Every finding on record at Mission Point Health Campus of Jackson

Based on observation, interview, and record review, the facility failed to: (1) effectively clean food service equipment, (2) effectively date mark all potentially hazardous ready-to-eat food products, and (3) label and date all food products affecting 46 residents who consume food, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness.Findings include:On 03/01/2026 at 8:50 A.M., an initial tour of the food service was conducted with Dietary [NAME] M, Dietary Aide N, Dietary Aide O, and Dietary Manager P. The following items were noted:On 03/01/2026 at 9:15 A.M., the mechanical dish machine stainless steel ventilation hood was observed soiled and corroded from excessive moisture exposure.On 03/01/2026 at 9:33 A.M., the ice machine blue plastic scoop caddy was observed soiled with accumulated and encrusted mineral (calcium and lime) deposits.The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 03/01/2026 at 9:34 A.M., 2 of 2 fabric upholstered chairs, located adjacent to the ice machine, were observed heavily stained with accumulated and encrusted soils. On 03/01/2026 at 9:35 A.M., one black vinyl covered swivel chair, located adjacent to the 2-door reach-in cooler, was observed with 2 of 2 arm rest pads etched and scored. The 2022 FDA Model Food Code section 6-501.114 states: The PREMISES shall be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as EQUIPMENT that is nonfunctional or no longer used; and (B) Litter.On 03/01/2026 at 9:39 A.M., one gallon (one-third full) of 2% Milk was observed within the True 2-door reach-in cooler, without an open or discard date. The manufacturer's use-by-date was also observed to read 3-10-26. One-half gallon container (one-fourth full) of chocolate milk was observed within the True 2-door reach-in cooler, without an effective open or discard date. The manufacturer's use-by-date was also observed to read 3-8-26.The 2022 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.On 03/01/2026 at 9:59 A.M., one hotel pan of Chicken Fillets (marinating) was observed in the True 2-door reach-in cooler covered with clear plastic wrap, without an effective date mark. One hotel pan of Chicken pieces was also observed in the True 2-door reach-in cooler covered with plastic wrap, without an effective date mark. One hotel pan of Beef Broth was further observed in the True 2-door reach-in cooler covered with plastic wrap, without an effective date mark.On 03/01/2026 at 10:05 A.M., an interview was conducted with Dietary Manager P regarding dating and labeling of food products. Dietary Manager P stated that all of the food products should have been dated and labeled by staff and that they will have to retrain staff on proper dating and labeling.The 2022 FDA Model Food Code section 3-602.11 states: (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin.On 03/01/2026 at 10:12 A.M., The South Bend convection oven interior and exterior surfaces were observed soiled with accumulated and encrusted food residue. Dietary Manager P stated that the unit has been out of service for approximately five months. The Pitco fryer interior cabinet and door surface were also observed soiled with accumulated and encrusted grease deposits. The South Bend char broiler was observed soiled with accumulated and encrusted food residue.On 03/01/2026 at 10:21 A.M., The [NAME] steamer support table was observed with accumulated and encrusted food residue. Dietary Manager P stated that the steamer and support table are cleaned weekly.On 03/01/2026 at 10:26 A.M., The commercial toaster interior and exterior surfaces were observed with accumulated and encrusted food residue.The 2022 FDA Model Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 03/01/2026 at 10:44 A.M., the side [NAME] tabletop surface was observed missing the laminate edge piece, within the Private Dining Room. The damaged edge piece measured approximately five-feet-long. The hand sink cabinet door hinge was also observed loose-to-mount.The 2022 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair.On 03/01/2026 at 10:54 A.M., the Main Dining Room hand sink faucet assembly and adjacent laminate surface area was observed soiled with accumulated and encrusted mineral (calcium and lime) deposits.The 2022 FDA Model Food Code section 4-602.13 states: NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues.On 03/01/2026 at 11:00 A.M., the Town Square Kitchenette microwave oven was observed with accumulated and encrusted food residue.The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 03/01/2026 at 11:05 A.M., the Town Square Kitchenette hand sink faucet assembly was observed loose-to-mount.The 2022 FDA Model Food Code section 5-205.15 states: A plumbing system shall be: (A) Repaired according to LAW; and (B) Maintained in good repair.On 03/01/2026 at 11:11 A.M., the 200 Hall Kitchenette microwave oven interior was observed with accumulated and encrusted food residue.The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 03/04/2026 at 10:30 A.M., record review of the Policy/Procedure entitled: Food Storage dated 01/2024 revealed under Policy: Food storage areas shall be maintained in a clean, safe, and sanitary manner. This includes maintaining temperatures of coolers and freezers at the appropriate temperature to promote food safety. Record review of the Policy/Procedure entitled: Food Storage dated 01/2024 further revealed under Policy Explanation and Compliance Guidelines: (3) Refrigerated food outside of original package shall be labeled, dated, and monitored so that it is used by the use-by-date, frozen, or discarded, whichever is applicable. (a) Fresh produce will have a receive date and be monitored for quality, discarding bruised or spoiled products. (b) Milk received and unopened will be stored according to manufacturer use-by/expiration date. Once opened it will be labeled with open and use-by-date, but not to exceed expiration date. (5) Ready-to-eat food can be stored by expiration date, until opened, then labeled with open and use-by-date, if not discarded.On 03/04/2026 at 10:45 A.M., record review of the Policy/Procedure entitled: Cleaning Equipment and Utensils dated 01/2024 revealed under Policy: Equipment and utensils will be properly cleaned and sanitized to prevent contamination. Record review of the Policy/Procedure entitled: Cleaning Equipment and Utensils dated 01/2024 further revealed under Purpose: Safe food handling and minimize the risk of cross-contamination.On 03/04/2026 at 11:00 A.M., record review of the Policy/Procedure entitled: Leftover Foods dated 01/05/2021 revealed under Policy: Leftovers will be handled according to 2013 Food Code regulation. Record review of the Policy/Procedure entitled: Leftover Foods dated 01/05/2021 further revealed under Purpose: To maintain safe food handling and minimize the risk of foodborne illness.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 46 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:Resident R14 (#14) Review of the medical record revealed R14 was admitted to the facility 08/14/2025 with diagnoses that included colon cancer, protein calorie malnutrition, thrombocytopenia (low platelet count), autistic disorder, paranoid schizophrenia, bipolar disorder, dementia, adjustment disorder, hypothyroidism (low thyroid hormone), ileostomy (an opening in the abdomen that connects the last part of the small bowel to the outside of the body), and cognitive communication deficit. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/14/2025, revealed R14 had a Brief Interview of Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15. Prior to entering R14's room on 03/01/2026 at 09:05 a.m. Licensed Practical Nurse (LPN) V explained that it was necessary to place foot coverings, located outside the room, over your shoes before entering R14's room. LPN V explained that R14 had a history of removing his ileostomy bag (a device that collects stool from the ileostomy) and throwing feces on the floor. Upon entering R14's room on 03/01/2026 at 09:08 a.m. it was observed that the floor had two dark spots on the carpet, in front of R14's couch. The dark spots appeared to be feces. R14's room smelled of feces. R14 was observed lying in bed and did not respond to verbal stimuli. On 03/02/2026 at 01:05 PM A common area environmental tour was conducted with Environmental Services Director (ESD) K and Housekeeping and Laundry Supervisor (HLS) L. The following items were noted: On 03/02/2026 at 1:10 P.M., the following observations were made within Resident room [ROOM NUMBER]: The carpeted flooring surface, the gray vinyl landing strip (adjacent to the resident bed), the bedside tabletop surface and metal support frame were observed soiled with accumulated and encrusted food residue. A strong pervasive urine odor was present. The Portable Terminal Air Conditioning (PTAC) Unit filters were heavily soiled with accumulated and encrusted dust/dirt deposits. The carpeted surface was soiled with accumulated and encrusted feces and bodily fluids residue. On 03/02/2026 at 1:16 P.M., the following observations were made within Resident room [ROOM NUMBER]: The carpeted flooring surface was observed soiled with accumulated and encrusted food residue. The Portable Terminal Air Conditioning (PTAC) Unit exterior cabinetry was observed soiled with accumulated and encrusted food residue, and the interior PTAC discharge grill surface was observed containing whole food particles and debris. The PTAC Unit filters were heavily soiled with accumulated and encrusted dust/dirt deposits. The restroom hand sink faucet assembly was observed soiled with accumulated and encrusted dirt and mineral (calcium and lime) deposits. On 03/02/2026 at 1:27 P.M., the following observations were made within Resident room [ROOM NUMBER]: The carpeted flooring surface was observed severely soiled with accumulated and encrusted bodily fluids/solids. The resident room was observed with an intense pervasive malodorous condition. The PTAC Unit filters were observed heavily soiled with accumulated and encrusted dust/dirt deposits. The carpeted surface, located directly outside of the entrance door, was further observed worn, stained, frayed, and missing. On 03/02/2026 at 1:48 P.M., the following observations were made within Resident room [ROOM NUMBER]: The carpeted flooring surface was observed soiled with accumulated and encrusted food residue. The room was also observed in complete disarray, with numerous personal items resting upon furniture surfaces. The PTAC Unit filters were observed heavily soiled with accumulated and encrusted dust/dirt deposits. The restroom hand sink basin was observed to be heavily soiled. The drywall surface, located directly behind the resident chair, measuring approximately 16-inches-wide by 16-inches-long, was observed etched and scored. The carpeted surface, located directly outside of the entrance door, was observed etched, worn, frayed, and missing. The carpeting surface adjacent to the 100 Hall Nursing Station was observed worn, frayed, and with the seams worn and separated, exposing the concrete subsurface. The carpeting surface and seams, adjacent to the 200 Hall Nursing Station were observed worn and frayed. The damaged carpeting surface measured approximately 12-inches- wide by 26-feet-long. The worn internal carpeting primary backing was also observed, adjacent to the carpeting seams. The 200 Hall Spa (Lift Sling Storage Room) was observed in disarray. Lift slings were observed stored in a pile, resting directly on the flooring surface. (ESD) K indicated he would have staff clean and organize the Lift Sling Storage Room as soon as possible. The facility carpeting surface was observed etched, worn, and frayed, adjacent to the 300 Hall Nursing Station. The carpeted surface seams were also observed worn, frayed, and separated. On 03/02/2026 at 4:05 P.M., an interview was conducted with Executive Director A regarding the flooring surface, within Resident room [ROOM NUMBER]. Executive Director A stated that the plan is to clean the room routinely, and that the. resident is not educatable and currently has a colostomy located in a bad space (skin fold). Executive Director A further stated that the ultimate plan is to remove the carpeting and replace the flooring surface with laminate material. On 03/04/26 at 01:00 P.M., record review of the Policy/Procedure entitled: Environmental Services Inspection dated 1/11/2021 revealed under Policy: It is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis. On 03/04/2026 at 01:15 P.M., record review of the Policy/Procedure entitled: Safe and Homelike Environment dated 1/11/2021 revealed under Policy: In accordance with resident's rights, the facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Record review of the Policy/Procedure entitled: Safe and Homelike Environment dated 1/11/2021 further revealed under Policy Explanation and Compliance Guidelines: (3) Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. On 03/04/2026 at 01:30 P.M., record review of the Direct Supply TELS Work Orders for the last 120 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on observations, interviews, record reviews, and 2 (R16, R55) of 16 sampled residents, the facility failed to provide palatable food products affecting 46 residents who consume food, resulting in the increased likelihood for residents decreased food acceptance and nutritional decline.Findings include:R55: Review of the medical record reflected R55 admitted to the facility on [DATE], with diagnoses that included lumbar region discitis (inflammation/swelling between spinal vertebrae) and sepsis due to Group B streptococcus (a type of bacteria). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/26/26, reflected R55 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 03/01/2026 at 11:21 AM, R55 was observed seated in a standard chair, in their room. R55 reported the facility's food was terrible. R55 reported they nibbled at the food but had not found any of it they liked yet. R55 reported having shakes (Boost), which they drank sometimes. R55 reported being unsure if there was an alternate food menu and did not think they were being offered anything else if they did not eat what was served. On 03/02/2026 at 9:57 AM, R55 was observed seated on the edge of the bed. A breakfast tray, including scrambled eggs, ham and a biscuit was observed on the overbed table. R55 stated the ham was good. When asked why it looked like they had not eaten much of the meal, R55 stated it was probably cold by that time, as the residents were told they could sleep in that morning. Review of R55's food acceptance record, on 3/4/26 at 2:43 PM, reflected they had consumed zero percent (%) of their meal two times, 25% of their meal three times, 50% of their meal 13 times, 75% of their meal six times, 100% of their meal one time and had refused a meal three times. Documentation did not reflect that R55 was offered an alternate meal option when their meal consumption was decreased. In an interview on 03/04/2026 at 2:28 PM, Registered Dietitian (RD) H reported it was up to the Certified Nurse Aide (CNA) on whether or not an alternate meal was offered for refusal or poor consumption of a meal. RD H reported the task documentation for amount eaten (food acceptance) did not include a question pertaining to an alternate being offered. In an interview on 03/04/2026 at 2:49 PM, Director of Nursing (DON) B reported if a resident did not like what was on their tray, staff always offered an alternate. DON B reported they always had sandwiches available, as well as snacks on the unit. DON B reported they personally had taken R55's tray to them several times, and they wanted an alternative. Resident #16 (R16) Review of the medial medical record revealed R16 was admitted to the facility 01/02/2026 with diagnoses that included type 2 diabetes, protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), end stage renal disease, pancytopenia (lower than normal red and white blood cells and platelets in blood), nonalcoholic steatohepatitis (fatty liver), cirrhosis of liver (scared and permanently damaged liver), heart failure, gastric ulcer (open sores of stomach lining), esophageal varices (enlarged veins in the esophagus, the tube that connects to throat and the stomach), fractured left femur (upper bone of the leg), fracture left patella (knee cap), fracture left tibia (bone in lower leg), peripheral vascular disease (PVD), gastro-esophageal reflux, thrombocytopenia (low platelet count), and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/2026, revealed R16 had a Brief Interview of Mental Status (BIMS) of 15 (intact cognition) out of 15. During observation and interview on 03/01/2026 at 08:47 a.m. R16 was observed sitting up in bed attempting to eat breakfast. Two waffles were observed on R16's plate and did not appear to be toasted. R16 explained that the waffles were not cooked and were cold. R16 explained that the waffles were also wet. R16 explained that it was her opinion that the facility placed frozen waffles on her plate and let them thaw. On 03/01/2026 at 12:50 p.m. a test tray as delivered to the conference room where the survey team was located. Observation of the lunch test tray revealed pork loin, green beans, mashed potatoes with gravy, blue berry cobbler, and cranberry juice. Consumption of the test tray by surveyor noted the pork loin to be lukewarm, the green beans were very soft and appeared to be overcooked and mushy, and the gravy appeared to be gelatinous (having a consistency of jelly). On 03/01/2026 at 11:55 A.M., an interview was conducted with Dietary Manager P regarding the resident meal tray delivery schedule. Dietary Manager P stated that meals are delivered to the 100 Hall and 300 Hall to Town Square, and then 200 Hall, and finally The Main Dining Room is served to residents as they arrive. On 03/01/2026 at 12:00 P.M., the 100 Hall and 300 Hall resident lunch meal food trays (22) were observed leaving the food production kitchen, within an insulated food transport cart, and arrived at Town Square at 12:02 PM. On 03/01/2026 at 12:07 P.M., The last lunch meal food tray was observed served to R312. R312 was also observed to decline their lunch meal food tray. On 03/01/2026 at 12:23 P.M., the 200 Hall resident lunch meal food trays (22) were observed leaving the food production kitchen, within an insulated food transport cart, and arrived at the 200 Hall at 12:24 PM. On 03/02/2026 at 12:08 P.M., The 100 Hall and 300 Hall resident lunch meal food trays (18) were observed leaving the food production kitchen, within an insulated food transport cart, and arrived at Town Square at 12:09 PM. On 03/02/2026 at 12:22 P.M., The 200 Hall resident lunch meal food trays (22) were observed leaving the food production kitchen, within an insulated food transport cart, and arrived at the 200 Hall at 12:23 PM. On 03/02/2026 at 12:28 P.M., food product temperatures were monitored utilizing a rapid read digital thermometer. The following food product temperatures were recorded for R16's lunch meal food tray: Oven Roasted Tilapia - 137.5Rice Pilaf – On Resident Dislike ListWinter Vegetable Blend - 128.4*Iced Apple Cake – On Resident Dislike ListBeverage (Lemonade) - 52.1 (*) The 2022 FDA Model Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, and except as specified under ¶ (B) and in ¶ (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 degrees C (135 degrees F) or above, except that roasts cooked to a temperature and for a time specified in ¶ 3-401.11(B) or reheated as specified in ¶ 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5 degrees C (41 degrees F) or less.

