Every finding on record at Medilodge of Sault Ste. Marie

This deficient practice pertains to Intakes 2809637, 3014371, 3014349, 3011210, 3021572, 3021668.Based on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the highest possible level of physical, mental, and psychological well-being for all 73 residents of the facility as evidenced by:Failure to ensure adequate supervision to prevent a resident-to-resident physical altercation.Failure to respond to call lights within an appropriate time frame.Failure to accommodate resident preferences including sleep/wake schedules.Failure to ensure assistance with activities of daily living (ADLs) including toileting and routine incontinence care.Findings include: Review of a facility investigation summary submitted to the State Agency (SA) on 5/11/26 revealed the following: .[On] 5/2/2026 [Certified Nursing Assistant (CNA) A] assigned to D Hall, heard a crying noise coming from [Resident #1 (R1's)] .Upon entering the room staff observed [Resident #2 (R2)] on [R1's] bed. [CNA A] observed [R1] to be tearful with visible markings on her face. At that time [R2] was sitting calmly but refused to leave the room. [CNA A] stayed in the room and called out for help. [Licensed Practical Nurse (LPN) B] entered the room and was able to redirect [R2] out and back to her own room further down the hallway. When asked what happened, [R2] stated, 'She's mean, she's going to get what's coming and she got what she deserved.' [LPN B] then returned to assess [R1]. [LPN B] noted scratches on [R1's] face with blood visible and bruising starting to appear on [R1's] face and hands. When asked what happened, [R1] stated 'she [R2] hit me with the brush, and I asked what was wrong and she slapped me and she squeezed my finger'. [R1] was transferred to ER (emergency room) where she received an evaluation. Review of an Incident Report, dated 5/2/26, written by LPN B read, in part: .Nursing Description: [R2] went into another female resident's room and sat on this resident's bed [R1's] when they were in it and appears/reported (by other resident) attacked the other female [R1]. Resident Description: SHE'S MEAN, SHE'S GOING TO GET WHAT'S COMING AND SHE GOT WHAT SHE DESERVED.Review of a Skin Assessment form, dated 5/2/26, read, in part: .List site(s) of any new abnormal skin areas. right hand (back) - bruising, left hand (back) - bruising, face - bruising-both cheeks and forehead, right lower leg (front) - bruising, left lower leg (front) - bruising, other (specify) - right cheek -abrasion.Review of a Pertinent Charting Follow-Up Change in Condition Form, dated 5/4/26, read, in part: Resident multiple bruising impairment on face, cheeks, forehead and top of her head, bilateral hands and arms and bruising lower extremities. Resident was on the receiving end of a resident-to-resident altercation.On 5/27/2026 at 8:55 AM, R1 was sitting in wheelchair in her room, eating breakfast. A nearly healed, yellow, quarter sized bruise was observed on her central forehead near her hairline. R1 was unable to recall the events related to the physical altercation on 5/2/26.On 5/26/26 at 12:50 PM, a phone interview was conducted with CNA A regarding the physical altercation that occurred on 5/2/26. CNA A stated she was the only aide assigned to D-Hall when she went on break around 4:00 PM. At that time, LPN B was left to supervise the entire hall in addition to her nursing duties. CNA A stated when she returned to the floor at 4:30 PM, she was providing cares and heard crying coming from a few doors down. When she arrived at R1's room, CNA A recalled R1 lying in bed with a large bump on her head and bruising on her face. CNA A remembered there was blood on the bed and R1's collarbone hollow was filled with blood, although she could not determine the source. CNA A stated R2 was sitting on R1's bed and saying, She deserved it. CNA A explained since she was the only aide on D-Hall, she used her cell phone to call the front desk to summon help. When asked how staffing numbers were on 5/2/26, CNA A stated, Really short. CNA A explained there is usually a minimum of two CNAs on D-hall due the number of residents and high clinical acuity of the hall. CNA A stated because she was the only assigned CNA on D-hall there wasn't an extra aide available to cover for her while she went on her scheduled break. CNA A recalled the last time she saw R1 was just before she went on break, around 4:00 PM.On 5/26/26 at 1:09 PM, an interview was conducted with LPN B who verified she responded to CNA A's phone call indicating an altercation had occurred between R1 and R2. LPN B stated upon assessment of R1, she noted bruising on her face and forehead, bruising on her left hand, and a scratch on her face that was bleeding and pooling into her collarbone hollow. LPN B asked R1 what had happened who stated R2 had repeatedly hit her with a hairbrush. When asked the last time LPN B visualized R1 she replied, I don't remember the last time I saw her. it was a day. When queried further, LPN B stated, Staffing was not good that day. LPN B explained there was only one assigned aide on the hall that day and she had been on her lunch break when the event occurred. LPN B stated she was covering the hall so CNA A could take her scheduled break, but it's not possible to complete assigned nursing duties and adequately supervise the hall at the same time.On 5/26/26 at approximately 4:40 PM, an interview was conducted with CNA E who stated she witnessed the aftermath of the resident altercation on 5/2/26. CNA E asserted, We were understaffed that day.On 5/27/26 at 8:24 AM, an interview was conducted with CNA G who recalled observing R1 leaving the facility on a stretcher on 5/2/26. When asked about staffing levels on 5/2/26, CNA G stated, We were short staffed that day. It was a crazy day. CNA G said, It [the altercation] could have been prevented if we had an available aide covering that hall.Review of the nursing schedule on 5/2/25 revealed five CNAs were scheduled for the 6:00 AM - 6:30 PM shift, for a total of 60.3 working hours. The facility census was 75. Three open shifts were highlighted and marked with a star and left blank.On 5/27/26 at 11:02 AM, an interview was conducted with Scheduler/Staff Q who verified she was responsible for scheduling both nurses and nursing assistants. Staff Q stated the day shift (6:00 AM - 6:30 PM) is supposed to be staffed with 8 CNAs, while night shift (6:00 PM - 6:00 AM) is supposed to be staffed with 5 CNAs for a sum of 98 and 60 total working hours, respectively. Staff Q verified day staff on 5/2/26 was short 3 CNAs as she was unable to fill the highlighted blanks on the schedule.Review of the Facility Assessment, reviewed 4/28/26, read, in part: Staffing Plan.Day Shift: 8-10 C.N.A.s.Midnight Shift: 5-6 CNAs.Review of the day shift schedules between 3/10/26 and 5/25/26 revealed 39 days (51.3% of all shifts) when total CNA working hours were fewer than eight CNAs (98 total working hours) as outlined in the Facility Assessment.3/10/26 - 91.60 total hours - 79 census3/13/26 - 72.70 total hours - 77 census3/15/26 - 87.30 total hours - 76 census3/16/26 - 94.10 total hours - 75 census3/17/26 - 92.40 total hours - 74 census3/19/26 - 80.0 total hours - 73 census3/20/26 - 91.50 total hours - 73 census3/21/26 - 75.50 total hours - 74 census3/25/26 - 90.80 total hours - 75 census3/29/26 - 82.60 total hours - 76 census4/4/26 - 70.10 total hours - 75 census4/5/26 - 72.60 total hours - 74 census4/8/26 - 95.40 total hours - 73 census4/9/26 - 87.80 total hours - 74 census4/10/26 - 84.50 total hours - 73 census4/12/26 - 84.40 total hours - 71 census4/14/26 - 82.80 total hours - 71 census4/17/26 - 85.20 total hours - 71 census4/18/26 - 68.50 total hours - 73 census4/19/26 - 65.30 total hours - 73 census4/20/26 - 93.10 total hours - 73 census4/23/26 - 64.40 total hours - 73 census4/24/26 - 74.40 total hours - 75 census4/25/26 - 94.40 total hours - 75 census 4/26/26 - 90.70 total hours - 74 census4/27/26 - 85.20 total hours - 74 census4/29/26 - 93.90 total hours - 74 census5/1/26 - 71.90 total hours - 75 census5/2/26 - 60.30 total hours - 76 census5/3/26 - 61.10 total hours - 74 census5/4/26 - 93.40 total hours - 75 census5/8/26 - 86.80 total hours - 76 census5/9/26 - 94.40 total hours - 77 census5/10/26 - 74.90 total hours - 77 census5/11/26 - 92.30 total hours - 77 census5/16/26 - 88.26 total hours - 76 census5/18/26 - 88.10 total hours - 75 census5/23/26 - 83.00 total hours - 72 census5/24/26 - 91.60 total hours - 73 censusReview of the night shift schedules between 3/10/26 and 5/25/26 revealed 20 days (26.3% of all shifts) when total CNA working hours were fewer than five CNAs (60 total working hours) as outlined in the Facility Assessment.3/15/26 - 52.8 total hours - 76 census3/16/26 - 44.20 total hours - 75 census3/17/26 - 57.40 total hours - 74 census4/2/26 - 56.30 total hours - 74 census4/6/26 - 50.80 total hours - 74 census4/7/26 - 59.00 total hours - 73 census4/13/26 - 57.40 total hours - 73 census4/16/26 - 47.30 total hours - 71 census4/17/26 - 53.40 total hours - 71 census4/23/26 - 56.70 total hours - 73 census4/24/26 - 55.30 total hours - 75 census4/25/26 - 58.80 total hours - 75 census5/1/26 - 57.70 total hours - 75 census5/2/26 - 58.50 total hours - 76 census5/5/26 - 53.80 total hours - 76 census5/9/26 - 58.90 total hours - 77 census5/14/26 - 47.80 total hours - 77 census5/15/26 - 48.20 total hours - 76 census5/24/26 - 47.80 total hours - 73 census5/25/26 - 42.20 total hours - 72 censusReview of a complaint submitted to the SA on 5/8/26, read, in part: I put my call light on to get turned and boosted in my bed and no one ever comes. I wait for hours sometimes to even see a person. I am unable to get out of bed or turn in bed myself. This happens a lot on the night shift but also happens a lot on the other shifts as well.On 5/27/26 at 5:45 AM, this surveyor arrived at the facility and observed a total of 3 CNAs. Registered Nurse (RN) M confirmed only 3 CNAs worked the midnight shift (6:00 PM - 6:30 AM) with a census of 76 residents. RN M expressed her continued frustration stating the facility continues to schedule just 3-4 CNAs on the night shift.On 5/27/26 at 6:05 AM, an interview was conducted with CNA K who stated she was responsible for the cares on two halls because there was only 3 CNAs scheduled on the night shift. Three call lights were observed illuminated on one of CNA K's designated halls. CNA K stated, It's after 6 [AM] and I still have 3 residents to get up. I have done zero charting, and I'm supposed to be done at 6:00 AM. I was behind on check and changes (incontinence care) all night.On 5/27/26 at 6:15 AM, an interview was conducted with CNA L who had just finished working the midnight shift. When asked how her shift went, CNA L stated, It was horrendous, it was horrible. There were only 3 of us [CNAs]. The last three nights in a row there have only been three of us. I can't possibly get to everybody. CNA L verified residents endured longer call light wait times and incontinent residents waited longer for brief changes.On 5/27/26 at 6:17 AM, Resident #7 (R7) was observed sleeping in his wheelchair at the nurses' station.On 5/27/26 at 6:43 AM, an interview was conducted with R7 while he was being loaded into the facility transport vehicle. R7 indicated he had been sleeping at the nursing circle since 4:30 AM which happens three times per week on the days he has to go to dialysis appointments. R7 stated the aides are forced to get him up at 4:30 AM to ensure he will be on time for his dialysis appointment due to the lack of staff. R7 stated he could be sleeping in bed rather than sleeping in his wheelchair for two extra hours.On 5/27/26 at 6:45 AM, and interview was conducted with Transport Driver/Staff I who verified R7 frequently sleeps in his wheelchair for hours prior to leaving for his dialysis appointments. Staff I indicated R7 often complains of being woken up too early.On 5/27/26 at 7:42 AM, an interview was conducted with Resident #8 (R8) who was observed sitting in a recliner in her room. When R8 was queried about the care she received at the facility, she replied, Staffing is one big problem, and it is a BIG one. You wait and you wait and you wait. When R8 asked if the staffing shortage affects her care, she replied, Just the other night I had to sit here for more than 30 minutes waiting to go to the bathroom. I was actually hurting I had to go so bad.On 5/26/26 at 1:46 PM, an interview was conducted with Family Member (FM) C who voiced their concerns regarding staffing shortages at the facility. FM C stated they try to visit their loved one every evening because they are uncertain their loved one will receive the care they need. FM C stated they often provide incontinence care and prepare their loved one for bed or else they end up waiting an extended period waiting for an available aide.Review of Resident Council Meeting Minutes from 3/10/26 to present day read, in part:5/16/26: Old Business: D Hall call light wait times at night have not improved. 30-45-minute wait. New Business: D Hall call light wait times 30-45 minutes at night.4/30/26: Old Business: D hall night call wait times continue being an issue .4/23/26: Old Business: D hall call light wait times continue to be an issue.4/16/26: New Business: D-Hall call light wait times 30-45 minutes. [resident] has concerns about facility, has overworked nurses, they have to work multiple halls.On 5/27/26 at 11:55 AM, an interview was conducted with interim Nursing Home Administration (NHA) who acknowledged low staffing concerns at the facility.

This citation pertains to Intake 2702621.Based on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the highest possible level of physical, mental, and psychological well-being for all 86 residents of the facility as evidenced by:Failure to ensure assistance with activities of daily living (ADLs) including routine incontinence care, bathing, shaving, turning and repositioning, and feeding.Failure to accommodate resident preferences including sleep/wake schedules, treatment times, and physical location within the facility.Failure to ensure a timely, dignified, and palatable meal service.Failure to maintain a restorative therapy program.Failure to respond to call lights within an appropriate time frame.These deficient practices resulted in harm when:Residents #4, #93, and #75 were forced to lay in her own excrement and urine for an extended period resulting in reported feelings of frustration, helplessness, humiliation, and anger and/or inference of these feelings based on the reasonable person concept.Resident #10 was forced to lay in bed for an extended period resulting in excruciating pain.Resident #91 experienced ongoing feelings of fear and panic following lack of staff response for over two hours after activation of a call light.Findings include:During an interview on 2/8/26 at 3:26 p.m., Licensed Practical Nurse (LPN) X reported There are never enough Certified Nurse Aides (CNA's) and they work short all the time. Resident #15 (R15) During an interview on 2/8/26 at 3:26 p.m., R15 stated I am scared to be here due to the lack of staffing. There are times when I can't reach my call light. What if I need some help and no one is here to help me. I don't want to die. I am petrified every day because I worry there will be no one to help me. During an interview on 2/10/26 at 2:23 p.m., CNA F reported Staffing here is awful, there are times when we can't take care of the residents. They don't get the care they deserve and they are being neglected. I was so glad when you came in on Sunday and we only had three CNAs. That is what it is like all the time. The management are never out here helping us. If people call in, they don't replace that person. The residents deserve better. We try to reposition people every two hours but with the lack of staff it is not possible. Resident #4 During an observation and interview on 2/8/26 at 2:27 p.m., prior to entering R4's room the smell of urine and feces emanated out into the hallway. R4 asked for the door to be closed. The smell of urine and feces permeated the room. Feces was noted on the pillowcase, and sheet that was partially covering R4. Feces was smeared on the fitted sheet and the fitted sheet was not around the mattress, as feces was noted on the mattress. R4's hands were lying on the top of a sheet with brown matter under her fingernails and on her hands. R4 reported she had not gotten out of bed yet today. R4 was visibly shivering. During an observation and interview on 2/8/26 at 2:48 p.m., R4 was yelling out for help while visibly shaking and reported, I am soaking wet.I wish someone would come and change me.I am so cold. During an observation on 2/8/26 at 2:56 p.m., R4 was yelling from her room, Please help me, Oh God please! with no staff visible in the hall. During an observation on 2/8/26 at 3:11 p.m., LPN/Unit Manager W walked into R4's room and quickly exited. LPN W said out loud to herself [Residents name] wants to get up. LPN W continued to walk down the hallway and did not return to assist resident. During an observation on 2/8/26 at 3:16 p.m., R4 continued yelling Nurse please help me. During an interview on 2/8/26 at 3:18 p.m., CNA L was queried about R4 and when she last received care. CNA L reported I honestly couldn't tell you. During an observation and interview on 2/9/26 at 4:20 p.m. R4 was yelling for help from her room. Upon entering her room, the smell of urine permeated the room. R4 was shivering in her bed. R4 stated I am so cold, I am so full of piss and I am so wet.would you please come and help me? I told that little nurse and she has not come in to help me. R4 had tears [NAME] up in her eyes and coming down her cheeks and stated, I am so tired of not being cared for, they don't take care of me here. I am from this town and I want to get the hell out of this place. I don't want to be here. I don't want to die here like this. During an interview on 2/9/26 at 4:28 p.m., the Senior Director of Nursing (DON) CC and the Director of Nursing (DON) were notified of R4 yelling for help. During an interview on 2/11/26 at 9:38 a.m., the Nursing Home Administrator (NHA) acknowledged concern regarding resident sitting in urine, feces, and shivering and the need for nursing care for resident. Review of policy titled Abuse, Neglect, and Exploitation date reviewed/revised 1/10/24, read in part .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. Resident #91 (R91) The facesheet for R91 had an original admission to the facility on 2/6/26. According to R91's Minimum Data Set (MDS) dated [DATE], a Brief Interview for Mental Status (BIMS) score of 15/15 indicated R91 was cognitively intact. On 2/8/26 at 2:33 PM, R91 provided a notebook where she had been writing about her experience at the facility since her admission on [DATE] at approximately 6:20 PM. R91 had written she was told dinner was on the way and at 7:15 PM still did not get dinner on 2/7/26. During her arrival staff scurried in, did a few things and flew back out of her room. R91 stated, I had no idea what was happening with the staff and there I was just lying in bed. No vital signs were taken at the time of my admission, no blood pressure, no assessment or anything else. I needed pillows to elevate my legs to prevent bed sores and reduce swelling. I just sat there in total silence. R91 made a note she had put her call light on during Friday night and it was on for quite a spell. R91 noted that no staff came for quite some time and she was scared and upset over having to stay at the facility. R91 laid in bed wondering if something happened at the facility. R91 was unable to move because of the recently broken leg she was admitted to the facility with. R91 felt helpless as her call light continued to be on without being answered. R91 then got her cell phone out and looked up the phone number to the facility after she thought about calling the police. R91 called the facility, the phone was answered but not by staff. R91 stated, The facility phone had been answered by a resident was living at the facility. I could not believe another resident had answered the phone. It was a female resident who remarked 'it's for you' and the phone was handed over to a male resident, who promptly asked 'who is this?'. That was the last straw! I was completely thrown off guard and lost it. I really thought there was an emergency somewhere in the building or it had been taken over! What a mess! Finally, a female staff came to my room, and I told her what had just happened with the phone and the female staff person just looked at me with a blank look. I gave the female staff a chance to answer me and the staff finally said 'wow, I could not make that story up if I wanted to.' I agreed. I put my call light on in the early morning of 2/9/26 at approximately 2:00 AM and it was not answered until 55 minutes later to help me to the bathroom. During an interview on 2/9/2026 at 11:00 AM, R91 was observed in her bed and said, I got here Friday and Saturday I did not get any lunch and today (2/8/26) I did not get breakfast. It is now lunch time. I am not even sure I will get lunch. They treat animals at the zoo better than this! R91 voiced concerns with long call light wait times 1.5 to 2 hours, low staffing, and not seeing any staff for extended periods of time. R91 stated she needed ice for her surgical wound on her right leg after falling a fracturing it at home and no staff brought her ice. Resident #93 (R93) The facesheet for R93 had an original admission to the facility on 1/29/26 with diagnoses including fracture of the left tibia/fibula (both of the lower leg bones were broken). According to R93's MDS dated [DATE], a BIMS score of 15/15 indicated R93 was cognitively intact. R93 was evaluated as dependent on staff for bathing, requiring the assistance of two staff personnel, and for toileting was a one-person assist. During an interview on 2/9/26 at 12:10 PM, R93 voiced, yesterday morning she had been left wet and soiled in her urine and fecal matter for an extended period of time that lasted over two hours. R93 described the experience as mortifying and it felt nasty. On 2/10/26 at 2:15 PM, an interview was conducted with R93 and was asked about personal hygiene and replied, I have not received a shower since I got here, and I have been here for two weeks. The staff hardly get me up in my chair. R93 was observed at the time to have disheveled hair. R93's preferences for customary routine and activities, dated 1/29/26 revealed it was very important to her to be able to choose between a tub bath, shower, bed bath, or sponge bath and chose to have showers. On 2/9/26 at 8:55 AM, an interview was conducted with CNA V, who was asked if R93 had received any showers since being admitted to the facility on [DATE] and replied, No, I do not have any shower sheets for her. Her (R93) shower days are Wednesday and Saturday. A lot of the times no showers are completed on Saturday because of call-ins. R93's task list for showers dated 1/29/26 through 2/10/26 were reviewed and revealed R93 did not receive a shower on 1/31/26 (Saturday), 2/4/26 (Wednesday), or 2/7/26 (Saturday). Resident #10 (R10) According to the medical record, R10 was admitted on [DATE] with diagnoses including spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy characterized by extreme muscle stiffness and poor motor control in all four limbs and trunk), need for assistance with personal care, major depressive disorder and chronic pain syndrome. R10's MDS dated [DATE] contained a BIMS score of 15 of 15, indicating intact cognition. R10's functional status assessment revealed substantial assistance from staff to roll right or left, total dependence on staff to sit from lying down and total dependence on staff to transfer to and from a bed to a chair (or wheelchair). On 2/8/2026 at 2:34 PM, a sign was observed on the outside of R10's door which read, Please wake up by 1 PM. The room was dark and R10 was lying awake in bed. R10 stated, No one has been in yet. I like to get up by 1 (PM) and it is now 2:35 [PM]. During an interview on 2/9/2026 at 2:00 PM, R10 confirmed her desire to get up by 1:00 PM. She stated again she was not up until way after 1:00 today. She said she felt it was because there were not enough staff to help the residents. R10 said, They need more help here. R10 said it was very frustrating that almost every weekend there was not enough staff to provide care. When asked if she had told anyone her concerns, she stated she had told management multiple times, but nothing had changed. During a telephone interview on 2/9/2026 at 3:18 PM, CNA R said, I feel really terrible but there were not enough people to provide quality care yesterday. She repeated, I feel really bad. CNA R said R10 was supposed to get up by 1:00 and she did not get up until 3 yesterday. CNA R said, She needs two people to get her up and going and there were only 4 CNAs in the building so we could not get to her. The observed workload for 2/9/26 revealed one of the four CNAs was assigned to care for one resident at all times so the remaining three CNAs were responsible for the other 85 residents. The grievance log was reviewed and R10 had submitted multiple grievances to the facility to alert them of her staffing concerns. On 10/28/25 R10 submitted a type-written grievance to the facility. It read: My concerns: Not having enough staff & having nurses toilet me and put me to bed Not having enough staff in general for example today I'm sleeping in my wheelchair because after 10am there are only 3 certified aides & you can be the best aide but it's hard to take care of so many residents & I have minimal pain in my wheelchair. Just recently I didn't get up until 4pm & got a blister now I can't say it's all from that but I bet it's a factor. Here's what I heard happened that day, the aide was going to get me up at 1:30pm the nurse told them to wait because the nurse wanted to go to lunch & then the hall got really busy & by the time they got to me it was 4pm. My pain level by then was a 9 & I was asked why I didn't hit the call light, well because I was sleeping because when I'm in pain I don't' cry I sleep I like to say it's a kin to passing out. That's why I need to be woken up. Some aides don't wake me up between 1pm & 2pm Some aides don't help out other aides Some aides don't ask for help. The facility response to this grievance: Findings: Resident states staff is not adhering to her wake up times and schedule. See attached letter Plan/Actions: Ensure that staff adheres to wake up times and schedule Describe: We have 6 new CNA's on the floor. Educated staff on wake up times On 1/6/2026 R10 submitted a type-written grievance to the staff during her care conference. It read: To whom it may concern; On Saturday December 27th the nurse asked me if I could wait until they (nurse & aide) went to lunch & I said NO because it was already after 2pm now they were short staffed & apparently the aide could not find help right then. But that doesn't mean that they can just go ahead and go to lunch anyway at least not without asking another aide to get me up while they are gone. I didn't get up until after 3pm and I was in a lot of pain because of it. I don't know if the aide needs better time management or something else but I can't lay in bed for like 10 hours my butt and back hurt. They can even get me up as early as 10 am and I will nap in my wheelchair as long as I'm not in bed for that long I'm good. I'm flexible but only up to a point. So please take care of this thank you, (signed R10) Resident #83 (R83) On 2/8/2026 at 2:50 PM, an observation of R83 revealed she was sitting in a reclined position in bed with her meal tray in front of her. R83 said she had just finished lunch and was fed by staff. When asked about her left contracted hand, R83 stated the staff do not work with her on it, and she is supposed to have a brace on but it is the weekend, so nothing is happening. On 2/10/2026 at 12:37 PM, R83 stated she was not getting restorative therapy and had not had it for a long time. R83 stated she was supposed to have a splint for her hand, and she needed assistance putting it on. R83 said, They (staff) do not put it on enough. During an interview on 2/10/2026 at 12:34 PM, CNA TT stated, the Restorative Aide put on the splints and did the restorative programs. CNA TT said, The CNAs do not do restorative unless we have time, and we don't usually have time. During an interview on 2/10/2026 at 12:36 PM, CNA J said there was a Restorative Aide who did Restorative. CNA J said, the CNAs did not do Restorative. According to the medical record, R83 was admitted on [DATE] with medical diagnoses including quadriplegia (paralysis affecting all four limbs and the torso), anoxic brain damage (damage from a shortage of oxygen to the brain), and need for assistance with personal care. R83's Minimum Data Set (MDS) dated [DATE] contained a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating intact cognition. R83's functional status assessment revealed total dependence from staff to roll right or left, total dependence of staff to lie down from sitting, and total dependence on staff to sit from lying down. Section O of the MDS also noted in the last 7 calendar days only one day had at least 15 minutes of passive range of motion (ROM) recorded and one day of splint or brace assistance. The medical record included the CNA task list for documentation of treatment as given. The most recent 14-day period was reviewed. For the task: Maintenance Restorative Nursing: Splint/Brace Assistance (12h) [NAME] palm protector splint to left hand for 3-4 hours of wear time. Check skin after doffing for redness or irritation. There were only two days when brace toleration was documented. All other days were documented as Did not occur. During an interview on 2/10/2026 at 12:58 PM, the Director of the Therapy Department/ Staff UU described the interaction between the therapy department and the nursing department. Staff UU reviewed her documentation and stated R83 was on the restorative list. During an interview on 2/10/2026 at 1:20 PM, Senior DON CC stated the facility was reorganizing their staff. DON CC said, We just got people in their roles in the past six months. We do not have a Restorative Nurse yet only a Restorative Aide. The Restorative Aide position was explained as a Monday – Friday position. DON CC stated the restorative program should be happening 7 days a week. When asked about the Restorative Aide, DON CC stated she currently had a medical incident and could not work. When asked who completed the restorative tasks on the weekend or when the current Restorative Aide was off, DON CC replied No one. Resident #75 (R75) Review of the MDS assessment, dated 1/20/2026, revealed R75 was admitted to the facility on [DATE] and had diagnoses including osteoarthritis, presence of an artificial knee joint and difficulty in walking. Further review revealed R75 required substantial/maximal assistance with transfers and was dependent on staff for toileting hygiene. R75 scored 12 out of 15 on the BIMS, indicating moderate cognitive impairment. On 2/08/2026 at 12:35 p.m., revealed LPN W was observed entering R75's room to assist the Resident's roommate. R75 was heard asking LPN W for assistance in getting cleaned up and out of bed for the day. LPN W informed R75 that she would attempt to find an aide to assist R75 and proceeded to leave the room. At that time, R75 was observed seated in bed wearing pajamas. A clean brief and clean clothing were observed to be folded atop the end of the Resident's bed. R75 reported she liked to be up in her wheelchair for the day and added, But I'm heavy and hard to get up. When asked if her brief was dry or if she needed assistance with incontinence care, R75 was observed reaching under the blanket to check her brief, then stated oh, well, yes, they will come eventually. During the observation, LPN W re-entered R75's room with a meal tray. After setting up the meal tray on an overbed table and placing it in front of R75, LPN W told the Resident, After you're done, we will come get you up and dressed. No incontinence care was offered or completed at the time of the observation. On 2/08/2026 at 1:12 p.m., CNA WW and CNA L were observed entering R75's room to assist the Resident with cares. When asked if it was normal practice to wait until after lunch to assist residents with morning cares, CNA L reported she came in a 6:00 a.m. that morning and the facility had a no call no show, one person quit and one person was placed on the scheduled in spite of her being on approved PTO [vacation time] this weekend. CNA L reported she called CNA WW and asked if she could pick up some hours to help out. CNA WW reported she arrived at the facility that morning at 10:00 a.m. Both CNAs reported they had to help in the dining room for meals so when survey team showed up, they were nervous because they knew they would not be able to answer call lights. Review of the Payroll Based Journal (PBJ) Data Report for Quarter 4, 2025 (July 1 – September 30) revealed the facility triggered for excessively low weekend staffing in the given timeframe. Review of a complaint submitted to the State Agency (SA) on 12/29/25 read, in part: .The safety of the staff and residents are progressively becoming more dangerous. From morning to nights there is never enough staff from the halls to the dining area. many incidents have occurred from falls to medical emergency's [sic] and there was no one to assist. A lot of the residents sit in their own stool and urine for hours on end throughout the day due to inadequate care from employees and staffing shortages all day. For many months I have worked 1 CNA [certified nurse aide] to 30 residents a hall due to inadequate staffing measures. Residents that require assistance into assisting devices I.E. wheelchairs using a lift are more times enforced [sic] into their rooms during dining times because it is easier than assisting them into the dining area for mealtimes or encouraging daily living activities. There are always residents sleeping in their assistant [sic] devices within the activity room, cafeteria, and halls through the night because staff just gives up encouraging them to their rooms or they are left there by other staff members until the very last minute of their shift or just never went to bed at all. I have had to assist residents who were left by other staff members covered in their own feces that they stepped in on the floor. if you go in to do a routine change you will find many of the residents get left with stool and urine all over them. On 2/9/26 at 2:00 PM, a confidential group interview was conducted where eight residents stated the facility had ongoing low-staffing issues. One Confidential Resident (CR) stated, They need more staff. A lot of times there's one CNA per hall. They're short [on staff]. Another CR indicated, I can't remember the last time we had enough staff. We get that as an excuse a lot: 'I can't help you right now because we don't have the staff.' I've waited over an hour [for a call light to be answered]. Usually about a half hour or more is standard [amount of time for a call light to be answered]. Yet another CR stated they consistently waited more than 30 minutes after engaging their call light. One CR revealed they had bought hairnets online to assist delivering meal trays due to ongoing staffing problems and were upset when the facility would not allow it. The CR indicated they frequently noticed meal trays stacking up in the service window because there aren't enough staff to deliver them timely. The CR stated, I feel bad for the other residents [waiting for food], I just want to help deliver trays. Review of Resident Council Meeting Minutes since March 2025 read, in part: 3/20/25: .New Business – Concerns/Complaints/Grievances: .residents stating meal times are not consistent. Weekends especially; all meals starting about 45 minutes late. Resident stating call light times are a problem. stating they know it's cause of staffing issues. 4/17/25: .List of old business (unresolved): C-hall call light times. 5/15/25: .New Business – Concerns/Complaints/Grievances: call lights are an issue down A hall at night. 6/19/25: .List of old business (unresolved): call light wait times remain an issue. New Business – Concerns/Complaints/Grievances: .Meal times inconsistent. Weekends (dinner especially). 7/17/25: .List of old business (unresolved): Meal times on weekends still inconsistent. 8/29/25: .List of old business (unresolved): meal times on weekends still a problem. Every meal late. 10/16/25: .New Business – Concerns/Complaints/Grievances: Residents stating meal times are late. State it's most meals. Dinner seems to be the biggest problem. 11/20/25: .List of old business (unresolved): Meal times being late. sometimes 30 minutes late. New Business – Concerns/Complaints/Grievances: .meal times continue being late. 1/15/26: .New Business – Concerns/Complaints/Grievances: Meals not starting on time. Residents state kitchen are [sic] shorthanded and CNAs to pass trays. On 2/11/26 at 8:05 AM, an interview was conducted with Activities Director/Staff KK regarding the repeated staffing/call light and untimely meal services issues that came up monthly in resident council meetings. Staff KK stated she brings these concerns up to management via a Quality Assistance Form after every meeting. When asked the response she receives from management after submission of the form, Staff KK responded, They [management] tell me we [facility] meet staffing guidelines. Staff KK stated she had to move the BINGO activity from mornings at 10:00 AM to the afternoons because some dependent residents were not receiving assistance in time to get out of bed to attend the activity. On 2/11/26 at 8:15 AM, an interview was conducted with Dietary Manager (DM/Staff) C regarding repeated issues with timely meal service. Staff C stated the food is prepared and ready to be served on trays at the established mealtimes, but the facility is lacking the staff to deliver them in a timely manner. Staff C stated trays will pile up in the meal service window or sit in the mobile food delivery carts for extensive periods of time due to the unavailability of staff. Review of Quality Assistance Forms submitted to the facility NHA revealed 15 grievances related to low staffing concerns since June 2025 which read, in part: 6/10/25: My mother needs assistance getting on + [and] off the toilet, I am very concerned about 1 aide being on the floor, when she rings for help, there is never any on around when she needs help. I don't like being told that 'I will get to her when I can'. this needs to be addressed. 6/11/25: On 6/10/25 night shift resident had her call light on for over an hour (she timed the staff with phone). Staff would not answer her light. 7/16/25: 3 full urinals when breakfast delivered. He stated 'they are not checking on me.' Previous day, no water brought to him. 7/25/25: Resident reported not seeing a CNA in her room until 4 PM. Reports not being checked on unless using call light. 8/25/25: Call light on over 45 minutes. 9/27/25: Resident stated that aide did not let her stay in bed after lunch per her per preference. Stated aide told her that there were not enough staff to keep getting her in and out of bed. 10/1/25: Resident voiced to CNA that she was tired and that she hadn't been put to bed until 2 AM last night. Resident said that she had been asking to go to bed for hours. 10/13/15: DPOA [durable power of attorney] states very long call light times, especially at night. States she has had to come up here [to the facility] in the middle of night to toilet or change her mother. 10/15/25: Resident says he hasn't gotten out of bed in 4-5 days. Feels like he is being ignored. Staff tell him they will come back to help, but never do. 10/21/25: Concerns about staffing on D-wing, feel she should not have to stay late taking care of her mom. Is worried that she will not get the care she needs. 10/28/25: My concerns: Not having enough staff. for example today I'm sleeping in my wheelchair because after 10 AM they're only 3 certified aides. just recently I didn't get up [out of bed] until 4 PM. 11/18/25: Spoke with family here [sic] are their concern: soars [sic] on coccyx. Redness between his legs. Personal hygiene not being done in the evens [evenings]. Long wait time at night after turning on call light. 11/19/25: Resident reported that this morning, aids came into room to change roommates diaper, waking her up. Resident was wet, and was not checked on, turned on call light, and sat for an hour in urine soaked clothes. Resident feels neglected. 12/3/25: Dec [December] 2nd I asked the CNA if they could put my dad to bed at 6:50 PM. The other CNA told me they would be right there. They finally showed up at 7:45 [PM] to take him to the bathroom. in bed at 8:20 PM. 1/6/25: On Saturday December 27th the nurse asked me if I could wait [to get out of bed] until they (nurse & aide) went to lunch & I said NO because it was already after 2pm now they were short staffed & apparently the aide could not find help right then. I didn't get up until at 3 PM and was in a lot of pain because of it. I can't lay in bed for like 10 hours my butt & back hurt. The Plan/Action box on the Quality Assistance Forms contained the following written responses as solutions: staff education (9 times), developed plan for call-ins (1), moved resident room (1), higher priority resident needed help more (1), the facility has adequate staff (1), resident happy with care (1), left blank (1). Ten out of 15 forms were marked as resolved. Five out of 15 forms were left blank in the resolution section (neither 'yes' or 'no' had been selected). Review of a document titled, Caring Partner Concerns/Comments, dated 6/20/25, read, in part: He [resident] states he turns his call light on because he has to be changed [into a clean brief]. CNA comes in and turns light off and leaves room. Says they leave him laying in [expletive]. No resolution was found in relation to this concern. Review of the Facility Assessment, reviewed 9/16/25, revealed an average daily census of 72, ranging from a minimum 64 residents to a maximum of 78 residents. Review of census numbers from 10/1/25 – 2/11/26 revealed 90 days the facility census exceeded the maximum census (78 residents) outlined by the facility assessment. The highest census during this timeframe was 87 residents on 2/6/26. Further review of the facility assessment revealed 35.5% and 34.1% of resident admissions and discharges, respectively, occurred on Friday-Sunday. Review of night shift (6:00 PM – 6:00 AM) schedules between Friday-Sunday from 7/1/26 – 9/30/26 (quarter 3), revealed 17 days when 4 or fewer CNAs were working when a census ranged between 73-82 residents: 7/4/25: 3.5 CNAs – census of 75 7/5/25: 4.12 CNAs – census of 75 8/29/25: 4 CNAs - census of 73 8/31/25:

