . Review of Resident #101's fall timeline provided by 8/18/2020 at 7:06 AM via email by Corporate Consultant (CC) HH indicated the resident had a fall on 7/25/2020 at 2:30 AM where she was observed on the floor with her walker in front of her. A new intervention that was to be implemented was to place a locked wheelchair at the bedside. The care plan for the resident to have the new intervention put in place was not initiated until 7/27/2020, 2 (two) days after the incident. During an interview on 8/13/2020 at 8:30 AM Family Member (FM) D stated, I am (Resident #101) DPOA (Durable Power of Attorney). My brother, (FM EE) are both DPOAs for (Resident #101). On July 31, 2020 I got a call from an ER doctor that he was stitching up my mother's eyebrow and she had multiple bruising on her body. My mother was admitted to the hospital and was there for 4 days. When I saw her, the bruising was bad. It was on both eyes, the right side of her head, and under her right jaw was a huge blood blister. Under her left breast around her rib cage and up her neck was a bruise all the way to her back. On her left arm there were a bunch of bruises like a hand. Her chest was bruised. My mother was not on blood thinners. She walked with a walker. I did not know she was in a wheelchair. She is very healthy for being 93. Her hearing is gone but hears on her right side. During an interview on 8/13/2020 at 10:20 AM Resident #102 FM EE stated, When I saw my mother in the hospital after her fall from her wheelchair, her eyes were swollen, her face was bruised and she had seven (7) stitches above her left eyebrow. Her elbow looked swollen. Hospital staff said she looked like she had been in a car accident. They said she fell out of a wheelchair at the facility. During an interview on 8/18/2020 at 12:20 PM, Unit Manager (UM) N stated, (Resident #101) had a gradual decline in condition. She was very independent and would walk to meals. She broke her hand sometime early this summer pushing a door open. Then she had a fall on July 25th (2020) because at that time she was still independent. Her walker was taken away to alleviate putting weight on the broken wrist, her bed was put against the wall, and the wheelchair was locked next to her bed in case she tried to get up. She kept trying to get up. She would not listen to education and continued to try and do things. That was about all we could do for her. We didn't really have anything we could try. UM M did not indicate whether increase supervision was implemented due to Resident #101's impulsivity and inability to comprehend education for a length of time due to a BIMS score of 3. During an interview on 8/18/2020 at 1:12 PM, Registered Nurse (RN) Mstated, I was not the nurse for (Resident #101) on July 31st (2020), (UM S) was. She had a big cut on her left forehead. When she broke her hand a few months ago and came back to the facility, I had her in the quarantine unit. She was impulsive. During an interview on 8/18/2020 at 2:57 PM, UM S stated, On 7/31/2020, (Resident #101) had a really bad fall. She was observed on the floor by staff. It looked like she fell out of bed transferring from bed to wheelchair. She had a deep laceration on her forehead over her left eye. The bleeding was stopped and sent her out to ER. Resident #102 Review of a Face Sheet revealed Resident #102 was a [AGE] year-old female, originally admitted to the facility on [DATE], with a pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 7/31/2020, revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #102 was severely cognitively impaired. Review of Resident #102's Fall Risk Evaluation V4 dated 6/19/2020 at 20:25 (9:25 PM) indicated the resident had a history of [REDACTED]. Resident #102 was documented as being confined to a chair with her balance not being steady while standing, sitting, and during transitions and only able to stabilize with physical assistance. Review of Resident #102's Incidents dated 6/25/2020 at 1745 (5:45 PM) indicated the resident was agitated with memory, physically, and decision-making impaired. The fall occurred in the resident's room unobserved. Review of Resident #102's Fall Investigation Report dated 6/25/2020 at 1745 indicated the resident had been alone and unattended, and lost her balance while attempting to self-transfer. Review of Resident #102's Incidents dated 6/28/2020 at 13:35 (1:35 PM) indicated the resident was confused and disoriented. The fall occurred in the resident's room unobserved. Review of Resident #102's Fall Investigation Report dated 6/28/2020 at 1335, indicated the resident had been alone and unattended, and lost her balance while attempting to self-transfer with the wheelchair not locked. During an interview on 8/18/2020 at 2:20 PM Housekeeping FF stated, I saw her (referring to Resident #102) on the ground in her room. I hollered at one of the CNAs to come help. Review of Resident #102's Incidents dated 7/10/2020 at 2200 (10:00 PM) indicated the resident was confused and disoriented with memory, physical, and decision-making impairments. The fall was witnessed by a staff who said the resident was standing up while in her room, lost her balance and sat down on the floor, scraping her arm on a table. Attempts to contact Certified Nursing Assistant (CNA) I on 8/13/2020 at 2:05 PM and 8/18/2020 at 9:30 AM were not answered nor returned. Review of Resident #102's Fall Investigation Report dated 7/10/2020 at 2200 indicated the resident had been alone and unattended in her room when she lost her balance while attempting to self-transfer. Review of Resident #102's Incidents dated 7/20/2020 at 18:00 (6:00 PM) indicated the resident was confused and disoriented with memory, hearing/vision, physical, and decision-making impairments. The fall occurred in a hallway and was unobserved. Review of Resident #102's Fall Investigation Report dated 7/20/2020 2200 indicated the resident's fall was witnessed but found on the floor unwitnessed. The resident was alone and unattended. The report further indicated the resident stood up from her wheelchair, began leaning to the left, lost her balance and fell to the floor. The witness statement revealed the fall was not observed but staff had heard the fall. Attempts to contact Licensed Practical Nurse (LPN) II on 8/13/2020 at 2:00 PM and 8/18/2020 at 9:20 AM were not answered. LPN II no longer was employed at the facility. Review of Resident #102's Incidents dated 7/26/2020 at 1235 (12:35 PM) indicated the resident was confused and disoriented, with memory, hearing/vision, physical, and decision-making impairments. The fall occurred in the resident's room while attempting to self-transfer and was observed. Review of Resident #102's Fall Investigation Report dated 7/26/2020 at 1235 indicated the resident's fall was witnessed as the resident lost her balance while in her room, alone, unattended, and attempting to self-transfer and pull up her pants. Witness statement made by Housekeeping JJ on 7/26/2020 at 1235, indicated Resident #102 was observed standing up to pull up pants and then began to lean and fell to the floor. Review of Resident #102's Incidents dated 7/29/2020 at 1315 (1:15 PM) indicated the resident was confused and disoriented when found in a hallway from an unobserved fall. Review of Resident #102's Fall Investigation Report dated 7/29/2020 at 1315 indicated the resident's fall was unobserved. She was found on the floor in a hallway, alone and unattended. While ambulating she became weak and lost her balance and fell to the floor. Witness stated made by Housekeeping FF on 7/29/2020 untimed, indicated Resident #102 was found on the floor. During an interview on 8/13/2020 at 4:01 PM, Family Member (FM) E stated, (Resident #102) was admitted to the facility due to a fall that broke her right hip. She went to another facility where she fell twice and rebroke that same hip and had to have a second surgery. After the surgery she came to this facility. She was a fall risk due to [MEDICAL CONDITION]. She forgets she cannot get up. We told the facility that she needed to be monitored. Every single fall my mother had was from her getting out of her wheelchair. Three times she fell in her room. She had no idea to use a call-light. She did not have the cognitive ability to function that way. We begged the facility to find a way to protect her. My dad told staff someone needed to stay with her or she would get up and try to get to him and fall when she they had window visits. So, my father had to stop window visits. My father had gone for a window visit in June (2020) and when he came to window, he saw my mother on the floor. During an interview on 8/18/2020 at 9:56 AM, FM F stated, I am the DPOA for (Resident #102) and (FM E) will step in when I can't. Our children would call ahead to arrange times to have window visits because if my wife saw us or knew we were coming she would get out of her chair and look for us. In June I had pre-arranged a time with facility staff to do a room window visit. I was on time. When I got there, she had fallen out of her wheelchair and was laying on the floor of her room. At that point we stopped window visits because it was too risky. My wife would know we were coming and fall. Because of the dementia, my wife is not aware of the whole situation. She does not have the capacity to remember anything. You must have eyes on her or else she will fall. She had 2 falls at the other facility prior to coming to this facility. I had decisions at the beginning before she came and right after she came to the facility because of the falls at the other facility where she broke a hip. The facility knew she was a fall risk. I had discussions with the unit manager, nurses, and therapists regarding her memory and her falls. They stated they could not protect her. I told them from the beginning what I would like for them to try and they did not use a wedge cushion to make it harder to get out of wheelchair. I begged for safety measures and we got nothing. I talked to (Unit Manager (UM) N) about the safety measures that could be taken with waivers, but the facility never went any further to try new interventions. The facility did not make any other accommodations to prevent her falls and keep here safe. My wife had bruising from the falls. They moved her to a room closer to an office, but that person was not there all the time and when they were in there they had to work. They could have done something. They did not. They could not protect my wife and admitted it. During a telephone interview on 8/19/2020 at 1:10 PM, FM F stated, The date I went to the facility to have a window visit with my wife who is a resident at the facility, was June 28th (2020). She was laying on the floor of her room when I looked in the window. I had told the facility countless times to keep her safe because she fell a lot. They told me they could not prevent her falls, yet they agreed to admit her. The facility did not discuss many ways to help (Resident #102). They could have used a lap tray when I asked but the facility never tried. I asked them what they could do when we talked about helping (Resident #102) and they said they could not keep her from falling. They did not do everything they could have. I would have paid for a private sitter. During an interview on 8/18/2020 at 2:09 PM, Waiver Aide (WA) GG stated, (Resident #102) was saying she saw her husband on the day of that fall (6/28/2020). She was in her room and I was with another resident giving care. The housekeeper saw her first. There was a sign by the resident's bed in big red lettering that said call for help. She knew her husband was coming. I knew (Resident #102) would do things she did not know she was not supposed to do from working with her. I don't know if it was on her Kardex. During an interview on 8/18/2020 at 2:30 PM, RN R stated, (Resident #102) was very impulsive and had quite a few falls. The fall in her room on July 10th (2020) I remembered thinking I had just seen her. Staff had just asked her if she needed anything and tried putting her down in bed. She just got up before you knew what was happening. Resident #104 Review of a Face Sheet revealed Resident #104` was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 7/15/2020, revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #104 was severely cognitively impaired. Further review of the MDS indicated Resident #104 required the use of a wheelchair for mobility. Review of Resident #104's Care Plans revealed, Focus . at risk for falls related to: hx recurrent falls with pain, [MEDICAL CONDITION], dementia, generalized muscle weakness, unsteadiness of feet, lack of coordination, impulsivity, anxiety, difficulty in walking, mood disorder, cognitive communication deficit, diminished vision, will transfer without assistance, resident to use wheelchair for locomotion in facility but prefers to not use devices at time and ambulate independently; hx of toileting self without staff assistance. Date Initiated: 04/20/2019.Goal . To reduce the risk of serious injury in the event of a fall through the review date. Date Initiated: 04/20/2019 Revision on: 07/28/2020 .Interventions . Anti-rollbacks, Anti-thrust cushion, wheelchair cushion tilted back. Anti-tippers on w/c . RESOLVED: encourage resident to use call light and wait for assistance with transfers Date Initiated: 07/08/2019 Revision on: 07/20/2020 Resolved Date: 07/20/2020 . Resident should wear the following footwear for ambulation well-fitting hard sole shoes Date Initiated: 07/13/2020 Revision on: 07/13/2020 . Review of Resident #104 Incidents 7/9/2020 at 1425 (2:45 PM) indicated resident was confused and disoriented with memory, hearing/vision, physical, and decision-making impairments. Resident #104's fall was unobserved and unwitnessed, happening in a hallway while resident trying to get out of wheelchair. A STAT (NOW) x-ray was ordered for resident's right hand. Review of Resident #104's Fall Investigation Report 7/9/2020 at 1425 indicated the resident was found in B hall on the floor after he appeared to become weak and lost his balance while ambulating alone and unattended. Review of Resident #104's Progress Notes 7/20/20 at 1420 (2:20 PM) revealed, .unobserved fall on 7/9/2020 at 1425 in the hallway .noted bruising, swelling, and limited range of motion to the right hand thumb .STAT right hand x-ray .The x-ray showed acute first proximal phalanx base fracture with malalignment .sent to ER .returned with a soft cast placed to his right arm/hand . Review of Resident #104's Incidents 7/31/2020 at 1310 (1:10 PM) indicated the resident was confused and disoriented with memory, hearing/vision, physical, and decision-making impairments. The fall was observed while the resident was in his room attempting to place his feet on the bed and tipping over backwards in wheelchair hitting his head. Review of Resident #104's Fall Investigation Report 7/31/2020 at 1310 indicated the resident's wheelchair was unlocked and tipped backwards after attempting to put his feet on the bed. The resident was in his room alone and unattended and fell to the floor. No witness statement was provided to surveyor by exit. Review of Resident #104's Progress Notes 8/3/2020 1027 (10:27 AM) revealed, .Resident was in his room sitting in his WC (wheelchair). CENA (aide) entered room and observed resident attempting to out (out) his feet up on his bed causing his WC to lean backwards and tip over. Observed on 8/12/2020 at 12:15 PM observed Resident #104 self-propelling wheelchair by nursing station wearing a blue cast on right hand/lower arm. During an interview on 8/18/2020 at 2:43 PM LPN T stated, I remember (Resident #104) was on the floor face down. I did not see him fall. It was change of shift time. I sent him to the hospital. I knew his hand or wrist was broken the way it looked. During an interview on 8/18/2020 at 2:57 PM UM S stated, I was working on the floor when staff found (Resident #104). I was told he was attempting to put his feet on the bed, and he fell backwards. He moves around quite a bit. I assessed him and he had a small hematoma on his head.