Based on observations, interviews and record review, the facility failed to maintain a wound care program, that included weekly wound care assessments and treatments in five residents (R2, R5, R16, R29, R46) of five residents investigated for pressure ulcers.Findings IncludeResident #2 (R2) Review of the medical record reflected that R2 was admitted to the facility on [DATE]. Diagnoses of cerebral infarction due to unspecific occlusion or stenosis of the left middle cerebral artery, hemiplegia and hemiparesis on affecting right dominate side, aphasia, dysphagia, and protein- calorie malnutrition. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/24/2026 revealed R2 had a Brief Interview of Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R2 needed maximum assistance with showering and personal care. R2 was dependent on toileting, lower body dressing, and perineal hygiene. During an interview with DON B on 03/04/26 at 7:15 AM, DON B stated she had just completed the wound care assessment on R2 at 0630 AM this morning, stated she contacted the NP and received new orders and discontinued the old orders due to the status of the pressure ulcer. Had this writer not brought this wound to the attention of the DON B, this wound assessment would not have been completed today under normal circumstances. Record review of the timeline of R2's pressure ulcer that was received by the DON B just prior to completion of the survey noted .area to right heal was noted on 01/14/2026 and treatment was initiated. Area measured 2cm x 2 cm with no depth noted at this time of discovery. The provider was notified of the open area. Treatment continued to area with current measurements of 1.1cm x 0.6cm with no depth. New Orders 03/04/26- Cleanse left heel with NS. Apply Xeroform to wound bed and cover with foam dressing. Change every day and as needed. 02/26/26 IDT note. Interdisciplinary Team (IDT) met to review due to open area on heel. Treatment in place, continue to monitor. Continue to encourage good nutrition intake to promote wound healing. No weekly wound assessment completed the week of 02/23/2026. 02/24/26- NP. Noted a small right heel ulcer, continue current topical treatment to right heel ulcer, discussed with nursing. Weekly skin sweep dated 02/24/26 reported rt heel, coccyx, right and left lower leg, no measurements recorded. 02/17/26- NP. continue current treatment due to right heel ulcer, slow healing. Plan- continue current treatment due to right heel, slow healing, guarded prognosis secondary to immobility, multiple comorbidities, nutrition status. Noted small right heel ulcer with pink base with some brown drainage. No weekly wound assessment completed the week of 02/16/2026. No Weekly Skin Sweep for the week of 02/16/2026 Weekly skin sweep dated 02/10/26 reported right heel, right lower leg, left lower leg, coccyx no measurements recorded. No weekly wound assessment completed the week of 02/09/2026. 02/03/26 NP. Re-evaluate right heel pressure ulcer and response to current treatment. Plan- continue current topical treatment to right heel ulcer, pressure relieving devices, frequent repositioning. Small right heel ulcer with pink base, scant amount of drainage. No weekly wound assessment completed the week of 02/02/2026. No Weekly Skin Sweep completed the week of 02/02/2026. 01/27/26- NP. No mention of a pressure ulcer. No weekly wound assessment completed the week of 01/26/2026. 01/26/26- Nutrition note-nursing noted an open area on her right heel. Weekly skin sweep dated 01/25/26 reported right heel, coccyx, left lower leg, rt lower leg with no measurements recorded. MDS dated [DATE] reported 1 pressure ulcer at stage 2. 01/21/26- Refused to have dressing changed. 01/20/26- NP. new order-Calcium alginate, R2 seen today to evaluate right heel ulcer. Small right heel ulcer, pinkish wound bed with some surrounding maceration. 01/20/26- discontinued 03/04/26 Right heel ulcer. Cleanse with NS, apply calcium alginate and cover with Allevyn. Change daily. Apply skin prep to surrounding skin and to left heel. No Weekly Skin Sweep the week of 01/19/2026 No weekly wound assessment completed in the week of 01/19/2026. 01/14/26- nursing note- R was complaining of pain in her right foot, upon assessment, a pressure ulcer was noted. NP and DON notified. Change in condition done. Weekly Skin Sweep on 01/14/26 reported rash/excoriation on the sacrum, right buttock, left buttock. 01/14/26- discontinued 01/20/26 Apply skin prep to bilateral heels. Cover right heel pressure ulcer with comfort foam dressing. Change daily and prn. No weekly wound assessment completed the week of 01/12/2026. No Weekly Skin Sweep the week of 01/12/2026. 01/08/26- Alert note- impaired skin integrity was documented, treatment in placed. Weekly skin sweep dated 01/07/26 reports rash/excoriation No weekly wound assessment completed the week of 01/05/2026. No Weekly Skin Sweep the week of 01/05/2026. 12/30/25- No other new skin issues, rash resolved. Dr. MD No weekly wound assessment completed the week of 12/29/2025. No Weekly Skin Sweep the week of 12/29/2025. 12/23/25- No other skin issues besides rash on left arm. NP No weekly wound assessment completed the week of 12/22/2025. No Weekly Skin Sweep the week of 12/22/2025. 12/15/2025- No weekly wound assessment completed the week of 12/15/2025. No Weekly Skin Sweep the week of 12/15/2025. 12/08/2025- No weekly wound assessment completed the week of 12/08/2025. No Weekly Skin Sweep the week of 12/08/2025. 12/01/2025- No weekly wound assessment completed the week of 12/01/2025. No Weekly Skin Sweep the week of 12/01/2025. 11/20/2025- Impaired skin integrity was documented, known skin condition, assessment completed. 10/21/25- Weekly Skin Sweep completed. 09/02/25-Nursing progress note, notes approx. 1 cm circular, appearance of abrasion/open area on the coccyx. Daughter and provider notified. 09/02/25 NP noted approx 1 cm circular, appearance of abrasion/open area on the coccyx, pink surrounding tissue blanchable, no active bleeding, until after the area softly patted with normal saline than noticed small amount of bright red blood to site. No applied ointment and no further bleeding noted. Covered with 4x4. Resident #5 (R5) Review of the medical record reflected that R5 was admitted to the facility on [DATE]. Diagnoses of non-pressure chronic ulcer of the other part of right foot with necrosis of bone, respiratory failure, chronic obstructive pulmonary disease, muscle weakness, abnormalities of gait and mobility, chronic pain syndrome, and dementia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/16/2026 revealed R5 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R5 needed maximum assistance with showering and personal care. R5 was dependent on toileting, lower body dressing, and perineal hygiene. During an observation and interview on 03/02/2026 at 10:22 AM Observation of Licensed Practical Nurse (LPN) R perform wound care on R5's right foot 4th. LPN R performed hand hygiene, applied gloves, laid a blue pad under the right foot, old/soiled dressings removed, performed hand hygiene, applied gloves, wounds cleaned with normal saline and gauze dressing. LPN R then removed dressing from right heel, performed hand hygiene applied new gloves, held foot up in the air with left hand approx 1' off the floor, trying to measure heel wound from around the inside with his right hand, and had to learn over to get to the measurements of 2.5 x .5 in depth. LPN R was not able to view the pressure ulcer straight on to get accurate measurements. LPN R removed his gloves, hand hygiene completed, swabbed iodine with sterile Q-tips to both pressure ulcers, right foot on the 4th toe and right foot heel. Band aide applied to 4th toes on right foot, and foam dressing to right heel. LPN R removed gloves, completed hand hygiene. Record review revealed provider order for right foot great toe, not the 4th toe. Apply iodine to black scab to right big toe everyday shift for skin integrity. Written on 1/10/2026 06:00. Order for right heel-Cleanse right heel with NS, apply iodine to open area and cover with foam dressing. Everyday shift for skin integrity. 1/10/2026 06:00. Cover red/pink area to buttocks with 4x4 foam dressing -change daily and as needed. Every day shift and change as needed. Written on 12/25/25. During an observation and interview on 03/02/2026 at 1:47 PM, LPN R was performing wound care on R5's coccyx, he stated they use this dressing to provide a barrier for his skin. Observed 2 areas noted to be pink, stage 1 on the inner edges of his buttock on the right side and the left side just above the anus, also observed a pink area was noted on the bottom side of scrotum. Observed blanchable areas on both hips, with the right hip covered with foam dressing for protection. Observed LPN R hand sanitized and put gloves on, cleaned the buttock and scrotum with normal saline, put gloves after hand hygiene, applied barrier cream to scrotum, buttock and coccyx, removed his gloves and performed hand hygiene, applied new gloves, covered the coccyx with a foam dressing. Removed gloves and performed hand hygiene. During an interview on 03/02/2026 at 3:55 PM, DON B was asked what the provider's orders were for R5's pressure ulcer and altered skin integrity. DON B stated there was an order for right foot great toe, the right foot heel, and the right hip. Writer asked DON B what the order was for the right foot, 4th toe. DON B stated they didn't have one because that isn't the toe being treated. Writer informed DON B that the right foot great toe was healed and did not observed treatment to that toe. Writer also informed DON B the order for the great toe is still active and not discontinued when the wound healed. There was not an order for the treatment on the right foot, 4th toe that was performed. DON B stated she was unaware of an issue with the right foot, 4th toe. DON B also stated she was going down to assess the 4th toe and the appropriate treatment. Writer asked DON B how this was missed and asked if Weekly Wound Assessments and Weekly Skin Sweeps were capturing those skin concerns. DON B stated they were not completing these assessments routinely. Writer asked DON B who their provider was that was overseeing the facilities pressure ulcer and skin alterations. DON B stated that they did not have one at this time. DON B stated she had called NP or MD and told them what was going on with the resident's skin and asked for orders for wound care treatment. During this same interview writer asked DON B who was responsible for the wound care program overall. DON B stated she was overseeing the wound care program, but they did not have a wound care provider. DON B stated said wound care provider parted ways the end of November 2025. DON B added the floor nurses were supposed to be measuring the wounds and putting in the assessments, Weekly Skin Sweeps were not getting done completely, Wound Care Assessments were not done weekly, the ones that were done did not include all 3 wounds, just the right heel wound. 03/02/26- Weekly Skin Sweep- not completed. 03/02/26- Weekly Wound Assessment- not completed. 02/23/26- Weekly Wound Assessment- not completed. 02/24/26 Weekly Skin Sweep- blanchable red area and open area. Did not list the site or a description. 02/16/26- Weekly Wound Assessment- not completed. 02/17/26- Weekly Skin Sweep- discoloration, blanchable red area, open area. Right heel- open area, under treatment. Sacrum- blanchable redness to area under treatment. 02/09/26- Weekly Wound Assessment- not completed. 02/10/26- Weekly Skin Sweep- discoloration, blanchable red area, open area. Right heel- open area under treatment. Sacrum- blanchable redness to area under treatment. Other- bruising purple in color noted on bilateral forearms. 02/02/26- Weekly Wound Assessment- Right heel pressure ulcer- 3.0cm x 2cm x 0.1cm. Treatment- cleanse with normal saline, pat dry, apply Betadine to wound bed, cover with foam dressing. 02/02/26- Weekly Skin Sweep- not completed. 01/26/26- Weekly Skin Sweep- not completed. 01/26/26- Weekly Wound Assessment- not completed. 01/24/26- Weekly Skin Sweep- Blanchable red area and open area. Right heel- open area, treatment ordered. Sacrum- blanchable redness. 01/24/26-Weekly Wound Assessment- right heel pressure ulcer- 2.6cm x 2.3cm x 0.1cm. Treatment- cleanse with normal saline, pat dry, apply Betadine to wound bed, cover with foam dressing. 01/19/26- Weekly Skin Sweep- not completed. 01/16/26- Weekly Skin Sweep- Blanchable red area and open area, surgical wound site. Right heel- open area to right heel. Sacrum- blanchable redness to sacrum and buttocks. Other- Right great toe lesion. Other- Suprapubic catheter. 01/16/26- Weekly Wound Assessment- right heel pressure ulcer- 3cm x 2.7cm x 0.2cm. Treatment- cleanse with normal saline, part dry, apply Betadine to wound bed, cover with foam dressing. 01/05/26- Weekly Skin Sweep- not completed. 01/05/26- Weekly Wound Assessment- not completed. 12/29/25- Weekly Skin Sweep. not completed. 12/29/25- Weekly Wound Assessment. Not completed. 12/22/25- Weekly Skin Sweep. not completed. 12/22/25- Weekly Wound Assessment. Not completed. 12/17/25- Weekly Wound Assessment- right heel pressure ulcer- 0.4cm x 0.3cm x 3cm. Stage 4. Treatment- right heel cleanse with normal saline, apply small amount of calcium alginate to wound bed, cover with foam bordered dressing. 12/16/25- Weekly Skin Sweep- Open area- left heel- wound care orders in place. 12/10/25- Weekly Wound Assessment- Right heel pressure ulcer- 0.3cm x 0.3cm x 0. Stage 4. Treatment- right heel cleansed with normal saline, apply small amount of calcium alginate to wound bed, cover with foam bordered dressing. 12/09/25- Weekly Skin Sweep- marked none-skin intact. Right heel, stage 2 pressure ulcer. Wound care orders in place. 12/03/25- Weekly Wound Assessment- Right heel pressure ulcer- 0.5cm x 0.4cm x 0. Stage 4. Treatment- right heel cleansed with normal saline, apply small amount of calcium alginate to wound bed, cover with foam bordered dressing. 12/03/25- Provider assessed wound- rt heel, stage 4. Pressure ulcer of Right heel cleansed with normal saline. Apply small amount to calcium alginate to wound bed. Cover with bordered gauze. Type: pressure 12/02/25- Weekly Skin Sweep- open area- right heel- wound care orders in place. 11/30/25- Weekly Skin Sweep- open area- right heel- wound care orders in place. 11/26/25- Provider assessed wound. Pressure ulcer of right heel, stage 4: Off load pressure with frequent repositioning. Others relevant intervention: Right heel cleansed with normal saline. Apply small amounts to calcium alginate to wound bed. Cover with bordered gauze. Type: pressure 11/26/25- Weekly Wound Assessment- right heel pressure ulcer 0.8cm x 1.0cm x 0.1cm. stage 4. Treatment- left heel cleansed with normal saline. Apply small amount of calcium alginate to wound bed, cover with bordered gauze. 11/23/25- Weekly Skin Sweep- Blanchable red area. Coccyx intact, right heel- small open area. 11/23/25- Weekly Skin Sweep- Coccyx was intact, right heel had small open area. 11/19/25- Provider assessed wound- rt heel, stage 4. Pressure ulcer of right heel, stage 4: Off load pressure with frequent repositioning. Others relevant intervention: Cleanse right heel wound with normal saline and pat dry, apply calcium alginate cover with boarder gauze. Pressure ulcer unavoidable: No Measurements: 11/19/25- Weekly Wound Assessment- right heal pressure ulcer 0.8cm x 0.5cm x 0.2cm. Treatment- left heel cleansed with normal saline, apply small amount of calcium alginate to wound bed, cover with bordered gauze. 11/17/25- Weekly Skin Sweep. Not completed. 11/14/25- Weekly Skin Sweep- right ankle outer- open are to the right heel, under treatment. Sacrum- blanchable redness. 11/13/25- Weekly Wound Assessment- right heel pressure ulcer- 1.5cm x 1.5cm x 0.10cm, stage 4. Treatment- left heel pressure ulcer cleansed with normal saline, area painted with Betadine, foam bordered dressing applied to cover site. 11/12/25- Provider assessed wound- rt heel, stage 4. Pressure ulcer of right heel, stage 4: Off load pressure with frequent repositioning. Others relevant intervention: Cleanse right heel wound with normal saline and pat dry, paint with betadine and apply foam border dressing to site. Pressure ulcer unavoidable: No Measurements: 11/07/25- Weekly Skin Sweep- right heel- open area to right heel, treatment ordered. Sacrum was blanchable redness to sacrum. 11/05/25- Provider assessed wound- rt heel, stage 4. Pressure ulcer of right heel, stage 4: Off load pressure with frequent repositioning. Others relevant intervention: Clean with NS pat dry paint with Iodine, apply foam dressing. Pressure ulcer unavoidable: No Measurements: 11/05/25- Weekly Wound Assessment- right heel pressure ulcer- 1.0cm x 0.5cm x 0. Stage 4. Treatment- left heel cleansed with normal saline, are painted with Betadine, foam bordered dressing applied to cover site. 11/04/25-Weekly Skin Sweep- right heel pressure ulcer had an open sore, treatment ordered and completed as ordered. Sacrum was blanchable redness to sacrum. 10/29/25- Provider assessed wound- rt heel, stage 4. Pressure ulcer of right heel, stage 4: Off load pressure with frequent repositioning. Others relevant intervention: Keep Rt heel scab over area clean and place foam border on daily and as needed for safety and comfort. Pressure ulcer unavoidable: No Measurements: 10/29/25- Weekly Wound Assessment- right heel pressure ulcer, 0.5cm x 0.5cm x 0, stage 4. No treatment documented. 10/22/25- Provider assessed wound- rt heel, stage 4. Pressure ulcer of right heel, stage 4: Off load pressure with frequent repositioning. Others relevant intervention: Clean buttocks with NS, apply barrier cream, cover with foam patch. Pressure ulcer unavoidable: No Measurements: 10/22/25- Weekly Skin Sweep. Not completed. 10/22/25- Weekly Wound Assessment. Not completed. 10/16/25- Weekly Wound Assessment. Right heel pressure ulcer- 0.5cm x 0.5cm x 0, stage 4. Treatment- cleanse with normal saline and continue collagen fiber. 10/15/25- Provider assessed wound- rt heel, stage 4. Pressure ulcer of right heel, stage 4: Off load pressure with frequent repositioning. Others relevant intervention: Clean with NS pat dry apply calcium alginate cover with foam gauze. Pressure ulcer unavoidable: No Measurements: 10/15/25- Weekly Skin Sweep. Not completed. 10/15/25. Weekly Wound Assessment. Not completed. 10/09/25. Weekly Wound Assessment- Right heel pressure ulcer- 0.5cm x 0.5cm x 0. Stage 4. Treatment- cleanse with normal saline and continue collagen fiber. 10/06/25- Weekly Skin Sweep. Not completed. 10/02/25- Weekly Wound Assessment- Right heel pressure ulcer 1.0cm x 1.0cm x 0. Stage 4. Treatment- cleanse with normal saline and continue collagen fiber. 09/29/25- Weekly Skin Sweep- Not completed. 09/25/25- Weekly Skin Sweep- Coccyx red and right heel had an open area on right heel, treatment orders ongoing. 09/22/25- Weekly Wound Assessment. Not completed. 09/18/25- Provider assessed wound- rt heel, stage 4. Pressure ulcer of right heel, stage 4: Stage 4 pressure ulcer right heel. Others relevant intervention: Treatment is collagen packing dry dressing. Right heel stage 4 pressure ulcerMeasures 2.0 cm x 2.0 cm x 0.2 cm 09/18/25- Weekly Wound Assessment- right heel pressure ulcer 2.0cm x 2.0cm x 0. Stage 4. Treatment- cleanse with normal saline and continue collagen fiber. 09/15/25- Weekly Skin Sweeps. Not completed. 09/12/25-Weekly Wound Assessment- Right heel pressure ulcer-2.0cm x 2.5cm x 0.3cm. Stage 4. Treatment- cleanse with normal saline and continue collagen fiber. 09/11/25- Provider assessed wound- rt heel, stage 4. Pressure ulcer of right heel, stage 4: Stage 4 pressure ulcer right heel. Others relevant intervention: Treatment is collagen packing dry dressing. Right heel stage 4 pressure ulcerMeasures 2.0 cm x 2.0 cm x 0.2 cm 09/09/25- Weekly Skin Sweep- blanchable red area but no site listed. 09/08/25-Weekly Wound Assessment- Right heel pressure ulcer- 0.5cm x 0.5cm x 0. Stage 4. Treatment- Cleanse with normal saline and continue collagen fiber. 09/04/25- Provider assessed wound- rt heel, stage 4. Pressure ulcer of right heel, stage 4: Stage 4 pressure ulcer right heel. Others relevant intervention: Treatment is collagen packing dry dressing. Right heel stage 4 pressure ulcer. Measures 2.0 cm x 2.5 cm x 0.2 cm. 09/01/25- Weekly Wound Assessment- Right heel- 0.5cm x 0.5cm x 0.1cm. Stage 4. Treatment- cleanse with normal saline and continue collagen fiber. 09/01/25 Weekly Skin Sweep. Not completed. Noted, R5 did not receive regular weekly skin sweeps, weekly wound assessment, oversight from a wound care provider, measurements of the pressure ulcers were not consistent, treatment of the pressure ulcers did not fit the status of the pressure ulcers, right heel pressure ulcer, but treatment was written on the wound assessments for left heel, not right. Wound care orders for buttocks (cover red/pink area with 4x4 foam dressing), however this order was used on sacrum, coccyx and buttock, not identifying a new pressure ulcer area. Resident #29 (R29) Review of the medical record reflected that R29 was admitted to the facility on [DATE]. Diagnoses of acute kidney failure, osteomyelitis of left ankle and foot, paraplegia, cognitive communication deficit and severe protein-calorie malnutrition. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/27/2026 revealed R29 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R29 was dependent on toileting, lower body dressing, showering and personal care. Record review revealed R29's last Minimum Data Set (MDS) assessment dated [DATE] was marked having no pressure ulcers. During an interview on 03/04/2026 at12:37 PM, MDS Coordinator F stated that assessment did not include the measurements and staging of any pressure ulcers so she cannot put in the information if it's not documented. MDS Coordinator F stated DON B told her she had the information but had not put the information in before the 7-day window. MDS Coordinator F stated if it wasn't added in during the 7 days, she couldn't add it. Record review revealed R29 did not have Weekly Skin Sweeps, Weekly Wound Assessment. Writer requested a copy of all Weekly skin Sweeps and Weekly Wound Assessments and did not receive any prior to exiting the survey. 02/24/26- Provider progress note. No mention of the pressure ulcers. 02/17/26- Provider progress note. No mention of the pressure ulcers. 02/13/26- Provider Progress notes. No mention of the pressure ulcers. 02/05/26- Provider progress notes. No mention of the pressure ulcers. 02/04/26- Provider progress notes. Gives a history of present illnesses. No mention of current pressure ulcers. Resident #16 (R16) Review of the medial medical record revealed R16 was admitted to the facility 01/02/2026 with diagnoses that included type 2 diabetes, protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), end stage renal disease, pancytopenia (lower than normal red and white blood cells and platelets in blood), nonalcoholic steatohepatitis (fatty liver), cirrhosis of liver (scared and permanently damaged liver), heart failure, gastric ulcer (open sores of stomach lining), esophageal varices (enlarged veins in the esophagus, the tube that connects to throat and the stomach), fractured left femur (upper bone of the leg), fracture left patella (knee cap), fracture left tibia (bone in lower leg), peripheral vascular disease (PVD), gastro-esophageal reflux, thrombocytopenia (low platelet count), and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/2026, revealed R16 had a Brief Interview of Mental Status (BIMS) of 15 (intact cognition) out of 15. During observation and interview on 03/04/2026 at 09:15 a.m. R16 as observed lying down in bed. R16 explained that she had an open area on her bottom. R16 could not explain if the open area was present upon admission or if it was acquired at the facility. R16 explained that the open area had been improving. Review of R16's medical record revealed a document entitled Admission/readmission Assessment-V2.2, completion date of 02/11/2026, revealed: site: 31) right buttock, Type: open area, length: (blank), and width: (blank). Review of document entitled Weekly Skin Sweep, effective date of 02/15/2026, revealed: Site: 23) Coccyx, Description: open area measured 2cm(centimeters) length and 0.5cm with. and Site: 32) Left buttock, Description: open area 2cm length by 2cm width. Review of document entitled Weekly Skin Sweep, effective date of 03/01/2026, revealed: Site: 53) Sacrum, Description: open area-treatment applied. R16's medical record did not contain any documentation entitled Wound Assessment V2.1 (document completed weekly to include measurements and staging of wounds). R16's medical record did not contain any documentation of the wound by the attending physician. Review of R16's medical record did not demonstrate that the wound had been included in her Plan of Care. Review of R16's medical record revealed a physician order, initiated 02/15/2026 and to start 02/16/2025), which stated, clean coccyx and right buttocks with normal saline. Then apply hydrophilic sound ointment to wound bed and cover with foam dressing change daily and PRN (as needed) in the afternoon for wound care. On 03/04/2026 at 09:17 a.m. R16 was observed lying down in bed. Licensed Practical Nurse (LPN) S was observed explaining dressing procedure to R16. R16 was rolled to her left side with the assistance of Certified Nursing Aide (CNA) T. R16's brief was removed and no dressing was observed on R16's bottom. LPN S proceeded to cleanses R16's open wound, which was located to the left of her coccyx, with normal saline. After cleansing of wound Director of Nursing (DON) B performed measurements of the wound. R16's open wound to the left of her coccyx was observed to be 1.4cm (centimeters) in length, 1.0 cm in width, and 0.1cm in depth. The wound bed was observed to be red with granulation tissue present. DON B verbalized that R16's wound was a stage 2 pressure ulcer. LPN S was then observed to apply hydrophilic wound ointment to wound bed and covered the wound with a foam dressing. In an interview on 03/04/2026 at 10:04 a.m. Director of Nursing (DON) B explained that residents are assessed upon admission, and a complete skin assessment was completed within 24 hours. DON B explained that if a wound was present measurements would be recorded and a description of the wound be recorded. DON B explained that if the assessing nurse was a Registered Nurse, then the wound would be staged appropriately. DON B explained that the attending physician would be contacted and a treatment order would be obtained. DON B explained that if a current resident was found to have any skin wounds that she was to be notified and she would ensure that the assessment was completed, the treatment was initiated, and the physician would view the wound and document appropriately. DON B explained that it was facility policy that skin sweeps are to be completed weekly. DON B explained if a resident had a skin wound that a Wound Assessment V2.1 document would be completed weekly. DON B explained that residents with skin issues and/or open wounds would be included in their plan of care. DON B confirmed that R16 did not have a treatment order for her wound until 02/16/2026. DON B confirmed that R16 did not have a Weekly Skin Sweep document completed weekly. DON B confirmed that R16 did not have a Wound Assessment document completed when R16's wound was identified or completed weekly. DON B confirmed that R16's medical record had not revealed that the attending physician had recorded any documentation regarding R16's wound, progression of the wound, or treatment of the wound. DON B confirmed that R16's Care Plan did not include her stage 2 pressure ulcer or interventions to prevent or assist in the healing of the wound. Resident # 46 (R46) Review of the medical record reflected R46 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included acute respiratory failure with hypoxia, diabetes and acquired absence of the left leg, below the knee. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/12/26, reflected R46 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was at risk of developing pressure ulcers/injuries. On 03/03/2026 at 3:28 PM, R46 was observed lying in bed, on their back, on a standard mattress. A wheelchair, at the right bedside, was noted to have a seating cushion in place. R46 stated before their initial admission to the facility, they had a rash on their bottom. R46 acknowledged a dressing was in place, on their bottom, which was changed the night prior. To R46's knowledge, the skin was not open or draining. An Admission/readmission Assessment, dated 2/6/26, reflected non-blanchable (skin color does not fade when pressed on) redness to R46's sacrum. A Nurse Practitioner Progress Note for 2/7/26 reflected, .Wound coccyx dressing order placed . A Physician's Order, with a revision date of 2/15/26 and a start date of 2/17/26, reflected to cleanse the coccyx wound with barrier or bath wipes, cover with silicone border foam dressing and change every three days and as needed. The February 2026 Treatment Administration Record (TAR) reflected treatment to the sacrum/coccyx did not begin until 2/17/26. R46's medical record reflected Weekly Skin Sweeps, dated 1/13/26, 1/28/26 and 2/13/26, which were marked for, Scar and Surgical wound site. In an interview on 03/04/2026 at 10:04 AM, Director of Nursing (DON) B reported at the time of readmission from the hospital, on 2/6/26, R46 had non-blanchable redness on the sacrum, which indicated a stage one pressure ulcer was present. DON B reported she would have expected the wound to be staged, measured and fo