This citation pertains to intake 2702621Based on observation, interview, and record review the facility failed to provide routine incontinence care for one Resident #4 (R4) of two residents reviewed for incontinence care. This deficient practice resulted in harm including anger, frustration, helplessness, and sadness based on the reasonable person concept.Findings include: On 2/8/2026 at 1:55 PM a foul odor was noted while standing near the doorway of R4's room and R4 could be heard calling out Nurse? Nurse? Upon entering R4's room, R4 was observed lying in a fetal position in bed with her bottom sheet pulled off the mattress and gathered around her and a top sheet draped over her torso and lower body. Upon approaching the bed, an overpowering smell of urine and feces was noted. R4 reported she was waiting for staff to come assist her to clean up. R4 reported she was cold and stated, I peed myself. R4 was asked if she had used her call light to call for assistance, which was observed to be attached to the left upper grab bar of her bed. At 1:57 PM R4 was observed to push the red call button to activate a call for assistance. Upon immediately exiting R4's room, it was noted the light above R4's door was lit, indicating activation of the call light. While this surveyor remained directly outside R4's room, an unidentified male staff person was observed entering R4's room. R4 was heard informing the staff person of her need to be cleaned up and that she was cold. The male staff person deactivated R4's call light as indicated by the light above her door being turned off and was heard telling R4, let me see if I can get an aide for you. The male staff person then immediately left R4's room and travelled toward the nurse's station at the end of the hallway. Further observation from the hall outside R4's room, revealed no staff entered R4's room and at 2:26 p.m. R4 was heard calling out, Nurse? Nurse? Upon re-entering R4's room it was noted the smell of urine and feces remained and R4 was observed lying in bed with her bottom sheet gathered around her and the top sheet draped over her torso and lower body. R4 was asked if anyone had come to assist her to which she answered no and further reported, I'm so cold. It was noted 29 minutes had elapsed from the time R4 activated her call light at 1:57 p.m. During an observation and interview on 2/8/26 at 2:27 p.m., prior to entering R4's room the smell of urine and feces emanated out into the hallway. R4 asked for the door to be closed. The smell of urine and feces permeated the room. Feces was noted on the pillowcase, and sheet that was partially covering R4. Feces was smeared on the fitted sheet and the fitted sheet was not around the mattress, as feces was noted on the mattress. R4's hands were lying on the top of a sheet with brown matter under her fingernails and on her hands. R4 reported she had not gotten out of bed yet today. R4 was visibly shivering. During an observation and interview on 2/8/26 at 2:48 p.m., R4 was yelling out for help while visibly shaking and reported, I am soaking wet.I wish someone would come and change me.I am so cold. During an observation on 2/8/26 at 2:56 p.m., R4 was yelling from her room, Please help me, Oh God please! with no staff visible in the hall. During an observation on 2/8/26 at 3:11 p.m., Licensed Practical Nurse (LPN)/Unit Manager W walked into R4's room and quickly exited. LPN/Unit Manager W and said out loud to herself [Residents name] wants to get up. LPN/Unit Manager W continued to walk down the hallway and did not return to assist resident. During an observation on 2/8/26 at 3:16 p.m., R4 continued yelling Nurse please help me. During an interview on 2/8/26 at 3:18 p.m., Certified Nurse Aide (CNA) L was queried about R4 and when she last received care. CNA L reported I honestly couldn't tell you. During an observation and interview on 2/9/26 at 4:20 p.m. R4 was yelling for help from her room. Upon entering her room, the smell of urine permeated the room. R4 was shivering in her bed. R4 stated I am so cold, I am so full of piss and I am so wet.would you please come and help me? I told that little nurse and she has not come in to help me. R4 had tears [NAME] up in her eyes and coming down her cheeks and stated, I am so tired of not being cared for, they don't take care of me here. I am from this town and I want to get the hell out of this place. I don't want to be here. I don't want to die here like this. Review of the Minimum Data Set (MDS) assessment, dated 1/8/2026, revealed R4 was admitted to the facility on [DATE] and had diagnoses including dementia, sarcopenia (age-related muscle loss), abnormal gait, generalized weakness and chronic respiratory failure. Further review of the assessment, revealed R4 had severe cognitive impairment, frequent urinary incontinence and was occasionally incontinent of bowel. During an interview on 2/9/26 at 4:28 p.m., the Senior Director of Nursing (DON) CC and the Director of Nursing (DON) were notified of R4 yelling for help. During an interview on 2/11/26 at 9:38 a.m., the Nursing Home Administrator (NHA) acknowledged concern regarding resident sitting in urine, feces, and shivering and the need for nursing care for resident. Review of policy titled Abuse, Neglect, and Exploitation date reviewed/revised 1/10/24, read in part .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.

Based on observation, interview and record review, the facility failed to ensure accurate nurse staffing information was posted on a daily basis, resulting in the potential for all 86 residents and their representatives to be misinformed of current facility staffing.Finding include:During initial entry to the facility on 2/8/2026 at 12:20 p.m., the Daily Nurse Staffing Form, was observed posted on the wall at the end of E-Hall, near the nurses' station. The form was dated 2/6/2026 and the resident census was listed as 84. The Nursing Home Administrator (NHA), present at the time of the observation, reported the current census to be 86. During an interview on 2/9/2026 at 12:05 p.m., facility scheduler, Staff VV reported she was responsible for ensure the posting of the Daily Nurse Staffing Form, during her work week, which was Monday through Friday. Staff VV reported she provided pre-filled forms for nursing staff to complete and post on Saturdays and Sundays. Staff VV was asked how the forms could be accurate if filled out ahead of time to which she reported, nursing staff were instructed to make adjustments on the form, if necessary, such as if the census changed and when more or less staff is needed based on resident acuity and care needs. Staff VV presented the Daily Nurse Staffing Form, dated 2/08/2026, the day of survey entry. Review of the form revealed no census number included on the form to reflect the prefilled staffing numbers reported as prefilled by Staff VV. Staff VV confirmed the facility had new admissions since 2/06/2026 and there was a potential the staffing needs in the facility had changed with the arrival of new admissions from 2/06/2026 through 2/08/2026, increasing the census from 84 to 86. Staff VV reported the staffing form for 2/08/2026 did not accurately reflect the needs of the facility for that day and she was unsure why nursing had not adjusted and posted the staffing from on 2/08/2026. During an interview on 2/10/2026 at 4:45 p.m., the Nursing Home Administrator (NHA) confirmed the Daily Nurse Staffing Form(s), should be completed and posted daily to reflect the current census and staffing needs of the facility.

Based on observation, interview and record review, the facility failed to provide a qualified dietitian, other clinically qualified nutrition professional, and/or director of food and nutrition services who met the required qualifications in the timeframe allowed. Findings include: On 2/8/2026 at 3:15 PM, Dietary Director C was asked if he was a Certified Dietary Manager or if he had a food service manager certification and stated he is working on his Dietary Manager certificate but is not currently certified. He stated he is also not a Certified Professional Food Manager through a nationally accredited program. He stated he has many years of experience. On 2/9/2026 at 4:00 PM, during interview with the Nursing Home Administrator NHA it was discussed that the dietary manager was not a certified dietary manager nor a Certified Professional Food Manager and that he was unable to produce any certificates showing he was certified in a nationally recognized food manager program. NHA stated that Dietary Director C was supposed to have submitted these after hiring.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: During a lunch meal observation on B Hall 2/8/2026 at 1:47 PM, CNA I was moving in and out of resident rooms bringing soiled meal trays back to the food cart for transport to the kitchen to be washed. At 1:51 PM on 2/8/2026, the food cart was observed to have six unserved meal trays remaining inside along with soiled food trays. Some of the soiled trays had been placed above the unserved trays and two soiled trays had been placed on the same shelf next to two unserved trays, touching and blocking service. CNA R looked into the cart and said, I'm not sure who did this. There is not supposed to be dirty trays in with the new trays. During a breakfast meal observation on D Hall 2/9/2026 at 9:43 AM, the food cart on the hall was observed. One tray remained to be served, and eight soiled trays had been returned from resident rooms and placed in the cart with the unserved tray. CNA L and CNA O approached the food cart. CNA L stated they had to wait to serve the last tray because the resident was a 2-person approach. When they opened the food cart CNA L said, Oh they should not have put dirty trays in with her meal. According to the 2022 FDA Food Code section 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation.(A) FOOD shall be protected from cross contamination by: .(b) Arranging each type of FOOD in EQUIPMENT so that cross contamination of one type with another is prevented . On 2/8/2026 at 12:35 PM observed the hood filters above the cooking equipment were soiled with dust and debris. On 2/8/2026 at 1:13 PM stainless steel steam table pans were observed stored on the lower storage shelf below the steam table. The shelf was partially covered with the original protective plastic sheeting, which was noted half peeled off and what remained was soiled with food debris and grime. The pans were observed turned upside down sitting on the soiled surface with food debris on the pans themselves. According to the 2022 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in ¶ (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under ¶ (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. On 2/8/2026 at 1:15 PM the garbage disposal was observed backed up and the bowl of the unit was half full of wastewater. Kitchen dietary aide A stated that it has been broken for a while, and a work order has been placed to repair it. According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2 On 2/8/2026 at 1:20 PM observed dietary cook B drink from a bottle on the prep line, place the drink bottle back down on the prep table and then take the cleaned parts of the food processor and place them on top of the food processor without washing hands prior to touching the cleaned utensils. 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 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 products, 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. Upon record review of the Infection Prevention and Control Program, revised and reviewed on 12/27/2023 states: Policy #15 Staff Education: a. Staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function. b. Staff shall demonstrate competence in relevant infection control practices. On 2/9/2026 at 8:15 AM a large 1000-piece box of single serve Styrofoam cups, two 1000 count boxes of Hot or Cold Insulated bowls and one 1000 count box of single serve lids were observed sitting on the floor of the dry storage room. According to the 2022 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in ¶ (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.

Based on interview and record review, the facility failed to maintain a comprehensive and accurate facility assessment to ensure sufficient staffing levels for all 86 residents of the facility.Findings include:Review of the facility assessment, revised 9/16/25, revealed an average daily census of 72, ranging from a minimum of 64 residents to a maximum of 78 residents.Review of facility census numbers from 10/1/25 - 2/11/26 revealed 90 days the census exceeded the maximum census (78 residents) outlined by the facility assessment. The highest census in this timeframe was 87 residents on 2/6/26.Review of the facility assessment's resident acuity levels revealed the subsequent population percentages requiring maximum assistance or total dependency for the following activities of daily living (ADLs):Self-care (eating, oral hygiene, toileting hygiene, bathing, upper and lower body dressing, donning and doffing footware [sic]): 37% Bed Mobility: 40%Transfers: 54% Walking: 51%Wheelchair/Scooter: 48% Review of the facility assessment's, Staffing Plan subsection revealed the following: .The scheduler uses a staffing ladder based on the facility budget to determine baseline staffing requirements.Day Shift 5-7 C.N.A.'s [certified nursing assistants] and 2-3 nursesAfternoon shift 5-7 C.N.A.'s and 2-3 nursesMidnight shift 3-5 C.N.A.'s and 2-3 nurses.Develop and maintain a plan to maximize recruitment and retention of direct care staff.Staffing/Recruitment meetings are held daily to maximize our recruitment and retention efforts.Review of the facility assessment's Other section read:Inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing. See Appendix 3 for more details.Since we are a member of a large corporation, we have the opportunity to utilize staff from other facilities when needed.Further review of the facility's assessment's Appendix 3 read: Contingency Plans: Describe your contingency planning for events that do not require activation of the facility's emergency plan but do have the protentional to affect resident care such as available of direct care nursing staffing. For example, how are call-offs managed? What if you discover there will be 5 admissions arriving after 5 PM? What if a direct care staff member must leave mid-shift due to illness or a family emergency?This portion of the facility assessment was left blank apart from various staff signatures.On 2/11/26 at 9:47 AM, an interview was conducted with the Nursing Home Administrator (NHA) regarding low staffing level concerns in relation to inaccurate data, incomplete portions, and an inadequate staffing plan in the facility assessment. The NHA responded, We don't have a staffing problem, we have a call-in problem [staff reporting they are unable to work their shift]. Therefore, no retention or recruiting efforts/meeting nor utilization of staff from other facilities occurred. The NHA made no comment as to why the facility assessment did not contain a staffing contingency plan but stated phone calls are made to try to get other staff to come in to work in the event of a call-in. When asked if 3 CNAs are considered sufficient staff to safely and adequately cover a census of 79 or greater with the aforementioned mobility level acuity data, the NHA did not respond.

