Every finding on record at Mill-Pond

Based on clinical record review, staff interview and policy review, the facility failed to attempt a gradual dose reduction for a resident prescribed psychotropic medication (medication that affect a person's mental state) for 1 of 5 residents reviewed for medications (Resident #16). The facility reported a census of 55 residents. Findings include:The Minimum Data Set (MDS), dated [DATE], documented Resident #16 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS included diagnoses of heart failure, anxiety disorder and depression. The MDS indicated Resident #16 took antianxiety and antidepressant medications during the lookback period. The Care Plan Focus revised 8/21/25 indicated Resident #16 used an antianxiety medication (lorazepam) due to a diagnosis of anxiety. The goal reflected Resident #15 would be free from discomfort or adverse reactions related to antianxiety therapy through the review date. The interventions included:a. Administer medications as ordered.b. Monitor/document side effects and effectiveness.c. Inform resident, family and caregivers about risks, benefits and the side effects and/or toxic symptoms of antianxiety medications being given. Review of the Electronic Health Record (EHR) for Resident #16 revealed an order dated 3/18/24 for lorazepam (antianxiety) 0.5 mg at bedtime for anxiety. The order lacked a discontinue date. Review of the EHR for Resident #16 revealed no attempt at a gradual dose reduction (GDR) since March 2024 for lorazepam. Review of the facility consulting pharmacy monthly reviews for psychotropic medication revealed they didn't have the lorazepam listed for Resident #16. Review of the EHR for Resident #16 revealed an annual psychotropic medication evaluation completed 8/12/25. It documented Resident #16 received antianxiety medication, lorazepam. The evaluation further documented the last GDR was from 0.75 mg nightly to 0.5 mg nightly on 3/18/24. The evaluation documented a GDR was not contraindicated for the medication. Review of the EHR for Resident #16 revealed a quarterly psychotropic medication evaluation completed on 2/5/26 documented Resident #16 didn't currently receive antianxiety medications. During an interview 3/19/26 at 8:58 AM, the Director of Nursing (DON) stated the pharmacy had access to their EHRs and reviewed the EHR before sending the facility their monthly medication reviews. The facility MDS coordinator did a quarterly review as well for all residents on psychotropic medications. The Clinical Coordinator completed a psychotropic evaluation of the residents on psychotropic medications completed quarterly and annually. The DON acknowledged the facility missed the psychotropic medication lorazepam on the last psychotropic evaluation completed in February 2026 for Resident #16. The DON acknowledged the facility hadn't attempted or discussed a GDR for the psychotropic medication lorazepam since 2024 for Resident #16. The DON stated not only did the consulting pharmacy review miss the recommendation for a GDR on this psychotropic medication, but the facility also missed that it was not completed since 2024. The DON stated there should have been a GDR recommendation in the last year and stated an expectation of an attempt at a GDR or a rationale from the Primary Care Physician (PCP) as to why a GDR should not be attempted.Review of the facility Psychotropic Medication Use policy, modified March 2025, documented gradual dose reduction/tapering of a medication dose will be implemented under the direction of a physician and with clinical monitoring as per CMS regulation unless clinically contraindicated. Pharmacist consultant has primary responsibility to monitor GDR attempts. Household Coordinator/Resident Services and Clinical Coordinator jointly monitor results of GDR attempts. This will be documented during the MDS assessment process using the Psychotropic Medication Assessment. The goal of tapering a medication dose or Gradual Dose Reduction (GDR) is to seek the appropriate dose and duration for each medication and minimize the risk of adverse consequences.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure the drug regimen is free from unnecessary drugs, to include a resident on an antibiotic for excessive duration and without adequate monitoring for 1 of 5 residents reviewed for unnecessary medication (Resident #47). The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], documented Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had diagnoses to include medically complex conditions and acne, unspecified. The MDS documented Resident #47 took an antibiotic in the look back period. The Care Plan Focus initiated 3/5/25 Resident #47 had the potential for an infection related to acne (preventative antibiotic use). The goal reflected the resident will remain free from complications through the next review date. The interventions directed the following:a. Give resident medications per orders.b. Monitor for increased symptoms of infection which may include increased temperature, altered mental status, lethargy or redness of site.c. Monitor lab results per physician orders.d. Monitor vital signse. Observe for and document signs/symptoms of a Urinary Tract Infection (UTI). Review of the Electronic Health Record (EHR) revealed Resident #47 took a daily prescribed antibiotic since admission to the facility on 2/18/25. Review of the EHR for Resident #47 revealed an order dated 2/18/25 for doxycycline hyclate oral tablet (Antibiotic) 100 milligrams (mg), give one tablet by mouth one time a day for prophylaxis (preventative) for chronic skin related to acne, unspecified. The order directed to discontinue on 6/26/25. Review of the EHR for Resident #47 revealed an order dated 6/26/25 for doxycycline hyclate oral tablet (Antibiotic) 50 mg, give one tablet by mouth one time a day for prophylaxis (preventative) for chronic skin related to acne, unspecified. The order didn't include a discontinue date.Review of the EHR for Resident #47 revealed a Medication Regimen Review (MRR) from the facility consulting pharmacist dated 12/21/25 with recommendations related to the resident taking an antibiotic doxycycline 50 mg daily for prophylaxis, antimicrobial stewardship refers to the careful and correct use of antibiotics, due to the increase in antibiotic resistance, there is an attempt to evaluate and document the continued need for antibiotics and requested the facility provide information to include:a. Antibiotic diagnosis, the facility responded acne.b. Clinical rationale for continued need, the facility responded acne, will have resident follow up with dermatology.c. Is antibiotic use prescribed by a specialist, the facility responded will follow up with dermatology.d. How often does the resident see specialist, the facility responded no recent follow up, will set up. e. Has the resident failed trial off therapy, the facility responded no.f. Please give re-evaluation date, the facility did not respond with a date. The General Note, dated 1/5/26, reflected the staff spoke to Resident #47 about Dermatology. Resident #47 to see the Dermatologist, will update doctor. The Medication Administration Note dated 1/7/26 indicated the staff spoke to Resident #47 about their Dermatology preference. Resident #47 reported she didn't want to go to the Dermatologist, as she wanted her doctor to take care of her dermatology issues as well. The staff left a note for Nurse Practitioner (NP) the day before with no new orders. The staff added Resident #47 to the Doctor (Primary Care Physician - PCP) list for tomorrow. Review of the EHR lacked documentation the PCP followed up with the review for Resident #47's prescribed antibiotic. During an interview 3/18/26 at 8:37 AM, the Director of Nursing (DON) acknowledged Resident #47 took a daily prescribed antibiotic since her admission to the facility in February of 2025. In January 2026, after the pharmacy recommendation to review the prescribed antibiotic, Resident #47 did not want to follow up with a Dermatologist. The review went to the resident's PCP in January 2026. During an interview 3/18/26 at 9:45 AM, the DON stated the facility didn't have any medical records or notes from the Dermatologist who initially prescribed the antibiotic for Resident #47. The DON reported there is no documentation since October 2025 from Resident #47's PCP regarding the acne and the need for the daily antibiotic. The DON further reported there is no documentation in the EHR about a referral made to the PCP in January 2026 to follow Resident #47 for the antibiotic after the resident declined to return to the Dermatologist. The DON stated the nursing staff dropped the ball in January 2026 and did not make the referral to the resident's PCP to follow Resident #47 related to her acne and prescribed antibiotic. The DON couldn't find documentation about the PCP managing Resident #47's acne, the prescribed antibiotic, or documentation the PCP reviewed the prescribed antibiotic after the pharmacy recommendation in December 2025 for review of continued need for the antibiotic. The DON stated when a resident is on a long term, continuous antibiotic this is referred to the facility Infection Preventionist (IP) to follow. Resident #47's continuous antibiotic was not referred to the IP for review to monitor and assess side effects of the continuous antibiotic and the need for the continued use of the antibiotic. The DON stated the PCP last had a routine visit with Resident #47 in February of 2026, on the 16th. The PCP did not review the acne at that time or document a rationale to continue the prescribed antibiotic. During an interview 3/18/26 at 12:45 PM, the Infection Preventionist (IP) stated as the facility IP she receives a monthly infection report and a report when a resident is placed on an antibiotic. If a resident is admitted to the facility on an antibiotic a report will be sent to her as well. The IP stated she did not receive a report on Resident #47 when she admitted to the facility that the resident was on an antibiotic. The IP stated she should have received a report of the resident being on an antibiotic. Since the resident's admission in February of 2025 until now, Resident #47 has not been on her list of residents on an antibiotic and she has not been monitoring the resident's antibiotic use. The IP stated she keeps a log of all residents who are on an antibiotic and this log is updated monthly and reported on monthly. The IP stated Resident #47 should have been on the log, and the IP should have been monitoring her antibiotic use. The IP should have been monitoring Resident $#47 for adverse side effects of the antibiotic and if the antibiotic was effective. The IP should have reviewed lab work at least yearly for renal function for Resident #47. Resident #47's antibiotic was added to the IP's list today for residents on an antibiotic. Review of the facility policy Infection Control-Antibiotic Stewardship Procedure, modified November 2022, documented the staff nurse would complete progress note documentation at the start and end of an antibiotic regimen. They will monitor/review response to antibiotics and laboratory results when available to determine if the antibiotic is still indicated. The Infection Control and Prevention Specialist will complete the infection control log line list document form which is to be kept up to date throughout the month with any new antibiotic orders, analyze the data for trends, clusters, antibiotic stewardship and prophylactic antibiotic use. Review of the facility policy Clinical Medication Review, dated September 2018, documented the purpose was to ensure residents have clinically significant medication issues identified and addressed in a timely manner. The consulting pharmacist completes drug regimen review; it is the responsibility of the licensed nurse to communicate those items that could be clinically significant to the primary care provider.

Based on observation, staff interviews and policy review, the facility failed to date, seal, and label open food items stored in the kitchen pantry. The facility reported a census of 55 residents. Findings include:On 3/16/26 beginning at 12:45 PM observed the dry pantry storage area in the main kitchen, with the Certified Dietary Manager (CDM) present. The observation revealed the following items:a. 1 bag of dried croutons opened and unsealed without a label of the date received or opened.b. 1 bag of dried cereal opened and unsealed without a label of the date received or opened.c. 3 bags of dried pasta opened and unsealed without a label of the date received or opened.d. 1 bag of almonds opened and unsealed without a label of the date received or opened. The CDM stated they expected the opened bags of food should have a label when opened and securely sealed when stored in the pantry. During an interview 3/16/26 at 12:15 PM, the Administrator stated they expected opened bags of food stored in the pantry should have a label with the date opened and be securely sealed. Review of the facility policy Safe Food Storage, updated May 2019, documented employees who receive and store food will maintain the storage areas including dry, refrigerated and frozen storage areas utilizing the following guidelines: a. Make sure all goods are dated with received dates.b. Label, date and properly cover all food items upon opening of package.