Based on observations, interview and record review, the facility failed to ensure there was Physician oversight and orders for care provided in three residents (R2, R5 and R16) out of five residents.Finding IncludeResident #2 (R2) Review of the medical record reflected that R2 was admitted to the facility on [DATE]. Diagnoses of cerebral infarction due to unspecific occlusion or stenosis of the left middle cerebral artery, hemiplegia and hemiparesis on affecting right dominate side, aphasia, dysphagia, and protein- calorie malnutrition. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/24/2026 revealed R2 had a Brief Interview of Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R2 needed maximum assistance with showering and personal care. R2 was dependent on toileting, lower body dressing, and perineal hygiene. During an interview with DON B on 03/04/26 at 7:15 AM, DON B stated she had just completed the wound care assessment on R2 at 0630 AM this morning, stated she contacted the NP and received new orders and discontinued the old orders due to the status of the pressure ulcer. Had this writer not brought this wound to the attention of the DON B, this wound assessment would not have been completed today under normal circumstances. Record review of the timeline of R2's pressure ulcer that was received by the DON B just prior to completion of the survey noted .area to right heal was noted on 01/14/2026 and treatment was initiated. Area measured 2cm x 2 cm with no depth noted at this time of discovery. The provider was notified of the open area. Treatment continued to area with current measurements of 1.1cm x 0.6cm with no depth. New Orders 03/04/26- Cleanse left heel with NS. Apply Xeroform to wound bed and cover with foam dressing. Change every day and as needed. 02/26/26 IDT note. Interdisciplinary Team (IDT) met to review due to open area on heel. Treatment in place, continue to monitor. Continue to encourage good nutrition intake to promote wound healing. No weekly wound assessment completed the week of 02/23/2026. 02/24/26- NP. Noted a small right heel ulcer, continue current topical treatment to right heel ulcer, discussed with nursing. Weekly skin sweep dated 02/24/26 reported rt heel, coccyx, right and left lower leg, no measurements recorded. 02/17/26- NP. continue current treatment due to right heel ulcer, slow healing. Plan- continue current treatment due to right heel, slow healing, guarded prognosis secondary to immobility, multiple comorbidities, nutrition status. Noted small right heel ulcer with pink base with some brown drainage. No weekly wound assessment completed the week of 02/16/2026. No Weekly Skin Sweep for the week of 02/16/2026 Weekly skin sweep dated 02/10/26 reported right heel, right lower leg, left lower leg, coccyx no measurements recorded. No weekly wound assessment completed the week of 02/09/2026. 02/03/26 NP. Re-evaluate right heel pressure ulcer and response to current treatment. Plan- continue current topical treatment to right heel ulcer, pressure relieving devices, frequent repositioning. Small right heel ulcer with pink base, scant amount of drainage. No weekly wound assessment completed the week of 02/02/2026. No Weekly Skin Sweep completed the week of 02/02/2026. 01/27/26- NP. No mention of a pressure ulcer. No weekly wound assessment completed the week of 01/26/2026. 01/26/26- Nutrition note-nursing noted an open area on her right heel. Weekly skin sweep dated 01/25/26 reported right heel, coccyx, left lower leg, rt lower leg with no measurements recorded. MDS dated [DATE] reported 1 pressure ulcer at stage 2. 01/21/26- Refused to have dressing changed. 01/20/26- NP. new order-Calcium alginate, R2 seen today to evaluate right heel ulcer. Small right heel ulcer, pinkish wound bed with some surrounding maceration. 01/20/26- discontinued 03/04/26 Right heel ulcer. Cleanse with NS, apply calcium alginate and cover with Allevyn. Change daily. Apply skin prep to surrounding skin and to left heel. No Weekly Skin Sweep the week of 01/19/2026 No weekly wound assessment completed in the week of 01/19/2026. 01/14/26- nursing note- R was complaining of pain in her right foot, upon assessment, a pressure ulcer was noted. NP and DON notified. Change in condition done. Weekly Skin Sweep on 01/14/26 reported rash/excoriation on the sacrum, right buttock, left buttock. 01/14/26- discontinued 01/20/26 Apply skin prep to bilateral heels. Cover right heel pressure ulcer with comfort foam dressing. Change daily and prn. No weekly wound assessment completed the week of 01/12/2026. No Weekly Skin Sweep the week of 01/12/2026. 01/08/26- Alert note- impaired skin integrity was documented, treatment in placed. Weekly skin sweep dated 01/07/26 reports rash/excoriation No weekly wound assessment completed the week of 01/05/2026. No Weekly Skin Sweep the week of 01/05/2026. 12/30/25- No other new skin issues, rash resolved. Dr. MD No weekly wound assessment completed the week of 12/29/2025. No Weekly Skin Sweep the week of 12/29/2025. 12/23/25- No other skin issues besides rash on left arm. NP No weekly wound assessment completed the week of 12/22/2025. No Weekly Skin Sweep the week of 12/22/2025. 12/15/2025- No weekly wound assessment completed the week of 12/15/2025. No Weekly Skin Sweep the week of 12/15/2025. 12/08/2025- No weekly wound assessment completed the week of 12/08/2025. No Weekly Skin Sweep the week of 12/08/2025. 12/01/2025- No weekly wound assessment completed the week of 12/01/2025. No Weekly Skin Sweep the week of 12/01/2025. 11/20/2025- Impaired skin integrity was documented, known skin condition, assessment completed. 10/21/25- Weekly Skin Sweep completed. 09/02/25-Nursing progress note, notes approx. 1 cm circular, appearance of abrasion/open area on the coccyx. Daughter and provider notified. 09/02/25 NP noted approx 1 cm circular, appearance of abrasion/open area on the coccyx, pink surrounding tissue blanchable, no active bleeding, until after the area softly patted with normal saline than noticed small amount of bright red blood to site. No applied ointment and no further bleeding noted. Covered with 4x4. Resident #5 (R5) Review of the medical record reflected that R5 was admitted to the facility on [DATE]. Diagnoses of non-pressure chronic ulcer of the other part of right foot with necrosis of bone, respiratory failure, chronic obstructive pulmonary disease, muscle weakness, abnormalities of gait and mobility, chronic pain syndrome, and dementia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/16/2026 revealed R5 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R5 needed maximum assistance with showering and personal care. R5 was dependent on toileting, lower body dressing, and perineal hygiene. During an observation and interview on 03/02/2026 at 10:22 AM Observation of Licensed Practical Nurse (LPN) R perform wound care on R5's right foot 4th. LPN R performed hand hygiene, applied gloves, laid a blue pad under the right foot, old/soiled dressings removed, performed hand hygiene, applied gloves, wounds cleaned with normal saline and gauze dressing. LPN R then removed dressing from right heel, performed hand hygiene applied new gloves, held foot up in the air with left hand approx 1' off the floor, trying to measure heel wound from around the inside with his right hand, and had to learn over to get to the measurements of 2.5 x .5 in depth. LPN R was not able to view the pressure ulcer straight on to get accurate measurements. LPN R removed his gloves, hand hygiene completed, swabbed iodine with sterile Q-tips to both pressure ulcers, right foot on the 4th toe and right foot heel. Band aide applied to 4th toes on right foot, and foam dressing to right heel. LPN R removed gloves, completed hand hygiene. Record review revealed provider order for right foot great toe, not the 4th toe. Apply iodine to black scab to right big toe everyday shift for skin integrity. Written on 1/10/2026 06:00. Order for right heel-Cleanse right heel with NS, apply iodine to open area and cover with foam dressing. Everyday shift for skin integrity. 1/10/2026 06:00. Cover red/pink area to buttocks with 4x4 foam dressing -change daily and as needed. Every day shift and change as needed. Written on 12/25/25. During an observation and interview on 03/02/2026 at 1:47 PM, LPN R was performing wound care on R5's coccyx, he stated they use this dressing to provide a barrier for his skin. Observed 2 areas noted to be pink, stage 1 on the inner edges of his buttock on the right side and the left side just above the anus, also observed a pink area was noted on the bottom side of scrotum. Observed blanchable areas on both hips, with the right hip covered with foam dressing for protection. Observed LPN R hand sanitized and put gloves on, cleaned the buttock and scrotum with normal saline, put gloves after hand hygiene, applied barrier cream to scrotum, buttock and coccyx, removed his gloves and performed hand hygiene, applied new gloves, covered the coccyx with a foam dressing. Removed gloves and performed hand hygiene. During an interview on 03/02/2026 at 3:55 PM, DON B was asked what the provider's orders were for R5's pressure ulcer and altered skin integrity. DON B stated there was an order for right foot great toe, the right foot heel, and the right hip. Writer asked DON B what the order was for the right foot, 4th toe. DON B stated they didn't have one because that isn't the toe being treated. Writer informed DON B that the right foot great toe was healed and did not observed treatment to that toe. Writer also informed DON B the order for the great toe is still active and not discontinued when the wound healed. There was not an order for the treatment on the right foot, 4th toe that was performed. DON B stated she was unaware of an issue with the right foot, 4th toe. DON B also stated she was going down to assess the 4th toe and the appropriate treatment. Writer asked DON B how this was missed and asked if Weekly Wound Assessments and Weekly Skin Sweeps were capturing those skin concerns. DON B stated they were not completing these assessments routinely. Writer asked DON B who their provider was that was overseeing the facilities pressure ulcer and skin alterations. DON B stated that they did not have one at this time. DON B stated she had called NP or MD and told them what was going on with the resident's skin and asked for orders for wound care treatment. During this same interview writer asked DON B who was responsible for the wound care program overall. DON B stated she was overseeing the wound care program, but they did not have a wound care provider. DON B stated said wound care provider parted ways the end of November 2025. DON B added the floor nurses were supposed to be measuring the wounds and putting in the assessments, Weekly Skin Sweeps were not getting done completely, Wound Care Assessments were not done weekly, the ones that were done did not include all 3 wounds, just the right heel wound. Resident #16 (R16) Review of the medial medical record revealed R16 was admitted to the facility 01/02/2026 with diagnoses that included type 2 diabetes, protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), end stage renal disease, pancytopenia (lower than normal red and white blood cells and platelets in blood), nonalcoholic steatohepatitis (fatty liver), cirrhosis of liver (scared and permanently damaged liver), heart failure, gastric ulcer (open sores of stomach lining), esophageal varices (enlarged veins in the esophagus, the tube that connects to throat and the stomach), fractured left femur (upper bone of the leg), fracture left patella (knee cap), fracture left tibia (bone in lower leg), peripheral vascular disease (PVD), gastro-esophageal reflux, thrombocytopenia (low platelet count), and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/2026, revealed R16 had a Brief Interview of Mental Status (BIMS) of 15 (intact cognition) out of 15. During observation and interview on 03/04/2026 at 09:15 a.m. R16 as observed lying down in bed. R16 explained that she had an open area on her bottom. R16 could not explain if the open area was present upon admission or if it was acquired at the facility. R16 explained that the open area had been improving. Review of R16's medical record revealed a document entitled Admission/readmission Assessment-V2.2, completion date of 02/11/2026, revealed: site: 31) right buttock, Type: open area, length: (blank), and width: (blank). Review of document entitled Weekly Skin Sweep, effective date of 02/15/2026, revealed: Site: 23) Coccyx, Description: open area measured 2cm(centimeters) length and 0.5cm with. and Site: 32) Left buttock, Description: open area 2cm length by 2cm width. Review of document entitled Weekly Skin Sweep, effective date of 03/01/2026, revealed: Site: 53) Sacrum, Description: open area-treatment applied. R16's medical record did not contain any documentation entitled Wound Assessment V2.1 (document completed weekly to include measurements and staging of wounds). R16's medical record did not contain any documentation of the wound by the attending physician. Review of R16's medical record did not demonstrate that the wound had been included in her Plan of Care. Review of R16's medical record revealed a physician order, initiated 02/15/2026 and to start 02/16/2025), which stated, clean coccyx and right buttocks with normal saline. Then apply hydrophilic sound ointment to wound bed and cover with foam dressing change daily and PRN (as needed) in the afternoon for wound care. On 03/04/2026 at 09:17 a.m. R16 was observed lying down in bed. Licensed Practical Nurse (LPN) S was observed explaining dressing procedure to R16. R16 was rolled to her left side with the assistance of Certified Nursing Aide (CNA) T. R16's brief was removed and no dressing was observed on R16's bottom. LPN S proceeded to cleanses R16's open wound, which was located to the left of her coccyx, with normal saline. After cleansing of wound Director of Nursing (DON) B performed measurements of the wound. R16's open wound to the left of her coccyx was observed to be 1.4cm (centimeters) in length, 1.0 cm in width, and 0.1cm in depth. The wound bed was observed to be red with granulation tissue present. DON B verbalized that R16's wound was a stage 2 pressure ulcer. LPN S was then observed to apply hydrophilic wound ointment to wound bed and covered the wound with a foam dressing. In an interview on 03/04/2026 at 10:04 a.m. Director of Nursing (DON) B explained that residents are assessed upon admission, and a complete skin assessment was completed within 24 hours. DON B explained that if a wound was present measurements would be recorded and a description of the wound be recorded. DON B explained that if the assessing nurse was a Registered Nurse then the wound would be staged appropriately. DON B explained that the attending physician would be contacted and a treatment order would be obtained. DON B explained that if a current resident was found to have any skin wounds that she was to be notified and she would ensure that the assessment was completed, the treatment was initiated, and the physician would view the wound and document appropriately. DON B explained that it was facility policy that skin sweeps are to be completed weekly. DON B explained if a resident had a skin wound that a Wound Assessment V2.1 document would be completed weekly. DON B explained that residents with skin issues and/or open wounds would be included in their plan of care. DON B confirmed that R16 did not have a treatment order for her wound until 02/16/2026. DON B confirmed that R16 did not have a Weekly Skin Sweep document completed weekly. DON B confirmed that R16 did not have a Wound Assessment document completed when R16's wound was identified or completed weekly. DON B confirmed that R16's medical record had not revealed that the attending physician had recorded any documentation regarding R16's wound, progression of the wound, or treatment of the wound. DON B confirmed that R16's Care Plan did not include her stage 2 pressure ulcer or interventions to prevent or assist in the healing of the wound.

Based on observation, interviews and record reviews, the facility failed to maintain Dignity in one (R31) of 16 residents when yelling out for help.Findings IncludeResident #31 (R31)Review of the medical record reflected that R31 was admitted to the facility on [DATE]. Diagnoses of displaced Tri malleolar fracture of right lower leg, history of a stroke, polyneuropathy, obesity and rheumatoid arthritis.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2026 revealed R31 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 needed substantial assistance with showering and personal care. R31 was dependent on toileting, lower body dressing, and perineal hygiene.During an observation and interview on 03/01/2026 at 8:51 AM, R31 stated she was supposed to be up in her wheelchair and ready for physical therapy, but the CNA assigned to her did not get her up in time for physical therapy. R31 stated nobody answered her call light for two hours, added that she yelling for help hoping someone would come in and help her. R31 stated during this time, physical therapy (PT) X came into her room to see if she was ready for her session, but she was still in bed. R31 stated her CNA finally came in and got her up in her wheelchair for physical therapy and moved her wheelchair over by the television, across the room. R31 stated the CNA did not give her the call light so she had no way of calling for help other than yelling out. R31 stated this was on Friday 02/27/26.During an interview on 03/02/26 at 3:55pm, Director of Nursing (DON) B stated she had not been notified of this concern. DON B stated she would go down to the R31's room and talk to her about that dignity issue.During an interview on 03/03/2026 at 11:28 AM, DON B stated she had discussed the concern with R31. DON B stated R31 told her she had a rough day on Friday, as she was set away from her call light and could not reach it. DON B asked R31 who her CNA was that day and R31 told her it was CNA X.Observation and interview on 03/03/2026 at 11:42 AM, CNA X was working with R31 today. Call light was in reach, R31stated today was a much better day, CNA X was more attentive to her needs and made sure she had everything she needed before leaving the room.

Based on observation, interview and record review, the facility failed to prevent a significant weight loss for one resident (resident 5) of 2 reviewed from a total sample of 16.Findings include: Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed Resident #5 (R5) was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses dementia, depression, depression, Transient Ischemic Attack. R5 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status. On 03/01/2026 at 10:04 am, R5 was observed in his room, there was scrambled egg observed in two areas on the floor. R5 was sitting up in his wheelchair he was noted to have some tremors in both hands. When queried if he had breakfast yet, he replied he did but he didn't like it. R5 elaborated in great length that he wants oatmeal and asks for it every day, but depending on which Certified Nursing Assistant (CNA) is working he may or may not get it. When queried if he had met with Registered Dietician or the facility dietary manager R5 replied he doesn't know who they are. R5 stated his appetite was fair but he went from 140 pounds down to 118 because he does not get the foods that he likes. Further review of R5's clinical record revealed on 01/05/2026, the resident weighed 131.6 lbs. On 02/18/2026, the resident weighed 118.6 pounds, which is a -9.88% Loss. Review of Registered Dietician (RD) H assessment dated [DATE] revealed food preferences honored Further review of R5's clinical record revealed there was no documentation as to what R5's food preferences were. Review of R5's nutritional care plan dated 5/14/25 identified R5's beverage preference between meals was water but did not identify any likes or dislikes for meals or snacks. On 03/02/2026 at 10:05 AM, during an interview with CNA Q, she reported R5 was difficult to care for and that he needs help with eating because his hands and body shakes, and food falls to the floor but he refuses want assistance to be fed. CNA Q stated she believed R5 could benefit from weighted utensils. Hence the scrambled eggs observed on R5's floor that was observed the day prior. Review of Interdisciplinary Team (IDT) notes dated 2/26/26, revealed the IDT met to discuss R5's general decline, weight loss, behaviors .encouraging snacks and extra portions. R5's nutritional care plan dated 7/31/24 with revision date of 2/18/26 does not reflect extra portions or that snacks are to be encouraged. On 03/02/2026 at 12:35 PM, during an interview with RD H, she reported she was regional Dietician and came to the facility once a week. RD H reported R5 had a poor appetite, significant weight loss and that she had recommended supplements which were ordered by the physician. RD H stated she had not talked with or observed R5 eat since the significant weight loss. Review of R5's electronic medical record with RD H, resident food preferences were not documented in the medical record. RD H stated she put R5's food and drink preferences on his meal ticket. A copy of R5's meal ticket was requested and provided at that time and revealed R5 disliked salad there was nothing noted on what R5 liked or preferred. When queried why R5's clinical record or meal ticket had no likes or preferences, RD H stated they usually focuses on dislikes. When queried if she thought ensuring R5 food preferences should be met particularly with a 9.88% weight loss in one month RD H stated she didn't have a good answer. When quired if she attended or was part of the IDT meeting held on 2/26/26 RD H stated no she was not at the facility that day. On 03/04/2026 10:51 AM during an interview with Rehab Director W reported the therapy department trialed R5 with weighted utensils a few months ago and R5 did not like it. Requested copy of documentation related to R5's trial of weighted silverware, screening or evaluation that pertained to R5's ability to feed himself. Rehab Director W was unable to locate any documentation.

Based on observations, interviews, and record reviews, the facility failed to effectively maintain the resident call system for 2 (R21, R55) of 16 sampled residents affecting 2 residents, resulting in the increased likelihood for resident negative outcomes related to delayed and/or no emergency response.Findings include:Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] BIMS of 14, revealed Resident #21 was a [AGE] year-old female admitted on [DATE] with diagnosis of dysphonia (impairment in voice production, characterized by hoarseness, breathiness, strain or breaks in voice quality) depression and anxiety. On 03/01/2026 at 2:17 PM, the call light was tested in R21's (room and bathroom) with another surveyor. While testing the call light, Director of Nursing (DON) B brought in a [NAME] bell and handheld service bell and placed in on R21's overbed table. Interview with Licensed Practical Nurse (LPN) V stated the bathroom light should light up red. When the cord was pulled there was no noted change in color of the light. When queried if there was a panel somewhere, possibly the nurses' station, that would notify staff what call light was on in what room, LPN V said they used to have that, but it got taken out about one year ago. On 03/01/2026 at 2:44 PM, while in R21's room with DON B and another surveyor present, R21 was observed in bed, the nightstand was behind R21 and was not in reach to open the drawers or reach on top of the drawers. DON B queried R21 to where the handheld bell and [NAME] bell was from last week. R21 reported in a soft voice They moved it. DON B replied Oh you moved it? R21 stated No and again reiterated that staff moved the bells out of reach. Resident #55 (R55) On 03/01/2026 at 11:37 A.M., the call light system was observed not working as designed, within resident R55s room. The corridor visual light was observed dimly lit. The audible signal was also observed providing extremely low volume. On 03/01/2026 at 1:04 P.M., an interview was conducted with Environmental Services Director (ESD) K regarding the facility call system, within resident R55s room. ESD K stated that the duty station (audible enunciator) is located at each nursing station, they have the lights in the hallway, and that the system has a visual and an audible component. On 03/01/2026 at 1:15 P.M., the resident call system duty station (audible enunciator) was observed located within the Medication Room of each neighborhood (100 Hall, 200 Hall, and 300 Hall) nursing station. On 03/01/2026 at 1:20 P.M., an interview was conducted with (ESD) K regarding the specifications of the current resident call system. (ESD) K stated that the current system is a hard-wired system that was installed in 2010 and went obsolete in 2020. (ESD) K further stated that Resident rooms R21 and R55 are currently experiencing the same issue. On 03/01/2026 at 1:25 P.M., an interview was conducted with R21 regarding her resident call system. R21 stated that they have to go out into the corridor to find someone to help me them. R21 was observed to be on oxygen and with reduced ambulation skills. On 03/01/2026 at 2:18 P.M., an interview was conducted with (ESD) K regarding the facility resident call system. (ESD) K stated that the call system has been obsolete since 2021 and that they have attempted to change faulty components for repair. (ESD) K additionally stated that the interventions used if there were to be a system failure would be to use bells in each room; one is a hand-held tambourine style, and the other is a stem type bell. (ESD) K was queried regarding the call light system functionality and stated that when the bathroom call system is activated, the outside visual will turn red. (ESD) K also stated that the visual for rooms for R 55 and R 21 is currently a faint red. (ESD) K was queried regarding when the call light system functionality failure had occurred and replied that it was late December 2025 or early January 2026. On 03/01/2026 at 2:58 P.M., an interview was conducted with Certified Nursing Assistant (CNA) Q regarding the resident call system, within resident room [ROOM NUMBER]. (CNA) Q stated that the call system failed in late December 2025. On 03/01/2026 at 3:00 P.M., an interview was conducted with (ESD) K regarding the resident call system. (ESD) K stated that the call light in resident R21 room had a work order initiated on January 8th and again on February 18th. On 03/01/2026 at 3:25 P.M., an interview was conducted with R21 regarding her restroom call light system. When queried if they use the restroom, R21 stated yes. When queried how they would summons emergency help if they were in the restroom, R21 stated they would pull the cord for help. R21 further stated: Sometimes it takes a long time to get help. On 03/01/2026 at 3:44 P.M., an interview was conducted with (ESD) K regarding the facility resident call system work order generated for residentR55 room (dated 8/4/17). (ESD) K stated that the call system failed for resident R55s room on January 22nd and that they placed a jingle bell (hand-held tambourine) in resident R55s room on January 22nd. (ESD) K additionally stated that the call system failed for resident R 21s room on January 8th and they had nursing place a stick bell in the room on January 8th. On 03/02/2026 at 9:06 A.M., an interview was conducted with Executive Director A regarding the facility call light system. Executive Director A stated that they are moving both residents from their current rooms to rooms with functioning call light systems. On 03/04/26 at 07:00 A.M., record review of the Policy/Procedure entitled: Resident Call System dated 1/11/2021 revealed under Policy: (Name of Facility) is committed to following a proper procedure for resident, staff, and visitor safety. Record review of the Policy/Procedure entitled: Resident Call System dated 1/11/2021 also revealed under Purpose: To ensure the facilities call system is designed, constructed, equipped, and maintained to protect the health and safety of the residents. Record review of the Policy/Procedure entitled: Resident Call System dated 1/11/2021 further revealed under Procedure: The facility will be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, toilet, and bathing facilities.

Based on observation, interview and record review, the facility failed to maintain complete and accurate medical records for one (R1) of 16 reviewed. Findings include:Review of the medical record reflected R1 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included pneumonia, malignant neoplasm (cancerous tumor) of middle third of esophagus, unspecified severe protein-calorie malnutrition and gastrostomy status (surgical opening into the stomach). The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/30/26, reflected R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and received 51% or more of their total calories through parenteral of tube feeding. On 03/01/2026 at 11:48 AM, R1 was observed in bed, with the head of the bed elevated. They reported receiving bolus tube feeding (specified amount of feeding administered over a brief period of time) via feeding tube. R1 reported they were supposed to receive bolus feedings four times per day but believed the rate of the bolus feedings were too rapid, causing them to experience some diarrhea. On 03/02/2026 at 9:56 AM, R1 was observed lying in bed, with the head of bed elevated and their eyes closed. On 03/03/2026 at 10:16 AM, R1 was observed seated on the edge of their bed. When queried about tolerance of their bolus tube feedings, R1 acknowledged their tolerance had improved, and it was being administered slower, four times daily. A Progress Note for 2/26/26 at 10:08 AM reflected R1 requested to be changed to bolus feeding. The Registered Dietitian (RD) recommended discontinuing the current enteral nutrition order and starting [NAME] Farms Peptide 1.5, one carton (325 milliliters (mL)), four times daily, with a 100 mL water flush before and after. The note reflected the ordered amount provided 2000 kilocalories and 96 grams of protein. The February 2026 Medication Administration Record (MAR) reflected R1's bolus tube feedings were started on 2/26/26. The order reflected R1 was to receive bolus feedings of [NAME] Farms Peptide 1.5, one carton (325 mL), four times daily, with a 100 mL water flush before and after each bolus feeding. Progress Notes for 2/27/26 at 12:32 PM and 12:33 PM reflected R1 had been requesting half the bolus feeding amount. The MAR reflected bolus feeding was administered as ordered for the afternoon of 2/27/26 and did not include an option to record the actual amount received. A Progress Note for 3/3/26 at 7:29 AM reflected R1 received 50 percent (%) of their morning bolus feeding due to refusing to accept the full amount. R1's March 2026 MAR reflected their bolus tube feeding of [NAME] Farms Peptide 1.5, one carton (325 mL), four times daily, with a 100 mL water flush before and after each bolus feeding was administered as ordered the morning of 3/3/26. The MAR did not include an option to record the actual amount received. In an interview on 03/03/2026 at 10:21 AM, Registered Nurse (RN) G reported R1 had switched from continuous feeding to bolus feeding the week prior. RN G stated R1 had been refusing their bolus feedings and only accepting approximately half of the ordered amount. RN G reported they administered half of R1's ordered bolus feeding that morning, per R1's request. In an interview on 03/03/2026 at 12:59 PM, RN G reported administering two bolus tube feedings to R1 that day, with acceptance of approximately 50 percent (%). RN G stated the amount of tube feeding accepted was not measured. They stopped administration when R1 requested, and there was approximately 50% of the formula left in the carton. R1's March 2026 MAR reflected their bolus tube feedings of [NAME] Farms Peptide 1.5, one carton (325 mL), four times daily, with a 100 mL water flush before and after each bolus feeding were administered as ordered on 3/1/26 and 3/2/26. The MAR did not include an option to record the actual amount received. In a phone interview on 03/03/2026 at 1:06 PM, Licensed Practical Nurse (LPN) I reported R1 had only been wanting half a bottle of their tube feeding at a time and was very adamant about not getting more. LPN I reported due to their shift times on 3/1/26, they administered two bolus feedings to R1 that day. LPN I reported R1 had an appointment on 3/2/26 and refused one of their bolus feedings. LPN I stated they administered two bolus feedings during their shift on 3/2/26. When asked about the MAR documentation, which reflected they administered three bolus feedings to R1 on 3/2/26, LPN I reported they must have made an error in their documentation and stated R1 absolutely did not get three bolus feedings on their shift that day. LPN I stated the amount of tube feeding accepted by R1 was not measured but was determined by eyeing and feeling the amount left in the carton. R1's Progress Notes for 3/1/26 and 3/2/26 did not reflect refusal of the full amount of the ordered bolus tube feeding.

Based on observation, interview, and record review, the facility failed to provide dental services for two residents (#5, #40) out of three resident's review for dental services. Findings include: Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed Resident #5 (R5) was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses dementia, depression, depression, Transient Ischemic Attack. R5 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status. On 03/01/26 at 10:00 am, during an interview with R5, he was observed sitting in his room in his wheelchair. R5 complained of mouth pain and was observed to have some missing teeth. R5 reported he's told several staff members that he needed to see dentist again due to the pain but hasn't gotten any response. Review of the Physician order dated 01/07/26 reflected R5 was in need of a referral to oral surgeon, per dentist consult patient #20 tooth pain and causing sore on patient tongue. On 03/02/2026 9:05 AM, during an interview with Social Worker D stated she doesn't handle referrals to an oral surgeon just the routine dental, podiatry. SW D further stated nursing would make those arrangements, possibly the Director of Nursing (DON) but not Social Work. 03/02/2026 9:13 AM during an interview with DON B she reported SW D would have been the one to make arrangements with the oral surgeon or possibly the Nurse Unit Manager who had recently resigned. Documentation was requested at that time and again on 03/05/26 there had been follow up on the Physician order for R5's oral surgeon was requested and not received by the end of the survey dated 3/06/26. Resident #40 (R40) Review of the medical record revealed R40 was admitted to the facility 10/03/2024 with diagnoses that included encephalopathy (a group of conditions that cause brain dysfunction), chronic respiratory failure, chronic obstructive pulmonary disease (COPD), type 2 diabetes, lung cancer, generalized edema (swelling cause by fluid in body tissue), heart disease, hypertension, depression, anemia (low red blood cells), myocardial infarction (heart attack), hyperlipidemia (high fat content in blood), cardiomegaly (enlarged heart), syphilis (an infection caused by bacteria), and cognitive communication deficit. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/2026, revealed R40 had a Brief Interview of Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. During observation and interview on 03/01/2026 at 10:56 a.m. R40 was observed lying down in bed. R40 explained that staff would not give him his dentures. R40 then was observed opening his mouth and demonstrating that he had no teeth or dentures present. R40 explained that he would like to use his dentures. R40 could not explain where his dentures were in the room. No dentures were observed in R40's bedside dresser. Review of R40's medical record revealed that he was currently receiving hospice benefits and was receiving Medicaid Services. Review of R40's medical record had not revealed that R40 had received any dental services. Review of R40's plan of care revealed a intervention, dated 11/25/2025, which stated Dentures: I have dentures, please assist me to ensure that they fit properly and are securely in place. Review of R10''s Kardex (document explaining care that was required to be provide by the bedside direct care givers.) revealed a section entitled Personal Hygiene/Oral Care which stated Dentures: I have dentures, please assist me to ensure they fit properly and a securely in place. In an Interview on 03/02/2026 at 11:09 a.m. Certified Nursing Aide (CNA) U explained that R40 had dentures in the past. CNA U explained that when he had dentures in the past. CNA U explained that he currently had not used his dentures because they were loose fitting and R40 was choking on them. CNA U could not explain where R40's dentures were located. In an interview on 03/02/2026 at 09:55 a.m. Social Worker (SW) D explained that she was responsible for the arrangement of dental services. SW D explained that dental services were provide by a visiting Dentist. SW D explained it was her responsibility to verify if the residents would like ancillary dental services and then provide a list of residents to the visiting dentist. SW D explained that she was not aware that R40 required dental services related to his dentures. SW D confirmed that a consent for dental services was not present in R40's medical record. SW D also confirmed that R40 had not every been seen by a dentist while at the facility. SW D could not explain why R40 had not been provide dental services. In an interview on 03/02/2026 at 10:26 a.m. Director of Nursing (DON) B explained that dental services were coordinated by Social Services. DON B explained that nursing staff could report to Social Services if a resident needed dental services. DON B could not explain why R40 had not received routine dental services or dental services for loose fitting dentures. Review of facility policy entitled Dental Services, implemented 10/17 and last revision date of 06/23, revealed Policy: It is the policy of this facility, in accordance with residents' needs, to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care.

