Every finding on record at Optalis Health and Rehabilitation of Canton

This citation pertains to intake 3108819. Based on observation, interview, and record review, the facility failed to implement interventions to prevent a fall for one (R107) of four residents reviewed for accidents resulting in R107 rolling off the bed during care from one staff member and sustaining a laceration of the right eyebrow. Findings include:On 8/25/26 at 10:15 AM R107 was observed in their room seated in a wheelchair. Upon inquiry R107 reported that they had a previous fall about a month ago when only one staff member rolled them off the bed during care. R107 said, I had an aide with me when I rolled off the bed. Turned me over right off the bed. Hit my eye and busted my eyebrow open. Went to the hospital and got a few stitches. She was by herself and we are supposed to have two. I told her that and she said she didn't know. She was a young girl from the agency. She hasn't been back since. According to R107's Electronic Health Record (EHR), R107 admitted to the facility on [DATE] with multiple diagnoses that include Diabetes, Atrial Fibrillation, and Pulmonary Embolism. The Minimum Data Set (MDS) dated [DATE] indicated R107 had moderately impaired cognition and required a mechanical lift with two persons assist for mobility and transfers from surface to surface. A care plan for Activities of Daily Living (ADLs) initiated on 5/15/26 indicated R107 required the assistance of 2 staff members for all ADLs including bed mobility. On 7/12/26 at 12:37 AM a progress note written by Licensed Practical Nurse (LPN) B documented the following; Resident was being changed by staff. Was rolled away from them and fell out of the bed. Resident stated hit his head on the floor. Resident has a contusion on the forehead and was sent out. On 8/25/26 at 11:49 AM during interview with the Director of Nursing (DON) she said, That resident was a two-person assist for all care. The CNA (Certified Nursing Assistant) did not ask for assistance when she provided care. The resident did fall and sustain a laceration to the eyebrow and had two stitches put in at the Emergency Room. The CNA was from an agency and has not returned to the facility. At this time the DON was asked to provide the facility's policy for ADL care and the contact information for CNA C who provided care to R107 on 7/12/26 at the time of the fall. On 8/25/26 at 12:26 AM during a phone interview with CNA C she said, I don't recall anything about that resident or any fall. CNA C declined to be interviewed any further. On 8/25/26 at 12:33 PM during interview, LPN B said, The young lady who was changing the resident rolled him away from her during care and walked away. She said she went to go get something from the cabinet and the resident fell on the floor. The resident is on an air mattress and always needs two people. She never asked for anyone to help her. We didn't even know she was in there providing care to the resident. LPN B reported that the CNA had not returned to the facility. According to the facility's policy for Activities of Daily Living (ADL) last revised on 2/2/2026 in part reads; Appropriate care and services will be provided for residents who are unable to carry out ADL independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:- Mobility (transfer and ambulation, including walking)The amount of assistance the resident needs to complete their ADL care will be documented in the resident's care plan

This citation pertains to intake 3097507. Based on interview and record review, the facility failed to provide pain management for one resident (R101) out of three residents reviewed, resulting in pain and discomfort.Findings include:It was reported to the State Agency that the facility failed to provide pain management for R101, who recently underwent surgery, resulting in the resident calling 911 for a transfer back to the hospital within 24 hours of admittance due to acute pain. On 08/25/2026 at 10:25 AM, R101 was interviewed and reported being denied pain medications after a surgical procedure on her nervous system. R101 said she was admitted to the facility on [DATE] for rehabilitation and was informed by a nurse that pain medications would not be available until 05/11/2026. R101 said she called 911 to be transferred back to the hospital due to excruciating pain and the lack of access to needed pain medications. Record review of a progress note written by LPN D on 05/10/2026 revealed: R101 called 911 to be transported to the hospital due to increased pain.Doctor notified earlier in shift regarding waiting on pain medication from the pharmacy. Writer explained to R101 that the pain medications would arrive in the morning batch. R101 didn't want to wait. No other nurse in the building with access to (automated medication dispensary) to pull from backup. R101 is refusing to wait at this time. R101 is being transported to hospital via two paramedics on stretcher. On 08/25/2026 at 2:16 PM, Licensed Practical Nurse (LPN) D could not be reached via telephone. On 08/25/2026 at 2:45 PM, the Director of Nursing (DON) was interviewed and stated, Licensed Practical Nurse (LPN) D had access to the (automated medication dispensary) System (a backup supply of securely stored, tracked medications and medical supplies within the facility). The DON further stated, LPN D should have pulled pain medications from the backup supply to ensure R101 had proper pain management and LPN D should have assessed R101's pain needs and could have prevented the rehospitalization. The DON also stated, Several staff are always available within the facility to access medications through (automated medication dispensary) as needed, especially to address pain. Record review of the Electronic Health Record (EHR) revealed R101 was admitted to the facility on [DATE] and discharged on 05/10/2026 with diagnoses of Radiculopathy, Cervicothoracic Region, Heart Failure, Atrial Fibrillation, Arthrodesis Status, Hypertension, Encounter for Surgical Aftercare following surgery on the Nervous System, Presence of Cardiac Pacemaker. Record review of R101's Care Plan dated 05/09/2026 revealed the following focus: At risk for pain with intervention: Administer pain medication as ordered. Record review further revealed a prescription and an order for Oxycodone HCL Oral Tablet 10mg dated 05/09/2026, to be given by mouth every 4 hours as needed for severe pain. A review of the facility's policy titled, Pharmacy Services for Nursing Facilities, with revision date: January 2018, read in part: The Automated Dispensing Unit is designed to aid in situations in which an emergency or starter dose of a medication is needed.The facility may use automated dispensing machines for first dose and emergency medications where permitted by regulation or law. A review of the facility's policy entitled, Pain Management with revision date 04/18/2024, read in part: Pain is a highly subjective and personal experience which is impacted by one's previous experiences with pain.

This citation pertains to intakes #2786224 and 2965279.Based on interview and record review, the facility failed to utilize a two-person assist and appropriate bed mobility techniques during a brief change of one resident (R511) of three residents reviewed for falls, resulting in the resident sustaining a closed head injury, abdominal hematoma, and a closed fracture of the femur requiring hospitalization.Findings include:On 4/15/2026 at 08:08 AM, the complainant, Family Member J was interviewed and queried about R511's fall. Family Member J said, On February 7th (2026), I receive a call from the facility that (R511) fell out of bed while staff were changing the (incontinence brief).(R511) was sent to the hospital with a broken leg. A review of R511's electronic medical record (EMR) revealed an admission to the facility on [DATE] with the diagnosis of Chronic Kidney Disease, Legally Blind, Atherosclerotic Heart Disease, Heart Failure, Spinal Stenosis (narrowing of spaces in the spine, causing nerve compression that leads to back/neck pain, numbness, and leg weakness), Muscle Weakness, Deep Vein Thrombosis (DVT), and Paraplegia (immobility causing loss of voluntary movement and sensation in the lower half of the body-typically both legs and sometimes torso). R511 was also on medication Eliquis (a blood thinner).A review of R511's Brief Interview for Mental Status (BIMS) dated 01/23/2026 disclosed a score of 10/15 (Moderately Impaired Cognition). A review of R511's care plan revealed the following: ADL (Activities of Daily Living) assist of 2 staff. Date Initiated: 01/22/Assist to bath / shower as preferred per shower schedule and as needed Date Initiated: 02/03/2026. Bed Mobility:2 person assists.dated 01/22/2026. Assist with daily hygiene, grooming, dressing, oral care and eating as needed Date Initiated: 02/03/2026.Bathing/Showering: 2 person assist. At risk for falls secondary to muscle weakness, paraplegia, encephalopathy, blindness.Dated 01/22/2026. A review of R511's Kardex (used to summarize essential patient information, medical orders, and nursing care needs) revealed the following: Bed Mobility: Two person assist.Toileting Use:2 person assist in bed. A review of R511 Emergency document Department (ED) Inpatient RN Handoff Note revealed the following: Patient presents with fall, leg pain Final Diagnoses:Acute Kidney InjuryFallClosed Head Injury, initial encounterAbdominal HematomaClosed fracture of femurED Intervention: Blood transfusion started HGB 6.8.Blood transfusionAcute right femoral distal metaphysical fracture due to witnessed fall-Presented after a rollover/fall from a bed.while changing clothes.-Imaging showed 5.1 CM left deep subcutaneous hematoma overlying the left hip.-Pain management. On 4/15/26 at 09:03 AM, Certified Nursing Assistant (CNA) A was interviewed by phone and queried about the care that was provided to R511's. CNA A stated, I was changing (R511's) brief I rolled (R511) to the other side of the bed.(R511) threw (their) leg over too hard and rolled off the bed as I walked to the other side of the bed. CNA A said she took her hands off R511while walking around to the other side of the bed. CNA A was asked if there was anyone assisting during the brief change. CNA A stated, I've changed (R511) alone several times.I did not have any help because I was the only aide down the [NAME] Hall. CNA A added that R511 was very sleepy during care. CNA A was asked the number of staff needed to assist R511during care according to the Kardex. CNA A said, The Kardex has (R511) two persons assisting. CNA A was asked if they were trained to roll residents toward or away. CNA A said that R511 should have been rolled towards her and not away. A review of the facility's daily assignment document revealed a census of 12 residents, one CNA and one Nurse for the [NAME] Hall. 4/16/2026 at 1:45 PM, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was interviewed and discussed R511falling out of bed after CNA A rolled the resident over, resulting in hospitalization and fracture. The DON said CNA A should have rolled the resident towards her and not away. A review of the facility's policy Bed Mobility-Safety Education dated 5/27/2025 revealed the following: Check Kardex and check for assist needed for bed mobility.

Based on observation, interview and record review, the facility failed to (1) ensure the use of personal protective equipment when providing care for residents on Enhanced Barrier Precautions and (2) failed to continuously maintain, implement and operationalize a comprehensive infection control program, encompassing outcome and process surveillance, accurate data collection/documentation/analysis, resulting in missed opportunities to prevent the spread of infection.Findings include:On 4/15/2026, at 6:28 AM Certified Nurse Aid (CNA) B was observed changing R519 incontinent brief without wearing proper personal protective equipment (PPE) despite R519 being on Enhanced Barrier Precautions (EBP) for a stage III pressure ulcer to the sacrum/ coccyx area. CNA B did not wear a gown when performing hygiene care. CNA B was observed changing gloves after performing hygiene care. CNA B did not use sanitizer or soap and water to wash hands before applying new gloves. After performing hygiene care to R519 CNA B applied new gloves and moved to R520 and started hygiene care. On 4/15/2026 at 6:37 AM, observed (CNA) B perform incontinence care on R520. CNA B was observed providing incontinence care without wearing proper PPE despite R520 being on EBP for having a Percutaneous Endoscopic Gastrostomy tube (PEG tube), which is a feeding tube. CNA B did not wear a gown when performing hygiene care. On 4/15/2026 at 6:45 AM CNA B was interviewed and said they were in a hurry and did not see the EBP sign on the room door for residents R519 and R520. On 4/15/26 at 6:47 AM Licensed Practical Nurse (LPN) C was interviewed and acknowledged they observed CNA B perform hygiene on R519 and R520 without wearing proper PPE. LPN C was interviewed concerning EBP and said that CNA B should have had a gown on when performing hygiene care on EBP residents. On 4/16/2026 at 2:00 PM, interviewed the Director of Nursing (DON) who reported when a resident has (EBP) the staff are expected to wear the proper (PPE), which includes wearing a gown. The DON said staff should perform hand hygiene between residents. Review of facilities policy titled, Enhanced Barrier Precautions, revision date 2-6-2026. The policy was to serve as a guideline to prevent the transmission of multidrug resistant organisms. The EBP policy noted utilizing PPE a gown and gloves for certain residents which included residents with wounds R519 had a stage III wound and R520 had a feeding tube. On 4/16/26 at 09:55 AM, A review of the facility's infection control program was conducted with the Director of Nursing (DON) and the Corporate Nurse K. A review of the infection control binder provided by the facility revealed no documentation of an infection control program from September 1, 2025, through April 1, 2026. The DON stated, I was not employed here at that time. Corporate Nurse K said that the missing information was identified on 4/6/2026 during an internal facility audit. Corporate Nurse K said despite having several Infection Preventionist (IP)in the role, they did not perform IP core responsibilities of identifying, investigating, monitoring, and reporting infections. A review of the facility's Infection Control Binder revealed the following missing documentation: Antibiotic stewardship program Staff education and competency checks Environmental Audits Emergency preparedness for outbreaks Audit tools for hand hygiene, PPE, and cleaning McGeer Criteria (standardized infection classifications used for surveillance in long-term care (LTC) facilities to distinguish true infections from non-infectious symptoms) Outbreak Investigations On 4/16/2026 at 10:12 AM, requested the Infection Control Policy from the DON. This policy was not received upon exit.

Based on interview and record review the facility failed to maintain a continuous Antibiotic Stewardship Program that includes monitoring antibiotic usage, tracking resistance, prevent emergence of resistance, and following protocols for antibiotic use, which has the potential to affects all residents residing in the facility.Findings include:A review of the facility's policy Antibiotic Stewardship dated 02/04/2026, revealed the following: Facility staff and medical practitioners have a responsibility to assure that antibiotics are requested and provided only when the root cause is determined to be a bacterial infection and only for the length of time needed to adequately treat the infection.The overall goals of antibiotic stewardship is to:o Improve appropriate utilization of antibiotic therapy.o Reduce resistance to antibiotic therapy.o Reduce adverse drug events related to antibiotic therapy (including allergic rash, anaphylaxis, death, C. difficile, colonization, disruption of normal flora and the development of resistant organisms).o Reduce administration of unnecessary antibiotics.o Improve resident outcomes.The facility follows the CDC's core elements for antibiotic stewardship which includes:o Leadership commitment, including the Director of Nursing, Infection Preventionist, Medical Director, and Consultant Pharmacist, to the safe and appropriate use of antibiotics by ensuring that:Antibiotic stewardship prescribing protocols are followed: Utilization of McGeer's criteria in determining the presence of symptoms meets the definition of an infection. Diagnostic testing required to be completed per McGeer's criteria prior to initiation of antibiotic orders. Diagnostic test results received that do not meet criteria will be reported to the medical practitioner for further evaluation of need. Orders for antibiotics will include the name, dose, route, frequency of the antibiotic as well as indication for use and stop date. Pharmacy to assist with dosing recommendations especially for antibiotics that require peak and trough levels to determine therapeutic levels.racking is demonstrated by: Monitoring various measures of antibiotic use, which may include:o Adherence to clinical evaluation documentation including signs, symptoms, and other physical examination findings in the resident's electronic medical record.o Adherence to cultures obtained before antibiotics are initiated or changed after culture results are received.o Adherence to completeness of orders with name, dose, route, frequency, duration, and indication.On 4/16/26 at 09:55 AM, A review of the facility's Antibiotic Stewardship Program was conducted with the Director of Nursing (DON) and Corporate Nurse K. During the program review there was missing documentation in the Antibiotic Stewardship Program from September 1, 2025, through April 1, 2026. The DON was asked if they had an Infection Preventionist during September 1, 2025, through April 1, 2026. The DON stated, I was not employed here at that time and was unable to explain why the ABT stewardship program was not in affect during this time. Corporate Nurse K said they found inadequate documentation for the Antibiotic Stewardship Program during an audit conducted on April 6, 2026, indicating the program was not properly implemented.

