Every finding on record at Parkside Homes

Based on observation, interview, and record revise, the facility failed to ensure the walk-in freezer in one of one kitchen of the facility was in clean, safe operating condition.Findings included:- During an initial tour of the kitchen on 07/20/2026 at 09:02 AM, the following area of concern was noted:The inside of the walk-in freezer had a heavy build-up of frost on all areas, including multiple boxes of food.Review of the walk-in freezer temperatures, documented daily by staff, revealed the freezer stayed within the appropriate temperature range, and all foods in the freezer were solidly frozen.On 07/20/2026 at 10:43 AM, Administrative Staff A stated staff were installing rubber door flaps on the inside of the freezer at the door to help keep the cold air on the inside. A new door for the walk-in freezer had been ordered and would be installed next week. Administrative Staff A stated the food inside the freezer had not thawed and was safe to be served to the residents.The facility policy for Food Preparation and Handling, dated 10/17/2024, included: The kitchen and equipment will be kept clean, neat, orderly, and well-maintained.

Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to the residents of the facility appropriately to prevent the potential for food borne bacteria.Findings included: - During an initial tour of the kitchen on 07/20/2026 at 09:02 AM, the following areas of concern were noted:1. The front of the microwave had dried-on food on the inside.2. The covered black plastic trash can had dried-on food and liquids.3. A shelf holding gallon jugs of pancake syrup had spilled, dried syrup on the wire shelf.4. A shelf holding clean steam table pans had scattered food debris.5. Two three-tiered wire carts used to transport food and drinks to the residents had multiple areas of rust.6. Two hot carts used to transport residents' food to another dining room had multiple areas of dried-on food.7. A bread cart had a covering of a sticky substance on the runners.8. Six colored plastic cutting boards were heavily gauged and discolored.On 07/22/2026 at 09:13 AM, Dietary Staff BB confirmed the areas noted above needed to be added to the cleaning list.The facility policy for Food Preparation and Handling, dated 10/17/2024, included: The facility will store, prepare, distribute, and serve food in accordance with professional standards for food safety services. Cutting boards will be washed and sanitized following each use.

Based on record review and interview, the facility failed to complete an annual performance review at least once every 12 months for one Certified Nurse Aide (CNA), employed greater than one year.Findings included:- Review of five CNA personnel files, employed by the facility for greater than one year, revealed the following concern:Certified Nurse Aide (CNA) N, hired 12/04/2017, lacked an annual performance review.On 07/21/2026 at 02:30 PM, Administrative Nurse D stated the facility only completed annual performance reviews on full-time and part-time employees but did not complete annual performance reviews on as-needed (PRN) employees, such as CNA N.The facility's Employee Handbook included: PRN team members are scheduled no more than 19 hours per week. PRN team members must work at least two shifts per pay period or 4 shifts each calendar month to remain employed. A performance review will be conducted once per year for each team member.

Based on observation, interview, and record review, the facility failed to complete the Care Area Assessment (CAA) analysis related to a Comprehensive Minimum Data Set (MDS), for Residents (R)2, R9, R12, R21, R29, R33, and R38 to address the underlying cause, risk factors, and other contributing factors to ensure the resident received care based on their individual needs. Findings included:- Review of residents' most recent comprehensive MDS documentation revealed the triggered CAA lacked completion as follows:1. R2's Significant Change in Status MDS, dated 02/11/2026, lacked completion of CAAs dated 02/27/2026 for Cognitive Loss/Dementia, Communication, Urinary Incontinence and Indwelling Catheter, Psychosocial Well-Being, Nutritional Status, Pressure Ulcer, and Psychotropic Drug Use.2. R9's Annual MDS, dated 12/07/2026, lacked completion of CAAs dated 12/16/2026 for Cognitive Loss/Dementia, Visual Function, Functional Abilities (Self-care and Mobility), Urinary Incontinence, Psychosocial Well-Being, Behavioral Symptoms, Falls, Nutritional Status, Pressure Ulcers, and Psychotropic Drug Use.3. R12's Annual MDS, dated 02/21/2026, lacked completion of CAAs dated 02/21/2026 for Cognitive Loss/Dementia Care, Functional Abilities (Self-Care and Mobility), and Pain.4. R21's Annual MD, dated 08/09/2026, lacked completion of CAAs dated 08/25/2025 for Cognitive Loss/Dementia, Functional Abilities (Self- Care and Mobility), Communication, Falls, and Psychoactive Drug Use.5. R29's Modified admission MDS, dated 09/05/2025, lacked completion of CAAs dated 09/05/2025 for Cognitive Loss/Dementia, Communication, Urinary Incontinence and Indwelling Catheter, Behavioral Symptoms, Falls, Nutritional Status, Dehydration/Fluid Maintenance, Dental Care, Pressure Ulcer/Injury, Psychotropic Drug Use, and Pain.6. R33 's Annual MDS, dated 11/09/2025, lacked completion of CAAs dated 11/19/2025 for Functional Abilities (self-care mobility), Urinary Incontinence and Indwelling Catheter, Nutritional Status, and Dental.7. R38's Annual MDS, dated 05/24/2025, lacked completion of CAAs dated 05/29/2025 for Cognitive Loss/Dementia , Visual Function, Communication, Functional Abilities (Self-Care and Mobility), Urinary Incontinence and Indwelling Catheter, Falls, Pressure ulcer/injury, and Psychotropic Drug Use.On 07/22/2026 at 02:32 PM, Administrative Nurse E reported the facility used the Resident Assessment Manual (RAI) for guidance to complete the MDS and CAAs for comprehensive assessments. She reported she was not aware the CAA completion should include the location of the information and resource materials that led to the individualized analysis for the triggered areas of the CAA to develop the care plan until she received training on 04/26/2026. She verified the CAA documentation for the above named residents lacked source documentation of information to indicate the analysis of the data collected, other than the narrative for the location of the data that triggered the CAA, and lacked analysis keeping with the guidance provided in the RAI Manual.The Resident Assessment Instrument (R.A.I.) Manual, titled The Care Area Assessment (CAA) Process and Care Plan Completion, dated 2025, documentation included . Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's care plans that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA process provide the foundation upon which the care plan is formulated. There are 20 problem-oriented CAAs, each of which includes MDS-based Trigger conditions that signal the need for additional assessment and review of the triggered care area. Detailed information regarding each care area and the CAA process, including definitions and triggers, appears in Chapter 4 of this manual. Chapter 4 also contains detailed information on care planning development utilizing the RAI and CAA process. CAA(s) completion is required for comprehensive assessments.

Based on observation, record review, and interview, the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment in the facility laundry.Findings included: - On 07/22/2026 at 09:58AM, laundry tour with Housekeeping/Maintenance Staff U revealed the following concerns:1. The floor in front of the washers was unsanitary with missing paint/sealant on the concrete floor approximately three inches by three feet section.2. The floor throughout the laundry processing area was unsanitary due to missing paint/sealant on the concrete floor in an approximately three-inch by three-foot section.3. The intake ventilation unit had peeling sheetrock above the screen which measured approximately six inches by five inches.On 07/22/2026 at 10:03 AM, Administrative Staff A and Housekeeping/Maintenance Staff U confirmed the laundry floor and sheetrock surrounding the ventilation intake were in need of repair to provide a safe and sanitary environment for the laundry staff processing residents' linen.The facility policy titled Laundry Infection Control and Prevention Policy, dated 03/2026, documented that the facility must provide and maintain a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections.