Based on observation, staff interview, and policy review, the facility failed to obtain final cooking food temperatures on alternative menu items prepared in the satellite kitchen. The facility reported a census of 59 residents. Findings include: During a continuous lunch service observation on 3/5/25, at 11:45 AM, Staff A, Cook, and Staff B, server, both seen preparing tomato soup for two separate residents. In both instances, a final cooking temperature was not obtained after the soup was removed from the microwave and served to residents. Staff B also observed preparing a microwaveable cup of macaroni and cheese. A final cooking temperature was not obtained. During an interview on 3/5/25, at 12:45 PM, Staff C, Nutrition and Culinary Supervisor, stated final cooking temperatures are normally obtained on items that are prepared in the satellite kitchen. During an interview on 3/6/25, at 8:00 AM, the Certified Dietary Manager, CDM, acknowledged the lack of temperatures for items prepared in the satellite kitchen. With the variety of foods available to residents on the alternative/always available menu (which include hamburgers), the CDM voiced final cooking temperatures should be obtained. This will ensure proper cooking temperature reached for food safety but also to ensure resident safety. The policy Dietary-F812 Regulation-Food Safety Requirements, dated 2020, stated cooking food to the required temperature will either kill dangerous organisms or inactivate them enough so there is little risk to the resident and food is safe to eat. Reheated cooked foods must be reheated to an internal temperature of 165 Fahrenheit. Ready-to-eat foods should be reheated to at least 135 Fahrenheit.