This citation is related to intake #2962412.Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for one resident (R504) of three residents reviewed for neglect, resulting in the resident calling three times to the local police/ fire departments for allegations of neglect of care by the nursing staff.Findings include: On 4/15/26 at 3:00 A.M. an onsite investigation was initiated concerning the allegations of neglect for R504.On 4/15/26 at 4:30 A.M. R504 was observed in bed sleeping. R504 was easily aroused and after introductions indicated the next day would be best for further discussions related to no response to call lights. The resident continued to talk and pointed to a chair in the hallway stating, you see that chair outside in the hall staff sit there and sleep and talk on their phones all night. Staff do not respond to our call lights at the front desk or at the nursing station. R504 continued to express his concern in an agitated manner repeating come back tomorrow, please.On 4/16/26 at approximately 9:00 A.M. R504 was interviewed. R504 initially declined to discuss the incident stating agency staff did not answer the call lights and after dialing the nursing station and the front desk R504 felt there was no other way to get help but to call 911. R504 indicated that the concern was ongoing and it did not matter who you reported the concern to it was not addressed. The care here is bad on the midnight shift. The nurses and aides just ignore you, it's like you do not exist in here.On 4/16/26 at 10:00 A.M. R504 admitted repeatedly calling 911 on (local police/Fire) department on 3/15/26 in the A.M leading into the next day. R504 stated putting his call light on . no one answered or responded after waiting two to three hours, My catheter was blocked I was in pain, I have had so many problems, and urinary tract infections. My roommate R79 can verify calling to the nursing station no one answers, we both began hollering out the door for help, no one came or responded. R504 stated agency staff were terrible, and the nursing staff did not see the urgency or the need to address concerns of neglect. The resident stated the same concerns were reported to two previous Administrator and nurse P who no longer was employed at the facility. Review of Police report case #2604 , dated 3/16/26 stated in part. on 3/15/26 time stamped 20:30 on 03/15/2026 R504 called 911 on two different occasions, hours apart after not being able to call or get assistance from facility staff to be changed when he soiled himself. The Fire department and dispatch called the facility multiple times, with no answers. The Fire department responded, upon arrival at the facility staff were unaware the patient needed assistance. When 911 was called the second time, The Fire Department called the facility within the building and did not hear any phones ringing. There were nurses located on their personal phones and afterwards they tended to R504 after being prompted by the Fire Department. Due to the suspected neglect Police were called to the scene by the fire department. During this onsite visit at the facility the police physically observed staff change the patient seeing a soiled diaper.R504 reported during the interview on 3/15/26 lying in a soiled diaper for approximately four hours requesting assistance from staff around 20:30 hours (8:30 P.M.) at 22:55 hours (10:55 P.M) R504 called 911 for assistance in which the police department responded leading to no change in staff behavior as R504 diaper was still never changed, Instead R504 was provided with a blanket. The Fire department left the facility at 23:38 hours (1:38 P.M.). R504 called 911 a second time at 0012 hours to report the same situation. This call was then reported to the police department.Further record review revealed case report #2602LOVE R504 made a service call to the local police department on 3/30/26 at 21:31 hours (9:31P.M.) stating staff not answering him. At 22:05 hours (10:05 P.M.) Nurse was in the resident's room prior to officer's arrival, no other issues notified.R504 was admitted to the facility on [DATE], with diagnoses which included: progressive multiple sclerosis, calculus in bladder, anxiety disorder, neuromuscular dysfunction of the bladder, gross hematuria, adjustment disorder, major depressive disorder, adjustment insomnia and protein calorie malnutrition.According to the Minimum Data Set (MDS) dated [DATE], R504 was moderately impaired cognitively (ability to think) with a Brief Interview for Mental Status (BIMs of 10/15) and was totally dependent on staff to provide all activities of daily living.On 4/16/26 at 1:00 p.m. The Administrator denied knowledge of R504's concerns related to nursing and agency staff not responding to call lights. The Administrator reported residents should not be calling the Police/Fire department for assistance with care at the Nursing facility at any time.On 4/17/26 at 4:00 p.m. review of the facility's policy titled Abuse revised 2/2/2026 stated. Residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint that is not required to treat the patient/resident's medical symptoms.Upon exiting the facility on 4/17/26 at 4:30 P.M no other additional information was provided regarding R504 calling local fire/police department on three separate occasions reporting that nursing staff were not answering or responding to his call light in a timely manner.

This citation pertains to 2980193, 2981179, 2966122, 2962412, 2962938, 2795382, 2794223, 2797203 and 2791414Based on observation, interview and record review, the facility failed to ensure appropriate urinary incontinence care for two residents (R519 and R520) of 14 residents reviewed, resulting in the potential to cause skin breakdown, discomfort and poor moisture management. Findings Include:On 4/15/2026 at 5:18 AM, a strong smell of urine was noted to come from the room of R519 and R520. At that time, Licensed Practical Nurse (LPN) C was interviewed regarding the smell of urine. LPN C said they did notice a smell and the room floor was sticky.At 5:43 AM Certified Nurse Aid (CNA) B took a white incontinence brief and towels in the room of R519 and R520. CNA B left the items and exited the room. At 5:58 AM (CNA) B returned to the room and asked R519 about performing incontinence care. CNA B exited the room.At 6:28 AM (CNA) B was observed to perform incontinence care on R519. While performing incontinence on R519 it was observed to have on two incontinence briefs. R519 had on a white incontinence brief with a green brief on the inside.4/15/2026 at 6:28 AM CNA B was interviewed about R519 having on two incontinence briefs. CNA B said they did not consider that double briefing because the brief that was placed on the inside was not closed.R512 was initially admitted on [DATE] diagnosed with the following: ACUTE RESPIRATORY FAILURE WITH HYPERCAPNIA, CHRONIC KIDNEY DISEASE, STAGE 3, ADJUSTMENT DISORDER WITH MIXED ANXIETY AND DEPRESSED MOOD, HEART FAILURE and DIFFICULTY IN WALKING.Review of R519 Minimum Data Set (MDS) dated [DATE] revealed Brief Interview for Mental Status (BIMS) was 11 out of 15 moderately cognitively impaired.Review of R519 care plan focus indicated the following ADL self-care deficit related to muscle weakness, impaired physical mobility, COPD, CHF, low back pain. The goal was as follows: Will receive assistance necessary to meet ADL needs. Intervention for toileting was TOILETING USE: 1-2 person assist in bed.On 4/15/2026 at 6:37 AM, (CNA) B performed incontinence care on R520. While performing care CNA B was observed to remove multiple layers of clothing as well as two white incontinent briefs one brief inside of the other.On 4/15/2026 at 6:47 AM, LPN C was also queried about placing more than one incontinence briefs on residents at a time. LPN C said that staff are not allowed to double brief.On 4/16/2026 at 9:25 AM R520 was interviewed about staff applying multiple briefs. R520 said staff double brief residents at night.(R513) was initially admitted on [DATE] with diagnosis as follows: CEREBRAL INFARCTION, BIPOLAR DISORDER, GENERALIZED ANXIETY DISORDER, MILD COGNITIVE IMPAIRMENT, HEMIPLEGIA AND HEMIPARESIS, ACUTE RESPIRATORY FAILURE WITH HYPOXIA and DISORDER OF MUSCLE.Review of R520 Minimum Data Set (MDS) dated [DATE] Brief Interview for Mental Status (BIMS) was noted as 12 out of 15.On 4/16/2026 at 2:00 PM, interviewed the Director of Nursing (DON) said the staff should not double brief residents. The DON said they expect staff would check and change residents according to policy.Review of policy title, Incontinence Care-Urinary and Fecal with a review date of 2-3-2026 the policy did not address multiple briefs.

This citation pertains to intakes 2980193 and 2962412Based on observation, interview and record review the facility failed to ensure that one resident (R519) with a stage III pressure injury received necessary treatment and services to promote healing of six reviewed for wound care.Findings include: At 5:43 AM Certified Nurse Aid (CNA) B took a white incontinence brief and towels in the room of R519. CNA B left the items and exited the room. At 5:58 AM (CNA) B returned to the room and asked R519 about performing incontinence care. CNA B exited the room.At 6:28 AM (CNA) B was observed to perform incontinence care on R519. While performing incontinence on R519 it was observed to have on two incontinence briefs. R519 had on a white incontinence brief with a green brief on the inside.4/15/2026 at 6:28 AM CNA B was interviewed about R519 having on two incontinence briefs. CNA B said they did not consider that double briefing because the brief that was placed on the inside was not closed.On 4/16/2026 at 9:14 AM, interviewed the Wound Care Nurse about R519. The Wound Care Nurse said R519 had a wound that was classified as stage III pressure ulcer. The wound was located to the sacral/coccyx area. The treatment was zinc oxide with alginate for stage III pressure ulcer. The Wound Care Nurse said residents with this type of wound should not have multiple incontinence briefs applied because additional moisture can impede healing. R519 was initially admitted on [DATE] diagnosed with the following: ACUTE RESPIRATORY FAILURE WITH HYPERCAPNIA, CHRONIC KIDNEY DISEASE, STAGE 3, ADJUSTMENT DISORDER WITH MIXED ANXIETY AND DEPRESSED MOOD, HEART FAILURE and DIFFICULTY IN WALKING.Review of R519 Minimum Data Set (MDS) dated [DATE] revealed Brief Interview for Mental Status (BIMS) was 11 out of 15 moderately cognitively impaired.Review of R519 care plan focus indicated the following ADL self-care deficit related to muscle weakness, impaired physical mobility, COPD, CHF, low back pain. The goal was as follows: Will receive assistance necessary to meet ADL needs. Intervention for toileting was TOILETING USE: 1-2 person assist in bed.On 4/16/2026 at 2:00 PM, interviewed the Director of Nursing (DON) said the staff should not double brief residents. The DON said they expect staff would check and change residents according to policy.

This citation is related to intake #2962412.Based on interview and record review the facility failed to develop and revise a comprehensive Care plan for one resident (R504) of 14 residents reviewed for care plans, resulting in the potential for unmet care and services.Findings include:On 4/16/26 at 8:45 A.M. review of the Electronic Health Record indicated R504 was admitted to the facility on [DATE], with diagnoses which included: progressive multiple sclerosis, calculus in the bladder, anxiety disorder, neuromuscular dysfunction of the bladder, adjustment disorder, major depressive disorder, adjustment insomnia and protein calorie malnutrition.According to the Minimum Data Set (MDS) dated [DATE], R504 was moderately impaired in cognition (ability to think) and was totally dependent on staff to provide all Activities of Daily Living. (ADL's). On 4/16/26 at 8:50 A.M, review of the Care Plan Report initiated 8/4/2025 Titled: AT risk for changes in behavior and mood related to anxiety, MDD, with a Goal: R504 will accept care and medication as prescribed.Interventions documented to accomplish the goal included:Administer medications per physician ordersCalls police and Fire DepartmentMay attempt distraction intervention, music activities, relaxation techniques positioningOffer choices to enhance sense of controlPsy consult as orderedRedirect as needed.Record review on 4/16/26 at 9:30 A.M. revealed R504 had a history of calling the police and fire department requesting their assistance when the midnight shift failed to respond to the call light. The fire/police department reported R504 initiated three separate calls to their departments with the last call being made on 3/30/26 requesting a service call to the hospital. On each call officers and/ fire dispatch company responded to the resident.Further review of the Care Plan Report did not identify any interventions to prevent recurrences nor were there any revisions in the implemented care plans identifying R504 as receiving hospice care/services.According to the Nurses notes dated 3/17/26 through 4/17/26 by Director of Nursing (DON) Q, R504 was interviewed concerning one of the three incidents where the resident called the fire/police department. Per the nurses Note R504's only concern or complaint was he did not want agency staff caring for him. Safety measures were reported to be in place, however, there was no care plan or interventions addressing safety measures for R504.On 4/16/26 at 12:30 P.M Social Worker (SW) N was interviewed concerning the resident's behavior of calling the fire/police department. SW N reviewed the care plan but had no explanation how the intervention for calling the police/fire department was listed as a step to provide R504 assistance with agency or nursing staff. On 4/17/26 at 3:00 P.M. interview with the corporate consultant, the Administrator, Director of Nursing and Nurse K no additional information was provided. At this time a request was made of the facility's policy pertaining to care planning.Review of the facility's policy Titled: Care Plan-Comprehensive and Revision, dated 2/2/2026 indicated in part. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: When there has been a significant change in the resident's condition.o When the desired outcome is not met.

This citation is related to intake #2962412.Based on observation, interview, and record review the facility failed to adequately address and resolve grievances in a timely manner for one (R504) of four residents reviewed for grievances, resulting in neglect related to care by nursing staff.Findings include:On 4/15/26 at 4:30 A.M. R504 was observed in bed sleeping. R504 was easily aroused and after introductions indicated the next day would be best for further discussions related to no response to call lights. The resident went on and stated you see that chair outside in the hall staff sit there and sleep and talk on their phones all night. Staff do not respond to our calls to the desk or nursing station.During an interview on 4/16/26 at 10:00 A.M. R504 reported on 3/15/26 lying in a soiled diaper for approximately four hours requesting assistance from staff around 20:30 hours (8:30 P.M.). At 22:55 hours (10:55 P.M) R504 called 911 for assistance in which the police department responded leading to no change in staff behavior as R504 diaper was still never changed. R504 was provided with a blanket. The Fire department left the facility at 23:38 hours (11:38 P.M.). R504 called 911 a second time at 0012 hours to report the same situation. This call was then reported to the police department. A written case report (#2604 ) was referenced and obtained for review.R504 was admitted to the facility on [DATE], with diagnoses which included: progressive multiple sclerosis, calculus in bladder, anxiety disorder, neuromuscular dysfunction of the bladder, gross hematuria, adjustment disorder, major depressive disorder, adjustment insomnia and protein calorie malnutrition.According to the Minimum Data Set (MDS) dated [DATE], R504 was moderately impaired in cognitive thinking with a BIMs of 10/15, was totally dependent on staff to provide all activities of daily living. According to the written case report #(2604 ), dated 3/15/26, noted, On the next day a follow-up from the local police/fire department was reported to the facility. Contact was made with the former Director of Nursing (DON) Q who initially advised she was not aware of the incident, and suspected staff to be turning the phones off at night and would be conducting an internal investigation and were provided with names for those staff interviewed by Police. Shortly after, voicemail was received from DON Q stating she was told about the incident but was half asleep when she was told and wanted to discuss further. Call was returned, email was sent, and no response was received.During the onsite investigation conducted 4/15/26 at 3:20 A.M., R504 was asked whether concerns related to delays or no response to call lights were presented to the facility administrator (Abuse Coordinator). R504 responded yes. The resident could not remember the exact dates but did indicate concerns were discussed with two previous administrators and another employee that later was reported to no longer be employed at the facility.On 4/16/26 at 11:50 A.M a request was made to review the concern forms submitted for R504 from 11/2025 to the present date. At 4:00 P.M. the Administrator presented one concern from dated 1/16/2026. Concerns from Resident: R504 On Friday, January 16,2026, R504 called me at approximately 12:28 P.M. and requested my presence to discuss his concerns. We spoke for over an hour, and he gave a multitude of grievances. They are as follows: (In the order written and submitted by staff). 1. On Midnight shift we must wait over two hours for his call lights to be answered.2. Both nurses and CENAs are constantly on their phones while performing patient care.4. Agency CENA's are usually horrible and rude.5. R504 has gone two weeks without bed bath on Thursday, specifically when CNA M was assigned to the resident, never got cleaned up resident state when assigned to him tends to disappear.11. When staff get upset, they curse patients out.Review of the resolution to this grievance was reviewed and documented education will take place on his specific concern; The writer also assured the resident that his concerns are valid.On 4/17/26 at approximately 9:30 A.M. Administrator reported there was no evidence of the education of staff for the grievance and the individual who was assigned that job their last day of work was 3/27/26.On 4/17/2026 at 2:30 P.M. the facility's policy for grievances was requested and provided. Review of the facility policy titled : Concerns and (Grievances) Process, dated 2/4/2024 stated in part. The Administrator is the Grievance Officer of the facility. The Grievance Officer is responsible for overseeing the concern (grievance) process which includes receiving and tracking concerns through to their conclusion, maintaining the confidentiality of information associated with grievances, and issuing written grievance decisions to the residents upon their request. The grievance officer may choose to lead or delegate any necessary investigations and/or follow-up related to the concern. The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect, and misappropriation of property, as per state and federal law and facility policy, including taking immediate action to prevent further potential violations of resident's right while the alleged violation is being investigated.