This citation pertains to intake number MI 058. Based on observation, interview, and record review the facility failed to perform surveillance, and follow the standards of infection control for 1 of 14 residents (Resident #100) reviewed for transmission based precautions, resulting in an Immediate Jeopardy when facility staff did not follow contact precautions exposing all 21 residents on the hall to [MEDICAL CONDITION] ([MEDICAL CONDITION], a bacteria in the intestinal system that causes diarrhea and more serious conditions such as [MEDICAL CONDITION]) . Findings include: Review of the Centers for Disease Control [MEDICAL CONDITION] Infection information for Patients revealed, People who have other illnesses or conditions requiring prolonged use of antibiotics, and the elderly, are at greater risk of acquiring this disease. The bacteria are found in the feces. People can become infected if they touch items or surfaces that are contaminated with feces and then touch their mouth or mucous membranes. Healthcare workers can spread the bacteria to patients or contaminate surfaces through hand contact. [MEDICAL CONDITION] is shed in feces. Any surface, device, or material (e.g., toilets, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the [MEDICAL CONDITION] spores. [MEDICAL CONDITION] spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. [MEDICAL CONDITION] can live for long periods on surfaces. Review of the facility Isolation Categories of Transmission-Based Precautions Policy (no date), reflected Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others .Contact Precautions - 26. If use of common items is unavoidable, then adequately clean and disinfect them before use for another resident. In addition to Standard Precaution, implement Contact Precautions for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in resident's environment. Review of Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., and [MEDICAL CONDITION]. The MDS indicated Resident #100 was severely impaired for daily decision-making skills and required the assistance of one staff member for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the laboratory results dated reported 10/22/18, positive toxigenic[DIAGNOSES REDACTED]icile detected. Review of the [DIAGNOSES REDACTED]icile Care Plan updated 10/23/18, reflected Interventions *CONTACT ISOLATION: wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. Revision on: 10/23/18 *Disinfect all equipment used before it leaves the room. Revision on: 10/23/18 * Educated resident/family/staff regarding preventive measures to contain the infection. Revision on:10/23/18 Review of the Physician order [REDACTED]. During an observation on 11/4/18 at 4:05 p.m., Resident #100's door was noted to have a stop sign on it. During an observation on 11/4/18 at 6:30 p.m., Resident #100 was sitting her wheelchair, CNA D entered her room without washing her hands to assist with helping to feed her. CNA D then washed her hands to butter the resident's bread, Resident #100 refused, CNA D asked if she was done eating and removed the tray from the room to the tray holder in the hallway, came back to the room and washed her hands. CNA E entered the room without washing her hands and cleaned food from Resident #100's chest, after determining Resident #100 had to use the toilet, both CNA's washed hands and gloved and assisted resident to the bedside commode, removing her briefs as she was backed against commode, the base was too tall and mushy brown stool started coming out on the floor before the CNA's D and E picked Resident #100 up under her arms and assisted her on to the commode. While on the commode Resident #100 was touching her vaginal area and the commode. CNA D cleaned a glob of stool off the floor with a wipe, removed her gloves and left the room to go to the supply closet to get a clean brief, without washing her hands, another glob of stool plopped onto the floor from the commode. CNA D returned to the room and washed her hands before she put on gloves, both CNA's stood Resident #100 and used wet wipes to clean the mushy yellow brown stool from vaginal area out towards her buttock and then guided Resident #100 to the bed and cleaned her vaginal area, CNA E used a wipe to clean the floor. A clean brief was placed on Resident #100 she was repositioned in bed, pillows were touched as well as sheet that covered resident prior to CNA D and E removing soiled gloves. No hand care was offered to Resident #100. CNA E cleaned her hands and left the room. CNA D washed hands and returned to room with bleach wipes removed the bedside commode toilet top and emptied the contents into the trash, then added water to the bedside commode from the sink swished it around and dumped in into the toilet that had a riser on it, splashing water on the seat of the riser, CNA D rinsed the commode again in the sink then wiped it the bedside commode toilte top with the bleach wipes and put everything away. CNA D did not wipe down the bathroom sink, toilet, or riser with the bleach wipes. During an interview on 11/4/18 at 7:00 p.m. Administrator A reported that Resident #100 had tested positive for [MEDICAL CONDITION] and that she would have expected the staff to wear and follow contact precautions when coming in contact with body fluids. During an interview on 11/5/18 at 11:20 AM and 2:11 PM, Infection Control (IC) L reported that when a resident was placed in contact isolation they need to be asymptomatic and at the end of their treatment before they come out of isolation, and they would need to talk to the provider for orders. IC L reported that Resident #100's last antibiotic was on 11/5/18 and with her stools still soft, he would need to talk to the provider. IC L reviewed the CNA documented data for stool features and on 11/4/18 at 21:08 (7:08 PM) CNA documented the stool as medium, which IC L reported would be formed. IC L reported that the descriptors could be misleading and the staff would need to ask questions before taking a resident out of isolation since the data the CNA's chart by does not give them enough information to adequately describe all forms of stools. During an observation and interview on 11/5/18 at 1:10 PM, revealed Resident #100's door had a stop sign and isolation gowns in the room CNA M reported that Resident #100 had not had any stool last night or today. On 11/5/18 at 9:24 AM, NHA A was notified of the immediate jeopardy that began on 11/4/18 and was identified on 11/4/18 as a result of the facilities failure to identify, monitor and provide surveillance for a resident in transmission based precautions. On 11/5/18 and 11/7/18, the following was verified to remove the immediate jeopardy: 1. On 11/4/18 the shared bathroom was disinfected per facility protocol. 2. On 11/4/18 at approximately 7:30 PM during last rounds Resident #100's hands were cleaned. 3. On 11/4/18 residents that share a restroom with Resident #100 were assessed for signs and symptoms of infection. 4. On 11/4/18 residents residing on B hall were assessed for signs and symptoms of infection. 5. On 11/4/18 1:1 re-education with CNA D and E regarding isolation precautions and hand hygiene with return demonstration completed. 6. On 11/4/18 a review of the infection line listings from the infection control program book from (MONTH) 1 to present was conducted with no trends identified. 7. On 11/5/18 the bedside commode was lowered to the appropriated height for Resident #100. 8. On 11/5/18 CNA D and E were re-educated on tray service for residents in isolation, offering the resident to wash their hands following using the restroom, and how to transfer the resident. 9. On 11/5/18 the IDT met to review residents with infection orders, care plans, and Kardex to ensure appropriate assessment and interventions were in place. 10. On 11/4/18, 57 out of 131 employees have been re-educated related to the Infection Control Policies and Procedures which includes prevention and management of infections. No employee will be allowed to work without receiving education. 11. On 11/4/18, 57 out of 131 employees have been checked off on hand hygiene with return demonstration. No employee will be allowed to work without receiving education. 12. Beginning 11/5/18, re-education was provided to the nursing staff regarding tray service for residents in isolation, offering the resident to wash their hands following using the restroom, and how to transfer a resident that is a stand pivot transfer. No employee will be allowed to work without receiving education. Although the immediate jeopardy was removed on 11/5/18, the facility remained out of compliance at a scope of pattern and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to all staff had not yet received education and the State Agency had not verified sustained compliance.

This citation pertain to MI 635 and MI 850. Based on observation, interview and record review the facility failed to ensure the safety of a resident during a transfer in 1 of 8 sampled residents (Resident #5) reviewed for falls, from a total sample of 18 residents resulting in Resident #5 falling from a lift and sustaining a fractured leg. Findings include: Review of the State Operations Manual (SOM) dated 12/6/15 revealed a Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Review of the Face Sheet revealed Resident #5 was an [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 #5 had a brief interview for mental status (BIMS) score of 6 out of 15 which indicated cognitive impairment. According to the MDS, Resident #5 was total dependence on 2 staff persons for transfer. Review of the Care Plan for ADL (activities of daily living) self care dated 5/25/16 revealed, the resident requires Dependent Lift with 2 staff assistance for transfer. Review of the Incident Report dated 11/20/16 at 12:01 pm revealed Resident #5 started to slip out of the tempo (Hoyer/dependent/mechanical lift) sling during the transfer from her bed to the w/c (wheelchair), and was lowered to the floor . In an observation and interview on 12/15/16 at 12:33 pm, Resident #5 was noted to be in her bed. Resident #5 was asked by the surveyor how her leg was broken. Resident #5 stated, I don't know, I just slipped down. In an interview on 12/15/16 at 12:56 pm, Certified Nurse Aide (CNA) CC stated, on 11/20/16 at around noon, she was supposed to use 2 people (staff members) for a transfer (mechanical lift transfer) and after she put the sling on her (Resident #5) in bed, looked around for somebody and couldn't find anybody. CNA CC stated she had then used a Hoyer/Tempo (mechanical lift device) to lift her (Resident #5) up from the bed. CNA CC stated, she (Resident #5) starts slipping through the sling and lowered her (Resident #5) to the ground. CNA CC stated, it was a fall and her (Resident #5) feet hit the ground first. CNA CC stated, I called for help and the nurse came in. In an interview on 12/14/16 at 2:11 pm, Licensed Practical Nurse (LPN) EE stated, I was at my cart (medication cart) and CNA PP was coming up the hall. LPN EE stated, heard a yell and I ran down there to Resident #5's room. LPN EE stated upon entry to Resident #5's room she saw Resident #5 on her back, feet at the doorway, on her back. LPN EE stated CNA CC was standing next to Resident #5 when she entered the room. In an interview on 12/14/16 at 3:36 pm, CNA PP stated, I was coming back from lunch and heard the call for help. CNA PP stated she entered Resident #5's room and Resident #5 was on the floor, on her back. CNA PP stated she saw LPN EE and CNA CC and went to assist my other residents. Review of the Performance Improvement Form dated 11/20/16 revealed CNA CC had a Failure to operate Invacare (mechanical lift) according to facility policy. Did not use two people for transfer of a resident. Review of the Medication Administration Record (MAR) dated 11/2016 revealed Resident #5 received PRN (as needed) Norco (pain medication) on 11/20/16 at 1400 (2:00 pm) for moaning. Review of the Medication Administration Record (MAR) dated 11/2016 revealed Resident #5 received PRN (as needed) Norco (pain medication) on 11/21/16 at 2320 (11:20 pm) for moaning. Review of the Medication Administration Record (MAR) dated 11/2016 revealed Resident #5 received PRN (as needed) Norco (pain medication) on 11/22/16 at 1700 (5:00 pm) for ankle pain, hurts a lot. Review of the Nurses Notes dated 11/22/16 at 2300 (11:00 pm) revealed daughter .here and noticed while rubbing patient, that she (Resident #5) indicated (by facial grimace) pain in R (right) shin (lower leg) area .order received for STAT (immediate) x-ray. Review of the Radiology Report dated 11/22/16 at 1:58 am revealed Resident #5 had a fracture involving the distal tibial metaphysis with no displacement .There is associated soft tissue swelling. Review of the Hospital Radiology Department results dated 11/22/16 at 8:38 am, revealed Resident #5 had an acute nondisplaced fracture of distal tibial metaphysis (lower leg bone) with mild impaction. In an interview on 12/14/16 at 1:38 pm, Director of Nursing (DON) B stated, on 11/20/16 at noon, She (Resident #5) was lowered to the floor by CNA CC. DON B stated, there wasn't anybody with CNA CC when the mechanical lift transfer was performed on Resident #5. DON B stated there was supposed to be 2 staff members present during the mechanical lift. In an interview on 12/15/16 at 10:38 am, Regional Consultant (RC) C stated, I was the DON when this occurred. RN C stated, I received a phone call she (Resident #5) was lowered to the floor, on 11/20/16. RC C stated, her (Resident #5) daughter came in Monday (11/22/16) night and said mother (Resident #5) was having pain. RC C stated, no other incident occurred between the Resident #5's fall on 11/20/16 and the discovery of the fractured leg on 11/22/16. Post investigation, the facility provided Past Non-compliance information where it was confirmed the staff member involved in the transfer did not complete the transfer per facility policy. The facility took the following steps to correct the noncompliance. 1. On 11/20/16, all residents who required power lift for transfers were identified as likely to be affected. 2. New admissions will be assessed for transfer needs and reviewed for accuracy. 3. An audit of all current residents in the facility was completed on 11/21/16 to ensure residents were being transferred per the facility policy. 4. CNA CC received immediate education regarding transfers. 5. On 11/20/16, the Lift Safety Program was reviewed and deeped appropriate by the Nursing Home Adminstrator and Director of Nursing. 6. Beginning 11/21/16, all nursing staff began re-education regarding the use of 2 staff members for all powered lift transfers and the facilities internal procedure to cross the legs of the straps of a divided leg/universal sling prior to connecting the lift. 7. Beginning 11/21/16, the educator or designee will randomly observe 3 powered lift tranfers for ensure the program is being followed. 8. On 12/15/16, this surveyor reviewed the educational logs of facility staff and determined that all nursing staff received the required education by 11/29/16. A Past Non-compliance was granted for the fall that occurred on 11/20/16 for Resident #5 due to the the above information and during the onsite survey, there was no noted noncompliance with transfers of sampled residents. The corrected date was 11/29/16. ( )