Based on interview and record review, the facility failed to develop and maintain a Quality Assistance and Process Improvement (QAPI) program which identified and prioritized quality deficiencies, systematically analyzed the underlying causes of systemic quality deficiencies, and implemented effective corrective action or performance improvement activities to remedy those deficiencies. This deficient practice has the potential to affect the safety and quality of life of all 86 residents at the facility.Findings include:On 2/11/26 at 9:47 AM, an interview was conducted with the Nursing Home Administrator (NHA) regarding concerns of low staffing levels translating to quality-of-care concerns and systemic issues in several areas including assistance with activities of daily living (ADLs), incontinence care, prompt and palatable meal service, positioning needs, and honoring resident preferences which were identified during the recertification process. Review of the facility's performance improvement projects with the NHA failed to reveal staffing levels concerns nor any other systemic issues had been appropriately identified and carried out through the QAPI process. When asked if low staffing levels had been identified as a concern, the NHA stated, Not at this time. We are fully staffed right now. We have a couple open nurse positions we need to fill. CNAs [certified nursing assistants] are fully staffed. The NHA was asked if she was aware the facility triggered for excessively low weekend staffing on the third quarter PBJ report to which she replied, Through the survey process, I am. When asked if excessively low weekend staffing was considered a staffing problem, the NHA replied, We don't have a staffing problem, we have a call-in problem [staff reporting they are unable to work their shift]. The NHA stated they have not discussed a contingency staffing plan in QAPI but have instead been enforcing employee attendance expectations. The NHA stated, We need to focus a little bit more on our process after call-ins. We are following up with our attendance policy and our write-up [disciplinary] policy. The NHA did not respond when asked if this solution was effective.Review of the Payroll Based Journal (PBJ) Data Report for Quarter 4, 2025 (July 1 - September 30) revealed the facility triggered for excessively low weekend in the same timeframe.On 2/11/26 at 10:10 AM, the Regional Director of Operations (RDO) LL stated, Our QAPI program needs work.Review of the facility policy titled, QAPI Plan, reviewed 10/24/22, read, in part: It is the policy of this facility to systematically collect data as part of the QAPI program to ensure the care services it delivers meet acceptable standards of quality in accordance with recognized standards of practice. The goal is to create a process that ensures care and services delivered meet accepted standards of quality. The QAPI program will be ongoing, comprehensive, and will address the full range of care and services provided by the facility. At a minimum, the QAPI program will: i. address all systems of care and management practices. ii. Include clinical care, quality of life, and resident choice. All identified problems will be addressed and prioritized. Considerations include, but are not limited to: i. high-risk, high-volume, or problem prone areas. ii. Incidence, prevalence, and severity of problems in those areas. iii. Measures affecting resident health, safety, autonomy, choice, and quality of choice. Once the root cause of a problem is identified, the QAA [Quality Assessment and Assurance] committee oversees the development of the of an appropriate corrective action. An appropriate corrective action is one that addresses the underlying cause of the issue comprehensively, at the systems level.

Based on interview and record review, the facility failed to incorporate high-risk, high-volume, and high-priority quality concerns from feedback obtained from direct care staff, residents, and resident representatives into an effective Quality Assistance and Process Improvement (QAPI) program. This deficient practice resulted in ongoing quality-of-care concerns and systemic issues in several areas including assistance with activities of daily living (ADLs), incontinence care, prompt and palatable meal service, positioning needs, and honoring resident preferences which had the potential to affect all 86 residents in the facility. Findings include:Review of Quality Assistance Forms submitted to the facility Nursing Home Administrator (NHA) revealed 15 grievances from staff, residents, and/or resident representatives related to low staffing concerns since June 2025.Review of Resident Council Meeting Minutes since March 2025 revealed repeated staffing concerns, including excessively late mealtimes, for the previous 9 out of 11 months. On 2/9/26 at 2:00 PM, a confidential group interview was conducted where eight out of nine residents stated the facility still had ongoing low-staffing concerns directly translating to poor resident outcomes.Throughout the recertification process (2/8/26-2/11/26), three staff members across three non-nursing departments (activities, dietary, and housekeeping) relayed their concerns regarding low staffing:On 2/11/26 at 8:05 AM, an interview was conducted with Activities Director (AD) KK regarding the repeated staffing/call light and untimely meal services issues that came up in the monthly Resident Council meetings. AD KK stated she brought these concerns up to management with a Quality Assistance Form after every meeting. When asked the response she receives from management after submission of the form, AD KK responded, They [management] tell me we meet staffing guidelines.On 2/11/26 at 8:15 AM, an interview was conducted with Dietary Manager (DM/Staff) C regarding repeated issues with timely meal services. Staff C stated the food is prepared and ready to be served on trays at the established mealtimes, but the facility is lacking the staff to deliver them in a timely manner. Staff C stated when this issue is presented to management it, goes nowhere.On 2/11/26 at 8:05 AM, an interview was conducted with Housekeeper/Staff NN regarding their opinion of staffing levels. Staff NN replied, I think they're [certified nursing assistants] short staffed. They get to call lights when they can. Review of a complaint submitted to the State Agency (SA) on 12/29/25 read, in part: .The safety of the staff and residents are progressively becoming more dangerous. From morning to nights there is never enough staff from the halls to the dining area. A lot of the residents sit in their own stool and urine for hours on end throughout the day due to inadequate care from employees and staffing shortages all day. For many months I have worked 1 CNA to 30 residents a hall due to inadequate staffing measures.On 2/11/26 at 9:47 AM, an interview was conducted with the Nursing Home Administrator (NHA) regarding the QAPI process. When specifically asked if low staffing levels had been an identified concern in QAPI as the result of extensive feedback from staff, residents, and resident representatives, the NHA stated, Not at this time. We are fully staffed right now. We have a couple open nurse positions we need to fill. CNAs [certified nursing assistants] are fully staffed. When asked how she interpreted the large quantity of grievances, resident council minutes, and staff interviews related to low staffing concerns, the NHA replied, The way we're addressing staffing is through our write-up [disciplinary] process . Following our attendance policy and doing write-ups. We are just getting started on this process. The NHA did not respond when asked why this was not implemented in March 2025, when staffing concerns were first voiced. Review of the facility policy titled, QAPI Plan, reviewed 10/24/22, read, in part: .Data will be collected from all departments, residents, and family members. sources of data include, but are not limited to: . grievance logs. staffing trends. Quality measures (QM report)/5 star reports.suggestions from staff, residents, and families. at staff meetings, or shift-to shift huddles. Resident Council Minutes. Performance indicators will be established based on data, and will be monitored/evaluated in the [Quality Assessment and Assurance] Committee meetings. The facility draws data from multiple sources, including input from all staff, resident, families, and others as appropriate. All identified problems will be addressed and prioritized.Review of the Facility Assessment, reviewed 9/16/25, read, in part: .The QAPI committee, along with input from all staff, identifies areas for improvement and devise action plans to correct potential areas that are deficient or to improve an area identified by staff for improvement. How do we determine if we have sufficient staffing? Consider the following: Gather input from residents, family members, and/or resident representatives, CNAs, licensed nurses providing direct cares, and the long-term care local ombudsman about how well the current staffing plan has been working and any concerns, and make sure to consider this information when developing the staffing plan.

This citation pertains to Intake 2702621.Based on observation, interview, and record review, the facility failed to:Implement Enhanced Barrier Precautions (EBP) in a timely manner for six Residents (#33, #93, #90, #92, #94, & #91).Properly don (put on) personal protective equipment (PPE) prior to entering EBP rooms.Update infection control policies on an annual basis.Maintain sanitary medication and treatment carts.Ensure appropriate hand hygiene during feeding assistance.Ensure separation of unserved food trays and soiled meal trays within transport carts.These deficient practices resulted in the potential for the transmission of pathogens between residents and the spread of infectious organisms to all 86 residents in the facility. Findings include:On 2/8/26 at 12:33 PM, an observation was made of the B Hall medication cart and had two drinks sitting on top of the cart. One drink was coffee and the other was a can of name brand energy drink. On 2/8/26 at 12:40 PM, an interview was conducted with Registered Nurse (RN) X who was asked if open drinks on top of a medication cart were very sanitary and replied, No, the drinks should not be there. Resident #91 (R91) the facesheet for R91 had an original admission to the facility on 2/6/26 with diagnoses including fracture of the right tibia/fibula (fracture of both lower leg bones), anxiety, and depression. According to R91's Minimum Data Set (MDS) dated [DATE], a Brief Interview for Mental Status (BIMS) score of 15/15 indicated R91 was cognitively intact. On 2/8/26 at 12:35 PM, an observation was made of R91's room which lacked any signage for enhanced barrier precautions (EBP) or a personal protective equipment (PPE) cart outside of the room. On 2/8/26 1:30 PM, an observation was made of R91 receiving physical therapy from Occupational Therapist (OT) RR who was not wearing proper PPE and lacked wearing a gown. Review of R91's physician order, dated 2/9/26, for enhanced barrier precautions was not placed until three days after her admission to the facility at 8:40 AM. Resident #93 (R93) The facesheet for R93 had an original admission to the facility on 1/29/26 with diagnoses including fracture of the left tibia/fibula (fracture of both the lower leg bones), diabetes mellitus, and chronic kidney disease requiring dialysis (a treatment where blood is filtered of waste and excess fluid by a machine). R93 had a dialysis port in her chest. According to R93's MDS dated [DATE], a BIMS score of 15/15 indicated R93 was cognitively intact. R93's MDS assessment indicated she was dependent on staff for bathing, requiring the assistance of two staff personnel, and for toileting R93 was a one-person assist. On 2/8/26 at 12:37 PM, an observation was made of R93's room which lacked any signage for EBP or a PPE cart outside of the room. Review of R93's physician order, dated 2/9/26, for EBP was not placed until three days after her admission to the facility at 8:42 AM. On 2/10/26 at 3:10 PM, an observation was made of Licensed Practical Nurse (LPN) U removing R93's right leg brace without wearing a gown. During an interview on 2/10/26 at 3:18 PM, an interview was conducted with LPN U who was asked if he should have been wearing a gown during the removal of R93's right leg brace and replied, Yeah, I should have I did not realize she was EBP resident. The Director of Nursing (DON) confirmed on 2/10/26 at 4:10 PM that open personal drinks should not be left on top of medication carts and staff are to be wearing PPE during direct care contact with residents under EBP. Resident #33 (R33) Review of R33's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/19/26. Review of Section M: Skin Conditions on R33's Minimum Data Set (MDS) Assessment, submitted 2/4/26, revealed one stage two pressure ulcer that was present upon admission. Review of R33's EMR revealed the following physician's order, initiated 2/2/26 (14 days after admission to the facility): Use enhanced barriers while performing high contact activity with the resident. Resident #93 (R93) Review of R93's EMR revealed initial admission to the facility on 1/28/26 with diagnoses including dependence on renal dialysis with presence of a right central venous catheter. Review of R93's EMR revealed the following physician's order, initiated 2/9/26 (12 days after admission to the facility): Use enhanced barriers while performing high contact activity with the resident. Resident #90 (R90) Review of R90's EMR revealed initial admission to the facility on 1/29/26 with diagnoses including fracture of the 3rd, 4th, 6th and 7th cervical (neck) vertebrae. Review of R90's Plan of Care reviewed a focus, initiated 1/29/26, that read, in part: Resident has impaired skin integrity as evidenced by: surgical incision to neck related to.recent surgery. Review of R90's EMR revealed the following physician's order, initiated 2/9/26 (11 days after admission to the facility): Use enhanced barriers while performing high contact activity with the resident. Resident #92 (R92) Review of R92's EMR revealed initial admission to the facility on 1/30/26 with diagnoses including acute kidney failure and benign prostatic hyperplasia. Review of R92's EMR revealed a progress note dated 2/3/26 at 18:59 [6:59 PM] that read, in part: Returned from ER [emergency room] with indwelling cath [catheter] for urinary retention. Review of R92's EMR revealed the following physician's order, initiated 2/9/26 (3 days after re-admission to the facility): Use enhanced barriers while performing high contact activity with the resident. Resident #94 (R94) Review of R94's EMR revealed initial admission to the facility on 2/6/26 with diagnoses including fracture of the right femur requiring surgical intervention. Review of R94's EMR revealed the following physician's order, initiated 2/9/26 (3 days after admission to the facility): Use enhanced barriers while performing high contact activity with the resident. Resident #91 (R91) Review of R91's EMR revealed initial admission to the facility on 2/6/26 with diagnoses including fracture of the right tibia. Review of R91's Plan of Care reviewed a focus, initiated 2/7/26, that read, in part: Resident has imparted skin integrity as evidenced by: surgical incision to right leg related to fracture to the right tibial [sic]. Review of R91's EMR revealed the following physician's order, initiated 2/9/26 (3 days after admission to the facility): Use enhanced barriers while performing high contact activity with the resident. Review of the following facility policies revealed the respective reviewed and/or revised dates: Infection Prevention and Control Program Policy and Procedures - Date Reviewed/Revised: 12/27/23. Antibiotic Stewardship Program Policy - Date Reviewed/Revised: 12/13/23. Influenza Vaccine Policy - Reviewed/Revised: 10/26/23. Pneumococcal Vaccine Policy - Reviewed/Revised: 10/30/23. On 2/10/26 at 12:59 PM, an interview was conducted with Infection Preventionist (IP) T regarding infection control concerns within the facility. IP T acknowledged the concern regarding delayed implementation of EBP, stating this often gets missed if she is out of the facility because there is not a designated back-up person to oversee the process. IP T stated since the arrival of the State Agency (SA) [on 2/8/26], she has begun educating staff, especially unit managers, on the medical indications for EBP and how to appropriately initiate those orders in the EMR upon admission of the resident. IP T confirmed the provided Infection Prevention and Control Program Policies and Procedures, including the Antibiotic Stewardship program and the Influenza, Pneumococcal, and COVID-19 Immunization Policy & Procedures were the most up-to-date versions available. Review of the facility policy titled, Enhanced Barrier Precautions (EBP), revised 3/26/24, read, in part: .Initiation of Enhanced Barrier Precautions - . even if the resident is not known to be infected or colonized with a MDRO [multidrug-resistant organisms], an order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e.g. chronic wounds such as pressure injuries.unhealed surgical wounds.). Indwelling medical devices (e.g. central lines, urinary catheters.). Review of the facility policy titled, Infection Prevention and Control Program, revised 12/27/23, read, in part: .Annual Review: The facility shall conduct an annual review of the infection prevention and control program, including associated programs and policies and procedures based upon the facility assessment which includes any facility and community risk. Resident # 90 (R90) and Resident #98 (R98) On 2/8/2026 at 3:00 p.m., CNA L was observed pushing two wheeled carts of PPE down D-Hall. CNA L deposited one cart inside R90's room and the other into R98's room. When asked why the carts were being placed in the rooms, CNA L stated, I don't know, I'm just doing what I was asked. During the same period of observation, Unit Manager, LPN S was observed adhering signs for EBP on the doorways of R90 and R98's rooms. Review of R90's EMR revealed an admission date of 1/29/2026. Review of R90's active physician orders revealed, Cleanse incision on neck with wound cleanser. Cover with island dressing. Change daily in the afternoon for surgical wound. Start date: 2/4/2026. Review of R90's February 2026 Medication and Treatment Administration Record(s) (MAR/TAR) revealed documentation of consistent daily dressing changes per the order. Further review revealed an order for the use of Enhanced Barrier Precautions (EBP) while performing all high-contact activity with the resident . Surgical wound. Start date: 2/9/2026. Review of R90's care plan revealed, Resident has impaired skin integrity as evidenced by: surgical incision to neck . Date initiated: 1/29/2026. Review of R98's EMR revealed an admission date of 2/5/2026. Review of R98's active physician orders revealed, Border gauze to left abdomen change daily and prn [as needed] one time a day for abdominal incision. Start date: 2/6/2026. Review of R98's February 2026 MAR and TAR revealed documentation of consistent daily dressing changes per the order. Further review revealed an order for the use of EBP while performing all high-contact activity with the resident . Start date: 2/6/2026. Review of R98's care plan revealed, Resident requires Enhanced Barrier Precautions related to surgical wound. Date initiated: 2/6/2026. Facility An observation on 2/8/2026 at 1:50 p.m. revealed a treatment cart positioned in the D Hall corridor, Further observation revealed dark rings on the surface of the top of the cart resembling coffee rings as if a drink had been sitting on the cart. The surface of the cart appeared visibly soiled and a large amount of debris and dust was observed under the two boxes of gloves positioned the glove rack. An observation on 2/9/2026 at 9:48 a.m. revealed a treatment cart positioned in the corridor of B Hall. Further observation revealed a supply of disposable cups and straws sitting atop the cart. Food crumbs were visible on the surface of the cart and the empty glove rack was observed to have a large amount of debris including pieces of straw wrapper, hair, dust and larger black unidentifiable particles. Registered Nurse (RN) observe M, who was present at the time of the observation, reported she believe the CNA staff used the cart as an extra surface when passing meals and snacks. RN M confirmed the cart housed wound care supplies and the surface is used when pulling supplies from the cart in preparation for wound care. During a lunch meal observation on 2/10/2026 at 12:35 PM, Certified Nurse Aide (CNA) J was feeding R83, a resident needing partial/moderate assistance with feeding (according to her Minimum Data Set [MDS] assessment dated [DATE]). After serving several spoonfuls of food to R83, CNA J set the utensil down, adjusted the plate and moved to assist R50. Following assistance feeding R50, CNA J then moved to another chair at the same table and assisted R44 with his tray. CNA J moved from chair to chair back and forth assisting the three residents using different utensils and cups, and adjusting the plates, trays, and clothing protectors. CNA J did not perform hand hygiene at any time during the lunch observation. When CNA J was asked if she should be performing hand hygiene between assisting residents, she replied she was not 100% sure. CNA J said, I will find out for you. She explained there had been another person assisting residents with the meal at her table, but the Nursing Home Administrator (NHA) had needed her, CNA J was left to feed the residents at her table alone. The facility policy titled, Hand Hygiene was dated as reviewed/revised on 12/13/2023. This policy read in part, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. During a lunch meal observation on B Hall 2/08/2026 at 1:47 PM, CNA I was moving in and out of resident rooms bringing soiled meal trays back to the food cart for transport to the kitchen to be washed. At 1:51 PM on 2/8/2026, the food cart was observed to have six unserved meal trays remaining inside along with soiled food trays. Some of the soiled trays had been placed above the unserved trays and two soiled trays had been placed on the same shelf next to two unserved trays, touching and blocking service. CNA R looked into the cart and said, I'm not sure who did this. There is not supposed to be dirty trays in with the new trays. During a breakfast meal observation on D Hall 2/09/2026 at 9:43 AM, the food cart on the hall was observed. One tray remained to be served, and eight soiled trays had been returned from resident rooms and placed in the cart with the unserved tray. CNA L and CNA O approached the food cart. CNA L stated they had to wait to serve the last tray because the resident was a 2-person approach. When they opened the food cart CNA L said, Oh they should not have put dirty trays in with her meal. According to the 2022 FDA Food Code section 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation.(A) FOOD shall be protected from cross contamination by: .(b) Arranging each type of FOOD in EQUIPMENT so that cross contamination of one type with another is prevented .

This citation pertains to Intake 2702621. Based on observation and interview, the facility failed to maintain general cleanliness and repair of the facility, resulting in an increased potential for contamination and a possible decrease in satisfaction of living to all residents. Findings Include:On 02/08/2026 at 1:34 PM observed a pink Caution Wet Floor sign on the floor sitting next to a waste container with a couple of inches of water in it in in the front entrance foyer across from the front door. The ceiling around the sky light above this area was observed water damaged. On 02/09/2026 at 8:45 AM during interview with Maintenance Director D stated that he has tried a few times to repair the roof but was told that it could void the roof warranty and not to attempt to repair any further.On 02/08/2026 at 2:55 PM observed the floor in the bathroom shared between rooms D 14 and D 16 was soiled and the paint on the door and door frame was observed chipped and worn off along the bottom of the door and casing.On 02/08/2026 at 2:57 PM in room D 11 observed damaged walls and paint missing in several locations exposing the bare plaster wall below. On 02/08/2026 at 3:00 PM wall paint was observed missing in room D 9. On 02/08/2026 at 3:05 PM the cove base molding was noted peeled away from the wall in D 5.

Based on observation, interview, and record review the facility failed to assist, set up, or place meals within reach for four Residents (#4, #47, #69, and #83) of four residents reviewed for reasonable accommodation of needs.Resident #4 (R4) Review of R4's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 7/25/23 with diagnoses including malnutrition, depression and anxiety disorder. R4 scored 3 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment. During an observation on 2/9/26 at 4:20 p.m., R3's lunch was sitting on her bedside table away from her bed and out of reach of the resident. The sandwich was covered with plastic wrap. During an observation on 2/10/26 at 8:32 a.m., R4 laid in bed with her meal try on the bedside table with the food and beverage covers over her food and beverage items. The food was out of the reach of the resident. Review of R4's menu card dated 2/10/26 read in part .Regular diet, thin liquids Alert: Independent, offer set up assistance (for meals). During an observation on 2/10/26 at 10:14 a.m., Hospitality aide G walked into R4's room and picked up the breakfast tray. R4 had not eaten any of the food from the tray as it was out of her reach. Hospitality aide G walked out of R4's room and did not offer any food or beverage to R4. Resident #47 (R47) Review of R47's MDS assessment, dated 1/16/26 revealed admission to the facility on 5/16/25 with diagnoses including diabetes mellitus and hip fracture. R47 scored 13 of 15 on the BIMS assessment reflective of intact cognition. During an observation on 2/9/26 at 9:45 a.m., R47 was lying in his bed with a tray of food that had food covers over the food and out of the resident's reach. Review of the menu card revealed R47 had been given another resident's meal tray. Review of facility policy titled Tray Identification last reviewed/revised 7/1/25, read in part .To assist in setting up and serving the correct food trays/diets to resident .the food services manager or designee will check trays for correct diets before the food cares are transported to their designated areas. Nursing staff shall check each food tray for the correct diet before serving the residents . During an observation on 2/9/26 at 9:56 a.m., Licensed Practical Nurse (LPN) H walked into R47;'s room and removed the meal tray from R47's bedside. LPN H did not offer any food or beverage to R47. Review of R47's menu card dated 2/9/26 read in part, .Alert: Independent offer set up assistance (for meals). Review of policy titled Resident Meal Service date reviewed/revised 7/1/25, read in part . Nursing personnel will ensure that residents are served the correct food tray.prior to serving the food tray, the Nurse Aide/feeding assistant must check the tray card to ensure that correct food tray is being served to the resident. Resident #69 (R69) Review of the MDS assessment, dated 1/24/2026, revealed R69 was admitted to the facility on [DATE] with diagnoses including demyelinating disease of the central nervous system, osteoporosis, arthritis, generalized weakness and frequent falls. Further review of the assessment revealed R13 required set-up assistance only with eating, substantial/maximal assistance with sitting to standing and partial/moderate assistance with chair/bed-to-chair transfers. R69 scored 13 out of 15 on the BIMS, indicating there is mild cognitive impairment. On 2/9/2026 at 10:10 AM R69 was observed lying in bed, awake. The left side of the R69's bed was against the wall, and a fall mat was positioned on the floor on the right side of the bed. An over bed table was positioned approximately two feet from the resident in bed and on the opposite side of the fall mat. Atop the over bed table was a meal tray containing an unopened container of oatmeal, an unopened lidded glass of apple juice and an unopened lidded glass of milk. At the time of the observation R69 reported she must have been asleep when the tray was dropped off in her room. R69 was asked if she was able to retrieve her meal from across the room to which she answered, I think I can manage. R69 was observed attempting to rise by swinging her legs over the side of the bed but was unable to rise to a seated position. During the observation, Certified Nurse Aide (CNA) L entered the room and was queried as to the location of R69's breakfast tray and if the Resident had the ability to retrieve the tray herself. CNA L reported R69 had declined in recent weeks and required assistance to set up meals. CNA L was unsure when the meal was placed in R69's room and confirmed the oatmeal was coagulated and cold at the time of the observation. On 2/11/2026 at 8:25 AM an observation revealed Resident #69's morning meal tray atop an overbed table positioned against the wall between the resident's sink and bathroom door on the opposite side of the room from the Resident's bed. R69 was observed lying in bed with her legs over the side of the bed and feet resting on the fall matt that was positioned on the floor on the right side of the bed. CNA PP was approached in the hallway as she was passing meal trays to other resident rooms. CNA PP entered R69's room with this surveyor and reported she placed the tray in the Resident's room, but there was no one else in the hall at the time to assist in passing meal trays, so she left the tray without setting it up so she could pass the remaining trays. CNA PP stated she intended on returning to assist the resident with set up. When asked if the resident would attempt to retrieve the tray herself upon waking, CNA PP stated Oh, she never tries that. Review of R69's care plan revealed the following: Resident is at risk for altered nutritional status . Provide assistance with meals, as needed. Dated initiated: 6/06/2025 . Resident is at risk for falls/injury . Encourage resident to keep needed items within reach. Dated initiated: 12/30/2024. Resident #83 (R83) According to the medical record, R83 was admitted on [DATE] with medical diagnoses including quadriplegia (paralysis affecting all four limbs and the torso), anoxic brain damage (damage from a shortage of oxygen to the brain), need for assistance with personal care, major depressive disorder and post-traumatic stress disorder (PTSD). R83's MDS assessment dated [DATE] contained a BIMS score of 14 of 15, indicating R83 was cognitively intact. R83's functional status assessment revealed total dependence on staff to roll right or left, total dependence of staff to lie down from sitting, and total dependence on staff to sit from lying down. During an observation on 2/10/2026 at 11:08 AM, R83 was lying in bed with her breakfast tray on the bedside table away from the bed and pushed up against the wall of the room. The breakfast meal tray appeared to be untouched. When R83 was asked if she saw her breakfast which was positioned approximately 2-3 feet from the bed, she replied, I did not even see it. When asked if she was hungry, R83 replied with an emphatic yes and indicated she would like to eat. When asked if she needed help, R83 said she did as she stated she could not reach the tray. The tray card included with the meal read in part: Needs assistance with meals. The medical record included a care plan for activities of daily living with interventions including: EATING: 1 person assist, independent with finger foods & set up assistance Date Initiated: 08/18/2023. Another care plan had a focus of Resident is at risk for altered nutritional status RT (regards to) functional quadriplegia., finger food texture order, required assistance with meals if not finger foods texture Date Initiated: 12/19/2023 Revision on: 06/16/2025 with an intervention included for this focus of, Provide assistance with meals as needed.