Based on observation, interview and record review, the facility failed to follow Physician Orders for enteral (tube) feeding and accurately document enteral feeding acceptance for one (R1) of one reviewed.Findings include: Review of the medical record reflected R1 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included pneumonia, malignant neoplasm (cancerous tumor) of middle third of esophagus, unspecified severe protein-calorie malnutrition and gastrostomy status (surgical opening into the stomach). The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/30/26, reflected R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and received 51% or more of their total calories through parenteral of tube feeding. On 03/01/2026 at 11:48 AM, R1 was observed in bed, with the head of the bed elevated. They reported receiving bolus tube feeding (specified amount of feeding administered over a brief period of time) via feeding tube. R1 reported they were supposed to receive bolus feedings four times per day but believed the rate of the bolus feedings were too rapid, causing them to experience some diarrhea. On 03/02/2026 at 9:56 AM, R1 was observed lying in bed, with the head of bed elevated and their eyes closed. On 03/03/2026 at 10:16 AM, R1 was observed seated on the edge of their bed. When queried about tolerance of their bolus tube feedings, R1 acknowledged their tolerance had improved, and it was being administered slower, four times daily. A Progress Note for 2/26/26 at 10:08 AM reflected R1 requested to be changed to bolus feeding. The Registered Dietitian (RD) recommended discontinuing the current enteral nutrition order and starting [NAME] Farms Peptide 1.5, one carton (325 milliliters (mL)), four times daily, with a 100 mL water flush before and after. The note reflected the ordered amount provided 2000 kilocalories and 96 grams of protein. The February 2026 Medication Administration Record (MAR) reflected R1's bolus tube feedings were started on 2/26/26. The order reflected R1 was to receive bolus feedings of [NAME] Farms Peptide 1.5, one carton (325 mL), four times daily, with a 100 mL water flush before and after each bolus feeding. The MAR reflected refusal of the evening bolus feedings on 2/26/26, 2/27/26 and 2/28/26. Progress Notes for 2/27/26 at 12:32 PM and 12:33 PM reflected R1 had been requesting half the bolus feeding amount. The MAR reflected bolus feeding was administered as ordered for the afternoon of 2/27/26 and did not include an option to record the actual amount received. A Progress Note for 3/3/26 at 7:29 AM reflected R1 received 50 percent (%) of their morning bolus feeding due to refusing to accept the full amount. R1's March 2026 MAR reflected their bolus tube feeding of [NAME] Farms Peptide 1.5, one carton (325 mL), four times daily, with a 100 mL water flush before and after each bolus feeding was administered as ordered the morning of 3/3/26. The MAR did not include an option to record the actual amount received. In an interview on 03/03/2026 at 10:21 AM, Registered Nurse (RN) G reported R1 had switched from continuous feeding to bolus feeding the week prior. RN G stated R1 had been refusing their bolus feedings and only accepting approximately half of the ordered amount. RN G reported they administered half of R1's ordered bolus feeding that morning, per R1's request. RN G was unsure if the providers knew that R1 was not accepting the full amount of their ordered bolus feedings. A Progress Note for 3/3/26 at 10:58 AM reflected the Nurse Practitioner was notified of R1's acceptance of 50% of their bolus feedings. The note reflected they were advised to offer the bolus feeds as ordered and document the actual intake. In an interview on 03/03/2026 at 12:01 PM, RD H reported after returning from the hospital, R1 wanted to be on shakes or smoothies but was on a clear liquid diet. RD H stated R1 was refusing continuous tube feedings and agreed to bolus feeding. When asked if staff would notify her if R1 was not accepting the full amount of bolus feedings, RD H stated staff would document it. RD H stated if it was happening more continuously, staff should be notifying the provider. On 03/03/2026 at 12:30 PM, RD H reported following up with R1, who was agreeable to trying smaller amounts of the bolus tube feedings, more times per day. RD H stated the last time she was notified of R1's tube feeding acceptance was when R1 wanted to switch to bolus feedings, which was the same day the bolus feedings were started (2/26/26). In an interview on 03/03/2026 at 12:59 PM, RN G reported administering two bolus tube feedings to R1 that day, with acceptance of approximately 50 percent (%). RN G stated the amount of tube feeding accepted was not measured. They stopped administration when R1 requested, and there was approximately 50% of the formula left in the carton. RN G stated they notified the Nurse Practitioner that day, who had not been made aware prior. R1's March 2026 MAR reflected their bolus tube feedings of [NAME] Farms Peptide 1.5, one carton (325 mL), four times daily, with a 100 mL water flush before and after each bolus feeding were administered as ordered on 3/1/26 and 3/2/26. The MAR did not include an option to record the actual amount received. In a phone interview on 03/03/2026 at 1:06 PM, Licensed Practical Nurse (LPN) I reported R1 had only been wanting half a bottle of their tube feeding at a time and was very adamant about not getting more. LPN I reported due to their shift times on 3/1/26, they administered two bolus feedings to R1 that day. LPN I reported R1 had an appointment on 3/2/26 and refused one of their bolus feedings. LPN I stated they administered two bolus feedings during their shift on 3/2/26. When asked about the MAR documentation, which reflected they administered three bolus feedings to R1 on 3/2/26, LPN I reported they must have made an error in their documentation and stated R1 absolutely did not get three bolus feedings on their shift that day. LPN I stated the amount of tube feeding accepted by R1 was not measured but was determined by eyeing and feeling the amount left in the carton. LPN I stated they had not personally notified a provider or the RD of R1's tube feeding acceptance, as they were told it had already been communicated by other nurses. R1's Progress Notes for 3/1/26 and 3/2/26 did not reflect refusal of the full amount of the ordered bolus tube feeding.

Based on observation, interview and record review, the facility failed to provide timely Notice of Medicare Non-Coverage for one (R37) of four reviewed.Findings include: Review of the medical record reflected R37 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included cerebral infarction (stroke). The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/2/26, reflected R37 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 03/02/2026 at 1:36 PM, R37 was observed lying in bed and did not recall receiving notification for the end of Medicare Part A services. R37's Notice of Medicare Non-Coverage document reflected their last covered day of Medicare Part A benefits was 11/18/25. The document was signed with R37's name on 11/17/25. According to the document, .How to ask for an immediate appeal .Ask for the appeal as soon as possible. You must ask for a timely appeal no later than noon of the day before the above date . In an interview on 03/02/2026 at 2:14 PM, Social Worker D reported residents were given 48 hours' notice for Notice of Medicare Non-Coverage. SW D reported they had until noon on the day before the last covered day to file an appeal. SW D acknowledged that R37 was not provided with a 48-hour notice for their Notice of Medicare Non-Coverage.

Based on observation, interview, and record review the facility failed to provide and document evidence of prompt resolution to a grievance for missing personal items of one (resident #16) out of one resident reviewed.Findings Included:Resident #16 (R16)Review of the medial medical record revealed R16 was admitted to the facility 01/02/2026 with diagnoses that included type 2 diabetes, protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), end stage renal disease, pancytopenia (lower than normal red and white blood cells and platelets in blood), nonalcoholic steatohepatitis (fatty liver), cirrhosis of liver (scared and permanently damaged liver), heart failure, gastric ulcer (open sores of stomach lining), esophageal varices (enlarged veins in the esophagus, the tube that connects to throat and the stomach), fractured left femur (upper bone of the leg), fracture left patella (knee cap), fracture left tibia (bone in lower leg), peripheral vascular disease (PVD), gastro-esophageal reflux, thrombocytopenia (low platelet count), and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/2026, revealed R16 had a Brief Interview of Mental Status (BIMS) of 15 (intact cognition) out of 15. During observation and interview on 03/01/2026 at 10:35 a.m. R16 was observed lying in bed. R16 explained that she had lost a shirt at the facility. R16 explained that she had informed Certified Nursing Aide (CNA) Q. R16 explained that staff were unable to find the shirt. R16 explained that staff were going to bring her a Concern Information form but had yet provided it to her. R16 explained that the she had reported the missing shirt the previous week. Review of the facility Grievance Log had not demonstrated that R16 had filed a Concern Information form. In an interview on 03/02/2026 at 11:09 a.m. Certified Nursing Aide (CNA) Q explained that R16 had reported to her that she was missing one pair of pants and two shirts. CNA Q explained that she had located and returned the pants and one shirt to R16. CNA Q explained that she had not completed a Concern Information form for R16's shirt that could not be found. CNA Q explained that the event had occurred the previous week. CNA Q could not explain why she had not completed a Concern Information form or provided one to R16. CNA Q explained that she would complete a Concern Information and provide it to Nursing Home Administrator (NHA) A. In an interview on 03/02/2026 at 11:15 a.m. Nursing Home Administrator (NHA) A confirmed that there were no Concern Information forms for R16. NHA A explained that it was his expectation and the facility policy that a Concern Information form was to be completed for missing clothing. Review of the facility policy Resident and Family Grievances, date of implementation 07/03/2007 and last revised 06/2024, revealed 10. Procedure: b. The staff member receiving the grievance will record the nature and specifics of the grievance on a designated resident assistance form or assist the resident or family member to complete the form. C. Forward the grievance form to the Grievance Officer as soon as possible.

Based on observation, interview, and record review the facility failed to develop and implement comprehensive care plan for three residents (#16,#31,#40) of 16 residents reviewed for care plan development and implementation. Resident #31 (R31) Review of the medical record reflected that R31 was admitted to the facility on [DATE]. Diagnoses of displaced Tri malleolar fracture of right lower leg, history of a stroke, polyneuropathy, obesity and rheumatoid arthritis. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2026 revealed R31 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 needed substantial assistance with showering and personal care. R31 was dependent on toileting, lower body dressing, and perineal hygiene. During an observation and interview on 03/01/2026 at 8:56 AM, R31 stated she doesn't get down to the activities because it took so much to get her up in her wheelchair and taken down there. Writer asked if the activity department brings her things to do in her room and she stated no. No observation of any activity's information, calendar or items visible in her room. During an interview on 03/03/26 at 7:49 AM, Activity Director (AD) AA stated they had four activities daily and the therapy department offers an exercise event on Fridays and everyone is invited. AD AA stated their hours are from 8:15am to 4:45pm. They cover the whole building, assisted living and long-term care. These hours were set up so they could help with breakfast trays in the morning, lunch trays and the dinner tray at the end of their day. First activity is at 9:00am, a word search, or provide one on one room visits, word puzzles, puzzles, crafts, magazines, books, activity is under task. Writer asked AD AA where they document which activities residents attend or the amount of time they spend on the one on ones. AD AA stated they cannot document the amount of time they spend with residents. AD AA added that they stop in the resident's room to check in on them throughout the week. AD AA stated they talk to other staff and if residents complain of being boarded but refuse everything, they note that. AD AA stated works closely with therapy department. Writer asked to look at the activity calendar for February and March. March calendar started out with a TV program first thing in the morning, no documentation on efforts with collaboration after tuning the TV on. Room visits do not reflect what the intent is or what they plan on doing during that visit. Resident Council meetings are listed as an activity. Popcorn cart delivering popcorn to residents was listed. The calendar did reflect an interactive activity with puzzles, church services, kitchen activities, bunco, card games, and crafts on certain days. Saturday activity was a game at 2:00pm and nothing else and Sunday activities were church and a game at 2:00pm. The calendar of events had a lot of times with no activities to do. During an observation and interview on 03/03/2026 at 9:39 AM, no observation of any activity materials visible in R31's room. R31 stated nobody had been in to talk to her about doing things that she would enjoy during her time at the facility. Record review revealed the care plan had a focus on having/offering therapeutic activities that support her rehab goals. R31's goal was to have her participate in leisure activities of interest almost daily. Interventions/task indicated that the following items were important to her including TV programs and news, cell phone use, social media, conversations and visits with family and friends. Please provide room supplies upon her request and encourage her to join groups of interest. The care plan interventions had not been implemented as established on 02/04/2026. Resident #16 (R16) Review of the medial medical record revealed R16 was admitted to the facility 01/02/2026 with diagnoses that included type 2 diabetes, protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), end stage renal disease, pancytopenia (lower than normal red and white blood cells and platelets in blood), nonalcoholic steatohepatitis (fatty liver), cirrhosis of liver (scared and permanently damaged liver), heart failure, gastric ulcer (open sores of stomach lining), esophageal varices (enlarged veins in the esophagus, the tube that connects to throat and the stomach), fractured left femur (upper bone of the leg), fracture left patella (knee cap), fracture left tibia (bone in lower leg), peripheral vascular disease (PVD), gastro-esophageal reflux, thrombocytopenia (low platelet count), and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/2026, revealed R16 had a Brief Interview of Mental Status (BIMS) of 15 (intact cognition) out of 15. During observation and interview on 03/04/2026 at 09:15 a.m. R16 as observed lying down in bed. R16 explained that she had an open area on her bottom. R16 could not explain if the open area was present upon admission or if it was acquired at the facility. R16 explained that the open area had been improving. Review of R16's medical record revealed a document entitled Admission/readmission Assessment-V2.2, completion date of 02/11/2026, revealed: site: 31) right buttock, Type: open area, length: (blank), and width: (blank). Review of document entitled Weekly Skin Sweep, effective date of 02/15/2026, revealed: Site: 23) Coccyx, Description: open area measured 2cm(centimeters) length and 0.5cm with. and Site: 32) Left buttock, Description: open area 2cm length by 2cm width. Review of document entitled Weekly Skin Sweep, effective date of 03/01/2026, revealed: Site: 53) Sacrum, Description: open area-treatment applied. R16's medical record did not contain any documentation entitled Wound Assessment V2.1 (document completed weekly to include measurements and staging of wounds). R16's medical record did not contain any documentation of the wound by the attending physician. Review of R16's medical record did not demonstrate that the wound had been included in her Plan of Care. Review of R16's medical record revealed a physician order, initiated 02/15/2026 and to start 02/16/2025), which stated, clean coccyx and right buttocks with normal saline. Then apply hydrophilic sound ointment to wound bed and cover with foam dressing change daily and PRN (as needed) in the afternoon for wound care. On 03/04/2026 at 09:17 a.m. R16 was observed lying down in bed. Licensed Practical Nurse (LPN) S was observed explaining dressing procedure to R16. R16 was rolled to her left side with the assistance of Certified Nursing Aide (CNA) T. R16's brief was removed and no dressing was observed on R16's bottom. LPN S proceeded to cleanses R16's open wound, which was located to the left of her coccyx, with normal saline. After cleansing of wound Director of Nursing (DON) B performed measurements of the wound. R16's open wound to the left of her coccyx was observed to be 1.4cm (centimeters) in length, 1.0 cm in width, and 0.1cm in depth. The wound bed was observed to be red with granulation tissue present. DON B verbalized that R16's wound was a stage 2 pressure ulcer. LPN S was then observed to apply hydrophilic wound ointment to wound bed and covered the wound with a foam dressing. In an interview on 03/04/2026 at 10:04 a.m. Director of Nursing (DON) B explained that residents are assessed upon admission, and a complete skin assessment was completed within 24 hours. DON B explained that if a wound was present measurements would be recorded and a description of the wound be recorded. DON B explained that if the assessing nurse was a Registered Nurse then the wound would be staged appropriately. DON B explained that the attending physician would be contacted and a treatment order would be obtained. DON B explained that if a current resident was found to have any skin wounds that she was to be notified and she would ensure that the assessment was completed, the treatment was initiated, and the physician would view the wound and document appropriately. DON B explained that it was facility policy that skin sweeps are to be completed weekly. DON B explained if a resident had a skin wound that a Wound Assessment V2.1 document would be completed weekly. DON B explained that residents with skin issues and/or open wounds would be included in their plan of care. DON B confirmed that R16 did not have a treatment order for her wound until 02/16/2026. DON B confirmed that R16 did not have a Weekly Skin Sweep document completed weekly. DON B confirmed that R16 did not have a Wound Assessment document completed when R16's wound was identified or completed weekly. DON B confirmed that R16's medical record had not revealed that the attending physician had recorded any documentation regarding R16's wound, progression of the wound, or treatment of the wound. DON B confirmed that R16's Care Plan did not include her stage 2 pressure ulcer or interventions to prevent or assist in the healing of the wound. Resident #40 (R40) Review of the medical record revealed R40 was admitted to the facility 10/03/2024 with diagnoses that included encephalopathy (a group of conditions that cause brain dysfunction), chronic respiratory failure, chronic obstructive pulmonary disease (COPD), type 2 diabetes, lung cancer, generalized edema (swelling cause by fluid in body tissue), heart disease, hypertension, depression, anemia (low red blood cells), myocardial infarction (heart attack), hyperlipidemia (high fat content in blood), cardiomegaly (enlarged heart), syphilis (an infection caused by bacteria), and cognitive communication deficit. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/2026, revealed R40 had a Brief Interview of Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. During observation and interview on 03/01/2026 at 10:56 a.m. R40 was observed lying down in bed. R40 explained that staff would not give him his dentures. R40 then was observed opening his mouth and demonstrating that he had no teeth or dentures present. R40 explained that he would like to use his dentures. R40 could not explain where his dentures were in the room. No dentures were observed in R40's bedside dresser. Review of R40's medical record revealed that he was currently receiving hospice benefits and was receiving Medicaid Services. Review of R40's medical record had not revealed that R40 had received any dental services. Review of R40's plan of care revealed a intervention, dated 11/25/2025, which stated Dentures: I have dentures, please assist me to ensure that they fit properly and are securely in place. Review of R10''s Kardex (document explaining care that was required to be provide by the bedside direct care givers.) revealed a section entitled Personal Hygiene/Oral Care which stated Dentures: I have dentures, please assist me to ensure they fit properly and a securely in place. In an Interview on 03/02/2026 at 11:09 a.m. Certified Nursing Aide (CNA) U explained that R40 had dentures in the past. CNA U explained that when he had dentures in the past. CNA U explained that he currently had not used his dentures because they were loose fitting and R40 was choking on them. CNA U could not explain where R40's dentures were located. In an interview on 03/02/2026 at 10:26 a.m. Director of Nursing (DON) B explained that it was her expectation that nursing staff would follow a resident's plan of care. DON B also explained that it was her expectation that a residents plan of care would be updated as necessary. DON B confirmed that R40's plan of care included a intervention, dated 11/25/2025, which stated Dentures: I have dentures, please assist me to ensure that they fit properly and are securely in place. DON B confirmed that R40's Kardex revealed a section entitled Personal Hygiene/Oral Care which stated Dentures: I have dentures, please assist me to ensure they fit properly and a securely in place. DON B could not explain why R40's plan of care was not being followed by the nursing staff.

Based on observation, interview and record review, the facility failed to update/implement revisions for one resident (resident #46) and failed to ensure one resident (resident #7) along with resident #7's legal representative was afforded the opportunity to participate resident #7's care conference. Findings include: Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was admitted to the facility on [DATE] with diagnoses that include dementia. R7 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Further review of the clinical record revealed R7 had an activated Durable Power of Attorney (DPOA) for health care in place. On 03/01/2026 at 10:36 AM, during an interview R7's DPOA expressed concern about lack of being informed and updated on R7's status. R7's DPOA further reported they lived out state and was originally told care conferences were held approximately every 90 days, but this had not been occurring. On 03/02/2026 11:12 AM, during an interview with Social Worker (SW) D she reported she was responsible for arranging and inviting participants to care conference and further stated activated DPOA's would be included. SW D further stated care conferences were held within 72 hours, and then coinciding with the MDS/quarterly thereafter, and if residents or families opt not to participate the interdisciplinary team would still meet and discuss the residents plan of care and document the meeting/care conference in the residents' medical record. R7's medical record was reviewed with SW D completed with SW D who agreed R7's quarterly MDS dated [DATE] did not have a coinciding care conference. SW D offered no explanation as to why a care conference was not held in February 2026. Resident 46 (R46) Review of the medical record reflected R46 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included acute respiratory failure with hypoxia, diabetes and acquired absence of the left leg, below the knee. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/12/26, reflected R46 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was at risk of developing pressure ulcers/injuries. On 03/03/2026 at 3:28 PM, R46 was observed lying in bed, on their back, on a standard mattress. A wheelchair, at the right bedside, was noted to have a seating cushion in place. R46 stated before their initial admission to the facility, they had a rash on their bottom. R46 acknowledged a dressing was in place, on their bottom, which was changed the night prior. To R46's knowledge, the skin was not open or draining. An Admission/readmission Assessment, dated 2/6/26, reflected non-blanchable (skin color does not fade when pressed on) redness to R46's sacrum. A Nurse Practitioner Progress Note for 2/7/26 reflected, .Wound coccyx dressing order placed . R46's Care Plan, with a revision date of 1/15/26, reflected they were at risk for impaired or worsening skin integrity related to a healed scar and blanchable redness on the coccyx. In an interview on 03/04/2026 at 10:04 AM, Director of Nursing (DON) B reported at the time of readmission from the hospital, on 2/6/26, R46 had non-blanchable redness on the sacrum, which indicated a stage one pressure ulcer was present. DON B acknowledged R46's Care Plan was not updated to reflect the presence of non-blanchable redness and still read as blanchable redness.

Based on interviews and record reviews, the facility failed to provide person centered care to two dependent residents (R31, R55) out of three residents investigated for ALD's.Findings Include Resident #31 (R31) Review of the medical record reflected that R31 was admitted to the facility on [DATE]. Diagnoses of displaced Tri malleolar fracture of right lower leg, history of a stroke, polyneuropathy, obesity and rheumatoid arthritis. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2026 revealed R31 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 needed substantial assistance with showering and personal care. R31 was dependent on toileting, lower body dressing, and perineal hygiene. During an observation and interview on 03/01/2026 at 8:57 AM, R31stated she had only received 1 shower since admission of 02/03/2026. R31 was in her hospital gown, hair was messy, matted in the back of her head. R31 stated she washed her hair a couple times a week at home before coming to the facility and she had not had her hair washed for more than a week. During an interview on 03/02/2026 at 12:02 PM, CNA C stated they were able to get the residents showered, assist with brushing their teeth, wash their hands and face. CNA C stated if a resident refuses a shower, she would ask the resident 2 times and then let the nurse know. CNA C stated they do situations where the food trays come to the floor and it sit there until care is given. CNA C stated there is one CNA on this hall and she had three residents that are 2 person assist, so she would have to wait for someone from another call can help her transfer them. Record review revealed R31 has had 3 bed baths in the last 30 days, but preferred showers. Record review did not have any refused shower or bath documentation. Care plan revealed R31 reported it was important for her to choose between a tub bath, shower or bed bath. Shower/Bathing/Bed Bath Scheduled- twice a week (Tuesday and Friday) and as needed. R31 did not receive her scheduled showers as scheduled. During an interview on 03/02/2026 at 9:49, CNA Z and CNA Z stated sometimes they could meet resident's needs, they would ask other coworkers for help or schedule the showers on Saturday, because no showers are scheduled on Saturdays, only Sunday through Friday. If a resident refused, they would ask them 3 times if they want a shower and if they still refuse, then they tell the nurse. First thing they do on their shift is to get vital signs for the nurse, pass waters, pass breakfast trays, then get residents up for the day. CNA Z stated if therapy asked for residents to be up and around for therapy, they are put on the priority list and get up first. Both CNAs reported they have been mandated a lot in the last 6 weeks, and they do the best they can. Writer asked them if they know why R31 had not had a shower since her admission on [DATE], only 3 bed baths in the last 30 days? CNA Z stated she did not know, maybe she refused them. Writer asked if the resident refused, where would they document that? CNA Z stated it should be in the progress notes in their chart. Writer reported there was nothing in her chart/electronic medical record (EMR) stating she refused any showers. CNA's looked at each other and stated they didn't know then. Resident #55 (R55) Review of the medical record reflected R55 admitted to the facility on [DATE], with diagnoses that included lumbar region discitis (inflammation/swelling between spinal vertebrae), and sepsis due to Group B streptococcus (a type of bacteria). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/26/26, reflected R55 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and required substantial/maximal assistance for showering/bathing and tub/shower transfers. According to the MDS, substantial/maximal assistance meant, Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. On 03/01/2026 at 11:24 AM, R55 was observed seated in a standard chair, in their room. R55 reported they had not received a shower at the facility. R55 reported asking for a shower a couple times and being told it was not their shower day. On 03/02/2026 at 10:13 AM, R55's Certified Nurse Aide (CNA) task documentation for scheduled shower/bathing/bed bath twice a week and as needed was reviewed and reflected documentation of a refusal on 2/27/26 at 9:59 PM. There was no further documentation pertaining to offered bathing or showers. R55's Activities of Daily Living (ADL) Care Plan reflected interventions for 2/20/26 that included it was important to R55 to choose between a tub bath, shower or bed bath and for scheduled shower/bathing/bed bath twice weekly and as needed. In an interview on 03/02/2026 at 1:27 PM, CNA E reported R55 was scheduled for showers on second shift, on Tuesday's and Friday's. CNA E reported they had heard from some residents that they did not receive their scheduled showers on second shift. On 03/02/2026 at 1:39 PM, CNA E reported showers were documented in the CNA task charting for showers/bathing and on shower sheets. On 03/02/2026 at 1:42 PM, R55's shower sheets, since admission, were verbally requested from Director of Nursing (DON) B. On 03/02/2026 at 3:46 PM, DON B reported she could not find shower sheets for R55. DON B reported staff should have filled out a shower sheet and completed task documentation. DON B stated she reviewed R55's shower task and only noted documentation for a refusal for 2/27/26.