Based on observation, interview and record review the facility failed to provide the necessary care and services to maintain the highest practical physical level of well being (adequate care after a burn) in 1 of 3 sampled residents (Resident #101) reviewed for residents at risk with hot liquids, resulting in second [MEDICAL CONDITION] Resident #101 after spilling hot chilli in her lap. Findings include: According to the facility Hot Food and Beverage Safety Policy and Procedure dated July 2008, Policy: (named facility) requires staff supervision of food and beverage serves to residents. Staff will receive this safety awareness at the time of general Nutrition Services Orientation. (Named facility) will properly position residents for meal services to promote independence in self feeding and to prevent spillage. Residents at risk for burn injury will be assisted with tray set up or with eating to prevent spills of hot food or beverages. Residents at risk for a bun injury may demonstrate some of the following: (1) Slow response time. (2) Need for assistance with tray setup. (3) Need for assistance with eating. (4)Cognitive impairment (Dementia). Food with visible steam will not be served to unattended residents at risk for hot food or beverage injury .Procedure: 1. Attend residents at risk for hot food injury when serving hot food or beverages. 2. Dispers heat or chill as appropriate .(3) Add appropriate liquid or ice per resident preference e.g., milk in coffee or cereal, ice in soup .Hot Food/Beverage Spill: 5. Quickly cool area with cool water and pull clothing away from skin to prevent penetration of a thermal injury. a. Notify a licensed nurse to check the resident. Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #101 was a [AGE] year of female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #101's had a BIM (assessment tool) score of 7 which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with locomotion on unit, dressing, eating, hygiene, bathing and two person physical assist with transfers. Review of facility Incident and Accident Report, provided by the Director of Nursing (DON) B, dated 7/18/15 revealed Resident #101 had an unwitnessed, unobserved skin injury at 6:15 p.m. The report noted Resident #101 was memory impaired, physically impaired and decision making was impaired. The report noted under brief description:, Res. (Resident #101) was found with dinner (chili) on her lap. Res. (Resident #101) pants were cool to touch and she denied pain. Temp. log dietary 180 (degrees) out of oven. Res. (Resident #101) brought to room, undressed and cool cloths applied .Injury type: Burn .Treatment: First Aid (cool cloths) administered by Registered Nurse C .Actions taken: Care Plans updated, Therapy Screen, Staff Re-education .Physician notified: Nurse Practitioner (NP) I, Date: 7/18/15, Time: 18:45(6:45 p.m.). The Report also revealed that on 7/18/15 Resident #101's daughter, the Administrator A and the DON B had been notified. Review of the Physician's Telephone Orders dated 7/18/15 (with no time noted) revealed, apply cool cloths to upper right(circled R) leg burn. Monitor burn for pain & blisters x 24 hours. T.O. NP 'I'. Signed by RN C. Review of Nursing Progress Notes dated 7/18/15 at 10:00 p.m. revealed, .at dinner Res. (Resident #101) spilt chili on her (circled R) leg - redness noted after undressed, res. (Resident #101) denied pain at time of incident but has mild pain on assessment, NP & UM (Unit Manager) notified, cool cloths applied, res. (Resident #101) resting in bed, will monitor. Note signed by RN C. Review of Nursing Progress Notes dated 7/18/15 at labeled 11-7 revealed, .Resident (#101) denies pain to red area on (circled R) leg (signed by RN J). Area has 3 small blisters (signed by RN J). Review of Nursing Progress Notes dated 7/19/15 at 1:45 p.m. for Resident #101 revealed, .Burn on right (circled R) upper thigh has lighten up and res. isn't complaining of pain. Res. had a clothing protector on her lap and chest for lunch. Burn #1 L: 12 3/4cm, W: 7 1/2cm. Burn #2 L: 4 1/2cm, W: 3cm. Blister: L: 1 3/4cm, W: 3 3/4cm. Blister: L: 1/2cm, W: 1cm. Will cont. to monitor. Signed by Licensed Practical Nurse (LPN) K. Review of Nursing Progress Notes dated 7/19/15 through 7/20/15 for Resident #101 revealed no documentation that indicated the Physician or Nurse Practitioner was notified of a change in condition related to Resident #101 developing blisters at her burn site on the right upper thigh. Review of the facility Food Temperature Log dated 7/18/15 at dinner revealed 2 pounds chili with cheese start temperature documented at 180 degrees Farenheit including meat, beans and sauce. In an interview on 7/21/15 at 2:15 p.m. the Dietary Manager G reported he is currently performing training with staff related to the Hot Food and Beverage Safety Policy and Procedure related to the burn incident that occurred on 7/18/15 with Resident #101. In an interview on 7/21/15 at 3:25 p.m. Registered Nurse (RN) C reported that she was working on 7/18/15 at dinner time. RN C reported no one witnessed Resident #101 spill her chili, but staff in dining room did notice beans on floor under Resident #101, then notified her. RN C reported Resident #101 denied pain and pants were, cool to touch. RN C reported that staff took Resident #101 to her room and and removed pants. RN C reported she assessed Resident #101 and found a red area to the right upper thigh that stretched from Resident #101's inner thigh to outer thigh. In a second interview on 7/22/15 at 2:45 p.m. RN C reported that Certified Nurse Aide(CNA) F was cleaning Resident #101 when she arrived in dining room to assess Resident #101. RN C reported Resident #101 denied any pain and the food on her pants was cool to touch. RN C stated CNA F returned Resident #101 to her room. RN C reported CNA H transferred Resident #101 via the sit to stand lift to bed and removed her clothing. RN C reported she assessed Resident #101 skin between 6:20 p.m. and 6:25 p.m. and found Resident #101 had a 2 inch wide red area from the inner, upper thigh to outer thigh area with no blisters. RN C reported she applied a cool cloth at that time and placed call to the Nurse Practitioner (NP) I. RN C reported she received a telephone order from NP I to continue to apply cool cloths and monitor for blistering and pain for 24 hours. RN C reported she reapplied cool clothes about ten times between 6:25 p.m. and 10:30 p.m. RN C reported there were no blisters noted to Resident #101's right upper thigh by end of her shift at 10:30 p.m. and the redness had diminished. RN C reported she did not document size of red areas for Resident #101 right upper thigh or how frequently cool cloth was applied. RN C stated she gave report to RN J. RN C reported she worked on 7/19/15 second shift. RN C reported she assessed Resident #101 on 7/19/15 between 3:00 p.m. and 4:30 p.m. and found the red area to Resident #101's right upper thigh had decreased in size from the day prior but had two to three blisters present. RN C denied performing measurements of burn site because day shift had already done measurements. RN C denied placing call to the Physician or Nurse Practitioner to notify of change in burn status including development of blisters. RN C reported she had assumed the nurse that was caring for Resident #101 when the blisters developed would have contacted the doctor. RN C reported she did not verify if the Physician or NP had been called or not. In an observation and interview on 7/21/15 at 4:00 p.m. RN C reported she was monitoring burn to Resident #101 right upper thigh. Upon entering the room, Resident #101 was in bed covered. RN C lowered the covers and reported that the burn area to Resident #101's right upper thigh had improved since the incident and currently had 1 blister remaining. This surveyor observed a large, raised, fluid filled blister to the right anterior upper thigh that measured approximately 5 cm by 5 cm and raised was about 1 cm with a red area noted to medial and lateral sides of the blister. RN C reported that the NP had ordered [MEDICATION NAME] as needed for pain but Resident #101 had not complained so Resident #101 had not received the [MEDICATION NAME]. Review of the Treatment Administration Record dated 7/1/15 through 7/31/15 revealed Resident #101 had no documentation noted for receiving [MEDICATION NAME] cream by 4:15 p.m. on 7/21/15. In a telephone interview on 7/22/15 at 1:05 p.m. RN D reported she was passing medications to residents in the dining room when she noticed beans under Resident #101's chair. RN D reported CNA F was in dining room at next table at that time but there was no staff sitting at Resident #101's table. RN D reported she informed RN C (who was about 10 feet away) that Resident #101 had spilled the chili in her lap In a telephone interview on 7/22/15 at 2:30 p.m. CNA F reported she was sitting at table B(by kitchen) assisting residents during dinner meal. CNA F reported there was no staff at Table B (by walkway) where Resident #101 was sitting. CNA F reported a few minutes into the meal about 6:10 p.m. RN D approach CNA F and told her that Resident #101 had spilled chili on her lap. CNA F reported that RN D asked her to clean up Resident #101. CNA F reported Resident #101 had a clothing protector around her neck and found the chili bowl, chili, beans on Resident #101's jeans in her lap and beans on the floor. CNA F reported she used a towel to scoop chili and from Resident #101's lap and clean her hands and chair. CNA F reported the chili was not hot to touch. CNA F reported she had been facing Resident #101 during the meal supervising the residents at that table and did not see Resident #101 spill chili and did not at any time hear or see any signs of pain, crying out, pushing or banging on the table to indicate spill had occurred. CNA F reported while Resident #101 was being cleaned RN C was present. CNA F reported she pushed Resident #101 to her room and met CNA H at the doorway and informed him about the spill and instructed CNA H to transfer Resident #101 into bed and remove clothes so nurse could assess the skin. In an interview on 7/22/15 at 4:10 p.m. RN N reported she did not work 7/18/15 or 7/19/15. RN N reported she started shift on 7/20/15 at 6:30 a.m. and was told in report that Resident #101 spilled chili in lap over the weekend and had a burn with blisters to right upper thigh area. RN N reported there was an order to monitor burn area and document in Treatment Administration Record and Progress Notes. RN N reported monitoring the area means to look at the burn area, and document if skin is intact and signs and symptoms of infection. RN N reported she assessed Resident #101's right upper thigh burn area about 10:30 a.m. on 7/20/15 and observed at that time 4 blisters that had been given no treatment. RN N reported she knew that NP would be in that day so she did not contact Physician or NP. RN N reported the NP saw Resident #101 at about 1:30 p.m. and order for [MEDICATION NAME] was written to be applied as needed for pain or [MEDICATION NAME] blister. RN N reported pharmacy can ship items the facility needs the same day. RN N reported she did apply [MEDICATION NAME] to Resident #101 right upper thigh 7/22/15 between 10:30 a.m. and 11:00 a.m. related to discomfort. In a telephone interview on 7/23/15 at 11:00 a.m. NP I reported she received a telephone call on 7/18/15 related to Resident #101 spilling chili in lap. NP I reported she gave an order to apply cool cloths and monitor burn site for blisters and pain for 24 hours. NP I was asked by this surveyor if she would expect to be notified if blisters developed. NP I reported, yes, any changes. NP I denied receiving any additional calls related to Resident #101 burn site. NP I reported Resident #101 was seen by NP L on 7/20/15. In a telephone interview on 7/23/15 at 11:30 a.m. NP L reported she assessed Resident #101's burn to the right upper thigh and wrote an order to apply [MEDICATION NAME] to burn tissue on right upper thigh PRN (as needed), apply after cleansed as needed for pain or [MEDICATION NAME] blister. NP L reported [MEDICATION NAME] was ordered to help sooth burn area and prevent itching. NP L reported she spoke with Resident #101 and she denied any pain at the time of the assessment on 7/20/15. NP L report her goal for treatment for [REDACTED]. NP L reported [MEDICATION NAME] does not need to be used but mostly for comfort. In an interview on 7/23/15 at 3:20 p.m. Director of Nursing (DON) B reported it was her expectation that the staff are expected to follow the Hot Food and Beverage Safety Policy and Procedure including to pour a pitcher of cool water over the burn area when the staff identify there has been a hot beverage or food spill. ( )

Based on observation, interview and record review, the facility's failure to: 1.) provide supervision and assistance with eating and, 2.) care plan interventions for assistance with hot liquids for Resident #101, who had been identified on 4/2/15 as being unsafe for hot liquids, who then spilled hot soup onto her lap on 7/18/15 at approximately 6:15 p.m. that was 180 degrees Fahrenheit (measured by dietary staff), resulting in second degree burns to Resident #101 right upper thigh. Findings include: According to the facility Hot Food and Beverage Safety Policy and Procedure dated July 2008, Policy: (named facility) requires staff supervision of food and beverage serves to residents. Staff will receive this safety awareness at the time of general Nutrition Services Orientation. (Named facility) will properly position residents for meal services to promote independence in self feeding and to prevent spillage. Residents at risk for burn injury will be assisted with tray set up or with eating to prevent spills of hot food or beverages. Residents at risk for a bun injury may demonstrate some of the following: (1) Slow response time. (2) Need for assistance with tray setup. (3) Need for assistance with eating. (4)Cognitive impairment (Dementia). Food with visible steam will not be served to unattended residents at risk for hot food or beverage injury .Procedure: 1. Attend residents at risk for hot food injury when serving hot food or beverages. 2. Dispers heat or chill as appropriate .(3) Add appropriate liquid or ice per resident preference e.g., milk in coffee or cereal, ice in soup .Hot Food/Beverage Spill: 5. Quickly cool area with cool water and pull clothing away from skin to prevent penetration of a thermal injury. a. Notify a licensed nurse to check the resident. Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #101 was a [AGE] year of female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #101's had a BIM (assessment tool) score of 7 which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with locomotion on unit, dressing, eating, hygiene, bathing and two person physical assist with transfers. Review of facility Incident and Accident Report, provided by the Director of Nursing (DON) B, dated 7/18/15 revealed Resident #101 had an unwitnessed, unobserved skin injury at 6:15 p.m. The report noted Resident #101 was memory impaired, physically impaired and decision making was impaired. The report noted under brief description:, Res. (Resident #101) was found with dinner (chili) on her lap. Res. (Resident #101) pants were cool to touch and she denied pain. Temp. log dietary 180 (degrees) out of oven. Res. (Resident #101) brought to room, undressed and cool cloths applied .Injury type: Burn .Treatment: First Aid (cool cloths) administered by Registered Nurse C .Actions taken: Care Plans updated, Therapy Screen, Staff Re-education .Physician notified: Nurse Practitioner (NP) I, Date: 7/18/15, Time: 18:45(6:45 p.m.). The Report also revealed that on 7/18/15 Resident #101's daughter, the Administrator A and the DON B had been notified. Review of the ADL/Mobility Care Plan dated 4/21/15 revealed Resident #101 had potential or actual ADL/Mobility deficit, poor oral hygiene, oral infection related to the following including: Arthritis, Cognitive Impairment(Dementia), Anxiety, Depression, Parkinson's, Hypertension, Irritable Bowel Syndrome, Diabetes, Seizures. Interventions included supervision during meals. No documentation noted on any of Resident #101's Care Plans related to high risk for hot liquids or use of modified mug with lid for hot liquids. Review of facility menu dated week 5-2015, 7/13/15 revealed Saturday, 7/18/15 dinner was chili with cheese had been served. Review of the facility Food Temperature Log dated 7/18/15 at dinner revealed 2 pounds chili with cheese start temperature documented at 180 degrees Farenheit including meat, beans and sauce. Puree summer fluff had documented temperature. No additional temperatures documented on the log. In an interview on 7/21/15 at 2:15 p.m. the Dietary Manager G reported he is currently performing training with staff related to the Hot Food and Beverage Safety Policy and Procedure related to the burn incident that occurred on 7/18/15 with Resident #101. Reviewed the food temperature logs from 7/18/15 and the Dietary Manager G reported he is aware that there were several missing food temperatures, however that was included in the training as well. In an interview on 7/21/15 at 3:25 p.m. Registered Nurse (RN) C reported that she was working on 7/18/15 at dinner time. RN C reported no one witnessed Resident #101 spill her chili, but staff in dining room did notice beans on floor under resident #101. Staff notified her and RN C reported Resident #101 denied pain and pants were, cool to touch. RN C reported that staff took Resident #101 to her room and and removed pants. RN C reported she assessed Resident #101 and found a red area to the right upper thigh that stretch from Resident #101's inner thigh to outer thigh. In an interview on 7/22/15 at 2:45 p.m. RN C reported that RN D had informed her that Resident #101 had spilled chili in lap. RN C verified the witness statement from 7/18/15 at 6:15 p.m. was correct. RN C reported that Certified Nurse Aide(CNA) F was cleaning Resident #101 when she arrived in dining room to assess