This citation pertains to intake 2702621. Based on observation, interview, and record review, the facility failed to provide a homelike dining environment for five of nine residents interviewed in a confidential group meeting. Findings include: During lunch observations on 2/8/2026 at 1:17 PM, the meal was delivered in food carts and served on trays. During observation on the A Hall and B Hall each tray included only disposable plastic utensils. Certified Nurse Aide (CNA) R serving the meal stated disposable plastic utensils often came on the trays. CNA R said sometimes meal trays sat near the kitchen door in the dining room and did not get washed in time for the next meal. During breakfast observations on 2/9/2026 at 8:31 AM, the meal was delivered to the halls in food carts and served on trays. During this observation on the A Hall, each tray included regular forks and spoons and plastic disposable knives. On 2/11/2026 at 10:27 AM, the Food Service Manager/Staff C stated, It goes down the hall, and it does not come back. Staff C said the trays did not come back in time to be washed for the next meal and he felt residents were keeping the silverware. Staff C knew the disposable plastic utensils were being used and he had not ordered any more silver utensils. On 2/9/26 at 2:00 PM, a confidential group interview was conducted where five residents voiced their frustration with the plastic cutlery served at mealtimes. One Confidential Resident (CR) stated, It [a plastic knife] won't even cut the meat. Review of a complaint submitted to the State Agency (SA) on 12/29/25 read, in part: .meals are never adequately served due to limited utensils. Review of the facility policy titled, Residents' Rights and Quality of Life, reviewed 1/1/22, read, in part:It is the policy that all residents have the right to a dignified existence.

Based on observation, interview, and record review, the facility failed to secure medications, maintain the security for one medication cart of three medication carts and three of five treatment carts reviewed for medication storage. Findings include:On 2/8/26 at 12:37 PM, an observation was made of Resident #64 (R64) lying in his bed asleep with a full cup of medications sitting on his bedside table.On 2/8/26 at 12:38 PM, an observation was made of Resident #91 (R91) lying in her bed with a full cup of medications sitting on his bedside table. R91's medications were later identified as being morning medications. R91 also had a rescue inhaler on her bedside table identified as albuterol.An observation was made on 2/9/26 at 11:45 AM, of Resident #93 (R93) who had a topical ointment on her bedside table. R93 states it is her ointment mupirocin. During an observation on 2/8/26 at 12:53 PM, A Hall treatment cart was unlocked with a tube of diclofenac sodium topical gel 1% and an opened can of soda pop on top of treatment cart.During an interview on 2/8/26 at 1:26 PM, Registered Nurse (RN) Q reported she started working at 6:00 AM, and she had not completed any of the treatments for the residents on A Hall but did acknowledge the treatment carts should be locked when licensed staff are not using them.Record review and observation on 2/9/26 at 1:50 PM, revealed R93 had medication at the bedside table ointment mupirocin 2% and there was no order or an assessment for medication self-administration.Review of the medication administration record (MAR), dated 2/8/26, showed R91 had received medications as follows by Registered Nurse (RN) DD dispensed at 10:55 AM:amlodipine 5 milligrams (mg)aspirin 81 mgdesvenlafaxine extended release (ER) 100 mg atorvastatin 20 mgfludrocortisone 0.1 mgfolic acid 400 micrograms (mcg)multivitaminomeprazole 20 mgpotassium chloride 10 milliequivalents (mEq)valsartan 320 mgvitamin D3 125 mcgcarvedilol 25 mgcyclobenzaprine HCL 5 mgapixaban 2.5 mg Review of the medication administration record (MAR), dated 2/8/26, revealed R64 had received medications as follows by RN Q dispensed at 8:06 AM:aspirin 81 mglosartan potassium 100 mgduloxetine HCL 30 mgdapagliflozin propanediol 10 mgtamsulosin HCL 0.4 mgpsyllium two capsules metformin HCL ER 500 mgmultivitaminfinasteride 5 mglactobacillus two capsulesspironolactone 25 mgomeprazole 20 mgGabapentin 100 mgA record review was completed for R64, R91, and R93 and no assessment for medication self-administration, care plan to self-administer medication, or interdisciplinary notes indicating the identified residents ability to self-administer medications could be located.On 2/9/26 at 4:23 AM, an unlocked medication cart was observed located near the nurses' station with no staff present at the nurses' station or near the medication cart.During an observation on 2/9/26 between 4:23 AM, and 4:29 AM, treatment carts were unlocked on A Hall, E Hall, and D Hall.During an observation and interview on 4/9/26 at 4:38 AM, Licensed Practical Nurse (LPN) SS was queried regarding lancets that were left on top of the medication cart with no staff present. LPN SS reported we are not supposed to leave lancets on the medication cart unattended.On 2/10/26 at 4:05 PM, an observation was made of the B Hall medication cart which was unlocked and unsecured. RN N was away from her medication cart and sitting at the nurses' station.On 2/10/26 at 4:15 PM, an interview was conducted with RN N who was asked if she was aware her medication cart was unlocked and unattended and replied, No, I was just signing out a resident to go smoke.Review of policy titled, Medication Storage, dated 1/30/2024, read in part Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy explanation and compliance guidelines: 1. General guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.c. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.Review of policy titled, Medication - Resident Self-Administration, dated 1/30/2024, read in part Policy: It is the policy of this facility to support each residents' right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determine which medications may be self-administered safely.Policy explanation and compliance guidelines: 1. Each resident is offered the opportunity to self-administer medications during the routine assessment .

This citation pertains to intake 2702621Based on observation, interview, and record review, the facility failed to ensure palatable meals were served at preferred and appetizing temperatures for six of nine residents interviewed in a confidential group meeting, and for one Resident (#93) of one resident who voiced concerns about food temperatures. Findings include:On 2/9/26 at 2:00 PM, a confidential group interview was conducted where six residents stated the food delivered at mealtimes is often cold. One Confidential Resident (CR) stated, Sometimes it's cold, other times it's lukewarm. Another CR indicated food trays either sit in the serving window or in food delivery carts for extended periods of time which contributes to the cold food temperatures. One CR revealed they had bought hairnets online in attempt to assist delivering meal trays due to ongoing staffing problems and were upset when the facility would not allow it. The CR indicated they frequently noticed meal trays stacking up in the serving window because there weren't enough staff to deliver them in a timely manner. The CR stated, I feel bad for the other residents, I just want to help deliver trays. Review of Resident Council Meeting Minutes since March 2025 read, in part: 5/15/25: .New Business – Concerns/Complaints/Grievances: Residents stating food (in room) is cold when served. Coffee is sometimes lukewarm/cold in dining room. 6/19/25: .List of old business (unresolved): food still cold down halls. Lukewarm in dining room. 11/20/25: .New Business – Concerns/Complaints/Grievances: staff are pre-pouring coffee making it so residents get lukewarm/cold coffee. 12/17/25: .New Business – Concerns/Complaints/Grievances: Meals being served lukewarm/cold in the dining room/room trays. Residents would like hot food. 1/15/26: .List of old business (unresolved): .Food/coffee temp[erature] – 1/2 state improved, 1/2 not [improved]. Review of the facility policy titled, Resident Meal Service, reviewed 7/1/25, read, in part: Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service. Resident #93 (R93) The facesheet for R93 had an original admission to the facility on 1/29/26 with diagnoses including fracture of the left tibia/fibula (both of the lower leg bones were broken). According to R93's MDS dated [DATE], indicated a BIMS score of 15/15 indicating R93 was cognitively intact. R93's MDS assessment indicated she was dependent on staff for bathing, requiring the assistance of two staff personnel, and for toileting R93 was a one-person assist. During an interview on 2/9/26 at 12:10 PM, R93 voiced both of her meals, breakfast and lunch were cold. It happens a lot, because they need to check my blood sugar and they are always late. On 2/8/26 at 1:59 PM, the residents on A Hall received their lunch meal. The temperatures of the food on the last tray on this food cart were measured. The temperatures were as follows: milk 59 degrees, juice 59 degrees, chicken breast 106 degrees, and sliced cooked carrots 107 degrees. The 2022 FDA Food Code reads as follows, Section 501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, and except as specified under ¶ (B) and in ¶ (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 degrees C (135 degrees F) or above, except that roasts cooked to a temperature and for a time specified in ¶ 3-401.11(B) or reheated as specified in ¶ 3- 403.11(E) may be held at a temperature of 54 degrees C (130 degrees F) or above; or (2) At 5 degrees C (41 degrees F) or less.

This citation pertains to intake #2702621.Based on observation, interview, and record review the facility failed to honor resident food preferences or failed to offer substitutes or alternative menu items for 19 of 24 residents (#4, #6, #12, #13, #22, #23, #24, #30, #31, #37, #R41, #47, #48, #77, & #82) and four Residents in a confidential group meeting) reviewed for nutritional services.Findings include:During the lunch meal observation on 2/8/2026 at approximately 1:15 PM, the meal tray cards on each tray specified what each resident preferred or had been ordered by the Physician. Resident #30 (R30) R30 had a meal tray card which indicated, Standing Orders: 8 fl oz (fluid ounces) Assorted Fruit Juices. R30 received 4 oz orange juice. Resident #22 (R22) R22 had a meal tray card which indicated Standing Orders: 4 fl oz Assorted Fruit Juices (lemonade, cran[berry], or apple). R22 received 4 oz orange juice. Resident #48 (R48) R48 had a meal tray card which indicated, Standing Orders: 8 fl oz Assorted Fruit Juices (fill cup). R48 received 4 oz juice. Resident #12 (R12) R12 had a meal tray card which indicated, Standing Orders: 8 fl oz Apple Juice (2 x small). R12 received one 4 oz apple juice not the two as specified. R12's meal tray card also indicated a dislike for, Vegetables (ONLY LIKES corn, green beans, regular potatoes). Sliced cooked carrots were on the menu and R12 did not receive an alternative to carrots and had no vegetables on his plate. Resident #6 (R6) R6 had a meal tray card which indicated, Notes: Can have deli meat/lunch meat. Alternative meal: Ham or turkey sandwich. R6 received a peanut butter and jelly sandwich. Resident #47 (R47) R47 had a meal tray card which indicated, Standing Orders: Would like 2 bowls of soup unless Deli Slip is filled out. R47 did not have a selective menu filled out and did not get any soup on the tray. Resident #82 (R82) No condiments (salt, pepper or sugar) were noted on the meal trays to flavor the food. R82 had a meal tray card which indicated, Standing Orders: . 2 cream, 1 sugar sub (substitute). No cream, sugar, salt or pepper were on the meal tray for R82. The Certified Nurse Aide (CNA) R said, She's going to want salt and pepper for sure along with the cream and sugar substitute. Resident #77 (R77) Some residents had filled out a handwritten menu with selections of the Always Available Menu. R77 had written Hot Dog x2 on the selective menu card and received two hamburgers with cheese. R41 had written HOT DOG W/MUSTARD on the selective menu card and had received a hamburger. Resident #22 (R22) R22 had a meal tray card which indicated, Extra sauces or gravy to Foods. R22 had dry ground meat without sauce or gravy. Resident #37 (R37) R37 had a meal tray card which indicated, Extra sauces or gravy to Foods. R37 had dry chopped meat without sauce or gravy. Resident #31 (R31) R31 had a meal tray card which indicated, Sauce/gravy on all meats. R31 had dry ground meat without sauce or gravy. During an interview on 2/8/2026 at 1:58 PM, R31 was asked about her meal. R31 replied, They did not give me gravy, so it was too dry. I did not like it and did not eat anything but one sip of milk. R31's meal tray was sitting at her bedside and appeared untouched except approximately 50% of her serving of chocolate muffin had been consumed. Resident #13 (R13) During the breakfast meal observation in the dining room on 2/9/2026 at 8:31 AM, R13 discussed her meal and said it was Ok but I did not get any yogurt. R13 had handwritten yourgut (sic) on her selective menu. R13 continued to explain, They must be out again. R24 was also in the dining room at this time. R24's meal tray card was observed, and it included, Standing Orders: 1 ea (each) Fresh Banana. There was not a banana on R24's tray although other residents were observed to have a banana. R24 said he got a banana every day and would like one. During an interview on 2/11/2026 at 9:30 AM, the Registered Dietitian (RD) K stated, she would expect condiments on the trays and the meal items on the tray cards to be served as written. Resident #4 (R4) Review of R4's MDS assessment dated [DATE], revealed admission to the facility on 7/25/23 with diagnoses including malnutrition, depression and anxiety disorder. R4 scored 3 of 15 on the BIMS assessment reflective of severe cognitive impairment. During an observation on 2/10/26 at 10:14 a.m., Hospitality aide G walked into R4's room and picked up the breakfast tray. R4 had not eaten any of the food from the tray as it was out of her reach. Hospitality aide G walked out of R4's room and did not offer any food or beverage substitutes or alternative menu items. Resident #47 (R47) Review of R47's MDS assessment, dated 1/16/26 revealed admission to the facility on 5/16/25 with active diagnoses that included: diabetes mellitus and hip fracture. R47 scored 13 of 15 on the BIMS assessment reflective of intact cognition. During an observation on 2/9/26 at 9:56 a.m., Licensed Practical Nurse (LPN) H walked into R47;'s room and removed the meal tray from R47's bedside. LPN H did not offer any food or beverage substitutes or alternatives menu items On 2/9/26 at 2:00 PM, a confidential group interview was conducted where four residents stated the facility frequently ran out of their preferred food choices including ice cream, yogurt, pudding, cookies, hamburgers, and hot dogs, which are supposed to be on the Always Available food menu. One Confidential Resident (CR) stated due to a medical condition, they required a gluten-free diet and was served a salad for two meals a day, five days per week. When asked what they would prefer instead of a salad, the CR replied, I'm tired of salads, anything but a damn salad. Review of Resident Council Meeting Minutes since March 2025 read, in part: 3/20/25: .New Business – Concerns/Complaints/Grievances: Residents stating their dislikes are listed right on meal ticket and the kitchen still sends their dislikes to them. 4/17/25: .List of old business (unresolved): Residents continue to get their dislikes (meal ticket) for their meal. New Business – Concerns/Complaints/Grievances: .Residents continue getting food that are listed on their dislikes on meal tickets. 11/20/25: .New Business – Concerns/Complaints/Grievances: Kitchen not having food available that residents ask for. Examples: hamburgers, hot dogs, tomato juice, hot chocolate, ice cream, creamer, sweetener . 12/17/25: .List of old business (unresolved): Kitchen continues to run out of items residents want to order. New Business – Concerns/Complaints/Grievances: .Kitchen continues running out of times. Example: hamburgers, ice cream, cottage cheese, hot chocolate, creamer. 1/15/26: .List of old business (unresolved): Kitchen running out of items – not improved. Review of a facility document titled, A La Carte Menu [Facility Name], read, in part: Breakfast Options Available: . yogurt. Lunch & Dinner Options Available: . hamburger or cheeseburger, hot dog. Sides or Desserts: pudding.ice cream, cookies. Review of the facility policy titled, Resident Meal Service, reviewed 7/1/25, read, in part: Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance. the interdisciplinary staff. will assess each resident's nutritional needs, food likes, dislikes, and eating habits. Review of the facility policy titled, Resident Food Preferences, reviewed 7/31/20, read, in part: .Upon the resident's admission, Dietary Manger or designee will identify a resident's food preferences. Whenever possible, the staff and physician will strive to minimize dietary restrictions in order to accommodate those preferences. the resident's clinical record (orders, care plan, or other appropriate locations) will document the resident's likes and dislikes and special dietary instructions or limitations. The Food Service Department will offer food substitutes.

Based on observation, interview, and record review, the facility failed to provide dining adaptive equipment for four Residents (#6, #23, #30 & #48) of five residents reviewed for dining assistive devices. Findings include: During the lunch meal observation on 2/8/2026 at 1:15 PM, four meals did not receive the prescribed special adaptive equipment per the meal tray cards:Resident #6 (R6)R6 had a meal tray card which indicated Adap. Equip: (Adaptive Equipment) 2-handle Cup, Built-Up Utensil Handles, red plate. R6 received plastic silverware but did not receive silverware with built -up utensil handles and did not receive the specialty red plate.Resident #23 (R23)R23 had a meal tray card which indicated Adap. Equip including straws. No straws were observed on R23's tray.Resident #30 (R30)R30 had a meal tray card which indicated Adap. Equip including 2-handled cup, and straw. R30's tray did not include a straw or beverage in a 2-handled cup.Resident #48 (R48)During the breakfast meal observation on 2/9/2026 at 9:01 AM, R48 had a meal tray card which indicated Adap. Equip including 2-handled cup and on the side of the meal tray card contained an ALERT: 2 handled cup FLAT LID. R48's beverage was not served in a 2- handled cup with a flat lid.The facility policy titled Use of Assistive Devices dated as reviewed/revised on 10/26/2023 read in part, The purpose of the 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. Assistive devices are tools, products, types of equipment, or technology that help individuals perform tasks and activities.Assistive devices include:.g. Eating utensils.3. 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.The facility policy titled Resident Meal Service dated as reviewed/revised on 7/1/2025 read in part, Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance. 6. Assistive devices will be made available to residents who need them.

Based on observation, interview and record review the facility failed to promote and facilitate resident self-determination through support of resident choice for three Residents (#10, #12, & #30) of three Resident reviewed for resident choice.Findings include: Resident #10 (R10) According to the medical record, R10 was admitted on [DATE] with diagnoses including spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy characterized by extreme muscle stiffness and poor motor control in all four limbs and trunk), need for assistance with personal care, major depressive disorder and chronic pain syndrome. R10's Minimum Data Set (MDS) dated [DATE] contained a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating R10 was cognitively intact. R10's functional status assessment revealed substantial assistance from staff to roll right or left, total dependence on staff to sit from lying down and total dependence on staff to transfer to and from a bed to a chair (or wheelchair). On 2/8/2026 at 2:34 PM, a sign was observed on the outside of R10's door which read, Please wake up by 1 PM. The room was dark and R10 was lying awake in bed. R10 stated, No one has been in yet. I like to get up by 1 (PM) and it is now 2:35 [PM]. During an interview on 2/9/2026 at 2:00 PM, R10 confirmed her desire to get up by 1:00 PM. She stated again she was not up until way after 1:00 today. She said she felt it was because there were not enough staff to help the residents. R10 said, They need more help here. R10 said it was very frustrating that almost every weekend there was not enough staff to provide care. During a telephone interview on 2/9/2026 at 3:18 PM, Certified Nurse Aide (CNA) R said, I feel really terrible but there were not enough people to provide quality care yesterday. She repeated, I feel really bad. CNA R said R10 was supposed to get up by 1:00 and she did not get up until 3 yesterday. CNA R said, She needs two people to get her up and going and there were only 4 CNAs in the building so we could not get to her. The observed workload for 2/9/26 revealed one of the four CNAs was assigned to monitor one resident at all times so the remaining three CNAs were responsible for the other 85 residents. The care plan for R10 was reviewed and the Activities of Daily Living focus had an intervention of, TRANSFERS: Sit-to-Stand lift with 2 person assist. The care plan also included a focus of Resident preferences/quality of life. with an intervention of Honor resident's bedtime preference: (R10) likes to go to bed at 4am and wake up between 1pm -2pm. Date Initiated: 08/08/2023. R10 has submitted multiple grievances to the facility to attempt to solve this issue. On 10/28/25, R10 submitted a type-written letter to the facility stating concerns of not getting up until as late as 4 PM because the nurse wanted to go to lunch and then the hall got really busy. On 1/6/26, R10 presented a typed letter to the facility which stated on 12/27/25 she was not assisted out of bed until after 2 PM. The letter stated, the nurse asked me if I could wait until they (nurse and aide) went to lunch & I said NO because it was already after 2pm. Both solutions of the grievance involved staff education on getting resident up prior to 2 pm. Resident #12 (R12) Review of MDS assessment dated [DATE], revealed admission to the facility on 6/7/25 with diagnoses including diabetes mellitus and peripheral vascular disease (PVD) [circulation disorder involving narrowing, blockage, or spasms in blood vessels outside the heart and brain, most commonly affecting the legs and feet] or peripheral arterial disease (PAD) [vascular condition where fatty plaque builds up in the arteries that carry blood to the limbs, usually the legs]. R12 scored 11 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of moderate cognitive impairment. During an interview on 2/9/26 at 9:36 a.m., R12 reported, I have a wound on the bottom on my foot and the nurse will come in during the night or very early in the morning.they wake me up and I can't get back to sleep.I would like the treatment to be done during the day when I am awake. Resident #30 (R30) Review of MDS assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: cancer and arthritis. R30 scored 11 of 15 on the BIMS assessment reflective of moderate cognitive impairment. During an interview on 2/8/26 at approximately 9:38 a.m., R30 reported, The nurse comes in the middle of the night for my roommates dressing change and turns all the lights on, I don't know why they have to turn all the lights on like that.I can't sleep the rest of the night. During an interview on 2/10/26 at 12:35 p.m., Licensed Practical Nurse (LPN)/Unit Manager S reported, I haven't asked R12 what time he would like his dressing change.I schedule them at night. During an interview on 2/10/26 at 12:38 p.m., R12 reported, I have told the nurse before that I didn't want to have the dressing changed at night, but the nurse still changes my dressing in the middle of the night. I would like to sleep through the night. Review of policy titled Pressure Injury Prevention and Management last date reviewed/revised 3/20/24, read in part .Evidence based treatments in accordance with current stands of practice will be provided for all resident who have a pressure injury present.the goals and preferences of the resident.will be included in the plan of care. Review of policy titled Promoting/Maintaining Resident Dignity last dated reviewed/revised 10/26/23, read in part .It is the practice of this facility to protect and promote resident rights.the resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences.

Based on observation, interview, and record review, the facility failed to ensure accurate advanced directive information was in place for one Resident (#11) of two residents reviewed for accuracy of advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time).Findings include:Resident #11 (R11)The Electronic Medical Record (EMR) for R11 revealed an admission on [DATE] with a primary diagnosis of autistic disorder (a lifelong neurological condition characterized by difficulties with social communication, restricted interests and repetitive behavior). The Minimum Data Set (MDS) assessment indicated the Brief Interview for Mental Status (BIMS) assessment could not be completed as the resident was rarely/never understood. The Physician Orders included Full Resuscitation, dated as 8/17/2022. R11's EMR was noted to have a chart banner on each page indicating Code Status: (Advanced Directives) Full Resuscitate.The documents filed in the EMR included a form titled DO NOT RESUSCITATE (DNR) ORDER GUARDIAN CONSENT COURT APPOINTED GUARDIAN MAKING DECISIONS. This form was signed by the Legal Guardian and the Physician on 12/12/2025. There were lines on the form for the attestation of two witnesses with their signatures and these lines were blank.Further documents dated 11/12/2024 signed by the Legal Guardian and the Physician indicated a box checked, I want efforts made to prolong my life and want life sustaining treatment to be provided.During an interview on 2/9/2026 at 3:54 PM, the Social Service Designee/Staff P reviewed the documents that indicated R11 should be resuscitated and others which indicated R11 should not be resuscitated. Staff P said he was not sure if R11 was a full code or a DNR.During an interview on 2/9/2026 at 3:59 PM, License Practical Nurse (LPN) H looked at the banner on the EMR and stated R11 was a full code (and should be resuscitated). She said she thought he had always been a full code. The EMR form titled DO NOT RESUSCITATE (DNR) ORDER GUARDIAN CONSENT COURT APPOINTED GUARDIAN MAKING DECISIONS for R11 was also reviewed and then LPN H stated she did not know what the directive should be. The facility policy titled, Residents' Rights Regarding Treatment and Advance Directives revised on 10/30/2023 read in part: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. 8. Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions.

Based on observation and interview, the facility failed to protect the privacy of medical records for one Resident (#99) of one resident reviewed for privacy of medical records.Findings include:During an observation on 2/11/26 at 8:22 a.m., A medication cart at the beginning of C Hall had a facility laptop computer open with R99's personal health information present on the screen with no facility staff present near the medication cart.During an interview on 2/11/26 at 8:23 a.m., Licensed Practical Nurse (LPN) U reported, I know I am not supposed to leave the screen opened with resident information available for anyone to have access to.During an interview on 2/11/26 at 9:38 a.m., the Nursing Home Administrator (NHA) acknowledged medical record information was not secured when the LPN walked away from the medication cart.