Based on observation, interviews and record review, the facility failed to provide meaningful activities to one resident (R31) out of one resident investigated.Findings IncludeResident #31 (R31)Review of the medical record reflected that R31 was admitted to the facility on [DATE]. Diagnoses of displaced Tri malleolar fracture of right lower leg, history of a stroke, polyneuropathy, obesity and rheumatoid arthritis.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2026 revealed R31 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 needed substantial assistance with showering and personal care. R31 was dependent on toileting, lower body dressing, and perineal hygiene.During an observation and interview on 03/01/2026 at 8:56 AM, R31 stated she doesn't get down to the activities because it took so much to get her up in her wheelchair and taken down there. Writer asked if the activity department brings her things to do in her room and she stated no. No observation of any activity's information, calendar or items visible in her room.During an interview on 03/03/26 at 7:49 AM, Activity Director (AD) AA stated they had four activities daily and the therapy department offers an exercise event on Fridays and everyone is invited. AD AA stated their hours are from 8:15am to 4:45pm. They cover the whole building, assisted living and long-term care. These hours were set up so they could help with breakfast trays in the morning, lunch trays and the dinner tray at the end of their day. First activity is at 9:00am, a word search, or provide one on one room visits, word puzzles, puzzles, crafts, magazines, books, activity is under task. Writer asked AD AA where they document which activities residents attend or the amount of time they spend on the one on ones. AD AA stated they cannot document the amount of time they spend with residents. AD AA added that they stop in the resident's room to check in on them throughout the week. AD AA stated they talk to other staff and if residents complain of being boarded but refuse everything, they note that. AD AA stated works closely with therapy department. Writer asked to look at the activity calendar for February and March.March calendar started out with a TV program first thing in the morning, no documentation on efforts with collaboration after tuning the TV on. Room visits do not reflect what the intent is or what they plan on doing during that visit. Resident Council meetings are listed as an activity. Popcorn cart delivering popcorn to residents was listed. The calendar did reflect an interactive activity with puzzles, church services, kitchen activities, bunco, card games, and crafts on certain days. Saturday activity was a game at 2:00pm and nothing else and Sunday activities were church and a game at 2:00pm. The calendar of events had a lot of times with no activities to do.During an observation and interview on 03/03/2026 at 9:39 AM, no observation of any activity materials visible in R31's room. R31 stated nobody had been in to talk to her about doing things that she would enjoy during her time at the facility.Record review revealed the care plan had a focus on having/offering therapeutic activities that support her rehab goals. R31's goal was to have her participate in leisure activities of interest almost daily. Interventions/task indicated that the following items were important to her including TV programs and news, cell phone use, social media, conversations and visits with family and friends. Please provide room supplies upon her request and encourage her to join groups of interest.State Operations Manual defines. Activities refer to any endeavor, other than routine ADLs, in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence.

Based on observation and interview, the facility failed to ensure the daily nurse staffing information was accurately posted for each shift in accordance with State Operations Manual, Appendix PP. Findings include: The facility staffing that was observed posted on 03/01/2026 09:10 AM was dated 2/27/26. On 03/03/2026 at 10:43 AM, during an Interview with Director of Nursing (DON) B stated new scheduler should have put posted the staffing for the weekend on Friday before she left. When queried how that could be done i.e., residents being transferred to the hospital, discharged home, staff call ins etc . It was queried who was responsible for the posting on the weekends. DON B stated she would have to review and then devise a plan.

Based on interview and record review, the facility failed to treat two (R202, R204) of five residents reviewed with dignity and respect.Findings include:This citation pertains to intake 2726697R202Review of the clinical record revealed R202 was admitted into the facility on 9/25/25 with diagnoses that included: Alzheimer's disease, depression, and anxiety. According to the Minimum Data Set (MDS) assessment dated [DATE], R202 scored 8/15 on the Brief Interview for Mental Status exam (which indicated moderately impaired cognition).On 1/27/26 at 3:06 PM R202 was observed sitting up in his wheelchair. R202 reported feeling tired and answered questions appropriately.A review of the Facility Reported Incident file pertaining to R202, the facility administrator was notified of inappropriate language being used by LPN G with R202, after an unwitnessed fall on 1/8/26. It also revealed the following witness statements:LPN G: I was called to room (room number redacted) because the resident was on the floor. I went into the room and observed the resident lying on the mat beside his bed. I then left to get the Hoyer lift to assist the resident off of the floor. After I got the Hoyer lift when returning to the resident room, I made the statement that he does this sh*t every night. I did not make the statement to the resident; I made the statement in the hallway as I was approaching the entrance to the resident room.CNA F: .The nurse (LPN G) was coming into the room and she stated that every night you keep doing this shit. It was not said in a mean way. The resident said to the nurse I'm just an *sshole.RN E: (RNE) reported that LPN G had stated to resident in a harsh and annoyed tone I am sick of this sh*t, you fall all the timeIn an interview with LPN G on 1/28/26 at 9:18 AM, it was reported that R202 frequently falls and on 1/8/26 he had been throwing stuff on the floor and repeated to me that he was an *sshole. LPN G denied saying anything inappropriate to R202.In an interview with CNA F on 1/28/26 at 12:36 PM, it was reported that after R202 had fallen, LPN G asked R202 Why do you keep doing this sh*t? and that LPN G kept asking R202 why he was on the floor to which R202 replied because he was an *sshole.In an interview with RN E on 1/27/26 at 2:04 PM, it was reported that LPN G had entered R202's room after a fall and was heard saying to the resident that she was sick of this sh*t, your *ss is always on the God d*mn floor, this is bullsh*t and that R202 responded by apologizing and calling himself an *sshole. R204Review of the clinical record revealed R204 was admitted into the facility on [DATE] with diagnoses that included: Respiratory failure and heart disease. According to the Minimum Data Set (MDS) assessment dated 1/26/26, R204 scored 13/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).Review of Intersect Healthcare Resident Assistance Form (facilities grievance form) revealed on 1/23/26 R204 reported the following concerns: Nurse (LPN G) has a very bad attitude. Told me to stay in my room. No response for drug request. Very snotty.During an observation and interview on 1/28/26 at 9:49 AM, R204 was observed lying in bed. R204 reported that one night a resident across the hall had fallen, was calling out for help and after approximately 15 minutes R204 got in her wheelchair to go get help. She found a CNA and notified them, as she was headed back to her room LPN G told her to go back to her room multiple times and enough is enough. R204 reported this made her feel angry.A review of the facilities policy titled Resident Rights documented in part The resident has a right to be treated with respect and dignity.

Based on observations, interviews, and record reviews the facility failed to: (1) effectively clean and maintain food service equipment, and (2) date mark all potentially hazardous ready-to-eat food products effecting 39 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 12/10/24 at 07:35 A.M., An initial tour of the food service was conducted with Director of Food and Nutrition Services D and Dietary [NAME] L. The following items were noted: The ceiling surface was observed (etched, scored, particulate), adjacent to the pot and pan storage rack. The damaged ceiling surface measured approximately 6-inches-wide by 12-inches-long. The damaged ceiling surface also contained a black watery substance, within the opening. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. The South Bend convection oven interior surfaces were observed soiled with accumulated and encrusted food residue. The South Bend stove/oven(s) were observed soiled with accumulated and encrusted food residue. The South Bend stove/oven backsplash was also observed soiled with accumulated and encrusted food residue. The South Bend griddle side panels and backsplash were also observed soiled with accumulated and encrusted food residue. The South Bend char broiler was observed soiled with accumulated and encrusted food residue. The ventilation hood filters were observed soiled with accumulated and encrusted food residue, especially directly above the South Bend char broiler. The can opener assembly was observed soiled with accumulated and encrusted food residue. Director of Food and Nutrition Services D stated: I will have staff clean the opener. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Walk-In Cooler: One full case (six 32-ounce containers) of Yoplait Natural Yogurt was observed resting upon a rack with a manufacturer's use-by-date that read 11-24-2024. Director of Food and Nutrition Services D indicated she would remove and discard the outdated case of Yoplait Natural Yogurt immediately. The 2017 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The mechanical dish machine wash temperature gauge was observed to read 127-128 degrees Fahrenheit during the wash cycle. The wash temperature gauge should read a minimum of 150 degrees Fahrenheit. The 2017 FDA Model Food Code section 4-501.110 states: (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than: (1) For a stationary rack, single temperature machine, 74oC (165oF); (2) For a stationary rack, dual temperature machine, 66oC (150oF); (3) For a single tank, conveyor, dual temperature machine, 71oC (160oF); or (4) For a multitank, conveyor, multitemperature machine, 66oC (150oF). The final rinse temperature gauge was observed to read 164 degrees Fahrenheit during the final rinse cycle. The dishware surface was monitored utilizing Paper Thermometer 1-Temp Thermolabel. The Paper Thermometer 1-Temp Thermolabel was observed to not turn black, indicating the dishware surface did not reach a minimum of 160 degrees Fahrenheit for effective hot water sanitization. The 2017 FDA Model Food Code section 4-501.112 states: (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90oC (194oF), or less than: (1) For a stationary rack, single temperature machine, 74oC (165oF); or (2) For all other machines, 82oC (180oF). On 12/10/24 at 09:05 A.M., An initial tour of the facility kitchenettes was conducted with Director of Food and Nutrition Services D. The following items were noted: Town Square Kitchenette: The General Electric refrigerator/freezer interior and exterior surfaces were observed soiled with accumulated food residue and dust/dirt deposits. Director of Food and Nutrition Services D indicated she would have staff thoroughly clean and sanitize the General Electric refrigerator/freezer interior and exterior surfaces as soon as possible. 200 Hall Kitchenette: The General Electric microwave oven interior was observed (etched, scored, particulate). Director of Food and Nutrition Services D indicated she would contact maintenance for removal and replacement as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 12/13/24 at 01:00 P.M., Record review of the Policy/Procedure entitled: Cleaning Equipment and Utensils dated 01/2024 revealed under Policy: Equipment and utensils will be properly cleaned and sanitized to prevent contamination. Record review of the Policy/Procedure entitled: Cleaning Equipment and Utensils dated 01/2024 further revealed under Purpose: Safe food handling and minimize the risk of cross-contamination. On 12/13/24 at 01:15 P.M., Record review of the Policy/Procedure entitled: Food Storage dated 01/2021 revealed under Policy: Food storage areas shall be maintained in a clean, safe, and sanitary manner. This includes maintaining temperatures of coolers and freezers at the appropriate temperature to promote food safety. Record review of the Policy/Procedure entitled: Food Storage dated 01/2021 further revealed under Policy Explanation and Compliance Guidelines: (3) Refrigerated food outside of original package shall be labeled, dated, and monitored so that it is used by the use-by-date, frozen, or discarded, whichever is applicable. (b) Milk received and unopened will be stored according to manufacturer's use-by/expiration date. Once opened will be labeled with open and use-by-date, but not to exceed expiration date. On 12/13/24 at 01:30 P.M., Record review of the Policy/Procedure entitled: Dish Machine Usage dated 01/05/2021 revealed under Policy: Dietary staff will operate the dish machine in safe and sanitary manner. Record review of the Policy/Procedure entitled: Dish Machine Usage dated 01/05/2021 further revealed under Procedure: If high temperature machine: (1) Dietary staff will check dish machine temperatures before running dishes through the machine. (2) Wash temperature of 150 degrees Fahrenheit. (3) Hot water sanitizing rinse temperature of 180 degrees Fahrenheit. (4) Dietary staff will check temperatures using the machine gauge and will record the results in a facility approved log. (5) The operator will monitor the gauge frequently during dish machine cycle. On 12/13/24 at 01:45 P.M., Record review of the Policy/Procedure entitled: Food Dating dated (no date) revealed under Dairy: Use-By or Best By date if unopened on packaging. Milk, Yogurt, Cottage Cheese, Potato Salad: Use-By date if unopened, or 7 days after opening. On 12/13/24 at 02:00 P.M., Record review of the High-Temp Dish Machine Log dated 12/2024 revealed 3 out of 7 recorded Paper Thermometer 1-Temp Thermolabel tapes did not turn black, indicating the final rinse temperature at the dishware surface was less than 160 degrees Fahrenheit.

This citation pertains to intake MI00140359. Based on interview and record review, the facility failed to prevent and treat pressure ulcers, in 2 of 3 residents reviewed for pressure ulcers (Resident #1 & #2), resulting in worsening of pressure ulcers (Resident #1), multiple facility acquired pressure ulcers (Resident #1) and pain (Resident #2). Findings include: Resident #1 (R1) Progress Note dated 9/25/23 at 11:42 AM revealed prior to her hospitalization and admission to the nursing home, she was independent at home and lived alone. R1 was evaluated in the emergency room for back pain and paralysis in her lower extremities. R1 had a bone infection in her spine, underwent surgery on 8/22/23, and received treatment for her infection during her hospitalization . In review of R1's Discharge Summary and Discharge instructions dated 8/31/23, she was to change positions about every 30 to 60 minutes while sitting, standing, or lying; avoid reaching, and logroll to the side to get out of bed. R1's discharge instructions also instructed No Bending Lifting Twisting; no Pushing and Pulling for approximately 6 to 12 weeks. Discharge instructions dated 8/31/23 indicated R1 was to receive intravenous antibiotic medications during her nursing home stay. Nurse Progress Note dated 8/31/23 revealed R1 was admitted to the facility at 11:15 AM, was bed bound due to lack of sensation from the waist down. Admission assessment dated [DATE] at 1:27 PM revealed R1 was admitted with a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed without slough [yellow, tan, gray, green or brown devitalized tissue]) on her right buttock that was 2.2 centimeters (cm) in length by 0.5 cm in width, and depth was not measured/documented. The same assessment included care planning; R1's care plan did not include hospital instructions of changing positions every 30 to 60 minutes, log roll, or No Bending Lifting Twisting; no Pushing and Pulling restrictions. R1's same admission assessment included a Braden assessment (standardized, evidence-based assessment tool used to determine Pressure Ulcer/Injury Risk; six risk factors were rated on a scale from 1 to 4, with 1 being completely limited and 4 being no impairment; total score of less than 9 indicated a severe risk for skin breakdown, total score of 10 to 12 indicated a high risk, a total score of 13 to 14 indicated a moderate risk and a score 15 to 18 revealed a mild risk of skin breakdown). R1's score was 14, a moderate risk for skin breakdown. The same Braden assessment, under sensory perception, indicated R1 had the ability to respond meaningfully to pressure-related discomfort; and was a score of 4. The same assessment, under nutrition revealed R1 had a score of 4 (Eats most of every meal, never refused a meal, usually ate a total of 4 or more servings of meat and dairy products, occasionally ate between meals, and did not require supplementation). R1's Minimum Data Set (MDS) assessment with assessment reference date of 9/06/23 revealed R1 had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive assessment, score of 15 (13-15 Cognitively Intact) and was admitted with one stage II pressure ulcer. Registered Dietitian (RD) note dated 8/31/23 at 1:42 PM revealed R1 was at risk for weight changes related to poor appetite and fluid shifts (swelling). R1's Baseline care plan, signed by R1 and dated 9/01/23 revealed that she had a Braden score of 19 (no risk). The same care plan did not instruct R1 to change positions about every 30 to 60 minutes while sitting, standing, or lying; avoid reaching, to log roll to get out of bed, or No Bending Lifting Twisting; no Pushing and Pulling restrictions. R1's care plans dated 8/31/23 indicated she was at risk for impaired skin integrity related to intraspinal abscess (pus-filled blister between the spinal cord and backbone), granuloma (tiny lump of immune cells that form when the body tries to fight off an infection, inflammation, or foreign object) and limited range of motion (ROM) due to lower extremity paralysis, surgical incision, weakness and deconditioning and wounds. R1's goal was to not have further skin breakdown. The same care plan had an intervention dated 9/25/23 to assist to turn and/or reposition routinely during certified nurse assistant (CNA) rounds while in bed and frequently redistribute weight if/when up in the chair. Wound assessment dated [DATE] at 12:11 PM revealed R1 developed a new Stage II pressure ulcer on her right groin that was 3.5 cm by 3.4 cm, and depth was left blank. The same assessment revealed R1's pressure ulcer on her right buttock increased in size from admission (2.2 cm by 0.5 cm) to 7.5 cm by 2.5 cm and depth was left blank. R1 developed a facility acquired stage II pressure ulcer on her left gluteal fold that was 2.0 cm in length by 3.0 cm width, the depth was left blank. No other information regarding the wound base, drainage, or periwound (skin around the wound) was documented. Wound assessment dated [DATE] revealed R1's stage II pressure ulcer on her left gluteal fold increased in size to 3.0 cm by 3.5 cm, depth was left blank. The same form indicated the pressure ulcer on R1's left gluteal fold was not new; however, there was no left gluteal fold pressure ulcer documented on the admission assessment or wound assessment on 9/08/23. The same assessment revealed R1 had an unstageable pressure ulcer (wound bed was covered by over 80 percent (%) of devitalized tissue and depth could not be determined) on the coccyx (tailbone) that was not new, measured 8.0 cm in length by 9.0 cm in width; and the wound bed consisted of 100 % slough. The same assessment indicated R1 had a stage II pressure ulcer to her left gluteal fold inferior, that was 0.5 cm by 2.5 cm. There was not information on the 9/19/23 assessment regarding R1's pressure ulcers on her right buttock or right groin. Wound assessment dated [DATE] revealed R1's coccyx continued to be unstageable, measured 4.0 cm by 10 cm; and the wound bed was covered with 20% slough and 80% eschar (collection of dead tissue in wound bed that can be tan, black, or brown) and the wound edges were macerated (skin soft, soggy or wet to the touch). The same assessment revealed R1's right lower buttock was a stage II and was 5.0 cm by 3.5 cm and the depth was 0.5 cm; and the wound bed consisted of 20 % granulation tissue (red tissue with cobblestone or bumpy appearance; bleeds easily when injured) and 80 % slough. There was not information on the 9/29/23 assessment regarding R1's pressure ulcers on her right groin or left gluteal fold. Physician Progress note dated 10/04/23 at 9:40 AM indicated R1's wounds were evaluated; coccyx wound had tan slough, superior portion with tunneling present, inferior portion with less slough and beef red wound bed. R1's left gluteal fold wound had tan slough, and some of the wound bed was beefy red with tan colored drainage. The same note indicated the plan was to increase dressing changes from daily to twice a day and a wound clinic consult. Licensed Practical Nurse/Unit Manager/Wound Nurse (WN) C was interviewed on 10/26/23 at 2:03 PM and stated Braden Assessment tools were not reviewed by the interdisciplinary team for accuracy. WN C was interviewed regarding the accuracy of the Braden Assessment tool completed for R1 on 8/21/23; and stated the assessment was probably inaccurate. WN C stated that she didn't find a physician statement indicating R1's facility acquired pressure ulcers were unavoidable. WN C stated in the same interview she assessed wounds every week, but could not explain why there was no assessment of R1's right buttock pressure ulcer from 9/09/23 to 9/28/23. WN C stated she did not know if a stage II pressure ulcer characteristics included granulation and slough. WN C did not know why wound documentation on 9/13/23 didn't include description of the wound bed. WC C stated she had been pulled several times to the floor nurse position due to staffing levels. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.18.11, October 2023, manual, indicated stage II pressure ulcers may worsen without proper interventions. Stage II pressure ulcers by definition have partial thickness loss of the dermis; granulation tissue, slough, and eschar would not present in Stage 2 pressure ulcers. The same reference indicated the comprehensive care plan should be reevaluated to ensure that appropriate preventative measures and pressure ulcer/injury management principles were being adhered to when new pressure ulcers/injuries develop or when existing pressure ulcers/injuries worsen. MDS dated [DATE] revealed R1 was admitted to the hospital and discharged from the facility. 48637 Resident #2 (R2) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R2 admitted to the facility on [DATE] and had diagnoses of pneumonia, diabetes, chronic kidney disease, and high blood pressure. Brief Interview for Mental Status (BIMS) score was an 8 which indicates her cognition was moderately impaired (8-12 moderately impaired). Review of resident chart revealed she was admitted with a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) to her left buttocks on 10/13/2023. On 10/26/2023 at 9:45 AM, R2 wasn't in her room and it was observed that she didn't have an alternating pressure mattress on her bed or a seat cushion in her recliner. During an interview on 10/26/2023 at 12:45 PM, R2 was sitting in her recliner. R2 reported that she has a wound on her bottom in the crease and it hurts. It was observed that there wasn't a seat cushion underneath her on top of the recliner. Review of R2's care plan indicated that an individualized turning schedule and repositioning in her reclining chair was not implemented. Specific interventions of her pressure area related to putting an alternating pressure mattress on her bed or a seat cushion on her recliner were also not in the care plan. During an interview on 10/26/2023 at 3:10 PM, Wound nurse, (WN) C stated that R2 did not have interventions of a seat cushion or alternating pressure mattress. She (WN C) said that they didn't put it in yet and they will get it in place. When asked how soon they put an intervention in place when a resident has a pressure ulcer, WN C stated that they try to put it in as soon as they can since residents with pressure ulcers were discussed daily Monday to Friday during their interdisciplinary team meetings and clinical meetings.