Based on interview and record review, the facility failed to inform Resident (R) 1 and R32 and/or their representatives regarding the risks related to psychotropic (alters mood or thoughts) medications. Findings included:1. R1's Electronic Medical Record (EMR) listed a Physician's Order for buspirone (antianxiety- a class of medications that calm and relax people), 5 milligrams (mg) tablets, give one tablet by mouth three times a day for anxiety, dated 03/03/2026.R1's EMR documented an order for lorazepam (antianxiety- a class of medications that calm and relax people) 0.5 mg tablet, give one tablet by mouth every four hours as needed for anxiety/restlessness, dated 05/29/2026.R1's EMR lacked evidence that R1, or her representative, received education and/or informed consent with regard to the buspirone and lorazepam.On 07/20/2026 at 09:09 AM, R1 sat in her recliner wearing her glasses and hearing aids. R1 reported she felt safe and the staff listened to her even though she did not speak much. R1 could not recall what medications she was administered.2. R32's EMR documented an order for Remeron (antidepressant- a class of medications used to treat mood disorders)15 mg tablet, give one tablet by mouth at bedtime for insomnia (inability to sleep), dated 06/30/2026.R32's EMR lacked evidence that R32, or her representative, received education and/or informed consent with regard to the Remeron.On 07/20/2026 at 09:24 AM, R32 was in her bed, and she reported she did not feel good.On 07/21/26 at 01:28 PM, Licensed Nurse (LN) G reported that the psychoactive consents were completed by Administrative Nurse D. On 07/22/2026 at 11:48 AM, Administrative Nurse D reported she had not completed an informed consent for R32' s Remeron. Administrative Nurse D produced two informed consent forms for R1. The buspirone consent had a date signed by Administrative Nurse D documented 03/04/2026; the durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) signature had no date; LN G signed as a witness on 07/22/2026. The lorazepam consent had a date signed by Administrative Nurse D, documented 05/29/2026; the DPOA signature had no date; LN G signed as a witness on 07/22/2026. Administrative Nurse D reported that the forms were completed that day.On 07/22/2026 at 12:22 PM, R1's DPOA was in the dining room; she reported that she had just signed the informed consent forms and said that she did not think to date the forms. She reported that there were no other signatures or dates on the informed consent forms when she signed them. On 07/22/2026 at 01:33 PM, Administrative Nurse D reported that she expected to have informed consents for all psychotropic medications completed upon admission or before a resident would start a psychotropic medication.The facility's policy Psychotropic Medication Use dated 03/2026 lacked documentation in regard to completing an informed consent.The facility's Informed Consent Form, undated, documented that the proposed treatment will not be started by the facility until this signed consent is returned to the facility. Please complete this document prior to initiation of any treatment of chemical or physical restraint, or psychoactive drugs.

Based on observation, record review and interviews, the facility failed to ensure Resident (R) 1's as needed (PRN) psychotropic medication (alters mood or thoughts) had a 14 day stop date, or a specified duration with a physician rationale for extended use. Additionally, the facility failed to monitor R25's for target behaviors or side effects of the psychotropic medications.Findings included:- R1's Electronic Medical Record (EMR) revealed a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R1's 06/09/2026 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R1's MDS revealed he was administered an anti-anxiety medication. R1's 06/23/2026 Psychotropic Drug Use Care Area Assessment (CAA) documented R1 was administered high-risk psychotropic medications. R1 would be at high risk for falls. R1's Care Plan dated 03/30/2026 instructed staff to administer antianxiety medications as ordered and to monitor and document side effects and effectiveness. R1's EMR noted an order for lorazepam 0.5 milligrams (mg), one tablet by mouth, every four hours as needed for anxiety/restlessness, dated 05/29/2026. The order lacked a stop date. On 07/20/2026 at 09:09 AM, R1 sat in her recliner wearing her glasses and hearing aids. R1 reported she felt safe here and the staff listened to her even though she did not speak much. R1 could not recall what medications she was administered. On 07/21/2026 at 02:42 PM, Licensed Nurse (LN) G reported that any as-needed psychotropic medication orders required a 14-day stop date. LN G reported that the nurse who documented the order in EMR was responsible for documenting a stop date. On 07/21/2026 at 04:30 PM, Administrative Nurse D reported she expected all as needed psychotropic medications to have a 14 day stop date to have the medication reassessed. The facility's policy Psychotropic Medication Use dated 03/2026 documented that any PRN psychotropic medication, such as anti-anxiety medication, will only continue for a duration of 14 days. If the medication must continue past the 14 days, it must have a physician-explained rationale and a duration of no more than 6 months. - R25's Electronic Medical Record (EMR) documented the following diagnoses: depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and insomnia (the inability to sleep). R25's admission Minimum Data Set (MDS), dated [DATE], documented he had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He received antidepressant medications (medications used to treat the signs and symptoms of depression) during the assessment process. R25's Psychotropic Drug Use Care Area Assessment (CAA), dated 06/25/26, documented R25 had antidepressant medications, which placed him at risk for falls. R25's Care Plan, dated 06/18/26, lacked staff instruction regarding the administration and monitoring of target behaviors and side effects of psychotropic drug use. R25's EMR documented the following physician's orders: Trazodone (an antidepressant medication), 50 milligrams (mg), by mouth (PO), at bedtime (HS), for a diagnosis of insomnia, ordered 06/18/2026. Sertraline (an antidepressant medication), 50 mg, PO, in the morning (AM), for a diagnosis of depression, ordered 06/19/2026. Bupropion (an antidepressant medication), 300 mg, PO, in the AM, for a diagnosis of depression, ordered 06/19/2026. R25's Medication Administration Record (MAR) for June and July 2026 revealed he received the medications, as ordered. R25's EMR lacked documentation of monitoring for target behaviors or side effects of the psychotropic medications. On 07/22/2026 at 08:50 AM, Licensed Nurse (LN) G stated staff monitors for side effects and target behaviors on residents who receive psychotropic medications every shift. On 07/22/2026 at 08:55 AM, Administrative Nurse D stated it was the expectation for staff to monitor psychotropic medications each shift. Administrative Nurse D stated staff instruction for residents receiving psychotropic medications should be included in their care plans. The facility policy Psychotropic Medication Use, revised 03/2026, included: The staff shall monitor for target behaviors related to psychotropic medication every shift. The facility policy for Care Planning, revised 03/2026, included: The facility shall develop and implement a comprehensive person-centered care plan for each resident to meet each resident's medical, nursing, and psychosocial needs.

Based on record review and interview, the facility failed to notify the State Ombudsman of two resident discharges to the hospital, regarding Resident R1 and R3, as required.Findings included:1. R1's Electronic Medical Record (EMR) documented that she admitted to the hospital on [DATE]. The EMR lacked documentation that the State Ombudsman had been notified of the resident's hospital admission. The facility was unable to provide evidence upon request.2. R3's EMR documented he admitted to the hospital on [DATE]. The EMR lacked documentation that the State Ombudsman had been notified of the resident's hospital admission. The facility was unable to provide evidence upon request.On 07/22/2026 at 10:30 AM, Social Services X stated she had not notified the State Ombudsman of R1 and R3's hospital admissions.The facility policy for Admission, Transfer and Discharge, revised 01/2026, included: The State Ombudsman will be notified of all transfers and discharges.

Based on observation, interview, and record review, the facility failed to provide a written baseline care plan to Resident (R) 32, and R37. Findings include:1. R32's Electronic Medical Record (EMR) lacked documentation that a written baseline care plan was given to or reviewed by R32 or a representative since she was admitted on [DATE].On 07/20/2026 at 09:24 AM, R32 was in her bed, and she reported she did not feel good.2. R37's EMR lacked documentation that a written baseline care plan was given or reviewed by R37 or a representative since she was admitted on [DATE].On 07/21/2026 at 08:01 AM, R37's durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) reported that she had no care plan discussed with her since R37 was admitted to the facility.On 07/21/2026 at 04:13 PM, Licensed Nurse (LN) G reported that the nurse would complete the base line care plan on admission that was documented in the EMR in the assessment tab.On 07/21/2026 at 04:15 PM, Administrative Nurse D reported that she expected the baseline care plan to be completed within 48 hours of admission.The facility's policy Baseline Care Plan dated 10/17/2024, documented this facility will develop an initial person-centered care plan within the first forty-eight (48) hours of admission for every resident. A baseline care plan will provide instructions for care of the resident. Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among all facility staff members, increase resident safety and safeguard against adverse events that are most likely to occur in the immediate days after admission prior to development of the comprehensive care plan and to ensure the resident and representative are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan or a copy of the baseline care plan.