This citation pertains to intake 2720794.Based in observation, interview and record review, the facility failed to implement timely interventions to prevent the development and worsening of pressure ulcers for two Residents (#10 and (#14) of three residents reviewed. This deficient practice resulted in R10 developing an unstageable (a severe, full-thickness wound covered with necrotic tissue covering the wound bed causing inability to determine true wound depth) requiring surgical debridement (surgical removal of dead tissue), intravenous (IV) antibiotic therapy and hospitalization.Findings include:Resident #10 (R10)Review of a confidential complaint submitted to the State Agency (SA) on 1/12/2026 at 12:25 p.m. revealed an allegation that the facility failed to provide care to prevent the development and worsening of pressure ulcers for R10. The information submitted cited, On 01/08/2026, [R10] was admitted to the hospital for the second time in about three months since being at [facility name]. [R10] was admitted for severe bed sores with exposed bone on his buttocks. While at [facility name], [R10] was neglected. He was not moved regularly . The neglect of [R10] led to the occurrence of his severe wounds. He was admitted to [facility name] in August 2025 without any bedsores . He will remain admitted to the hospital until there is a bed open in a hospice house.Review of R10's electronic medical record (EMR) revealed the following:1/7/2026 at 10:41 p.m. Resident vomited during cares . He could not catch his breath after vomiting and oxygen saturations are 83% . MD [physician] stated to send resident to the hospital and EMS was contacted.12/30/2025 at 9:15 a.m. Skin Issues . Right gluteus . Pressure ulcer/injury . Stage 3 pressure ulcer/injury - full thickness skin loss . Wound acquired in-house. Length (cm) [centimeters]: 3.53. Width (cm) 6.76. Depth (cm): 2. Area (cm2) [centimeters squared]: 20.05. Undermining: Yes . Undermining length (cm): 3.5 .Review of the resident profile information retrieved from the EMR revealed R10 was initially admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, adult failure to thrive, weakness, and cognitive communication deficit. Review of R10's, Nursing admission Evaluation, dated 9/17/2025, revealed R10 was assessed as having bilateral lower leg arterial/venous wounds, scabs/bruising on both arms and had bowel incontinence. The Evaluation noted R10 was at risk for and had actual skin impairment with interventions indicated including a pressure redistribution mattress to bed.Review of R10's EMR from the time of admission on [DATE] through the date of re-hospitalization on 10/27/2025, revealed the following:9/18/2025 at 2:52 a.m. Braden Scale for Predicting Pressure Sore Risk . Mobility: Very limited. Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes . The assessment scored R10 at 15, at risk for pressure ulcers.A physician progress note, dated 9/24/2025 at 3:57 p.m., revealed R10 was assessed as having no open wounds.9/24/2025 12:30 p.m. IDT - Interdisciplinary Progress Note . Max Ax2 [assistance of two staff] for transfers, Max A [assistance] ADLs. Pertinent Charting - Skin, dated 9/26/2025 at 10:25 a.m., revealed identification of MASD [Moisture-Associated Skin Damage] on BL [bilateral] buttocks. 3.54 cm [centimeters] x 5.65 cm . New Orders: calmoseptin bid [twice daily] to BL buttocks.9/26/2025 at 10:48 a.m. Resident was noted to have a new skin issue to his bilateral buttocks. In review of wound it was noted that the skin was red with several areas where the skin was eroded. He was noted to be having loose stools .10/1/2025 at 8:00 p.m. bilateral buttocks area not improving as he has had recent loose stools . continue to apply cream and off load while in bed.10/2/2025 at 10:37 a.m. OT [Occupational Therapy] 10/01/2025 - Upon initiation of OT, [R10] was found lying in liquid stool in brief. [R10] reported he was not aware he was incontinent.10/4/2025 at 8:59 p.m. sheering of both buttocks .10/5/2025 at 6:58 p.m. sheering of both buttocks .10/7/2025 at 2:22 a.m. and 5:45 p.m. sheering of both buttocks .10/8/2025 at 3:01 a.m. and 7:23 p.m. sheering of bilat [bilateral] buttocks .10/9/2025 at 4:12 a.m. and 7:47 p.m. sheering of bilat buttocks .10/10/2025 at 3:48 p.m. dressing placed on buttocks this [morning] after peri-care done. [R10] does have ve [sic] liquid stools.10/15/2025 at 7:41 p.m. buttocks are purple in areas with scattered open superficial area .10/17/2025 at 4:29 p.m. buttocks are purple in areas with scattered open superficial area .10/18/2025 at 5:36 p.m. buttocks in [sic] deteriorating. Low air loss mattress ordered .10/20/2025 at 12:45 a.m. Low air mattress is on as ordered .A physician progress note dated 10/23/2025 at 4:03 p.m. Patient is seen for follow-up of wound care. He presents with deteriorating and [sic] left gluteal wounds. The wound initially began as MASD mid-September and has since progressed to what appears to be suspected deep tissue wounds as there is a moderate amount of slough [versus] eschar.A physician progress note dated 10/27/2025 at 11:06 p.m. Patient is seen for follow-up of wound care. Last Thursday he presented with deteriorating buttock wounds which have progressed to unstageable pressure ulcers. Today he presents with nearly 100% black necrotic [dead] tissues, purulence from wound and erythema [redness] with induration quite concerning for wound infection [versus] necrotizing fasciitis as his wounds have worsened with haste. He has a low grade [temperature] and lower blood pressures from his norm along with elevated [heart rate]. He will be shipped to ER for evaluation and treatment as his wound advancement is beyond our care here.Review of R10's Inpatient Discharge Summary, dated 11/3/2025, revealed R10 was hospitalized on [DATE] with return to the facility on [DATE]. Further review of the Discharge Summary revealed the following: On arrival to the emergency department patient was noted to be ill-appearing and tachycardic with a heart rate of 106 and respiratory rate of 28. A physical exam revealed a necrotizing, foul-smelling wound over the sacrum and bilateral buttocks. A sepsis workup was initiated, and CT of the pelvis was obtained, which revealed soft tissue ulceration, edema and gas within the right sacral and proximal gluteal region consistent with a decubitus ulcer . Labs were significant for leukocytosis of 34.0, CRP of 29.9 and sed rate of 87. The patient received a sepsis fluid bolus and was started on broad-spectrum antibiotics including vancomycin, clindamycin and meropenem. General surgery was consulted and [surgeon name] took the patient to the operating room for an urgent incision and debridement . The patient was admitted to the ICU [intensive care unit] . the patient was started on midodrine 10mg 3 times daily for suspect vasoplegia [a form of severe shock characterized by dangerously low blood pressure] secondary to sepsis . Physical exam at discharge . Skin . large surgical dressing to sacral area with wound VAC in place .Review of physician orders for R10 revealed and order dated 10/17/2025 for Low air loss mattress: Staff to ensure mattress is working properly. If any noted malfunctions or suspected malfunctions notify charge nurse immediately.During an interview on 2/4/2026 at 2:30 p.m. Maintenance Director (Staff) C was queried regarding the process for receiving work orders for placement of low air loss mattresses. Staff C reported nursing staff enter the order into communication program and upon receiving the order, maintenance staff complete the order generally within 48 hours since the facility has a large supply of low air loss mattresses on hand. When asked for the tracking data for the work order for the placement of R10's low air loss mattress, Staff C reported once the work order is completed, there was no way to retrieve the data. When asked to clarify, Staff C reported there was no record of when work orders are placed or completed to reference.During an interview on 2/4/2026 at 2:45 p.m., Unit Manager/Licensed Practical Nurse (LPN) A was queried regarding the indications for use of low air loss mattresses. LPN A reported indications included a variety of assessment data and discussion with the IDT (interdisciplinary team). The LPN A confirmed indications for use of low air loss mattresses to aid in the prevention of pressure ulcers included the presence of MASD, moisture, Braden assessments indicating residents at risk and decreased mobility. LPN A added that she defers the decision to the DON. Review of R10's September 2025 and October 2025 MARs (Medication Administration Records) and TARs [Treatment Administration Records) revealed no documented order, application or monitoring of a low air loss mattress.Review of POC (point of care) documentation for September 2025, October 2025 and November 2025 revealed consistent documentation of the presence of a Pressure Redistribution Mattress to Bed, from the time of R10's admission on [DATE] through the Resident's hospitalization on 10/27/2025. Further review revealed bed mobility documentation of R14 being totally dependent on two-person assistance on 12 days and of requiring extensive two-person assistance on 14 days of 30 days reviewed.During an interview on 2/4/2026 at 3:15 p.m., Unit Manager, LPN B reported POC tasks originated from nursing assessment findings and applicable interventions marked on the assessment form deemed appropriate for implementation. LPN B reported the nursing interventions listed in the evaluations were not orders but identified recommendations. During an interview on 2/4/2026 at 3:54 p.m., the DON reported indications for the use of low air loss mattresses included a diagnosis of failure to thrive, which increased the risk of pressure ulcer development. The DON reported R10 was very ill and was frequently incontinent of stool. The DON was asked if consistent moisture related to bowel incontinence posed an increased risk for skin breakdown to which she reported moisture does increase risk of developing pressure ulcers. The DON was aware the facility had a supply of low air loss mattresses on hand, but the placement of the mattresses required nursing staff to obtain a physician's order. The DON reported she was not involved in R10's care until she took over the position from the facility's previous DON who resigned unexpectedly in December 2025. The DON stated she could not account for nursing or POC documentation of the presence of a low air loss mattress prior to 10/17/2025 or prior to placement of the mattress. The DON confirmed the low air loss mattress would not have been placed until after the order was obtained and maintenance notified of the need.Review of the Completed Work Order #4451, provided by the Nursing Home Administrator (NHA) and Senior Nursing Home Administrator (NHA) E at 4:20 p.m. revealed the order for the placement of the low air loss mattress was placed by the NHA on 10/17/2025. Review of the timeline with NHA E revealed the order was created on 10/17/2025 at 4:43 p.m. with documented completion of the air mattress placement on 11/04/2025 at 10:51 a.m. NHA E stated, It's not really what we wanted to see. It was noted in review, the air mattress was not placed on R10's bed until after the Resident returned from hospitalization on 11/03/2025 and post-surgical debridement, wound vac placement and treatment for sepsis.Resident #14 (R14)Review of the resident profile documentation gleaned from the EMR revealed R14 was admitted to the facility on [DATE] and had diagnoses including diabetes, adult failure to thrive, dehydration, difficulty walking, and osteoarthritis. Review of the MDS assessment, dated 1/25/2026, revealed R14 required substantial/maximal assistance with bed mobility and was dependent on staff for transfers. Further review of the MDS assessment revealed the presence of one stage 2 (partial-thickness tissue loss) pressure ulcer/injury and the risk of developing pressure ulcer/injuries.An observation on 2/4/2026 at 10:10 a.m. revealed R14 seated in bed with the head of the bed at approximately 45 degrees. R14 was noted to have a pillow under her knees and upper portion of lower legs with her heels directly on mattress. Heel protection boots were observed to be on nightstand in corner of the room. When asked if staff put the boots on her while in bed, the Resident reported no, they bother me. That's what the pillow is for. When asked if resident had any open wounds, she reported yes and motioned her left outer thigh. It was noted during the observation that there was no low air loss mattress on R14's bed.Review of R14's, Nursing admission Evaluation, dated 1/19/2026, revealed the Resident was assessed as having a right buttock rash, a left buttock blister, and a pressure wound on her right rear thigh and left gluteus on admission. The Assessment care plan interventions to be implemented included Pressure redistribution mattress to bed.Review of physician orders from the time of admission on [DATE] through 2/04/2026 revealed no order for placement or monitoring of a low air loss mattress for R14.Further review of the EMR revealed the following:1/20/2026 at 8:27 a.m. Resident admitted with multiple areas of skin concerns . She had two pressure ulcers one on the left and right gluteus.An observation on 2/4/2026 at 12:10 p.m., revealed R14 seated in bed directly on her buttocks. No wedge pillow or positioning device was observed in R14's bed to offer offloading from buttocks. A pillow was noted to be under R14's knees but R14's heels were resting directly on the mattress. It was noted during the observation that there was no low air loss mattress on R14's bed.An observation on 2/4/2026 at 2:18 p.m., revealed R14 seated in bed. R14's heels were observed to be resting directly on the mattress, and a pillow was noted to be on the bed to the right of the resident's right lower leg. R14 was asked if she could move around independently in bed at which time she raised her right leg approximately 3 inches off the bed. R14 reported she could not move her left leg up off the bed due to severe knee pain. Heel protection boots were observed atop a nightstand in the corner of R14's room. It was noted during the observation that there was no low air loss mattress on R14's bed.During an interview on 2/4/2026 at 2:20 p.m., Registered Nurse (RN) D stated R14 was very leery and fearful when it comes to turning and repositioning. RN D confirmed R14 had left knee pain and was unable to move left leg consistently or reposition herself in bed. RN D stated she does not like to wear the heel boots and is at risk for developing further pressure injuries. RN D confirmed there was no low air loss mattress on R14's bed.During an interview on 2/4/2026 at 2:45 Unit Manager, LPN A reported she was unaware of R14's declination to wear heel protection boots. LPN A reported she was aware R14 was admitted with pressure injuries which placed the Resident at higher risk for development of future wounds.No declaration or documentation related to facility past non-compliance was offered by the facility through survey completion and exit on 2/4/2025 at 5:00 p.m.Review of the facility policy titled, This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries . 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 . Interventions will be based on specific factors identified in the risk assessment, skin assessment and any pressure injury assessment (e.g., moisture management, impaired mobility . wound characteristics . Evidence-based interventions for prevention will be implement for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: Minimize exposure to moisture and keep skin clean, especially of fecal contamination. Provide appropriate pressure-redistributing support surfaces.

This citation pertains to intake MI00153461. Based on interview, and record review, the facility failed to implement a timely dressing change to a post-operative surgical area, correctly document an initial skin assessment, and communicate a change in wound condition to facility physician for one resident (Resident #11) of six residents reviewed for quality of care. This deficient practice resulted in a secondary surgery which included an incision and drainage and re-closure of the wound, antibiotics, and hospital admission. Findings include: Resident #11 (R11) Review of R11's admission face sheet, dated 6/18/25, revealed an admission to the facility on 2/1/25 with diagnoses including fracture of the right hip, fusion of the spine, diabetes mellitus, adrenal insufficiency, and arthritis. The discharge date was recorded as 2/12/25. On 6/17/25 at 7:24 PM, an interview was conducted with Complainant I regarding the intake allegations and replied, I begged the facility to change the dressing on my back from my spinal surgery. The nurses told me they were only to do the dressing on my right hip. Finally, they did after several days. The nurse did not do the dressing change on my back on 2/7/25. I went to have a follow-up appointment on my hip on 2/11/25 and I asked the orthopedic doctor to please look at my back because I was having increased pain in my back. The orthopedic surgeon looked at my back and stated that the incision was reddened, had some yellow drainage, and asked if the facility could get in contact with my back surgeon immediately. I had the facility staff take a picture of my back and the back surgeon's office called me and told me to get to the emergency room at 6:00 AM on 2/13/25, down state where I had my original back surgery done. On 2/13/25, the back surgeon took me to the operating room and washed out my back incision and put me on intravenous antibiotics for four days. I was discharged home on the fourth day (2/17/25) with oral antibiotics that I had to take until the beginning of March. R11 stated she was originally admitted to the facility after a fall at home and fracturing her right hip. Review of R11's hospital discharge, dated 1/13/25 revealed the reason for hospitalization was a L(lumbar)4-5 and L5-S(sacral)1 lumbar fusion on 1/10/25 and was discharged to home on 1/13/25. Review of the hospital history of present illness document, dated 2/13/25, read in part, .Sutures (to back surgery on 1/10/25) were apparently removed in rehab (nursing facility) all at once .patient began experiencing incisional drainage .Assessment/Plan .Discussed option of local rehab post-operatively so we can progressively remove sutures one at a time, which is what I recommend in patients on chronic steroids . Review of emergency room visit, dated 2/13/25 at 10:28 AM, read in part, .Patient has back surgery about a month ago and was sent in by (back surgeon's name) for infected incision site on the back .Patient developed infection lower back complains of pain .Back: There is tenderness lower back area incision site there is some wound dehiscence and swelling erythema (redness) .Case was discussed with (back surgeon's name) patient will be admitted and taken to OR (operating room) for cleanout of wound. Patient will be given vancomycin pharmacy to dose . Review of R11's hospital discharge, dated 2/17/25, revealed the reason for hospitalization was, the patient underwent a lumbar fusion last month. Past few days, patient began experiencing incisional drainage. She was admitted to hospital for wound washout and ID (incision and drainage) recommendations. Patient had a lumbar wound washout on 2/14/25. (name brand drain) removed today. Surgical site infection. Wound infection. Review of R11's discharge summary from the local hospital, dated 2/1/25, read in part, .R (right) hip dressing in place post op [operation] . some dried blood on dressing but no surrounding erythema. Sutures on back noted from recent back surgery. Good wound healing and no dehiscence noted . Review of admission report to facility from local hospital, dated 2/1/25, read in part, .Fall at home, R (right) hip fx (fracture) - post op day 4 .Skin & Wounds: Small dressing, upper buttock, foam dressing . Review of nursing admission evaluation, Section V. Skin, dated 2/1/25 at 3:48 PM, read in part, .Other, right midline buttock, pressure . Further review of the nursing admission evaluation revealed no documentation of R11's post-operative back incision. Review of R11's facility physician order, dated 2/3/25 at 11:00 AM, revealed an order to monitor wound to central lower back, wash with wound cleanser, pat dry and cover with foam dressing daily and PRN (as needed), in the afternoon for the wound present from admission. R11 had their first surgical back wound care dressing change on 2/3/25 on the third day of her initial admission date to the facility. No dressing change was provided on 2/7/25 and on 2/11/25 which was marked as 9in the electronic medical record (EMR), indicating a nursing note was associated with the treatment. Further review of the EMR revealed no nurses note was documented. Review of R11's physician progress note, dated 2/4/25 at 3:27 PM, read in part, .admitted for therapy services s/p (status post) hospitalization for fall with .fracture of the right hip joint. She continues participating with therapies per orders .Plan: Continue with therapies as directed, update provider with changes or concerns. The physician note lacked any documentation of observing the surgical back wound that was still in the healing process. Review of R11's progress note, dated 2/5/25 at 1:22 PM, read in part, .Nursing .dehiscence to surgical wound to lower back . Review of R11's physician progress note, dated 2/6/25 at 10:53 AM, Patient continues participating with therapy as ordered .Assessment: femur fracture, admission .Plan: No changes to plan of care . The physician note lacked any documentation of observing the surgical back wound that was dehiscence. Review of R11's facility physician order, dated 2/6/25 at 11:00 AM, revealed an order to cleanse surgical incision to spine with wound cleaner, pat dry, apply medi-honey to wound bed, then cover with silicone dressing, change daily and PRN, in the afternoon for wound. Review of R11's post op orthopedic progress note for right hip fracture, dated 2/12/25 at 12:06 PM, read in part, .Patient and her husband wanted me to look at her lumbar incision when she had lumbar surgery approximately 4 weeks ago does appear to be having some wound dehiscence and some mild drainage from the area .she in independent enough now to be stable at home we will refill her pain medications for I have urged her to go see her spine surgeon as soon as possible and she may need a washout of that wound . Review of R11's progress note, dated 2/12/25 at 1:03 PM, read in part, .Nursing .dehiscence to surgical wound to lower back, daily wound care . Review of R11's progress note, dated 2/12/25 at 4:55 PM, read in part, Wound care asked to go to resident's room and follow up on surgical incision to back .Nurse asked how the incision has been feeling resident states that she is having more pain. Resident's (sic) states a nurse has told her that she will not receive treatment to that surgical incision due to it being from another surgeon's office .removed dressing, light drainageon (sic) dressing, skin around wound is reddened, slough in wound bed . Review of R11's progress note, dated 2/12/25 at 7:13 PM, read in part, (back surgeon's name) office phoned and inquired about surgical incision .(back surgeon's name) office would like to see her in ER (emergency room) .tomorrow . On 6/18/25 at 11:00 AM, an interview was conducted with Nurse Practitioner (NP) J, who was asked if they were notified or were made aware R11 had a post-op spinal incision and whether they assessed the site. NP Jreplied, I don't recall one on R11's back. If I observed that area, I would have stated in my provider notes under assessments that I had. NP J was asked if they were notified of R11's surgical back incision dehiscence, and replied, No, if it is not in my notes, I was not made aware. I would have referred the wound care nurse to the original surgeon for further direction and wound dressing care orders. On 6/18/25 at 12:35 PM, during an interview, the Director of Nursing (DON) was asked if skin assessments should be accurately documented by nursing and replied, Yes. R11's skin assessment was incorrectly documented. The DON was asked the expectation should floor staff identify a new wound or deterioration of an existing wound and replied, The nurse should have called the physician and notified them and make a progress note indicating the communication such as new orders. The DON was asked if R11 should have had back wound dressing change orders on the first day of their admission and replied, Yes. The DON was asked if the physician should have been made aware of R11's wound dehiscence and replied, Yes. The nurse should also document the response of the physician. Review of policy titled, Wound Treatment Management, dated 10/30/20, read in part, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders .

This deficiency pertains to Facility Reported Incident (FRI) MI00145815. Based on observation, interview, and record review, the facility failed to prevent, detect, and respond to an elopement resulting in the likelihood of serious harm, injury, impairment, or death for two Residents #4 and #5 (R4, R5) of three residents reviewed for elopement. Findings Include: The Immediate Jeopardy began on 7/13/24 at 6:18 PM when R4 and R5 eloped from the facility undetected and whose location was subsequently identified and reported to be on a thoroughfare by a facility visitor. Regional Director of Operations F was notified of the immediate jeopardy on 7/25/24 at 4:27 PM. At that time, a written plan of correction for removal was requested from the facility. This surveyor confirmed by interview and record review that the immediacy was removed on 7/25/24 at 5:45 PM, however, noncompliance remains at the potential for more than minimal harm due to sustained compliance which has not been verified by the State Agency (SA). Resident #4 (R4): Review of R4's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including Alzheimer's Disease and diabetes. Record review of R4's most recent Minimum Data Set (MDS) assessment, dated 5/20/24, revealed a Brief Interview for Mental Status (BIMS) score of 7, indicative of severe cognitive impairment. Review of MDS Section GG, Functional Abilities and Goals, revealed R5 was unable to ambulate (walk) due to a medical condition or safety concern. Review of R4's plan of care revealed the following focus, initiated 5/17/24: Resident is at risk for elopement . with the following intervention: Resident wears Wanderguard; monitor placement/function. Resident #5 (R5): Review of R5's EMR revealed admission to the facility on [DATE] with diagnoses including vascular dementia, congestive heart failure, and adjustment disorder with anxiety. Record review of R5's most recent Minimum Data Set (MDS) assessment, dated 5/20/24, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicative of intact cognition. Review of R5's plan of care revealed the following focus, initiated 5/17/24: Resident is at risk for elopement . with the following intervention: Resident wears Wanderguard; monitor placement/function. On 7/23/24 at 11:15 AM, R4 was observed ambulating in the corridor outside her room with a staff member closely following. A wanderguard was observed on R4's left wrist. An interview was attempted and R4 was unable to answer questions related to the FRI. On 7/30/24 at approximately 12:40 PM, R4 was observed pushing R5 in a wheelchair throughout the facility corridors with a staff member closely following. A wanderguard was observed on R4 and R5's left and right wrists, respectively. Review of the FRI submitted to the SA included an incident summary which read, in part: .On 7/13/24, [R4] had assisted [R5] outside of the facility by a door held open by a visitor. Staff outside witnessed the residents and went to accompany them back into the facility. Another visitor saw them exit the facility and notified the nurses . Per the camera footage, residents [R5] and [R4] were outside on the sidewalk 7 minutes in which at that time they were accompanied inside the facility with staff . The wanderguard bracelets were removed per [R4], she took it off as they were annoying . The alarm did not go off in the facility as a visitor held the door open. Through investigation it was shown that this was not a true elopement as the visitor did open and hold the door open and the residents were wanting to go for a walk outside . This was not an elopement . On 7/23/24 at 1:07 PM, a phone interview was conducted with Licensed Practical Nurse (LPN) A who verified she was on duty at the time R4 and R5 eloped from the facility. LPN A stated she was standing at the nursing circle giving report to the oncoming nurse [Registered Nurse (RN) B] when a facility visitor approached her and RN B and notified them R4 and R5 were outside the facility. LPN A reported she and RN B ran outside and observed R4 pushing R5 in a wheelchair eastbound in a westbound lane on a roadway adjacent to the facility. When LPN A was asked if the door alarm sounded prior to R4 and R5's exit, she stated she couldn't recall as visitors were constantly coming in and out of the facility and the alarm sounds each time. LPN A stated, We don't have a receptionist. The alarm sounding has just become normal for us. When asked if R4 or R5 had a history of exit seeking behaviors, LPN A confirmed R5 attempted to exit the facility before. On 7/25/24 at 9:49 AM, a phone interview was conducted with RN B who confirmed she was receiving report from LPN A at the nurse's circle when a facility visitor approached them and stated, Do you know [R4 and R5] are outside? RN B stated she and LPN A immediately responded and, [R4 and R5] were nowhere to be found. RN B continued, We went to the end of the driveway and then to the left where there's an adjacent side road. RN B stated Certified Nursing Assistant (CNA) C was approaching R4 and R5 after spotting them when leaving work. RN B stated, I kept thinking to myself, how is this possible? They are supposed to have wanderguards. RN B stated after examination, neither R4 nor R5 were wearing wanderguards. On 7/24/24 at 2:41 PM, an interview was conducted with CNA C who confirmed she observed R4 pushing R5 in a wheelchair in the roadway when she was exiting the employee parking lot in her vehicle at the end of her shift. CNA C stated, I saw [R4] pushing [R5] in the road . they hit a pothole, and I immediately parked my car and ran toward them. It looked like [R5] was either going to fall out of his chair or was going to try to stand up to navigate the pothole. Review of R4's progress notes revealed the following entries: 1. 5/16/24: .res [resident] started to leave the facility stating she could not stay here . When resident redirected, she gets upset and verbalizing of going home . Writer obtained wander guard order for elopement . 2. 5/17/24: ELOPEMENT: resident left front doors with writer + [and] Resident Advocate (RA) following. Writer +RA offering support, encouragement, reassurance but resident refusing to come back. Writer gave call out to staff at door to call the police . 3. 7/15/24: IDT [interdisciplinary team] met and reviewed resident related to recent elopement .Resident attempted elopement on the day she admitted to this facility but was able to be redirected and a wanderguard was placed, however resident did exit the facility the next day on 5/17/2024 with staff present .On the evening of 7/13 staff were alerted by a visitor that a resident was outside with another resident. Staff immediately responded and found them southeast of the front main entrance . their wander guards were removed. Staff were unable to locate the missing wander guards and it is unclear if this resident removed both wanderguards . On 7/24/24 at 3:15 PM, video footage of the elopement was reviewed by this surveyor with the Director of Nursing (DON). The following written timeline was provided to this surveyor: 18:12:00 [6:12:00 PM] - Residents left the building. 18:13:30 [6:12:30 PM] - [Employee, later identified as CNA D] shuts off door alarm. 18:19:00 - Residents return in [sic] to front door. On 7/25/24 at 1:00 PM, a phone interview was conducted with CNA D who verified she shut off the door alarm on 7/13/24 at the time of the elopement. CNA D stated, I should have used my CNA brain, but I didn't look around [for residents], I just shut it [the alarm] off . I had no education . I didn't know what residents were allowed in or out . when I was there, the alarm would go off constantly and somebody would just go and blindly shut it off [without checking for residents] . I was just shutting the alarm off because it was chaotic, and I didn't look around because everybody was doing it [shutting off the alarm without looking] throughout the day . On 7/25/24 at 2:15 PM, a follow-up interview was conducted with the DON who confirmed R4 and R5 were found in the road. The DON verified CNA D turned off the door alarm according to the video footage. When asked why it was reported to the SA that R4 and R5 were found on the facility sidewalk and the door alarm did not sound, the DON replied, I don't know. On 7/24/24 at 3:39 PM, an interview was conducted with Regional Director of Operations F who verified she was the author of the facility reported incident submitted to the SA. Regional Director of Operations F stated, I didn't do a good job explaining it [the elopement event] in the report. Regional Director of Operations F clarified R4 and R5 were initially spotted in the roadway, not on the facility sidewalk as originally reported. Regional Director of Operations F added, The first time I watched the video footage was yesterday [7/23/24] . I didn't think the alarm went off until I watched the video. I wasn't there [at the facility] when the investigation happened, I guess it was just an assumption [that the facility alarm did not sound]. On 7/24/24 at 4:17 PM, an email was received by Regional Director of Operations F that read, in part: Please see attached 5 day [report] that was revised from my original 5 day that had non accurate information in it. Review of the revised incident summary read, in part: .residents [R5] and [R4] were outside where they exited on the sidewalk and rounded down the road left on [street name] . The door was held open by a visitor, the alarm was silenced by an employee . Review of Facility Policy titled Accidents and Supervision, revised 12/27/24 read, in part: .Identification of Hazards and Risks .all staff .are to be involved in observing and identifying potential hazards in the environment and the risk of a resident having an avoidable accident . implementation of interventions .this process includes .ensuring that the interventions are put into action .educating staff .monitoring and modification processes include .ensuring that interventions are implemented correctly and consistently .supervision is an intervention and a means of mitigating accident risk. The facility provides adequate supervision to prevent accidents . The Immediate Jeopardy which began on 7/13/24 was removed on 7/24/24 at 5:45 PM when the facility took the following actions to remove the immediacy. The Facility Removal Plan read: 1. Education was completed with all staff prior to their next shift worked regarding elopement risk and alarm fatigue. Any staff new at the facility will be educated prior to their shift regarding the residents at risk for elopement and orientation to the exit door and alarm. 2. A perimeter walk through was completed; all doors were noted to be secured. 3. Door codes were changed. 4. There is an employee stationed to monitor the front door from 8am-8pm with the door to be locked after to ensure safety until the front entry way is renovated to include a second set of doors alarmed.