resident. RN C reported Resident #101 denied any pain and food on jeans was cool to touch CNA F returned Resident #101 to her room. RN C reported CNA H transferred Resident #101 via the sit to stand lift to bed and removed clothing. RN C reported she assessed Resident #101 skin between 6:20 p.m. and 6:25 p.m. and reported Resident #101 had a 2 inch wide red area from the inner, upper thigh to outer thigh area with no blisters. RN C reported she applied at that time and placed call to the Nurse Practitioner (NP) I. RN C reported she received a telephone order from NP I to continue to apply cool cloths and monitor for blistering and pain for 24 hours. RN C reported she reapplied cool clothes about ten times between 6:25 p.m. and 10:30 p.m. RN C reported there were no blisters noted to Resident #101's right upper thigh by end of her shift at 10:30 p.m. and the redness had diminished. RN C reported she did not document size of red areas for Resident #101 right upper thigh or how frequently cool cloth was applied. RN C stated she gave report to RN J. RN C reported she worked on 7/19/15 second shift. RN C reported she assessed Resident #101 on 7/19/15 between 3:00 p.m. and 4:30 p.m. and found the red area to Resident #101's right upper thigh had decreased in size from the day prior but had two to three blisters present. RN C denied performing measurements of burn site because day shift had already done measurements. RN C denied placing call to the Physician or Nurse Practitioner to notify of change in burn status including development of blisters. RN C reported she had assumed the nurse that was caring for Resident #101 when the blisters developed would have contacted the doctor. RN C reported she did not verify if the Physician or NP had been called or not. In an observation on 7/21/15 at 4:00 p.m. RN C reported she was monitoring burn to Resident #101 right upper thigh. Upon entering Resident #101 room she was in bed covered. RN C reported she had removed Resident #101's pants prior. RN C lowered the covers and reported that the burn area to Resident #101's right upper thigh had improved over time and currently had 1 blister remaining. This surveyor observed a large, raised, fluid filled blister that measured about 5 cm by 5 cm and raised about 1 cm to the right anterior upper thigh with a red area noted to medial and lateral sides of the blister. In a telephone interview on 7/22/15 at 1:05 p.m. RN D reported she was passing medications to residents in the dining room when she noticed beans under Resident #101 chair. RN D reported Resident #101 chair was sitting with the left side of chair against the table table. RN D reported CNA F was in dining room at next table at that time but there was no staff sitting at Resident #101's table. RN D reported she informed RN C (who was about 10 feet away) that Resident #101 had spilled the chili in her lap In an interview on 7/22/15 at 2:15 p.m. CNA M reported she was not present in the dining room on 7/18/15 because she was off site at infusion clinic with another resident. CNA M reported Resident #101 always sits at table B by walkway(second table on left when walking in dining room). CNA M reported Resident #101 sits at table with left side of chair against table and feet elevated off to side of table. In a telephone interview on 7/22/15 at 2:30 p.m. CNA F reported she was sitting at table B(by kitchen) assisting residents during dinner meal. CNA F reports there was not staff at Table B (by walkway) where Resident #101 was sitting. CNA F reports a few minutes into the meal about 6:10 p.m. RN D approach CNA F and told her that Resident #101 had spilled chili on her lap. CNA F reported that RN D asked CNA F to clean up Resident #101. CNA F reported Resident #101 had a clothing protector around her neck and found the chili bowl, chili, beans on Resident #101's jeans in her lap and beans on the floor. CNA F reported she used a towel to scoop chili and from Resident #101's lap and clean her hands and chair. CNA F reported chili was not hot to touch. CNA F reported she had been facing Resident #101 during the meal supervising the residents at that table and did not see Resident #101 spill chili and did not at any time hear or see any signs of pain, crying out, pushing or banging on the table to indicate spill had occurred. CNA F reported while Resident #101 was being cleaned RN C was present. CNA F reported she pushed Resident #101 to her room and met CNA H at the doorway and informed him about the spill and instructed CNA H to transfer Resident #101 into bed and remove clothes so nurse could assess the skin. In an interview on 7/22/15 at 4:10 p.m. RN N reported she did not work 7/18/15 or 7/19/15. RN N reported she started shift on 7/20/15 at 6:30 a.m. and was told in report that Resident #101 spilled chili in lap over the weekend and had a burn with blisters to right upper thigh area. RN N reported there was an order to monitor burn area and document in Treatment Administration Record and Progress Notes. RN N reported monitoring the area means to look at the burn area, and document if skin is intact and signs and symptoms of infection. RN N reported she assessed Resident #101's right upper thigh burn area about 10:30 a.m. on 7/20/15 and observed at that time 4 blisters with no treatment. RN N reported she knew that NP would be in that day so RN N reported she did not contact Physician or NP. RN N reported the NP saw Resident #101 at about 1:30 p.m. and order for silvadene was written to be applied as needed for pain or debriding blister. RN N reported pharmacy can ship items the facility needs the same day. RN N reported she did apply silvadene to Resident #101 right upper thigh 7/22/15 between 10:30 a.m. and 11:00 a.m. related to discomfort. In an interview on 7/22/15 at 4:40 p.m. Registered Dietician O reported that therapy makes recommendations for lids on hot liquids. In an interview on 7/22/15 at 4:50 p.m. Occupational Therapist Manager (OTM) P reported he was not able to locate OT note related to Resident #101 hot liquid assessment. This surveyor asked why Resident #101 had a lid on mugs and OTM P reported that Resident #101 has Parkinson's Disease with tremors and is at risk for spilling hot liquids. This surveyor ask OTM O how he felt Resident #101 would do with hot soups. OTM O reported Resident #101 would need assistance with feeding from staff with spoon for soups. OTM O reported Resident #101 is right hand dominate. Review of the document labeled Nutrition Risk Data Collection and assessment dated [DATE] revealed Resident #101 had a dysphagia [DIAGNOSES REDACTED]. Assessment Summary revealed Resident #101 was able to feed self with assistance at times. Review of the facility document labeled OT - Therapist Progress & Updated Plan of Care dated 3/31/15 revealed under Analysis of Functional Outcome/Clinical Impression, resident is demonstrating deficits in fine motor control resulting increased need for assist with feeding tasks, implementation use of modified cup for hot liquids to prevent spilling . Note also revealed under Justification for updated Plan of Care, continues to benefit from further intervention to ensure safety at meals with hot liquids as well as with changes to w/c positioning system. Signed by an OT on 4/2/15 and Physician 4/10/15. In an observation on 7/23/15 at 12:10 p.m. Resident #101 was sitting in dining room at the second table on left next to walkway with wheel chair pushed directly up to the table and the foot rests removed. Resident #101 had a clothing protector around her neck and in her lap. A staff member was sitting next to Resident #101's left side. Resident #101 was observed using both hands while eating a sandwich and using a mug with a lid. Resident #101 was given a glass of juice by the staff (with no lid) and Resident #101 grasp the glass with right hand, raised to mouth and slight tremors noted(shaking). Resident #101 used the spoon to eat fruit cocktail with slight tremors noted. Resident #101's daughter arrived at that point to assist with feeding. In an interview on 7/23/15 at 1:05 p.m. CNA Q reported Resident #101 does receive assistance in the dining room at times. This surveyor asked if Resident #101 could safely handle liquids independently. CNA Q reported when she assists Resident #101 she helps with liquids related to increased shaking. This surveyor ask if Resident #101 needs help with soup. CNA Q reported Resident #101 feeds independently with oatmeal but soup she would have difficulty with. In an interview on 7/23/15 3:20 p.m. Director of Nursing (DON) B reported it was her expectation that Resident #101 could eat independently with supervision. DON B reported staff was at next table but did not hear Resident #101 make any noise that would indicate spill. DON B reported Occupational Therapy had been consulted related to positioning at meal times and an intervention added for a clothing protector in lap as well as around neck to be used. This surveyor placed 2 telephone calls to RN J during survey and left messages to return calls. No return calls prior to exit of the survey received. ( )

This citation pertains to intake number MI 244. Based on interview and record review, the facility failed to assess and monitor residents to prevent falls in 1 (#100) of 4 sampled residents reviewed for falls prevention, resulting in a left hip fracture for Resident #100. Findings include: Review of the Face Sheet dated 3/21/14, revealed Resident #100 was a [AGE] year old male with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE], Resident #100's Brief Interview For Mental Status (BIMS) score was an 8, which indicated Resident #100 had moderate mentation issues (difficulty recalling and understanding information). According to the MDS, Resident #100's functional status for ambulation in his room was coded as a 2, which indicated he required one person physical assist and was frequently incontinent of both bowel and bladder. The MDS indicated Resident #100 had a history of [REDACTED]. Review of the Falls Care Plan dated 1/21/14 revealed Resident #100 was at risk for falls related to a history of falls, history of left hip fracture, an unsteady gait, pain, and dementia. The care plan indicated Resident #100 had a fall on 1/6/14 in his bedroom with no injury, and a fall on 1/26/14 in his room with no injury. Interventions included non-skid socks at all times, grab bar, and educate resident/responsible part/staff as needed. Review of the Safety Device Care Plan dated 1/15/14 revealed Resident #100 was to have bilateral grab bars and anti-tip bars to high back wheelchair due to decreased safety awareness, general weakness, and dementia. Review of the Resident Incident Report dated 3/9/14 under Incident Description revealed, "Resident (Resident #100) was found on floor head near end of bed feet near closet door. Resident was lying on a bag with foot pedals in it. Resident nose was bleeding." The Incident Report, under Final Outcome, revealed, "Resident was attempting to get himself ready for his family to come and ambulated unassisted in his room. He was attempting to put on a sweater and had a bag in his hands and tripped on his bed. Residents bed was placed against the wall to clear his room from environmental obstacles. Staff was also educated to assist resident when his family is coming to attempt to prevent him from doing it unassisted." Review of the Interdisciplinary Team Progress Notes (IDT) dated 3/10/14 revealed, "IDT met to review res (resident) chart post fall. Res found on floor in room 8 a.m. without complaints of pain after fall, bloody nose. All x-rays negative, L (left) hip x-ray negative as well. Vitals and neuro's WNL (Within Normal Limits). Res stated he tripped on bed. Res bed was moved against the wall. All CP's (Care Plans) and assessments completed. Son xxxx aware." Review of the physician's orders [REDACTED].#101 was to have, "check ammonia level next lab day - s/p (status [REDACTED]. Review of the Laboratory report dated 3/12/14 revealed Resident #100's ammonia level was elevated at 96 (normal is 47 or less). Symptoms of elevated blood ammonia include muscle weakness, fatigue or other symptoms of liver and kidney damage and failure. If left untreated, elevated blood ammonia can affect brain tissue, leading to symptoms such as confusion and delirium (rapid change in cognitive function). (http://labtestsonline.org/understanding/analytes/ammonia/tab/test). Review of the physician's orders [REDACTED].#100 was to have his medication Lactulose (medication used to reduce ammonia levels) increased to 30 milliliters twice daily. According to Lippincott's Nursing Drug Guide 2008, lactulose therapeutic action is to increase stool water content, stool softening, laxative action resulting in the migration of blood ammonia into the colon contents with subsequent trapping and expulsion in the feces. The drug guide indicated that those on the medication need "ready access to the bathroom; bowel movements will be increased to two or three per day." Review of the medical record revealed no update to the care plan or the CNA care guide to indicate Resident #100 would require additional opportunities for toileting assistance. Review of the facility Incident report dated 3/14/14 revealed at 10:30 a.m. Resident #100 was "found on the bedroom floor yelling for help." According to the report, Resident #100 was "bleeding from right wrist. Left leg was twisted and internally rotated beneath him." The report indicated Resident #100 had a pain level of 10 out of 10 (indicating the most pain), was unable to flex or extend his left knee, had a 6 cm abrasion to his right wrist, and was sent to the emergency room for evaluation and treatment. The report indicated the resident incident description revealed that Resident #100 reported he was trying to go to the bathroom, fell and grabbed the wheelchair flipping that and the bedside table tray over with him onto the floor. Resident #100 reported being weak and complained of dizziness prior to the fall and lost his balance. The report indicated "Resident Specific Circumstances" as Resident #100 had "had increased confusion over the last 24 hours". The report revealed Resident #100 was unable to answer why he didn't use the call light..." The reported "Summary of Investigation Outcome" revealed, .."Toileting plan was reviewed urinal in place when resident was checked after breakfast appeared to be sleeping and was not offered to be taken to the toilet." Review of the hospital documentation for Resident #100 dated 3/20/14 revealed "Left femoral X-Ray. There is a complete oblique fracture through the mid to distal left femoral diaphysis with approximately 1.5 cm (centimeters) of lateral displacement of the distal fracture fragment with anterior apex angulation. The proximal portion of the distal femoral left knee arthorplasty prosthesis extends into the fracture. In an interview on 3/31/14 at 4:30 p.m. Registered Nurse (RN) "J" stated Resident #100 was found in his room after the fall and was noted to have his left leg internally rotated to the right. RN "J" stated, "He was sent to the emergency room immediately, we did not move him from the floor. Resident said he was trying to get to the bathroom." RN "J" stated that Resident #100 was "a little more confused since the fall on 3/9/14" and had experienced "hallucinations" (seeing things that weren't there). RN "J" stated, relative to the call system, "no, (Resident #100) never uses the call light." Review of the Witness Investigation Statement dated 3/14/14 revealed RN "G" documented that Resident #100 was on the the floor with the wheelchair tipped over on it's side and Resident #100's left leg was twisted and he had complained of pain in his left leg. RN "G" documented that Resident #100 stated he was going to the bathroom to have a bowel movement. Review of the Progress Note dated 3/14/14 at 10:30 a.m. revealed, "Resident (Resident #100) was found on bedroom floor yelling for help. Resident was tangled in wheelchair that was flipped over partially on top of him. Water was spilt on the floor and on resident. Resident was bleeding from right wrist. Left leg was twisted and internally rotated beneath him." Under Final Outcome revealed, "Resident change in mentation with lab value changes reported to Dr. . Medication change was initiated with care plan updated. 24 hour reported to (State Agency) due possible change in adl status form previous stand and ambulate with stand by assistance." In an interview on 3/31/14 at 4:00 p.m. Certified Nurse Aide (CNA) "E" reported that Resident #100 had worsening dementia and would attempt to self-transfer occasionally. CNA "E" additionally indicated Resident #100 uses his call system on occasion, however was not consistent.