Based on observation, record review, and interview, the facility failed to ensure residents received assistance with activities of daily living (ADL) including nail care for Resident (R)1, and R32. Findings included:1. R1's Electronic Medical Record (EMR) revealed diagnoses of anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin)R1's 06/09/2026 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R1's MDS revealed she required maximal assistance with personal hygiene.R1's 06/23/2026 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R1 required assistance with all ADLs to ensure safety.R1's Care Plan dated 03/15/2026 instructed staff to keep R1's fingernails short.R1's Care Plan dated 06/23/2026 instructed staff that R1 required moderate assistance with personal hygiene.On 07/21/2026 at 07:55 AM, R1 sat in the dining room as she was eating yogurt. She had a visitor and reported she was doing fine. R1 had long fingernails and nail polish that was chipped off all the nails.On 07/21/2026 at 01:52 PM, R1 was administered her breathing treatment by Licensed Nurse (LN) G in her room. R1's fingernails were long, and they all had chipped nail polish. LN G reported that Activity Staff K had not done a nail manicure activity lately, and that is when the residents would have new nail polish applied.On 07/22/2026 at 08:00 AM, R1 sat in her recliner with her eyes closed; her fingernails remained the same as yesterday's observation.2. R32's EMR revealed diagnoses of diabetes mellitus and needing assistance for personal care.R32's 07/07/2026 admission MDS documented a BIMS score of three, indicating severely impaired cognition. R32's MDS revealed she required moderate assistance for personal hygiene.R32's 07/13/2026 Functional Abilities (Self-Care and Mobility) CAA did not trigger.R32's 07/13/2026 Activities CAA documented R32 had visual and some hearing impairment. She has physical limitations such as weakness and pain. Her disability may prevent her from attending/participating in some activities, which will cause her to want to stay in her room often and become isolated and lonely. R32 would be care plan is initiated to encourage social interaction and active participation.R32's Care Plan dated 07/13/2026 staff instructed to ask yes/no questions to determine R32's needs.R32's Care Plan dated 07/20/2026 lacked direction for staff for R32's preferences of nail care and staff assistance required.On 07/20/2026 at 03:39 PM, R32 was assisted to her recliner by Certified Nurse Aide (CNA) P. R32's fingernails were long and had brown substance under some of the fingernails; all of her fingernails had chipped nail polish noted on them.On 07/22/2026 at 07:58 AM, R32 sat in the dining room drinking coffee. R32's her nails remained with long, chipped nail polish on all the fingernails and brown substance under some of her nails.On 07/21/2026 at 01:23 PM, CNA P reported that residents' fingernails are trimmed and cleaned on shower days and as needed. CNA P reported that the nurse would cut the diabetic residents' nails.On 07/22/2026 at 11:50 AM, Activity Staff Z (Activity Director) reported that she had not completed a manicure activity for about 2 months now, and she was the staff member who painted the residents' fingernails.On 07/22/2026 at 12:40 PM, Administrative Nurse D expected the staff to clean and trim residents' fingernails. Administrative Nurse D reported that activities would complete the manicures and new nail polish. Administrative Nurse D reported she was unsure when activities had completed that activity last but expected residents to have nice nail polish on their nails.The facility's policy Cleaning and Trimming Nails dated 03/2026, documented that cleaned and trimmed fingernails and toenails are important for overall health. Bacteria often collect under and around nailbeds. This facility is committed to providing high-quality care to all residents residing in the facility.

Based on interviews, observations, and record review, the facility failed to monitor Resident (R) 38's nutritional and hydration status during an acute change of condition. The facility failed to monitor for complications related to R2's multiple bruises and a skin tear. Findings included:- R38 Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dysphagia (difficulty swallowing), stage four chronic kidney disease (disease where the kidneys were moderately or severely damaged and were not working as well as they should be to filter waste from the blood), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and Influenza A (highly contagious viral infection). R38's Annual Minimum Data Set (MDS), dated 05/24/2025, documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. He had functional limitations in range of motion (ROM) to both sides of his upper and lower extremities. He required staff touch and set up assistance with eating and did not exhibit swallowing or choking issues. R38 was 65 inches in height and weighed 222 pounds (lbs). R38's Quarterly MDS, dated 11/24/2025, documented a BIMS score of nine, which indicated moderate cognitive impairment. His weight was 208 lbs, which was a 14lb or 7.5% weight loss from the previous assessment. R38's Discharge Return Anticipated MDS, dated 01/23/2026, documented R38 was discharged from the facility and was sent to the hospital with an anticipated return. R38's Nutritional Status Care Area Assessment (CAA) documented the CAA triggered due to high Body Mass Index (BMI- the body calculation of resident body fat) and a no-salt-added diet order. He ate well at meals with a stable weight. He had no complications. R38's 11/25/2025 Care Plan directed that R38's recommended diet was a mechanical soft level two (mechanically altered diet where the foods are moist, with soft texture for easy swallowing). R38 and his representative requested not to follow the recommended diet. His representative signed a risk versus benefit agreement for him to be allowed to have a regular diet. He and his representative declined any further speech (ST) evaluations and stated that, no matter the outcome, they will continue to sign a waiver. He usually ate 50-100% at meals. He had his own teeth without any chewing or swallowing difficulty noted. His BMI indicated obesity (severe overweight), but he was stable. R38 had diuretic orders which may impact fluid shifts/weight trends. R38's EMR revealed the following, indicating a change in condition: A Health Status Note, dated 01/18/2026 at 03:15 PM, documented R38 woke up with a low-grade fever and moist cough. His temperature was 99.0 degrees Fahrenheit (F), and his lungs sounded clear. R38 had a pleasant mood; he ate a cinnamon roll and drank juice for breakfast. He remained in his room due to a cough and per his representative's request. On 01/18/2026 at 08:10 PM, R38's EMR noted his temperature was 100 degrees F, his blood pressure was 183/103 millimeters of mercury (mmHg), his pulse was irregular at 102 beats per minute (bpm), and his oxygen saturation was 96% on room air. A Health Status Note on 01/19/2026 at 04:18 PM, documented while R38 was out of the facility at a scheduled physician visit, the physician's office called and reported R38 tested positive for influenza A. The facility received an order for Tamiflu (medication used to treat influenza) 75 milligrams (mg) twice a day for five days. Staff notified R38's representative. A Health Status Note, dated 01/21/2026 at 05:47 AM, documented that R38 started Tamiflu on 01/20/26. His oxygen saturation had been 88 to 92% on oxygen therapy with respirations of 20 to 32 per minute. R38 had coarse lung sounds, and staff checked on him frequently. A Health Status Note on 01/23/2026 at 10:32 AM documented that the nurse was called to R38's room due to him not responding with a dry brief. The nurse notified R38's provider and obtained an order, then notified his representative. R38 left the facility at 09:48 AM via emergency medical services (EMS), and the nurse called report to the hospital at 09:49 AM. Review of R38's meal percentage EMR documentation from 01/15/2026 to 01/23/2026 revealed the following: On 01/15/2026 and 01/16/2026, R38 ate 76 to 100% at breakfast, lunch, and dinner. There was a lack of evidence of meal percentage documentation on 01/17/26 for breakfast, lunch, or dinner. On 01/18/2026, there was a lack of evidence of meal percentage documentation for breakfast or lunch. R38 ate 51 to 75% at dinner. On 01/19/2026, R38 ate 26 to 50% at breakfast and lunch. There was a lack of evidence of meal percentage documentation for dinner. On 01/20/2026, there was a lack of evidence of meal percentage documentation for breakfast. R38 ate 0 to 25% at lunch and drank a protein shake. R38 ate 0 to 25% at dinner. On 01/21/1026, R38 ate 0 to 25% for breakfast and dinner. There was a lack of evidence of meal percentage documentation for lunch. On 1/22/2026, R38 ate 0 to 25% for breakfast and dinner. There was a lack of evidence of meal percentage documentation for lunch. On 07/21/2026 at 09:39 AM, Certified Nurse Aide (CNA) P stated R38's representative visited every day and was highly involved in his care. CNA P stated R38 went to the hospital because he was not responsive, and he had influenza. He was coughing up green mucus and rattling when he breathed. CNA P stated she offered R38 house shakes, which he would take a couple of sips of, but he would not eat and would only drink water occasionally. She stated he loved Dr. Pepper, but he barely drank that as well. CNA P stated R38's intake decreased over a period of a few weeks. She stated staff documented in the EMR for each meal offered and documented the percentage eaten. She stated the nurse monitored the resident's intake and reported it to the physician. CNA P stated it seemed they noticed his change in condition on the day they sent him out. On 07/21/2026 10:20 AM, Licensed Nurse (LN) G stated the interventions to treat residents were communicated through the care plan, messages, and report. She stated staff monitored for changes in condition through different assessments. When residents had condition changes, staff monitored their vital signs and encouraged fluids based on their area of decline. LN G stated the CNAs notified the nurse of changes, and the nurse assessed the resident, then notified the physician. She stated the CNAs documented in the EMR what the residents ate or drank, but she did not review that documentation because she did not have time and depended on the CNAs to let her know if the resident ate or not. LN G stated she remembered when R38 stopped eating as much when he had influenza; he did not have an appetite, and his kidneys were impaired. She stated she did not recall if R38 received fluids or not, as that would be a better question for the CNA. LN G stated she did not recall if staff notified her that R38 coughed up green mucus or was coughing up more. She stated she would implement standing orders and notify the physician and/or family of changes. LN G stated staff should have documented meal intake and notified the nurse of the intake to maintain their medical record. On 07/21/2026 at 02:14 PM, Administrative Nurse D reviewed the EMR related to the meal intake and associated change in condition. She confirmed the lack of documented intake monitoring that would be expected during R38's change in condition. - R2's Electronic Medical Record (EMR) revealed a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and dementia (a progressive mental disorder characterized by failing memory and confusion) R2's 02/11/2026 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS); no BIMS interview completed as resident was rarely/never understood. Staff assessment completed indicating severely impaired cognition. R2's MDS revealed no behaviors noted, and she required total dependence from staff for activities of daily living (ADLs). R2's 02/27/26 Care Area Assessment (CAA) section revealed none of the CAAs were documented that triggered. R2's Care Plan dated 04/04/2022, staff were instructed to observe R2's skin during daily cares and report concerns to the charge nurse. R2's Care Plan dated 11/03/2023 instructed staff to place a floormat beside the bed. R2's Care Plan dated 11/05/2024, staff were instructed to apply Tubi-grips (elasticated tubular bandage designed to provide tissue support in treating strains, sprains, soft tissue injuries, general edema, and tissue protection) to both arms for protection apply in the morning and removed in the evening. R2's Care Plan dated 04/14/2026, staff were instructed to apply Tubi-grips to both arms for protection, apply in the morning and remove in the evening to prevent skin issues. At times, durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to)will demand sleeves/Tubi-grip to be removed, although DPOA had been educated on the benefits of skin protection in preventing future wounds. R2's Weekly Skin Check reviewed from 05/12/2026 and 07/08/2026 revealed no documentation for any bruises on R2's arms or right hand middle finger. R2's Weekly Skin Issues reviewed from 05/12/2026 and 07/08/2026 revealed no documentation for any bruises on R2's arms or right hand middle finger. R2's Hospice Nurse Visit Log dated 06/10/2026 documented bruising on both upper forearms. The documentation lacked sizes, colors, and whether facility staff was notified. On 07/21/2026 at 11:10 AM, Certified Nurse Aide (CNA) Q and Certified Medication Aide (CMA) R assisted R2 to bed when they used the mechanical lift and transferred R2 to her bed, observed several purple bruises on both her posterior forearms and a purple bruise on her right hand middle finger. CMA R operated the lift, and CNA Q did not support R2's legs while she was in the lift. CMA R removed her pants with no bruises or skin issues noted on R2's legs. On 07/22/2026 at 08:01 AM, R2 was lying in her bed moving her arms around and mumbling her bed was in low position, and no fall mat was noted on the floor. R2 had no Tubi grips on her arms, and the bruises remained the same on her arms and right-hand middle finger as in the 07/21/2026 observation. R2's right arm had six purple bruises noted on the posterior forearms ranging in approximate sizes of 1 centimeter (cm) diameter to 3 cm diameter; R2's right middle finger purple bruise approximate size of 1 cm diameter. R2's left forearm purple colored bruises noted, five ranging in approximate size of 1cm to 3 cm in diameter. The new fall mat was in the bathroom, folded in a plastic bag. On 07/22/2026 at 08:58 AM, CMA R reported that she was pretty sure a new fall mat was delivered before she left work around 06:00 PM on 07/21/2026. CMA R looked in R2's bathroom and reported that the new fall mat was in the bathroom, folded and still in the plastic wrap, and reported well no one laid it down. CMA R reported that R2's husband would not allow the staff to apply any type of arm protectors. CMA R observed several bruises on R2's arms and right hand middle finger and reported that R2 would pinch her arms at times, and that is why she has bruises. On 07/22/2026 at 09:00 AM, CNA Q reported she did not notice that R2 did not have a fall mat on the floor this morning when she gave care earlier. CNA Q reported she was not aware if R2 required any type of arm protectors. On 07/22/2026 at 09:05 AM, Licensed Nurse (LN) G reported that R2's fall mat was delivered to her room on 07/21/2026 in the evening before she left work. LN G reported that CNA O removed the old fall mat from R2's room. LN G reported that R2's family requested she not wear arm protectors during the summertime as it would be too hot for her. LN G reported that R2 would bruise easily with transfers and sometimes the husband would grab at her arms when he assisted her with her meal. LN G reported that she did see all the purple bruises on R2's arms when she applied the dressing to her right elbow skin tear on 07/21/2026. LN G reported she expected the staff to use all the fall interventions on the care plan. LN G reported that the nurse would complete the weekly skin check and should document all areas of concern. 07/22/2026 at 09:10 AM, Administrative Nurse D expected staff to always have all fall interventions in place. On 07/22/2026 at 01:31 PM, CNA M reported she would notify the nurse verbally if a resident were to have a new bruise or skin tear or any new skin issue. CNA M reported that the staff would not document that anywhere; they just verbally let the nurse know. 07/22/2026 at 01:37 PM, Administrative Nurse D reported she expected the nurse to complete a weekly skin check in EMR that would include any skin issues; she also expected the staff to complete an incident report for skin tears and bruises if unknown injury. On 07/22/2026 at 02:30 PM, Administrative Staff A reported that the bruises were not documented in R2's EMR; She expected them to be documented. The facility's policy Skin Integrity dated 03/2026 documented, residents who are admitted will have every effort made in order to assure that their skin integrity is maintained though correlated efforts from the interdisciplinary care team. The policy lacked documentation for bruises.