This citation pertains to MI 452 Based on observation, interview and record review the facility failed to: 1.) ensure the safety, 2.) implement care-planned and non-care-planned interventions, 3.) ensure that those interventions were functional and in place for 2 of 4 sampled residents (R201 and R202) reviewed for falls and accidents from a total sample of 4 residents, resulting in R201's third fall in four days with right [MEDICAL CONDITION] on 7/13/19 and R202's unwitnessed fall behind a locked, non resident door, with the increased likelihood for harm and/or injury. Findings include: Review of the facility Fall Management Program Guidelines Policy and Procedure, dated 5/22/18, reflected, PURPOSE (company name) strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures .PR[NAME]EDURE: 1. The fall risk assessment is included as part of the Admission and Quarterly Nursing Observation and other Events/Observation in EHR: a. Identified risk factors should be evaluated for the contribution they may have to the resident's likelihood of falling. b. Care plan interventions should be implemented that address the resident ' s risk factors. 2. Should the resident experience a fall the attending nurse shall complete the Fall Event This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions .5. The resident care plan should be updated to reflect any new or change in interventions. 6. Nursing staff will monitor and document continued resident response and effectiveness of interventions for 72 hours. 7. Discuss risks and interventions with resident and/or responsible party and communicate interventions during shift report . Resident #201(R201) Review of the Face Sheet, reflected R201 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Facility Reported Incident, dated 7/13/19 at 1:26 p.m., reflected, Resident (R201) found in room on floor next to bed. Apparent self-transfer. Transported to hospital for evaluation. When nurse called hospital 7/14/19 to check on resident he was told she had a fracture of her right femur . The Facility Reported Incident Summary included staff interviews in a summary format with no details including times of interviews, location of staff on duty at time of the fall. The summary reflected statements that residents on hall 300 were interviewed for care and services(no interview documents, who, when, responses were included with investigation). During an interview on 10/23/19 at 12:05 p.m., both ADM A and DON B, reported the Electronic Medical Record included the complete investigation for R201's fall on 7/13/19. ADM A and DON B reported there was no additional information including no written staff interviews for R201 facility reported incident on 7/13/19. Review of the facility Event Report, dated 7/13/19 at 1:24 p.m., reflected R201 had an unwitnessed fall in room with right hip pain of nine out of ten pain. The Event Report reflected R201 had an abrasion to the right cheek and R201 was unable to move or complete Range of Motion of right lower extremity with positive rotation, deformity, shortening of the right lower extremity with suspected fracture. The Report reflected R201 had a fall risk re-assessment that reflected, Resident requires us of an assistive device and/or often forgets to use device .Resident requires assistance to transfer .Resident requires assistance to ambulate safely with or without assistive device . The report reflected R201 was sent to the emergency room for evaluation immediately. The reported included an evaluation that included R201 had a fall that resulted in a fracture, resident was sent to hospital and did not return, incident was reported to state agency, and fall resulted in serious injury, harm, impairment, or death to resident. Review of the Nursing Progress Notes, dated 7/10/2019 at 8:02 p.m., for R201, reflected, Attempted to transfer self from chair to bed, walker was within reach, feet were bare on carpet. States could not get to the bed so she just fell landing on buttocks against bed. Denies striking head. Complains of discomfort in left arm stating name band pinched the skin. No injury noted. Full active ROM. Physician notified, attempts to notify family with phone not answered, and no voice mail. Will continue to attempt to reach for notification. The Note was written by DON J Review of the IDT Review Progress Note, dated 7/11/2019 at 3:28p.m, for R201, reflected, (Recorded as Late Entry on 07/29/2019 15:28) IDT Review: Resident was reviewed after fall occurred in evening on 7/10/19. Resident was attempting to self-transfer from wheelchair to bed when she was not able to complete the transfer, resulting in her falling onto her bottom. No injuries were noted. Root cause of fall is self-transferring. Intervention is to educate resident to use call light for assistance. Resident able to use call light appropriately. Nursing staff will continue to monitor. Review of the Nursing Progress Note, dated 7/12/2019 at 7:00 p.m., for R201, reflected, Was called to residents room by Cenas only to find resident sitting on floor. Asked resident what she was doing on floor, she replied I slipped out of my chair. Resident was leaning on bed with back and feet out in front of her. Findings suggestive of self transferring. Call light was in reach. ROM shows no evidence of deformity or rotation. Denies any pain. No physician injuries noted. DON notified. Resident request not to tell daughter. The Progress Note was written by Licensed Practical Nurse O. Review of the Nursing Progress Notes, dated 7/13/2019 at 1:16 p.m., reflected, Resident (R201) fall at approx. 13:00, 173/98 81 97.4 99% on RA, A&O x3, stated got up to get my clothes resident showing redness to right check, and external rotation to right hip, with right leg shorter than left. Resident had a pillow under head, and left on floor, (named local hospital) called resident to HFAH ER, report called. The residents Daughter has been called and informed of this as well as the residents Doctor. The Progress Noted with completed by Registered Nurse (RN) N. Review of the Nursing Progress Notes, dated 7/15/2019 at 5:15 p.m., for R201, reflected, (Recorded as Late Entry on 07/24/2019 17:20) IDT Review: Resident reviewed after experiencing two falls; one on 7/12/19 and another on 7/13/19. On 7/12, fall occurred in the evening in resident's room. She was attempting to self transfer and fell on to bottom. No injuries were noted. New intervention was to place fall mat next to bed. Resident was again reminded to use call light for assistance. Another fall occurred around lunchtime on 7/13/19. Resident had stood up from chair and was attempting to get clothing out of dresser when she fell . Resident was observed on floor with R leg externally rotated and shorter than [MI] Resident c/o severe pain. Resident was left on floor with nursing staff present until (named Emergency Medical Services) arrived to transport to ED. Resident was admitted to hospital for fx of R hip. During an interview and record review on 10/23/19 at 1:18 p.m., Therapy Director P reported R201 was seen for a therapy evaluation on 7/10/19 and was evaluated to be a two person transfers with an order written [REDACTED]. During an interview on 10/23/19 at 1:35 p.m., Physical Therapist(PT) Q reported completing R201 new admission therapy evaluation on 7/10/19. PT Q reported R201 was alert but pleasantly confused and was recommended to be two person transfer. During an interview and record review on 10/23/19 at 2:25 p.m., LPN K reported being employed with the facility for four months as staff development and scheduler. LPN K reported she has been advised to schedule 3 nurses and 5 CNA staff for day shift. Review of the 7/13/19 schedule reflected the census was 48 and 3 nurse and 4 CNA staff were working day shift when R201 fell and fractured her right hip. LPN K reported they were short one CNA that day and should have had five CNA's. During a telephone interview on 10/23/19 at 4:24 p.m., RN N reported had been employed by the facility for one year as weekend nurse and was caring for R201 on 7/13/19 at the time of the fall. RN N reported 300 hall Certified Nurse Aide(CNA) found R201 on the floor. RN N reported R201 reported she tried to get clothes and self transferred from recliner to get clothes and fell . RN N reported after CNA informed him of fall they immediately assessed R201 on the floor and observed R201's right hip bowed out, pain and suspected a fracture. RN N reported in report, prior to R201 fall, he was told R201 was not able to self transfer and was a one person assist and was not aware of any history of falls. RN N reported R201 was alert to self with no change after fall. RN N reported resident information can be located by reviewing resident records and charting. RN N reported RN M also assisted with R201 fall follow-up and transfer to the hospital. RN N reported short staffing is a normal issue on the weekends. RN N reported he worked 10/19/19 and 10/20/19 and was unsure if the facility had a DON. During an interview on 10/24/19 at 11:06 a.m, RN M reported she was the current employed as the Assisted Living Director for past three weeks and was past skilled nursing Assistant Director of Nursing(ADON) for six months. RN M reported was ADON at the time of R201 third fall on 7/13/19 and was called into room for assistance. RN M reported R201 on the floor in her room with complaints of right hip pain and right hip was visibly bulging. RN M reported the facility would discuss falls at clinical daily meetings that included the ADM, ADON, MDS nurse, therapy, and activity staff and discuss falls including interventions. During an interview on 10/24/19 at 12:30 p.m., Certified Nurse Aid (CNA) R reported being employed with the facility for [AGE] years, CNA R reported she was not assigned to R201 on 7/13/19 but was called to her room by Dietary Manager Assistant S. CNA R reported CNA T was R201 aid at the time but was in the Dining Room. CNA R reported Dietary Manager Assistant S observed R201 on the floor and yelled for CNA R help. CNA R reported she entered R201 room and saw her on the floor and could tell R201 right hip was displaced with bulge noted at right hip and complaints of pain. CNA R reported had been working on 100 hall that day. CNA R reported prior DON J had her complete a written stated. CNA R stated, I knew as soon is I walked in the room her(R201) hip was broke. CNA R reported RN N wanted her to pick R201 up off the floor but reported she did not think that was a good idea because of obvious [MEDICAL CONDITION] and stated, you do this job long enough, you know. CNA R reported that is when she went and found RN M who advised that R201 remain on the floor until the EMS arrive. CNA R reported was a new admission and had recent falls prior to 7/13/19 and should have had interventions that included additional supervision, encourage to be in common area, encourage to come out for meals. CNA R reported new admissions do not have complete care plans to follow for care which makes it difficult to care for residents and know each residents needs. CNA R reported call lights have not been sounding at the nurse station properly in the 100 hall for several weeks During an interview on 10/24/19 at 1:15 p.m., Dietary Manager Assistant(DMA) S reported on 7/13/19 he was walking down hall with another dietary staff who had observed R201 on the floor in her room. DMA S reported he attempted to have Physical Therapy assist but was told the nurse has to be informed. DMA S reported R201 appeared to be in pain by the look on her face and holding of right hip. DMA S reported he had completed a written witness statement. She looked like she was in pain. not yelling out but look on face did not look comfortable. reported Deb and his was combined witness that he agreed. he was concerned no witness statement because he knows there was one and he signed it. Deb will know as well. During an interview on 10/24/19 at 1:42 p.m., DON B entered the conference room and provided with surveyor with file that included written witness statements, resident interviews. DON B apologized that he was not aware he had additional information related to the investigation for the Facility Reported Incident dated 7/13/19(over 24 hours after DON informed this surveyor he had provided the complete investigation). Review of R201's baseline care plan related to her fall risk, dated 7/10/19 with no revisions noted after 7/10/19 and 7/12/19 fall, reflected R201 had cognitive impairment that affects safety/judgment, history of falls, history of or incontinence of bowel or bladder, [DIAGNOSES REDACTED]. The interventions identified related to her fall risk included Assess fall risk at admission and as needed until comprehensive care plan complete. Observe elopement attempts and wandering and implement exit seeking alarm bracelet as appropriate. Therapy eval and treat per MD order Implement enabler to assist with fall prevention and safety. Provide assistive devices and ensure accessible Implement restraint after assessing and obtaining MD order to assist with fall prevention and safety. Keep call light within reach and encourage use of it. Encourage and educate, if applicable, resident to utilize safety measures. Observe medications for side effects that could affect balance, cognition, or gait. Assist resident with transfers/mobility as needed. During an observation and interview on 10/24/19 at 3:00 p.m., this surveyor observed call lights in the 100 hall had a visual cue above the door but no audio noted at the nurse station or in the hall. CNA U entered R204's room to answer the call light and reported she was outside the door and was able to see the light come on but was informed during report that the audio was not functioning. During an interview on 10/24/19 at 4:11 p.m., CNA W reported being employed with the facility for 6 years. CNA W verified her witness statement dated 7/15/19 related to R201 fall on 7/10/19 and 7/12/19 including, On 7/12 on the 2-10:30 shift sometime between 2 and 5pm (R201) attempted to self transfer 3 times, once to get candy, once to pick something up from the floor and she had no explanation for the third. I reported this behavior to the nurse. CNA W reviewed care tracker for several new residents on the hall and explained usually transfer status and diet and the only guide they have to provide care to residents because the care trackers are not being completed. During an interview on 10/24/19 at 4:39 p.m., Interview CNA V verified her witness statement dated 7/18/19 related to R201 7/13/19 fall. CNA V reported R201 was non compliant a lot and getting up a lot. CNA V reported worried about R201 falling and reported witness statement was correct except had incorrect date, should have been dated 7/12/19. During an interview on 10/24/19 at 5:45 p.m., DON B reported Baseline Care Plans were located at the Nurse Stations so staff could reference resident care needs for new admissions. DON B attempted to locate binder at 100 hall Nurse Station and was unable to locate and the 100 hall nurse informed DON B she was not aware of a binder with the baseline care plans at the nurse station. DON B reported it was the company policy to have baseline careplans available at the nurse stations for review. Resident #202(R202) Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected R202 was a [AGE] year old female admitted to the facility on [DATE] with re-admission 3/23/19, with [DIAGNOSES REDACTED]. The MDS reflected R202' had a BIM (assessment tool) score of 5 which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, transfers, locomotion on unit, dressing, hygiene, bathing and toileting. Review of the facility Event Report, dated 9/6/19 at 5:19 p.m, reflected confused R202 had an unwitnessed fall behind a locked non resident employee bathroom that resulted in a head injury and not reported to the state agency. Review of facility Care Plans, dated 10/23/18 through current, reflected R202 had identified problems and interventions that included: Resident demonstrates exit-seeking and wandering behaviors .Interventions: Monitor for wandering triggers such as need for toileting, inactivity, time of day, etc .Re-direct resident away from doors/exits as needed .Resident has impaired cognition with associated short term memory impairment D/T Dementia. Is at risk for confusion, disorientation, altered mood, impaired or reduced safety awareness .Interventions .Observe for exit seeking behaviors, wandering into unsafe areas .Resident has a [DIAGNOSES REDACTED]. has Hx of rib fractures and L [MEDICAL CONDITION] .Interventions .Assist as needed with mobility .Resident at risk for falling R/T: Poor safety awareness, impaired balance, self transfers, refusal of care, wandering, impulsive with impaired cognition, HTN, dizziness, muscle weakness, hx of UTI which increases her risk of falls, [MEDICAL CONDITION], hx of fall with left rib fracture and left [MEDICAL CONDITION] . Inability to effectively communicate toileting needs D/T Dementia. Resident witnessed lowering self to the floor .Interventions .Pt is an assist of 1 for transfers. Pt to use a w/c to/from bathroom until upgraded by therapy .Staff to provide increased rounding to resident's room observing movement of resident. If resident is awake staff to encourage resident to get up in w/c sit in common area.--neuro check per policy--encourage resident to be out at the atrium/ nurses station or in activities while awake in wheelchair as tolerated with hx of wandering . During a telephone interview and record review on 10/28/19 at 3:13 p.m., prior DON J reported at the time of R201 falls on 7/10/19, 7/12/19 and 7/13/19 that resulted in right [MEDICAL CONDITION] she was the facility DON and also covered the floor. DON J reported on 7/10/19, no long after R201 admission, she worked the afternoon shift on the 300 hall. DON J reported R201 had a lot of family present during the day and after they had left R201 was in the recliner chair, attempted to self transfer and fell and was found with back against bed without using call light. DON J reported immediate interventions implemented was R201 was re-educated on the call light. Review of R201 Event Report completed by DON J on 7/10/19 and closed on 8/1/19, reflected a fall risk re-evaluation that included, Resident has cognitive or memory impairment that effects safety and judgement, resident requires us of an assistive device and/or often forgets to use device, resident requires assistance to transfer, resident requires assistance to ambulate safely with or without assistive device, resident refuses to comply with safety measures such as call light use, alarms, appliances, etc .New Interventions .Other, describe-education . The Event Report reflected physician and family were notified and Care Plans reviewed on 7/18/19. DON J verified she completed Event Report dated 7/10/19 and felt that re-educating R201 on the use of the call light was appropriate but did not recall R201 having any cognitive issues as indicated on Event Report that she completed. DON J reported the dates were incorrect on the Event Report related to physician, family notification because she had forgot to change dates. DON J reported she did notify the physician and family on 7/10/19 but forgot to document and was noticed during the audit, therefore DON J entered a late entry Progress Note on 7/26/19 that family and physician were notified of self transfer on 7/10/19. The Event Report reflected R201 had an IDT Progress Note, dated 7/29/19, reflected root cause of fall was self-transferring with intervention to educate resident on use of call light. DON J reported R201 had a second unwitnessed fall with no injury on 7/12/19 at 6:00 p.m. in her room after apparent self transfer while under care of another nurse. DON J reported she was DON at time and was informed of the fall and closed the event on 7/18/19. The Event Report, completed by LPN O, reflected R201 often forgets to use device, resident had cognitive or memory impairment that affect safety and judgement and resident refuses to comply with safety measures such as call light. DON J reported nurses are responsible for adding interventions to Care Plans but not all nurses know how to do so. DON J stated, (named R201) fell on e night after another within a few days. DON J reported she was unsure if R201 was at risk for falls on admission. DON J reported facility did not do an investigation after R201's 7/10/19 fall or 7/12/19 fall because R201 did not have an injury and appeared to self transfer. DON J reported R201 had a third unwitnessed fall on 7/13/19 in her room at 1:24 p.m. after an apparent self transfer. DON J reported she completed an investigation at that time that included two prior falls since R201 admission on 7/9/19 that included staff interviews because R201's had an injury. DON J reported R201 was transferred to the hospital on [DATE] after the third fall that resulted in right [MEDICAL CONDITION]. DON J reported R202 had an unwitnessed fall on 9/6/19 at 5:19 p.m. behind a locked door of an employee restroom. DON J reported she was R202's nurse at the time of the fall and R202 had been attending an activity. DON J reported staff knew to keep a very close eye on R202 because she was capable of anything, was exit seeking and was able to self propel wheel chair. DON J reported during the activity R202 self propelled into employee restroom, closed and lock the door and fell . DON J reported CNA X was heard R202 yell for help, was able to unlock the door. DON J reported she completed the Event Report, dated 9/6/19, that reflected R202 hit her head and had a hematoma. DON J reported she was no longer the DON at that time. DON J reported R202 was not alert and oriented prior to fall. DON J reported she completed an initial neurological assessment that was negative but did not complete any additional neurological assessments after R202's unwitnessed fall with head injury and was unsure why. DON J reported should have completed neurological assessment throughout night for R202 after head injury and should have completed investigation related to R202 fall behind locked door for known confused resident. According to the professional standard of quality of performing complete neuro checks is to assess level of consciousness, pupil response, hand grasps, movement of extremities, pain response, and vital signs. (Nursing care of neurological patients, sweetheaven services, 206) During a telephone interview on 10/23/19 at 4:45 p.m, CNA X reported on 9/6/19 at dinner time, CNA Y heard R202 calling for help from an employee bathroom. CNA X reported the employee bathroom was not a resident area and did not have a call light in the employee bathroom, and door was locked. CNA X reported he was able to use part of his badge to unlock the door and found R202 on the bathroom floor with feet toward the door and head by toilet with no visible injuries. CNA X reported several staff including nurses were present. CNA X reported he did not complete witness statement. CNA X reported was not caring for R202 that day and was unsure who had her. CNA X reported CNA Y was working on the 100 hall that day and R202 lived on the 200 hall and was unsure how long R202 had been unsupervised in bathroom. CNA X reported at the time of R202 fall staff were assisting residents to dining room. CNA X reported lights work on 100 hall but no sound for 1-2 weeks. CNA X reported medication room has sound but very faint behind closed door. During a confidential interview on 10/23/19 at 4:35 p.m., confidential staff reported worked over past weekend(10/26/19 and 10/27/19) and the call lights for 100 hall continued to be not functioning properly and had not been working properly for about 3 weeks. Confidential staff reported the light turned on over the resident doors but there was no sound and had been reported to Maintenance who reported had been waiting on parts. Confidential staff reported staff are only able to see of call lights are on if in direct view and unable to know if call lights are on if providing care to another resident and often only one nurse and one cna on the 100 hall.

Based on observation, interview and record review the facility failed to ensure a safe transfer from a bed to a geri chair for 1 resident (#61) reviewed for falls from a total sample of 4 residents resulting in a slightly comminuted and minimally displaced fracture of the left tibia (large bone of the lower leg) and a minimally displaced left fibula small bone of the lower leg that sits next to the tibia on the outside of the leg) fracture for Resident #61. Findings: Based on the MDS assessments, dated 12/22/16 and 1/10/17, Resident #61 was an [AGE] year old severely cognitively impaired female whose [DIAGNOSES REDACTED]. Based on the BIMS completed by staff in the above MDS Resident #61 was rated a 3 on a 0-3 scale indicating severe cognitively impaired. Based on the above MDS assessments Resident #61 was mostly non-verbal and totally dependent on staff for all care. The care plan for Activities of Daily Living reflected Resident #61 required two staff to assist with transfers. Based on the Resident Progress Notes in the EMR, dated 12/25/16 at 10:57 AM and written by Licensed Practical Nurse C, a Certified Nursing Aide (CNA, identified by the facility as CNA D) reported a hematoma (raised area) measuring 4.0 cm by 4.3 cm on Resident #61's left shin and a bruise on her left foot measuring 0.7 cm by 1.0 cm. The physician and the responsible party were notified. The progress note on the same date and by the same LPN at 2:12 PM reflected an increase in swelling of the raised area and increased pain expressed by the Resident. Orders for an X-ray, ice to the area and non weight bearing status to the left leg were obtained from the physician. Based on the progress note at 11:25 PM the same day and written by LPN E the physician and DON B were notified at approximately 4:45 PM of the X-ray result of a minimally displaced fracture of the left tibia and fibula for Resident #61. The same note reflected Resident #61 was sent to the hospital emergency room for treatment at approximately 6:00 PM and returned at 9:45 PM with a splint to the left leg. Based on the Event Report, dated 12/25/16 at 10:23 AM the area on the shin was large and raised but not bruised, measuring 4 cm by 4.3 cm. The bruise on the left foot was described as black-blue in color measuring 0.7 cm by 1 cm. The X-ray report from the facility radiology provider, dated 12/25/16 at 4:24 PM and signed by the radiologist, reflected Results: There is a fracture involving mid tibial shaft with minimal lateral (to the side) displacement. Fibular neck impacted (occurs with force exerted on the bone from the top or bottom) fracture shows no displacement . The X-ray from the hospital on the same date and signed by the radiologist at 7:12 PM, reflected Acute slightly comminuted (fracture where bone is separated and is due to an impact force) seen of the mid tibial shaft with minimal lateral and dorsal (toward the back) displacement of major distal (lower part) fracture fragment. Minimally displaced fracture of the fibular neck (top of the bone below the knee) is also identified. The bones appear osteopenic (lower bone density that weakens the bone) . On 1/11/17 at 1:44 PM CNA D was interviewed by telephone and stated when she came on duty on 12/25/16 between 6:00-6:30 AM Resident #61 was in bed. CNA D stated she went with CNA F to gather items needed to dress the Resident before getting her into her chair then left the room to get report. CNA D stated CNA G assisted CNA F in transferring Resident #61 to her chair before CNA D returned about 15 minutes later. CNA D stated she pulled up Resident #61's left pant leg to put on her compression stocking and noticed there was a knot without discoloration on the Resident's shin slightly smaller than a golf ball about half way between the ankle and the knee. In addition, there was a purplish bruise on the Resident's left big toe. CNA D stated she immediately reported the observations to LPN C. CNA D stated Resident #61 didn't look comfortable but that was not unusual for the Resident. CNA D stated the Resident became more agitated after lunch (12:00-12:30 PM) and the knot on her left shin was larger and more discolored. On 1/12/17 at 2:54 PM LPN C was interviewed by telephone. LPN C stated there had been no injury to Resident's #61's left lower leg on 12/24/16 and no report of any unusual activity for the Resident. LPN C stated Resident #61 did not usually move herself and was a two person pivot transfer (resident stands on feet while one staff on each side hold a gait belt around the resident's waist and pivot the resident from one surface to another). LPN C confirmed her above documentation in the progress notes was accurate. On 1/12/17 at 1:38 PM LPN H was interviewed by telephone and stated she had cared for Resident #61 on the 10:00 PM-6:30 AM shift of 12/24/16-12/25/16. LPN H stated there was no injury to the Resident's left leg when she had applied a cream to her knees. LPN H stated she was familiar with the Resident and she could tell if the Resident was painful by the expression on her face. LPN H stated Resident #61 did not show signs of pain during the above shift. On 1/11/17 at 3:10 PM CNA F was interviewed and stated Resident #61 did not speak, just makes sounds and cries out at night. CNA F stated she had cared for the Resident regularly during the 10:30 PM-6:00 AM shift. CNA F stated that on 12/25/16 at approximately 5:30 AM she bathed and dressed the Resident then transferred her to her geri chair (wheeled reclining chair with leg rest) with the assistance of CNA G. CNA F stated they used a gait belt around the Resident's waist and performed a pivot transfer from the bed to the geri chair while Resident #61 bore none of her weight on her legs. CNA F stated nothing out of the ordinary happened during the transfer. On 1/11/17 at 4:30 PM CNA G was interviewed by telephone and stated she had assisted CNA F in transferring Resident #61 from the bed to the geri chair at about 6:25 AM on 12/25/16. CNA G stated Resident #61 did not bear any of her weight on her feet that were on the floor during the transfer. In addition, CNA G stated she did not pay attention to the Resident's feet at all during the transfer. The facility procedure Types of Transfers, undated, reflected the following types of transfers; stand pivot, sit pivot, two person sit pivot and sliding board. The instructions for the sit pivot transfer were; the resident will remain flexed forward at the trunk through the entire transfer, this transfer depends on the momentum of the person helping the resident, have the resident place both feet on the floor, lean forward and scoot. The two person sit pivot instructions were; a variation of the sit pivot transfer, use this transfer when the resident requires the aid of two people, the second person will help from behind, the second person will boost the resident's hips and guide the transfer. The picture with instructions showed the use of a gait belt. There were no instructions for what to do with a resident's feet who could not bear their own weight. Resident #61 was unable to bear her own weight or assist with the transfer in any way. On 1/1/7/16 at 3:15 PM Administrator A stated CNA competencies for tasks used in resident care were evaluated on hire and annually. Administrator A stated the Job Specific Checklist for CRCA's (CNA) was the form used to document the competencies. The check list did not specifically address transfers. The use of gait belts, walkers and transporting residents in a wheelchair, shower chair and lift were the items listed. Administrator A confirmed transfers were not specifically listed on the form. The most recent check list completed for CNA F was dated 12/14/15. In addition, CNA F had received education related to the used of gait belts and mechanical lifts on 5/6/16 and 5/7/16. There was no documentation provided for CNA G who was hired on 9/20/16. Administrator G stated CNA G had not turned in the Job Specific Checklist for CRCA's from her orientation. Review of Staff One to One Education and In-Service forms dated 12/29/16 for CNAs F and G reflected the topic was transfers and the content was review of the two person transfer process, use of a gait belt, reviewing the plan of care for appropriate transfer method for the resident, monitoring the placement the resident's feet during the transfer and watching the area for items that could impede the transfer such as wheelchair foot pedals, floor mats, bed frames and chairs. A return demonstration of a two person transfer was documented and a reminder to notify the nurse manager of any charges to a resident's condition. The in-service was provided by Director of Nursing B and signed by CNAs F and G. ( )

Based on observation, interview and record review the facility failed to monitor skin integrity for 1 of 11 sampled residents (#1), resulting in a unstageable pressure ulcer with slough. Findings include: Resident #1 was admitted to the facility on [DATE] according to the Electronic Medical Record (EMR), with [DIAGNOSES REDACTED]. On 3/15/16 at around 9:03 AM during the facility tour, the Assistant Director of Nursing (ADON H) was asked to inform writer if any residents had any pressure ulcers. ADON H revealed that Resident #1 had an acquired unstageable pressure ulcer with slough on his gluteal fold. On 3/15/16 at 12:07 PM Resident #1 was observed sitting up in his recliner cleanly clothed with sneakers on. A two wheeled walker was observed in front of him. A padded cushion was noted under the resident's bottom in the recliner. When asked if he had any open areas/sore spots Resident #1 stated he had one on the left side of his bottom. Resident #1 stated the area was not painful. Resident #1 revealed he slept in his recliner chair, and that his dressing to his bottom was changed everyday. Resident denied request of writer to observe the dressing change to his bottom. The admission Minimum Data Set (MDS) 3/15/16 reflected Resident #1 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 (cognitively intact), required limited assistance of one person for transfers/hygiene, extensive assist for bathing, and (1) Unstageable pressure ulcer measuring 2.5 cm L x 1.0 cm L with slough. LPN J was interviewed 3/16/17 at 11:45 AM. She was given the admission assessment she completed dated 2/22/16 to view, and was asked to recall Resident #1's skin status to his bottom. LPN J stated, I thought I did a skin circumstance/event form .I looked at his whole body including his bottom. I want to say just barely right at his tailbone/coccyx was red blanchable . Also, that there were no opened areas that she saw. LPN J revealed that Resident #1 liked to move around because he was a scooter. She was not aware that Resident #1 had developed a Stage 3/unstageable pressure ulcer on 2/27/16. LPN J stated, I did not document about his bottom. The admission assessment dated [DATE] completed by Licensed Practical Nurse (LPN J) was negative for any redness, blanchable areas or pressure ulcer to Resident #1's bottom. The facility's CRCA Daily Skin Check Sheet documentation reflected staff, Didn't see skin on 2/23/16, 2/24/16, and 2/25/16. On 2/27/16 the CRCA Daily Skin Check Sheet documentation reflected an open sore (circled on the human imaged) at Resident #'1's coccyx/buttock area. No documentation was available or provided by the facility reflecting Resident #1's bottom had been monitored since the initial blanchable redness on 2/22/16, not documented by LPN J. The facility's Skin Integrity Events--(facility's name)-Pressure Wound Circumstance 11.15 CV form dated 2/27/16 at 9:37 AM reflected Resident #1 had the following: Coccyx-two areas: Larger, reddened area 2.5 cm L x 1.0 cm W, and smaller open area central to large reddened area 1.0 cm L x 0.5 cm W. Marked Stage 3 - Full thickness of skin is lost, exposing the subcutaneous tissues, presents as a deep crater with or without undermining adjacent tissue. Marked Slough - yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. Periwound with [DIAGNOSES REDACTED]. Resident #1's skin integrity care plan was not started until 2/27/16 related to his pressure ulcer to his coccyx and surgical site from recent cardiac catheterization with stent placement. Resident #1 Progress notes reflected measurements on the following dates: 2/27/16: 1 cm L x 0.5 cm W, wound bed yellow slough. Reddened area around open area is 2.5 cm L x 1 cm W and intact. 3/9/16 (11 days later): 2 cm x 1.6 cm. Yellow wound base. 3/11/16: 1 cm by 0.5 cm slough areas. No other measurements were noted or available. On 3/16/16 the Assistant Director of Nursing (ADON H) at 11:53 AM stated, We should have done a thorough assessment. At 12:27 PM ADON H returned and revealed Resident #1 had a partial bath on 2/24/16 and required partial assistance with bathing. Staging was not accurately staged, It should have been unstageable, because you can't see the base. He liked to provide his own personal care. ( )