This citation pertains to intake #2786224 Based on observation, interview and record review, the facility failed to ensure training, evidence of skills performed, and confirmed Certified Nurse Assistants (CNAs) were capable of delivering safe care to vulnerable residents, resulting in one resident (R511) of three residents reviewed for falls, resulting in R511 sustaining a closed head injury, abdominal hematoma, and a closed fracture of the femur, requiring hospitalization. This has the potential to affect all residents Findings include: On 4/15/2026 at 08:08 AM, the complainant, Family Member J was interviewed and queried about R511's fall. Family Member J said, On February 7th (2026), I receive a call from the facility that (R511) fell out of bed while staff were changing the (incontinence brief).(R511) was sent to the hospital due to a broken leg. A review of R511's electronic medical record (EMR) revealed an admission to the facility on [DATE] with the diagnosis of Legally Blind, Atherosclerotic Heart Disease, Spinal Stenosis (narrowing of spaces in the spine, causing nerve compression that leads to back/neck pain, numbness, and leg weakness), Muscle Weakness, and Paraplegia. A review of R511's Brief Interview for Mental Status (BIMS) dated 01/23/2026 was a score of 10/15 (Moderately Impaired Cognition). A review of R511's care plan revealed the following: A review of R511's Kardex (used to summarize essential patient information, medical orders, and nursing care needs) revealed the following: Bed Mobility: Two person assist.Toileting Use:2 person assists in bed. A review of R511's progress note created by LPN L, dated 2/7/2026 at 07:21 AM revealed the following: Staff made nurse aware that the resident had a fall while changing brief. Upon entering the nurse observed resident on the floor, lying on Right side. On 4/15/2026 at 09:03 AM, Certified Nursing Assistant (CNA) A was interviewed by phone and queried about the care that was provided to R511's. CNA A stated, I was changing (R511's) brief I rolled (R511) to the other side (away from CNA A) of the bed.(R511) threw (their) leg over to hard and rolled off the bed while I walked to the other side of the bed. CNA A was asked if there was anyone assisting during the brief change. CNA A stated, I've changed (R511) alone several times.I did not have any help because I was the only aide down that hall. CNA A was asked how many persons were needed to assist during care according to the Kardex. CNA A said, The Kardex has (R511) two persons assisting. CNA A was asked if they were trained to roll residents toward or away. CNA A said that R511 should have been rolled towards her and not away. CNA A was asked if they received training or education following R511's fall from the bed. CNA A said, No one said anything to me about (R511's) fall.No one said I did anything wrong.I did not receive training at this facility about bed mobility.I don't know if we have a trainer here (at this facility). 4/16/2026 at 1:45 PM, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was interviewed and discussed R511falling out of bed after CNA A while receiving care and additional resident care training. The DON said CNA A should have rolled the resident towards her and not away. The DON said the Staff Educator/Trainer did not meet the expectations of the job. The DON said this position was not fully functioning since September 2025 (September 1, 2025 - April 1, 2026). The NHA said that preceptors were providing training to new staff. The NHA said a new Staff Educator/Trainer will start next week. A review of the facility's policy Skills Evaluations dated 02/09/2024 revealed the following: The skills evaluations checklist(s) is completed during job-specific orientation, re-validated annually, and completed as needed.The Human Resources Director is responsible for maintaining employee records involving performance appraisals, skills evaluation, and in-service records.

Based on observation, interview and record review the facility failed to ensure operational, systemic systems were maintained to ensure the highest, practicable, physical, mental and psychosocial well-being of each resident, resulting in multiple complaints related to Quality of Care and Quality of Life in the facility. This deficient practice has the potential to affect all residents residing in the facility.Findings include:During the abbreviated survey conducted April 15, 2026, at approximately 3:30 A.M. multiple deficiencies were identified and are presented as follows:The facility failed to provide adequate supervision, transfer assistance and interventions to prevent a resident fall resulting in a fracture and hospitalization.There was no system or individual to consistently monitor, assess and coordinate the competency and skill level of Agency staff and nursing personnel of the facility from September 2025 through April 2026.There was no consistent Infection Control Program resulting in missed opportunities to prevent the spread of infections from September 2025 through April 2026.The staff turnover and the lack of utilization of effective resources was evident as the midnight shift on 4/15/26 could not identify what nurse was in charge and repeatedly identified each other. Nursing staff on the first floor reported they had been instructed to call the current Director of Nursing should any problem arise.There was an allegation of neglect reported to the Grievance Officer (The Administrator serves as the Grievance Officer) on 1/16/2026 by a resident. Subsequently, two more additional incidents were reported to Director of Nursing Q on 3/19/26 for the same resident after the resident called the local Fire/Police Department stating nursing staff failed to respond to the call light within a timely manner (more than a two-hour waiting period). There was no available evidence that the allegations were investigated or reported to state Agency after a 1:1 meeting with the Grievance Officer who interviewed the resident and documented resolution of the allegation.In addition, the standards of practices for incontinence care were not consistent with the most recent and latest Best Practices specified in PubMed: The effect of multiple layers of linens on surface interface pressure (2013): Evidence indicates that adding extra layers (like extra briefs or liners) increases pressure on the sacrum, directly contradicting pressure redistribution needs. Double briefing of two residents provided an unpleasant odor which permeated the halls on the second floor as well as the potential loss of the residents' dignity.There were multiple incidents reported by residents, local Fire/police and family members indicating the facility was called during the midnight shift and no one answered the telephone. This allegation was verified during the abbreviated survey. Calls were made to the facility on and off-site and no staff answered or responded to the calls. The Maintenance Director verified that the phones were on but not audible by staff.During the survey attempts were made to call the facility at 4:11 am and 4:48 am the facility phone-rang 6 times and went to voice mail without staff answering. One call was placed while present at the First-Floor nursing station, and no phone was heard to ring.Corporate Nurse K explained that during an internal facility audit on 4/6/2026 was unable to be completed and resulted in termination due to insufficient action and documentation of department leadership employed at that time.In an interview on 4/17/26 at 3:15 P.M. with Corporate Consultant P, the Administrator, Director of Nursing and RN K these issues were presented and reviewed. The facility staff explained that the previous Administrator and Director of Nursing Q were terminated the week of 3/29/26. The Administrator and the Director of Nursing explained that they were unable to address the concerns presented by the State Agency. At that time, additional information and explanations were requested in order to ascertain what concerns the facility was aware of.Upon existing the facility on 4/17/26 at approximately 4:30 P.M., no other information was provided or presented.

This citation pertains to intake: 2785066.Based on interview and record review the facility failed to thoroughly investigate an allegation of an injury of unknown origin for one (R603) of three residents reviewed for abuse. Findings include: The State Agency (SA) received a complaint that R603 had an injury of unknown origin to their lip. According to R603's Electronic Health Record (EHR) R603 admitted to the facility on [DATE] with multiple diagnoses that included history of a stroke with residual right-sided hemiparesis (partial paralysis) and aphasia (impaired ability to speak, understand, read, and write). The Minimum Data Set (MDS) dated [DATE] indicated R603 had a BIMS (brief interview for mental status) score of 00/15 due to R603 being rarely understood, declining to answer, or could not complete the BIMS. On 2/23/26 at 4:28 PM a progress note written by Social Worker (SW) I documented R603's family member called to report they were upset regarding care issues over the past weekend. The Nursing Home Administrator (NHA) was present and spoke with R603's family member over the phone regarding the care concerns. On 2/25/26 at 5:19 PM a progress note written by SW I documented the following: Wellness visit completed with resident. Asked how they were doing following the incident. (R603) constantly pointed at their mouth and nodded yes they would like to see someone regarding the incident. There were no additional progress notes regarding an incident with R603's lip injury. There was no skin assessment. There were no additional progress notes regarding a mouth, lip, or oral assessment for R603.On 3/11/26 at 2:55 PM during interview SW I stated, The resident's family called me on the phone and said she (R603) had something on her lip and the resident was upset about it. The family didn't know what happened and was upset. SW I said during this time the Nursing Home Administrator (NHA) walked into the Social Work office and overheard the conversation. At this time R603's family reported the concerns to the NHA over the phone. The NHA is the abuse coordinator. SW I said during their follow up visit with R603 there were no signs of injury on the outside of R603's mouth. SW I said they did not complete an assessment to the inside of R603's mouth because, That would be for the nurse to do.On 3/11/26 at approximately 3:10 PM during interview with the NHA and Nurse Unit Manager License Practical Nurse (LPN) F they said a soft investigation had been completed on 2/20/26 for R603 by the Director of Nursing (DON) and she had it. The DON was not present in the facility at this time. LPN F said they had looked at R603's mouth and saw a small, dried crack on their (R603's) bottom lip that looked chapped. LPN F confirmed there was no progress note or documentation regarding this assessment. LPN F said she did not conduct any type of interview or investigation into the allegation.On 3/11/26 at 3:20 PM during a phone interview with the DON they said they had completed an investigation for R603, and it was in a paper file. The DON said it was determined that during oral care the resident (R603) bit down on the toothbrush. There was no bruise only a small crack or split on bottom lip that looked like chapped lips and not an injury. The DON said she interviewed the CNA who performed the care on the R603. The DON said she did not interview anyone else and could not recall the name of the CNA. On 3/12/26 at 10:45 AM the DON provided a paper file of the investigation for R603's incident on 2/20/26. The investigation included a skin assessment dated [DATE] (untimed) that documented R603 had dry cracked lips. The DON said she interviewed CNA J who was assigned to care for R603 on 2/20/26. A witness statement dated 2/20/26 (untimed) indicated CNA J reported the small slit on R603's bottom lip happened while providing oral care. The statement was unsigned by CNA J. The DON said that CNA J was from an agency and there was no contact information and that CNA J had not worked in the facility since that date. The DON confirmed there were no additional staff or resident interviews, assessments, or documentation regarding this allegation or the subsequent investigation. According to the facility's policy for Abuse last reviewed on 2/2/2026 in part reads: Key to investigating abuse allegations is an environment that facilitates the reporting of such allegations. Once reported, the center conducts a timely, thorough, and objective investigation of any allegation of abuse. It is the Center's policy to investigate all alleged violations involving Abuse, Neglect, Misappropriation of Resident Property, Exploitation or Mistreatment, including Injuries of Unknown Source to ensure that all individuals who report such; incidents amid allegations are free from retaliation or reprisal for reporting the incident. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of ail investigations to the administrator or designee and to the State Agency in accordance with State law. The investigation process includes: Identifying staff responsible for the investigation. Determining the purpose of the investigation and issue(s)to be investigated, whether or not the alleged violation has occurred, the extent, and cause.* Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations (such as other residents, family members, staff who worked closely with the alleged perpetrator and/or alleged victim). Conducting observations of the alleged victim, including identification of any injuries as appropriate, the. location where the alleged situation occurred, interactions and relationships between staff and the alleged victim and/or other residents, and interactions/relationships between resident to other residents as applicable. Identifying and reviewing all relevant medical records and facility documentation as applicable.:. If the alleged perpetrator is a staff member, review their employment records. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence). Providing complete and thorough documentation of the investigation. After completion of the investigation, the evidence should be analyzed, and the Administrator or designee will make a determination regarding whether the allegation is substantiated or unsubstantiated. The Administrator will determine if modifications to existing policies and procedures (or new policies and procedures) are needed to prevent similar Incidents or injuries from occurring in the future in accordance with its QAPI Plan. The quality assurance investigative materials will be reviewed by the quality assurance committee in accordance with the facility QAPI Plan. The quality assurance committee will take all actions deemed necessary based upon their review.Conclusion Reporting: The facility will ensure: The results of the investigation are reported to the Administrator and a final report will be submitted tothe State Survey Agency no later than five working days after the discovery of the incident. Any knowledge it has of any actions by a court of law which would indicate an employee is unfit forservice is reported to the state nurse aide registry or licensing authorities.Whether the incident/allegation is substantiated or unsubstantiated the Administrator and/or DON or designeewill:, Ensure involved patient/resident's plan of care is reviewed and revised, as appropriate, consistent with the results of the investigation. Review and analyze the results of the investigation with the QAPI committee to: Ensure a thorough investigation was completed, resident(s) are protected, root cause is determined. Determine if modifications to existing policies and procedures (or new policies and procedures)are needed to prevent similar events from occurring in the future, as applicable. Complete staff training, discipline, or termination, if appropriate, as determined by the results of the investigation. Implement any other measures as deemed necessary by the investigation including staff responsible f implementation of corrective actions and measures including the date of implementation and staff responsible for oversight.

This citation pertains to intake: 2785066.Based on interview and record review the facility failed to follow physician orders for one (R603) of three residents reviewed for standards of practices resulting in R603 not having a urinalysis collected in a timely manner.Findings include:The State Agency received a complaint that the facility did not follow the physician's order to collect a urinalysis in a timely manner. According to the Electronic Health Record (EHR) R603 admitted to the facility on [DATE] with multiple diagnoses that included history of Urinary Tract Infection (UTI). On 2/5/26 the Nurse Practitioner (NP) B ordered R603 to have a urinalysis (UA) with culture and sensitivity (C&S) sent to the lab for complaints of abdominal pain and history of recurrent UTI. On 2/6/26, Licensed Practical Nurse (LPN) E documented that R603 had refused straight catheterization (tube inserted through urethra into the bladder to drain urine, then immediately removed) and a urine sample could not be obtained. There was no documentation to support additional attempts to obtain a UA and C&S had been made. On 2/24/26 (19 days later) NP B re-ordered for R603 to have a UA and C&S. There was no additional documentation to indicate a UA had been collected. On 3/1/26 (5 days later) NP B re-ordered R603 to have a UA and C&S. On 3/1/26, Registered Nurse (RN) G documented that a UA had been collected and sent to the lab. The Minimum Data Set (MDS) dated [DATE] indicated R603 had a BIMS (brief interview for mental status) score of 00/15 due to R603 being rarely understood, declining to answer, or could not complete the BIMS. The MDS documented R603 was usually continent of urine and able to use the toilet with 1 - 2 person assist. A care plan for Activities of Daily Living initiated on 1/30/26 indicated R603 was a 1-2 person assist to the toilet for urination. A care plan for dehydration related to UTI initiated on 2/6/2026 included the following interventions: Labs as ordered. Report abnormal results to physician promptly. Attempts to contact LPN E and NP B were unsuccessful during the time of the survey.On 3/11/26 at 2:30 PM, RN G stated, On 3/1/26 the family asked me about the UA results and there was none. I called the NP and got another order to collect the UA by doing a clean catch (method for collecting urine to detect infections, while minimizing skin bacteria contamination). I put a clean hat (disposable plastic container designed to fit over a standard toilet to collect urine sample) in the toilet and was able to collect the urine sample right away. RN G said R603 discharged from the facility the next day and was unaware of the results.On 3/11/26 at 1:30 PM during an interview with unit manager, Registered Nurse (RN) F they said there had been attempts to obtain R603's urine sample by straight catheterization method but R603 declined. RN F confirmed that there were progress notes to indicate R603 was able to urinate in a toilet with assistance. RN F could not explain why R603's urine sample was not collected as a 'clean catch' prior to 3/1/26.On 3/11/26 at 3:40 PM during an interview with the Nursing Home Administrator they stated, No we did not collect the urine sample in a timely manner. We should have done it earlier. We own that and will complete in-service educations on that.