Based on interviews, observation, and record review, the facility failed to implement adequate infection control practices related to respiratory equipment for Resident (R) 1 and R37, and hand hygiene during incontinence care for R2. Findings included:1. On 07/20/2026 at 09:09 AM, R1 sat in her recliner wearing her glasses and hearing aids. A portable oxygen tank was observed on the back of R1's wheelchair; the nasal cannula tubing was draped over the tank, and the nose part touched the tank.On 07/21/2026 at 07:59 AM, R1's oxygen tubing laid on the floor.2. On 07/20/2026 at 10:49 AM, R2 had a fall mat in her bathroom; the fall mat had frayed open areas noted in the corners.On 07/20/2026 at 03:37 PM, R2 was in her low bed with a fall mat on the floor that had worn areas in the corners and cracks noted on the surface.On 07/21/2026 at 02:30 PM, Consultant Staff HH (Hospice Nurse) looked at R2's fall mat and reported that the fall mat in R2's room should be replaced as it was cracked and had uncleanable surfaces. Consultant Staff HH reported that hospice did not supply that fall mat.On 07/21/2026 at 02:38 PM, Licensed Nurse (LN) G reported that fall mats should not have cracks on them and that the family would appreciate a new mat. On 07/21/2026 at 04:15 PM, Administrative Nurse D reported that the fall mats should have a cleanable surface and the fall mat would be replaced for R2.3. 07/20/2026 12:17 PM R37 had oxygen tubing wrapped up and laid on top of her overbed table.On 07/20/2026 at 03:38 PM, R37 slept in her recliner; a portable oxygen tank was observed on the back of R37's wheelchair. The nasal cannula tubing was draped over the wheelchair seat, and the nose part lay on the pad of the wheelchair seat.On 07/21/2026 at 02:21 PM, R37's nasal cannula lay on the floor in her room.On 07/21/2026 at 02:14 PM, Certified Medication Aide (CMA) R reported that all oxygen tubing, when not in use, should be placed in a bag, as she looked at R1's oxygen tubing laid on the wheel of her wheelchair.On 07/21/2026 at 02:17 PM, LN G reported that all oxygen cannula's/mask should be placed in a bag when not in use.On 07/21/2026 at 04:23 PM, Administrative Nurse D expected all oxygen tubing to be placed in a bag when not in use.4. On 07/21/2026 at 11:01 AM, CMA R and Certified Nurse Aide (CNA) Q provided incontinent care to R2. CMA R cleansed R2's buttocks, then removed her gloves to retrieve a brief liner from the bathroom. CMA R applied new gloves; no hand hygiene was performed. CNA Q cleansed R2's peri-area. CNA Q left her soiled gloves on after she cleansed R2 as she assisted R2 with dressing R2. CMA R removed her gloves with no hand hygiene performed. CNA Q and CMA R transferred R2 to her recliner with the mechanical lift. CNA Q picked up the package of cleansing wipes and extra brief and placed those items into R2's bathroom while wearing the same gloves she used to cleanse R2. CNA Q removed her gloves, and no hand hygiene was performed. CMA Q propelled R2 down the hallway to the television lounge; she then stopped at the nurse's desk and exited the facility; no hand hygiene was performed.On 07/21/2026 at 01:12 PM, CNA Q reported that she should have removed her gloves and performed hand hygiene after she cleaned R2's peri area.On 07/21/2026 at 02:14 PM, CMA R reported that she should have washed her hands after she removed her gloves before she placed a new pair on when she completed incontinent care to R2.On 07/21/2026 at 02:38 PM, LN G reported that the staff should perform hand hygiene every time they remove their gloves.On 07/21/2026 at 04:23 PM, Administrative Nurse D reported she expected all staff to perform hand hygiene after they remove their gloves.The facility's policy Hand Hygiene dated 03/2026 documented the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Key recommendations for hand hygiene included before and after removing gloves.The facility did not provide a policy for the care of respiratory equipment.