This citation has 2 deficient practice statements DPS 1 and DPS 2: Deficient practice statement 1) Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance to prevent fall for 1 of 2 residents (#6) reviewed for falls, failed to use appropriate transfer technique for 1 resident (#1) from a total 13 sampled residents, resulting in a right hip fracture for resident #6 and potential for injury for resident #1. Findings include: The hand written physician's orders [REDACTED].#6 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Imaging Service Report dated 2/2/14 from the emergency room stated resident #6 had an impacted subcapital right femoral fracture. Resident #6 had a surgical repair and returned to the facility on [DATE]. The printed physician orders [REDACTED].#6 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of old record revealed resident #6 was originally admitted to the facility on [DATE]. The most current annual minimum data set ((MDS) dated [DATE] (nearly one and one half years ago) under the Activities of Daily Living (ADL) reflected resident #6, "...was alert and oriented x 1...required one person assist with a gait belt for transfers...ambulated using a four wheeled walker (FWW), occasionally used a wheelchair...resident required supervision with eating, and ate in restorative dining room...resident was incontinent of bowel and bladder and wore a brief at all times..." According to the incidents reports in the past 6 month resident #6 had 2 falls (10/16/13 and 2/2/14). The first incident dated 10/16/13 stated resident #6 "was transferring self from wheelchair to bed and did not lock wheelchair and fell ." The Nurse's Notes dated 10/16/13 reflected, "at 1745 (5:45 p.m.) resident was transferring self from wheelchair to bed and fell . No injury noted. This writer witnessed fall. Resident did not hit head. She didn't lock her wheelchair before getting up..." The care plan dated 10/17/13 reflected, "fall risk. Do not transfer on the seat of the rolled walker, ambulate to meals with FWW and gait belt, short straw, scoop mattress, floor mat x 2, gait belt with ambulation, hands on at all times, therapy to reassess for any therapy needs, maintenance to assess wheel chair for safety functionality-add self locking brakes, transfer resident to bed after meals to avoid self transfers resulting in falls." On 2/26/14 at 11:30 a.m., the certified resident care associate (CRCA), (staff "N") who had known resident #6 since she was admitted (over 5 years) stated, resident #6 would not be cognizant enough to comprehend locking the wheelchair. Staff "N" stated the resident was now transported to all meals by staff. On 2/26/14 at 12:45 p.m., the occupational therapist, (staff "U") was asked how did the self- locking brakes work since the resident may not remember to use the brake. Staff "U" stated the wheelchair wheels automatically locked when the resident stood up. On 2/27/14 at 2:00 p.m., the Assistant Director of Nursing, (staff "C") stated the facility did not rate residents by severity of fall risk, but resident #6 was always considered as being a high risk due to her severe cognitive impairment. Staff "C" was asked whether resident #6 had attempted to sit on the seat of her rolled walker. Staff "C" stated the care plan were written to encourage all residents with rolled walker with seat, not to sit on the seat during a transfer, not necessarily resident #6 had a history of [REDACTED]. The second incident occurred on 2/2/14. The Accident/Incident Report dated 2/2/14 reflected,"at 1300 (1:00 p.m.) I was in room 219 administering medications. On my way back to the medication cart I heard yelling. I entered resident #6's room and found her on the ground. She was against the wall by her bed on her right side. I asked if she was in any pain. She nodded "No." CRCA (staff "N") was bringing residents back from restorative and I asked her if she could help me get her up in her wheelchair...I asked her where it hurt and she pointed to her right leg/hip area." The Imaging Service Report dated 2/2/14 from the emergency room stated resident #6 had an impacted subcapital right femoral fracture. Resident #6 had a surgical repair and returned to the facility on [DATE]. The updated care plan on 2/7/14 included adding alarms to bed and chair and motion sensor alarm to the door. The investigative summary report dated 2/6/14 stated resident #6 was trying to get back into her bed from her wheelchair after she came back from her lunch. She may have attempted to walk (without a walker) and fell . The alarms were considered not to be needed. On 2/27/14 at 1:30 p.m., the Director of Nursing, (staff "B") was asked what was the primary mode of transportation resident #6 utilized. Staff "B" stated it was variable depending on the resident's clinical condition. Resident usually ambulated with her walker in the morning but she used her wheelchair in the afternoon if she got tired. Staff "B" stated she had reviewed the incident report and found no irregularities. Staff "B" stated resident #6 was propelling her wheelchair on her own, self transferring in the room and fell . Staff "B" added, "We can't watch every body every second, because all residents need care at the same time." On 2/28/14 at 9:30 a.m., CRCA, (staff "R") was interviewed in the conference room. Staff "R" was very loud and talking so fast that she was asked to slow down several times. Staff "R" stated she had been working at the facility less than one year and was assigned to provide care for resident #6 on the day of fall. Staff "R" stated resident #6 could not be left alone in her room because she did not have alarms on and she was propelling herself and lost her way to her room. Staff "R" stated she had to redirect resident #6 verbally where her room ("200" wing) was as the resident was heading toward "100" wing after lunch. Staff "R" stated 2 of 3 CRCA's had to transport approximately 20-23 residents back and forth for every meal in a rather constrained time period, because the kitchen staff asked all residents to be out as soon as meal time was over. This distance was observed to be approximately 300 feet. On 2/27/14 at 12:40 p.m., resident #6 was observed brought back to her room from the dining room by CRCA, (Staff "P"). Staff "P" took resident #6 to the bathroom and attempted to toilet her by herself. Staff "P" asked resident #6 to grab on to the metal bar next the toilet and attempted to get resident up by pulling up the back of her pants. Staff "P" realized she could not assist the resident by herself. Staff "P" went out of the room and brought registered nurse, (staff "E"). Both staff "P" and "E" then grabbed the resident's arm pits and pivoted her before she could be seated on the toilet. Neither the staff "P" nor staff "E" used a gait belt to transfer the resident. On 2/26/14 at 3:15 p.m., one family member who wished to remain anonymous stated her frustration with the facility staff and stated the facility seems not able to keep same staff who can provide consistent care to residents. The family member continued to state, "aides are constantly changing, most of the new aides are not educated in detail to meet individual resident's specific needs. They don't seem to use common sense when they transfer residents. They often grab residents' hands to get them up from the chair, causing bruises, offer deserts or supplements before offering regular meals." On 2/28/14 at 8:15 a.m., resident #6 was getting ready to be transported to the restorative dining room by CRCA, (staff "G"). Staff "G" stated she had worked at the facility for [AGE] years, mostly at the dementia unit. Staff "G" was asked how well she knew resident #6. Staff "G" stated she had resident #6 about a month ago and she was "assigned to provide care for (name of resident #6) today." Staff "G" was asked if she knew how long resident #6 had alarms on. Staff "G" was hesitant about answering the question as she had not been caring for resident #6 until today. Staff "G" stated she thought resident #6 may have had alarms when she had her about a month ago. According to the care plan, the alarms were added only after she came back from the hospital on [DATE]. On 2/28/14 at 9:15 a.m., resident #6 was observed ambulating with a four wheeled walker, assisted by 2 therapists; occupational therapist, (staff "S") and physical therapist, (staff "T") in hall on "200" nursing unit. Staff "T" stated resident #6 walked fairly well with her walker prior to her fall, but she always needed one person assist. The Rehabilitation Screening report dated 10/17/13 (after first fall) reflected, "...report is that patient was self transferring and did not lock wheelchair brakes. Per staff resident did not typically use wheelchair and they are not sure why she was in it..." The Monthly Nursing Assessment and Data Collection dated August 2013 through January 2014 under the safety and fall risk assessment, reflected resident #6 was always checked not requiring POC (plan of care) and was to be continued for observing changes, even after she had a fall on 10/16/13. Resident #6 was at high risk of fall due to severe cognitive impairment as well as inability to talk and inability to independently walk. Leaving the resident alone without adequate supervision and adequate physical assist would result in a fall that could have been avoided. ( ) According the facility Record of Admission Resident #1 was an [AGE] year old female admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/28/14 at 9:15 am, Resident #1 was observed for transfer from her wheel chair to her recliner with a sit to stand mechanical lift with Certified Nurse Aide (CNA) "G" and CNA "H." CNA "G" was observed to motivate the mechanical lift and CNA "G" was near the wheel chair and resident #1. Resident #1's wheel chair was not observed to have been locked during the entire transfer. Resident #1 was assisted into the sit to stand lift. CNA "G" attempted to place the leg straps around Resident #1's legs and stated "Oh, they are broke." CNA "G" immediately stated, "She (Resident #1) does not want them on." Resident #1 was not heard to state she had requested to not have the straps placed at that time. Resident #1 continued being transferred with the lift with a "broken" strap. Following the transfer, CNA "G" and "H" were questioned on the how long the straps to the lift were "broken" and both staff responded, "I don't know." CNA "G" reported she had floated from another unit . CNA"G" and CNA "H" both reported they were not sure if a work order had been completed for repair. CNA "G and CNA "H" were questioned on the wheel chair and what position the wheel chair should have been in during the transfer. CNA "G" responded, "if I was transferring a resident into the chair I would have locked it." CNA "H" was questioned if it should have been locked prior to the transfer and CNA "H" responded, "probably I am sure. I just started here so I am not sure." On 2/28/14 at 9:45 am, Director of Plant Operations "L" reported the unit had been inspected by the company 2 weeks ago. The inspection tag was noted to have been signed 2/12/14. On 2/28/14 at 11:05 am, Director of Nursing provided in-service training that was completed on 5/21/13 for transfers and wheel chair locking and in-service information for safe transfer for residents that required a transfer with a mechanical lift for CNA "G". DON "B" stated CNA "H" was "a new employee and I just in-serviced her." On 2/28/14 at 12:30 pm, The Director of Nursing provided this surveyor a copy of a "Staff One to One Education and In-service" form identified as a "Safety" in-service that was provided to both CNA "G" and "H," with content that included, "When transferring a resident the wheelchair should be locked during the transfer process. Any equipment utilized for resident care should immediately be taken out of service when noted to be defective. Never continue to use a piece of equipment that is broken/defective. A maintenance request form needs to be completed immediately." According to the facility "Guidelines for Resident Transfers," (no date), "to ensure the safety of residents and staff when performing mobility/transfer tasks." ( ) Deficient practice statement 2) Based on observation and interview, the facility failed to prevent recapping a dirty needle (sharps) for 1 supplemental resident (#17) from a total 13 sampled residents during medication pass observation, resulting in the potential for an accidental injury as well as contamination of microorganisms from the dirty needle. Findings include: On 2/25/14 at 11:30 a.m., resident #17 was observed receiving an insulin injection from a registered nurse, (staff "E") inside her room. Staff "E" drew up 3 units of "Humalog" insulin by using a 1 ml insulin syringe. The insulin syringe did not have a safety sleeve to push up to protect the needle. Staff "E" recapped the clean needle and carried it to resident #17's room and administered the insulin to resident's abdomen. Staff "E" then recapped the dirty needle (sharps) and brought it out to the medication cart before discarding it into a biohazard sharp box. Staff "E" was asked about recapping the needle. Staff "E" stated she was aware of not recapping the dirty needle, but the syringe had no sleeve that she could push up to protect the open needle during transport, thus she had no other choice but to recap the needle. The article called "Sharps Safety," written by the University of Texas at Austin, (undated), states Recapping needles whether they are clean or dirty is extremely dangerous, because 1) the needle could miss the cap and stab the hand holding the cap, 2) the needle could pierce the cap and stab the hand holding it, 3) the poorly fitting cap could slip off a recapped needle and stab the hand holding it. On 2/25/14 at 12:45 p.m., Staff "E" stated she had just found out the syringe did have a mechanism for the needle to be pulled down inside the syringe. However, she had not been taught this safety feature during orientation when she was hired in December 2013. Staff "E" had been recapping needles until today when the concern was brought to her attention. ( )

REFER TO INTAKE MI 848. BASED ON INTERVIEWS AND RECORD REVIEWS, THE FACILITY FAILED TO FOLLOW THEIR POLICY REGARDING USE OF GAIT BELTS DURING GAIT TRAINING AND FAILED TO IDENTIFY POTENTIAL HAZARDS (NON-USE OF ORTHOTIC DEVICE AND PRIOR OCCURRENCE OF KNEE BUCKLING) FOR 1 (#501) OF 4 SAMPLED RESIDENTS REVIEWED FOR FALLS IN A TOTAL SAMPLE OF 7, RESULTING IN A FALL WITH INJURY REQUIRING surgery for [REDACTED]. ACCORDING TO A LOCAL ACUTE-CARE HOSPITAL HISTORY & PHYSICAL (H&P) REPORT, DATED 6/2/12, RESIDENT #501 REPORTED TO THE PHYSICIAN THAT HE HAD BECOME "PROGRESSIVELY WEAKENED AND LATER THIS AFTERNOON WAS ACTUALLY UNABLE TO AMBULATE." RESIDENT #501 HAD A medical history of [REDACTED]. IN MAY, 2012, THE RESIDENT fell AT HOME AND INJURED HIS BACK. ACCORDING TO THE NEUROLOGIC ASSESSMENT, "HE HAS ACTUALLY A SLIGHT FOOT DROP WITH BILATERAL MODERATE STRENGTH WITH EXTENSION, BUT FLEXING IS LIMITED AND VERY WEAK. UNABLE TO DO STRAIGHT LEG LIFTS AND UNABLE TO PUT ANY PRESSURE ON HIS LEGS WITHOUT BUCKLING. HE HAS GOOD CMS (CIRCULATION, MOTION, SENSATION) OF HIS BILATERAL LOWER EXTREMITIES. NO EDEMA NOTED. HE HAS SIGNIFICANT DECREASE IN REFLEXES OF BILATERAL LOWER EXTREMITIES." THE resident underwent [REDACTED]. RESIDENT #501, [AGE] years OLD, WAS INITIALLY admitted to the facility on [DATE]. RESIDENT #501, ACCORDING TO A 6/19/12 MINIMUM DATA SET (MDS) ASSESSMENT, HAD NO COGNITIVE OR MEMORY DEFICITS. THE MDS ASSESSMENT DOCUMENTED THAT THE RESIDENT WAS 69 INCHES TALL AND WEIGHED 183 POUNDS. A 7/23/12 OCCUPATION THERAPY PROGRESS REPORT INDICATED THAT RESIDENT #501 WAS ABLE TO MAINTAIN PROPER POSTURAL ALIGNMENT AND WEIGHT DISTRIBUTION FOR 9 MINUTES WITH 1 HAND SUPPORT AT TABLE TOP. THE RESIDENT REQUIRED MINIMUM ASSISTANCE TO COMPLETE BATHING TASKS SECONDARY TO NO BENDING RESTRICTIONS PER THE PHYSICIAN. THE RESIDENT COULD SAFELY DRESS HIMSELF USING ASSISTIVE DEVICES WHILE SEATED IN A CHAIR. HE COULD TRANSFER TO THE TOILET INDEPENDENTLY USING AN ASSISTIVE DEVICE. A 7/23/12 PHYSICAL THERAPY PROGRESS REPORT STATED THAT RESIDENT #501 COULD AMBULATE 300 TO 350 FEET WITH SUPERVISION/MODIFIED INDEPENDENCE WITH A 4 WHEEL WALKER. THE POLICY FOR SKILLED THERAPISTS, DATED JANUARY, 2007, READ, "GAIT BELT MUST BE USED BY ALL STAFF DURING GAIT TRAINING OR TRANSFERRING PATIENTS. . .IF PATIENT BEGINS TO FALL, USE THE GAIT BELT TO: DRAW PATIENT CLOSE TO YOUR BODY WITH THE BELT, AND GENTLY AND SLOWLY LOWER PATIENT TO THE FLOOR BY ALLOWING HIM/HER TO SLIDE DOWN YOUR LEG." ACCORDING TO THIS POLICY, A GAIT BELT SHOULD BE USED WITH "CAUTION" IF THE PATIENT HAS HAD A RECENT RIB FRACTURE, RECENT SURGERY IN AREA OF BELT, A GASTROSTOMY TUBE, HIATAL HERNIA, COLOSTOMY, OR SEVERE HEART OR RESPIRATORY DISEASE. AN INCIDENT REPORT, DATED 7/26/12, INDICATED THAT RESIDENT #501 HAD AN "UNASSISTED FALL" AT 10:50 A.M. ACCORDING TO THE REPORT, COMPLETED AND SIGNED BY LICENSED PRACTICAL NURSE (LPN) #9, "RESIDENT AMBULATING, STATES MY LEFT LEG GAVE OUT." THERE WAS NO INJURY AND NO X-RAYS WERE ORDERED. THE RESIDENT'S VITAL SIGNS WERE DOCUMENTED AS NORMAL. UNDER THE SECTION LABELED "ADDITIONAL INFORMATION," LPN #9 DOCUMENTED, "RESIDENT STATES I WAS WALKING WITH THERAPY, MY LEFT LEG GAVE OUT, DENIES PAIN FROM FALL." THERE WAS ANOTHER ENTRY IN THIS SECTION, WITHOUT A SIGNATURE, TIME OR DATE THAT READ, "RESIDENT AMBULATING WITH THERAPIST (PHYSICAL THERAPY ASSISTANT #4) DURING THERAPY SESSION WHEN (L) LEG GAVE OUT. THERAPIST LOWERED RESIDENT TO THE FLOOR NO INJURIES WITH ASSESSMENT--STAFF TO CONTINUE TO AMBULATE WITH I (ONE PERSON) ASSIST AND GAIT BELT--FOLLOWED BY W/C (WHEELCHAIR) PER THERAPY RECOMMENDATION. RESIDENT TO CONTINUE TO WORK WITH THERAPY ON STRENGTHENING AND AMBULATION." THERE WAS A NURSE'S NOTE WRITTEN BY LICENSED PRACTICAL NURSE #9 AT 10:50 A.M. ON 7/26/12 WHICH READ, "RESIDENT LOST HIS BALANCE WHILE AMBULATING WITH WALKER fell TO FLOOR, (VITAL SIGNS DOCUMENTED) DENIES ANY PAIN, RESIDENT REQUESTED PAIN MED - 2 PERCOCET @ 1100 RATES PAIN @ 2/10, WILL CONTINUE TO MONITOR." A NOTE ON THE WEEKLY PHYSICAL THERAPY PROGRESS NOTE ON 7/27/12 STATED, "PT (PATIENT) HAD A FALL DURING AMBULATION WITH 4WW (WHEELED WALKER) (SEE ATTACHED NOTE). PT HAS INCREASED IN AMBULATION, LE STRENGTH AND BALANCE. PT IS ABLE TO COMPLETE 15 STEPS USING TWO RAILS." NO ADDITIONAL NOTE REGARDING THE FALL, WRITTEN BY THE PHYSICAL THERAPIST, WAS FOUND IN THE MEDICAL RECORD. RESIDENT #501 WAS INTERVIEWED WHILE HE WAS IN HIS BED ON 9/21/12 AT 10:15 A.M. THE RESIDENT SAID HE WAS AMBULATING ON 7/26/12 WITH PHYSICAL THERAPY ASSISTANT (PTA) #4 AT APPROXIMATELY 10 A.M. ACCORDING TO RESIDENT #501, HE WAS WEARING HIS BACK BRACE AT THE TIME AND HE WAS USING A FOUR WHEEL WALKER. THE RESIDENT SAID HE HAD BEEN WEARING AFOS (ANKLE FOOT ORTHOTICS, WHICH ARE DEVICES USED TO MODIFY THE STRUCTURE AND FUNCTION OF THE ANKLES AND FEET TO FACILITATE AMBULATION), "RELIGIOUSLY," BUT THAT DAY HE DID NOT WEAR THEM. THE RESIDENT SAID SINCE HE HAD BEEN WALKING, ONE OF THE AFOS WAS "BOTHERING MY FOOT." RESIDENT #501 STATED THAT IT HAD BEEN UNCOMFORTABLE FOR HIM TO WEAR THE AFOS. RESIDENT #501 ALSO STATED THAT SINCE HE WAS A DIABETIC, HE WAS CONCERNED ABOUT DEVELOPING A SORE ON HIS FOOT FROM THE UNCOMFORTABLE AFO. THE RESIDENT SAID THAT HIS USUAL PRACTICE WAS TO WEAR THE AFOS ON BOTH FEET WHEN THE CERTIFIED NURSING ASSISTANTS (CNAS) WALKED WITH HIM TO THE DINING ROOM. HE SAID USUALLY THAT PHYSICAL THERAPY HAD HIM WEAR ONLY THE RIGHT AFO WHEN HE WAS IN THERAPY. RESIDENT #501 SAID THAT PTA #4 DID NOT USE A GAIT BELT DURING HIS THERAPY SESSION ON 7/26/12. THE RESIDENT SAID HE AND PTA #4 WERE WALKING DOWN THE HALL TO THE THERAPY ROOM WHEN HIS LEG BUCKLED. PTA #4 WAS WALKING TO HIS LEFT, PULLING THE WHEELCHAIR. RESIDENT #501SAID HE (#501) fell TO THE RIGHT. HE TRIED TO GRAB THE RAILING ON THE WALL. THE RESIDENT SAID HE PROBABLY LANDED ON HIS BACK BECAUSE THE THERAPY STAFF SAT HIM UPRIGHT AND PLACED HIM IN A SITTING POSITION WITH HIS BACK AGAINST THE WALL. WHEN ASKED WHETHER PTA #4 GRABBED HIM, THE RESIDENT SAID, "I ASSUME HE TRIED TO." ACCORDING TO RESIDENT #501, AFTER THIS FALL, HE WAS NOT EXAMINED BY A PHYSICIAN UNTIL 7/30/12, WHEN HE SAW HIS NEUROSURGEON AT A PREVIOUSLY SCHEDULED APPOINTMENT. PTA #4 WAS INTERVIEWED ON 9/24/12 AT 10 A.M. HE SAID HE HAD WORKED CONSISTENTLY WITH RESIDENT #501 IN THERAPY. ACCORDING TO A WEEKLY PHYSICAL THERAPY PROGRESS NOTE DATED 7/20/12, THE RESIDENT WAS AMBULATING 300 FEET WITH A FOUR WHEELED WALKER AND SUPERVISION, MEANING NEEDING VERBAL CUEING WITH NO PHYSICAL ASSISTANCE. PTA #4 SAID THAT RESIDENT #501, ON 7/26/12, WAS MODIFIED INDEPENDENCE FOR AMBULATION, MEANING HE COULD WALK INDEPENDENTLY WITH THE WALKER. WHEN QUESTIONED ABOUT THE POLICY INDICATING THAT GAIT BELTS WERE ALWAYS TO BE USED, THE PTA SAID IT HAD BEEN A "PROFESSIONAL JUDGMENT WITH THE PHYSICAL THERAPIST THAT A GAIT BELT WAS NO LONGER NECESSARY." PTA #4 SAID THAT HE WAS WALKING ALONGSIDE RESIDENT #501 ON 7/26/12, WITH NO HANDS ON THE RESIDENT AND NO GAIT BELT. WHILE WALKING WITH PT#4, RESIDENT #501 STOPPED TO LET ANOTHER RESIDENT PASS BY, AND RESIDENT #501'S LEG BUCKLED. PTA #4 SAID THAT HE (PTA #4) GRABBED THE RESIDENT'S PANTS AND ASSISTED HIM TO THE FLOOR. ACCORDING TO PTA #4, THE NURSE ARRIVED HE (PTA #4) LEFT TO GET A GAIT BELT TO LIFT THE RESIDENT OFF THE FLOOR. PTA #4 SAID THAT RESIDENT #501'S BACK BRACE WAS ON WHEN HE fell on [DATE], BUT THAT HE (PTAA #4) DID NOT REMEMBER IF RESIDENT #501 WAS WEARING THE AFOS AT THE TIME OF THE FALL. PTA #4 SAID HE WOULD BE ABLE TO TELL IF THE AFOS WERE NOT ON JUST BY OBSERVING THE RESIDENT'S GAIT, AND HE DID NOT OBSERVE ANY UNUSUAL GAIT. PTA #4 CONCLUDED THAT THE AFOS MUST HAVE BEEN ON. PTA #4 SAID RESIDENT #501 HAD NO INJURIES, AND THEY CONTINUED ON TO THE THERAPY ROOM. THE THERAPY TREATMENT CONTINUED AS USUAL. PTA #4 SAID HE DID NOT TALK WITH THE PHYSICIAN OR THE NEUROSURGEON BEFORE CONTINUING THERAPY. THE PTA SAID HE DID NOT KNOW WHETHER THE PHYSICAL THERAPIST EXAMINED THE RESIDENT AFTER THE INJURY. THE PTA SAID HE ASSESSED THE RESIDENT DURING THE PHYSICAL THERAPY SESSION BY OBSERVING HIM FOR SYMPTOMS AND BY ASKING HIM WHETHER HE HAD PAIN. HE SAID HE PALPATED THE RESIDENT'S LOW BACK AREA. THE PTA SAID HE DID NOT KNOW ANYTHING ABOUT THE RESIDENT'S FALL PRIOR TO ADMISSION. HE SAID HE DID KNOW THAT THE RESIDENT HAD SURGERY. PHYSICAL THERAPIST (PT) #5 WAS INTERVIEWED ON 9/24/12 AT 9:40 A.M. PT #5 SAID HE WAS NOT IN THE FACILITY AT THE TIME OF THE FALL. HE SAID THE DAY BEFORE THE INCIDENT (7/25/12), A STAFF MEMBER SAW RESIDENT #501 WALKING UNASSISTED WITH HIS 4 WHEELED WALKER FROM THE DINING ROOM. PT #5 SAID THAT HE DISCUSSED THE RESIDENT'S PROGRESS WITH PTA #4 AND THE RESIDENT, AND A DECISION WAS MADE TO MAKE THE RESIDENT "MODIFIED INDEPENDENCE WITH THE WALKER" FOR AMBULATION. ACCORDING TO PT #5, THIS MEANT THAT THE RESIDENT COULD WALK INDEPENDENTLY, AND THERE WAS NO NEED TO USE A GAIT BELT. AFTER REVIEWING RESIDENT #105'S CLINICAL RECORD, PT #5 COULD NOT FIND DOCUMENTATION THAT THE AMBULATORY STATUS OF THE RESIDENT HAD CHANGED ON 7/26/12 OR THAT THE RESIDENT DID NOT NEED A GAIT BELT WHILE AMBULATING. ACCORDING TO PT #5, "IT MAKES NO SENSE TO USE A GAIT BELT IF THE RESIDENT IS ABLE TO AMBULATE INDEPENDENTLY." PHYSICAL THERAPIST #5 SAID HE PROVIDED PHYSICAL THERAPY FOR RESIDENT #501 ON 7/27/12 BECAUSE PTA #4 WAS NOT IN THE BUILDING. PT #5 SAID HE DID NOT KNOW ANYTHING ABOUT THE FALL ON 7/26/12 UNTIL A NURSE SAW PT #5 WALKING WITH THE RESIDENT WITHOUT USE OF A GAIT BELT. THE NURSE INFORMED PT #5 THAT THE RESIDENT WAS NOW TO BE AMBULATED WITH A GAIT BELT SINCE THE RESIDENT HAD FALLEN ON 7/26/12. PT #5 SAID HE DIDN'T BELIEVE THAT RESIDENT #501 WAS WALKING WITHOUT HIS AFOS IN PLACE ON 7/26/12. ACCORDING TO PT #5, "THE RESIDENT WOULD NOT BE ABLE TO PICK HIS FOOT UP FROM THE FLOOR, SO YOU WOULD BE ABLE TO TELL IN A SECOND." PT #5 SAID THAT IT IS THE RESPONSIBILITY OF THE THERAPIST TO MAKE SURE ALL ADAPTIVE DEVICES ARE IN PLACE. HE SAID THERE HAD BEEN NO PROBLEMS WITH THE RESIDENT'S AMBULATION IN THE PAST WHICH WOULD SUGGEST THAT A GAIT BELT WAS NECESSARY. HE SAID HE DIDN'T THINK HE KNEW ABOUT THE RESIDENT'S FIRST FALL WHICH HAD OCCURRED PRIOR TO ADMISSION EVEN THOUGH IT WAS DISCUSSED IN A HOSPITAL RECORD PRESENT IN THE RESIDENT'S CHART. OCCUPATIONAL THERAPIST (OT) #6 WAS INTERVIEWED ON 9/24/12 AT 110 A.M. OT #6 SAID THAT SHE (OT #6) HAD WORKED WITH RESIDENT #501 CONSISTENTLY PRIOR TO THE FALL ON 7/26/12. SHE SAID THE RESIDENT'S KNEE BUCKLED ONCE ABOUT A WEEK AND A HALF BEFORE HIS FALL ON 7/26/12. SHE SAID SHE GRABBED THE RESIDENT, AND HE WAS ABLE TO STAND BACK UP. OT #6 SAID SHE NOTICED THAT ONE OF THE AFOS WAS CUTTING INTO RESIDENT #501'S FOOT AND THAT SHE WAS CONCERNED ABOUT THIS BECAUSE SHE KNEW HE WAS A DIABETIC, AND SHE DIDN'T WANT HIM TO DEVELOP ANY PRESSURE SORES. SHE SAID THE RESIDENT HAD BEEN DOING EXERCISES ON HER RECOMMENDATION TO CORRECT FOOT DROP, WHICH WAS THE REASON FOR THE USE OF THE AFOS. ACCORDING TO OT #6, THE RESIDENT HAD SOME RETURN OF FUNCTION WITH HIS FEET AND ANKLES. OT #6 WENT ON TO SAY THAT SAID THERE WERE TIMES WHEN THE RESIDENT DID NOT WEAR THE AFOS DURING OCCUPATIONAL THERAPY. OT #6 SAID THAT THE ONLY TIME IT WAS EVIDENT THAT THE RESIDENT HAD PROBLEMS WALKING WITHOUT THE AFOS OCCURRED WHEN HE WAS TIRED. RESIDENT #506 WENT FOR A SCHEDULED VISIT WITH THE NEUROSURGEON ON 7/30/12. AN ASSESSMENT OF THE RESIDENT READ, "THE PATIENT TOOK A FALL 5 DAYS AGO. IN REVIEWING HIS X-RAYS IT APPEARS THAT HE MAY HAVE FRACTURED THE L3 PEDICLES (TWO SHORT THICK PROCESSES WHICH PROJECT DORSALLY, ONE ON EACH SIDE OF THE SPINAL VERTEBRAE) BILATERALLY. I HAVE DISCUSSED THIS WITH THE PATIENT AND EXPLAINED TO THE PATIENT THAT HE WILL MOST LIKELY END UP WITH AN EXTENSION OF HIS FUSION TO THE LEVEL OF L2. I SHOULD NOTE THAT HE HAS EXTRUDED DISC SPACER/CAGE POSTERIORLY AT THE LEVEL OF L3-4 ON THE RIGHT. . . I WILL ALSO HAVE HIM FITTED FOR A RIGHT KNEE STABILIZER AS HE HAS PROFOUND WEAKNESS IN BOTH HIS LOWER EXTREMITIES ESPECIALLY ON THE RIGHT." THE REPORT ALSO DOCUMENTED THAT "PATIENT REPORTS POSTOP STATUS AS WORSENING." HOSPITAL RECORDS FOR RESIDENT #501 WERE REVIEWED ON 7/26/12. A DISCHARGE SUMMARY, DATED 9/18/12, STATED, "(NAME OF RESIDENT) WAS BROUGHT TO THE OPERATING ROOM FOR A POSTERIOR LUMBAR DECOMPRESSION (REMOVAL OF MATERIAL TO GIVE NERVE ROOT MORE SPACE AND PROVIDE A BETTER HEALING ENVIRONMENT) WITH FIXATION (USING SCREWS TO POSITION BONES TOGETHER UNTIL THEY FUSE), GIVEN HIS NEW COMPRESSION FRACTURE. THE PATIENT UNDERWENT VERTEBROPLASTY (USE OF A SPECIALLY FORMULATED CEMENT TO STABILIZE COLLAPSED VERTEBRAE) WITH L2-S1 FUSION." THE RESIDENT WAS REadmitted to the facility on [DATE] AFTER THIS hospitalization . ( )