This citation pertains to intake 2723333.Based on observation, interview and record review, the facility failed to protect one resident (R905) from the right to be free from verbal abuse and neglect by Certified Nurse Assistant (CNA) A, out of five residents reviewed for abuse. This failure resulted in R905 experiencing degradation, humiliation, and episodes of tearfulness when retelling the incident.Findings include: An interview was conducted with R905 on 2/11/26 at 2:20 PM regarding an incident that occurred on 12/20/25 involving Certified Nursing Assistant (CNA) A. During the interview, R905 was observed and became tearful while describing the event. R905 said CNA A initially entered the room, placed a brief in the room, and was aware the resident was wet and required assistance but did not provide care until approximately one hour later. When CNA A returned, R905 requested a clean gown and flat sheet due to being wet with urine. R905 reported CNA A began yelling, stating the resident should have requested those items earlier and that she did not have time to obtain them, and indicated she would change the resident quickly and return later with the requested items. R905 reported CNA A yelled for approximately five minutes while providing care, which caused the resident to cry and feel degraded, humiliated, anxious, and uncomfortable. R905 said, CNA A returned approximately two hours later with a flat sheet and gown and behaved pleasantly in the presence of the nurse. R905 reported feeling anxious and uncomfortable while waiting approximately two hours for the requested items and sitting in urine.A follow-up interview was conducted with R905 on 2/12/26 at 9:30 AM for further information. R905 was observed and became tearful and stated, It just makes me sad that I was treated like that, I wish I could take care of myself.Record review of R905's electronic medical record revealed an original admission into the facility on [DATE] with a pertinent diagnosis of polyarthritis.Review of Minimum Data Set (MDS) dated [DATE], R905 had a Brief Interview for Mental Status (BIMS) score of 15/15, reflecting intact cognition, and required assistance with most Activities of Daily Living (ADL) care.Record review of R905's Care Plan Report dated 4/16/25, Assist with daily hygiene, grooming, dressing, oral care, etc.A phone interview with CNA A was attempted with no success on 2/12/26.Record review of Employee Counseling and Corrective Action Record dated 12/22/25, documented CNA A was terminated due to carelessness and negligence.An interview was conducted with the Director of Nursing (DON) on 2/12/26 at 1:30 PM. It was reported that an investigation was conducted and abuse was substantiated. It was reported that staff should not yell at residents and residents should receive incontinence care in a timely manner.An interview was conducted with Nursing Home Administrator on 2/12/26 at 2:55 PM, it was reported that an investigation was completed and abuse was substantiated. It was further reported that when staff yell at any resident it would be verbal abuse, and the CNA neglected the resident making her wait so long to be changed and causing her stress.Record review of facility's policy Abuse dated 2/2/26 documented the following: Residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint that is not required to treat the patient/resident's medical symptoms.

This citation pertains to intakes 2724140 and 2718825.Based on interview and record review the facility failed to adequately document, monitor and access one resident (R901) out of three residents reviewed for wound care, resulting in the potential for delayed treatment and worsening of R901's frost-bitten feet.Findings include:Record review revealed R901 was admitted into the facility on 1/9/26 with a pertinent diagnosis of pain in right and left foot and frost bite of feet.Record review of R901's Brief interview for Mental Status (BIMS) dated 1/10/26, R901 scored 15/15 reflecting intact cognition.A phone interview was conducted with Family Member (FM) B on 2/11/26 at 12:20 PM, it was reported the resident was admitted to the facility on [DATE] with bandages on both feet. It was further reported that during a visit on 1/10/26, R901's nurse was reminded by the FM B that the resident's bandages had not been changed. On a return visit on 1/11/26 in the morning, when R901's feet were inspected, both feet were still wrapped in the original bandage from hospital and had a bad stench to them. FM B said, the staff were reminded again: however, when staff did not come to the room in a timely manner emergency services were called, and R901 was transported to the hospital.Record review of admission Evaluation dated 1/9/26 at 12:17 PM, it was documented under Integumentary (skin)-both feet-frost bite.Record review of Physician Order Summary Report dated 2/12/26, revealed no orders to access, monitor or provide care for R901's bilateral feet.Record review of Progress Notes dated 1/9/26 - 1/11/26, revealed no documentation regarding a description of feet, assessment or monitoring of feet.Record review of Medication and Treatment Administration records revealed no physician orders.Record review of two Skilled Nursing Notes dated 1/10/26 documented no assessment or monitoring of resident's feet or dressings. Review of Skilled Nursing Notes dated 1/11/26 documented the resident had dressing on feet.Record review of R901's Skin Care Plan had no interventions to monitor, assess or treatment for the resident's feet.An interview was conducted on 2/11/26 at 1:50 PM with the Director of Nursing (DON), it was reported that the resident had no dressing applied to feet when resident was admitted on [DATE]. It was further reported that the resident's feet should have been assessed and monitored for any change in condition regardless of any bandage related to his diagnosis of frost bite.Record review of Emergency Department Admission paperwork dated 1/11/26. Pictures were reviewed of R901's feet that were taken on admission to the hospital and revealed the resident had the original dressings on both feet that were applied when discharged from the hospital on 1/9/26.A follow-up interview conducted with the DON on 2/12/26 at 1:45 PM, after reviewing paperwork for R905's admission to hospital, the DON reported that the nursing staff should do a thorough examination and should have documented the bandages in the resident's progress notes and informed the physician at the facility so orders could have been obtained and treatment orders implemented for the resident.Record review of facility's policy, Skin and Wound Guidelines dated 2/4/26, documented the following: Skin alterations and pressure injuries are evaluated and documented by the licensed nurse. Using the admission or readmission evaluation.

This citation pertains to intakes 2650924, 2663449, and 2668212.Based on interview and record review, the facility failed to implement policies and procedures for ensuring proper reporting of abuse to the State Agency for four residents (R102, R103, R104, R105) out of eight resident reviewed for abuse, resulting in the likelihood of further abuse and subsequent physical or psychological distress. Findings include:A review of a Facility Reported Incident (FRI) dated 10/6/2025 documented the following: R102 and R103. On 10/6/2025 at 3:00 p.m. the Administrator /Abuse Coordinator was notified by Licensed Practical Nurse (LPN) A that on October 2, 2025, R103 was heard swearing at the roommate R102. LPN A stated that the R103 was irritated and using abusive language with the roommate R102. The FRI continued and the Incident Summary documented: This was brought to the writer's (The Administrator/Abuse Coordinator) attention on today (10/6/2025) however the incident occurred on 10/2/1025. The (R103) as temporarily moved to another room due to verbiage from the (R102). Investigation initiated. Re-education started immediately on timely reporting adverse events to the Administrator/Director of Nursing (DON). The Investigation Conclusion documented: Following the facility's investigation, the incident between residents (R102) and (R103) was confirmed and that (R103's) room was changed to accommodate the comfortability of both residents. The facility will also do our due diligence in making sure that residents are appropriate to be in the same room to avoid any resident conflict in the future. R102 On 11/24/2025 at approximately 9:20 a.m. R102 was observed lying in bed with bilateral ear pods connected to a computer. During an interview R102 was asked to recall the incident that happened on October 2, 2025. R102 stated, I am alright, and I have not had any other altercation. R102 did not want to continue to elaborate on the incident, rolled over in bed, and continued to listen to the content on the computer. According to the electronic medical record (EHR), R102 was admitted to the facility on [DATE] with diagnoses of major depression, adjustment disorder with mixed anxiety and depressed mood, rheumatoid arthritis, and contracture of left and right hand. R102's quarterly Minimum Data Set (MDS) assessment, dated 10/29/2025, indicated R102 was cognitively intact with a BIMS (brief interview for mental status) score of 15/15. R102 was dependent with assistance with Activity Daily Living Care. R103. On 11/24/2025 at approximately 9:30 a.m. during an interview, R103 was asked to recall the incident that happened on October 2, 2025. R103 stated, I asked them (the staff) to move me after I had an altercation with my roommate because he kept the computer and the television on all night and I had to go to dialysis the next day early. I cussed him out because I was upset. According to the EHR, R103 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, immunodeficiency, type two diabetes mellitus, heart failure, and dependence on renal dialysis. R103's quarterly MDS, dated [DATE], indicated R103 was cognitively intact with a BIMS score of 15/15. R103 was dependent with assistance with Activity Daily Living Care. The facility's Nursing Home Administrator (NHA) was interviewed on 11/25/2025 at 4:45 p.m. regarding the verbal altercation between R102 and R103. The NHA was asked when the resident-to-resident verbal altercation happened. The NHA stated, The nurse did not notify me until October 6, 2025. I should have been notified of the day it happened on October 2, 2025. I already in-serviced my staff on reporting abuse timely. R104 and R105 A review of the clinical record documented R104 was admitted to the facility on [DATE]. R104's diagnoses included cerebral infarction, vascular dementia, and bipolar disorder. A Minimum Data Set assessment dated [DATE] documented intact cognition. A review of Incident/Accident reports for R104 documented in part the following: September 14, 2025: While doing the morning med pass, I saw (R105) and (R104) arguing and shouting to one another. Nurse L verbalized that he saw (R105) pushing (R104). (R104) verbalized that she was hit and pushed by another resident, and she is too old to fight other people. Denies pain and discomfort. A review of the clinical record documented R105 was initially admitted on [DATE] and readmitted on [DATE]. R105's diagnoses included chronic obstructive pulmonary disease, adjustment disorder with mixed anxiety and depressed mood. A MDS assessment dated [DATE] documented intact cognition. During an interview on 12/1/25 at 11:42 AM, the Nursing Home Administrator (NHA) confirmed that the 9/14/25 incident between R104 and R105 was reportable to the State Agency but was not reported due to an internal failure to notify her of the event. The facility policy titled, Abuse, dated 5/24/2023, was reviewed and documented in part the following: The facility will ensure that all allegations involving abuse .are reported immediately to the Administrator and: Reported to the State Survey Agency immediately but not later than two hours after the allegation is made if the allegation involves abuse or results in serious bodily injury .or Reported to the State Survey Agency no later than 24 hours if the allegation does not involve abuse an does not result in serious bodily injury. On 12/1/25 at 12:30 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to ensure showers for (R104) and grooming (R111) were provided per resident's preference resulting in unmet care needs and resident dissatisfaction. Findings include:R104A review of the clinical record documented R104 was admitted to the facility on [DATE]. R104's diagnoses included cerebral infarction, vascular dementia, and bipolar disorder. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition. A review of R104's care plans documented in part the following: ADL (activity of daily living) self-care deficit related to muscle weakness, unsteadiness on feet, behaviors. Date initiated: 5/19/25. Intervention: Assist to bathe/shower as preferred per shower schedule and as needed. Date initiated: 5/20/25. On 11/24/25 at 2:16 PM, Concerned Family Member (CFM) F said R104 had not been getting regular showers. On 11/25/25 at 12:15 PM, Licensed Practical Nurse/Unit Manager (LPN/UM) I said staff are to complete shower sheets when showers/bed baths were given or offered but refused. LPN/UM I said R104 was scheduled to receive showers on Tuesdays and Fridays on the afternoon shift. LPN/UM I added that showers were important because they help residents feel clean and better. If staff or family member gives the resident a shower, it should be documented. Certified Nurse Aide (CNA) documentation of baths for R104 during the past 30 days was reviewed with LPN/UM I and revealed the following:Bed bath given on 11/21/25Resident refusal documented on 11/11/25Not Applicable checked on 11/4/25, 11/7/25, 11/14/25, and 11/18/25.LPN/UM I was able to locate the following shower sheets:11/11/25 documented refusal11/18/25 documented refusalLPN/UM I said R104's refusals should have been reported to the nurse and documented in the medical record. A review of nursing documentation for the past 30 days did not reveal nursing documentation of shower refusals. On 12/1/25 at 10:59 AM, the Director of Nursing (DON) stated, showers and refusals should be documented. If it is not documented, it looks like it wasn't done. R111On 11/24/25 at 12:04 PM, R111 was observed alert and sitting in a wheelchair in his room. When asked about how he was doing, R111 responded that he was concerned because he had not been shaved since coming to the facility. R111 was observed to have a full, untrimmed, thick beard. On 11/24/25 at 12:18 PM, Certified Nurse Aide (CNA) O said R111's shower days were on Wednesdays and Saturdays. On 11/24/25 at 12:21 PM, R111 informed the State Surveyor and CNA O that the last time he was shaved was when he was in the hospital. A review of the clinical record documented R111 was admitted to the facility from the hospital on [DATE] with diagnoses that included left femur fracture, sarcoidosis of lung, Parkinsonism, and congestive heart failure. A MDS assessment dated [DATE] documented intact cognition. A review of R111's care plans documented in part the following: ADL self-care deficit related to impaired physical mobility due to left hip fracture, Parkinsonism, sarcoidosis. Date initiated: 11/13/25. Interventions included: Assist with daily hygiene, grooming, dressing, oral care and eating as needed. Date initiated: 11/14/25 CNA documentation of baths for R111 since admission on [DATE] revealed the following:Not applicable: 11/13/25, 11/14/25Bed bath: 11/15/25Shower: 11/19/25, 11/22/25 On 11/24/25, LPN P observed R111's facial hair and said it does not look like R111 was shaved Saturday, 11/22/25. On 11/25/25 at 11:35 AM, R111 was observed alert and sitting in his room. R111's full, untrimmed, thick beard remained. R111 said he still has not been shaved. On 11/25/25 at 11:53 AM, LPN/UM I said if the resident was alert and oriented and wanted to be shaved, we do shave them. We try to shave men more often than twice weekly, because less frequent shavings can be rough on their skin. LPN/UM I added, there was no reason why R111 should not have been shaved. On 11/25/25 at 1:02 PM, R111 was receiving care from CNA K. On 11/25/25 at 1:08 PM, CNA J said she showered R111 on 11/22/25 but did not offer to shave him. On 11/25/25 at 1:14 PM, R111 was interviewed in the presence of LPN/UM I. R111 said he wanted to be shaved on days he gets cleaned up. R111 was just shaved while receiving care and was smiling and grinning during the interview. On 11/25/25 at 1:17 PM, CNA K said R111 had a full beard, and it did not look like he had been shaved since admission. CNA K said R111's beard was thick, and it took five to six razors to shave him. A facility policy titled, Activities of Daily Living (ADL), dated 12/7/23 was reviewed and documented in part:- Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal, and oral hygiene.- Appropriate care and services will be provided for residents who are unable to carry out ADL independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).- The amount of assistance the resident needs to complete their ADL care will be documented in the resident's care plan. On 12/1/25 at 12:30 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

This citation pertains to 2598018. Based on observations interview, and record review, the facility failed to implement intervention to prevent falls in a timely manner for one resident (R101). Findings include: It was reported to the State Agency that the resident has fallen out of the bed and staff are not always ensuring the resident's bed was kept in a low position. On 11/24/25 at 2:51 PM, R101 was observed awake and lying in bed. The top of the mattress on R101's bed was approximately 24 inches from the floor. R101 said he fell out of bed a couple of months ago and that his left side, arms and legs got a little worse after the fall. On 11/25/25 at 3:37 PM, staff were observed putting R101 in bed. The bed was elevated. On 11/25/25 at 3:40 PM, R101 was observed in bed. The top of the mattress on R101's bed was approximately 20 inches from the floor. A review of the clinical record for R101 documented an admission date of 6/24/25 with diagnoses that included hemiplegia/hemiparesis following cerebral infarction, vascular dementia, aphasia, and gastrostomy status. A Minimum Data Set assessment dated [DATE] documented intact cognition. A review of R101's care plans documented the following interventions: - Bed in low position when resident is in bed. Initiated 6/24/25. - Bolsters to bed to define mattress edge. Initiated 7/14/25. - Always have two people to assist with changes and transfers. Initiated 9/22/25. Review of incident reports documented in part the following:1. 7/12/25: Fall during staff assist. Certified Nurse Aide (CNA) called my attention to resident, as staff doing care, resident was put on side lying position as stated by the staff and resident had a sudden movement and resident rolled out of bed. Resident was found on floor; head was up and lying on left side.2. 7/24/25: Un-witnessed fall. Patient was calling for help. Patient was observed on floor in room near bed. The writer has initiated more interventions in the care plan to help to minimize the risk of falls.3. 9/20/25: Fall during staff assist. Patient was being rolled onto his side during brief change when he fell out of bed landing on his left side. Patient's head struck the closet upon impact. Visible bump noted on left side of forehead and small laceration on left eyebrow. Bleeding controlled. Progress notes documented the following:- 7/14/25: CNA called my attention to resident, as staff doing care, resident was put on side lying position as stated by the staff and resident had a sudden movement and resident rolled out of bed. Resident was found on floor; head was up and lying on left side. IDT (Interdisciplinary Team) team reviewed & updated care plan the intervention is to add bolsters to the bed to define bed edges. - 7/29/25: Resident was found on floor by staff member, writer went to assess resident. took resident vital signs got resident into bed and notified doctor. no orders given. writer cleaned resident's face with normal saline and gauze and performed routinely neurochecks. VSS during neurochecks except heartrate was tachycardiac notified doctor no orders given. Ordered a wound consult due to resident face having a laceration on forehead and nosebleed due to fall. resident did not report pain in head area. notified brother-in-law of fall and doctor notified resident sister. Family did not want to send resident to hospital. Resident safe and stable in bed at end of shift. Interdisciplinary team reviewed & updated care plan. The intervention is to have reacher device at bedside. - 9/21/25: Patient was being rolled onto his side during brief change when he fell out of bed, landing on his left side. Patient's head struck the closet upon impact, visible bump noted on left side of forehead and small laceration on left eyebrow. Bleeding controlled. Patient was assessed for injury; neurochecks initiated. Physician and Family notified. Plavix and Aspirin to hold x 1 day. During an interview on 11/25/25 at 2:43 PM, Physical Therapist (PT) E said when R101 arrived he was totally dependent for bed mobility. This would include changing his briefs. Total dependence signified the need for two people to assist. At the time of R101's admission, he was recovering from an acute stroke. PT E added that R101 could not speak and had zero strength. He could not express himself or talk. His care plan should have reflected that he was dependent for bed mobility. On 11/25/25 at 4:12 PM, during a demonstration of the bed positions that R101 was observed in during the survey, the Director of Nursing (DON) said that neither position would be considered a low position but instead would be considered a transfer position. The DON said keeping R101's bed in a low position while in it was an intervention for someone that had a fall. The DON acknowledged that a two-person assist for bed mobility was not initiated for R101 until 9/22/25 and that dependence on bed mobility indicated he was a two-person assist. The DON indicated that had R101 been a two-person assist upon admission, his falls on 7/12/25 and 9/20/25 may have been prevented. A review of the facility policy titled, Fall Management Guidelines, dated 12/13/23, documented in part the following:- Fall management goals: Reduce the risk of falls by intervening in modifiable risk factors. Reduce the risk of injuries as a result of a fall.- The facility staff, with input of the attending physician, will implement a resident-centered comprehensive care plan that addresses the fall management program, the goal for fall management, individualized interventions to address the resident's modifiable fall risk factors, interventions to try to minimize the consequences of risk factors that are not modifiable, and the plan for reduction of risk and or risk for injury related to falls. On 12/1/25 at 12:30 PM during the exit conference, the NHA and DON did not offer additional documentation or information when asked.