Based on interview, observation, and record review, the facility failed to ensure Resident (R)1's bed was in safe condition.Findings included:- R1's Electronic Medical Record (EMR) revealed a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R1's 06/09/2026 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R1's MDS revealed she required moderate assistance with bed mobility.R1's 06/23/2026 Falls Care Area Assessment (CAA) documented: [NAME] is taking high-risk medications [NAME] had a fall resulting in a fall. She is continually a high fall risk.R1's Care Plan dated 03/16/2026 instructed staff R1 preferred to have bed rails on her bed to help her reposition in bed easier.R1's Bed Rail assessment dated [DATE] at 07:27 PM documented siderails/assist bar were indicated and serve as an enabler to promote independence; R1 had expressed a desire to have an assist bar.R1's Bed Rail assessment dated [DATE] at 05:57 PM documented siderails/assist bar were not indicated at this time.R1's Bed Rail assessment dated [DATE] at 05:44 PM documented siderails/assist bar was not indicated at this time.On 07/20/2026 at 09:09 AM, R1 sat in her recliner wearing her glasses and hearing aids. R1 reported she felt safe here and the staff listened to her even though she did not speak much. R1 had a bed assist bar on each side of her bed upright. The bed assist bar on the left side of the bed was quite loose; it freely moved away from the bed.On 07/21/2026 at 10:17 AM, R1's two bed assist bars remained on each side of her bed upright, and the left bed assist bar remained loose.On 07/21/2026 at 02:14 PM, Certified Medication Aide (CMA) R reported that R1 never used the bed assist bars on her bed and did not realize they were loose. CMA R reported that the staff communicates with maintenance in writing when something needs fixed.On 07/22/2026 at 10:13 AM, Maintenance Staff U (Maintenance Supervisor) reported that he did not complete a monthly check of bed positioning devices. He reported that once the device is applied to a resident's bed, we just remove the device at discharge. Maintenance Staff U reported that R1's positioning bar was loose as he looked and moved the bed assist bar attached to R1's bed at this time. Maintenance Staff U reported that the bed was the facility's bed and not provided by hospice.On 07/22/2026 at 01:33 PM, Administrative Nurse D reported that she was not aware that R1 had two bed rail assessments that documented R1 did not require the rails on her bed. Administrative Nurse D expected the nurse to communicate changes in assessments so the bed assist bars could be removed.On 07/22/2026 at 02:15 PM, Administrative Staff A reported that the staff would communicate to the maintenance staff in writing if anything needed to be repaired. She reported she was uncertain if the bed assist bars were required to be inspected.The facility's policy Electric Bed dated 03/2026 documented the facility would conduct regular inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment. When bed rails and mattresses are used and purchased separately from the bed frame, the facility must ensure that the bed rails, mattress, and bed frame are compatible. Report any malfunctions to the maintenance department.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by failing to ensure the lid of the dumpster was kept closed.Findings included:- During the initial tour of the kitchen on 07/20/2026 at 09:02 AM, observation revealed the covers of the dumpster were open.On 07/21/2026 at 10:30 AM, the dumpster lid remained open.On 07/22/2026 at 09:13 AM, the dumpster lid was held open by trash bags within the dumpster.On 07/22/2026 at 09:13 AM, Dietary Staff BB confirmed the lid to the dumpster was not always kept closed.The facility was unable to provide a policy regarding the dumpsters.

Based on observation, record review, and interview, the facility failed to display accurate, publicly accessible, and identifiable staffing information, on a daily basis, for the 30 residents who resided in the facility.Findings included:- Review of the facility's Daily Staffing Sheets from 06/20/2026 through 07/20/2026 revealed that the actual hours worked and the facility name had not been completed on the daily staffing sheets.On 07/21/2026 at 02:30 PM, Administrative Staff B confirmed the daily staffing sheets lacked the actual hours worked and the facility name, as required.The facility policy for Posting Daily Nurse Staffing Form, dated 01/2025, included: The Daily Nurse Staffing Form will include, but is not limited to, the facility name, current date, total number, and actual hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nurse Aides (CNA).

The facility reported a census of 38 with three residents included in the sample. Based on interviews and record review the facility failed to prevent a medication error when Licensed Nurse C did not follow the physician order and incorrectly administered five times the ordered amount of Ativan to Resident (R)1, who was on hospice. Findings included: - R1's Electronic Medical Record (EMR) dated 10/24/24 indicated the diagnosis of dementia with agitation (progressive mental disorder characterized by failing memory, confusion). R1's Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS noted R1 had behaviors symptoms of physical and verbal towards others. The 01/02/25 Significant Change (MDS) indicated R1's placement on hospice. The Care Area Assessment (CAA) dated 10/24/24 revealed behaviors triggered due to the physical, verbal abuse towards staff. The contributing factors included unspecified dementia with unspecified severe agitation and risk factors included injuring self and others. The Care Plan revised on 01/24/25 revealed R1 could become agitated at times, could be verbally and physically abusive, combative to staff, and resistive to care. The staff were to administer medications as ordered and monitor/document for side effects and effectiveness. The EMR revealed an order dated 01/09/25 for topical Ativan (lorazepam, a medication to treat anxiety) 1 milligram (mg) per 0.1 mg, every four hours as needed for anxiety, and use only 0.1 mg of syringe per dose (the syringe contained 5 doses in one syringe) every four hours, as needed for anxiety, and apply to the inner wrist or back of neck. Review of the Nurses Notes dated 01/14/25 to 01/20/25 lacked documentation regarding R1's response to the amount of Ativan given in error. The 01/16/25 at 04:32 PM note included staff notified the physician regarding the medication error that occurred on 01/14/25 with no new orders received During an interview on 03/17/25 at 02:30 PM Administrative Nurse B revealed Licensed Nurse (LN) C gave the wrong dose of Ativan. Administrative Nurse B said instead of administering one dose as ordered LN C gave five doses of the resident's topical Ativan all at once. Administrative Nurse B stated this occurred on 01/14/25 and the error was not discovered until 01/16/25 when another nurse discovered the wrong dose had been given. Administrative Nurse B stated they completed a teachable moment of education with LN C on 01/16/25 regarding medication error. During an interview on 03/17/25 at 03:50 PM, Licensed Nurse (LN) C revealed R1 had a lot of anxiety and needed an as needed Ativan. LN C said she was used to the single dose syringes of topical ativan, and she looked at the syringe incorrectly and administered the wrong dose. During an interveiw on 03/17/25 at 04:00 PM, Administrative Nurse B revealed she expected the nurses to check the dose of medication and follow the medication rights when administering medications. The facility's policy Medication Administration dated October 2024 revealed the facility must ensure that its residents are free of any significant medication errors. The individual administering the medication must check the label three times to verify the right medication, right dosage right time and right method (route) of administration before giving the medications, The facility failed to prevent a medication error for R1 when Licensed Nurse C administered five times the physician ordered dose of Ativan to the hospice resident.