Based on electronic health record review, staff interview, and policy review, the facility failed to ensure documentation of insulin administration for 1 of 4 resident reviewed for medication regimen review (Resident #12). The facility reported a census of 59 residents. Findings include: The Minimum Data Set (MDS) Assessment, dated 1/16/25, listed Resident #12's medical diagnoses, which include diabetes and Parkinson's. The MDS noted the use of insulin. The Order Summary Report, dated 3/6/25, listed an order for Glargine (long acting insulin), which is administered one time a day at night and an order for Lispro or Aspart (both fast-acting insulin), which is administered three times a day with meals. The Medication Administration Record (MAR) revealed the following: a. In September 2024, Glargine was not recorded as administered in 1 out of 30 days b. In October 2024, Aspart was not recorded as administered at noon in 1 out of 31 days c. In December 2024, Glargine was not recorded as administered in 1 of out of 31 days d. In January 2025, Glargine was not recorded as administered in 1 out of 30 days e. In February 2025, Glargine was not recorded as administered in 1 out of 28 days The review of Progress Notes in the electronic health record lacked documentation to address if the insulin had or had not been given to Resident #12. During an interview on 3/5/25, the Director of Nursing (DON) could not verify if the insulin had been administered and staff did not document or if the insulin was not administered at all. The DON would expect staff to document all medication administration. If the medication could not be given, additional documentation should be written to explain why it had not. The policy Medication Administration Policy, modified May 2021, stated medications are documented immediately after administration by the nurse or medication aide. If the resident refuses, staff should indicated this in the electronic MAR as well as the medical record.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to ensure staff treated residents with dignity and respect for 1 of 1 residents reviewed for dignity (Resident #45). The facility reported a census of 57 residents. Findings include: 1. The Annual Minimum Data Set(MDS) assessment tool, dated 1/12/24, listed diagnoses for Resident #45 which included anxiety, heart failure, and post-polio syndrome. The MDS reported he had upper extremity impairment on one side and lower extremity impairment on both sides. The MDS stated he required partial/moderate assistance with upper body dressing and rolling and substantial/maximal assistance with toileting, hygiene, showering, and lower body dressing, and was dependent on staff for taking off foot wear. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, which indicated intact cognition. The facility policy Vulnerable Adult Abuse Prevention Plan, modified January 2023, stated the facility would provide services of the highest quality to promote dignity and holistic well being. 1/11/23 Care Plan entries stated the resident had an activities of daily living(ADL) self-care performance deficit related to weakness, impaired range of motion, and post-polio syndrome. The Care Plan documented the resident required the assistance of 1 staff for dressing, grooming, and hygiene. 7/6/23 Care Plan entries stated the resident had the potential for a psychosocial well being problem related to the need for long term care placement, anxiety and physical limitations. The Care Plan directed staff to allow the resident time to answer questions to verbalize feelings, perceptions, and fears. The 1/17/24 facility Daily Assignment Sheet documented Staff J agency Certified Nursing Assistant(CNA) and Staff K agency CNA worked the evening shift. The 1/18/24 facility Daily Assignment Sheet documented Staff I, CNA worked the day shift. Staff J's name is on the schedule for the evening shift but had a line through it. The 1/19/24 Daily Assignment Sheet documented Staff K worked the evening shift. In a 1/19/24 3:42 p.m. email to the facility from Resident #45, the resident stated he had a very bad experience with two agency CNAs on 1/17/24. He stated that they tried to take his brace off without unlacing first and he yelled and told them to unlace his shoes first and then pull them off but they did not. He stated they kept pulling and yanking until he thought his ankles were going to break. He stated one of the aides looked down at his leg and said eeeooo, what happened to your leg?. He stated they had no respect for him and behaved as if they were extremely hurried. On 4/9/24 at 9:36 a.m., Resident #45 reported he had two agency CNAs that took care of him and were horrible. He stated they were unbelievably rough and he asked them to slow down. He stated they twisted his shoes in order to get them off and stated one of the CNA's looked at his leg and said ew, what happened to your leg?. He said he told them to get out. He stated the next day one of them came back and was swearing and accused Staff B Licensed Practical Nurse(LPN) of pushing her up against the wall and then called the police to report Staff B. In a subsequent interview on 4/10/24 at 10:46 a.m., the resident stated when the two staff members were trying to take his shoes off, it hurt and he even had pain in the left ankle the next day. He stated they hurt both of his feet and continued after he told them to stop. He stated they also hurt his left leg when they were taking his brace off and would not let him explain how to do things. He said he felt scared and frightened and said he did not feel like they hurt him deliberately but they would not listen. He said the next night one of the CNAs came back to the facility to work and the night after that the other came back to the facility to work. He stated he reported his concerns with the care to Staff H CNA on the night the police were called to the facility. On 4/10/24 at 3:26 p.m. Staff H CNA stated the resident reported to her when two female staff members took his shoes off, they were rough. She stated he told her about it the next day and she was pretty sure she told the nurse. On 4/10/24 at 4:07 p.m., Staff I CNA stated that when she came on to her shift on 1/18/24 the resident reported he was treated terribly the night before. He stated he was glad to see her and he had the worst aides who made fun of him, wound not listen to him, and hurt him. Staff I stated the resident described the staff members as African American females who were agency staff. Staff I stated she did not report this but kept the information that he told her in her mind. Staff I stated the resident told her this around 7:30-8:00 a.m. and later in her shift there was an agency staff member(Staff J CNA) who would not assist Staff B LPN with a resident transfer. Staff I stated Staff B and Staff J got into a verbal altercation and Staff J was using profane language. She stated the facility ended up asking Staff J to leave the facility and Staff J ended up calling the police to report Staff B for assault. Staff I stated in the midst of this altercation, the dots all connected and she wondered if Staff J was one of the staff members the resident had complained about to her earlier in the day. Staff I stated prior to Staff J leaving the facility she(Staff I) took her(Staff J's) picture at 5:27 p.m. and then showed it to the resident. Staff I stated the resident confirmed this was one of the staff members who mistreated him the night before. In a phone interview on 4/11/24 at 8:30 a.m., Staff J CNA stated she worked with the resident one night and had no problems with him other than accidentally dropping his leg down on the bed when they tried to take his brace off. She stated nothing was said about the situation until the next day when a resident's call light was going off and she was feeding. She stated a nurse was rude with her and she ended up calling her agency and they told her to leave the facility. In a phone interview on 4/11/24 at 8:42 a.m., Staff K CNA stated she assisted Staff J in helping the resident to bed. She stated as they pulled his leg over, his leg dropped on the bed by accident but stated nothing else occurred during the cares. She stated she did not hear anything else about the situation until 2 days later during her shift when she was feeding dinner when they told her she had to leave the facility. On 4/11/24 at 2:49 p.m., the Clinical Administrator stated the facility would report allegations of abuse within 2 hours and she expected staff to treat residents with kindness. She stated as soon as she received the email from the resident, she acted. She stated she was not aware that the resident reported the allegation to a staff member prior to this. On 4/15/24 at 12:37 p.m., the Clinical Administrator stated alleged perpetrators of abuse should be separated from residents immediately.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to report an allegation of abuse in a timely manner to the State Agency for 1 of 2 residents reviewed for abuse (Resident #45). The facility reported a census of 57 residents. Findings include: 1. The Annual Minimum Data Set (MDS) assessment tool, dated 1/12/24, listed diagnoses for Resident #45 which included anxiety, heart failure, and post-polio syndrome. The MDS stated he had upper extremity impairment on one side and lower extremity impairment on both sides. The MDS stated he required partial/moderate assistance with upper body dressing and rolling and substantial/maximal assistance with toileting, hygiene, showering, and lower body dressing, and was dependent on staff for taking off foot wear. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, which indicated intact cognition. The facility policy Vulnerable Adult Abuse Prevention Plan, modified January 2023, stated the facility would provide services of the highest quality to promote dignity and holistic well-being. The policy listed an objective as to protect each resident from abuse by care givers. The policy stated residents had the right to be free from abuse and stated in the event of suspected maltreatment residents would be immediately assessed and separated from the alleged perpetrator to ensure safety. The policy stated once abuse was suspected or identified the facility would conduct a thorough investigation of the alleged violation and stated in the event of suspected maltreatment, the needs of the resident would be immediately assessed and separated from the alleged perpetrator to ensure the resident's safety. The policy stated the facility would report instances of maltreatment immediately and initiate an investigation. 1/11/23 Care Plan entries stated the resident had an activities of daily living (ADL) self-care performance deficit related to weakness, impaired range of motion, and post-polio syndrome. The Care Plan documented the resident required the assistance of 1 staff for dressing, grooming, and hygiene. 7/6/23 Care Plan entries stated the resident had the potential for a psychosocial well-being problem related to the need for long term care placement, anxiety, and physical limitations. The Care Plan directed staff to allow the resident time to answer questions to verbalize feelings, perceptions, and fears. The 1/17/24 facility Daily Assignment Sheet documented Staff J agency Certified Nursing Assistant (CNA) and Staff K agency CNA worked the evening shift. The 1/18/24 facility Daily Assignment Sheet documented Staff I CNA worked the day shift. Staff J's name is on the schedule for the evening shift but had a line through it. The 1/19/24 Daily Assignment Sheet documented Staff K worked the evening shift. In a 1/19/24 3:42 p.m. email to the facility from the Resident #45, the resident stated he had a very bad experience with two agency CNAs on 1/17/24. He stated that they tried to take his brace off without unlacing first and he yelled and told them to unlace his shoes first and then pull them off but they did not. He stated they kept pulling and yanking until he thought his ankles were going to break. He stated one of the aides looked down at his leg and said eeeooo, what happened to your leg?. He stated they had no respect for him and behaved as if they were extremely hurried. On 4/9/24 at 9:36 a.m., Resident #45 stated he had two agency CNAs that took care of him and were horrible. He stated they were unbelievably rough and he asked them to slow down. He stated they twisted his shoes in order to get them off and stated one of the CNA's looked at his leg and said ew, what happened to your leg?. He said he told them to get out. He stated the next day one of them came back and was swearing and accused Staff B Licensed Practical Nurse (LPN) of pushing her up against the wall and then called the police to report Staff B. In a subsequent interview on 4/10/24 at 10:46 a.m., the resident stated when the two staff members were trying to take his shoes off, it hurt and he even had pain in the left ankle the next day. He stated they hurt both of his feet and continued after he told them to stop. He stated they also hurt his left leg when they were taking his brace off and would not let him explain how to do things. He said he felt scared and frightened and said he did not feel like they hurt him deliberately but they would not listen. He said the next night one of the CNAs came back to the facility to work and the night after that the other came back to the facility to work. He stated he reported his concerns with the care to Staff H CNA on the night the police were called to the facility. On 4/10/24 at 3:26 p.m. Staff H CNA stated the resident reported to her when two female staff members took his shoes off, they were rough. She stated he told her about it the next day and she was pretty sure she told the nurse. On 4/10/24 at 4:07 p.m., Staff I CNA stated that when she came on to her shift on 1/18/24 the resident reported he was treated terribly the night before. He stated he was glad to see her and he had the worst aides who made fun of him, wound not listen to him, and hurt him. Staff I stated the resident described the staff members as African American females who were agency staff. Staff I stated she did not report this but kept the information that he told her in her mind. Staff I stated the resident told her this around 7:30-8:00 a.m. and later in her shift there was an agency staff member(Staff J CNA) who would not assist Staff B LPN with a resident transfer. Staff I stated Staff B and Staff J got into a verbal altercation and Staff J was using profane language. She stated the facility ended up asking Staff J to leave the facility and Staff J ended up calling the police to report Staff B for assault. Staff I stated in the midst of this altercation, the dots all connected and she wondered if Staff J was one of the staff members the resident had complained about to her earlier in the day. Staff I stated prior to Staff J leaving the facility she Staff I took her (Staff J's) picture at 5:27 p.m. and then showed it to the resident. Staff I stated the resident confirmed this was one of the staff members who mistreated him the night before. In a phone interview on 4/11/24 at 8:30 a.m., Staff J CNA stated she worked with the resident one night and had no problems with him other than accidentally dropping his leg down on the bed when they tried to take his brace off. She stated nothing was said about the situation until the next day when a resident's call light was going off and she was feeding. She stated a nurse was rude with her and she ended up calling her agency and they told her to leave the facility. In a phone interview on 4/11/24 at 8:42 a.m., Staff K CNA stated she assisted Staff J in helping the resident to bed. She stated as they pulled his leg over, his leg dropped on the bed by accident but stated nothing else occurred during the cares. She stated she did not hear anything else about the situation until 2 days later during her shift when she was feeding dinner when they told her she had to leave the facility. On 4/11/24 at 2:49 p.m., the Clinical Administrator stated the facility would report allegations of abuse within 2 hours and she expected staff to treat residents with kindness. She stated as soon as she received the email from the resident, she acted. She stated she was not aware that the resident reported the allegation to a staff member prior to this. On 4/15/24 at 12:37 p.m., the Clinical Administrator stated alleged perpetrators of abuse should be separated from residents immediately. The facility lacked documentation they reported the incident to the State Agency prior to 1/19/24.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to initiate an abuse investigation and failed to separate residents from alleged perpetrators of abuse in a timely manner after staff became aware of a resident report of maltreatment for 1 of 2 residents reviewed for abuse (Resident #45). The facility reported a census of 57 residents. Findings include: 1. The Annual Minimum Data Set (MDS) assessment tool, dated 1/12/24, listed diagnoses for Resident #45 which included anxiety, heart failure, and post-polio syndrome. The MDS stated he had upper extremity impairment on one side and lower extremity impairment on both sides. The MDS stated he required partial/moderate assistance with upper body dressing and rolling and substantial/maximal assistance with toileting, hygiene, showering, and lower body dressing, and was dependent on staff for taking off foot wear. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, which indicated intact cognition. The facility policy Vulnerable Adult Abuse Prevention Plan, modified January 2023, stated the facility would provide services of the highest quality to promote dignity and holistic well-being. The policy listed an objective as to protect each resident from abuse by care givers. The policy stated residents had the right to be free from abuse and stated in the event of suspected maltreatment residents would be immediately assessed and separated from the alleged perpetrator to ensure safety. The policy stated once abuse was suspected or identified the facility would conduct a thorough investigation of the alleged violation and stated in the event of suspected maltreatment, the needs of the resident would be immediately assessed and separated from the alleged perpetrator to ensure the resident's safety. The policy stated the facility would report instances of maltreatment immediately and initiate an investigation. 1/11/23 Care Plan entries stated the resident had an activities of daily living (ADL) self-care performance deficit related to weakness, impaired range of motion, and post-polio syndrome. The Care Plan documented the resident required the assistance of 1 staff for dressing, grooming, and hygiene. 7/6/23 Care Plan entries stated the resident had the potential for a psychosocial well-being problem related to the need for long term care placement, anxiety, and physical limitations. The Care Plan directed staff to allow the resident time to answer questions to verbalize feelings, perceptions, and fears. The 1/17/24 facility Daily Assignment Sheet documented Staff J agency Certified Nursing Assistant (CNA) and Staff K agency CNA worked the evening shift. The 1/18/24 facility Daily Assignment Sheet documented Staff I CNA worked the day shift. Staff J's name is on the schedule for the evening shift but had a line through it. The 1/19/24 Daily Assignment Sheet documented Staff K worked the evening shift. In a 1/19/24 3:42 p.m. email to the facility from the Resident #45, the resident stated he had a very bad experience with two agency CNAs on 1/17/24. He stated that they tried to take his brace off without unlacing first and he yelled and told them to unlace his shoes first and then pull them off but they did not. He stated they kept pulling and yanking until he thought his ankles were going to break. He stated one of the aides looked down at his leg and said eeeooo, what happened to your leg?. He stated they had no respect for him and behaved as if they were extremely hurried. On 4/9/24 at 9:36 a.m., Resident #45 reported he had two agency CNAs that took care of him and were horrible. He stated they were unbelievably rough and he asked them to slow down. He stated they twisted his shoes in order to get them off and stated one of the CNA's looked at his leg and said ew, what happened to your leg?. He said he told them to get out. He stated the next day one of them came back and was swearing and accused Staff B Licensed Practical Nurse (LPN) of pushing her up against the wall and then called the police to report Staff B. In a subsequent interview on 4/10/24 at 10:46 a.m., the resident stated when the two staff members were trying to take his shoes off, it hurt and he even had pain in the left ankle the next day. He stated they hurt both of his feet and continued after he told them to stop. He stated they also hurt his left leg when they were taking his brace off and would not let him explain how to do things. He said he felt scared and frightened and said he did not feel like they hurt him deliberately but they would not listen. He said the next night one of the CNAs came back to the facility to work and the night after that the other came back to the facility to work. He stated he reported his concerns with the care to Staff H CNA on the night the police were called to the facility. On 4/10/24 at 3:26 p.m. Staff H CNA stated the resident reported to her when two female staff members took his shoes off, they were rough. She stated he told her about it the next day and she was pretty sure she told the nurse. On 4/10/24 at 4:07 p.m., Staff I CNA stated that when she came on to her shift on 1/18/24 the resident reported he was treated terribly the night before. He stated he was glad to see her and he had the worst aides who made fun of him, wound not listen to him, and hurt him. Staff I stated the resident described the staff members as African American females who were agency staff. Staff I stated she did not report this but kept the information that he told her in her mind. Staff I stated the resident told her this around 7:30-8:00 a.m. and later in her shift there was an agency staff member (Staff J CNA) who would not assist Staff B LPN with a resident transfer. Staff I stated Staff B and Staff J got into a verbal altercation and Staff J was using profane language. She stated the facility ended up asking Staff J to leave the facility and Staff J ended up calling the police to report Staff B for assault. Staff I stated in the midst of this altercation, the dots all connected and she wondered if Staff J was one of the staff members the resident had complained about to her earlier in the day. Staff I stated prior to Staff J leaving the facility she (Staff I) took her (Staff J's) picture at 5:27 p.m. and then showed it to the resident. Staff I stated the resident confirmed this was one of the staff members who mistreated him the night before. In a phone interview on 4/11/24 at 8:30 a.m., Staff J CNA stated she worked with the resident one night and had no problems with him other than accidentally dropping his leg down on the bed when they tried to take his brace off. She stated nothing was said about the situation until the next day when a resident's call light was going off and she was feeding. She stated a nurse was rude with her and she ended up calling her agency and they told her to leave the facility. In a phone interview on 4/11/24 at 8:42 a.m., Staff K CNA stated she assisted Staff J in helping the resident to bed. She stated as they pulled his leg over, his leg dropped on the bed by accident but stated nothing else occurred during the cares. She stated she did not hear anything else about the situation until 2 days later during her shift when she was feeding dinner when they told her she had to leave the facility. On 4/11/24 at 2:49 p.m., the Clinical Administrator stated the facility would report allegations of abuse within 2 hours and she expected staff to treat residents with kindness. She stated as soon as she received the email from the resident, she acted. She stated she was not aware that the resident reported the allegation to a staff member prior to this. On 4/15/24 at 12:37 p.m., the Clinical Administrator stated alleged perpetrators of abuse should be separated from residents immediately. The facility lacked documentation they initiated an investigation of the alleged incident immediately after the resident informed Staff I of his concerns on the morning of 1/18/24 and failed to ensure Staff J and Staff K did not return to work after the report.