This citation pertains to 2663449 and 2668212. Based on interview and record review, the facility failed to ensure resident-to-resident verbal and physical abuse did not occur for two residents (R104 and R105), resulting in verbal and physical abuse. Findings include:Allegations of resident-to-resident abuse were reported to the State Agency. A review of the facility's investigation summary of a resident-to-resident incident between R104 and R105 documented in part the following: On October 11, 2025 at approximately 8:45 PM, R104 and R105 were involved in a physical altercation on the Cherry Hill unit. According to witness statements from staff and other resident, R104 was walking down the hallway returning to her room. R104 began using unprovoked profanity towards the nurse. At that time, R105 had just returned to her room from downstairs. R105 told R104 to be quiet and go back into her room. R104 said to R105, don't tell me what to do. R104 included profanity in her response. R105 said, what did you say? R104 replied again using profanity. R105 stood up quickly from her chair and ran towards R104. The nurse immediately intervened and attempted to de-escalate the situation. Despite efforts to separate them, R105 grabbed and forcefully pulled R104's and the nurse's hair causing both the nurse and R104 to fall to the floor. Staff immediately intervened and separated both residents. R105A review of the clinical record documented R105 was initially admitted on [DATE] and readmitted on [DATE]. R105's diagnoses included chronic obstructive pulmonary disease, adjustment disorder with mixed anxiety and depressed mood. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition. A review of R105's care plans documented in part: - Social with roommate, staff and peers. Can be argumentative and verbally aggressive, benefits from redirection. Date initiated 9/11/25.- Altered behavior in which resident acts characterized by ineffective coping verbal aggression toward other residents. Date initiated 9/16/25. Review of R105's progress notes documented in part the following:- Behavior note of 9/13/25: Writer summoned to room by resident's roommate due to resident yelling out, using profanity and making threats towards roommate. When writer asked resident what the conflict was about, she stated, I told her (profanity used) I like the door open, and she don't (profanity used) listen she can get the (profanity used) out. Writer de-escalated the situation and removed residents apart. Roommate stated she does not feel comfortable staying. Writer notified on call midnight supervisor and received order to move roommate into new room for safety.- Nurse note of 9/14/25: Writer was notified by unit manager and previous nurse about resident being transferred down to MedBridge on writer's set due to a problem with previous roommate. (R105) is okay and content with new room change. (R105) stated, she does not want a new roommate. She needs to be in the room by herself. Will continue to monitor for any new behavior changes. A review of room assignments for R105 documented the following:- Upon readmission to the facility on 9/10/25, R105 resided on the second-floor Cherry Hill South unit.- On 9/14/25, R105 was moved to the first-floor MedBridge unit.- On 9/15/25, R105 was moved to the second-floor Cherry Hill South unit.- R105 was discharged on 9/28/25 and upon return to the facility on [DATE], R105 returned to the second-floor [NAME] Hill South unit.- On 10/11/25, R105 was moved to the first-floor MedBridge unit. On 11/24/25 at 2:16 PM, R104's Concerned Family Member (CFM) F reported that R104 had been attacked by R105 on two separate occasions. R104A review of the clinical record documented R104 was admitted to the facility on [DATE]. R104's diagnoses included cerebral infarction, vascular dementia, and bipolar disorder. A MDS assessment dated [DATE] documented intact cognition. A review of R104's care plans documented in part: The resident has a behavior problem r/t (related to) patient continuously yells at staff and others. Date initiated 6/13/25. A 9/14/25 incident report for R104 documented in part the following: While doing the morning med pass, I saw (R105) and (R104) arguing and shouting to one another. Nurse L verbalized that he saw (R105) pushing (R104). (R104) verbalized that she was hit and pushed by another resident, and she is too old to fight other people. Denies pain and discomfort. A 10/11/25 incident report for R104 documented in part the following: A verbal and physical altercation occurred between (R105) and (R104) in the hallway. The incident began when (R104) directed profanity toward (R105). (R105) verbally confronted (R104) which escalated into (R105) physically assaulted (R104). (R104) said (R105) pulled her hair. A 10/12/25 progress/incident note for R104 documented in part the following: A verbal and physical altercation occurred between (R105) and (R104) in the hallway. The incident began when (R104) directed profanity toward (R105). (R105) verbally confronted (R104) which escalated into (R105) physically assaulted (R104) by grabbing her hair and slamming her on the floor. (R104) was assisted back to her room, assessment completed. Family, MD (Medical Doctor), DON (Director of Nursing) and Administrator were notified. (R104) was transferred to ER (emergency room) for evaluation per family request. During an interview on 12/1/25 at 11:42 AM, the Nursing Home Administrator (NHA) acknowledged that the resident-to-resident verbal and physical altercation between R104 and R105 on 10/11/25 could have been prevented had R105 remained on the first-floor MedBridge unit, rather than being moved back to the second-floor Cherry Hill South unit. The facility policy titled, Abuse, dated 5/24/23 was reviewed and documented in part the following:Residents have the right to be free from abuse.Prevention (of abuse) consists of facility systems designed to detect, identify, correct, and prevent the occurrence of abuse.Completing ongoing assessments and care planning for appropriate interventions, and monitoring of residents with behaviors, including but not limited to: verbally aggressive behaviors (screaming, cursing, demanding, insulting, etc, physically aggressive behaviors (hitting kicking, biting, spitting, throwing objects, threatening gestures, etc.)The facility will educate the staff in identifying abuse .Possible indicators of abuse include, but are not limited to: physical abuse of a resident observed.Any allegation of abuse must be immediately reported to the supervisor and the Abuse Prevention Coordinator. The Administrator initiates investigating any allegation of abuse against a patient.If a resident is the alleged perpetrator, the facility will ensure other residents are protected as determined by the circumstances, which may include but are not limited to resident room changes, increased supervision, or immediate transfer or discharge, if indicated. On 12/1/25 at 12:30 PM during the exit conference, the NHA and DON did not offer additional documentation or information when asked.

Based on interview and record review, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) for one resident (R108-with full code status by default on [DATE]) of one resident reviewed for CPR. R108 was found unresponsive with absent vital signs and CPR was not initiated.Findings include: On [DATE], when (R108) was found unresponsive without vital signs, the facility called a code and called 911. However, the facility did not initiate CPR because they executed an invalid Do Not Resuscitate (DNR) order. This deficient practice may result in the likelihood of other residents not receiving CPR according to code status resulting in serious harm, serious impairment, or death.The Immediate Jeopardy (IJ) began on [DATE] and the immediacy was removed [DATE] per review of the facility's responding interventions as verified on [DATE]. The IJ was identified on [DATE] during a recertification survey. The facility was notified of the IJ on [DATE] at 4:50 PM and was asked for a removal plan. The surveyor confirmed that the IJ was removed on [DATE], based on the facility's implementation of the removal plan as verified onsite on [DATE]. The facility executed a Do Not Resuscitate order without valid Durable Power of Attorney documentation of authority to make life sustaining decisions. The facility also entered two code status changes after R108 became unresponsive.Record review of the Electronic Health Record (EHR), revealed R108 entered the facility on [DATE] with a diagnosis of failure to thrive, paroxysmal A-fib with recurrent falls, ischemic cardiomyopathy with reduced ejection fraction, hypertension, hyperlipidemia, and pulmonary hypertension. R108 was hospitalized on [DATE] and re-admitted to the facility on [DATE]. Record review revealed R108 was deemed incompetent on [DATE]. According to the Minimum Data Set (MDS), R108 was severely cognitively impaired. On [DATE], record review of progress note from Social Worker (SW) J dated [DATE] at 14:11 PM documented, Message left for (Family Member, ( FM U)) to contact writer regarding Durable Power of Attorney (DPOA) paperwork.On [DATE], record review of progress note from SW J dated [DATE] documented, FM U reported he will bring (Power of Attorney) POA paperwork this evening. On [DATE], record review of progress note from (SW) P dated [DATE] documented, Care Conference held today with IDT (interdisciplinary team) and (FM U) via phone. SW reviewed the uploaded healthcare representation paperwork, however it only states HIPPA representative and financial. SW explained that the current paperwork does not state anything about being able to consent/withdraw care or any other medical treatment authority. (FM U) is going to bring in another copy to see if it is any different than what is uploaded. SW briefly explained that if the paperwork that (FM U) has does not allow authorization for care then Legal Guardianship will need to be started but we can review once SW reviews the paperwork.This note also denoted: SW will continue to monitor and assist as needed. (FM U) is open to changing R108 code status to (DNR, Durable Power of Attorney) however current paperwork does not provide (FM U) with the authority to complete DNR form which (FM U) appears to understand.Record review of progress note from SW P dated [DATE] documented, Emergent care conference held, yesterday [DATE]. (FM U) expressed wanting (R108) to be DNR and not full code. Current uploaded documentation did not show accurate DPOA, however (FM U), did provide DPOA paperwork today, per social work. Social work following regarding updated CODE STATUS. Record review of progress note dated [DATE] at 11:31 AM by SW N, documented, SW notified (FM U) that the DPOA is now activated. SW will continue to follow up as needed.Record review of progress note dated [DATE] documented, Discussed with (FM U), plan to sign onto hospice on [DATE]. Social work following on updating CODE STATUS. Record review of progress note dated [DATE] from Social Services Social Worker O, (FM U), brought in (DNR) order form on [DATE]. On [DATE], record review of document entitled (DNR) dated [DATE] was uploaded into the electronic medical record (EMR) on [DATE]. On [DATE], record review revealed two orders were placed into the EMR on [DATE]. Both orders were uploaded after R108 became unresponsive. R108 passed at the facility at 10:45 PM. On [DATE] at 22:45/10:45 PM- Do Not Resuscitate order initiated by Nurse Q. On [DATE] at 23:59/11:59 PM- Full Code order initiated by Director of Nursing (DON). A nursing progress note dated [DATE] revealed: Date and time vital signs absence. [DATE] 10:45 PM.Date and time physician notified. [DATE] 11:50 PM. A physician was contacted.Date and time family notified. [DATE] 11:00 PM. (FM U) was contacted. Date and time body released to mortuary. [DATE] 12:15 AM.Name & Phone number of the mortuary body is released to funeral home. On [DATE] at 2:08 PM, SW N was interviewed regarding the progress note entered by SW N on [DATE] that documented DPOA is now in effect. SW N was asked if additional DPOA paperwork was received, authorizing FM U to make life sustaining decisions for R108. SW N stated, I don't have any additional DPOA paperwork, and I don't see it in the system. R108's current documentation, which gave authority pursuant to (HIPPA) Health Insurance Portability and Accountability Act and Specific Power of Attorney to execute financial decisions, was reviewed with SW N. SW N explained that she thought this document gave FM U authority to change R108's code status to DNR. On [DATE], SW N at 10:55 AM queried whether the facility received documentation of Durable Power of Attorney over medical authority to make life sustaining decisions. (SW) N stated, I thought we did. I thought the current healthcare representative form for HIPPA covered the authority to sign a DNR.Record Review of Progress Note dated [DATE] at 17:48, SW O documented, (FM U) brought in Do-Not-Resuscitate order form. On [DATE] at 3:30 PM, Nurse BB was contacted and reported that R108 was a DNR and that Nurse S called 911.On [DATE] at 4:07 PM, FM U was contacted and confirmed submitting a signed DNR form to the facility on [DATE] prior to R108's death. FM U also reported that he had DPOA and provided the facility with a copy of the document on three different occasions, the last time being in mid-July. On [DATE] at 11:07 AM, SW P was interviewed and acknowledged her progress note regarding invalid medical DPOA papers. SW P reported having no recollection of receiving the appropriate DPOA paperwork from FM U to declare a change R108 code status from full code to DNR. On [DATE] at 10:15 AM, Nursing Health Administrator (NHA) was interviewed and acknowledged that the current Nomination of Agent as Healthcare Personal Representative form dated [DATE], provided by FM U, did not cover medical decisions. The NHA was queried about the orders regarding R108's code status that was documented after R108's time of death. The NHA reported being unaware of a physician order for DNR followed by a physician order for full code. When the NHA was asked, Why was 911 called if a DNR order was implemented? The NHA stated, I don't know, we don't usually tie up those resources like that. On [DATE] at 10:37 AM, The DON was interviewed and reported receiving a call from the midnight nursing supervisor Nurse R on [DATE]. According to the DON, Nurse R contacted the DON because the order in place at the time R108 was found unresponsive was a full code but Nurse R thought R108 was a DNR. The DON acknowledged that she wrote an order to change the code status back to Full Code after receiving the call from Nurse R. The DON also reported not knowing that R108 was deceased at the time of the code change. When asked why 911 was called if a DNR order was in place, she stated that's not normally the process.On [DATE] at 11:50 AM, Nurse Q was interviewed and confirmed confusion over code status at the time of R108's death on [DATE]. Nurse Q was asked, was CPR performed on R108? Nurse Q stated, No, I understood the code status was a DNR. On [DATE] at 12:54 PM Nurse R was contacted and reported that she knew the facility had a conflicting code status, so she called the DON. Nurse R reported that a Full Code was in the system, but DNR paperwork for R108 was produced. Nurse R also stated, I knew the facility did not have the correct DNR paperwork. According to Nurse R, the EMR noted Full Code status while the paperwork noted DNR. On [DATE] at 1:13 PM, Nurse Q requested to meet with the surveyors. Nurse Q stated, I put the DNR (physician's order) in. I did not know it needed signatures.On [DATE] at 10:10 AM, Medical Director T was interviewed and stated, I had a discussion last week with the facility about code status. We (the facility) were working with (FM U) for an extended period of time. (FM U) wanted a no code no CPR. We were working on that process. A DNR code status was placed in my book. I signed a code status DNR for (R108). The DNR was signed and done prior to the resident actually coding. On day (R108)'s death, (R108) coded and EMS was called. I was called by a nurse about a patient that coded, and EMS was called - I had no other conversation. Medical Director T was queried regarding the meaning of coded and stated, I interpretated that to mean that CPR was initiated because EMS was called. When asked if he was made aware of the physician orders changing R108's code status, Medical Director T said he was not aware of anything about changing the resident's code status after R108 was found unresponsive. Medical Director T was asked if a physician order for a DNR was written for R108 and stated, At no time did I give a verbal order for a DNR. That is not how it works. When there is a full code, CPR is initiated!Medical Director T stated, It is standard procedure that if the resident is a DNR that we would not call 911. If someone is DNR there is no need to call EMS. On [DATE] at 10 AM requested a copy of the Cardiac Arrest Emergency Management Policy and the Advanced Directive Code Status Policy. Review of facility policy titled, Social Services, revised [DATE], documented in part: The social Worker, or social service designee tasks include but are not limited to assisting residents with advanced care planning, which includes formulating an advanced directive and educating residents on code status choices.Review of facility policy titled, Cardiac Arrest Emergency Management (Michigan), issued [DATE] and reviewed on [DATE], documented in part: General Guidelines- CPR is to be initiated on residents in the event of a cardiac arrest unless the resident has a Do Not Resuscitate order and this is properly documented in the medical record. Guidelines for a Resident with a Full Code Order- First licensed nurse to arrive directs additional staff to review the resident's medical record for the resident's code status and whether there is a Do Not Resuscitate Order in place. If the resident has a Full Code order and is without a pulse/respiration: Direct designated staff to call 911 requesting emergency assistance. The licensed nurse should verify the resident's code status. Michigan Guidelines for a resident with a Do; Not Resuscitate Order- First licensed nurse to arrive directs additional staff to review the resident's medical record for the resident's code status and whether there is a Do Not Resuscitate Order in place. If the resident does have a DNR order and is without a pulse/respiration: Police or Medical Examiner notification as appropriate per county rules.Review of facility policy titled, Advanced Directives- Code Status, issued [DATE], revised [DATE] and reviewed on [DATE], documented in part: Code Status: In accordance with the Michigan Do-Not-Resuscitate Procedure Act a DNR must be documented on the Do-Not-Resuscitate (DNR) form for the DNR to be valid. Until the form is fully filled out and signed by the resident or the resident's legal representative, two witnesses and a physician, the resident will be a Full Code by default. If the resident and/or their legal representative has chosen for the resident's code status to be Do-Not Resuscitate: The attending physician writes an order for the resident's DNR code status. The Michigan Do-Not-Resuscitate form will be uploaded into the resident's electronic health record in Point Click Care under the documents tab. Until the form is fully filled out and signed by the resident or the resident's legal representative, two witnesses and a physician, the resident will be a Full Code by default. From the physician order the resident's DNR code status will auto populate and prominently displayed on the resident's chart header in PCC and will also populate to the resident's face sheet. The Immediate Jeopardy that began on [DATE] was removed and the deficient practice corrected on [DATE] when the facility took the following actions to remove the Immediacy and correct the noncompliance. 1. Residents that are currently reside in the facility were audited by licensed Social Worker on [DATE] to ensure that residents with a current Do-Not-Resuscitate (DNR) code status have the DNR form filled out fully and executed by the person who has authority to sign the form. Residents that currently reside in the facility has the appropriate Advanced Directives/Code Status in place, the appropriately signed DNR form, appropriate DPOA, Guardian, or Patient Advocate documentation, and the appropriate capacity documentation as applicable.2. Licensed nursing staff (including agency licensed nurses) and Social Workers were immediately re-educated on the Advanced Directive Code Status Policy. Licensed Nurses were also educated on the Cardiac Arrest Emergency Management Policy to include locating and confirming code status in the medical record-Once the code status order is entered into PCC, it is instantly transferred and displayed in the resident's banner, allowing for immediate identification. Education was started on [DATE] with 13 licensed nurses were educated including 7 agency licensed nurse and all (2) social workers were educated on [DATE]. Licensed nurses including and Social workers will be educated prior to working their next scheduled shift. 3. Audits will be conducted by Social Services/designee on 8 residents per week for 8 weeks to ensure the resident's Advanced Directives code status for DNR has the DNR form filled out fully and executed by the person who has authority to sign the form, and when applicable DPOA, Guardian, or Patient Advocate documentation and the appropriate capacity documentation.The facility alleges the immediacy of these discrepancies have been removed on [DATE].