Based on observation, interview and record review the facility failed to ensure adequate assessment post fall and adequate assistance to prevent falls in 3 of 7 sampled resident (#101, #105, and #108) reviewed for falls, from a total sample of 7 residents, resulting in the potential for injury and/or undetected injury. Findings include: Resident #101 Resident #101 was admitted to the facility on [DATE] with a medical history according to the facility [DIAGNOSES REDACTED]. Review of the facility MDS (minimum data set) dated 4/14 Resident #101 was mentally severely impaired for daily decision making skills, required limited one person assistance with transfers, required extensive one person assistance with toileting, was only able to balance self during transitions from sitting to standing position such as during toileting with the assistance of one person. Review of the facility nursing care plan titled "Fall/injury Assessment: Prevention and Management " care plan revealed on 3/25/14 "found on floor in room with pain to right hip". 4/10/14 "found kneeling on fall mat next to bed no injury". 4/13/14 "found sitting on floor mat next to bed no injury. " 5/12/14 "found kneeling in room on floor mat no injury". 5/25/14 "found on knees in room next to bed with laceration to back of head". Review of the facility Nurses Notes dated 5/25/14 at 3:45 PM revealed "Resident found on floor in room shortly after shift change. 3 CM laceration to right parietal head. Cleaned with normal saline, steri strips applied. Nero checks started WNL (within normal limits) 5:20 PM "wound on head continues bleeding. Cleansed, new steri strips applied. Family wants resident sent to ER for sutures. 6:15 PM wound continues to bleed, OK'd by on-call unit manager and on call PA (Physician Assistant) to send to ER for treatment " . 9 PM "returned from ER with 3 staples to wound on head." Review of the facility document titled "resident Incident" dated 5/25/14 revealed in the section "Incident Description", "CNA (certified Nursing Assistant) heard bed alarm, went to resident room and found him on his knees beside the bed. There is a small laceration to right posterior head (back of the head). Review of the section titled "initial assessment" Is there a head injury or suspected head injury? "YES". Neuro (neurological) check results: "with normal limits, pupils pinpoint " . Section titled "Post Incident Actions Immediate Nursing Actions", " Neuro checks started, within normal limits". Review of the facility medical record revealed no Neuro checks were documented /located for Resident #101. Upon request by this surveyor for the document at 4:15 PM on 5/28/14 Administrator "A" and Director of Nurses "B " stated, "we did not find the Neuro checks the nurse took them home we are missing both the 2nd and 3rd shift so no we don't have them." ( ) Resident #105 Resident #105 was admitted to the facility 2/13 with a medical history according to the facility [DIAGNOSES REDACTED]. Review of the facility MDS dated ,[DATE] revealed Resident #105 was cognitively intact for daily decision making skills, required extensive one person assistance with transfers, did not have steady balance while moving from surface to surface such as on and off the toilet. Review of the facility document titled "ADL/Mobility Care Plan" dated 2/13/13 revealed, "Provide assistive device as needed for transfer: stand and pivot 2/1/3/13." Facility document titled "Fall/injury assessment prevention and management Care Plan" revealed, Transfer: 1 A Stand-pivot (one assist). " Review of the facility document titled "daily worksheet for the nursing assistant" revealed Resident #105 was listed in the section titled "transfer SP" (stand and pivot). During an observation of a transfer on 5/28/14 at 9:28 AM this surveyor observed CNA "C" transfer Resident #105 from a wheelchair into a chair without a gait belt. A gait belt was noted to be around the CNA's waist during the transfer. During an interview with Director of Nurses "B" on 5/28/14 at 12:05 PM, she reported that "stand-pivot transfers yes a gait belt is to be used. " ( ) Resident #108 Resident #108 was admitted to the facility 4/13 with a medical history according to the facility medical [DIAGNOSES REDACTED]. Review of the facility MDS dated ,[DATE] revealed Resident #108 was cognitively intact for daily decision making skills, required extensive two person assistance with transfers, and was unsteady moving from a sitting to standing position. Review of the facility document titled "ADL/mobility plan of care dated 8/13 section revealed "assistive Devices" with intervention that included "provide assistive device as needed for transfer: "Sara lift with blue sling 5/13". Facility document titled "Fall/Injury Assessment: Prevention and management Plan of Care" dated 5/27/14 revealed, "fall from Sara lift resident lowered to floor by staff when she slid from the lift sling. " Review of the facility document titled "daily worksheet for the nursing assistant" revealed Resident #108 was listed in the section titled "transfers- max assist X 2". Review of the document "Mechanical Lift" dated 7/13 revealed " the sit-stand (STS) mechanical lift may be used for residents who can reliably bear weight on at least one leg and can offer assistance with transfers/lifts but who may need some physical assistance from staff or are at risk of falling. The STS mechanical lift is completed with the assistance of two. The second person may assist with ADL's. The second person is not used for supporting weight". Review of the document dated 5/27/14 titled "resident incident" at 9:30 AM revealed " resident (Resident #108) with CNA who had lowered resident to the floor, pillow placed under head. Tempo lift at resident's feet and wheelchair behind resident". The document section titled "Equipment circumstances" revealed " Was use of this equipment per POC (Plan of Care)? ' NO ' . Reason: Staff was using lift alone need two staff members." During an interview on 5/28/14 at 12:05 PM, Director of Nurses "B" reported that the equipment was appropriate for the resident correct lift and sling, but the plan of care was not met because two person transfer was not used. ( )

This citation pertains to intake MI 992. Based on interview and record review, the facility failed to provide a safety device as ordered by the physician in 1 of 3 sampled residents (#102), from a total sample of 4 residents, resulting in Resident #102 having a fall with injury with pain and swelling to her face. Findings include: The nurse is obligated to follow the physician's orders unless they believe the order is in error or would be detrimental to the resident. (Fundamentals of Nursing, Concepts, Process, and, Practice, Mosby, Perry, P., Potter, A., 1985). "Nurses must obey the orders of the physician in charge of a patient, unless an order would lead a reasonable person to anticipate injury if it were carried out", according to Creighton in Law Every Nurse Should Know, 5th Edition, page 98. Review of Resident #102's medical record revealed she was a [AGE] year old female who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #102's Minimum Data Set ((MDS) dated [DATE] indicated she was moderately impaired with cognitive skills, required extensive assistance of two persons for transfers, extensive assistance of one person for ambulation, dressing, and hygiene, had almost constant, severe pain, and a history of falls. A physician's order for Resident #102 dated 9/11/12 indicated Resident #102 was to have wheelchair equipment to be used for positioning to include a ROHO seat cushion (pressure relief cushion), foot support board, bilateral trunk supports, and a half lap tray on the left side. Monthly physician orders for Resident #102 for October 2012 and November 2012 under the section titled "safety device", indicated Resident #102 was to have wheelchair equipment to be used for positioning to include a ROHO seat cushion, foot support board, bilateral trunk supports, and a half lap tray on the left. During the initial tour of the facility on 11/13/12 at 9:50 am, the surveyor observed Resident #102 sitting in the hall in her wheelchair, with no lap tray on her wheelchair. Resident #102 had bruising present around both eyes, on her forehead, and on her nose. Resident #102 also had a raised swollen bump approximately half dollar size on her forehead with an approximately 2 centimeter (cm) abrasion in the center of the bump. Unit Manager #3 (UM #3) stated Resident #102 had fell . During observations of Resident #102 on 11/13/12 at 12:00 pm, 11/14/12 at 10:00 am, 11/14/12 at 11:00 am, 11/14/12 at 1:00 pm, and 11/14/12 at 3:00 pm, the surveyor did not observe at lap tray of any kind on Resident #102's wheelchair. Review of the Facility incident report dated 11/5/12, indicated Resident #102 was in another resident's room at 10:00 pm and was on the floor face down in front of her wheelchair holding her head. The incident report indicated that Resident #102 had a tennis ball sized lump on right side of her forehead that was bleeding, and that she stated she fell asleep and fell on the floor. In an interview on 11/14/12 at 12:55 pm, Director of Nursing #2 (DON #2) stated he is not sure what happened to the half lap tray that was ordered by the physician on 9/11/12. Unit Manager #3 (UM #3) was also in the room during the interview and stated the half lap tray may have been discontinued. DON #2 retrieved all thinned records for Resident #102 from the medical records department and reviewed physician orders from 9/1/12 to current with UM #3 and the surveyor. There was no physician order for [REDACTED].#2 stated the half lap tray was never placed on Resident #102's wheelchair. Occupational therapy note dated 9/18/12 for Resident #102 indicated Resident #102 was transferred to available tilt-in-space chair, lateral hip supports were adjusted, added lateral supports to encourage proper alignment, and a half lap tray was added on the left side. In an interview on 11/16/12 at 1:10 pm, Certified Nurse Aide (CNA) #21 stated she was the first person to arrive in the room when Resident #102 was found face down on the floor on 11/5/12. CNA #21 stated she heard a thud, then alarm, and ran to room [ROOM NUMBER] to find Resident #102 face down on the floor. CNA #21 stated Resident #102 was in a different wheelchair than the one she used to be in, and did not have a tray on her wheelchair at the time of the fall. Nurse's note dated 11/5/12 for Resident #102 indicated she fell asleep and fell and hit her head on the floor. The note indicated Resident #102 had a large swollen bruised area on the right side of her forehead. Nurse's note dated 11/6/12 at 4:10 pm indicated Resident #102 had Ecchymosis (bruising)and swelling to forehead area with [MEDICATION NAME] (narcotic pain medication) given in the morning for complaints of neck pain. Nurse's note dated 11/7/12 at 4:30 pm indicated Resident #102 had [MEDICATION NAME] and [MEDICATION NAME] (narcotic pain medication) given for complaints of neck discomfort and overall general discomfort. Nurse's note dated 11/7/12 at 11:00 pm indicated Resident #102 at very little dinner (25%), complained of a headache, had [MEDICATION NAME] (narcotic pain medication) given, which was effective. Ice also given for head. Nurse's note dated 11//12 at 11:00 pm indicated Resident #102 complained of moderate acute pain to facial area where bruising occurred with fall. #

This citation pertains to intake MI 992. Based on interview and record review, the facility failed to provide safety devices to prevent falls in 1 of 3 sampled residents (#102), from a total sample of 4 residents, resulting in Resident #102 falling forward out of her wheelchair onto the floor, onto her face where she sustained bruises and swelling to her face and pain. Findings include: Review of Resident #102's medical record revealed she was a [AGE] year old female who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #102's Minimum Data Set ((MDS) dated [DATE] indicated she was moderately impaired with cognitive skills, required extensive assistance of two persons for transfers, extensive assistance of one person for ambulation, dressing, and hygiene, had almost constant, severe pain, and a history of falls. Review of the falls care plan with a revised date of 10/1/12 indicated Resident #102 was at risk for falls related to pain, osteoarthritis, osteoporosis, pulse irregularities, cardiovascular diagnosis, bowel and bladder incontinence, left foot ulcers, and CVA (stroke). Interventions listed included bed and chair alarms, bilateral grab bars, high/low bed, roho cushion to wheelchair, trunk supports in wheelchair, tilt back wheelchair, Dycem in wheelchair, and recliner, encourage out of bed in wheelchair to supervised areas during waking hours, and assist resident to bed when noted fatigued. Occupational therapy note dated 9/13/12 indicated Resident #102 was assessed for effectiveness of positioning changes and use of adaptive equipment which resulted in an adjustment to her treatment plan. The therapy note indicated an additional lateral support for greater trunk support due to left side leaning, a half lap tray was added for left side leaning, a roho cushion was added to prevent sliding forward and Resident #102 could "greatly benefit from a tilt in space chair to prevent leaning/sliding forward for fall prevention." Occupational therapy note dated 9/18/12 for Resident #102 indicated Resident #102 was transferred to available tilt-in-space chair, lateral hip supports were adjusted, added lateral supports to encourage proper alignment, and a half lap tray was added on the left side. A physician's order for Resident #102 dated 9/11/12 indicated Resident #102 was to have wheelchair equipment to be used for positioning to include a ROHO seat cushion, foot support board, bilateral trunk supports, and a half lap tray on the left. Monthly physician orders for Resident #102 for October 2012 and November 2012 under the section titled, "safety device" indicated Resident #102 was to have wheelchair equipment to be used for positioning to include a ROHO seat cushion, foot support board, bilateral trunk supports, and a half lap tray on the left. Review of Resident #102's safety device plan of care with a revised date of 10/1/12 indicated Resident #102 was to use bilateral grab bars as of 5/31/12. There were no other safety device listed. Review of facility "safety device data collection" form for Resident #102 dated 10/2/12 revealed Unit Manager #3 documented that Resident #102 displayed a recent increase in proper positioning in tilt-in-space wheelchair. Review of the Nurse's note dated 10/27/12 indicated Resident #102 was unable to use her wheelchair as it needed service. Facility incident report for Resident #102 dated 11/5/12 indicated Resident #102 was in another resident's room at 10:00 pm and was on the floor face down in front of her wheelchair holding her head. The incident report indicated that Resident #102 had a tennis ball sized lump on right side of her forehead that was bleeding, and that she stated she fell asleep and fell on the floor. In an interview on 11/16/12 at 1:10 pm, Certified Nurse Aide (CNA) #21 stated she was the first person to arrive in the room when Resident #102 was found face down on the floor on 11/5/12. CNA #21 stated she heard a thud, then an alarm, and ran to room 6 to find Resident #102 face down on the floor. CNA #21 stated Resident #102 was in a different wheelchair than the one she used to be in, and did not have a tray on her wheelchair at the time of the fall. In an interview on 11/15/12 at 9:10 am, Licensed Practical Nurse (LPN) #13 stated the tilt-in-space wheelchair worked much better for Resident #102 because it helped position her better. Review of the Nurse's note dated 11/5/12 for Resident #102 indicated she fell asleep, fell , and hit her head on the floor. The note indicated Resident #102 had a large swollen bruised area on the right side of her forehead. Review of the Nurse's note dated 11/5/12 for Resident #102 indicated her head seemed to swell more throughout the shift, the nurse practitioner was notified, who initially wanted to send Resident #102 to the hospital. The note indicated Hospice