- The Electronic Health Records (EHR) documented R31 had the following diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion), abnormalities of gait and mobility and muscle weakness. The 01/21/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition, the depression score was two, indicating minimal depression and she had no behaviors. R31 required maximal assistance with activities of daily living (ADLs), with toileting hygiene, transfer, showering, personal hygiene and upper body dressing. The 01/29/24 Functional Abilities Care Area Assessment (CAA) documented R31 required substantial assistance with ADL's related to healing fractures of a shoulder and pelvis and was at risk for decline in ADLs, contractures (abnormal permanent fixation of a joint or muscle) and skin integrity. The Falls CAA triggered secondary to impaired gait and mobility and R31 required assistance for transfers. Contributing factors included history of falls prior to admission, weakness, and physical performance limitations. Risk factors included falls and other major/minor injuries related to falls. The 09/19/24 Quarterly MDS documented a BIMS score of four, indicating severely impaired cognition. R31 required maximal assistance with bathing, bed mobility and transfers. She required moderate assistance with toileting, dressing, personal hygiene, and ambulation. No falls documented. The 10/07/24 Care Plan Lacked any safety interventions to prevent falls until R31 had a fall on 02/17/24. Staff instructed to assist applying socks footwear in the morning, date completed 02/27/24, which was ten days after the fall. Staff were instructed to monitor and document for risk of falls and educate the resident, family, and caregivers on safety measures that need to be taken to reduce risk for falls. R31 was at high risk for falls and staff instructed to provide call light and encourage the resident to use a call bell. R31 required prompt response to all requests for assistance. Staff instructed to apply appropriate footwear when ambulating or mobilized in wheelchair, all initiated on 04/10/24. The Progress note on 02/17/24 at 08:20 AM, staff found R31 on the floor, seated upright at the foot of the bed attempting to put on her socks. No injuries noted, two staff assisted R31 off the floor and transferred the resident to a wheelchair. On 01/08/24, 01/17/24, 04/09/24, 07/09/24 and 09/16/24, a Morse fall scale (is a rapid and simple method of assessing a patient's likelihood of falling) completed all assessments were scored at 55, indicating a high risk for falling. The facility failed to provide a fall investigation upon inquiry. On 10/07/24 at 11:00 AM, R31 was in her room watching television her call pendant was placed on a table that was behind the resident out of reach and sight. Her call bell was located on the other side of her bed not in reach. R31 reported she was not sure if she required staff to assist her with ambulation. On 10/08/24 at 11:55 AM, R31 seated in dining room with a call pendant (a wearable call light system) around her neck. On 10/09/24 at 01:33 PM, R31 seated outside in front of a facility building and had her call pendant around her neck. R 31 reported, she loved to sit outside to get fresh air. On 10/08/24 at 01:10 PM, Certified Nurse Aide (CNA) J reported that she reviews the care plan in EHR for all the residents' care needs. She reported that the nurses should write on the communication board in EHR to notify staff of any change of care for residents. On 10/08/24 at 03:25 PM, License Nurse (LN) K reported if a resident had a fall, the nurse would assess the resident, make sure they were safe, determine a root cause and a neurological assessment (is a series of tests and questions that evaluate a person's nervous system) would be completed for 72 hours. If the resident had a high enough BIMS and could tell the staff they did not hit their head, then no neurological assessment would be required. Staff should update the family or responsible party, physician, Administrative Nurse B and Administrative Staff A. On 10/09/24 at 09:30 AM, LN K reported nurses do not update care plans in the EHR, she reported that an intervention should be immediately completed after an incident and communicated on the communication board in EHR. LN K reported that Administrative Nurse B or Administrative Nurse C should add the intervention to the care plan in the EHR. If neither of them was in the facility, they were to update the care plan the next day. The staff are responsible to read and review the care plan. On 10/09/24 at 09:44 AM, Administrative Nurse C reported her expectation for staff was to stay with the resident to ensure safety, alert the nurse who would assess and render aid as needed, investigate the root cause, develop an immediate intervention to mitigate risks for the remainder of the shift, then the interdisciplinary team would meet on the next morning or business day to develop a permanent care plan entry. On 10/09/24 at 01:35 PM, Certified Medication Aide (CMA) P reported R31 liked to sit outside, and staff were responsible to apply her call pendant when R31 was not in her room. She reported R31 will sometimes not call staff and she required staff assistance with transfers and ambulation. The facility policy Fall Follow-Up Protocol dated 01/01/24, documented each resident will be provided services to ensure that the resident's environment remains as free from accident hazards as possible, and each resident receives adequate supervision and assistive devices to prevent accidents. Every resident will be assessed for casual risk factors for falling at the time of admission, and after every fall and develop interventions to prevent further falls. Fall interventions are documented on the care plan. The facility failed to provide an environment that remained free from accident hazards for R31 when the facility failed to place effective interventions in place for this resident with a history of falls. 51334 The facility reported a census of 34 resident, with 12 sampled, including seven residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide an environment free from accident hazards for five residents. The facility failed to include fall prevention interventions on the care plan for Resident (R)238, who fell and sustained deep lacerations to his face, which required transfer to the ER and sutures/stitches and glue as treatment. The facility further failed to implement new care plan interventions to prevent further falls for R31 and failed to investigate the fall experienced by R24. The facility also failed to ensure staff did not leave R10 unattended in his bathroom, attached to the sit to stand mechanical lift (helps transfer patients from one seated surface to another) and staff also did not provide adequate supervision to R18 when staff left R18 unattended in his room and R18 attempted to self-transfer from his wheelchair. These deficient practices could potentially result in an injury. Findings included: - Review of the Electronic Health Record (EHR) revealed Resident (R)238 had the following diagnoses: extradural and subdural abscess (cavity containing pus and surrounded by inflamed tissue that is inside your skull or near your spine), Methicillin susceptible staphylococcus aureus infection (MRSA - a type of bacteria resistant to many antibiotics), sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infections which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), severe protein-calorie malnutrition, acute kidney failure, and management of a vascular device. Review of the 09/25/24 Admission Minimum Data Set revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident had a total mood severity score of seven, which indicated mild depression. The MDS documented R238 had functional limited range of motion impairment to bilateral (both) upper and lower extremities. R238 utilized a wheelchair for mobility. He was dependent with toileting, personal hygiene, and wheelchair mobility. He required substantial to maximal assistance with lower body dressing, applying footwear and going form laying to sitting position. He required partial to moderate assistance with upper body dressing, rolling from one side to the other in bed and going from a sitting to laying position, moving from a sitting to a standing position and transferring from a chair to a bed. R238 was totally incontinent of bowel and had a urinary catheter. He had a fall within the last month prior to admission, also had a fall in the last two to six months prior to admission, and a fall with a fracture in the 6 months prior to admission. Review of the Falls Care Area Assessment (CAA) dated 10/01/24, revealed R238 had falls prior to admission that resulted in fractures. He was impulsive and had a mild cognitive deficit and resistive to care at times. Review of the 09/21/24 Baseline Care Plan revealed R238 had a history of falling. The baseline care plan lacked interventions to prevent falls. Review of the 09/26/24 Neurological Check List revealed the facility completed one neuro check. Review of the resident's Care Plan revealed a new focus added on 09/27/24 to address the fall on 09/26/24. R238 had an actual fall with serious injury, poor balance, and unsteady gait. Prior to admission R238 had several falls at home. Staff were to assist the resident in a recliner or a bed when taking him into his room. Review of the assessments revealed a Morse Fall Scale assessment (a fall risk assessment that predicts the likelihood of falls) completed on 09/20/24 and on 10/08/24, and both assessments documented a score of 95, indicating R238 was a high risk for falls. Review of the assessments tab revealed two Skin Assessments completed on 09/27/24 indicating a laceration with no location documented, that measured 5.8 centimeters (cm) by 1.2 cm and required stitches on 09/26/24, and a 3.9 cm by 3.1 cm abrasion to the left shoulder. Review of the 09/26/24 at 04:04 PM Incident Note revealed R238 fell at 01:50 PM and was on his right side in front of his wheelchair with Administrative Nurse B applying pressure to the left side of his head. There was blood on the floor, his shirt, and his face. He was alert and talking but did not make sense. The resident reported pain to his head, legs, shoulders, and back. There were three lacerations (wound to the skin) to his left side of his head, above the eyebrow, next to the left eye, and under the left eye. Staff later noticed that his eyeglasses had fallen off him and had a piece of skin attached to them. R238 was not sure how he fell or what caused him to fall. The brakes were locked on the wheelchair and the catheter bag was attached to the wheelchair. The facility transferred R238 to the Emergency Department at a hospital. Review of the 09/26/24 at 08:01 PM Health Status Note revealed R238 received stitches. Review of the 09/26/204 at 08:01 PM Health Status Note revealed new orders to apply ice as needed and provide wound treatment. Review of the Health Status Note on 09/26/24 at 11:31 AM, revealed that staff checked on R238 every two hours He responded when questioned, refused vital signs and assessment. No further documentation found on checks or assessments. Review of the Health Status Note on 09/27/24 at 6:23 PM, revealed that the nurse spoke to the hospital and they stated R238 had a computed tomography scan (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) that was clear. EHR lacked documentation from the hospital that a CT scan was completed or results. Review of the hospital's Discharge Instructions revealed R238 had multiple deep lacerations to the forehead and left cheek area which required glue and stitches. The instructions included warnings for Head Injury Precautions: An observer must check on the patient frequently for 24 hrs. Also watch for signs and symptoms of infection. On 10/08/24 at 09:02 AM, R238 stood in front of his reclining chair in his room and attempted to push himself up to a standing position. During an interview on 10/08/24 at 12:52 PM, Certified Nurse Aide (CNA) J reported she was to review the care plan in EHR for all the residents' care needs. She also reported that the nurses were to write on the communication board in the EHR to notify staff of a change of care for residents. During an interview on 10/08/24 at 03:25 PM, License Nurse (LN) K reported if a resident had a fall the nurse would assess the resident make sure they are safe, determine a root cause a neurological assessment (is a series of tests and questions that evaluate a person's nervous system) would be completed for 72 hours. If the resident had a high enough BIMS and could tell the staff, they did not hit their head, no neurological assessment was required. LN K reported they would update the family or responsible party, physician, Administrative Nurse B and Administrative Staff A if a resident fell . During an interview on 10/09/24 at 12:45 PM, Administrative Nurse C revealed when a resident entered the facility the nurse completed a baseline care plan. Administrative Nurse C revealed it was printed and reviewed with the family and/or the resident, signed, and uploaded to the EHR. The facility policy Fall Follow-Up Protocol dated 01/01/24 documented each resident will be provided services to ensure that the resident's environment remains as free from accident hazards as possible, and each resident receives adequate supervision and assistive devices to prevent accidents. Every resident will be assessed for casual risk factors for falling at the time of admission, and after every fall and develop interventions to prevent further falls. Fall interventions are documented on the care plan. The facility policy Care Planning Policy last reviewed on 01/01/24 documented the Baseline Care Plan will be developed within 48 hours of admission and will include Falls and Safety concerns. A written summary of the Baseline Care Plan will be presented to the resident and/or their representative if desired. Documentation that the summary was offered must be made in the chart. The Baseline Care Plan will be started at admission and contains information that staff will utilize to care for the resident. The facility failed to provide an environment that remained free from accident hazards for R238, who had a history of falls, when the facility failed to include fall prevention interventions on the care plan. R238 fell and sustained deep lacerations to his face, which required transfer to the ER and sutures/stitches and glue as treatment. 