Based on observations, family and staff interviews, and record review, the facility failed to provide oral care after meals as directed and incontinent care for 1 of 3 residents reviewed for Activities of Living (Resident #51). The facility reported a census of 57 residents. Findings include: The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #51 revealed the diagnosis of Alzheimer's disease, dementia, gastroesophageal reflux disease (acid reflux), and dysphagia (partial loss of language). The MDS documented the resident was totally dependent on one staff member for eating, oral care, and assistance of two staff for toileting and personal care. The MDS identified the risk for pressure ulcers. The Brief Interview for Mental Status (BIMS) score of 99 revealed severe impaired mental cognition. The Care Plan identified a focus area with initiated date of 12/29/23 as the resident with a deficit of activities of daily living related to weakness, impaired mobility, dementia with agitation, poor eyesight, and difficulty swallowing. The Care Plan directed staff to care for the resident with the following interventions: a. Oral care, the resident had his own teeth, and required assistance with mouth care b. Follow Speech Therapy (ST) recommendations for oral cares after all meals, oral intake and prior to breakfast or first meal of the day c. Dressing, Grooming, Hygiene required assistance of one staff member d. Provide assistance to check and change for incontinence upon rising, after meals and at bedtime During an interview on 4/8/24 at 10:35 a.m. Family Member stated Resident #51 was not being changed every 2 hours, he was unable to alert staff to needs, and he is in his reclining wheelchair (w/c) in the front living area without attention provided by staff. Observations on 4/9/24 revealed the following for Resident #51: a. At 9:31 a.m. Resident #51 in wheelchair in dining room, staff pushed him to front living room. Returned Resident #51 to the dining room at 11:30 a.m. b. At 1:00 p.m. staff pushed Resident #51 outside for activity. c. At 1:44 p.m. Staff F, CNA assisted Resident #51 to room and provided incontinent care. No oral care provided. During an interview on 4/9/24 at 1:44 p.m. Staff F, Certified Nursing Assistant (CNA) stated this was the first time to care for this resident. During an observation on 4/9/24 at 1:45 p.m. Staff E, CNA gowned in Personal Protective Equipment (PPE) gown and gloves replaced Staff F to provide care. During an interview on 4/9/24 at 1:45 p.m. Staff E, CNA stated she had assisted Staff D, CNA to get Resident #51 out of bed to shower at 6:30 a.m. and not provided care during the morning. During an observation on 4/9/24 at 1:47 p.m., Staff D, CNA entered Resident #51's room wearing PPE gown and gloves, and assisted Staff E, CNA to transfer Resident #51 from w/c to bed by using the mechanical lift. Staff E provided catheter care and assisted Staff D to provide intontinence care for Resident #51. Staff G, Licensed Practical Nurse, (LPN) entered the room and applied ointment to Resident #51's buttocks. Staff E and Staff D used the mechanical lift to assist Resident #51 to his recliner. Neither CNA provided Resident #51 with oral care. During an interview on 4/9/24 at 1:47 p.m. Staff D, CNA stated she gave Resident #51 a bed bath at 6:30 a.m. and checked his skin then and did not provide oral care nor incontinent care after that as she was giving showers. During an interview on 4/9/24 at 1:52 P.M. Staff G, LPN stated she had provided a skin check for Resident #51 this morning during bath and applied ointment and had not seen him after that. During observations on 4/10/24 revealed for Resident #51: a. At 7:15 a.m. Resident #51 was in bed. b. At 8:30 a.m. Resident #51 was in the dining room then was moved to the front living room in the wheelchair. c. At 10:02 a.m. Restorative Aide moved Resident #51 to his room and provided Range of motion to upper and lower extremities then returned resident to the living room. d. At 10:53 a.m. Staff M, CNA and Staff L, CNA removed Resident #51 from the front living room to his room and provided incontinence care. No oral care provided. During an interview on 4/10/24 at 11:19 a.m. Staff M, CNA stated the facility provides a paper care plan for the agency CNA's. The undated and untitled document provided by the facility provided to the CNA's listed Resident #51 and directed staff to provide oral care before the first meal and after all meals/oral intake and to have the assistance of 2 persons for check and change. The Clinical Resident Profile for Resident #51 revealed special instructions to provide oral care after every meal. The Speech Therapy evaluation dated 12/19/23 revealed Res #51 presented with mild-moderate oropharyngeal dysphagia. The Speech Therapy Progress Notes dated 2/21/24 revealed due to the documented physical impairments and associated functional deficits, without skilled therapeutic interventions, the patient is at risk for aspiration (choking). Oral care Point Of Care dated 3/28/24 through 4/8/24 for Resident #51 lacked documentation of oral care after meals. During an interview on 4/11/24 at 11:35 AM The Clinical Administrator stated the staff are to reposition, check and change residents after meals and to provide oral care as recommended by Speech Therapy.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to notify the provider after a change in condition in a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers(Resident #37). The facility reported a census of 37 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The Annual MDS assessment tool, dated 9/11/23, listed diagnoses for Resident #37 which included coronary artery disease, diabetes, and non-Alzheimer's dementia. The MDS stated the resident required limited assistance of 1 staff for transfers, and personal hygiene, extensive assistance of 1 staff for bed mobility, dressing, and bathing, and extensive assistance of 2 staff for toileting. The MDS stated the resident was at risk for developing pressure ulcers but had no unhealed pressure ulcers. The MDS stated stated the resident had inattention and disorganized thinking. The facility Skin Integrity Management Policy-Iowa and Wisconsin, modified October 2022, stated the facility would identify, assess, and monitor residents whose clinical condition increased the risk for impaired skin integrity and pressure injuries. The policy directed staff to notify the physician if any evidence of deterioration was noted. An 11/15/23 4:56 p.m. provider Progress Note stated the resident had a corn (a small, tender area of thickened skin) on his left heel and the provider ordered a corn pad. An 11/22/23 Body Audit stated the resident had a dark red scab noted on the left heel. A 11/29/23 Body Audit stated the resident had a scab on the left heel, dark red, and the abrasion measured 6.2 centimeters(cm) x 1.8 cm. A 12/4/24 1:51 p.m. (Late Entry) General Note stated the resident complained that he had pain in his left heel and he had a dark wound. The resident refused to walk to dine as it hurt him to walk. The 12/4/24 at 1:06 p.m. Skin and Wound Evaluation stated the resident had an unstageable(obscured full-thickness skins and tissue loss) pressure area to the rear left malleolus(ankle bone) acquired in house and the area was new. The wound measured 0.3 cm x 0.8 cm x 0.5 cm, and tender to touch. The December Medication Administration Record(MAR) listed a 12/5/23 order for Medihoney Wound/Burn Dressing(a gel which aided in the removal of dead tissue) and directed staff to apply to the left heel every 3 days. The facility lacked documentation of provider notification of the change in condition of the resident's heel from 11/22/23-12/4/23. A 12/4/23 Care Plan entry stated the resident had a pressure ulcer and would remain free from infection in the left heel. A 12/4/23 Care Plan entry directed staff to elevate the heel off the bed surface using pillows/heel elevation products while in bed. On 4/10/24 at 10:36 a.m., Staff A Hospice Nurse measured a wound on the resident's left heel as 3.2 cm x 2.8 cm. The wound bed was covered with brown eschar and the rest of the resident's heel was red. On 4/11/24 at 2:49 p.m., the Clinical Administrator stated if there was a change in a wound, she would want staff to notify the provider and ask for a different treatment. On 4/15/24 at 10:23 a.m., Staff C Clinical Administrator stated she noticed that over the Thanksgiving holiday there was a difference in the wound when she looked through the Body Audits. She stated it was right before a holiday and staff were human and they missed it. She stated she could not find provider notification until 12/4/23. She stated during weekly skin checks if a wound was worse, staff should notify the provider.

Based on observations, staff interviews, record review and facility policy review, the facility failed to maintain acceptable parameters of nutritional status for 1 of 5 residents (Resident #2). The facility reported a census of 52 residents. Findings include: On 2/21/23, a record review revealed the resident had a 15-pound weight loss in two weeks. On 1/24/23, the documented weight was 195.2 pounds and 180.2 pounds on 2/07/23. On 2/21/2023 at 7:39 AM, Resident #2 was observed in dining room requiring assistance with eating. The Quarterly Minimum Data Set (MDS) for Resident#2 dated 11/29/22 indicated that the resident required extensive assistance with eating. The MDS documented that Resident had diagnoses which included Alzheimer's disease, macular degeneration, and osteoarthritis. The MDS revealed that the Resident weighed 196 pounds. The care plan, revised on 11/28/22, indicated the resident had a nutritional risk and required assistance with eating. It included a goal weight range and directed staff to obtain the resident's weight per physician orders. The physician order entered 10/06/20 states that the resident was to be weighed weekly every Tuesday evening. The progress notes lacked documentation of physician notification of significant weight loss. An interview with Staff A, Registered Nurse (RN) on 02/21/23 at 3:41 PM revealed Resident #2 was required to be weighed on a weekly basis on Tuesday evenings. She verified that his last documented weight was on 2/07/23. She verified that there was no documented weight completed on 2/14/23. She stated that if a weight is not completed as scheduled, a 24-hour reminder is entered into the electronic health record and the on-coming staff is verbally notified that a weight is needed. An interview with Staff B, Certified Nursing Aid (CNA) on 2/21/23 at 3:54 PM revealed resident weights are documented in the shower book. A review of the shower book revealed Resident #2 had a weight entry with no date, time, nor signature noted. Staff B stated that a signature is expected to be present with weight entries. At 4:31 PM, Staff B reweighed Resident #2 twice and obtained a weight of 178.4 pounds. On 2/22/23 at 9:19 AM, Staff C, Licensed Practical Nurse (LPN), stated that a resident's weight is obtained by the on-duty CNA and reported to the nurse, who enters it into the resident's record. The weight should be analyzed and a second weight obtained if a significant change is noted. She stated that if the weight change is accurate, the nurse is to notify the physician and document the notification in the resident's progress notes. She stated that the corresponding Clinical Coordinator is verbally notified so the resident's care plan can be updated. On 2/22/23 at 12:15 PM, the Director of Nursing (DON) stated that staff residents' significant weight changes staff are expected to reweigh the resident and analyze weight method used. If the weight change is accurate, the physician should be notified. She also stated that the dietician checks weights every week. On 2/22/23, a policy review indicates re-weighs are required for a 5-pound loss for residents who weigh over 100 pounds and a 3-pound loss for residents who weigh under 100 pounds. It states that nursing staff is responsible for reviewing the initial weight, documenting the weight, and notifying the physician, involved family member, and the dietician of significant weight changes.