This deficiency pertains to Complaint Intake MI00145750 and Facility Reported Incident (FRI) MI00145875. Based on observation, interview, and record review, the facility failed to prevent two separate incidents of resident-to-resident sexual abuse for four Residents (Residents #1, #2, #4, and #5) of nine residents reviewed for abuse and neglect. This deficient practice resulted in psychosocial harm when Resident #2 experienced ongoing feelings of embarrassment, anxiety, and fear. Findings Include: Resident #2 (R2): Review of R2's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including quadriplegia (paralysis that affects all limbs and body from the neck down), dysarthria (difficulty speaking), adjustment disorder with anxiety, and post-traumatic stress disorder (PTSD). Record review of R2's most recent Minimum Data Set (MDS) assessment, dated 6/21/24, revealed a Brief Interview for Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment. Resident #1 (R1): Review of R1's EMR revealed initial admission to the facility on [DATE] with diagnoses including dementia and personal history of behavioral disorders. Record review of R1's most recent MDS assessment, dated 7/2/24, revealed a BIMS score of 5, indicative of severe cognitive impairment. Review of the FRI submitted to the SA included an incident summary which read, in part: Residents [R2] and [R1] were in the dining room together when [R2] reported that [R1] was rubbing her hair then her leg and started rubbing towards her private area and she told him to stop . The police were notified as the alleged complaint was sexual abuse. [Licensed Practical Nurse (LPN) J] interviewed [R2] who stated I told him [R1] to stop, and he did not stop and touched my vaginal area . [R2] does have PTSD as she has a history of being a victim of sexual assault which has triggered from this event .She [R2] was strangled and left for dead in 1983 and was also assaulted from a partner . On 7/23/24 at 11:15 AM, an interview was conducted with R2 who verified the allegation details. R2 stated, Another resident, [R1], touched me inappropriately .touched my hair and private area. I told him to stop .he didn't stop . it made me feel bad and embarrassed. I didn't want to say anything or talk about it because I was embarrassed . On 7/23/24 at 1:49 PM, an interview was conducted with Activities Director (AD) K who verified she was the staff member whom R2 reported the altercation. Activities Director (AD) K stated R2 reported R1 rubbed her hair, leg, and vaginal area and did not stop despite R2's request to do so. On 7/23/24 at 2:10 PM, an interview was conducted with Social Services Director (SSD) L who verified R2's history of domestic abuse, rape, and strangulation that resulted in PTSD. Social Services Director (SSD) L confirmed R2 experienced prolong feelings of embarrassment following the incident with R1. When asked if R1 exhibited similar inappropriate behaviors in the past, SSD L stated, one other time. Review of an Incident and Accident reported dated 3/30/24, previously investigated by the State Agency (SA), revealed R1 was observed rubbing the buttocks of a female resident, R6, in her private room. On 7/23/24 at 3:01 PM, an interview was conducted with LPN J who confirmed she observed R1 sitting awfully close to R2 in the dining room around the time of the incident. LPN J continued R1 and R2 were sitting, too close for comfort. LPN J stated she removed R1 from the dining room but was not aware R1 had already made physical contact with R2. Review of R2's progress notes revealed the following entries: 1. 7/16/24: Social services met with [R2] to follow up on alleged incident that occurred on 7/15/24 .She did express that she was embarrassed of the incident . 2. 7/17/24: Social Services spoke with [R2] regarding the alleged incident that occurred on 07/15/24 .She expressed that she was still embarrassed about the incident . Review of R2's Plan of Care revealed the following focus, initiated 8/18/23: Resident has an impaired mood/psychiatric status related to depression, PTSD. Res [resident] states not known triggers - staff states resident gets very upset with things she perceives as sexual ie; if people [NAME] at her, blow her a kiss etc can make her feel threatened r/t [related to] her past hx [history]. R2 plan of care reflected no updated interventions following the event with R1 on 7/15/24. Review of a police report from the local law enforcement agency read, in part: .on 7/15/24 at approximately 1728 hours [5: 28 PM], Officers were advised of a possible inappropriate touching that occurred at the senior living center . I personally investigated a similar situation with the same subject . I spoke with [R2] . [R2] advised that [R1] toucher [sic] her hair and her leg. [R2] advised [R1] tried to reach under her blank and touch her vagina . [R1's Legal Guardian M] advised this is the 2nd time she's been called from something like this . [Guardian M] advised there is a serious staffing problem here at [facility name] . On 7/23/24 at 2:10 PM, an interview was conducted with Legal Guardian M who verified a previous incident occurred between R1 and a separate resident. Legal Guardian M stated R1 was not supposed to be in the dining room due to similar past behaviors. Legal Guardian M advised, The facility is understaffed. Review of R1's plan of care revealed the following intervention, initiated 8/7/23: **RESIDENT IS NOT TO EAT IN DINING ROOM AT ANY TIME** . Review of R1's behavioral symptom charting in the days leading up to the incident with R2 on 7/15/24 indicated R1 exhibited 7 instances of grabbing, one instance of threatening behavior, and 13 instances of sexually inappropriate behavior in a 21-day look-back period. Review of R1's Kardex (a documentation system that enables direct-care staff to easily reference key patient information that direct their nursing care) did not reveal R1's history of sexually inappropriate behavior nor did it outline any behavioral interventions. On 7/23/24 at approximately 3:00 PM, an interview was conducted with Regional Director of Clinical Services H regarding the incident between R1 and R2. When asked how direct-care staff were made aware of R1's behavioral history, Regional Director of Clinical Services H indicated staff is alerted to previous history by word-of-mouth. Regional Director of Clinical Services H was asked how new staff would be aware of R1's history if not reported during every shift change to which she replied, It is assumed they know given he is a 1:1 [receiving direct supervision from 1 staff member]. When asked if staff would be better equipped to prevent future incidents if R1's history was reflected in his Kardex, Regional Director of Clinical Services H replied, I hear what you're saying. Regional Director of Clinical Services H was unsure why R1 was stationed in the dining room at the time of the 7/15/24 incident, despite his care planned intervention to not eat in the dining room. Resident #4 (R4): Review of R4's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including Alzheimer's Disease and diabetes. Record review of R4's most recent MDS assessment, dated 5/20/24, revealed a BIMS score of 7, indicative of severe cognitive impairment. Resident #5 (R5): Review of R5's EMR revealed admission to the facility on [DATE] with diagnoses including vascular dementia, congestive heart failure, and adjustment disorder with anxiety. Record review of R5's most recent MDS assessment, dated 5/20/24, revealed a BIMS score of 13, indicative of intact cognition. On 7/30/24 at 10:30 AM, a telephone interview was conducted with Certified Nursing Assistant (CNA) O regarding the protocol for reporting allegations of abuse. CNA O stated during a shift on 7/30/24 she walked into R5's room and observed him lying in bed with his pants pulled down and genitalia exposed. CNA O stated she observed R4 standing beside the bed. When asked if a sexual act was being performed, CNA O stated, I'm not entirely sure . I don't think so. R5 had a washcloth near so she may have been performing peri-care. When asked her next steps, CNA O stated she notified the floor nurse on duty, LPN A, and informed Regional Director of Clinical Services G by telephone. CNA O stated, I was really upset by the whole thing. Review of R4 and R5's EMR revealed no documentation of the event. On 7/30/24 at 12:12 PM, a telephone interview was conducted with LPN A who vaguely recalled the incident. LPN A stated that she informed the Director of Nursing (DON) but did not document the allegation. When asked why the incident was not documented, LPN A stated, The days are just too busy. I don't have time. I usually have around 29 residents to care for. On 7/30/24 at 11:40 AM, an interview was conducted with Regional Director of Clinical Services G who verified she received a call from CNA O on 7/14/24 with details regarding the incident between R4 and R5. Regional Director of Clinical Services G stated she informed CNA O to notify the abuse coordinator. When asked if she had any further involvement, Regional Director of Clinical Services G stated, It's a new building for me, so I don't know the residents. That why I told her [CNA O] to follow up with the abuse coordinator. When asked if there was any follow-up following the allegation, Regional Director of Clinical Services G stated, There was a call, but I don't know what came of it. Review of facility policy titled, Abuse, Neglect and Exploitation, revised 1/10/24 read, in part: .The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: .establishing a safe environment .by establishing policies and protocols for preventing sexual abuse . Review of facility policy titled, Residents' Rights and Quality of Life, revised 1/1/22 read, in part: .Our residents have the right .to be free from verbal, sexual, physical and mental abuse . Review of facility policy titled, Trauma Informed Care, revised 10/30/23 read, in part: .the facility will account for residents' experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Potential causes of re-traumatization by staff may include . Failing to provide adequate safety . Care plans will be initiated/updated to address those identified. Individualized approaches will be identified, and interventions put into place .

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall with injury for one Resident (R3) of three residents reviewed for falls. This deficient practice resulted in hospitalization where R3 required ten staples placed in the back of his head to close a laceration and then subsequently required transfer to a higher level of care hospital due to a subdural hematoma requiring an intensive care stay. Findings include: This citation is linked to intake MI00143648. On 4/16/24 an email was sent to the complainant regarding the allegations of the intake. No email was returned, no phone number was attached to the report from the State Agency, and the complainant was unable to be called via phone. Review of the SA intake MI00143648, dated 3/29/24, revealed - A concern for R3 and frequent falls at the facility in a short period of time. Complainant stated, This last fall that occurred 03/26/2024 at around 2:21 am when called I was told that (R3) had falling (sic) and suffered a laceration to his head and that they would be sending him to the emergency room at (local hospital). I then received a call from (local hospital) stating that my father (R3) suffered a brain bleed due to the fall and that he would be shipped to (higher level of care hospital). Staff knew going in that my father was a fall risk, he was on the fall risk ward yet in 7 days he suffered 3 falls and 1 slide out of his chair . The (sic) were also made very, very aware of him trying to get up for the bathroom at night causing falls. When they came for a home visit prior to his enrollment at [facility name] again it was mentioned that the overnight hours are the hardest because he attempts to get out of bed to use the bathroom this is when his falls occur. I hate making this complaint but the first fall may have been an accident, the second fall shouldn't have happened let alone within 2 days and the 3rd fall was just plain and simple disregard to the needs of my father being met . Review of R3's Minimum Data Set (MDS) admission assessment, dated 3/22/24, revealed R3 was admitted to the facility on [DATE] with diagnoses including dementia, depression, history of falling, hearing loss, insomnia, and weakness. R3 was independent for eating and rolling from left to right. R3 required partial assistance with toileting, dressing, footwear, personal hygiene, walking 10, 50, and 150 feet, and showering and supervision with transfers. R3 was able to participate in the Brief Interview for Mental Status (BIMS) assessment, showing severe cognitive impairment and scoring 00/15. The sensory assessment revealed R3 was sometimes understood, and sometimes able to understand. Review of R3's MDS significant change, dated 4/14/24, revealed R3 had declined and now required assistance with eating needing supervision or touching or cues. For toileting hygiene, putting on footwear and upper body dressing R3 now required substantial or maximal assistance. R3 also required supervision or maximal assistance for walking 10 feet and was unable to ambulate further than 10 feet. Review of R3's accident and incident report, dated 3/26/24 at 2:05 AM, revealed R3 was found by Licensed Practical Nurse (LPN) I who thought she saw R3 in the hall, but it was R3's roommate. R3's roommate had alerted LPN I of R3's fall. R3 was observed lying on the floor in urine in his room after an unwitnessed fall. LPN I had assumed that R3 had slipped in his urine and fell . R3 was observed to have an 8 cm (centimeter) gash to the back of his skull and a skin tear to his right elbow. R3 was bleeding from his head wound. R3 was sent to the local Emergency Department (ED). Review of R3's ED report, dated 3/26/24 at 3:05 AM, read in part, .diagnosed with an 8 cm vertical left occipital laceration, oozing blood no arterial hemorrhaging, tenderness of the scalp with boggy edema surrounding this laceration .Using local lidocaine was able to staple this closed with a total of 10 staples placed. He does localize to pain 5/10 .Discharge plan acute intra-cranial hemorrhage and dementia .Disposition transfer to acute care hospital .CT (computed tomography) scan performed with findings of an acute hematoma in the medial left temporal lobe measuring 2 x 1.5 x 1.5 cm with an estimated volume 2.25 cm. discharged on [DATE] at 6:57 AM to another acute care hospital . Review of R3's history and physical, dated 3/26/24 at 1:09 PM, read in part, .presents to [hospital initials] ED as a level 2 activated trauma following an unwitnessed fall .With the intracranial findings noted, our facility was contacted for possible transfer .His daughter states .he has been having more and more falls .Assessment/Plan: Level 2 trauma - unwitnessed fall, intracranial hemorrhage, advanced dementia, frequent falls .admit to intensive care unit . Review of R3's consultation [secondary follow-up] CT from higher level of care hospital, dated 3/26/24 at 1:18 PM, read in part, .Impression: There is a globular area hyperdensity which is seen along the medial left temporal lobe with a surrounding rim .this area is measuring 2.4 x 1.9 x 1.7 cm with volume of 4.06 ml, and has the appearance of a possible hemorrhagic infarction . * Note increase in subdural hematoma size. Review of R3's Electronic Medical Record (EMR) showed a fall evaluation report, dated 3/18/24, which revealed a score of 26 indicating fall interventions were required and high fall risk. Review of LPN Is witness statement, dated 3/26/24, revealed, Aide was on lunch and float Aide was starting to head down A wing .Aide called for nurse to come .Resident lying on the floor .had an 8 cm gash to back of his skull .Resident did not have slipper socks on. Review of Certified Nurse Aide (CNA) O witness statement, dated 3/26/24, revealed, Aide last saw resident in bed sleeping at 1:25 AM. Aide was finishing up her lunch break when the incident occurred . Review of CNA P witness statement, dated 3/26/24, revealed, Aide just finished assisting a resident to the bathroom on D hall at the time of the fall and was at the Nurses Circle, when nurse saw a resident in A hall, standing in the doorway. Aide went to see if resident needed assistance and called for Nurse when she noticed roommate on the floor. Resident had blood on hand and blood on floor. Floor was wet with urine, but resident's brief was dry. Aide took a washcloth and applied pressure until she could be relieved. On 4/17/24 at 1:10 PM a call was placed to LPN I for an interview regarding R3's fall and no answer and message was left for return call and no returned phone call back to this Surveyor. On 4/18/24 at 10:25 AM a second call was placed to LPN I for an interview regarding R3's fall and no answer and message was left for return call and no returned phone call back to this Surveyor. On 4/18/24 at 10:28 AM a call was placed to CNA O for an interview regarding R3's fall and no answer and message was left for return call and no returned phone call back to this Surveyor. On 4/18/24 at 10:30 AM a call was placed to CNA P for an interview regarding R3's fall and no answer and message was left for return call and no returned phone call back to this Surveyor. Review of R3's task for bladder elimination, dated 3/25/24, revealed, prior to R3's fall he was last checked for urinary continence was at 9:52 AM and task for bowel and bladder last toileted was at 4:34 PM. No other elimination charting could be found in the EMR. Review of R3's progress note, dated 3/28/24 at 4:33 PM, read in part, .Resident drowsy, wanting to sleep, complaining of pain/soreness from laceration site with 10 staples in situ (on site). Foley catheter attached to leg bag in situ. Received report from [local hospital name and nurse] .Had brain bleed. Left temporal subdural bleed .DON given report. Review of R3's progress note, dated 3/28/24 at 5:46 PM, revealed, Called [facility physician's name] reviewed readmission .Review potential for hospice addition with resident daughter tomorrow and follow up with [facility physician's name] regarding her decision. Review of R3's progress note, dated 4/2/24 at 4:45 PM, read in part, [Occupational Therapy] screened resident at meal time. Patient requires scoop plate at meals to improve independence and assistance with meal overall due to coordination deficits .will follow progress and evaluate as needed. * Note: A significant decline from original baseline. Review of physician order, dated 3/18/24, read in part, Regular diet. Regular texture. Regular fluid, thin consistency. * Note: R3 required no special plate on original admission. Review of progress note, dated 4/3/24 at 10:44 AM, read in part, Resident had a hard time getting up this morning .this resident had no trunk control to hold himself up .laid back to bed. Resident unable to follow commands to eat or take medications . * Note: This was also a significant decline from baseline where R3 was originally a 1 person assist for transfers. Review of progress note, dated 4/3/24 at 11:33 AM, read in part, .Practitioner gives orders to ship to ER for treatment and evaluation. Review of progress note, dated 4/3/24 at 4:20 PM, read in part, Resident arrived via EMS (emergency medical services). New diagnosis of UTI (urinary tract infection) .new orders for antibiotics . Review of progress note, dated 4/4/24 at 1:41 PM, read in part, admitted to [hospice company name] services. Daughter .signed DNR (do not resuscitate). Comfort meds ordered . Review of physical therapy evaluation, dated 3/19/24, revealed, R3 had fall risk, poor safety awareness, and confusion. Daughter is unable to care for patient due to advanced dementia and multiple falls at home. Patient is ambulatory with 1 - 2 person assist. Functional mobility assessment - ambulation walk 10 feet substantial/maximum assistance. Review of R3's ADL care plan, date initiated 3/18/24, read in part, Focus: Resident has an ADL (activity of daily living) self-care performance deficit related to cognitive impairment .dementia .generalized weakness, history of falls, poor balance .Interventions: .requires reminders (initiated 3/19/24) .Ambulation: 1 person assist (initiated 3/18/24) .Bed Mobility: Supervision (initiated 3/18/24) .Toileting: 1 person assist. Offer to assist with toileting every 2 hours and as needed (initiated 3/18/24) .Transfers: 1 person assist (initiated 3/18/24) .Encourage resident to use call light when assistance is needed (initiated 3/18/24) .Resident uses a manual wheelchair for locomotion (initiated 3/18/24) . Review of R3's Fall Prevention care plan, date initiated 3/18/24, read in part, Focus: Resident is a risk for falls/injury related to bladder incontinence .generalized weakness, high risk for falls, history of falls .inability to use call light due to confusion .Interventions: .keep gripper socks on when in bed (initiated 3/26/24) .Ensure the resident's room is free from accident hazards (initiated 3/18/24) .Non-skid footwear to reduce the risk of slipping .(initiated 3/19/24) . Review of R3's Elimination care plan, date initiated 3/18/24, read in part, Focus: Resident has episodes of bladder/bowel incontinence .Interventions: .Assist resident with toileting needs (initiated 3/19/24), Check at regular intervals and change as needed (initiated 3/22/24) . Review of R3's accident and incident reports, dated 3/18/24 through 3/23/24, revealed, R3 had three falls prior to his last fall on 3/26/24 which resulted in the injury to the back of the head and the subdural hematoma. R3 had fallen on 3/18/24 the day of his admission to the facility, again on 3/19/24 the day after his admission, and again on 3/23/24 four days after his admission. *Note R3's admission room was down B hall and after his first fall he was placed on the falling star A hall. * Note: Complainant point out that falls while trying to toilet were the main reasons family could no longer keep R3 at home safely. On 4/18/24 at 11:40 AM, an interview was conducted with the Director of Nursing (DON) and was asked about R3 and his frequent falls in a short period of time after being admitted on [DATE] and had fallen four times in a week. The DON replied, Yes. He is one of our falling stars and that is why he is down A hall. There is always supposed to be a staff member on that hall listening, watching, and monitoring resident needs. The DON was then asked if there was a staff member present during the time and date of the R3's most recent fall on 3/26/24. The DON replied, No. Someone should have been down there. The aide assigned was at lunch, the nurse was at the nurses' circle and the aide that was relieving the aide that was assigned was not yet on the A hall. Review of policy titled, Fall Prevention Program, dated 10/26/23, read in part, Policy: Each resident will be assessed for the risk of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .Policy Explanation and Compliance Guidelines: .6. When a resident experiences a fall, the facility will: e. Review the resident's care plan and update as indicated . Review of policy titled, Admission to the Facility, dated 2/1/22, read in part, Policy: The facility will admit only those residents whose medical and nursing care needs can be met. This decision is based on both the needs of the community and the facility's clinical competencies. Admissions are accepted 24 hours a day, 7 days a week. Policy Explanation and Compliance Guidelines: .4. The objective of our admissions policies are to: a. Provide uniform guidelines for admitting residents to the facility; utilizing the clinical review/admit guide b. Admit residents who can be adequately cared for by the facility c. Address concerns of residents and families during the admission process . On 4/18/24 at 12:15 PM, an exit conference was held with the DON, the Nursing Home Administrator (NHA), the Regional Clinical Consultant Registered Nurse, and the Regional NHA. During the exit conference this Surveyor voiced her concerns of her findings related to the Abbreviated Survey process. On 4/18/24 at 1:10 PM, approximately one hour after exit the Regional Clinical Consultant Registered Nurse attempted to dispute concerns and called this Surveyor on her work cell phone stating she had further documentation regarding the witness statement for CNA O regarding R3's fall. The Regional Clinical Consultant Registered Nurse stated she re-interviewed CNA O later, on 3/26/24, regarding CNA Os witness statement. Regional Clinical Nurse Consultant Registered Nurse indicated CNA O stated R3 was toileted at 12:00 AM. The Regional Clinical Consultant Registered Nurse added the updated witness statement to the Egress system post survey. In review of the document at the bottom of the original witness statement from CNA O, dated 3/26/24, read in part, .(added documentation by Regional Clinical Consultant Registered Nurse) Interviewed [CNA O] again 3/26/24 at 5:30 PM then written over with 6:30 PM. Resident was toileted approximately 12:00 AM. [signed by the Regional Clinical Consultant Registered Nurse and not signed or initialed by CNA O]. *Note: Document was added to Egress system at 1:24 PM on 4/18/24 after survey exit had taken place.