staff recommended onsite X-ray, which was done, and medication was given for complaints of nasal and head pain. Review of the Nurse's note dated 11/6/12 at 4:10 pm indicated Resident #102 had Ecchymosis (bruising) and swelling to her forehead area with Norco (narcotic pain medication) was given in the morning for complaints of neck pain. Review of the Nurse's note dated 11/6/12 at 11:00 pm indicated Resident #102 had light purple bruising and swelling to forehead area and Resident #102 stated she was uncomfortable in her new chair. Nurse's note dated 11/7/12 at 4:30 pm indicated Resident #102 had Norco and Roxanol (narcotic pain medication) given for complaints of neck discomfort and overall general discomfort. Nurse's note dated 11/7/12 at 11:00 pm indicated Resident #102 at very little dinner (25%), complained of a headache, had Norco (narcotic pain medication) given, which was effective. Ice also given for head. Nurse's note dated 11//12 at 11:00 pm indicated Resident #102 complained of moderate acute pain to facial area where bruising occurred with fall. During the initial tour of the facility on 11/13/12 at 9:50 am, the surveyor observed Resident #102 sitting in the hall in a high backed wheelchair, which was not reclined, with no lap tray. Resident #102 had bruising present around both eyes, on her forehead, and on her nose and was leaning forward in the chair. Resident #102 also had a raised swollen bump approximately half dollar size on her forehead with an approximately 2 centimeter (cm) abrasion in the center of the bump. Unit Manager #3 (UM #3) stated Resident #102 had taken a fall. During observations of Resident #102 on 11/13/12 at 12:00 pm, 11/14/12 at 10:00 am, 11/14/12 at 11:00 am, 11/14/12 at 1:00 pm, and 11/14/12 at 3:00 pm, the surveyor did not observe at lap tray of any kind on Resident #102's wheelchair, and the high back wheelchair was in the upright, 90 degree position. During an observation on 11/14/12 at 1:00 pm, Resident #102 was observed to be sitting in her room with her lunch in front of her on a bedside table, in her wheelchair asleep, and leaning forward, with no staff present and no lap tray attached to the wheelchair. In an interview on 11/14/12 at 12:55 pm, Director of Nursing #2 (DON #2) stated he is not sure what happened to the half lap tray that was ordered by the physician on 9/11/12. Unit Manager #3 (UM #3) was also in the room during the interview and stated the half lap tray may have been discontinued. DON #2 retrieved all thinned records for Resident #102 from the medical records department and reviewed physician orders from 9/1/12 to current with UM #3 and the surveyor. There was no physician order found for Resident #102 to have the half lap tray on the left discontinued after 9/11/12. UM #3 and DON #2 stated the half lap tray was never placed on Resident #102's wheelchair. DON #2 and UM #3 stated Resident #102 is in the high back wheelchair while the tilt-in-space wheelchair is out for repairs. DON #2 brought Resident #102's tilt-in-space wheelchair to the surveyor and demonstrated the broken cable on the wheelchair to the surveyor. DON #2 was unable to give the surveyor a specific date as to when the tilt-in-space wheelchair would be repaired for Resident #102. When the surveyor asked UM #3 why the high backed wheelchair was not reclined for Resident #102, UM #3 stated she didn't know. #

This citation pertains to intake number MI 715. Based on interview and record review the facility failed to provide adequate supervision for a resident who was known to attempt to ambulate without assistance from in 1 of 5 sampled residents (Resident #501) who was assessed to be at a high risk for falls, from a total sample of 6 sampled residents, resulting in a subdural hematoma (bleeding in the brain) after Resident #501 fell from her wheelchair and required emergent transfer to the hospital. Findings include: Per the facility face sheet Resident #501 was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a facility incident report dated 4/23/2011 revealed Resident #501 was observed standing up attempting to self-transfer when staff ran to Resident #501, Resident #501 tripped over the foot pedals on her wheelchair causing Resident #501 to fall backwards onto her head which knocked Resident #501 unconscious. The incident report revealed an environmental obstacle was present at the time of Resident #501's fall and the obstacle was documented "foot rests" (wheelchair foot pedals). The incident report revealed Resident #501 was generally alert and oriented to person only, exhibited poor judgement, poor safety awareness, and lacked insight into her own limitations. The report revealed Resident #501 was placed in a room near the nurses' station due to the need for increased supervision, had fall alarms placed, and required one person assist to transfer due to Resident #501's poor safety awareness. The incident report revealed Resident #501 was transferred to the hospital. Review of a "Minimum Data Set" ((MDS) dated [DATE] revealed Resident #501 had an impaired ability to recall things told to her, had inattention, and disorganized thinking, required extensive assistance with transferring, and supervision and assistance with ambulating. Review of a care plan titled, "Fall/Injury Assessment: Prevention and Management Plan of Care" dated 4/13/2011 revealed Resident # 501 was at risk for falls. Interventions included a chair and bed fall alarms, foot rests to Resident #501's wheelchair when being propelled, and "increased supervision" (the care plan did not reveal what "increased supervision" consisted of). The care plan also revealed Resident #501 was a one person assist to transfer. Review of the care plan revealed that the care plan had not been updated since Resident #501 had been admitted to the facility on [DATE]. Review of facility policy and procedure for "Falls and Injuries" dated November 1998 and revised January 2009 and April 2012 revealed under "Supervision/Adequate Supervision:" "Adequate supervision is defined by the type and frequency of supervision, based on the individual residents assessed needs and identified hazards in the resident environment. Supervision may vary resident to resident and time to time for the same resident. The use of tools or items such as personal alarms can help monitor resident's activities but does not eliminate the need for staff vigilance and are not to be utilized in lieu of supervision." The policy revealed that "Resident Supervision" procedure was located in the "Clinical Administrative Manual." Review of the "Clinical Administrative Manual" dated January 2009 revealed under "Resident Supervision", "The facility will continually evaluate the level of supervision needed through assessment and observation of the resident's cognitive, behavioral, medical or other conditions that put them at risk to self or other." The policy revealed that the categories of supervision included, "general supervision, increased supervision, close visual supervision, and resident-specific supervision." The policy revealed that a resident under "increased supervision" was to have a review Monday through Friday during the appropriate daily clinical meeting and documentation of the supervision by utilizing the "24-hour Resident Flow Records." Lastly the policy revealed under, "Increased Supervision", the resident under this category would have a staff member assigned to do a visual check on the resident every 15 minutes and the observation would be documented every 15 minutes using the "24-Hour Resident Flow Record." Review of Resident #501's medical record revealed no documentation of 15 minute checks based on the need for "Increased Supervision" per Resident #501's care plan. Review of nurses' notes revealed that on the following dates Resident #501 was observed by staff to attempt to ambulate/transfer on her own without staff assistance: 4/13/2011 Resident #501 continued to attempt to get up out of bed and was confused, 4/14/2011 Resident #501 repeatedly attempted to get up out of her bed, 4/15/2011 Resident #501 tried to get up out of bed several times, 4/15/2011 Resident #501 repeatedly was up walking around her room without calling for assistance, 4/16/2011 Resident #501 stood up from her wheelchair without assistance, 4/16/2011 Resident #501 caused her pressure alarm (pad under resident, when resident gets off the pad the alarm sounds) to sound several times, 4/19/2011 Resident #501 up from wheelchair and bed and will not comply with wheelchair use or stay in bed, 4/22/2011 Resident #501 up walking around room several times, 4/23/2011 Resident #501 fell and hit her head, went unconscious two times, vomited two times, and was transferred to the hospital. Review of the hospital emergency room physician note dated 4/23/2011 revealed that a Cat Scan (CT) of Resident #501's head and neck revealed a subdural hematoma (bleed in the brain). The note revealed that a neurosurgeon looked at the CT and determined that there was no likelihood of Resident #501 having a good outcome from surgery. The note revealed Resident #501 was to be kept comfortable only. Another physician consultation note dated 4/23/2011 revealed that Resident #501 was unresponsive and had a "massive" subdural hematoma and therefore was comfort care only, per the family requests. Review of a hospital physician "History and Physical" (H&P) dated 4/23/2011 revealed Resident #501 had fallen backwards while at the facility and hit the back of her head resulting in Resident #501 being unconscious. The note revealed that there was a very little chance that Resident #501 would recover. Review of the emergency room nursing documentation dated 4/23/2011 revealed Resident #501 presented to the hospital with a hematoma to the back of her head. Review of a CT scan dated 4/8/2011 that was taken prior to Resident #501's admission to the facility revealed no evidence of any bleeding in the brain, or stroke. Certified Nurse Assistant (CNA) #1 was interviewed on 5/8/2012 at 10:00 AM. CNA #1 stated that he and Licensed Practical Nurse (LPN) #2 were in the hall that Resident #501 was sitting in while in her wheelchair on 4/23/2011. CNA #1 said that he and LPN #2 were performing their work duties and had their backs to Resident #501. CNA #1 said that he and LPN #2 heard Resident #501's fall alarm sound and that the alarm alerted them to look towards Resident #501. CNA #1 said that he and LPN #2 began to run towards Resident #501 because Resident #501 stood up from her wheelchair. CNA #1 said he saw Resident #501 take one step forward, trip and tangle her feet around each other causing Resident #501 to fall backwards onto her buttocks and then hitting her head onto the floor. CNA #1 said he heard Resident #501's head crack on the floor, which knocked Resident #501 out. CNA #1 said Resident #501 went limp after she hit her head on the floor. CNA #1 said Resident #501's gait was unsteady. LPN #2 was interviewed on 5/8/2012 at 10:30 AM. LPN #2 said on 4/23/2011 she had trouble keeping Resident #501 seated. LPN #2 said Resident #501 was in her wheelchair at the beginning of C-hall. LPN #2 said that her and CNA #1 were the only two staff members in the hall. LPN #2 said she saw Resident #501 tripped over the foot pedals on her wheelchair. LPN #2 said Resident #501 would always stand up while in the hall and take about two steps without assistance and this would cause Resident #501's fall alarms to sound. LPN #2 said Resident #501 would attempt to self ambulate anywhere and all the time. LPN #2 said on 4/23/2011 when Resident #501 fell she heard a loud crack when Resident #501's head hit the floor and stated that Resident #501 hit her head "hard". LPN #2 said Resident #501 went unresponsive and vomited. LPN #2 said she called 911 and did not move Resident #501 until the ambulance arrived. LPN #2 said "everyone" (staff) knew that Resident #501 was a high fall risk. LPN #2 said that based on her knowledge of the risk of Resident #501 falling she made no changes to Resident #501's plan of care, and stated that she did not increase supervision for Resident #501 prior to the fall on 4/23/2011. Certified Occupational Therapist Assistant (COTA) #6 was interviewed on 5/8/2012 at 10:03 PM. COTA #6 said that foot pedals on a resident's wheelchair were a "case by case" determination, meaning foot pedals on a wheelchair were resident specific, but stated that no assessment specifically for foot pedals was available. Registered Nurse (RN) #3 was interviewed on 5/8/2012 at 2:09 PM. RN #3 said that she had put interventions in place for Resident #501 at the time of Resident #501's admission and then added a toileting schedule at a later date. RN #3 said that no staff reported to her that Resident #501 continued to get up or attempt to get up on her own without assistance. Nurse Practitioner (NP) #9 and Physician #11 were interviewed on 5/9/2012 at 12:06 PM and 1:47 PM. Both NP #9 and Physician #11 could not remember specifically Resident #501. Review of a "Certificate of Death" dated 5/2/2011 revealed that Resident #501's cause of death, dated 4/24/2011, was "Intracranial Hemorrhage" (bleeding within the skull). Review of "Interdisciplinary Notes" (IDT) notes dated from 4/12 through 4/21/2011 revealed notations only from the facility Social Worker. The notations only on 4/20/2011 revealed that Resident #501 had poor safety awareness and that fall alarms were in place. The notes did not revealed any discussion of evaluation of safety measures and the effectiveness of those safety measures for Resident #501. On 5/7/2012 at 12:00 the Director of Nursing (DON) #4 stated that he did not investigation as the cause of Resident #501's fall nor did he report the incident to the State agency. ( )

This citation pertains to intake MI 750 Based on observation, interview and record review the facility failed to ensure facility staff provided care according to the professional standards of practice in 1 of 9 sampled residents (Resident #101) resulting in a delay in treatment of [REDACTED]. Findings include: Record review of the facility "Nutrition Services Procedure for Safety and Emergency Planning", indicate all nutrition services employees are in-serviced annually and upon hire on safety and disaster topics including preventing falls and burns. Review of a Medscape web page [MEDICAL CONDITION] scalds (burns that result from contact with hot liquids) The more [MEDICATION NAME] the liquid and the longer the contact with the skin, the greater the damage.