Based on clinical record review, observations, residents interviews, policy review, and staff interview, the facility failed to answer call lights promptly (15 minutes or less) for 3 of 6 residents reviewed (Resident #255, #254, and #10). The facility reported a census of 52 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 2/16/23 for Resident #255, documented a Brief Interview of Mental Status (BIMS) as 12 which indicated the resident had moderately impaired cognition. The MDS documented the need for extensive assistance of one person with bed mobility, transfers, dressing, and toileting. The MDS also documented the resident had a fracture. During an interview with Resident #255 on 2/20/23 at 9:06 AM, reported at times he had waited up to 30 minutes before the call light answered. 2. The MDS assessment dated [DATE] for Resident #254 documented a Brief Interview of Mental Status (BIMS) as 15 which indicated cognition intact. The MDS documented the resident needed extensive assistance of one person for bed mobility, transfers, dressing, and toileting. The MDS also documented the resident had a left femur fracture. During an interview with Resident #254 on 2/20/23 at 10:00 AM, reported she had waited up to 30 minutes for staff assistance after she turned her call light on. 3. The MDS assessment for Resident #10, dated 12/28/22 documented a BIMS as 15 which indicated no cognitive impairment. The MDS documented the resident needed extensive assistance of one person for bed mobility, transfers, dressing, and toileting. During continuous observation on 2/21/23 at 8:37 AM revealed the call light above Resident #10's room doorway on. At 09:01 AM the resident's call light remained on. At 9:05 AM the call light was observed off. The call light was observed on for 28 minutes. Record review of a document titled, Device Activity Report (the facilities call light system logs) dated 2/22/23, for Resident #10, documented on 2/21/23 at 8:30 AM the call light was turned on and at 9:05 AM the call light was turned off revealing a 34 minute wait time. Record review of a policy titled, Call Light Policy, modified November 2022 provided by the facility, lacked instruction to staff on the need to answer call lights within 15 minutes or less. In the interview on 2/22/23 at 10:12 AM, the Administrator stated he expected call lights answered within 15 minutes or less.

Based on observation, clinical record review, and interviews, the facility failed to provide a safe method of transfer for one of four residents reviewed, (Resident #153.) The resident fell and sustained fractures of the bones in the left shoulder and right hip when staff failed to use a full mechanical lift. The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) with assessment date 6/11/20 revealed Resident #153 had a Brief Interview for Mental Status score of 11, which indicated of moderately impaired cognition. The resident required the extensive assistance of two staff for transfers, bed mobility and toilet use. A balance during transition and walking test identified the resident as not steady but able to stabilize with staff assistance when moving from surface to surface transfer such as from between chair and bed. The active diagnoses listed on the MDS included:Non-Alzheimer's Dementia and [CONDITION(S)] (paralysis of one side of the body). Review of the Care Plan, on 9/22/21, with revised date 6/11/20 revealed Resident #153 was dependent on two staff with use of a full mechanical lift and the extra-large sling for transfers. Review of the facility document Team Sheet for Spring Park Rooms 46-51 revealed Resident #153 required a full mechanical lift for all transfers. The Progress Note dated 6/20/20 at 1:36 am documented Staff A, Registered Nurse was called to Resident #153's room and the resident was lying on the floor near the recliner. According to the CNA (Certified Nursing Assistant) Resident #153 slid down the recliner while being assisted. The resident was then transferred to bed with full mechanical lift, vital signs checked and recorded and no new injuries or bruises sustained. Resident #153 continued to be monitored. Intervention put into place was to keep dycem (non- slip material) in the recliner at all times. A Progress Note dated 6/21/20 at 5:30 am titled Fall Follow Up revealed Resident #153 was assessed, no changes in range of motion and no new injuries or bruises seen. The resident did not complain of any pain during the shift. The Progress Note dated 6/21/21 at 9:27 am revealed trace [CONDITION(S)] noted to bilateral lower extremities. Legs elevated with pillow in bed at this time. Resident had complaint of left arm pain this am unable to rate and routine [MEDICATION(S)] given. The Progress Note dated 6/21/20 at 6:27 pm revealed the facility had received call from the resident's daughter and she requested Resident #153 be evaluated related to discomfort. Assessment done by Staff B, Registered Nurse, revealed extreme pain with any movement to right lower extremity. Slight shortening and rotation to the right hip noted and no bruising. Residnet #153 complained of discomfort to left shoulder. The Director of Nursing and On Call Provider was notified. Resident #153 transferred by ambulance to the emergency room . The Progress Note dated 6/21/20 at 11:20 pm revealed a call was placed to the emergency room for update on resident status. Resident #153 was admitted to the hospital with left shoulder fracture and right hip fracture. Review of the hospital Health Care form titled Results of X-ray of Hip reviewed on 9/22/21 with a service date of 6/21/20 revealed a displaced, comminuted (bone splintered) and angulated (distal fracture fragment is in relation to the proximal fragment) of the intertrochanteric (right hip). Review of hospital Health Care form titled Results of X-ray of Shoulder reviewed on 9/22/21 with a service date of 6/21/20 revealed displaced left proximal humeral fracture, (fracture of upper arm bone). An Operative Note written on 6/22/20 at 2:38 pm revealed Resident #153 had a surgical procedure done which included inserted a nail/rod into the intramedullary (metal rod placed into a bone cavity) right femur. Review of Medication Administration record, on 9/22/21, dated 6/1/20-6/30/20 revealed Resident #153 received [MEDICATION(S)] 50 mg (pain med) by mouth every 6 hours related to displaced fracture of right femur and unspecified fracture of upper end of left humerus with an ordered date of 6/26/20. Review of Medication Administration record, on 9/22/21, dated 7/1/20-7/31/20 revealed Resident #153 received [MEDICATION(S)] 50 mg (pain med) by mouth every 6 hours related to displaced fracture of right femur and unspecified fracture of upper end of left humerus with an ordered date of 6/26/20. Discontinued date of 7/14/20. On 9/22/21 at 10:20 am Staff D, Registered Nurse stated she heard Staff C, CNA, from the North Hall called for help from Resident #153's room during rounds. Staff D saw Resident #153 on the floor just below the recliner and the male CNA was in the room. Stated no other staff members were present in the room when she entered. The nurse arrived and made the initial assessment and then lifted the resident with full mechanical lift into the bed. Staff D stated when she entered the room the mechanical lift was in the cove and not in the resident's room. Staff D stated Resident #153 did not seem to be in pain when she was put back to bed. Stated Staff C had called for help over the radio twice when the resident had fallen. Stated she had not seen Staff C at work since this incident. On 9/22/21 at 11:20 AM Staff E, CNA Staffing Agency, stated she went into Res #153's room to assist when the resident was on the floor. Staff E stated that Staff C had never called for help with the lift transfer. Staff E stated she thought Staff C used the lift by himself. Staff E stated the nurse asked her if she helped with the lift transfer and she stated no she did not help, the male CNA never called her for help on the radio. Staff E stated the facility trained her on their lifts and even had to take a test related to the use of lifts. On 9/22/21 at 11:40 a.m. Staff A, RN, stated Resident #153's fall occurred around midnight and heard the CNA calling for help after he transferred the resident by himself. Staff A stated she had just been in Resident #153's room to help her reposition. Resident #153 had been asking for pain pill prior to fall. After the fall the charge nurse assessed Resident #153 with vital signs, neuro checks and range of motion. Staff A stated Resident #153 did not appear to be in pain, gave the pain med because she had asked for it prior to the fall. On 9/22/21 at 12:23 pm the Clinical Administrator stated she was notified of the fall that occurred with Resident #153 around midnight on 6/20/20. Clinical Administrator stated she received a text related to the fall. Clinical Administrator stated at the time of the fall they did not have concerns of injuries or anything out of the ordinary had happened. She stated it was not until later the next day possible concern of fractures arose and then Resident #153 was sent to the emergency room . She stated she was never told the Care Plan might not have been followed and concerns never arose until her investigation when they questioned if the Care Plan was followed. She stated Staff C, CNA, initially was not forth coming and said he found her in the recliner in an awkward position and had complained of right hip pain. Staff C then told the Clinical Administrator that he tried to adjust the resident and she had slipped to the floor. Staff C then called the Clinical Administrator back the same day and admitted that he didn't want the resident to fall to the floor so he obtained the sit to stand lift to readjust Resident #153. Staff C admitted he placed the sling for the mechanical lift behind the resident and then she slipped out of the recliner. Staff C, CNA, carried a radio and did not call for help until after Resident #153 was on the floor. The Clinical Administrator stated Staff C, CNA, was trained on the mechanical lifts, slings and pause for the cause which is to double check that everything is hooked up right and that it takes two staff to utilize the lifts. The Clinical Administrator stated this training for Staff C had been done before he worked the floor. The Clinical Administrator stated after the incident he did not work again related to the investigation and he was placed on administrative leave. During an interview on 9/22/21 at 3:31 PM Staff C, CNA, stated he took care of Resident #153 the night she fell . Staff C stated the fall occurred around midnight and the resident had stayed in her recliner late and then wanted to go to bed. Staff C stated he obtained the lift and strapped Resident #153 into the sling. Staff C stated he waited for the other staff to come help transfer but he got impatient. Staff C stated he started to raise Resident #153 up in the lift by himself and resident started sliding but she was still over the recliner. Staff C, CNA stated it was his fault that he started to pick her up in the lift and didn't wait for another staff person to help with the transfer. Staff C stated the facility had provided him training related to mechanical lifts and needed to have two people at all times even when just placing the sling. Staff C again stated it was all of his fault and for whatever reason that night he got impatient. Staff C admitted he did not call for help with the transfer over the radio. Staff C, CNA stated he got Resident #153 immediate attention when she started sliding. On 9/23/21 at 12:18 pm Staff C, CNA was asked how he knew how to care for the residents. Staff C stated he got report from the off going staff every night when he came in and they would update him on residents with changes. Staff C verified he knew the resident was a full mechanical lift and he acknowledged there was a Care Plan to provide instruction and he did not follow it. Staff C, stated he grabbed the mechanical sit to stand lift that was right outside of her room. Staff C stated the slings for the lifts are color coded for sizes and used the extra-large one because the resident is bigger. Staff C stated he had used the full mechanical lift the other times like the Care Plan said but he had gotten in a hurry. Staff C acknowledged they had Care Plans they could carry with them but he did not have one that night. During an interview on 9/23/21 at 12:27 pm the Clinical Administrator stated Staff C attempted to use the sit to stand lift on Resident #153. The Clinical Administrator stated she had a picture of Staff C (see exhibit A) with the Sit to Stand lift coming in and out of Resident #153's room. The Clinical Administrator verified a full mechanical lift should have been used per the Care Plan. The Clinical Administrator stated not sure which exact size sling he used, it was a Sit to Stand sling. She stated the cubby where the lifts and slings are kept in the Spring Park hallway was very close to the resident's room. The Clinical Administrator stated Resident #153 did not have a change in her activities of daily living status (ADL) when she returned from the hospital after having a hip fracture repaired. She stated the resident was dependent on staff for her ADL's before she sustained fractures. She stated Resident #153 had a left shoulder fracture and a right hip fracture which required surgical intervention for the hip. She verified she had no change in transfer status, remained a mechanical lift. The Clinical Administrator stated she provided education to all of the nursing staff related to the use of mechanical lifts and following the Care Plans and education was completed by 6/23/20. On 9/27/21 at 8:27 am the Clinical Administrator stated she would expect the Care Plan to be followed. During record review on 9/28/21 of a facility provided form titled RA Skills Competency signed on 4/9/20 revealed Staff C had demonstrated skill competency in the use of mechanical lifts.