46960 - Review of the Electronic Health Record (EHR) for Resident (R)24 revealed diagnoses that included diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and unspecified epilepsy (a brain disorder characterized by repeated seizures and glaucoma (abnormal condition of elevated pressure within an eye which can cause loss of vision). Review of the 05/02/24 Annual Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The resident required supervision/setup assistance with eating and bathing but was otherwise independent with all cares. The resident used a walker. The resident had no falls since the previous assessment. Review of the Falls Care Area Assessment (CAA) dated 05/02/24 revealed R24 utilized a walker for ambulation and had a history of falls with injury prior to admission and several falls without injury since admission. Review of the Activities of Daily Living (ADL) Functional / Rehabilitation Potential CAA, dated 05/02/24 revealed R24 utilized a walker. Review of the 07/18/24 Quarterly MDS revealed the resident had a BIMS score of 15, which indicated intact cognition. The resident required supervision/setup assistance with eating and bathing but was otherwise independent with all cares. The resident used a walker. The resident had no falls since the previous assessment. Review of the Assessments Morse Fall Scale (an assessment tool utilized to determine an individual's risk or likelihood of falls) dated 02/16/24, 05/01/24, 05/05/24 and 07/16/24 revealed the resident had a high risk for falls. Review of the 10/08/24 Care Plan, revealed R24 was at high risk for falls related to a recent fall at home with injury and diagnoses that included epilepsy, weakness and impaired balance. The care plan included the following interventions: On 09/21/23, staff would ensure a shower chair was on a level surface during showers. On 09/25/23, staff would reeducate R24 to utilize his walker for ambulation (walking) and not rely on furniture and remind R24 to use the call light if something needed to be picked up from the floor. Staff would further ensure that R24's call light was within reach. On 01/17/24, R24 had an actual fall without injury and instructed staff to remind R24 to change positions more slowly for safety. Review of the 10/08/24 Care Plan lacked an intervention related to the fall on 06/21/24. Review of the 06/21/24 at 07:39 PM Progress Note documented staff found R24 on the floor in the pantry area at around 06:00 PM. R24 stated that he was trying to get a soda and fell , denied injury, and declined to allow staff to assess him for injuries. Two staff assisted R24 off the floor. The documentation lacked an intervention to possibly prevent the resident from another fall. The facility was unable to provide any fall investigation reports for the look-back period of 04/01/24 to 10/08/24 (which included the fall on 06/21/24) as requested on 10/08/24 while the survey team was on-site. However, when surveyors were off-site, the facility provided a fall investigation report on 10/10/24 at 11:45 AM, dated 06/21/24, and documentation determined the root cause of the fall was R24's unwillingness to ask staff for help. The fall investigation report lacked an immediate intervention to mitigate the risk for falls for the remainder of the shift. Additionally, the fall investigation report lacked a signature of the staff member or licensed nurse (LN) who completed the report. On 10/08/24 at 12:00 PM, R24 observed ambulating with a walker positioned at an arm's length in front of him with shuffling gait (style or manner of walking), R24's head was down, back was arched with arms almost fully extended. On 10/09/24 at 09:45 AM, R24 observed ambulating with a walker positioned at an arm's length in front of him and he had a shuffling gait, R24's head was down, back was arched with arms almost fully extended. On 10/07/24 at 11:11 AM, R24 stated that he had fallen since admission to the facility but was unable to recall when his last fall was. R24 further stated that his walker had a therapy band tied to his walker to remind him to walk close to the walker when ambulating. On 10/06/24 at 10:20 AM, Certified Nurse Aide (CNA) N stated that if a fall happened or resident was found on the floor, staff would ensure that the resident was safe and alert other staff and the nurse for assistance. Once the nurse arrived, staff would follow the instructions of the nurse. On 10/09/24 at 10:37 AM, Certified Medication Aide (CMA) M stated that if a fall happened, or if a resident was discovered to have fallen, staff would stay with the resident and make sure they were safe and alert other staff for assistance which included the nurse on duty. The staff would then follow the instructions of the nurse once the nurse arrived. On 10/08/24 03:25 PM, LN K stated if a resident fell , the LN would assess the resident make sure they are safe, perform an investigation to determine the root cause of the fall, develop an immediate intervention to mitigate the risk of falls for the remainder of the shift and communicate that to all staff, then submit the investigation so Administrative Nurse B or Administrative Nurse C would update the permanent care plan with an appropriate intervention. On 10/09/24 at 09:44 AM, Administrative Nurse C stated that a fall was defined as an unplanned change in position or plane such as from standing to standing to floor, or bed/chair to floor. Administrative Nurse C confirmed the progress note dated 06/21/24 at 07:39 PM and determined that a fall had occurred. Administrative Nurse C further confirmed the lack of a fall investigation, root cause analysis, immediate intervention, permanent care plan intervention or documentation of the fall on the MDS dated [DATE]. Administrative Nurse C stated that the LN on duty on 06/21/24 failed to investigate the fall to determine a root cause, therefore an immediate intervention and permanent care plan intervention were not possible. Administrative Nurse stated in the event of a fall, the expectation was for staff to ensure the safety of the resident and alert other staff for assistance which included the nurse on duty. The LN would then assess the resident for injuries and render aid as appropriate. The staff would then assist the resident as needed off the floor. The LN was to perform an investigation to determine the root cause of the fall and immediately communicate an immediate intervention to mitigate the risk for further falls to the staff on duty. The LN should submit a fall investigation report that would be reviewed during the next interdisciplinary team (IDT - a team of facility staff consisting of members of various departments including but not limited to; dietary, nursing, maintenance, therapy, etc.) meeting on the next business day. Administrative Nurse B or C would update the care plan to reflect an appropriate permanent care plan intervention related to that fall. Administrative Nurse C stated the LN have the ability to update the care plan with permanent interventions, but that they have declined to perform this task. The facility policy Fall Follow-Up Protocol dated 01/01/24 documented each resident will be provided services to ensure that the resident's environment remains as free from accident hazards as possible, and each resident would receive adequate supervision and assistive devices to prevent accidents. Every resident would be assessed for causal risk factors for falls at admission, and after every fall and develop interventions to prevent further falls. Fall interventions are documented on the care plan. The facility failed to complete the fall investigation and develop immediate and permanent care plan interventions to mitigate the risk for additional falls after the fall on 06/21/24. This deficient practice placed R24 at continued and on-going risk for falls which had the potential to negatively impact R24's physical and psychosocial well-being. 51332 - Review of The Electronic Medical Records (EMR) for Resident (R)18 included the diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), abnormal posture, cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dysphagia (swallowing difficulty), hemiplegia (paralysis of one side of the body), repeated falls, non-suicidal self-harm (intentional self-inflicted bodily harm without intent to kill themselves), and disorders of bone density and structure (disorders involve a loss of bone mass and changes in the bone's internal structure). A review of R18's Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of five, indicating severe impairment of cognition. The resident had a total mood severity score of one, indicating minimal depression. The MDS indicated he required total dependence on staff for toileting, dressing, and transfers. The MDS noted he required staff supervision for locomotion and eating his meals. The resident had hallucinations and delusions present, with no other behaviors noted. The resident required antipsychotic, antidepressant, anticoagulant, diuretic, opioid, and antiplatelet medications. The resident was frequently incontinent of bowel/bladder, no falls in since the last assessment documented. Review of the Falls Care Area assessment dated [DATE] revealed R18 had a high risk for falls related to having a history of falls, medications he received, and a history of CVA. R18 needed assistance with transfers due to a history of falls, weakness, and physical performance limitations affecting his balance, gait, strength, and muscle endurance. Risk factors included falls and other major/minor injuries related to falls. Review of the 04/05/24, Quarterly MDS revealed the resident had a BIMS score of 4, which indicated moderately impaired cognition. The resident had episodes of behaviors that included delusions and hallucinations. The MDS indicated he required maximum assistance for most cares. R18 used a wheelchair and walker for mobility. The resident had a fall in the last 2 to 6 months prior to admission/entry to the facility or reentry or most recent assessment. The resident had one fall identified since the prior assessment without injury. Review of the Morse Fall Scale (an assessment tool utilized to determine an individual's risk or likelihood of falls) dated 01/10/24, 04/09/24, 06/17/24, 08/04/24 and 09/18/24 revealed the resident had a high risk for falls. Review of the 09/20/24 at 10:30 AM Nurse Note revealed the Certified Medication Aide (CMA) arrived at the resident's room at approximately 10:30 AM. Upon entering R18's room the resident was found on the floor in front of the bathroom. The staff charted that R18 was toiled last at 09:30 AM and there was an abrasion noted on the left side of the resident's temple. His doctor was notified and aware that R18 was on prescribed blood thinners. The resident's record revealed only one fall follow up documented on 09/21/20 at 02:24 directly after his fall. Review of the 09/19/24, completed Care Plan revealed an intervention initiated dated 09/20/24, which stated for staff to please encourage the resident to be in the commons area when in wheelchair. If in his room the resident must be transferred to the bed or recliner. Intervention initiated dated 04/28/23, revised dated 10/13/23 stated, when the resident fell asleep in his wheelchair, staff were directed to assist him to the bed or recliner to sleep. During an interview on 10/09/24 at 10:13 AM, R18 stated he would rather sleep in his recliner than his wheelchair but, would prefer his bed over anything. R18 stated if he really wanted to move to the recliner, he could do it himself. During an observation on 10/09/24 11:43 AM, R18 uncovered his bed, which was left in a high position. R18 reached for his 3/4 side rail and attempted to transfer himself into his bed. On 10/09/24 at 10:25 AM, Certified Nurse Aide (CNA) N stated R18 required checks every two hours, and staff toileted him at that time. When R18 fell asleep in his wheelchair he only slept for short periods of time and in small intervals. He did not like to be confined or not able to get up and move when he felt that he wanted to. When he woke up, he was startled and delusional. On 10/09/24 at 03:30 PM, Licensed Nurse (LN) K stated R18 would be checked every two hours. LN K stated he used to have the tendency to go back to his room to attempt to go to bed, now R18 was not to stay in his room anymore. This change was to allow for staff to have eyes on him continuously. The expectation was that if R18 was sleeping in his wheelchair staff would offer to assist him into a recliner to sleep in the living area where everyone could visually keep an eye on him. Staff could offer to assist him into bed and place his bed in lowest position with his fall mat down so he could rest. Being left to sleep in his room while in his wheelchair was not an approved options for the resident. On 10/09/24 at 01:11 PM, Administrative Nurse C stated R18 was expected to have eyes placed on him every 30 minutes. If R18 was sleeping in his wheelchair, in his room, then the staff were to put him in the recliner in his room and if that was not available the other option was to offer the resident the recliner that was in the day room. The facility's Behavior Management for Dementia Care policy dated 01/01/24 documented the facility would promote person-centered care and consider all the resident's needs, not just medical or physical. The policy further documented the resident had the right to live in a safe, structured, and predictable environment. The facility failed to provide an environment free of accident hazards when staff left R18 unattended in his wheelchair, in his room after multiple assessments that documented him as a high risk for falls. This deficient practice placed R18 at continued and on-going risk for accident hazards which had the potential to negatively impact R18's physical and psychosocial well-being. - Review of the Electronic Health Record (EHR) revealed R10 had the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), west Nile virus (WNV - a virus that is spread by mosquitos that can cause critical illness that can include encephalitis [inflammatory condition of the brain]), cataract (clouding of the lens of the eye), contracture (abnormal permanent fixation of a joint or muscle), and motor neuron disease (a condition that causes weakness in the muscles, leading eventually to paralysis). Review of the 06/20/24,Admission Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The resident required maximum assistance with toileting, personal hygiene, rolling side to side, changing positions, transferring, propelling in wheelchair for mobility, and upper body dressing. The assessment documented no falls in the last month prior to admission/entry. Review of the 03/29/24, Quarterly MDS revealed the resident had a BIMS score of 10, which indicated moderately impaired cognition. The resident had episodes of behaviors that included delusions. The resident required maximum assistance for all cares and used a wheelchair for mobility. The assessment documented that R10 had impairment with both the upper and lower extremities. The resident had one fall identified since the prior assessment without injury. Review of the Morse Fall Scale (an assessment tool utilized to determine an individual's risk or likelihood of falls) dated 02/07/23, 05/02/23, 08/02/23, 10/15/23, 01/03/24, 04/05/24, 06/17/24 and 09/18/24 revealed the resident had a high risk for falls. Review of the Assessments lacked a safety assessment for R10 to be safely left unattended while attached to a mechanical lift. Review of the 08/31/24, Care Plan revealed an intervention dated 01/31/22 and revised 01/17/24, which stated the resident required extensive to total assistance of two staff to move between surfaces. He used the sit-to-stand lift (a mechanical lift that assists persons who are unable to bear weight to maintain a standing position) for all transfers. This intervention documented the resident as being a fall risk