This citation has two deficient practices. Deficient Practice #1: Based on interview and record review, the facility failed to implement appropriate safety interventions for one resident (R71) out of eight residents reviewed for accidents, resulting in a fall with injury (femoral fracture), and an emergency hospital encounter. Findings include: During an interview on 5/3/2023 at 9:31 AM, a concerned family member of Resident #71 (R71) stated, R71 fell in his room right in front of me. He fell hard and went to the hospital for surgery. A review of the Admission Record for R71 revealed an admitted [DATE] and readmitted [DATE] with diagnoses that included right femur (thigh bone) fracture. A Minimum Data Set assessment dated [DATE] and 5/1/2023 documented severe cognitive impairment. The MDS of 1/13/2023 documented no impairment of lower extremity and supervision with one-person physical assistance for transfer. The MDS of 5/1/2023 documented lower extremity impairment on one side and very limited bed transfers documented during the seven-day look back period. Further review of R71's clinical record and post-fall documents revealed in part the following: 1. Progress note date/time: 1/16/2023 at 5:55 AM: Writer found patient on floor at 2:45am, patient was assessed physically and there is no known injuries. Patient denies hitting his head or being in any pain. Patient states he was trying to stand up to put his pants back on. Teaching was reinforced to use call lights when he feels he is in need or has wants, the bed light was put on, and bed is put in lowest position. Neuro-checks was (in place) and there is no change in mental status. Physician and patient's son has been notified of incident. 2. Radiology Report date/time of 1/16/2023 at 12:12 PM: Femur 1 View: Conclusion: Acute intertrochanteric right femoral fracture as noted. 3. Progress note date/time of 1/16/23 at 3:48 PM: Acute intertrochanteric right femoral fracture as noted. (Physician) updated. New order for patient to be sent to emergency room . 4. Staff Statement dated 1/16/23: Certified Nurse Aide (CNA) R changed R71's brief at 2:00 AM. 5. Post-Fall Assessment, dated 1/16/2023. Observations included: poor lighting, improper bed height, water spills, patient reaching for items. Comments: Patient was trying to put on their pants. 6. Investigation Report dated 1/16/2023. Summary of alleged incident: Patient got himself out of bed attempting to put his pants on and fell while holding onto the bed side table. 7. Progress note date/time of 1/17/2023 at 1:23 PM (created on 1/23/2023 at 1:24 PM): IDT (interdisciplinary team) reviewed fall from 1/16/23. Patient fell attempting to get self dressed at (3:00 AM). Patient initially denied all pain. During the next shift patient began to complain of hip pain. X rays obtained and fx (fracture) noted. Patient sent out for treatment of fracture. Fall interventions in place at time of fall. Patient is cognitively impaired and unable to be educated on call light use . 8. Incident Report dated 1/17/23. Corrective Action: Bed is back into lowest position, reinforced teaching on using the call light, and bed light is turned on. 9. Review of at risk for falls care plan documented the following intervention: Bed in low position. Date initiated 10/11/2022. During an interview on 5/8/23 at 2:22 PM, CNA Q said she had been a CNA for approximately two years. CNA Q said that when she changes a resident's brief, she brings the bed up to a decent height so she doesn't strain her back. After the brief is changed, she puts the resident's pants back on and lowers the bed back down just in case the resident rolls out of the bed, or they try to get out of the bed. During an interview and record review on 5/8/2023 at 2:57 PM, the Director of Nursing (DON) said R71's fall was avoidable. The DON stated, If we had the bed at the right level, better lighting, and water off the floor. (We need) to make sure spills are wiped up and have items within reach. The DON listed the following as contributing to R71's fall: poor lighting, water spill, and improper bed height. The facility document titled, Fall Management Guidelines, dated April 2022, was reviewed and revealed in part the following: Fall reduction and injury prevention strategies that can be implemented upon admission may include, but are not limited to the following .Provide environmental modifications as indicated (use of appropriate height bed, removal of trip hazards, bedside commode) . Deficient practice #2. Based on observation, interview, and record review, the facility failed to ensure assessments for the use of electronic cigarettes were adequately completed for two residents (R128 and R230) observed using electronic cigarettes on the grounds of a non-smoking facility, resulting in the potential for harm from the use of electronic cigarettes. Findings include: During observations on 5/2/2023 at 8:30 AM, wall signage on the front entrance to the facility and on the front patio indicated: THIS IS A SMOKE FREE CAMPUS. During an observation on 5/4/2023 at 1:00 PM with Unit Manager (UM) F, Resident #128 (R128) and Resident #230 (R230) were observed on the facility's front patio using electronic cigarettes. R128 A review of the Admission Record for R128 documented an admitted [DATE] with diagnoses that included right fibula (calf bone) fracture, chronic pulmonary embolism, chronic obstructive pulmonary disease, and syncope (fainting) and collapse. A MDS assessment dated [DATE] documented intact cognition and no upper extremity impairment. A Non-Smoking Facility Smoking Evaluation was initiated and completed on 5/4/2023 at 1:59 PM and 2:00 PM respectively. The smoking evaluation completed on R128 did not specifically address the use of electronic cigarettes. R230 A review of the admission record for R230 documented an admitted [DATE] with diagnoses that included peripheral vascular disease, chronic obstructive pulmonary disease and stage 3 chronic kidney disease. A MDS assessment dated [DATE] documented intact cognition and no upper extremity impairment. Review of clinical record revealed R230 was offered education on risk of smoking and vaping. Patient offered smoking cessation and declined. Patient able to show safe vaping technique. Patient verbalized understanding to the sign out policy and that she needs to sign out and go outside independently. Progress note of 5/4/22 at 1:22 PM documented: Resident signed out for LOA with the understanding that she is her own responsible person and responsible for herself when leaving the building. She states that she wants to vape and her vape were provided to her. She was able to navigate the hallway to the outside sitting area and safely vaped while at the table. She was approached by the unit manager who informed her that we are a non-smoking facility and smoking must be 150' from the building to which the resident explained that she was not smoking and she was in fact vaping. The resident then stated that she would move to the city sidewalk. She was able to navigate the parking lot onto the city sidewalk off of (the facility's) property and safely vape. The resident understands the potential negative effects of smoking and vaping and declines smoking/nicotine cessation. During an interview and record review on 5/8/2023 at 2:48 PM with the DON, the Non-Smoking Facility Smoking Evaluation completed for R230 on 5/1/2023 was reviewed. The DON stated, A care plan has been done. Everything else is blank. (R230) does not have a completed smoking assessment. The areas left blank on the smoking evaluation were cognitive function, visual function, communication function, physical function, non-smoking facility, and patient observation. The DON said the purpose of the smoking assessment was to ensure the resident's safety when they go out to smoke and acknowledged the potential for harm is there with vaping. On 5/10/2023 at 1:30 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

This citation pertains to intakes MI 128 and MI 183. This citation contains two Deficient Practice Statements. DPS#1 Based on observation, interview, and record review the facility failed to prevent 2nd degree [CONDITION(S)] from hot liquids in 1 of 13 residents (R13) reviewed for safety, resulting in an immediate jeopardy when on 12/5/21, R913 was given broth from the kitchen that was not cooled per facility policy before serving and R913 spilled broth onto chest resulting in 2nd degree [CONDITION(S)] (damage to the skin includes the outer layer and penetrates the middle layer of tissue) to left chest and flank area. This deficient practice has the likelihood for all residents who eat foods from the kitchen to sustain [CONDITION(S)] at the facility causing serious injury and harm. Findings include: In an observation on 12/21/21, the kitchen hot water pot where R913's broth was made from was temped and the water was 190 degrees. During interview on 12/21/21 at 11:38 AM with Certified Dietary Manager (CDM) F, she was asked about the incident with resident R913 and said, We have a heating induction system- where coffee is brewed. We call it Bunn water. That water comes out at least 180 degrees if not hotter. When we make these broths, the dietary staff will put water in container and let it cool down before putting lid on it. It will then allow the broth to cool down before giving it to the patient. I spoke with Dietary Aide G, and I was told they came down for a tray and she was in the middle of other things, and she didn't let it cool down before sending off tray to resident. CDM F confirmed that the staff did not follow proper procedures. During observation on 12/21/21 at 11:58 AM in the kitchen area, CDM F used an electronic thermometer to measure water out of heating induction unit (coffee and water maker) it was observed to be at 190 degrees Fahrenheit. During interview on 12/21/22 at 1:10 PM with Administrator A it was confirmed that the kitchen should follow all policies when dispensing food to residents Review of Hot Beverage Safety policy dated November 2019 documented the following: . consider the temperature range of 150-155 F as an approximate guide for hot beverages leaving the kitchen; record the temperature taken on the Food Temperature Log Review of 913's face sheet revealed admission into the facility on [DATE] with diagnoses that included [CONDITION(S)] ([CONDITION(S)]), collapse, and heart failure. According to the Minimum Data Set (MDS) dated [DATE], R913 had intact cognition. During interview on 12/21/21 at 9:10 AM with R913, it was confirmed she sustained a 2nd degree burn after spilling hot broth on her chest. When asked about incident R913 stated, I asked to be given chicken broth, jello, and hot tea for dinner. When I went to pull the bowl toward me to drink it with a straw it caught on the side of the tray and spilled out. They never told me how hot it was before they gave it to me. I had to go to the burn center to get treatment. On 12/21/21 at 1:34 PM, Administrator A was notified of the Immediate Jeopardy (IJ) that began on 12/5/21 due to the facilities failure to follow facility policy on cooling hot liquid prior to serving to prevent a 2nd degree burn on R913's chest and flank. A written plan of removal for the immediate jeopardy was received and verified on 12/21/21. Actions: 1. Resident R913 identified 2. Patient assessed for injuries with the following findings: redness across chest, abdomen, and left side 3. Patient treated with cold compress to cool/soothe injury site photo taken for record 4. Per MD order patient sent to hospital 5. Family notified on 12/5/2021 6. Incident report created 12/5/2021 7. Investigation initiated on 12/5/2021 8. Care Plan reviewed and updated on 12/6/2021 9. QAPI Committee meeting held on 12/6/2021 @ 9am to review investigation process and to develop additional recommendations 10. Dietary staff education initiated on 12/6/2021 Abatement 12/21/21: 1. Patient R913 identified 2. QAPI Committee Ad-HOC Mtg. 1:45pm 3. Like Patients identified as all patients who consume food and beverage from the facility kitchen (84) 4. Reduced temperature of in-house coffee urn to 160 degrees @ 2:35PM 5. Policy Review: hot beverages should leave the kitchen between 150-155 degrees 6. Kitchen staff re-education: Hot Beverage Safety. All staff will be educated prior to beginning of next shift. All five staff currently in-house completed. 7. Education provided to 100% of staff currently in-house, on the importance of hot beverage safety. All off-duty staff will be educated prior to returning to work. Monitoring: 1. Random interviews of dietary staff in process pertaining to hot beverage safety. 2. Daily audits by Dietary Manager/Designee, for five weeks of hot-liquid. 3. Temperatures leaving the kitchen to ensure temperatures are within 150-155. 4. Results of audits submitted to the QAPI Committee for review and recommendation. Compliance: 1. The administrator is responsible for achieving and maintaining compliance. Although the immediate jeopardy was removed on 12/21/21 the facility remained out of compliance at a scope of isolated and severity of actual harm due to facility education had not yet been completed and sustained compliance had not yet been verified by the State Agency. DPS#2 Based on interview and record review the facility failed to provide adequate supervision for a confused resident, affecting one resident (R905) out of three residents reviewed for supervision, resulting in the resident being left at an appointment with no direct supervision against the families wishes. Findings include: During telephone interview on 12/15/21 at 10:23 AM with R905's family member, it was confirmed that the facility was made aware that R905 was only to go to appointments with family. It was confirmed that resident needed supervision because he was confused. It was confirmed that facility transported the resident to the wrong location and R905 was left there in a wheelchair. Review of R905's face sheet revealed admission into facility on 9/22/21 with a pertinent diagnosis of malignant neoplasm of brain (cancer). Review of General Progress Notes revealed the following: 9/23/21 at 16:25, Social Service Note: BIMS (brief interview for mental status) assessment completed with a score of 12 indicating moderate cognitive impairment. 9/25/21 at 4:24: Note Text- Pt. (patient) is alert and oriented x 2 with confusion and forgetfulness. 9/25/21 at 15:16- Note: Patient is alert and oriented with slight confusion. 9/25/21 at 21:55- Note text: Patient is alert and oriented with forgetfulness. 9/26/21 at 20:21: General Progress: Patient is A&O x3 (alert and oriented to person, place and time) with confusion. He requires cuing when taking his meds and doing any tasks. During interview on 12/20/21 at 10:38 AM with Unit Secretary (US) E it was confirmed that the son of R905 had informed her that resident was not to go anywhere without family. It was confirmed that she cancelled the appointment that was made for the resident to go to appointment. US E verbalized that another appointment was set up by previous unit secretary and she was not aware. The resident was sent to the appointment without any supervision. It was confirmed when residents are confused and family are not available, staff would be sent for supervision. During interview on 12/20/21 at 11:19AM with Director of Nursing (DON) B, it was confirmed that she was not aware of situation until the time it transpired. When asked if residents that are confused should have supervision at appointments, DON B verbalized Yes, but the resident with scores that high doesn't need it. I would have not sent staff with him. After request no policy was provided for transportation of confused residents was provided.