Based on observation, clinical record review, resident and staff interviews, the facility failed to provide the correct diet for one of two residents on a pureed diet. The facility census was 54 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #24 had [DIAGNOSES REDACTED]. A Physician order [REDACTED]. The Care plan dated 11/21/19, revealed the resident had poor or missing teeth and directed staff to serve the resident a pureed diet. A dietary document given to the surveyor on 1/12/20, listed residents and their diets. The document revealed Resident #24 was on a pureed diet. The facility's week 3 menu identified grilled steak or shrimp scampi as part of the planned menu for the pureed diet. During observation on 1/13/20 at 11:20 a.m., Staff A, Cook served Resident #24 ground steak instead of the prescribed pureed diet. During interview on 1/13/20 at 1:45 p.m., the resident reported she only ate a couple bites of the meat she had on her lunch tray because the meat had chunks in it. The resident reported she had trouble chewing the meat due to her bad teeth. The resident reported she filled out her menu slip and wrote pureed by the steak and circled the steak entree and reported the blue menu slip had pureed listed on top of the menu slip. During interview on 1/14/20 at 10:52 a.m., Staff B, certified nurse aide, CNA reported the menu slips were color coded and if the resident had a blue menu slip, they were on a pureed diet. Staff B stated it was staff's responsibility to check the trays to make sure the tray matched the diet and staff are trained to recognize when the food was incorrect. During interview on 1/14/20 at 10:56 a.m., Staff C, CNA reported staff had a pocket care plan which showed the diets for each resident and they had color coded menus to know the kind of diet the resident was on. The Pocket Care Plan dated 1/14/20, revealed the resident was on a pureed diet. During interview on 1/13/20 on 2:04 p.m., Staff A reported they used a spreadsheet with diets listed on it for the residents. Staff A reported the menu slips were color coded so they knew what diet type each resident needed. Staff A reported only two residents were on a pureed diet. When asked about ground meat that was given to Resident #24, Staff A realized she should have given the resident pureed steak. Staff A reported she thought the resident chose to have pureed texture as it was easier for the resident to chew. During interview on 1/13/20 at 2:20 p.m., the Dietary Manager (DM) reported the resident chose to be on a pureed diet and she told the resident whenever she got the wrong texture diet to let staff know. The DM reported they used color coded menu slips, as well as a color coded spreadsheet to help staff to know what kind of diet residents should be served and reported staff needed to double check the menu slip and what the resident had on their plate to ensure the resident received the prescribed diet.

Based on clinical record review and staff interview, the facility failed to notify the Long Term Care Ombudsman for one of three residents transferred to the hospital and returned. (Resident #26) The facility census was 56 residents. Findings: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #26 had [DIAGNOSES REDACTED]. Progress Notes date 9/20/18, documented the residents family was notified of the residents transfer to the hospital. Further review failed to reveal notification to the ombudsman was completed. During interview on 11/19/18 at 2:00 p.m., the Regional Director of Clinical Services acknowledged the lack of notification to the ombudsman.

Based on clinical record review and staff interview, the facility failed to provide notice to the resident and/or representative of the facility's bed-hold policy prior to and upon transfer to the hospital for one of three residents reviewed. (Resident #59). The facility census was 56 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #59 had [DIAGNOSES REDACTED]. Progress Notes dated 11/13/18, documented the residents family was notified of the transfer to the hospital, but no note of the bed hold policy was provided. During interview on 11/20/18 at 8:11 a.m., the DON stated the bed hold policy was explained only at admission and had not been done at the time of transfer to a hospital unless it was documented by the nurse in the progress notes. There was no transfer form completed. The facility bed hold policy documented upon admission and when the facility transfers a resident to a hospital or a resident goes on therapeutic leave , the facility will provide written information of the bed hold policy to the resident/and or resident representative.

Based on observation, Food and Drug Administration Food Code review and staff interview, the facility failed to ensure dietary staff dated resident food items when opened, failed to ensure dietary staff utilized proper food handling during dining service and failed to ensure the sanitation solution utilized to sanitize surfaces met acceptable levels as recommended. The facility census was 50 residents. Findings include: 1. During tour of the kitchen 9/5/17 at 8:00 a.m., observation revealed the following items had no open date listed on the package or container: In the True Freezer: a. One plastic tub of bread dough loaves b. Three packages of pancakes c. One open plastic bag of chicken nuggets d. Four beef patties e. One box of mini beef tacos In the Walk-In Freezer a. One box of donut holes b. One package of dumplings During interview on 9/5/17 at 12:50 p.m., the Dietary Manager reported food containers or packages should be labeled when opened. 2. During meal service on 9/5/17 at 11:55 a.m., observation revealed Staff D, Dietary Cook wore gloves and touched a variety of surfaces with gloved hands that included menu slips, lids and serving utensils. Observation revealed Staff D wore the same glove to place buns on sandwiches that were served. Observation of meal service in the southside dining room on 9/5/17 at 11:45 p.m., revealed Staff A, dietary aide and Staff B, dietary aide wore a single pair of gloves during service and touched plates, tables and menus. Observation revealed Staff A and Staff B continued to serve and touched ready-to-eat food items with their contaminated gloves. The ready-to-eat food items included hamburger buns, fresh sliced tomatoes, sliced onions, lettuce, and sliced cheese. Observation revealed Staff C, Certified Nurse Aide, CNA cut up Resident #1's hamburger bun with their bare hands. During interview on 9/6/17 at 8:25 a.m., the Dietary Manager reported they expected staff to wear gloves when handling ready to eat foods or handling foods directly such as bread. The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry requires single-use gloves be used for only one task, such as when touching ready-to-eat foods, and discarded when damaged or soiled or when interruptions occur in the operation. 3. During observation on 9/5/17 at 12:45 p.m., Staff D, cook checked the sanitation solution level in the red bucket by dipping a Quantom-40 Hydrion test strip into the bucket for 20 seconds. Staff D reported the strip color read 0 ppm (parts per million). Staff D reported the solution in the sanitizing bucket was last changed at 9:30 a.m. Staff D emptied the solution from the red bucket and refilled the bucket with water and chemical solution. Staff D re-checked the chemical concentration using another Hydrion test strip revealing a concentration level of 400 ppm. During observation 9/6/17 at 8:10 a.m., Staff D placed a Hydrion strip in the sanitizing bucket solution for 20 seconds. The color of the strip indicated a reading of 0 ppm. Staff D took another strip and dipped the strip in the solution and it also read ) ppm. Staff D reported the solution was changed at 7:00 a.m. on 9/6/17. The Dietary Manager advised staff they had too many cloths in the bucket, which had absorbed the chemical solution. The Dietary Manager removed the cloths, stirred the water, and retested the solution using another strip. The result was 0 ppm. Staff D emptied the sanitizing bucket and refilled the bucket with a chemical and water solution. Staff D dipped another test strip into the solution with a level of 400 ppm obtained. During interview on 9/6/17 at 2:35 p.m., the Dietary Manager stated staff to change the solution in the sanitizing bucket every 1 to 2 hours and checked the chemical concentration using the Hydrion QT-40 test strips. The chemical concentration should read at least 150 ppm (parts per million) or greater.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure staff changed gloves in accordance with proper infection control techniques to prevent cross contamination for one of 12 residents reviewed (Resident #11). The facility census was 50 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #11 had [DIAGNOSES REDACTED]. The Care Plan dated 5/2/17, revealed the resident had a recurrent right eye infection and history of MRSA (methicillin resistant staphylococcus aureus) with interventions to use contact precautions per protocol, disinfect frequently touched items and use gloves when assisted the resident with eye cares. A culture report obtained on 8/23/17, revealed a heavy growth of MRSA to the eye. A physician's orders [REDACTED]. The Medication Administration Record dated September, 2017, revealed [MEDICATION NAME] one drop in both eyes twice a day, and artificial tears 2 drops in both eyes four times a day. During observation on 9/5/17 at 4:13 p.m., Staff E, Registered Nurse, RN, donned a yellow gown and gloves and administered artificial tear eye drops to Resident #11 in the shower room. Without removing the contaminated gloves, Staff E opened the shower room door. Staff E walked to the resident's room, removed the yellow gown and gloves and used hand sanitizer to cleanse their hands. At 4:27 p.m., Staff E obtained [MEDICATION NAME] eye drops from the medication cart and walked to the shower room. Staff E donned a pair of gloves and administered the eye medication to Resident #11. Staff E opened the shower room door again without first removing the contaminated gloves. During interview on 9/5/17 at 4:30 p.m., Staff E reported the resident had a chronic eye infection and had MRSA in his/her eye. During interview on 9/6/17 at 2:45 p.m., the Director of Nursing, DON reported she expected staff to change gloves when they become contaminated and before touching other surfaces. The DON reported if a resident in contact isolation, she expected staff to change gloves and cleanse hands before they left the room. An undated policy titled Infection Prevention and Control, revealed antibiotic resistant microorganisms (ARM) are transmitted primarily by contaminated hands of staff. The policy revealed hand antisepsis after glove removal is the single most effective means of reducing ARM transmission. The policy directed staff to change gloves after contact with infective material, remove and discard gloves before leaving room, and washed hands immediately using soap and water or a waterless hand antiseptic.