(http://emedicine.medscape.com/article/ 3-overview). Review of "Textbook for Basic Nursing", by Caroline Bunker Rosdahl, Mary T. Kowalski, indicates emergency first aid for the treatment of [REDACTED]." Review of the Department of Community Health Alert on Scalding Injuries caused by excessive hot water, food, and hot beverage temperatures, dated 11/03/06; revealed water temperature of 150 degrees Fahrenheit takes less than 1 second to receive a second degree burn. Record review of a "Facility Face Sheet" and "Minimum Data Set" (MDS), dated [DATE], revealed resident #101 was a [AGE] year-old man originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #101 wore glasses, used a wheelchair for locomotion, required set up assistance only for eating, and required 1 to 2 person physical assistance for dressing. Record review of an "Accident/Incident Report", dated 3/08/11, revealed Resident #101 spilled hot soup into his lap causing a red area over his left thigh. Documentation of the injury on the Accident/Incident report indicated Resident #101 sustained a reddened area which measured 15 cm x 20 cm on the left thigh and 8 cm x 20 cm on the right thigh. The physical examination documented on the Accident/Incident report reveal Resident #101 had pain that was an 8/10 at the site where the soup was spilled. An interview, on 3/10/11 at 11:35 AM, with dietary aide #19, (who was the first to respond to the resident #101) heard him yell, "Help! Help! I'm getting burnt!". Upon reaching resident #101 she stated she saw liquid from the soup on his pants in his lap and vegetables on his thigh. When asked what she did to stop the resident from being further injured from hot soup she stated "I'm not to do anything (provide care) with any of the residents. I wheeled him away from the table to find a nurse. I saw Certified Nurse Aide (CNA) #12 and told her he (Resident #101) was being burnt." Dietary aide #19 estimated approximately 30 seconds had passed since she first realized the resident was in trouble to when she passed the resident off to CNA #12. An interview with CNA #12, at 10:15 AM on 3/10/11, revealed she had been entering the dining room with another resident when she saw dietary aide #19 wheeling Resident #101 toward the door to the dining room. CNA #12 said Resident #101 was saying "Oh it hurts, it hurts!", and could recall seeing soup pooled in his lap, and that he looked to be in pain, grimacing, with his hands clenched. CNA #12 also noticed vegetables on his right leg. When asked if she did anything to treat Resident #101 she stated "No I did not do anything to treat the situation". CNA #12 then proceeded to wheel Resident #101 out of the dining room, past the nurse's station, and down the hall toward resident #101's room. CNA #12 then passed Resident #101 off to another employee, CNA #11, and instructed her to get Resident #101's pants off him because he was burned from hot soup that had spilled onto his lap. CNA #11 was assigned to work the hall during lunch that day and was the third employee to receive Resident #101 after spilling hot soup on his lap. An interview with CNA #11, at 12:20 PM on 3/10/11, revealed she received Resident #101 from CNA #12 and was told to remove Resident #101's pants. CNA #11 recalled seeing a pool of liquid in his lap and vegetables on his left leg. CNA #11 got the assistance of CNA #13 because Resident #101 required a sit-to stand mechanical lift for transfers. CNA #13 stayed with Resident #101 while CNA #12 went to get the lift, and together they transferred him into bed. CNA #11 approximated the amount of time it took to get the lift and complete transfer was 1 minute. And observation of Resident #101 on 03/11/11 at 12:20 PM revealed a 5.5 cm x 1.5 cm reddened area on the right groin, a 9 cm x 4 cm reddened area in his left groin, a 3 cm x 1.75 cm raised blister on his left thigh, a 1 cm x 1.25 cm blister on the left thigh. An an interview with Resident #101 on 3/11/11 at 12:20 PM, Resident #101 reported pain at the site of the burn was a 10 on a scale of 1-10. Resident #101 also indicated he had [MEDICAL CONDITION] his genitals and could [MEDICAL CONDITION] his backside. When asked how long it took to remove the burning soup from his lap from the time he still resident #101 stated it took 10 min.( )

This citation pertains to intake MI 750 Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 (Resident #101) of 9 sampled residents when Resident #101 sustained a second degree burn after spilling hot soup at lunch time in the dining room at the facility. Findings include: Record review of a "Facility Face Sheet" and "Minimum Data Set" (MDS), dated [DATE], revealed resident #101 was a [AGE] year-old man originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #101 wore glasses, used a wheelchair for locomotion, required set up assistance only for eating, and required 1 to 2 person physical assistance for dressing. Record review of an "Accident/Incident Report", dated 3/08/11, revealed Resident #101 spilled hot soup into his lap causing a red area over his left thigh. Documentation of the injury on the Accident/Incident report indicated Resident #101 sustained a reddened area which measured 15 cm x 20 cm on the left thigh and 8cm x 20 cm on the right thigh. The physical examination documented on the accident last incident report reveal that pain was an 8/10 at the site where the soup made thighs red. An interview with Registered Dietitian #15, on 3/10/11 at 9:25 AM, revealed the temperature of the hot soup that was served was 180?F the day Resident #101 spilled on himself (3/8/11). Record review of the "Temperature Log" for the food items served at lunch that day confirmed the registered dietitian statement. An interview, on 3/10/11 at 11:35 AM, with dietary aide #19, who was the first to respond to the resident #101 after hearing him yell, "Help! Help! I'm getting burnt!". Upon reaching resident #101 she stated she saw soup on his lap and vegetables from the soup on his thigh. When asked what she did to stop the resident and being further injured from hot soup she stated "I'm not to do anything (provide care) with any of the residents. I wheeled him away from the table to find a nurse. I saw Certified Nurse Aide (CNA) #12 and said he (Resident #101) was being burnt." The dietary aide estimated about 30 seconds had passed since she first realized the resident was in trouble to when she passed the resident off to CNA #12. Record review of the facility "Nutrition Services Procedure for Safety and Emergency Planning", indicate all nutrition services employees are in-serviced annually and upon hire on safety and disaster topics including preventing falls and burns. Review of "Textbook for Basic Nursing", by Caroline Bunker Rosdahl, Mary T. Kowalski, indicates emergency first aid for the treatment of [REDACTED]." An interview with CNA #12, at 10:15 AM on 3/10/11, revealed she had been entering the dining room with another resident when she saw dietary aide #19 wheeling Resident #101 toward the door to the dining room. CNA #12 said Resident #101 was saying "Oh it hurts, it hurts!", and recalled seeing soup pooled in his lap, and that he looked to be in pain, grimacing, with his hands clenched. CNA #12 also noticed vegetables on his right leg. When asked if she did anything to treat Resident #101 she stated "No, I did not do anything to treat the situation". CNA #12 reported she then proceeded to wheel Resident #101 out of the dining room, past the nurse's station, and down the hall toward Resident #101's room. CNA #12 then passed Resident #101 off to yet another employee, CNA #11, and instructed her to get Resident #101's pants off him because he was burned from hot soup that had spilled. CNA #11 was assigned to work the hall during lunch that day and was the third employee to receive Resident #101 after spilling hot soup on his lap. An interview with CNA #11, at 12:20 PM on 3/10/11, revealed she received Resident #101 from CNA #12 and was told to remove Resident #101's pants. CNA #11 recalled seeing a pool of liquid in his lap and vegetables on his left leg. CNA #11 got the assistance of CNA #13 because Resident #101 required a sit-to stand mechanical lift for transfers. CNA #13 stayed with Resident #101 while CNA #12 got the lift, and together they transferred him into bed. CNA #11 approximated the amount of time it took to get the lift and complete transfer was 1 minute. CNA #11 also reported she recalled seeing very, very red areas across Resident #101's thighs and genitals. Licensed Practical Nurse (LPN) #20, the nurse assigned to care for Resident #101 instructed CNA #11 to apply cold compresses every 5 min. for 20 min. CNA #11 reported the reddened areas on Resident #101 subsided except for where the resident eventually developed blisters. Record review of a "Physicians Order", dated 3/8/11, was to apply silver [MEDICATION NAME] 1% cream (topical antimicrobial drug indicated as an adjunct for the prevention and treatment of [REDACTED]. Record review of a "Progress Notes", dated 3/9/11, indicated an order to apply silver [MEDICATION NAME] 1% cream to blisters/red area left and right thigh every day until healed. An observation of Resident #101, on 03/11/11 at 12:20 PM, revealed a 5.5 cm x 1.5 cm reddened area on the right groin, a 9 cm x 4 cm reddened area in his left groin, a 3 cm x 1.75 cm raised blister on the left thigh, a 1 cm x 1.25 cm blister on the left thigh. An interview with Resident #101, on 3/11/11 at 12:20 PM, revealed pain at the site of the burn was a 10 of 10. Resident #101 also indicated he had [MEDICAL CONDITION] his genitals and could [MEDICAL CONDITION] his backside. When asked how long it took to remove the burning soup from his lap from the time he spilled, Resident #101 stated it took 10 min. Review of the Department of Community Health Alert on Scalding Injuries caused by excessive hot water, food, and hot beverage temperatures, dated 11/03/06; revealed water temperature of 150 degrees Fahrenheit takes less than 1 second to receive a second degree burn. ( )

This citation pertains to intake numbers MI 303 & MI 395. Based on observations, interviews, and record review the facility failed to 1), ensure that 4 of 5 residents (#501, #502, #503, and #504) received adequate supervision to prevent falls resulting in a fall for Resident #501 who was found on the floor next to her bed with bruising to right eye area and right arm, for Resident #502 who had two (2) falls in the month of November with one fall resulting in a skin tear in two places, Resident #503 who had seven (7) falls between 9/3/2010 and 11/18/2010 with two (2) of the falls resulting in injury, and Resident #504 who had four (4) falls between 11/16/2010 and 12/11/2010 without injury, and 2) failed to use assistive devices and use assistive devices correctly, to prevent accidents for 2 of 5 residents (#500 and #502) when facility staff failed to use a gait belt while transferring Resident #500 resulting in her falling and receiving a hematoma (blood blister) to her forehead and bruising to her right elbow, and both knees, and Resident #502 who was observed to be transferred with a Sit to Stand (equipment used to assist a resident with standing) and staff did not apply the brakes to prevent the Sit to Stand from rolling while Resident #502 was lifted into a standing position, resulting in a high potential for harm or injury for Resident #502. Findings include: Resident #501: Per the facility face sheet Resident #501 was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the Minimum Data Set ((MDS) dated [DATE] revealed that Resident #501's cognitive skills were moderately impaired, she could make herself understood sometimes, speech was unclear, sometimes understood others, and had impaired vision. The MDS revealed that Resident #501 required a one person assist for transferring and was occasionally incontinent with her bladder and frequently incontinent with her bowels. Record review of an incident report dated 10/25/2010 revealed that Resident #501 was found on the floor in her room. The report revealed that Resident #501's bed was too high for her to transfer herself. The report revealed, "On 10/25/2010 at 7:30 AM (Resident #501) in room found on floor next to bed lying on right side resting on right forearm, right side of head resting on edge of night stand...bed was noted to be raised higher than usual and walker was by closet." The report revealed that Resident #501 received a bruise to her forehead along her right eye area to her hairline, as a result of the fall. The report also revealed that Resident #501 complained of pain in her buttocks region after the fall. Record review of a "Fall/Injury" Care Plan dated 6/17/2010 revealed, under interventions, for assistive devices to be within Resident #501's reach. The Care Plan revealed that Resident #501 was independent with transfers but with a nurse to standby. Record review of Nurses' notes dated 10/25/2010 revealed a notation that only stated, "Zero complaints pain or discomfort from the fall." Vital signs were document on 10/26 through 11/5/2010 but no documentation in regards to the bruising on Resident #501's head or right arm was noted. Staff Member #5, the Unit Manager, was interviewed on 12/28/2010 at 10:51 AM. She said that Resident #501 required staff to catheterize her at times in order to drain her bladder. Staff Member #5 said that on 10/25/2010 Resident #501 was catheterized by Staff Member #9, Resident #501's primary nurse, and the bed was not lowered back into the low position after the procedure. Staff Member #5 also stated that Resident #501's walker was not put back next to her bed and was left by the closet out of Resident #501's reach. She said that Resident #501 required one person to assist her with ambulation. Attempts were made to contact Staff Member #9 on 12/28/2010 at 1:50 PM and 12/29/2010 at 11:55 AM, but were unsuccessful. Record review of an incident report dated 12/12/2010 revealed that Resident #501 was heard yelling and Staff Member #9 found her sitting on the toilet. The incident report revealed that Resident #501 was not able to get up off the toilet. The incident report revealed that a large "scratch" was noted on Resident #501's left hip. The report revealed that Resident #501 was not able to say where the scratch had come from and Staff Member #9 searched the area to identify objects that could have caused the injury but was not able to identify the cause. Observation of a transfer of Resident #501 was conducted on 12/27/2010 at 12:25 PM. Resident #501 was sitting on the side of her bed with her call light on waiting to use the bathroom. The call light was answered within 5 minutes and Staff Member #13 assisted Resident #501 to the bathroom. Resident #501 walked to the bathroom with Staff Member #13 walking with her. After Resident #501 was placed on the toilet Staff Member #13 left her sitting on the toilet alone, told her to put the call light on when she was finished, and left the room. A healing large abrasion was noted on Resident #501's left upper lateral hip area. Record review of Nurses' notes dated 12/12/2010 revealed a notation of the "scratch". The note revealed, "Noted resident sitting on the toilet with a large scratch noted on her left hip area." No other documentation was noted in regards to the large scratch. No notation as to whether Resident #501 was assisted to the bathroom and left on the toilet or if her bed alarm sounded because she got up on her own. Staff Member #5, the Unit Manager, was interviewed on 12/28/2010 at 10:51 AM. She said that Staff Member #9 discovered the large scratch on Resident #501's hip. She said that she could not remember the details and was going to start an investigation of the event, stating that the injury of unknown origin was not reported to the State Agency, as far as Staff Member #5 was aware. Again attempts were made to contact Staff Member #9 which was unsuccessful. Resident #502: Per the facility face sheet Resident #502 was a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of a MDS dated [DATE] revealed Resident #502 did not ambulate and required extensive assistance for transferring. Record review of an incident report dated 11/7/2010 revealed that at 2:00 PM Resident #502 was found sitting beside his bed on the floor. The report revealed that Resident #502 said that he wanted to get back into his chair. The report that Resident #502 did not receive any injuries as a result of the fall and a bed alarm was put into place. The report revealed that Resident #502 was confused. Record review of Nurses' notes revealed no documentation of the fall. Record review of an incident report dated 11/23/2010 revealed that at 10:45 PM Resident #502 was found lying on the floor in his room with his feet sticking out of the door. The report revealed that Resident #502 received a skin tear from the fall. The report also revealed that Resident #502 had been agitated and "yelling out" prior to the fall. Record review of Nurses' notes revealed no documentation of the fall dated 11/23/2010. Observation of a transfer of Resident #502 from his bed to his wheelchair was conducted on 12/28/2010 at 10:00 AM. Staff Members #3 and #14 did the transfer of Resident #502 with a "Sit to Stand" (a piece of equipment that lifts a resident from a sitting position to a standing position) machine. The straps were placed correctly onto Resident #502 and he was lifted to a standing position. During the lift Resident #502 was yelling out to stop. Resident #502 was observed to be much afraid of the lift mechanism. The bed alarm sounded when Resident #502 was off the bed and in a standing position. While Resident #502 was being raised from a sitting position to a standing position and attached to the lift, Staff Member #3 did not lock the brakes on the lift in order to prevent the lift from sliding while lifting Resident #502. The lift was observed moving while Resident #502 was raised up. Staff