This citation pertains to intake numbers MI 825 and MI 397. Based on observation, interview and record review, the facility failed to properly assess, document, care plan and implement timely pressure relief devices and interventions for protection of heels for three (#s 402, 404, 407) of five sampled residents reviewed for skin integrity, resulting in the development of facility acquired pressure sores. Findings include: Complainants for resident #402 (R402) and resident #404 (R404) reported to the State agency that pressure sores developed while at the facility and that R402's pressure sore was heavily bruised. R402- On 2/7/19 at 12 Noon, per review of the clinical record, R402 was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS) completed 12/31/18 noted R402 was unable to communicate, required extensive assistance for transfers and bed mobility and had no skin breakdown on admission. The Admission/Readmission Screen dated 12/21/18 noted R402 was unable to communicate needs and had no open skin areas other than a surgical incision from repair of the [MEDICAL CONDITION]. The Braden (pressure sore risk) Scale dated 12/21/18 noted R402 was at high risk for development of pressure sores. On 12/26/18, the scale noted R402 was at risk. Per R402's 12/2018-1/2019 treatment records, daily skin audits were to be performed every evening. Per a nursing note dated 1/2/19, Patient has a 3 (centimeter-cm) by 6 cm open area on right foot with bruising. There was no other documented description, such as type of wound, exact location, drainage, color or stage (level of depth through skin layers). A physician's orders [REDACTED]. There was no documentation prior to 1/2/19 of skin impairment to the right heel. There were no documented devices specifically for pressure relief of the heels, such as heel protectors or pressure relief boots and no documented indication that R402 refused elevation or floating of the heels on pillows while in bed. R402 was discharged from the facility on 1/3/19 as previously planned. An Occupational Therapy Discharge Summary dated 1/2/19 noted R402 was totally dependent for care and required maximum assistance when discharged . At 12:30 PM, when asked how and why R402 developed a pressure sore, on the heel of the extremity affected by the fracture and if the sore development was unavoidable, the Director of Nursing (DON) did not respond. When asked, she did not explain why the sore became open and large enough to cover the entire heel (3 cm by 6 cm) on 1/2/19 without prior notice and documentation by any of the staff, if full body skin audits were performed properly. R404- On 2/6/19 at 4 PM, per review of the clinical record, R404 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS completed 1/4/19 noted R404 required extensive assistance for transfers and bed mobility and had no skin breakdown on admission. The Admission/Readmission Screen dated 12/25/18 noted R402 was oriented to person only and had no open skin areas other than a surgical incision from repair of the [MEDICAL CONDITION]. The Braden Scale dated 1/2/19 noted R404 was at risk for development of pressure sores. An At Risk for Alteration in Skin Integrity care plan, due to weakness and history of left [MEDICAL CONDITION] initiated 12/25/18, noted an intervention specific to heels: Elevate heels as able. The clinical record further noted the following: On 1/7/19-A Bilateral Heel Blisters (stage II pressure sores) care plan was initiated. There was no prior mention of pressure sores prior to this date. On 1/7/19-A physician's orders [REDACTED]. Per 1/2019 treatment records, wound care began 1/7/19. A nursing note dated 1/8/19-Dressings to bilateral heels dry and intact, prevalon (pressure relief) boots on when in bed. There was no prior documented mention of heel protectors or use of pressure relief boots to prevent development of the blisters. On 1/9/19-A Braden scale noted high risk for pressure sore development. A nursing note dated 1/11/19-Wound doctor (specialist) in on 1/10/19 to assess patient's pressure sores to bilateral heels. Right heel wound measures 3 cm by 2.5 cm and left heel measures 2.5 cm by 2.5 cm; wounds are fluid filled with no drainage noted. R404 was discharged from the facility on 1/17/19. At 12:50 PM, when asked how and why R404 developed pressure sores on bilateral heels and if the development was unavoidable, the DON said, She was compromised. She had lost weight and didn't eat much. The DON did not explain why, in that instance, sores developed only on the heels and on no other pressure points, such as the coccyx area, if the heels were kept elevated prior to receiving and applying the boots when the sores were first noted. Resident #407 (R407)- On 2/5/19 at 10:30 AM, R407 was observed sitting at the bedside with a prevalon boot on the left foot. When asked if he had a sore on the foot, he said yes and that he wore the boot every night while in bed. R407 said he had a fall prior to admission and I couldn't get this old leg to move while lifting and moving his left leg with his hands. On 2/6/19 at 10 AM, R407 was observed in bed with the prevalon boot on about to receive wound care by nurse 'K'. The boot and a dressing underneath were removed and revealed a stage III (full thickness skin loss) pressure sore partially covered with slough (dead, moist, shedding tissue) to the left heel, that had a foul odor. Nurse 'K' said, The odor is coming from there, pointing to the sore. The sore covered the entire heel and had two small necrotic (black, dead tissue) areas in the center. R407 winced when the sore was being cleaned. At 2 PM, per review of the clinical record, R407 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS completed 12/20/18 noted R407 had minimal cognitive impairment and required extensive assistance with transfers and bed mobility. A Skin Breakdown care plan initiated 12/11/18 noted R407 was admitted with excoriation to the sacrum and left buttock. An At Risk for Alteration in Skin Integrity due to impaired mobility care plan, was also initiated 12/11/18. Neither care plan noted interventions/devices specific for the heels. A Braden scale dated 12/12/18 noted moderate risk for development of pressure sores. On 12/12/18, a physical therapy evaluation noted strength impaired to R407's bilateral lower extremities. Braden scales on 12/19/18, 12/26/18 and 1/2/19 noted at risk for pressure sores. Treatment records for 1/2019 noted that R407 had received body skin audits every day shift. Per a nursing note dated 1/31/19 by nurse 'A', a body audit was conducted for skin observation and NO NEW SKIN ALTERATIONS (in all caps) found. However, the next day on 2/1/19, nurse 'L' noted: Writer called into room to assess patients skin concerns. Patient has 3.0 by 3.0 cm alteration to heel, moderate amount of serosanguineous (yellow/bloody) drainage noted, base of wound red with 50% slough noted, surrounding skin red, warm and swollen intermittent low grade temperatures patient has been experiencing, along with presentation of heel. New order for Bactrim (antibiotic tablets) twice a day for 10 days. Prevalon boots offered, patient originally refused, writer educated patient on importance of relieving the pressure of heel, patient reluctantly agreed to wearing boots while in bed. Patient stating 'I don't even feel anything.' There was no documented indication in the clinical record that boots were attempted and refused prior to 2/1/19, when the sore was first noted. Vital sign records noted the following temperatures for R407: 1/24/19 - 99.6 degrees 1/25/19 - 99.4 and 99.1 degrees 1/29/19 - 100 degrees An Alteration to Left Heel care plan initiated 2/1/19 noted interventions: Elevate heels as able and Offer and encourage prevalon boots both interventions initiated on 2/1/19. R407's Kardex (care guide used specifically by nurse aides) dated 2/5/19 noted a directive, elevate heels while awake. There was no previous documented Kardex for this admission. On 2/6/19 at 3 PM, nurse 'A' was interviewed by phone and asked if she had personally observed R407's skin during the audit that she conducted on 1/31/19 or whether she was told there was no new skin breakdown. Nurse 'A' said that she observed his skin. When asked how R407 could have developed a pressure sore to that extent by the next day on 2/1/19, she then said, I remember checking his backside (sacral area) because I always made sure to put cream there. She indicated that a complete skin audit including the feet, was not conducted. On 2/7/19 at 12:30 PM, when asked why and how R407's pressure sore developed, the DON said, He was noncompliant with a lot of stuff, fluid restrictions, his diet, he didn't want an air mattress. (Nurse 'L') talked to him about wearing boots and he refused. The DON said, I'm sure (nurse 'L') has some notes. I'll get them but there were none provided by survey exit. The DON did not respond when asked why other interventions specific for heels, such as heel protectors or elevation of heels, were not care planned and implemented if the boots were refused. There was no response when told of the improper skin audit by nurse 'A' and when asked why the sore was so large and open on 2/1/19 without prior notice and documentation by any of the staff, if full body skin audits were being properly performed. On 2/8/19 at 8 AM, per review of the facility's Skin Practice Guide dated 1/2013: Risk factors for development of skin alterations include, diabetes and immobility; Preventive interventions include, elevate heels and complete thorough skin observations; Care plans need to be individualized to meet patient specific need and risk factors; Elevate or 'float' heels, even if patient is on specialty support surface (such as a pressure relief or air mattress); Patients have the right to refuse the care designed in the care plan. In this case, staff performs several tasks, including: documenting patient's refusal designing an alternate plan This revised strategy needs to be described in the patient's medical record.

This citation pertains to intake #MI 228 It was reported that the Resident fell and sustained an injury. Based on interview and record review, the facility failed to ensure that staff provided adequate supervision for a Resident with active restless/agitated behaviors and fall risk (which included other falls during her brief stay due to the Resident's attempts to get up unassisted) for one (#701) of three sampled Residents reviewed for falls with injury in a total sample of three Residents, resulting in the Resident sustaining a fall which resulted in a right displaced angulated femoral neck fracture and subsequent surgery. Findings include: On 1/29/16 at 9:00 a.m., review of the facility's investigation for Resident #701's reported incident documented: On 1/7/16, at approximately 7:45 pm patient was observed on the floor in front of her wheelchair lying on her right side. Patient complained of pain to her right hip and head and was send (sp) to hospital for further evaluation. X-ray completed at hospital demonstrated a right femoral neck fracture. Review of the following statements obtained during the facility's investigation included: Licensed Practical Nurse (LPN G) - I was at the omni cell (machine to retrieve medication) when LPN I radio'd over the walkie that Resident #701 had a fall. I seen Resident #701 just before I went downstairs to the omni-cell machine she (Resident #701) was sitting by the nurses station just next to the nourishment room. It was probably 3 minutes from the time I seen her in the w/c until the time that LPN I radio'd me that Resident #701 was on the floor . Therapeutic Recreational Staff H - Around 7:30 pm I went to talk with Resident #701 in the hallway by the nurse's station and encourage her to come to the PEP program. Resident #701 took her arm and swatted at me! I could tell she was agitated so I thought it best to leave her alone for a bit and I was going to try again in a little while. About 10 minutes later I went into the hallway to see if she was less agitated and ready to come join use and she was on the floor with staff already tending to her. Certified Nursing Assistant (CNA J) - When Resident #701 fell I was in the (nourishment) room getting water. I heard a loud noise and when I opened the door Resident #701 was on the floor. I had just gone into the room and was only in there for probably a minutes. Prior to that minute Resident #701 was in her w/c in the hallway next to the room . Review of the hospital's Pelvis and right hip x-ray report dated Completed Date: 1/7/16 10:27 PM documented, There is a background of osteopenia. Superimposed upon this is a transversely oriented, acute, displaced, impacted, and angulated fracture through the subcapital right proximal femoral neck. There is apex superior lateral angulation at the level of the fracture with approximately one shaft width of overlap . Further review of the clinical record revealed that Resident #701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #701 was severely cognitively impaired (scored 2/15 on mental status), and required extensive assistance of one person for bed mobility and transfers. The section for Fall History on Admission (J1700) was marked 9. Unable to determine. Review of the fall care plan initiated 1/5/16 and revised 1/7/16 documented, At risk for falls due to impaired balance/poor coordination, unsteady gait .patient places self on floor to crawl, gets up unassisted and included the following interventions: offer third party sitter services to family provide assist to transfer and ambulate as needed re-inforce need to call for assistance Review of the admission nursing assessment dated [DATE] and fall assessment dated [DATE] documented Resident #701 was at risk for falls. Review of the interdisciplinary progress notes from 1/5/16 - 1/7/16 included: 1/5/2016 at 4:30 p.m .Pt (patient) is alert to self with confusion .Pt. ambulates with extensive assist x 1 with walker. 1/5/2016 at 5:15 p.m., Pt observed standing up OOB (out of bed) unassisted and kneeling to floor on hands and knees .Requested to family member that they let nurse know when they are leaving so patient is not left alone in room . 1/7/16 at 4:00 a.m., At around 2030H (8:30 p.m.) pt was observed lying on her Rt (right) side onto the floor by the nurses station. She tried to get up from her wheelchair and fell as witnessed by the other nurse .kept pt monitored, put on hipster for further precaution . 1/7/16 at 11:14 a.m., Writer (social services) received a message .stating patient's daughter is interested in sitter service information . 1/7/16 at 11:24 a.m., patient had fall on 1/6/16 around 8:30 pm. Patient was observed lying on her right side in front of her wheelchair at the nurses station. The patient attempted to stand up from her wheelchair and fell idt (interdisciplinary team) review and recommends offer third party services, encourage participation in PEP (Patient Engagement Program) program .writer spoke with both the husband of the patient and the daughter .they agreed with the safety interventions and stated they would give the sitter services a call. 1/7/16 at 1:50 p.m. patient's husband left facility but states he will return later on, patient is restless. Patient pulled peg tube and unhooked the feed .patient brought to nurses station for added stimuli. Patient given an activity mat which held her attention for short period of time. Patient then sat next to nurse at nurse's station and helped file paperwork .patient continuously attempts to stand up out of wheelchair. Will encourage her to participate in pep at this time. 1/7/16 at 8:07 p.m., pt was sitting in w/c at nurse station, TF up and running per orders. Pt observed on floor next to w/c on R (right) hip, hipsters intact, pt c/o R hip pain, pt c/o pain to head, pt stated she hit her head on floor, pt not moved, MD notified, ordered to send pt to (name of local hospital) .A&O x 1 person baseline. 1/8/16 at 9:44 a.m., patient had a fall on 1/7/16 around 7:45 p.m., patient was in her w/c at nurses station after dinner and pep. The patient attempted to stand up out of wheelchair and fell to her right side, patient states she did hit her head but could not state what she was attempting to do .family had not contacted facility in regards to the sitter services info provided earlier in the day. Therapy was scheduled throughout the day while patient's family was no present so that while she wasn't in therapy, family would be visiting (providing supervision) .writer also spoke with family earlier in the day on 1/6/16 in regards to finding different placement for the patient due to her cognition level. The family stated they were aware of that and already looking into different settings. On 1/29/16 at 9:45 a.m., an interview was conducted with the Director of Nursing (DON). At that time, the DON reported that following the fall on 1/7/16, the Resident was sent to the hospital and x-rays there showed positive for a right femoral neck fracture. The DON stated, The facility has a PEP program in place for cognitively impaired patients in the upstairs dining room. Therapeutic recreational staff encouraged Resident #701 at approximately 7:30 (p.m.) to come in and she (Resident #701) was agitated and came back ten minutes later. When asked for the reason why the Resident was stationed at the nurse's station, the DON stated, Not necessarily for more supervision. There was an aide who just passed behind her to go into the nourishment room. They (interdisciplinary team) don't always use one to ones (staff assigned to 1:1 supervision) and try to use the interventions that were in place that's why we have the PEP to keep patients busy. When asked why the facility had not provided adequate supervision to Resident #701 and was left unsupervised while the Nurse went to get medications and the CNA went into the nourishment room, the DON stated, She (Resident #701) didn't have a recommendation for one to one - that was recommended after we (interdisciplinary team) met following the Resident's transfer out. When asked why the Resident would be left unattended/unsupervised despite agitated behaviors (as noted by the therapeutic recreational staff) and earlier restlessness with repeated attempts to get out of the chair during the day shift, the DON offered no further explanation. The facility was asked to provide a policy for fall risk management. The documentation provided was a Falls Practice Guide dated 12/2011 which included, On the basis of the information obtained and analysis performed in the assessment and planning phases, the next step is to implement an organized approach for the management of the patient's falls or fall risk factors . ( )