Based on an observation, the facility failed to maintain resident privacy while giving shift change report. The facility census was 50 residents. Findings include: During an observation on 4/12/17 at 2:12 p.m. two nurses were providing a shift change report in the lobby area just outside the nurse's station. The conversation included private resident information and could be readily overheard by any passerby or visitor in the lobby area. In an interview on 4/20/17 at 10:02 a.m. Staff D, Certified Medication Aide, stated shift change report is given at the medication cart, outside of the nurse's station. In an interview on 4/20/17 at 10:00 a.m. Staff E, Licensed Practical Nurse, stated shift change report is given in the nurse's station. Staff E stated she has never known others to give report outside of the nurse's station.

This deficiency relates to complaint -C. Based on record review, observations and staff interviews the facility failed to provide the necessary services to maintain a resident's personal grooming needs in accordance with professional standards of care. (Resident #5 and #6) The facility census was 50 residents. Findings include: 1. According to Resident #5's Minimum Data Set (MDS) assessment with assessment reference date of 2/24/17, Resident #5 had long and short memory deficits and severely impaired cognitive abilities for daily decision making. Resident #5 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene needs. Resident #5's [DIAGNOSES REDACTED]. Resident #5's care plan identified a focus area of ADL (activities of daily living) self care deficits related to dementia and visual impairment with interventions which included personal hygiene and oral care require assistance of one staff. During an observation on 4/13/17 at 7:44 a.m. Resident #5 was assisted with morning cares by Staff A Certified Nurse Aide (CNA) and Staff B, CNA. Staff washed hands, donned gloves and completed perineal cares appropriately. Staff assisted Resident #5 with dressing self, transferring into his/her wheelchair, providing oral cares, brushing his/her hair and applying his/her glasses, before being propelled to the dining room for breakfast. Staff failed to wash Resident #5's face or hands during the morning cares. 2. According to Resident #6's MDS with assessment reference date of 2/8/17, Resident #6 had a Brief Interview for Mental Status (BIMS) score of 9 indicating a moderately impaired cognitive status. Resident #6 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene needs. Resident #6's [DIAGNOSES REDACTED]. Resident #6's care plan identified a focus area of ADL self care deficits related to dementia with interventions which included personal hygiene and oral care and required assistance of one staff. During an observation on 4/13/17 at 8:25 a.m. Resident #6 was assisted with morning cares by Staff C, CNA. Staff washed hands, donned gloves and applied lotion on Resident #6's legs before placing on TED (compression) hose. Resident #6 was partially dressed then transferred into his/her wheelchair and propelled to the bathroom where he/she was assisted onto the toilet. Resident #6 then provided perineal cares appropriately and finished with dressing and adjusting clothing. Staff C then brushed his/her hair and propelled him/her to the dining room for breakfast. Staff C stated Resident #6 brushes his/her teeth after breakfast. Staff failed to wash Resident #6's face or hands during the morning cares. In an interview on 4/13/17 at 7:55 a.m. Staff A, CNA, stated part of the morning routine includes washing a resident's face and hands. In an interview on 4/13/17 at 7:55 a.m. Staff B, CNA, stated part of getting a resident up and dressed in the morning includes washing a resident's face and hands. In an interview on 4/13/17 at 11:14 a.m. the Director of Nursing (DON) stated her expectations of morning cares would include incontinence cares, dressing, hair brushed, oral hygiene and placing of hearing aides, glasses, etc. The DON stated she believes the washing of a resident's face and hands might be more individualized, noting certainly after a meal or toilet use. The DON agreed offering the face and hands washed may be appropriate.

Based on observations, clinical record review and interviews, the facility failed to protect six (6) of seventeen (17) residents from hazards. Resident #10 sustained a fracture knee when he/she put their foot down while being transported in a wheelchair. At the time of the incident, Resident #10's wheelchair did not have foot pedals in-place. The staff providing the transfer reported the resident refused to use wheelchair petals, however the onsite observation the day prior to the injury, showed Resident #10 family member transporting him/her in the wheelchair with the foot petals in place. Resident #10's family member stated the staff normally used wheelchair foot pedals to transfer his/her loved one. The onsite investigation showed multiple residents being transported by staff in wheelchairs without foot pedals (Residents #15, #17, #2, #3, and #16). The facility reported a census of 53 residents. Findings include: 1. The quarterly MDS dated [DATE] revealed Resident #10 had [DIAGNOSES REDACTED]. The MDS documented the resident required the assistance of two staff members for bed mobility, transfers, depression, and toilet use. The Brief Interview for Mental Status (BIMS) cognitive test revealed the resident with no cognitive impairments. Resident #10 used a walker and wheelchair for locomotion. The resident's Care Plan with a revision date of 2/6/14 identified the resident had limited physical mobility related to a right hip fracture, and a stroke with right sided weakness, osteoporosis, and degenerative joint disease. The resident used a wheelchair for all destinations. The Care Plan revealed therapy and restorative staff only ambulated the resident with the use of a Hoyer and an ambulation sling with initiated date of 11/2/14. The Progress Notes dated 7/15/14 documented all the resident's bruises were healed. Observation on 7/21/14 at 2:30 p.m. the resident's spouse pushed the resident in a wheelchair with the foot pedals on, and the resident's feet in good position. A Late Entry Nurse Progress Note dated 7/22/14 11:00 a.m. documented by Staff G, Registered Nurse (R.N.) revealed the following: Nurse sitting at the nurse's desk, heard a person saying "owe". The Nurse looked down hall and observes Resident #10 in the hallway sitting in the wheelchair saying "owe". The CNA wheels the resident into the resident's room. The nurse followed the resident into the room and asked what happened. The CNA reported she had been wheeling the resident to lunch in the wheelchair, and the resident set his/her foot on the floor while he/she had been propelled. The CNA also stated the resident "always refused to wear his/her foot pedals." The Nurse asked the resident if the resident had pain, and the resident stated "yes" in the right foot. The Nurse assessed the resident's right foot and leg. No swelling, bruising, or redness had been noted. The resident had been able to lift and move the right foot and leg when asked. When the resident had been asked if he/she had been ok, the resident responded "yes". The nurse told the resident that he/she needed to wear the foot pedals when being propelled in a wheelchair from then on, the resident agreed with an "ok". The foot pedals were then put on the wheelchair and the resident had then been wheeled out to lunch. Nurses Progress Note dated 7/23/14 at 6:33 a.m. revealed the following documentation: That morning the resident complained of pain in the right knee when the C.N.A had been putting on the resident's Ted Hose (compression stockings). The C.N.A called the nurse into the room, and told the nurse that the day before the resident's right foot dropped while being pushed down the hallway ending with the foot getting stuck under the wheelchair, and this morning the right knee is very swollen, pink color, and warm to touch. A bruise had been noted on the front side of the right knee which measured 3 centimeters in width and 5 centimeters in length. The resident stated the pain is so great he/she did not want to get out of bed at that time. Nurses Progress Note dated 7/23/14 at 8:27 a.m. revealed a new order from a physician that directed staff to obtain an x-ray of the resident's right knee. A Portable X-ray findings dated 7/23/14 documented a right knee nondisplaced fracture. The findings identified presumably the fracture was acute. A Nurses Progress Note dated 7/23/14 at 11:16 a.m. documented the resident left for the orthopedic clinic per ambulance. A Nurses Progress Note dated 7/23/14 at 1:23 p.m. documented the resident returned from the orthopedic clinic with a right knee immobilizer at all times and a new physician's orders [REDACTED]. The resident would need to follow-up with clinic at a later date. During an interview on 7/23/14 at 8:10 a.m., Resident #10's spouse reported that this fracture was preventable, the staff usually had the foot petals on the resident's wheelchair. In an interview on 7/24/14 at 10:07 a.m., Staff H, CNA reported when transporting Resident #10 in the wheelchair she should check that the foot pedals are on, feet on the pedals and fingers away from the wheels. She also reported Resident #10 had a history of [REDACTED]. dropped. The then said owe then Staff H immediately pushed the resident to his/her room. Staff G RN checked the resident's leg and found no problems, they placed the foot pedals on the wheelchair and Staff H to the resident to the dining room. The resident never complained to Staff H about any pain before her shift ended. The next day at 6:15 a.m. as Staff H placed the TED hose on the resident's right leg, the resident said, "It hurts, it hurts. My knee hurts". Staff R, RN assessed the resident and found swelling and redness to the right leg and knee and had pain with any movement. An x-ray was done here, found out there was something broken in the knee. The family then decided to take him/her to the emergency room . The was not able to walk before this happened, could stand in the EZ stand lift only and able to self-propel in the wheelchair. When Resident #10 returned from the hospital with an immobilizer to the leg and not allowed to bear weight on it. A CNA was not allowed to go in there without a nurse present. This incident could have been prevented by placing foot pedals on the wheelchair. Mill Pond had never enforced making the foot pedals on. The resident normally never wants them on and the resident's spouse always taken the foot pedals off. Staff H reported she thought that the resident had the right to refuse to put the pedals on. In an interview on 7/24/14 at 7:37 a.m., Staff G, RN reported the following occurred on 7/22/14 with Resident #10: she did not witness the incident. She heard Resident #10 say owe while Staff H, CNA pushed the resident in the wheelchair into the resident's room without foot pedals on the wheelchair. When she asked what happened Staff H reported the resident set his/her right foot down on the floor while being pushed in the wheelchair. Staff G completed an assessment and found the resident complained of pain to the right and did not rate pain, removed the TED hose up and did not find any bruising, redness or swelling. The resident was able to pick up his/her foot and move it back and forth. Staff G reported she instructed the resident on the need to have the foot pedals on when being pushed in the wheelchair. At the time, the incident had not been identified as a fall, and no one had been notified until the next day. The following afternoon, the resident's spouse reported the resident complained of pain to the right knee which had been attributed to arthritis and medicated with Tylenol. The following day at 10:00 a.m., the resident complained of severe pain and refused to get out of bed. The physician had been notified, a portable x-ray had been ordered and the resident had been sent to the clinic per family request. The resident returned with a knee immobilizer on the right side, no weight bearing to the right leg and had a new prn order for Tramadol. Prior to the incident the resident did not ambulate with the nursing staff, only therapy. During an interview on 7/23/14 at 3:52 p.m., Staff F, CNA reported staff should ensure the foot pedals are on the wheelchair prior to pushing the resident. She also reported Resident #10 had a refused to have foot pedals placed on the wheelchair, however, could not recall if the resident refused prior to the incident which occurred 7/22/14. In an interview on 7/23/14 at 3:58 p.m., Staff D, RN reported staff should place the foot pedals on the wheelchair prior to pushing a resident in the wheelchair. Residents #10 and #16 had a history of [REDACTED]. If a resident refuses to have them on, it had not been documented anywhere in the past 3 years Staff D had been employed at the facility. During an interview on 7/24/14 at 6:52 a.m., the Administrator reported Staff H had propelled Resident #10 down the hallway in the wheelchair, the resident had his/her feet up as the resident refused to have the foot pedals. During the transport the resident's foot dropped down, got caught and his/ her leg bent back. The resident said "ouch" when it happened. The incident could have been avoided by putting the foot pedals on despite the resident's refusal to have them. Staff G, RN was at the nurse's station heard what happened and immediately assessed the resident. Resident #10 did not complain of any pain. However, yesterday morning, the resident started complaining of discomfort to the right leg which had some swelling. At 6:00 a.m., the resident received routine Tramadol and began to really complain of pain. The physician had been notified. A portable x-ray was ordered and completed and identified the resident with a fracture. The results were faxed to the doctor who gave orders to send the resident to the orthopedic clinic at the request of the family. The returned to the facility with an immobilizer. Yesterday the Administration in-service all staff regarding use of the foot pedals for wheelchair transports. The expectation is that if you are going to move someone in the wheelchair they should have foot pedals on. 2. The quarterly MDS dated [DATE] for Resident #15 revealed the resident had no cognitive impairments for daily decision making skills. The MDS revealed the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident required the assistance of two staff members for bed mobility, transfers, and toilet use. The resident ' s Care Plan revision date 8/30/13, identified a focus area as limited physical mobility related to weakness, osteoarthritis and pain. The Care Plan directed staff to assist the resident with wheelchair mobility as needed, the resident could propel independently for short distances. Observation on 7/23/14 at 8:12 a.m. Staff M, Staffing Coordinator propelled the resident in a wheelchair without the foot pedals on down the hallway to the dining room with the resident ' s feet skimming the carpeted surface. Observation on 7/23/14 at 4:25 p.m. the resident ' s room did not have foot pedals in the resident room. During an interview on 7/23/14 at 4:25 p.m. The resident reported that he/she can propel his/her own wheelchair, and the staff doesn ' t put the foot pedals on my wheelchair if they help me. The resident reported that he/she did not know where the foot pedals to the wheelchair are (located). 3. The admission MDS dated [DATE] for Resident #17 revealed the resident required one staff member to assist with bed mobility, transfers, and toilet use. The MDS documented the resident had severely impaired cognitive skills for daily decision making. The MDS indicated the resident had impairment of both lower extremities. The Admission Record dated 7/24/14 documented the resident had the [DIAGNOSES REDACTED]. The resident ' s Care Plan dated 5/16/14 identified a focus area of decrease physical mobility, with the goal to reach destinations safely. The Care Plan directed staff that the resident used a wheelchair for mobility and to assist the resident as needed. Observation on 7/24/14 at 8:20 a.m. revealed Staff P, Pastoral Care Director push the resident down the hallway without foot pedals on, and the resident ' s left had been dragging on the carpeted floor. 4. The Minimum Data Set (MDS) Quarterly review dated 6/4/14 indicated Resident #2 had severely impaired cognitive skills for daily decision making. The MDS revealed the resident required one staff assistance with transfers, and toilet use. The MDS documented the resident had [DIAGNOSES REDACTED]. The resident ' s Care Plan dated 9/9/13 identified a focus area as the resident ' s requirement for assist with mobility. The Care Plan directed staff to assist the resident with ambulation, and transfers with the assistance of one staff member. The Care Plan also directed staff to assist the resident with wheelchair mobility as needed, which had been the residents main mode of mobility. Observation on 7/21/14 at 3:25 p.m. Staff D, Registered Nurse (R.N.) propelled the resident in a wheelchair from the shower room to the nurses station without foot pedals on the resident ' s wheelchair, with the resident ' s feet just grazing the carpeted floor. 5. The Significant Change MDS dated [DATE] documented Resident #3 had [DIAGNOSES REDACTED]. The MDS indicated the resident required one staff to assist with personal hygiene, toilet use, and transfers. The MDS revealed the resident had been moderately impaired for daily decision making skills. The residents Care Plan revision dated 5/1/13 documented a focus area as limited physical ability related to weakness, and history of a stroke. The Care Plan directed staff to assist the resident with transfers, and assist the resident with the wheelchair if needed. Observation on 7/22/14 at 7:55 a.m. Staff N, Certified Nurses Aide (C.N.A.) propelled the resident in a wheelchair from the resident ' s room all the way to the main dining room without foot pedals, and the foot pedals were on the floor just inside the door to the resident ' room. The resident ' s feet skimmed the floor. 6. The quarterly MDS dated [DATE] revealed Resident #16 had [DIAGNOSES REDACTED]. The MDS indicated the resident had no cognitive impairments with daily decision making skills. The MDS documented that the resident required the assistance of two staff members for bed mobility, toilet use, and transfers. The MDS documented the resident used the wheelchair as the primary mobility device. The Care Plan identified a focus area for the resident as limited physical mobility related to weakness, and dementia. The Care Plan directed staff to provide supportive care, as assistance with mobility as needed. The residents Care Plan lacked documentation of the resident ' s choice not to use the wheelchair foot pedals. During an observation on 7/22/14 at 8:04 a.m. revealed Staff L, Licensed Practical Nurse propelled the resident in a wheelchair from the nurse ' s station to a shower room. During an interview on 7/23/14 at 4:18 p.m. the resident reported that he/she does not like the foot pedals on the wheelchair when being propelled in the wheelchair, and staff do not use the foot-pedals. In an interview on 7/23/14 at 3:35 p.m., Staff E, RN reported prior to pushing a resident in a wheelchair, staff must ensure the foot pedals are on the wheelchair and place the resident's feet on the foot pedals. Staff E reported there are residents who reuse to have foot pedals put on, but they are able to self propel (their wheelchair). During an interview on 7/24/14 at 9:30 a.m., Staff L, LPN reported staff should ensure that the foot pedals are placed on the wheelchair prior to pushing any resident in the wheelchair and instruct the resident to keep hands off the wheels. In an interview on 7/24/14 at 9:37 a.m., Staff Q, CNA reported prior to pushing a resident in a wheelchair, staff should ensure the foot pedals are on, place the resident's feet are on the foot pedals and ensure the resident's arms are on the armrests. During an interview on 7/24/14 at 9:44 a.m., Staff R, RN reported staff should ensure that the foot pedals are attached and the resident's feet are on the foot pedals prior to pushing the resident in a wheelchair.