REFER TO INTAKE MI 848. BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO MEET PROFESSIONAL STANDARDS OF CLINICAL PRACTICE BY, (1) FAILING TO FOLLOW A POLICY REGARDING USE OF GAIT BELTS, (2) FAILING TO COMMUNICATE A FALL TO ALL THERAPY PERSONNEL, (3) FAILING TO ASSESS AND DOCUMENT THOROUGHLY AFTER A FALL, AND (4) FAILING TO NOTIFY THE NEUROSURGEON OF A FALL FOR 1 (#501) OF 4 SAMPLED RESIDENTS FOR FALLS IN A TOTAL OF 7 SAMPLED RESIDENTS, RESULTING IN AN INJURY REQUIRING surgery for [REDACTED]. FINDINGS INCLUDE: STANDARDS OF CARE IS THE LEVEL OR DEGREE OF QUALITY CONSIDERED ADEQUATE BY A GIVEN PROFESSION, ACCORDING TO GUIDO IN "LEGAL AND ETHICAL ISSUES IN NURSING", 3RD EDITION. INTERNAL STANDARDS ARE SET BY THE ROLE AND EDUCATION OF THE PROFESSIONAL STAFF AND BY THE INSTITUTION. THESE INCLUDE THE JOB DESCRIPTION OF THE PROFESSIONAL STAFF MEMBER, THEIR EDUCATION AND EXPERTISE, AS WELL AS THE INSTITUTION'S POLICIES AND PROCEDURES." (P. 64) A STANDARD OF CARE WOULD ALSO INCLUDE COMMUNICATING PATIENT DATA TO THE APPROPRIATE PERSONS. IN "LEGAL AND ETHICAL ISSUES IN NURSING" BY GUIDO (2001), IT STATES THAT "DOCUMENTATION MUST SHOW CONTINUITY OF CARE, INTERVENTIONS THAT WERE USED, AND PATIENT RESPONSES TO THE THERAPIES IMPLEMENTED. NURSE'S NOTES ARE TO BE CONCISE, CLEAR, TIMELY, AND COMPLETE." (P. 171) IT STATES THAT A JURY CAN INFER THAT NO OBSERVATION OF THE PATIENT WAS CONDUCTED IF THERE IS NO MENTION OF A CHANGE IN THE CONDITION OF THE PATIENT. (P. 171) IN "LEGAL AND ETHICAL ISSUES IN NURSING" BY G. GUIDO (2001), IT IS WRITTEN THAT A BREACH OF DUTY (SUCH AS FAILING TO NOTIFY THE PHYSICIAN OF A CHANGE IN A PATIENT'S CONDITION) IS A DEVIATION FROM THE STANDARD OF PROFESSIONAL CARE OWED THE PATIENT. A BREACH OF DUTY COULD BE DOING SOMETHING THAT SHOULD NOT HAVE BEEN DONE OR DOING NOTHING WHEN SOMETHING SHOULD HAVE BEEN DONE. (P. 82) ACCORDING TO A LOCAL ACUTE-CARE HOSPITAL HISTORY & PHYSICAL (H&P) REPORT, DATED 6/2/12, RESIDENT #501 REPORTED TO THE PHYSICIAN THAT HE HAD BECOME "PROGRESSIVELY WEAKENED AND LATER THIS AFTERNOON WAS ACTUALLY UNABLE TO AMBULATE." RESIDENT #501 HAD A medical history of [REDACTED]. IN MAY, 2012, THE RESIDENT fell AT HOME AND INJURED HIS BACK. ACCORDING TO THE NEUROLOGIC ASSESSMENT, "HE HAS ACTUALLY A SLIGHT FOOT DROP WITH BILATERAL MODERATE STRENGTH WITH EXTENSION, BUT FLEXING IS LIMITED AND VERY WEAK. UNABLE TO DO STRAIGHT LEG LIFTS AND UNABLE TO PUT ANY PRESSURE ON HIS LEGS WITHOUT BUCKLING. HE HAS GOOD CMS (CIRCULATION, MOTION, SENSATION) OF HIS BILATERAL LOWER EXTREMITIES. NO [MEDICAL CONDITION] NOTED. HE HAS SIGNIFICANT DECREASE IN REFLEXES OF BILATERAL LOWER EXTREMITIES." THE resident underwent [REDACTED]. RESIDENT #501, [AGE] years OLD, WAS admitted TO THE FACILITY INITIALLY ON 6/12/12, PER AN ADMISSIONS RECORD. RESIDENT #501, ACCORDING TO A 6/19/12 MDS (MINIMUM DATA SET) ASSESSMENT, HAD NO COGNITIVE OR MEMORY DEFICITS. THE MDS ASSESSMENT DOCUMENTED THAT THE RESIDENT WAS 69 INCHES TALL AND WEIGHED 183 POUNDS. AN INCIDENT REPORT, DATED 7/26/12, INDICATED THAT RESIDENT #501 HAD AN "UNASSISTED FALL" AT 10:50 A.M. ACCORDING TO THE REPORT, COMPLETED AND SIGNED BY LICENSED PRACTICAL NURSE (LPN) #9, "RESIDENT AMBULATING, STATES MY LEFT LEG GAVE OUT." THERE WAS NO INJURY AND NO X-RAYS WERE ORDERED. THE RESIDENT'S VITAL SIGNS WERE DOCUMENTED AS NORMAL. UNDER THE SECTION LABELED "ADDITIONAL INFORMATION," LPN #9 DOCUMENTED, "RESIDENT STATES I WAS WALKING WITH THERAPY, MY LEFT LEG GAVE OUT, DENIES PAIN FROM FALL." THERE WAS ANOTHER ENTRY IN THIS SECTION, WITHOUT A SIGNATURE, TIME OR DATE THAT READ, "RESIDENT AMBULATING WITH THERAPIST (PHYSICAL THERAPY ASSISTANT #4) DURING THERAPY SESSION WHEN (L) LEG GAVE OUT. THERAPIST LOWERED RESIDENT TO THE FLOOR NO INJURIES WITH ASSESSMENT--STAFF TO CONTINUE TO AMBULATE WITH I (ONE PERSON) ASSIST AND GAIT BELT--FOLLOWED BY W/C (WHEELCHAIR) PER THERAPY RECOMMENDATION. RESIDENT TO CONTINUE TO WORK WITH THERAPY ON STRENGTHENING AND AMBULATION." THE POLICY FOR SKILLED THERAPISTS, DATED JANUARY, 2007, READ, "GAIT BELT MUST BE USED BY ALL STAFF DURING GAIT TRAINING OR TRANSFERRING PATIENTS. . .IF PATIENT BEGINS TO FALL, USE THE GAIT BELT TO: DRAW PATIENT CLOSE TO YOUR BODY WITH THE BELT, AND GENTLY AND SLOWLY LOWER PATIENT TO THE FLOOR BY ALLOWING HIM/HER TO SLIDE DOWN YOUR LEG." ACCORDING TO THIS POLICY, A GAIT BELT SHOULD BE USED WITH "CAUTION" IF THE PATIENT HAS HAD A RECENT RIB FRACTURE, RECENT SURGERY IN AREA OF BELT, A GASTROSTOMY TUBE, HIATAL HERNIA, [MEDICAL CONDITION], OR SEVERE HEART OR RESPIRATORY DISEASE. PHYSICAL THERAPY ASSISTANT (PTA) #4 WAS INTERVIEWED ON 9/24/12 AT 10 A.M. HE SAID HE HAD WORKED CONSISTENTLY WITH RESIDENT #501 IN THERAPY. ACCORDING TO A WEEKLY PHYSICAL THERAPY PROGRESS NOTE DATED 7/20/12, THE RESIDENT WAS AMBULATING 300 FEET WITH A FOUR WHEELED WALKER AND SUPERVISION, MEANING NEEDING VERBAL CUEING WITH NO PHYSICAL ASSISTANCE. PTA #4 SAID THAT RESIDENT #501, ON 7/26/12, WAS MODIFIED INDEPENDENCE FOR AMBULATION, MEANING HE COULD WALK INDEPENDENTLY WITH THE WALKER. WHEN QUESTIONED ABOUT THE POLICY INDICATING THAT GAIT BELTS WERE ALWAYS TO BE USED, THE PTA SAID IT HAD BEEN A "PROFESSIONAL JUDGMENT WITH THE PHYSICAL THERAPIST THAT A GAIT BELT WAS NO LONGER NECESSARY." PTA #4 SAID THAT HE WAS WALKING ALONGSIDE RESIDENT #501 ON 7/26/12, WITH NO HANDS ON THE RESIDENT AND NO GAIT BELT. WHILE WALKING WITH PT#4, RESIDENT #501 STOPPED TO LET ANOTHER RESIDENT PASS BY, AND RESIDENT #501'S LEG BUCKLED. PTA #4 SAID THAT HE (PTA #4) GRABBED THE RESIDENT'S PANTS AND ASSISTED HIM TO THE FLOOR. ACCORDING TO PTA #4, THE NURSE ARRIVED HE (PTA #4) LEFT TO GET A GAIT BELT TO LIFT THE RESIDENT OFF THE FLOOR. PHYSICAL THERAPIST (PT) #5 WAS INTERVIEWED ON 9/24/12 AT 9:40 A.M. PT #5 SAID HE WAS NOT IN THE FACILITY AT THE TIME OF THE FALL. HE SAID THE DAY BEFORE THE INCIDENT (7/25/12), A STAFF MEMBER SAW RESIDENT #501 WALKING UNASSISTED WITH HIS 4 WHEELED WALKER FROM THE DINING ROOM. PT #5 SAID THAT HE DISCUSSED THE RESIDENT'S PROGRESS WITH PTA #4 AND THE RESIDENT, AND A DECISION WAS MADE TO MAKE THE RESIDENT "MODIFIED INDEPENDENCE WITH THE WALKER" FOR AMBULATION. ACCORDING TO PT #5, THIS MEANT THAT THE RESIDENT COULD WALK INDEPENDENTLY, AND THERE WAS NO NEED TO USE A GAIT BELT. AFTER REVIEWING RESIDENT #105'S CLINICAL RECORD, PT #5 COULD NOT FIND DOCUMENTATION THAT THE AMBULATORY STATUS OF THE RESIDENT HAD CHANGED ON 7/26/12 OR THAT THE RESIDENT DID NOT NEED A GAIT BELT WHILE AMBULATING. ACCORDING TO PT #5, "IT MAKES NO SENSE TO USE A GAIT BELT IF THE RESIDENT IS ABLE TO AMBULATE INDEPENDENTLY." PHYSICAL THERAPIST #5 SAID HE PROVIDED PHYSICAL THERAPY FOR RESIDENT #501 ON 7/27/12 BECAUSE PTA #4 WAS NOT IN THE BUILDING. PT #5 SAID HE DID NOT KNOW ANYTHING ABOUT THE FALL ON 7/26/12 UNTIL A NURSE SAW PT #5 WALKING WITH THE RESIDENT WITHOUT USE OF A GAIT BELT. THE NURSE INFORMED PT #5 THAT THE RESIDENT WAS NOW TO BE AMBULATED WITH A GAIT BELT SINCE THE RESIDENT HAD FALLEN ON 7/26/12. RESIDENT #501 WAS INTERVIEWED WHILE HE WAS IN HIS BED ON 9/21/12 AT 10:15 A.M. THE RESIDENT SAID HE WAS AMBULATING ON 7/26/12 WITH PHYSICAL THERAPY ASSISTANT (PTA) #4 AT APPROXIMATELY 10 A.M. RESIDENT #501 SAID THAT PTA #4 DID NOT USE A GAIT BELT DURING HIS THERAPY SESSION ON 7/26/12. THE RESIDENT SAID HE AND PTA #4 WERE WALKING DOWN THE HALL TO THE THERAPY ROOM WHEN HIS LEG BUCKLED. PTA #4 WAS WALKING TO HIS LEFT, PULLING THE WHEELCHAIR. RESIDENT #501SAID HE (#501) fell TO THE RIGHT. HE TRIED TO GRAB THE RAILING ON THE WALL. THE RESIDENT SAID HE PROBABLY LANDED ON HIS BACK BECAUSE THE THERAPY STAFF SAT HIM UPRIGHT AND PLACED HIM IN A SITTING POSITION WITH HIS BACK AGAINST THE WALL. WHEN ASKED WHETHER PTA #4 GRABBED HIM, THE RESIDENT SAID, "I ASSUME HE TRIED TO." ACCORDING TO RESIDENT #501, AFTER THIS FALL, HE WAS NOT EXAMINED BY A PHYSICIAN UNTIL 7/30/12, WHEN HE SAW HIS NEUROSURGEON AT A PREVIOUSLY SCHEDULED APPOINTMENT. THERE WAS A NURSE'S NOTE WRITTEN AT 10:50 A.M. ON 7/26/12 WHICH READ, "RESIDENT LOST HIS BALANCE WHILE AMBULATING WITH WALKER fell TO FLOOR, (VITAL SIGNS DOCUMENTED) DENIES ANY PAIN, RESIDENT REQUESTED PAIN MED - 2 [MEDICATION NAME] @ 1100 RATES PAIN @ 2/10, WILL CONTINUE TO MONITOR." THERE WAS NO DOCUMENTATION WHETHER THE RESIDENT HIT HIS HEAD WHEN HE fell OR WHETHER HE LOST CONSCIOUSNESS. THERE WAS NO COMMENT REGARDING ANY CHANGE IN HIS MENTAL STATUS. THERE WAS NO DOCUMENTATION OF ASSESSMENTS REGARDING MOTOR OR SENSORY FUNCTION. LICENSED PRACTICAL NURSE (LPN) #9 WAS INTERVIEWED BY TELEPHONE ON 9/25/12 AT 11:10 A.M. SHE SAID SHE WAS COMING AROUND THE CORNER ON 7/26/12 AND SAW STAFF GETTING RESIDENT #501 OFF THE FLOOR. SHE SAID SHE WAS SURE SHE EXAMINED THE RESIDENT, BUT SHE COULD NOT GIVE SPECIFIC INFORMATION ABOUT THE ASSESSMENT SHE HAD DONE. SHE SAID SHE NOTIFIED THE PHYSICIAN ABOUT THE FALL BUT COULD NOT REMEMBER WHAT INFORMATION SHE GAVE THE PHYSICIAN OR WHAT RESPONSE HE GAVE BACK TO HER. DOCUMENTATION ON THE INCIDENT REPORT INDICATED THAT THE FACILITY PHYSICIAN WAS NOTIFIED ON 7/26/12. THE TIME OF THE NOTIFICATION WAS NOT DOCUMENTED. THE NOTATION, "NO NEW ORDERS" WAS WRITTEN BELOW THE PHYSICIAN'S NAME. THE PHYSICIAN HAD NOT SIGNED THE FORM OR MADE COMMENTS ON THE INCIDENT REPORT. PHYSICIAN #7 WAS INTERVIEWED ON 9/24/12 AT 2 P.M. BY TELEPHONE. HE SAID HE PROBABLY WAS INFORMED OF RESIDENT #501'S FALL WHICH OCCURRED ON 7/26/12, BUT HE SAID HE DOESN'T ALWAYS WRITE THE INFORMATION DOWN. HE SAID HE DID NOT KNOW WHAT HE WAS TOLD. HE SAID THAT IF A RESIDENT FALLS AND THERE IS NO INJURY OR PAIN, HE DOESN'T USUALLY ORDER AN X-RAY. THE PHYSICIAN SAID HE USUALLY REQUESTS THAT THE RESIDENT'S NAME BE PLACED ON A LIST TO BE SEEN ON HIS NEXT VISIT TO THE FACILITY. HE SAID HE DIDN'T THINK THE FALL WAS RESPONSIBLE FOR THE RESIDENT'S INJURY WHICH REQUIRED SURGERY. "A FALL DOES NOT CAUSE ANY MORE STRESS THAN THE ADLS (ACTIVITIES OF DAILY LIVING) THAT HE IS DOING HERE (IN THE FACILITY)." PHYSICAL THERAPY ASSISTANT #4, WHEN INTERVIEWED ON 9/24/12 AT 10 A.M., SAID HE OBSERVED RESIDENT #501 DURING HIS THERAPY SESSION WHICH CONTINUED IMMEDIATELY AFTER THE FALL. PTA #4 SAID THAT HE DID NOT NOTE ANY CHANGES IN RESIDENT 501'S CONDITION. HE SAID THE RESIDENT DENIED ANY PAIN. PTA #4 SAID THAT HE PALPATED THE LOW BACK AREA AND DID NOT NOTICE ANY SYMPTOMS. THERE WAS NO POST-FALL ASSESSMENT DOCUMENTED IN THE PHYSICAL THERAPY PROGRESS NOTES. PHYSICAL THERAPIST (PT) #5, INTERVIEWED ON 9/24/12 AT 10:40 A.M., SAID HE WAS NOT IN THE FACILITY ON 7/26/12 WHEN RESIDENT #501 fell . HE SAID HE DID NOT FIND OUT ABOUT RESIDENT #501'S FALL UNTIL THE FOLLOWING DAY AFTER HE HAD COMPLETED THE EXERCISE PORTION OF PHYSICAL THERAPY FOR THE RESIDENT. HE SAID HE DID NOT CONDUCT ANY ASSESSMENTS ON 7/27/12 BECAUSE THERE WERE NO PROBLEMS. PT #5 SAID HE DID NOT SEE ANY NEED TO CONTACT THE FACILITY PHYSICIAN OR THE NEUROSURGEON. RESIDENT #506 WENT FOR A SCHEDULED VISIT WITH THE NEUROSURGEON ON 7/30/12. AN ASSESSMENT OF THE RESIDENT READ, "THE PATIENT TOOK A FALL 5 DAYS AGO. IN REVIEWING HIS X-RAYS IT APPEARS THAT HE MAY HAVE FRACTURED THE L3 PEDICLES (TWO SHORT THICK PROCESSES WHICH PROJECT DORSALLY, ONE ON EACH SIDE OF THE SPINAL VERTEBRAE) BILATERALLY. I HAVE DISCUSSED THIS WITH THE PATIENT AND EXPLAINED TO THE PATIENT THAT HE WILL MOST LIKELY END UP WITH AN EXTENSION OF HIS FUSION TO THE LEVEL OF L2. I SHOULD NOTE THAT HE HAS EXTRUDED DISC SPACER/CAGE POSTERIORLY AT THE LEVEL OF L3-4 ON THE RIGHT. . . I WILL ALSO HAVE HIM FITTED FOR A RIGHT KNEE STABILIZER AS HE HAS PROFOUND WEAKNESS IN BOTH HIS LOWER EXTREMITIES ESPECIALLY ON THE RIGHT." THE REPORT ALSO DOCUMENTED THAT "PATIENT REPORTS POSTOP STATUS AS WORSENING." HOSPITAL RECORDS FOR RESIDENT #501 WERE REVIEWED ON 7/26/12. A DISCHARGE SUMMARY, DATED 9/18/12, STATED, "(NAME OF RESIDENT) WAS BROUGHT TO THE OPERATING ROOM FOR A POSTERIOR LUMBAR DECOMPRESSION (REMOVAL OF MATERIAL TO GIVE NERVE ROOT MORE SPACE AND PROVIDE A BETTER HEALING ENVIRONMENT) WITH FIXATION (USING SCREWS TO POSITION BONES TOGETHER UNTIL THEY FUSE), GIVEN HIS NEW COMPRESSION FRACTURE. THE PATIENT UNDERWENT VERTEBROPLASTY (USE OF A SPECIALLY FORMULATED CEMENT TO STABILIZE COLLAPSED VERTEBRAE) WITH L2-S1 FUSION." THE RESIDENT WAS REadmitted to the facility on [DATE] AFTER THIS hospitalization . ( )