This Deficient Practice Statement (DPS) has two parts: A and B. DPS A: This deficiency pertains to Facility Reported Incident (FRI) MI00142212. Based on observation, interview, and record review, the facility failed to provide adequate supervision resulting in an elopement with the likely serious harm, injury, impairment or death for one Resident (#49) of one resident reviewed for accidents/hazards. Findings Include: The Immediate Jeopardy began on 1/10/24 at 7:23AM when R49 was observed ambulating northbound in a southbound lane by an employee (Staff V) driving into work. Regional Senior Administrator GG was notified of the immediate jeopardy on 1/23/24 at 4:40PM. At that time, a written plan of correction for removal was requested from the facility. This surveyor confirmed by interview and record review that the immediacy was removed on 1/23/24 at 5:40PM, however, noncompliance remained at the potential for more than minimal harm due to sustained compliance which has not been verified by the State Agency (SA). Resident #49 (R49): Review of R49's electronic medical record (EMR) revealed a most recent admission to the facility on [DATE] with diagnoses including Parkinson's Disease with dyskinesia (uncontrolled, involuntary movements), cognitive communication deficit, dementia, difficulty in walking, and history of falling. Record review of R49's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicative of moderate cognitive impairment. On 1/22/24 at 11:27AM, R49 was observed sitting in a wheelchair in his room, brushing his teeth at the sink. A wander guard was observed on R47's right ankle and a four-wheel walker was stationed next to him. R49 declined to answer questions related to the FRI. Review of the FRI submitted to the SA included an incident summary which read, in part: .On the morning of 1/10/23 (sic), resident [R49] was observed exiting the facility in the front parking lot by kitchen staff, [Dietary Cook, W]. [Dietary Cook W] immediately notified [the NHA]. [The NHA] was in the facility and immediately responded and came outside and walked outside with [R49]. [R49] was adamant that he was going to go across the street to the college and see his mother who was coming to visit. [The NHA] accompanied [R49] to the college to ensure safety. [R49] was not left alone . [R49] was dressed appropriately for weather conditions. He was wearing boots, jeans, and a fleece lined jacket with a long sleeve undershirt .temperature was 23 degrees Fahrenheit with no precipitation .cameras were reviewed identifying that [R49] put the code in the door to open it to disable the alarm when he exited the facility . Review of Wunderground.com for daily weather history near the facility at; https://www.wunderground.com/history/daily/us/mi/[city name]/KANJ/date/2024-1-10, revealed a temperature of 23 degrees Fahrenheit with a wind speed of 15 miles per hour (mph) gusting to 25 mph. A will chill temperature was calculated as low as 6.7 degrees Fahrenheit according to the National Weather Service Wind Chill Calculator at the approximate time of R49's elopement from the facility. On 1/22/24 at 3:20PM, an interview was conducted with the NHA. The NHA stated he was sitting in his office when the Director of Nursing (DON) and Licensed Practical Nurse (LPN) X notified him that Dietary Cook W observed [R49] unsupervised outside the facility. The NHA reported he immediately exited the facility and saw R49, at the end of the driveway. The NHA stated he was unable to redirect R49 back to the facility, therefore elected to continue walking with him to ensure safety. The NHA stated, I crossed the road with [R49] and eventually entered [University Name] Recreation Center. The NHA acknowledged R49 was left unsupervised for approximately 7 (seven) minutes despite stating R49, was not left alone in the initial incident summary report submitted to the SA. When the NHA was asked if R49's safety was at risk during the 7 (seven) minutes he was left unattended the NHA responded, It's hard to say. He [R49] was ambulatory and dressed appropriately .He [R49] would know enough to not walk out into traffic. On 1/22/24 at approximately 3:30PM, the NHA confirmed the initial report of R49 entering the code to disable the exit door alarm per facility cameras. A request to view the camera footage was made at this time. The NHA stated he would retrieve the footage. Review of Administrative Progress Note by the NHA dated 1/10/24 at 11:00PM read: At approximately 7:23 AM, facility staff member arriving to work observed resident ambulating in facility driveway to the North [NAME] (sic) and alerted staff inside the building. NHA immediately exited building on foot to accompany resident, who was still withinthe (sic) facility driveway ambulating toward the university. Upon review of facility surveillance cameras, resident noted to exit front door at approximately 0723 [7:23AM] and NHA joined resident outside at 0731 [7:31AM]. NHA unable to redirect resident back to facility and continued walking with him to the nearby university building. NHA called for staff to bring facility transportation to the university for resident transport back, however NHA and 3 additional staff were unable to persuade resident to return. Resident's family member happened to be in vicinity and was able to persuade resident to accompany him to local restaurant for coffee and breakfast before return to facility . On 1/22/24, at 3:32PM, an interview was conducted with the DON. The DON stated she was in the general vicinity of the front lobby when Staff V ran into the facility. The DON stated that it was announced R49 was in the facility parking lot. The DON stated she immediately notified the NHA who located R49 at the end of the driveway. The DON soon after received a call from the NHA requesting the facility transport van. The DON stated, It snowed the night before, so it took awhile to clear off the van. The DON reported she found R49 and the NHA across the street at the [University Name] Recreation Center and was able to coax R49 inside the building. On 1/22/24 at approximately 3:43PM, an interview was conducted with Dietary Cook, W. When Dietary Cook W was asked for her account of witnessing R49 outside the facility, she stated, I don't know what they're talking about. I didn't witness that event . On 1/22/24 at 3:45PM, an interview was conducted with Staff V. Staff V reported she was driving into work at approximately 7:30AM when she saw an elderly person walking with a four-wheel walker against traffic in the roadway. Staff V stated she, recognized the walk right away [as R49] but was unable to safely exit her vehicle to tend to him. Staff V stated, I was sandwiched between two school buses, and couldn't get out of my car in the roadway. I rolled down the window and tried to tell him [R49] to stay put, but I don't think he heard me. Staff V reported she parked her vehicle near the entrance of the facility, ran inside, and immediately reported to LPN X that R49 was in the roadway. Staff V said, I was scared to death the school bus might hit him, that was the concern. On 1/22/24 at 5:54PM, a follow-up phone interview was conducted with Staff V who stated, They [facility] didn't have any idea he [R49] was out there. Nobody was out there looking for him [R49] .it was bad weather that morning. It had snowed overnight . On 1/22/24 at 3:59PM a follow-up interview was conducted with the NHA and Regional Senior Administrator GG. The NHA stated, I don't have the video [camera footage from R49 exiting the facility], it was erased . When asked why video evidence from a facility reported incident wasn't saved, Regional Senior Administrator GG stated, I don't know. We [facility] know he put the [door] code in himself and that's all the video says. We only wanted that video to determine our plan of action. We didn't think a state surveyor would want to see that. At this time, the NHA revealed that the staff member who witnessed R49 outside the facility was Staff V, not Dietary Cook W as originally reported on both the facility reported incident and in his prior verbal interview statement. On 1/22/24 at 6:03PM, a phone Interview with was conducted with Family Member AA who stated they were exercising at the [University] recreation area when a nurse approached him and told him his brother [R49] was in the building. Family Member AA stated, I looked over and saw him and was shocked .I was able to coax him into my vehicle and we went to get coffee at a drive-thru to calm him down . I brought him back to the facility . it was very difficult to get him out of my vehicle .He initially wouldn't get out of my vehicle, so I took him for another ride, then I eventually got him to back in [the facility]. On 1/23/24 at 7:19 AM, Regional Senior Administrator GG approached this surveyor and stated, I suspended [the NHA] last night and I will be the acting interim administrator. When the elopement initially happened, a trigger call was completed. I believe he [NHA] gave us the accurate information then and then obtained different information that he withheld. I don't believe he [NHA] had malicious intent. The incident was validated that he [R49] was in the parking lot at the time. When I spoke to [Staff V] on the phone last night [1/22/24], it was reported the resident was not in the parking lot. He [R49] was on the west side of the road, which means he crossed the road. When Regional Senior Administrator GG was asked if the NHA gave a false written statement and verbal testimony, she stated, I believe the resident crossed [the road] and came back .so the NHA could have seen him in the parking lot. Regional Senior Administrator GG was asked if she viewed witness statements or talked with any witnesses after the elopement to which she replied, No, I would base the findings off the administrator's word .I might as well be the administrator if I was expected to interview everybody. Regional Senior Administrator GG stated, I found these on [NHA]'s desk this morning and gave this surveyor a hand-written witness statement. Review of a witness statement written by Staff V dated 1/10/24 at 7:35AM read: Spotted Resident [R49] walking down [Street name] w (with)/ his 4ww (four wheel-walker); [I] parked + (and) hurried into to inform Nursing (mgt) [management] LPN X of observed occurrence. On 1/23/24 at 4:01 PM an interview was conducted with LPN X. LPN X recounted, I was sitting right here in my office and I saw [Staff V] frantically walk in .She told me she was pretty sure she saw [R49] walking in the middle of the street . On 1/24/24 at 12:03PM, an interview was conducted with R49 who recalled the events that occurred on the morning of 1/10/24, stating, It was time to go for a walk, that's all .I went out the front door .I used to walk across the street, so I went over there .I crossed the road. R49 was asked if he utilized the sidewalk to which he replied, It was snowing and blowing so hard, there was no sidewalk. I was walking on the road. I saw two yellow busses on the road. R49 was asked at what point an employee from the facility approached him and he replied, The first time somebody came up to me was in the road .that administrator [NHA], he said, 'What are you doing? Aren't you freezing?' R49 confirmed he was wearing a black fleece coat, black shoes, and no hat or gloves. R49 stated, I wasn't dressed for it [the weather] . My hands were freezing holding on to the walker. R49 was asked the purpose of the band (wander guard) that was observed fastened around his ankle to which he replied, It rings a bell off if I get close to the door .I'm going to take my scissors and cut it off. When it gets nicer out, I might leave again. During an observation on 1/25/24 at approximately 8:15AM, the elopement path was walked with Staff V. The driveway was asphalt with many holes and uneven surfaces, covered with ice and snow, sloping steeply to the main road. Staff V indicated the condition of the parking lot and road had much more snow and ice on the morning of the elopement (1/10/24) and expressed surprise that R49 ambulated to the roadway without a fall. Staff V indicated the exact location of R49 in the roadway when he was spotted from her vehicle on 1/10/24. Staff V expressed concern regarding danger from the road traffic given the time of day, stating it was dark, the resident [R49] had black clothing on, and it was rush hour for a nearby university and elementary school. Staff V stated, Like I said, I was sandwiched between two school buses. Review of Wunderground.com for daily weather history near the facility at; https://www.wunderground.com/history/daily/us/mi/[city name]/KANJ/date/2024-1-10, revealed a sunrise at 8:30AM, approximately 1 hour after the elopement reported on 1/10/24 at 7:23AM. During an observation on 1/25/24 at approximately 9:10AM, measurements of the elopement path were taken by this surveyor with a measuring wheel. It was determined R49 was spotted approximately 509 feet from the facility exit and approximately 108 feet down the road from the end of the facility's Northwest driveway. On 1/25/24 at 9:20AM, a follow-up interview was conducted with Family Member AA. Family Member AA stated, He [R49] was not dressed for the cold weather. The first thing he told me when he got in the truck was to put the heated seat on. Sh** happens, but this shouldn't have happened. On 1/25/24 at 8:50AM, an interview was conducted with LPN Y who was the floor nurse on R49's hall the morning of the elopement. LPN Y stated, The first time I knew [R49] was gone was when his roommate told me .I saw him in his wheelchair at the end of the hall approximately 20 minutes prior to hearing he left the facility . LPN Y was asked if a door alarm alerted around the time of his elopement. LPN Y replied, The green button [visitor button to silence the alarm] on the outside was working at the time and that's why it was eventually disabled [after the elopement]. It was suspected he [R49] pushed it to stop the alarm. On 1/25/24 at approximately 9:44AM, an interview was conducted with Maintenance Director, A. Maintenance Director A was asked why the green button was disabled on the outside of the building to which he replied, The green button was disabled because it was thought the resident [R49] has pushed it when he left the facility to silence the alarm. Review of R49's most recent Risk of Elopement/Wandering Review dated 11/23/24 indicated the following inaccuracies: 1.a. Is the resident cognitively impaired with poor decision-making skills (i.e. intermittent confusion, cognitive deficits, or disoriented?) 2. No was selected by the assessor. Review R49's MDS assessment dated [DATE], revealed a BIMS score of 12, indicative of moderate cognitive impairment. 2.b. Does the resident have a pertinent diagnosis of Dementia, OBS (organic brain syndrome), Alzheimer's, Delusions, Hallucinations, Anxiety Disorder, Manic Depression or Schizophrenia? 2. No was selected by the assessor. Review of R49's medical record revealed both, Unspecified dementia and vascular dementia diagnoses. 3.c. Does the resident have any hearing, vision, or communication problems? 2. No was selected by the assessor. Review of R49's medical record revealed a cognitive communication deficit diagnosis. On 1/23/24 at 12:08PM, an interview was conducted the Regional Director of Clinical Services (RDCS) D who was asked what criteria a resident had to meet to determine the need for a wander guard. RDCS D stated the determination was based on the Risk of Elopement/Wandering Review assessment. When asked if there was an objective measure to determine if a person would benefit from a wander guard, RDCS D stated, No. It is subjective and based on the opinions of the IDT (interdisciplinary team) .There is no standardized system. On 1/25/24 at 12:41 PM, a follow-up interview was conducted with RDCS D who acknowledged the inaccuracies in R49's Risk of Elopement/Wandering Review assessment. RDCS D stated that the inaccuracies could have impacted care planned interventions for R49 and other residents at risk for elopement due to inaccurate assessments. On 1/25/24 at 8:50AM, a follow-up interview was conducted with LPN Y who was asked if the facility conducted a head count following the elopement on 1/10/24. LPN Y stated no official head count was conducted. Review of a facility policy titled, Unsafe Wandering & Elopement Prevention revised 1/1/2022 read, in part: Should an employee discover that a resident is missing from the facility, .the Licensed nurse will assign a staff member to begin a head count of all current residents . The licensed nurse will also; .validate the head count is accurate and all residents are accounted for. Record review did not reveal verification of a head count following the elopement on 1/10/24. The Immediate Jeopardy which began on 1/10/24 was removed on 1/23/24 when the facility took the following actions to remove the immediacy. The Facility Removal Plan read: 1. Elopement binder was reviewed to ensure they included all the required information and were updated accordingly on 1/10/2024. 2. All doors were noted to be secured on 1/10/2024. 3. An in-service education program will be conducted by the Regional Nurse Consultant and the Director of Nursing Services with licensed staff including MDS Coordinator(s) addressing how to complete elopement assessments. (Completion date 1.23.2024). 4. The elopement policy was reviewed and deemed appropriate on 1.10.24. (Completion date 1.23.2024). 5. Elopement drills to be conducted weekly for 4 weeks, then quarterly to ensure ongoing compliance. 6. Education completed by Administrator/designee to the facility staff on: a. Elopement Policies and Procedures b. Changes in resident behaviors that may contribute to elopement behavior/notification of Supervisor when changes are identified. c. Elopement Books 7. An Adhoc (sic) QAPI meeting was held and reviewed plan and policy. These were deemed appropriate by the committee. (Completion date 1.23.2024). 35103 DPS B Based on interview and record review the facility failed to provide adequate supervision to prevent a fall with major injury resulting in harm for one Resident (R13) of four residents reviewed for accidents. This deficient practice resulted in an unwitnessed fall with facial trauma, fractured nose, and significant facial bruising. Findings include: On 1/22/24 at 12:49 p.m., R13 was observed as he was pushed into the dining room by facility staff. Bruises to R13's face were present on his upper right forehead and middle and lower left cheek. The Resident appeared to have had a recent fall. Review of R13's Minimum Data Set (MDS) assessment, dated 11/9/23, revealed R13 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), cervical disc degeneration and history of falling. On this Significant Change MDS the Brief Interview for Mental Status was not completed, however, R13 was documented with severely impaired cognition. Resident R13 used a wheelchair for mobility. Review of R13's Admission Record revealed he was documented as his own responsible party, with no activated Durable Power of Attorney. Review of R13's Incident/Accident reports for January 2023, revealed the following, in part: 1/3/24 4:10 a.m., Unwitnessed fall in Resident's room. Resident was found on the floor facing downward toward the floor on his right side, legs toward the door and unable to describe what happened. Resident complained of right shoulder pain. Incurred a skin tear to his right elbow and redness to right forehead. No injuries observed post incident. 1/3/24 3:38 p.m., Unwitnessed fall in Resident's room. Bleeding Laceration to right side of forehead. Physician was notified and R13 was transported to the Emergency Department (ED). Care Plan updated to reflect, Encourage [R13] to be in common areas when up in wheelchair. 1/9/23 6:00 a.m., Unwitnessed fall in Resident's room. Incident Description: at nursing circle for shift report and aide yelling to come, resident in on floor face down against the wall under TV, gushing blood from his LEFT nostril and midforehead/between eyebrows, and laceration to RIGHT bridge nose, facial, nose and head swelling, prior suture line to RIGHT forehead re-opened and bleeding. Resident unable to give description . Resident Taken to Hospital: Y (yes) . Other Info: resident sat in his chair and he self- transferred to floor. Resident was in chair for a moment unwitnessed . Pain Level: 10 . Review of a Standard of Care (SOC) Fall Review for R13, dated 1/18/24, revealed the following, in part: Date and Time of Fall: 1/9/24 06:00 (6:00 a.m.) . Resident fell from wheelchair in his room. Resident had been restless. CNAs got him up into WC (wheelchair) for a shower. They left the room and were in another resident's room for approximately 15 minutes. Upon completing cares on the other resident, they observed {R13} on the floor in his room next to his wheelchair . 3. Was there an injury - yes. Injury Description: Resident sustained a nasal fracture, prior suture line re-opened above R (right) eye and bleeding (from fall on 1/3/24), two lacerations bleeding to face 1) between eyebrows, and 2) Right side superior nose. Laceration between eyebrows required suturing . Review of one of R13's previous falls on 1/3/24 at 4:10 p.m., revealed the following Investigation Summary details, in part: Resident discovered on floor with laceration to forehead. Resident sent to Emergency Department. Three sutures to forehead. Resident returned to facility . The injury was determined to be from his fall from his chair and interventions were put in place to help decrease this type of incident happening again such as putting things within reach and encouraging him to be in common areas. Review of 1/9/24 fall investigation summary revealed, in part: Resident was waiting for shower in wheelchair in resident room. Resident was visualized approximately 10 minutes prior to fall. Visible laceration noted to face. Physician notified immediately. Resident sent to emergency department for evaluation. Fall resulted in nasal fracture . CNAs involved included [CNA O] and [CNA P] (who) had taken care of [R13] approximately 10 minutes prior to his fall, toileting him, positioning him in his chair with a blanket, his call light and an over-bed table with a snack and drink within his reach. [CNA O] and [CNA P] left [R13's] room to assist another resident for approximately 10 minutes. After leaving that room, they returned to [R13's] room to take him down for a shower. While the CNAs were assisting the other resident, R13 had fallen from his chair to the floor. During an interview on 1/24/24 at 3:17 p.m., CNA O was asked about R13's fall from a wheelchair on 1/9/24. CNA O stated, He (R13) was on A hall. He was yelling and trying to climb out of bed. We got him up and put him in his (wheel) chair put his foot pedals on and the foot buddy on. It wasn't 6:00 a.m. (yet) as [the shower aide] was not here to do the showers. We went to get someone else up and had left him (R13) in his room (in his wheelchair), and it was at most 10-15 minutes to get the other resident up and in his chair. He (R13) had (on) a gown with a sheet and a blanket and his brief. He was an easy shower. He was in his regular wheelchair . I was aware he had fallen previously. I had asked what the stitches were in his head and one of the aides said he had fallen a few days prior . I didn't know he fell twice on 1/3/24. That was my week off, so I did not know anything about that. I had not gotten report yet (on 1/9/24), CNA P had me come in early to get people up . I got report after he had fallen; when my partner got to the facility, and she got here at six . We were never told that he was not to be left in his room until after this fall. We work week on and week off - so he fell twice when I was off. Afterwards (after R13's fall) . one of the day shift nurses said, 'Oh how did he fall when he was not to be left in his room when he was up in his chair' . Review of R13's Fall Care Plan, with revisions, revealed the following intervention revisions, in part: 1/4/24 (after having two falls on 1/3/24) Do not leave [R13] unattended in room while in wheelchair. Date Initiated: 1/4/24, Revision on: 1/4/24. 1/4/24 Encourage [R13] to be in common areas while in wheelchair. Date Initiated: 1/4/24, Revision on: 1/4/24. 1/4/24, Encourage [R13] to be in common areas while in wheelchair. Offer to assist to bed when in room. Date Initiated: 1/4/24, Revision on: 1/16/24. Review of R13's Progress Notes, revealed the following, in part: 1/9/24 06:58 (6:58 a.m.), .Resident had been yelling out . and restless for the last hour of shift. He had just been sat in his wheelchair to get ready for a shower when aides had left resident for a short time to help another resident. When they came back into room, this resident was on the floor face down with gross amount of blood on the floor . Severe facial swelling started after 5 minutes of being with resident. Eyes started to swell. Kept talking to resident to keep him alert. 911 called within 2 minutes of this writer in room. EMR arrive 0615 (6:15 a.m.) and pressure bandage was applied and wrapped to head due to gross bleeding from head/forehead. Gauze placed in nose to plug. No vitals were obtained due to emergency of situation. 1/9/24 12:26 p.m., Resident returned to facility via EMS. Call placed to . ER . advised CT of the head and neck were performed both were negative except for the nasal fracture. Local anesthetic was given prior to suture placement for facial laceration repair . Continue fall precautions . Remove sutures in 7 days (1/16/2024). Nasal fracture to heal over the next 1 to 2 weeks and does not require any specific care. Review of R13's January 2024 Medication Administration Record (MAR) revealed the following physician orders and days of administration: 1. Ativan Oral Tablet 0.5 mg, Give 0.5 mg by mouth every 4 hours as needed for and (sic) of life comfort until 01/23/2024. Start Date 1/9/24 (Date of Fall). Ativan was administered one time each day on January 9th, 10th, 13th, and 14th. No other administration of this medication was documented. 2. Morphine Sulfate Solution 20 mg/ml, Give 0.25 ml by mouth every 4 hours as needed for SOB (shortness of breath)/Pain. Give Roxanol liquid 0.25 ml (5mg) every 4 hours as needed for pain. This prescription was administered, for pain levels on the following days: January 9th, Pain 10 and 7, administered twice. January 10th, Pain 5,5, and 5, administered three times. January 11th, Pain 5 and 5, administered twice. January 13th, Pain 5, administered once. January 14th, Pain 3, administered once. No other administration of this medication was documented prior to R13's fall or through the end of the survey in January of 2024. During an interview on 1/29/24 at 3:52 p.m., Regional Senior Administrator GG reviewed R13's Fall Care Plan interventions with this Surveyor and acknowledged R13's care plan was not followed following updates on 1/4/24, resulting in major injury.

Intake Number: MI 685 Based on observation, interview, and record review, the facility failed to administer narcotic pain medication timely for one Confidential Resident (CR 1) of one resident reviewed for pain relief. This deficient practice resulted in CR 1's delay in medication causing unrelenting pain. Findings include: On 11/17/21 at 8:30 a.m. an interview was conducted with Confidential Resident 1 in their room. CR 1 was noted to be sitting in their wheelchair with braces on their legs attempting to adjust themselves in their wheelchair to offload pressure and pain. During the interview, CR 1 stated when they were admitted to the facility, they had to wait two days to receive any pain medication that they were receiving at the hospital following fractures and surgical repair. CR 1 stated there was no explanation as to why they did not receive their medication and they felt hopeless and in constant pain those two days they did not receive any medication. CR 1 confirmed that he discussed his pain and concern with not receiving his medication to the nurse manager. Review of CR 1's Brief Interview for Mental Status (BIMS) score revealed a 13/15 indicating they were cognitively intact. Review of CR 1's [Hospital Name] Discharge Summary revealed, in part, .Prescriptions: oxycodone-acetaminophen 10-325 mg (milligrams) Tablet 1 tab PO (by mouth) Q4HR (every 4 hours) PRN (as needed) Reason : Pain Moderate (4-6) score 15 days Qty (quantity) 30 RF (refill) 0. Review of CR 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of CR 1's Care Plans revealed the following (CR 1) has [acute] pain date initiated 11/10/21 .interventions: Administer pain medication as ordered date initiated 11/17/21 . An interview was conducted with Registered Nurse (RN) U on 11/17/21 at 1:43 p.m. RN U stated that when the facility was having trouble receiving a medication from pharmacy RN U would usually call the physician and request they use a medication they have in their stock, especially if it was a pain medication the resident was missing. Review of the facility's Pain Medication policy, reference date 1/1/21, read in part, .The facility will ensure that pain management is provided to residents who require such services .Pharmacological interventions should follow a systematic approach. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain .If the resident's pain is not controlled by the current treatment regimen, the practitioner should be notified .