Based on record review, observation and staff interviews, the facility failed to provide adequate supervision to prevent accidents against hazards from self and failed to utilize equipment when ambulating a resident for safety. An agency staff person ambulated the resident to the bathroom without a walker. The resident ' s oxygen tubing became taunt and the staff person left the resident standing unattended to obtain the oxygen concentrator which the tubing was connected. The resident did not have equipment to stabilize her/himself and the resident fell on to the floor (Resident #1) when the agency staff person failed to supervise the resident. The sample consisted of 8 residents and the facility reported a census of 59 residents Findings include: 1. Resident #1 had a Minimum Data Set (MDS) with a reference date of 4/1/13 which identified the resident had a Brief Interview for Mental Status score (BIMS) of 4. A score of 4 represented the resident as severely cognitively impaired. The MDS also revealed the resident required extensive assistance of one staff person for transfers, dressing personal hygiene, and limited assistance of one for assistance to use the toilet. The same MDS reflected the resident had no history of falling. The MDS identified the resident as not steady with walking or turning around and required staff assistance. The resident used a walker and a wheelchair. The MDS assessment, with a reference date of 4/1/13, identified pertinent [DIAGNOSES REDACTED]. The Resident ' s Care Plan initiated on 11/4/2012 and revised on 2/2/2013 identified the resident needed staff assistance to transfer and ambulate for safety. The interventions reflected the resident would ambulate with the assistance of 1 staff person, a gait belt and a four wheeled walker. On 4/23/2013, the intervention was changed to transfer the resident with the assistance of 2 people instead of 1 person. The Resident's Care Plan initiated 11/4/11 and last reviewed for a problem of falls on 4/23/13 revealed the following pertinent interventions for the prevention of falls: appropriate footwear and wearing properly, night light when in bed at night, do not leave the resident standing alone (4/3/2013), have all items within reach, oxygen tubing long enough to reach or use portable tank (4/23/2013), and assistance of 2 for transfers (4/23/2013). Review of the Fall Follow-Up Form for Resident #1 (not dated) revealed a fall analysis and summary of cause: The agency CNA (Certified Nursing Assistant), Staff E, walked the resident towards the bathroom, the oxygen tubing getting tight, so he left the resident standing alone to get the concentrator and the resident lost his/her balance and fell to the floor (the resident did not have a walker to assist with balance). Review of the Biotech X-Ray form dated 4/29/13 revealed a nondisplaced humeral (shoulder area) neck fracture. On 5/9/13 at 9:15 AM, Staff A and Staff F, both CNA's assisted the resident to transfer with a walker to use the toilet. A gait belt had been placed around the waist and the resident wore supportive shoes. The staff completed the transfers without difficulty. The sling to the left arm had been removed for the transfer per the physician order. During an interview on 5/9/13 at 10:40 PM, Staff E, CNA stated he thought the resident would have been ok (alright) for a few seconds and because the resident had been steady and bearing weight pretty good. Staff E stated he knew the resident needed one person physical assist and the gait belt so he had a gait belt on the resident and let go long enough to reach for longer tubing from the concentrator. Staff E further stated as a Certified Nursing Assistant, they are expected to stay with the resident always, use a gait belt and keep them (the resident) safe. Staff E stated he did not use the walker when transferring the resident to the bathroom. During an interview on 5/9/13 at 2:32 PM, Staff C, CNA stated he worked the evening that Resident #1 fell . He stated he thought he heard someone yell " fall " , so he went into the hall and saw Staff E sticking his head out of Resident #1's room. Staff C had stated the resident fell . He stated Staff E told him he had left the resident long enough to get the concentrator and the resident fell . He further stated if this had happened to him, he would have taken the oxygen off long enough to have gotten the resident to the restroom. On 5/9/13 at 2:10 PM, Staff A, CNA was interviewed and stated she became a CNA last June and has worked at this facility since then. Staff A stated if she were in the same position, she would have gotten a portable tank of oxygen and used it or taken the oxygen off completely until she got the resident sat down safely.