This citation pertains to M 400 Based on observation, interview and record review, the facility failed to provide adequate monitoring and toileting assistance to protect from accidents in one of four sampled residents at risk for falls (#501) from a total sample of four, resulting in multiple fractures of resident #501's right lower extremity . Findings include: During a tour of the facility, on 10/31/2011 at 12:15 p.m., Resident #501 was observed sitting in a wheelchair in her room eating lunch. The resident was wearing a cast on her right lower extremity. When asked, the resident was unable to recall what happened to her. According to the facility "Incident Report," dated 10/19/11, at 5:25 a.m., Resident #501 was "observed on bathroom floor. Upon assessment patient's ankle was not in proper alignment. Severity of injury unknown, patient sent to hospital for evaluation and treatment." On 11/01/11 at 2:15 p.m., review of the hospital diagnostic report dated 10/19/11 revealed the following findings: "Multiple fractures are identified including an oblique fracture of the distal fibula, a transverse fracture of the medial malleolus, and a small vertical fracture through the distal posterior tibia. Significant disruption and lateral displacement of the ankle mortise is noted." Resident #501, a [AGE] year old female, was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 10/31/11 at 3:30 p.m., review of resident #502's clinical record and MDS (Minimum Data Set) Assessments, dated 08/23/11 and 10/27/11, revealed that the resident's cognitive skills were intact. The resident was not coded as having any cognitive, mood or behavior problems, despite the [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Review of Resident 501's Physician order [REDACTED]. The side effects for these medications include dizziness, lightheadedness upon standing, and drowsiness. The resident received the scheduled medications everyday during the month of October, prior to falling on 10/19/11. According to the MAR, she received the prn sleeping pill every night with one exception, on 10/04/2011. Review of Nursing Notes revealed the following: On 10/09/2011 at 3 a.m., "...ambulated to rest room sometimes by herself without using call light..." on 10/13/2011 (midnight shift), "non compliant trying to get out of bed even after she used her call light..." on 10/19/11, 7:00 am, "patient transferred to hospital approx 6am, patient found on bathroom floor. Upon assessment, ankle did not look right..." On 10/31/11 at 2:30 p.m. an interview was conducted with the Assistant Administrator who explained that she (the administrator) was new to the facility and had only been working one and one half weeks. The Assistant Administrator stated that she had conducted the investigation for the incident involving Resident #501. The Assistant Administrator concluded that no staff assisted the resident to the bathroom and the alarms on the resident's bed were not sounding at the time of the incident. On 10/31/11 at 3:15 p.m. a telephone interview was conducted with CNA #7 (Certified Nurse Aide), who explained that she was not assigned to the resident that night but she was the first one on the scene when the accident happened. The CNA said, "I was coming out of a room when I heard screaming and the sound of the resident hitting the bathroom door with a reacher." CNA #7 stated, "the resident was barefoot, her ankle was exposed and it began swelling and it got bigger and bigger and looked like it was out of place, her foot was dangling." CNA #7 further stated, "she was supposed to have assistance with toileting and she may not have had a chance to fall if the alarm was sounding." A telephone interview was conducted with the Registered Nurse (RN) #8 on 10/31/11 at 4:00 p.m. RN #8 reported that she had never been assigned to the resident before that day. RN #8 said that she worked at the facility part time and floated around the building so she (the RN) was not familiar with the resident and "wasn't aware of her history. All I got in report was she had alarms. At the start of the shift, I noticed that the resident was being toileted by an afternoon shift CNA. At the time of the incident, the resident's bathroom call light was blinking. There was no alarm going off. The box to the alarm was on. A CNA picked up the box and it was in the "on" position. I assessed the resident and her ankle was off set like it was popped out. The resident was transferred to her bed." On 11/01/2011 at 1:30 p.m., an interview with Licensed Practical Nurse (LPN) #9 was conducted by telephone. LPN #9 worked full time midnights on the second floor and was familiar with Resident #501. LPN #9 explained that Resident #501 ambulated herself to the bathroom and would constantly get up and go without asking for assistance. LPN #9 stated that "the resident is very aware of how to use the call light but has a history of noncompliance with using it. She has hidden the call button under her mattress. The resident gets up often on the midnight shift for toileting, I have sometimes taken her to the bathroom myself." On 11/01/11 at 1:45 p.m., a telephone interview was conducted with CNA #10. CNA #10 was not assigned to work the hall on which the resident lived the night of the incident, but CNA #10 was familiar with the resident. CNA #10 reported that she observed the resident getting up without assistance a few times. The CNA said, "she will not use her call light, and she is unstable on her feet. I have asked her to please use your call light but when she has to go to the bathroom nothing else registers. She has always needed assistance with going to the bathroom since she's been a resident there." On 11/01/11 at 2:00 p.m., an interview was conducted with CNA #11 who explained that she was assigned to take care of the resident that night but had never really worked directly with the resident before that night. CNA #11 explained that at the time of the fall, the resident yelled out and she (CNA#11) and another CNA went to the resident's room and found the resident on the bathroom floor. The CNA was unsure if the resident had toileted her self prior to falling on the floor. The resident was carried to her bed to prevent having any pressure to her foot. The CNA reported that the resident's bed alarm did not sound, but that in the past, she (#11) had witnessed the resident turn her alarm off. On the night of the incident the alarm was turned on, but it was not functioning. When asked if the alarm had been tested to ensure that it was in working condition, the aide said that "the green light was on. That means that it was working. But I did not test it further." Review of "Pointclickcare" documentation which indicated the toileting activity provided for Resident #501 revealed the resident was toileted: On 10/17/11 at 10:59 a.m. and 22:06 p.m. (two times in a 24 hour period) On 10/18/11 at 12:33 p.m. and 22:35 p.m. (two times in a 24 hour period) The resident was out to the hospital on [DATE], but returned to the facility 10/20/2011. On 10/21/2011 at 21:43 the resident was toileted. (one time in a 24 hour period) On 11/01/2011 at 2:20 p.m., review of the "Shift Routine: Nursing Assistant" workflow guideline for certified nurse aides revealed, "provide toileting assistance and incontinent care to patients at least every two hours or per individual schedules, needs or requests. Review of Resident' #501's plan of care entitled, "At risk for falls" initiated 08/16/11 revealed, "to minimize risk for falls...provide assist to transfer and ambulate as needed, ensure that alarm/device sensor pad is in place when in bed/wheelchair." Review of the plan of care entitled "ADL Self care deficit" for Resident #501 which indicated, "will receive assistance necessary to meet ADL needs, Assist with daily hygiene..." On 11/1/11, at 2:30 pm, the Director of Nursing (DON) was asked about the lack of toileting supervision and assistance and the non-functioning alarm that contributed to the resident's injury, but the DON stated she had only started her position as DON on the previous day (10/31/11). According to the DON, there was no care plan written specifically for the residents toileting needs documented. ( )

BASED ON OBSERVATION , INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT ACCIDENTS FOR ONE ( # 702) OF 23 SAMPLED RESIDENTS IDENTIFIED AT RISK FOR FALLS FROM A TOTAL SAMPLE OF 23, RESULTING IN MULTIPLE FALLS, AN ABRASION AND BRUISING TO THE FOREHEAD AND A CONTUSION TO THE LEFT EYE. FINDINGS INCLUDE: ON 3/15/11 AT 6:00 PM, RESIDENT #702 WAS OBSERVED IN HER ROOM SEATED IN A REGULAR WHEEL CHAIR. THE RESIDENT'S LEFT EYE ORBIT WAS BRUISED, SWOLLEN AND DISCOLORED (PURPLE, DARK BLUE AND RED) AND MID-FOREHEAD WAS BRUISED AND DISCOLORED. THERE WAS A BLOOD TINGED DRESSING IN PLACE ON THE RIGHT SIDE OF RESIDENT #702'S FOREHEAD. THE MEDICAL RECORD, REVIEWED ON 3/16/11 AT 9:00 A.M., , INDICATED RESIDENT #702 WAS ORIGINALLY admitted to the facility on [DATE] AND RECENTLY readmitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE MINIMAL DATA SET, DATED 2/15/10, INDICATED RESIDENT #702 WAS SEVERELY IMPAIRED IN COGNITIVE SKILLS FOR DECISION MAKING. RESIDENT #702 WAS NON-AMBULATORY, REQUIRED EXTENSIVE ASSISTANCE IN BED MOBILITY, TRANSFERS, TOILETING AND PERSONAL HYGIENE. A RESIDENT ASSESSMENT PROTOCOL, DATED 9/30/10, INDICATED RESIDENT #702 had a history of [REDACTED]. THE NURSING assessment dated [DATE], INDICATED RESIDENT #702 CONTINUED TO BE AT RISK FOR FALLS. THE OCCUPATIONAL THERAPY EVALUATION PROGRESS NOTE AND ASSESSMENT, DATED 2/09/11, STATED THE FOLLOWING: " SUMMARY AND ASSESSMENT: ...PT (PATIENT) IS AN [AGE] year OLD FEMALE WITH MULTIPLE ADMISSIONS TO THIS FACILITY ...DECREASE STRENGTH, ENDURANCE AND BALANCE, AND DECREASE ABILITY TO COMPLETE DAILY ACTIVITIES INDEPENDENTLY ...AT THE TIME OF EVALUATION, PT. IS UNRESPONSIVE TO PHYSICAL OR VERBAL STIMULI AND WAS UNABLE TO FOLLOW COMMANDS ...EQUIPMENT NEEDS: HIGH BACK RECLINING WHEELCHAIR OR GERI CHAIR RECOMMENDED ... " THE " PHYSICIAN ORDERS [REDACTED]. 1. OXYGEN THERAPY 2. FALL RISK 3. CARDIAC 4. EQUIPMENT: HIGH BACK RECLINING W/C (WHEELCHAIR) OR GERI CHAIR (GERIATRIC CHAIR) REVEIW OF INCIDENTS AND ACCIDENT REPORTS FOR RESIDENT #702 ON 3/16/11 AT 9:00 A.M., REVEALED THE FOLLOWING: 1. 10/25/10 AT 9:00 P.M., " ...CENA (COMPETNCEY EVALUATED NURSE ASSISTANT) REPORTED TO NURSE THAT PT. (PATIENT) HAD FALLEN ...PT. TRIED TO GET OUT OF BED WITHOUT HELP ...EDUCATED (RESIDENT) ON CALL LIGHT USE.." 2. 11/24/10 AT 2:00 P.M., " ...PT. (PATIENT) WAS NOTED BY THERAPIST ON THE FLOOR IN FRONT OF THE BR (BATHROOM) DOOR) ...PT. T/F (TRANSFER) SELF TO BATHROOM AND ON HER WAY OUT SHE LOST HER BALANCE..." 3. 2/26/11 AT 12:53 P.M., " ...PT. OBSERVED LYING ON BACK ON THE LEFT SIDE OF THE BED ...BED ALARM IN PLACE AND APPEARED TO BE FUNCTIONING BUT DID NO ALARM AT TIME OF FALL ... " THE RESIDENT WAS FOUND ON THE FLOOR. 4. 3/07/11 AT 9:35 A.M., "...RESIDENT WAS TRYING TO WALK, AND fell FROM W/C (WHEELCHAIR)...REORIENTED RESIDENT TO ASK FOR HELP ... " 5. 3/14/11 AT 9:30 A.M., "...PT. FOUND ON FLOOR NEXT TO W/C (WHEELCHAIR) LEANING ON RM (ROOMMATES) BEDSIDE TABLE ...OPENING TO FOREHEAD... CLEANSED AND DRESSED ...PT ATTEMPTING TO AMBULATE UNASSISTED ... " REVIEW OF A FALLS ASSESSMENT, DATED 3/07/11, INDICATED RESIDENT #702 WAS AT RISK FOR FALLS DUE TO CARDIOVASCULAR MEDICATIONS, NARCOTIC ANALGESICS, CONGESTIVE HEART FAILURE, DECLINE IN FUNCTIONAL STATUS, PERIPHERAL NEUROPATHY AND IMPULSIVITY AND POOR SAFETY AWARENESS. REVIEW OF A NURSING NOTE, DATED 3/14/11, DOCUMENTED, " ...PT FOUND ON FLOOR OF ROOM AT APPROX (APPROXIMATELY) 9:15 A.M... PT WAS LAYING ON (R) (RIGHT) SIDE WITH HEAD RESTING ON ROOMMATES BEDSIDE TABLE BAR...OPEN AREA TO RIGHT FOREHEAD, 1.7 CM (CENTERMETER) X 0.2 CM... PT. NOSE RED/PURPLE AND SWOLLEN ... " ON 3/16/11 AT 9:00 A.M., THE " AT RISK FOR FALLS " PLAN OF CARE FOR RESIDENT #702, INITIATED 10/22/10 AND REVISED ON 2/09/11, WAS REVIEWED. THE PLAN OF CARE DID NOT INCLUDE INTERVENTION FOR A RECLINING WHEELCHAIR OR A GERI CHAIR AS RECOMMENDED AND ORDERED BY OCCUPATIONAL THERAPY ON 2/09/11. THE PLAN OF CARE DID NOT INCLUDE ANY INTERVENTION TO ADDRESS RESIDENT #702 ' S IMPULSIVE BEHAVIOR OF ATTEMPTING TO AMBULATE AND/OR TO TRANSFERS HERSELF INDEPENDENTLY AND POOR SAFETY AWARENESS. THE " RESIDENT INFORMATION GUIDE " (USED TO DIRECT RESIDENT CARE TO NURSE AIDES WAS REVIEWED AT 9:00 A.M. ON 3/16/11. THE RESIDENT INFORMATION GUIDE DID NOT INCLUDE ANY INTERVENTIONS TO ADDRESS RESIDENT #702'S IMPULSIVE BEHAVIORS. THERE WERE NO INTERVENTIONS FOR TRANSFERS, MOBILITY OR FALLS PREVENTION DEVICES FOR RESIDENT #702. ON 3/16/11 AT 10:00 A.M., AN INTERVIEW WAS CONDUCTED WITH UNIT MANAGER (A) AND THE DIRECTOR OF REHABILITATION REGARDING THE LACK OF FOLLOW THROUGH IN OBTAINING THE HIGH BACK RECLINING WHEELCHAIR OR GERI CHAIR FOR RESIDENT #702 AND FALL PREVENTION MEASURES. THE DIRECTOR OF REHABILITATION STATED IT WAS THE RESPONSIBILITY OF THE THERAPY DEPARTMENT AND NURSING TO ASSURE RESIDENT #702 WAS PROVIDED THE NECESSARY EQUIPMENT AS NEEDED OR RECOMMENDED. UNIT MANAGER (A) AND THE DIRECTOR OF REHABILITATION WERE UNABLE TO EXPLAIN WHY RESIDENT #702 HAD NOT RECEIVED THE HIGH BACK RECLINING WHEELCHAIR OR GERI CHAIR AS ORDERED. UNIT MANAGER (A) WAS ALSO UNABLE TO EXPLAIN WHY THERE WERE NO INTERVENTION IN THE NURSE ASSISTANT PLAN OF CARE WITH INTERVENTION TO HELP PREVENT FALLS FOR RESIDENT #702. ON 3/16/11 AT 3:15 P.M. NURSE ( B) REMOVED THE BLOODY DRESSING FROM RESIDENT #702'S FOREHEAD TO PERFORM A DRESSING CHANGE, AS RESIDENT #702 WAS SEATED IN A REGULAR WHEELCHAIR IN HER ROOM. THERE WAS AN ABRASION ON RESIDENT #702'S RIGHT FOREHEAD THAT MEASURED 1 CM X 4.5 CM. RESIDENT #702'S LEFT EYE ORBIT WAS SWOLLEN, BRUISED AND DISCOLORED (PURPLE, DARK BLUE AND RED). RESIDENT #702 MID-FOREHEAD WAS BRUISED AND DISCOLORED (PURPLE, DARK BLUE AND RED). ( )