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE DEVELOPMENT OF TWO PRESSURE ULCERS, FAILED TO TIMELY REASSESS THE ULCERS, AND FAILED TO IMPLEMENT PRESSURE REDISTRIBUTION INTERVENTIONS IN ONE RESIDENT (#9) OF FIVE RESIDENTS REVIEWED FOR PRESSURE ULCER ISSUES IN 15 TOTAL SAMPLED RESIDENTS OUT OF A FACILITY POPULATION OF 68 RESIDENTS. THIS DEFICIENT PRACTICE RESULTED IN RESIDENT #9 DEVELOPING TWO FACILITY ACQUIRED STAGE III PRESSURE ULCERS. FINDINGS INCLUDE: RESIDENT #9 IS A [AGE] year-old MALE. HIS [DIAGNOSES REDACTED]. MEDICAL RECORD REVIEW INCLUDED A NUTRITION RISK CARE PLAN DATED 7/18/12 WHICH DOCUMENTED RESIDENT #9'S MODERATE RISK FOR SKIN INTEGRITY ISSUES BASED ON: 1. DEHYDRATION RISK - DIURETIC USE. 2. HISTORY OF CONSUMING LESS THAN 75% OF MEAL VOLUME. 3. ABNORMAL LAB VALUES INCLUDING LOW HEMOGLOBIN. 4. INSIDIOUS WEIGHT LOSS SECONDARY TO DEMENTIA, ADVANCED AGE, AND DYSPHAGIA. THE CAA (CARE AREA ASSESSMENT) REGARDING PRESSURE ULCERS REFLECTED RESIDENT #9 DID NOT HAVE AN EXISTING PRESSURE ULCER AS OF 7/25/12. ON 9/17/12, A FACILITY FORM TITLED "SKIN GRID - PRESSURE ULCER FORM", DOCUMENTS THE INITIAL IDENTIFICATION OF A PRESSURE ULCER ON RESIDENT #9'S LEFT BUTTOCK. THIS FORM REFLECTS THE ULCER WAS NOT PRESENT ON ADMISSION - IT WAS FACILITY ACQUIRED. THE FACILITY DID NOT IDENTIFY THE STAGE OF THE PRESSURE ULCER OR ITS' DIMENSIONS. THERE IS NO FURTHER REASSESSMENT OF RESIDENT #9'S LEFT BUTTOCK PRESSURE ULCER RECORDED UNTIL 11/7/12 - APPROXIMATELY 7 WEEKS AFTER IT WAS FIRST IDENTIFIED. ON 11/7/12, RESIDENT #9'S PRESSURE ULCER TO HIS LEFT BUTTOCK HAD DETERIORATED TO A STAGE III (FULL THICKNESS TISSUE LOSS) MEASURING 1.2 CENTIMETERS (CM) X 1 CM. THIS PRESSURE ULCER WAS DESCRIBED AS "WOUND BED RED WITH LARGE AMOUNTS OF PURULENT DRAINAGE". ON 11/27/12, THE WOUND WAS NOTED TO HAVE A FOUL ODOR. ON 9/25/12, A "SKIN GRID - PRESSURE ULCER FORM", DOCUMENTS THE INITIAL IDENTIFICATION OF ANOTHER PRESSURE ULCER ON RESIDENT #9'S COCCYX. THIS FORM REFLECTS THIS SECOND PRESSURE ULCER WAS ALSO FACILITY ACQUIRED. THE FACILITY FAILED TO DOCUMENT THE STAGE OF THE PRESSURE ULCER OR ITS' DIMENSIONS. THE FACILITY FAILED TO DOCUMENT A REASSESSMENT OF RESIDENT #9'S PRESSURE ULCER ON HIS COCCYX UNTIL 11/6/12 - APPROXIMATELY 6 WEEKS AFTER IT WAS FIRST IDENTIFIED. ON 11/06/12, RESIDENT #9'S PRESSURE ULCER TO HIS COCCYX HAD DETERIORATED TO A STAGE III MEASURING 4.5 CM BY 4.2 CM. ON 1/02/13, THIS WOUND HAD FURTHER INCREASED IN SIZE - DOCUMENTED AS 8 X 8 CM. RESIDENT #9'S PRESSURE ULCER WAS DESCRIBED AS "WOUND BED YELLOW WITH 50% SLOUGH (NECROTIC TISSUE IN THE PROCESS OF SEPARATING FROM VIABLE PORTIONS OF THE BODY) SMALL AMOUNT OF PURULENT DRAINAGE NOTED...FOUL ODOR NOTED..." A REVIEW OF PHYSICIAN ORDERS [REDACTED]. A WOUND VAC (VACUUM ASSISTED CLOSURE) IS A DEVICE WHICH PROVIDES NEGATIVE PRESSURE WOUND THERAPY. THIS TYPE OF THERAPY IS MOST COMMONLY USED FOR WOUNDS THAT ARE NOT RESPONDING TO OTHER FORMS OF TREATMENT. ON 1/15/13, OBSERVATION OF THE PRESSURE ULCER TO RESIDENT #9'S COCCYX REVEALED THE WOUND MEASURED 7.5 X 4.5 CM WITH A DEPTH OF 5 CM. A MEDICAL RECORD DOCUMENT KNOWN AS THE "CARE DELIVERY GUIDE" IS USED BY DIRECT CARE WORKERS (CERTIFIED NURSES AIDES (CNAS)) TO PROVIDE BASIC CARE TO THE RESIDENT. RESIDENT #9'S CARE DELIVERY GUIDE DOCUMENTS THE NEED FOR: 1. ASSISTED POSITIONING EVERY 2 HOURS. 2. THE OPTION FOR THIS RESIDENT'S BED TO BE ELEVATED UP TO 30 DEGREES. 3. THE "YELLOW DOT PROGRAM" DIRECTS CNAS TO CHANGE THE RESIDENT'S POSITION EVERY TWO HOURS, ON THE EVEN HOURS OF THE DAY (EXAMPLE: 12 PM, 2 PM, 4 PM). THE FACILITY PROVIDED A FORM TITLED "PROCEDURE GUIDE FOR WOUND PREVENTION AND MANAGEMENT" DATED APRIL 2009 WHICH INCLUDED BULLET 2. d. "MANAGE FRICTION & SHEAR - ELEVATE HEAD OF BED (HOB) NO MORE THAN 30 DEGREES, UNLESS CLINICAL CONDITION WARRANTS GREATER ELEVATION." ON 1/14/13 AT 3:45 P.M., RESIDENT #9 WAS OBSERVED LYING ON HIS RIGHT SIDE IN BED. CNA "N" WAS BRIEFLY INTERVIEWED AT 3:45 P.M. ON 1/14/13. CNA "N" WAS ASKED IF RESIDENT #9 WAS ON A TURNING AND REPOSITIONING SCHEDULE. CNA "N" STATED, "YES. WE WILL BE TURNING RESIDENTS AT 4:00 P.M." ON 1/14/13 AT 4:40 P.M., RESIDENT #9 REMAINED POSITIONED ON HIS RIGHT SIDE. AT 4:43 P.M. ON 1/14/13, THIS WRITER STATED TO CNA "N" THAT RESIDENT #9 WAS STILL ON HIS RIGHT SIDE. CNA "N" STATED, "WE WILL BE TURNING HIM THIS HOUR." ON 1/17/13 AT 8:30 A.M., RESIDENT #9 WAS OBSERVED SITTING IN BED WITH THE HOB ELEVATED SEVERELY TO ABOUT 70-80 DEGREES. CNA "F" WAS FEEDING RESIDENT #9. THIS RESIDENT'S "YELLOW DOT PROGRAM" DOCUMENTS THAT HE IS NOT TO BE POSITIONED ON HIS BACK AT ALL (CREATING PRESSURE ON THE COCCYX WOUND). AT 9:00 A.M. ON 1/17/13, RESIDENT #9 WAS OBSERVED STILL SITTING UPRIGHT AT THE SEVERE ANGLE, APPROXIMATELY 75 DEGREES. THE DIRECT CARE STAFF WERE NO LONGER PRESENT WITH RESIDENT #9. ( ) --

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT PREVENTIVE SKIN BREAKDOWN MEASURES FOR TWO RESIDENTS (#101 AND #104) OF THREE RESIDENTS REVIEWED WITH PRESSURE ULCERS FROM A TOTAL OF SIX SAMPLED RESIDENTS, BY NOT IMPLEMENTING THE RECOMMENDED PRESSURE RELIEVING DEVICE AND THE TURNING AND REPOSITIONING PROGRAM. THIS FAILURE RESULTED IN HARM TO BOTH RESIDENTS WHEN RESIDENT #104 DEVELOPED FOUR OPENED PRESSURE ULCERS LOCATED ON HER BUTTOCK AND RESIDENT #101 DEVELOPED A RECURRENT PRESSURE ULCER ON THE BUTTOCK, WITH DELAYED HEALING. FINDINGS INCLUDE: ACCORDING TO THE MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #104 IS A [AGE] year OLD WOMAN WHO WAS REadmitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE 6/7/12 MDS DOCUMENTED RESIDENT #104 AS BEING COGNITIVELY INTACT. THIS MDS ALSO REVEALED RESIDENT #104 NEEDED EXTENSIVE ASSISTANCE OF TWO WITH TRANSFERS WITH THE MODE OF TRANSPORTATION BEING A WHEELCHAIR AND HAD IMPAIRMENT ON ONE SIDE TO BOTH LOWER AND UPPER EXTREMITIES. A "BRADEN RISK ASSESSMENT SCALE" DATED 7/6/12, SCORED RESIDENT #104 AT 17 INDICATING SHE WAS AT MINIMAL RISK FOR SKIN BREAKDOWN. THE "ADMISSION SKIN ASSESSMENT" SHEET (NOT DATED) REVEALED RESIDENT #104 HAD AN EXCORIATED AREA ON THE BUTTOCK. A "SKIN INTEGRITY ASSESSMENT: PREVENTION AND TREATMENT PLAN OF CARE" DATED 6/15/12, REVEALED RESIDENT #104 WAS AT RISK FOR SKIN BREAKDOWN AND INDICATED RESIDENT #104 NEEDED INTERVENTIONS INCLUDING "FREQUENT TURNING, MAXIMAL REMOBILIZATION, AND PRESSURE-REDUCTION SUPPORT SURFACE IF BED OR CHAIR BOUND." THE GOAL READ, "WILL REMAIN FREE OF OPEN AREAS". RESIDENT #104'S "CARE DELIVERY GUIDE" UPDATED 7/6/12, READ "ASSIST POSITIONING WITH ONE PERSON EVERY TWO HOURS". A "SKIN GRID - PRESSURE/[MEDICAL CONDITION] ULCER/OTHER" FORM, DATED 8/2/12, REVEALED THE FOLLOWING SKIN BREAKDOWN FOR RESIDENT #104: - (LEFT) BUTTOCK STAGE 2 PRESSURE ULCER MEASURING 2.0 CM X 1.4 CM WITH SCANT DRAINAGE - (RIGHT) UPPER BUTTOCK STAGE 2 PRESSURE ULCER MEASURING 1.2 CM X 0.6 CM WITH SCANT DRAINAGE - (RIGHT) LOWER BUTTOCK STAGE 2 PRESSURE ULCER MEASURING 0.9 CM X 0.4 CM WITH SCANT DRAINAGE - (RIGHT) MID-BUTTOCK STAGE 2 PRESSURE ULCER MEASURING 1.0 CM X 1.5 CM WITH SCANT DRAINAGE. AN INTERDISCIPLINARY TEAM (IDT) PROGRESS NOTE DATED 8/9/12, READ: "...(RESIDENT #104) NOTED TO HAVE 4 X STAGE II PU (PRESSURE ULCERS) ... FOUND 8/2/12...ON YELLOW DOT PROGRAM. AIR MATTRESS IS IN PLACE FOR POSITIONING." THE FACILITY'S PROCEDURE TITLED "TURNING AND REPOSITIONING PROGRAM" REVISED DATE OF 4/09, READ " PROCEDURE: (1.) PLACE A YELLOW DOT ON THE NAMEPLATE OF THE RESIDENT'S DOOR AND/OR WHEELCHAIR WHENEVER A RESIDENT IS: UNABLE TO TURN SELF (AND UNABLE TO REPOSITION SELF. (2.) TURN AND REPOSITION RESIDENTS EVERY 1-2 HOURS WHEN: IN BED (AND/OR) IN WHEELCHAIR /GERICHAIR. (3.) OFFER REMINDERS TO TURN AND REPOSITION RESIDENTS WITH SENSORY IMPAIRMENT WHENEVER A RESIDENT IS ABLE TO TURN SELF (AND ) ABLE TO REPOSITION SELF." THE "YELLOW DOT PROGRAM" POSITIONING SCHEDULE SHOWED THAT A RESIDENT SHOULD BE POSITIONED AT 8:00 TOWARDS WINDOW, 10:00 TOWARDS DOOR, 12:00 ON BACK, 2:00 TOWARDS WINDOW, 4:00 TOWARD DOOR, AND 6:00 ON BACK PER 24 HOURS. ON 8/23/12 AT 9:45 A.M., RESIDENT #104 WAS OBSERVED IN HER ROOM, RESTING IN BED WITHOUT AN AIR MATTRESS, ON HER BACK ALTHOUGH THE IDT NOTE DATED 8/09/12, DESCRIBED THE RESIDENT AS HAVING AN AIR MATTRESS ON HER BED. ON 8/23/12 AT 10:25 A.M., RESIDENT #104 WAS AGAIN OBSERVED IN HER BED, RESTING ON HER BACK WITHOUT AN AIR MATTRESS. THIS SURVEYOR ASKED RESIDENT #104 IF SHE HAD EVER HAD AN AIR MATTRESS ON HER BED AND SHE REPLIED, "NO...THERE HAS NEVER BEEN AN AIR MATTRESS...I WAS GOING TO HAVE ONE BUT A LADY CAME IN THAT NEEDED IT ...SO I NEVER GOT ONE." WHEN ASKED IF SHE WAS AWARE SHE WAS ON A TURNING AND REPOSITIONING PROGRAM TO MAINTAIN HER SKIN INTEGRITY, RESIDENT #104 STATED "NO. NO, THEY DON'T COME IN AND REMIND ME TO TURN ...NO... I THINK THEY JUST THINK I'M UP...YES, I'VE BEEN ON MY BACK ALL MORNING... NO ONE SUGGESTED I TURN ONTO MY SIDE ...". DURING AN INTERVIEW ON 8/23/12 AT 10:45 A.M., CERTIFIED NURSE AIDE (CNA) "N" STATED, "YES, SHE (RESIDENT #104) WAS IN BED ALL MORNING AND NO...I DID NOT MAKE SURE SHE WAS ON THAT TURNING SCHEDULE (REFERRING TO THE YELLOW DOT PROGRAM). NO, I DIDN'T. SHE IS USUALLY IN HER WHEELCHAIR SO I NEVER THINK OF TELLING HER TO REPOSITION...SORRY I JUST DON'T." DURING AN OBSERVATION OF INCONTINENCE CARE ON 8/23/12 AT 11:50 A.M. WITH CNA "N", THE BUTTOCK AREA OF RESIDENT #104 WAS EXAMINED. ON THE LEFT BUTTOCK, THERE WAS A TENNIS BALL SIZE AREA WHICH WAS DARK RED IN COLOR. INSIDE THIS AREA TO THE LEFT OF CENTER, THERE WAS A DIME SIZE AREA THAT HAD DARK, HARD CRUSTED TISSUE ON IT WITH DRY SKIN ABOVE IT. THIS AREA WAS NOT BLANCHING WITH CARE. THE RIGHT BUTTOCK SKIN WAS INTACT WITH A DARK RED AREA OF DISCOLORATION WHICH WAS NOT BLANCHING. RESIDENT #104 STATED (DURING CARE), "THE NURSES CHECK IT DAILY AND IF ITS OPENED AT ALL THEY PUT THAT TAN STUFF ON IT ...BUT IT ALWAYS COMES OFF." DURING AN INTERVIEW ON 8/23/12 AT 12:20 P.M. WITH REGIONAL DIRECTOR "I" AND EDUCATION DIRECTOR "C", THEY WERE ASKED ABOUT THE LACK OF AN AIR MATTRESS ON THE RESIDENT'S BED AND FOR EVIDENCE RESIDENTS INCLUDING RESIDENT #104, WERE TURNED AND REPOSITIONED ACCORDING TO THE YELLOW DOT PROGRAM. THERE WAS NO RESPONSE BY REGIONAL DIRECTOR "I" OR BY EDUCATION DIRECTOR "C" REGARDING THESE QUESTIONS, NOR COULD THEY PROVIDE EVIDENCE THE DEVELOPMENT OF PRESSURE ULCERS FOR RESIDENT #104 WERE UNAVOIDABLE SINCE CARE PLANNED PREVENTIVE MEASURES AND PRESSURE RELIEVING DEVICES WERE NOT FOUND TO BE IN PLACE. THE MDS dated [DATE], SHOWED RESIDENT #101 IS A [AGE] year OLD WOMAN REadmitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE REVIEW OF THE 6/21/12 MDS ASSESSMENT FOR RESIDENT #101 REVEALED SHE WAS COGNITIVELY INTACT. THE MDS SHOWED RESIDENT #101 NEEDED EXTENSIVE ASSISTANCE OF TWO WITH TRANSFERS. THE 6/21/12 MDS ALSO SHOWED RESIDENT #1 HAD ONE STAGE 4 PRESSURE ULCER ON HER COCCYX AREA. THIS MDS ALSO INDICATED RESIDENT #101 WAS ON A TURNING AND REPOSITIONING PROGRAM TO IMPROVE/MAINTAIN HER SKIN INTEGRITY. THE "SKIN INTEGRITY ASSESSMENT: PREVENTION AND TREATMENT PLAN OF CARE" FOR RESIDENT #101 DATED 12/28/11, SHOWED A "YELLOW DOT" ADHERED TO THE TOP OF THE INTERVENTION SECTION. THIS INDICATED RESIDENT #101 WAS ON THE "YELLOW DOT" TURNING AND REPOSITIONING PROGRAM. THE CARE PLAN INCLUDED AN INTERVENTION, REVISION DATE 6/4/12, WHICH READ "NOT TO BE UP FOR LONG PERIODS OF TIME IN W/C (WHEELCHAIR)." THE "CARE DELIVERY GUIDE" REVISED 7/31/12 AND USED BY THE CNAS, GAVE THESE INSTRUCTIONS TO THE CNAS WHEN CARING FOR RESIDENT #101: "SPECIAL EQUIPMENT: WHEELCHAIR; ASSIST OF 2 (WITH) POSITIONING EVERY 2 HOURS. UNDER "COMMENTS/SPECIAL NEEDS: IT WAS HAND-WRITTEN: "NOT TO BE UP IN CHAIR FOR LONG PERIODS OF TIME." THE FACILITY'S PROCEDURE TITLED "TURNING AND REPOSITIONING PROGRAM" REVISED DATE OF 4/09, READ: "PROCEDURE: (1.) PLACE A YELLOW DOT ON THE NAMEPLATE OF THE RESIDENT'S DOOR AND/OR WHEELCHAIR WHENEVER A RESIDENT IS: UNABLE TO TURN SELF (AND) UNABLE TO REPOSITION SELF. (2.) TURN AND REPOSITION RESIDENTS EVERY 1-2 HOURS WHEN: IN BED (AND/OR) IN WHEELCHAIR /GERICHAIR." THE FOLLOWING OBSERVATIONS AND AN INTERVIEWS CONDUCTED ON 8/22/12, SHOWED STAFF WERE NOT TURNING/REPOSITIONING RESIDENT #101 ACCORDING TO HER CARE PLAN, AND PER FACILITY PROTOCOL. ON 8/22/12 AT 9:00 A.M., RESIDENT #101 WAS OBSERVED SITTING IN HER WHEELCHAIR, IN HER ROOM. THE WHEELCHAIR WAS PLACED IMMEDIATELY INSIDE THE LEFT-HAND SIDE OF THE DOOR, WITH THE RESIDENT LOOKING OUT THE WINDOW. RESIDENT #101 WAS ALSO OBSERVED ON 8/22/12 AT 9:25 A.M. AND AGAIN AT 11:30 A.M., SITTING IN HER WHEELCHAIR, IN THE SAME LOCATION AND POSITION. AT 11:50 A.M. ON 8/22/12, THE SURVEYOR WENT INTO RESIDENT #101'S ROOM TO SPEAK TO HER. THE RESIDENT WAS SITTING IN HER WHEELCHAIR IN THE SAME LOCATION/POSITION. THE INTERVIEW LASTED APPROXIMATELY 45 MINUTES UNTIL APPROXIMATELY 12:35 P.M., WHEN RESIDENT #101 WAS SERVED HER LUNCH TRAY WHILE SITTING IN HER WHEELCHAIR. A FOLLOW-UP INTERVIEW WITH RESIDENT #101 ON 8/22/12 AT 4:20 P.M., CONFIRMED SHE HAD BEEN IN HER WHEELCHAIR FROM BREAKFAST UNTIL AFTER HER 1:30 P.M. SMOKE BREAK. RESIDENT #101 SAID, SHE WAS THEN ASSISTED BACK TO BED. RESIDENT #101 STATED "NO ONE REMINDS ME TO REPOSITION MYSELF IN MY WHEELCHAIR...I'M PRETTY MUCH ON MY OWN ONCE I'M UP...NO ONE COMES IN UNLESS I CALL..." OBSERVATION OF THE ELECTRIC WHEELCHAIR SHOWED THE CONTROLS COULD CHANGE THE TILT POSITION OF THE CHAIR. WHEN ASKED BY THE SURVEYOR IF SHE WAS AWARE HER POSITION SHOULD BE CHANGED EVERY 2 HOURS TO HELP MAINTAIN HER SKIN INTEGRITY, RESIDENT #101 STATED "NO... NO ONE TELLS ME TO CHANGE POSITION WHEN I'M IN MY WHEELCHAIR...". IN AN INTERVIEW ON 8/20/12 AT 2:50 P.M., RESIDENT #101 REPORTED WHEN THE RESIDENT ADVOCATE, OMBUDSMAN "F" WAS VISITING HER FOR THE DAY, OMBUDSMAN "F" HAD WITNESSED THE STAFF WERE NOT FOLLOWING THE CARE PLAN AND NOT PUTTING HER TO BED WHEN REQUESTED BY RESIDENT #101, AND INSTEAD, LEFT HER UP IN HER WHEELCHAIR FOR LONG PERIODS OF TIME. ON 8/24/12, AT 1:30 P.M., A PHONE INTERVIEW WAS CONDUCTED WITH OMBUDSMAN "F" WHO STATED SHE WAS WITH RESIDENT #101 ON 4/20/12 FOR THE MAJORITY OF THE MORNING AND EARLY AFTERNOON. DURING THIS TIME, OMBUDSMAN "F" STATED SHE WITNESSED RESIDENT #101 HAD BEEN UP IN HER WHEELCHAIR FOR A PERIOD OF TIME IN THE MORNING. ACCORDING TO OMBUDSMAN "F", WHEN RESIDENT #101 ASKED HER ASSIGNED (UNIDENTIFIED) CNA AT 10:00 A.M. TO PUT HER BACK TO BED, THERE WAS NO RESPONSE FROM THE CNA. THE OMBUDSMAN SAID AT 11:15 A.M., RESIDENT #101 ASKED THE SAME CNA TO PUT HER TO BED BECAUSE SHE WAS HAVING PAIN. AGAIN, ACCORDING TO OMBUDSMAN "F", THERE WAS NO RESPONSE FROM THE CNA. OMBUDSMAN "F" STATED AT AROUND 1:45 P.M., THREE AND THREE QUARTER HOURS AFTER SHE HAD FIRST REQUESTED TO LAY DOWN, THE SAME CNA CAME INTO THE ROOM AND STATED SHE HAD COME TO PUT RESIDENT #101 TO BED. OMBUDSMAN "F" TOLD THE CNA THAT RESIDENT #101 WAS OUTSIDE HAVING A CIGARETTE. OMBUDSMAN "F" REPORTED RESIDENT #101 WAS NOT PLACED BACK TO BED ON 4/20/12 UNTIL 2:00 P.M. THE PRESSURE ULCER TREATMENT RECORDS FOR RESIDENT #101 WERE REVIEWED. ON THE FACILITY'S FORM "SKIN GRID - PRESSURE/[MEDICAL CONDITION] ULCER/OTHER", THE TREATMENT NURSE DOCUMENTED RESIDENT #101'S PRESSURE ULCER ON 4/2/12 WAS A STAGE 4 WITH THE FOLLOWING MEASUREMENTS: (LENGTH) 3 CENTIMETERS (CM) X 1.0 CM (WIDTH) AND 3.0 CM (DEPTH) WITH TUNNELING / UNDERMINING AT 12:00 MEASURING 0.2 CM. THREE AND A HALF WEEKS LATER ON 4/27/12, THE STAGE 4 PRESSURE ULCER MEASURED 2.5 CM X 1.1 CM WITH A DEPTH OF 3.3 CM AND TUNNELING / UNDERMINING AT 12:00 EQUALING 0.2 CM. THESE MEASUREMENTS SHOWED NO EVIDENCE OF WOUND HEALING. ON 8/22/12 AT 1:20 P.M., WOUND CARE FOR RESIDENT #101 WAS OBSERVED. RESIDENT #101 WAS LYING IN HER BED,WHILE REGISTERED NURSE (RN) "P" WAS PREPARING TO PERFORM THE PRESSURE ULCER TREATMENT TO THE RESIDENT'S COCCYX. RESIDENT #101 WAS REPOSITIONED, AT WHICH TIME ANOTHER OPEN AREA ON THE LEFT BUTTOCK CHEEK WAS NOTED. REGISTERED NURSE "P" MEASURED THE OPENED AREA, WHICH WAS IRREGULARLY SHAPED, AT 3.0 CM X 0.9 CM WITH A SCANT AMOUNT OF SEROSANGUINOUS DRAINAGE PRESENT. THE SURROUNDING SKIN WAS WHITISH ALONG WITH DARK RED SHINY SKIN, WHICH HAD THE APPEARANCE OF SCAR TISSUE. REGISTERED NURSE "P" STATED "YES, IT IS A RECURRENCE OF A BREAKDOWN OF AN OLD AREA. WHEN ASKED BY THE SURVEYOR, RN "P" CONFIRMED THE WOUND WAS A RECURRENT STAGE II PRESSURE ULCER. ( ) --