Members #3 and #14 transferred Resident #502 to his wheelchair. Resident #502 was not sitting properly in his wheelchair and therefore needed a boost in order to be positioned correctly. Staff Member #14 reached around Resident #502's left arm in order to lift him but then said that was his sore arm. Staff Member #3 then stated that she left her gait belt in another resident's room and needed to go retrieve it. Staff Member #3 was asked by the surveyor if the brakes were routinely applied before lifting a resident with the Sit to Stand. Staff Member #3 said, "Yes" usually we do, but today it has been...nerves I guess." Resident #503: Per the facility face sheet Resident #503 was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the MDS dated [DATE] revealed Resident #503 had memory problems, cognitive skills were impaired, required extensive assistance with transfers and was not able to ambulate. Record review of the Care Plan dated 5/4/2010 revealed that Resident #503 had a fall on 9/3, 9/7,10/13, 10/19, 11/15, and 11/19/2010. The Care Plan revealed that the alarm sounded prior to the falls on 11/15 and 11/19/2010. The Care Plan was updated per fall, but revealed that from 4/22/2010 through 11/19/2010 Resident #503 had twenty-two (22) falls. The Care Plan revealed that on 9/9/2010 every 15 minutes checks on Resident #503 were initiated as an intervention. Record review of a "24 hour Resident Flow Record" dated 10/4/2010 revealed that 15 minute checks on Resident #503 were done from 10:15 PM through 10/5/2010 at 6:15 AM. There was no documentation from 6:30 AM until 10:15 PM on 10/5/2010. Another "24 Hour Resident Flow Record" dated 10/10/2010 was reviewed. The record revealed that 15 minute checks were conducted from 10:30 PM beginning 10/9/2010 and stopping at 12:15 AM on 10/10/2010. The record revealed that no checks were documented from 12:30 AM until 3:00 PM on 10/10/2010. The Care Plan revealed that the 15 minutes checks were stopped on 10/10/10. Record review of an incident report dated 9/3/2010 revealed that Resident #503 had a fall and the alarm had sounded; no injury was noted. An incident report dated 9/7/2010 revealed that Resident #504 was found on the floor; no injury was noted. No indication whether the bed alarm had sounded, was noted. An incident report dated 10/13/2010 revealed that Resident #503 was observed sitting on the floor and the alarm had sounded. Resident #503 received a skin tear to her left knee. An incident report dated 10/17/2010 revealed that Resident #503 was on the floor and as a result a seatbelt was applied to her wheelchair. Resident #503 received an approximately 3 centimeter by 1.5 centimeter hematoma (a blood blister) to the left side of her head. The incident report revealed that the seatbelt to Resident #503's wheelchair was not applied before the fall. The report indicated that the mobility alarm sounded. An incident report dated 11/15/2010 revealed that Resident #503 was observed sitting on the floor in front of her wheelchair. The alarm had sounded. No injury was noted. An incident report dated 11/18/2010 revealed that Resident #503 was found on her knees on the floor. The pressure pad alarm had sounded and no injury was noted. The incident report revealed that this was the second fall for Resident #503 that week. Observation of a transfer of Resident #503 was done on 12/28/2010 at 9:45 AM. Staff Member #4 and #15 did the transfer using the Sit to Stand machine. The transfer was conducted correctly. The bed alarm was functioning. Resident #504: Per the facility face sheet Resident #504 was a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the MDS dated [DATE] revealed that Resident #504 had moderately impaired cognitive skills, was sometimes understood and sometimes understood others, required extensive assistance for transfers, and did not ambulate. Record review of a Care Plan dated 5/9/2010 revealed that Resident #504 was to be transferred with the use of a gait belt. The Care Plan revealed that Resident #504 had a fall on 3/7, 3/13, 3/16, 3/21, 5/15, 6/5, 9/17, 9/27, and 12/13/2010. Record review of incident reports revealed that on 11/16/2010 Resident #504 fell , the alarm sounded, and she did not receive an injury. Review of an incident report dated 11/19/2010 revealed that Resident #504 fell , the alarm sounded, and no injury was noted. Review of an incident report dated 11/30/2010 revealed that Resident #504 was found on the floor, the alarm had sounded, and there was no injury noted. Review of an incident report dated 12/11/2010 revealed that Resident #504 fell , the alarm was noted to have sounded, and no injuries were noted. Observation was done on 12/28/2010 at 9:30 AM of Staff Member #3 transferring Resident #504. When Staff Member #3 applied the gait around Resident #504's waist, Resident #504 asked Staff Member #3 what the gait belt was for. Staff Member #3 explained the belt usage to Resident #504. The transfer was done correctly. Resident #504 was asked by the surveyor if the gait belt was routinely used by staff when staff assisted her with transfers. Resident #504 shook her head and said "No". Resident # 500: Per the facility face sheet Resident #500 was a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the MDS dated [DATE] revealed that Resident #500 had severely impaired cognitive skills, required extensive assistance for transfers, and was not ambulatory. Record review of a Care Plan for fall prevention dated 5/28/2010 revealed an intervention for transferring Resident #500 of one person assist with a gait belt. Record review of an incident report dated 11/2/2010 revealed that Staff Member #11 assisted Resident #500 to shower. While transferring Resident #500 from her wheelchair to the shower chair Resident #500 grabbed for the seat handle of the shower chair and then fell . The report revealed that Resident #500 was a one person assist to transfer. The report revealed that while transferring, Resident #500 lost her balance and fell . Resident #500 received a hematoma to her right forehead, bruising to her right elbow and both knees. Staff Member #11, the Certified Nurse Aid (CNA) who cared for Resident #500, was interviewed on 12/28/2010 at 2:00 PM. Staff Member #11 said that she routinely showered Resident #500 and had been for 3 years. Staff Member #11 said that she did not know why Resident #11 fell . She said that she did not use a gait belt to transfer Resident #500. Staff Member #11 said that she did not look at the care card to see how Resident #500 was to be transferred. She said that Resident #500 had been ill and was weaker than usual. Staff Member #11 said that initially she received education about the use of a gait belt, right after the fall occurred, but a month later the incident was investigated and she was terminated. Record review of the "Care Delivery Guide" for Resident #500 dated 5/26/2010 and up- dated 10/23/2010 revealed that Resident #500 was to be transferred with the use of a gait belt. Record review of the facility investigation report dated 12/22/2010 revealed that due to family concern in regards to the fall the facility began an investigation. The report revealed that after an extensive review of the fall, a significant safety violation concerning Staff Member #11 during a transfer of Resident #500 was concluded, and Staff Member #11 was terminated from the facility as a result. The report revealed that Staff Member #11 had Resident #500 stand up from her wheelchair as Staff Member #11 held Resident #500 under her arm. The report revealed that Staff Member #11 intent was to assist to guide Resident #500 from one chair to the other as that was how Staff Member #11 always transferred Resident #500 in the past. The report further revealed that when Resident #500 stood up, Staff Member #11 pivoted Resident #500 to the right and it appeared as though Resident #500 attempted to grab the shower chair arm and fell because the shower chair moved sideways. The report revealed that Staff Member #11 explained that Resident #500 fell on to her right side and struck her head on the toilet. The report revealed that Staff Member #11 stated that she did not use a gait belt while transferring Resident #500 from her wheelchair to the shower chair. The report also revealed that Staff Member #11 did not review the resident Care Guides prior to providing resident care. The report revealed that Staff Member #11 stated, "I always went by what the other CNA ' s told me regarding the residents and their needs. "The report revealed that the shower chair used in the transfer was taken out of the shower in order to replace the wheels with better non-skid type of wheels. The report revealed that Staff Member #11 was aware that the shower chair would slide prior to the fall but had not reported the fact to anyone. The report revealed that Staff Member #11 failed to properly transfer Resident #500 with a gait belt during a stand pivot transfer. Lastly the report revealed that the incident was not report to the State agency nor did Staff Member #11 receive any disciplinary action based on the incident that occurred 11/2/2010 Observation on 12/27/2010 at 1:45 PM revealed an old yellow bruise on the right side of Resident #500's forehead. Observation of a transfer of Resident #500 was conducted on 12/28/2010 at 3:10 PM. The transfer was completed correctly and without complications by Staff Member #16. Resident #500 was observed to have an approximately 6 centimeter green/yellow bruise to her right knee. Staff Member #12, the Director of Nursing (DON), was interviewed on 12/28/2010 at 2:30 PM. He said that at the time of Resident #500's fall he was not in the DON position. Although, he was in the staff education position and did educate Staff Member #11 on the proper use of a gait belt. He said that there had been a lot of falls at the facility. He said that a resident would be on the floor already when the alarm was heard. The DON said that he received 7 fall incident reports in one week. He stated that he would begin education soon. ( )

This citation pertains to intake # Based on observation, interview and record review the facility failed to keep 1 Resident #(101) of 4 sampled Resident free from physical abuse resulting Resident #101 being slapped and pinched by an employee. Findings include: Resident #101 was a [AGE] year old female admitted to the facility on [DATE]. According to her [DIAGNOSES REDACTED]. According to her Minimum Data Set ((MDS) dated [DATE], her cognitive skills for daily decision making were moderately impaired. According to the Facility Incident Report 11-6-2010 under the description it stated, "11-5-2010, 21:00 (9:00 p.m.). Reported by (CNA #1) that (CNA #2) was observed with open hand and hit Resident's (Resident #101) right arm in a loud manner. (CNA #2) also observed grabbing Resident's left cheek in pinching motion. No injury noted to either cheek, right forearm bruising 6 cm x 4.5 cm dark purple, red, brown bruise near wrist, 1.5 cm x 1.3 cm purple bruise near elbow, 1 cm x 1.3 cm red/purple area mid forearm. Staff member suspended per protocol pending investigation. Resident returned to activities of daily living." CNA #1 provided the facility a hand written statement on 11-7-2010 and it reads as follows: On Friday, October 6 th, 2010 (CNA #2) and I were putting (Resident #101) on A-Hall to bed. (Resident #101) was wailing her arms around, and to try and make her stop, (CNA #2) grabbed Resident #101's arm and slapped her about three times as she was telling (Resident #101) to calm down and stop. After we had gotten her ready for bed, (Resident #101) started calling (CNA #2) the "N" word. (CNA #2) got very angry and seemed to have pinched (Resident #101's) cheek quite hard. She did that multiple time to try and make (Resident #101) stop. Then, the nurse came in the room to give medications and (CNA #2) immediately stopped. (CNA #2) did all of it without any second thought or remorse of what she did. She walked away like nothing happened. CNA #2 provided the facility a written statement on 11-6-10 and it reads as follows: "Yesterday, 11-5-10, at approximately 20:00, I was helping (CNA #1) take care of (Resident #101), she did not want to go to the bathroom, so we took her to bed. We wanted to take off her clothes and put on a night gown, she started fighting and kicking me and did not want me to change her. As she was kicking and insulting me, I held her hands and her legs and told her to stop because she was hurting me. She started screaming and calling me names (nigger). I bend down toward her and told her to stop. But she kept on say she will kill me and that I am a nigger. I finally change her clothes and with the help of the other aid got her in bed. Saying that mishandle a resident is not true because I never hit or beat at her. All I did was held her legs when she kicked me." According to the facility five day investigation dated 11-12-2010, the second to last paragraph stated, "Following the completion of this investigation, the allegation of abuse (slapping and pinching (Resident #101's) cheek) cannot be substantiated. It has been determined that the (CNA #2) did not hold (Resident #101's) wrists and legs while attempting to protect herself from being hit or kicked." In an interview with the Director of Nursing (DON), on 11-30-2010, at 10:00 AM, the DON was asked why she did not substantiate abuse of Resident #101. The DON said that CNA #1 did not have a clear view of the incident and later changed her testimony. The DON was asked for a copy of the changed testimony and she said she did not have her write it down because she changed it in her interview. In an interview with CNA #1, on 11-30-2010, at 2:10 PM, CNA #1 was asked what happened when she and CNA #2 were caring for Resident #101 on 11-5-2010. CNA #1 said, she saw CNA #2 slap Resident #101 3 times and pinch her cheek. She went on to explain the events of care like she did in her written statement to the facility on [DATE]. CNA also wrote a more detailed statement of the events of 11-5-2010 during this interview. On 11-30-2010, at 4:45 PM, CNA #1 was asked to demonstrate what she did and saw during her care of Resident #101 on 11-5-10. The surveyor observed CNA #1 act out what happen in Resident #101's room. Residents were not present during the demonstration. The Director of Nursing was present for the Demonstration. The CNA was observed turning on the water at the bathroom sink with the bathroom door open. The foot of the Residents bed was less than 4' from the bathroom door. CNA #1 said when she heard a slapping noise and yelling she stepped into the bathroom door way and she saw CNA #2 holding Residents right wrist with one hand and CNA #2 slapping the Residents right forearm with her other hand. (distance to the head of the bed from the bathroom door was approximately 10' and the bed over head light was on) CNA #1 then stepped up to the right side of the Residents bed and said CNA #2 was right next to her when she said stop. She said, CNA #2 than started pinching the Residents left cheek, then the Medication nurse entered the room and heard Resident #101 calling the CNA #2 the "N" word, so the medication nurse came around the curtain and told the Resident that was not nice. CNA #1 said she and CNA #2 completed Resident #101's care without any other problems after the Medication nurse came into the room. CNA #1 was asked why she did not tell the Medication nurse about the abuses and CNA #1 said she was not sure who she was supposed to report it to. CNA #1 was asked if Residents #101 cheek was red and she said it was at first, but by the end of her care it was not. The Medication nurse was interviewed by telephone on 11-30-2010, at 3:00 PM. The Medication nurse was able to recall Resident #101 using the "N" when CNA #2 was giving care on 11-5-2010. The Medication nurse denied hearing or seeing any abuse on 11-5-2010. CNA #2 was interviewed on 11-30-2010 at 1:05 PM. During the interview CNA #2 had tears in her eyes and said she loves her patients, she denied slapping or pinching Resident #101 during care on 11-5-2010. CNA #2 said she knows now she should have left and got help and that the facility gave her more training to deal with combative patients.