The facility reported a census of 34 residents. Based on observation, interview, and record review, the facility failed to ensure that meals were served at safe and appetizing temperature. Residents (R) 24 and 35 complained of cold food temperatures at meals. Findings included: - On 10/07/24 at 11:11 AM, Resident (R) 24 reported that the food was cold at times, when it should be hot. R24 revealed he was the President of the Resident Council and the concern for cold food had been discussed in the meetings over the past several months and it had improved a little. On 10/08/24 at 09:35 AM, R35 was assisted to the dining room for breakfast by Certified Nurse Aide (CNA) J. Dietary Staff G prepared R35's food from warmer, then covered the dish as CNA J was not ready to assist R35 with his meal. At 09:40 AM, Dietary Staff G uncovered the breakfast plate full of food, opened refrigerator door looked inside of it and closed the door, he then entered the kitchen leaving the food uncovered. At 09:46 AM, Dietary Staff G exited the kitchen with a container of applesauce, he poured some applesauce in R35's divided dish, then picked up the dish to serve to R35. Dietary Staff G was asked to obtain a temperature of the pureed sausage gravy and toast. The temperature was 100 degrees Fahrenheit (F). Dietary Staff G stated the pureed food on the steamtable was gone and he delivered the food to R35. Dietary Staff G reported that the food was cooked to 165 degrees F and was unsure what the temperature was to be maintained in the steamer table. He confirmed he left the food uncovered when he went to the kitchen. On 10/08/24 at 09:48 AM, Dietary Manager D confirmed that the temperature of 100 degrees F was not acceptable, that the food should have been warmed up. She reported the temperature of the food should be maintained at 135 degrees in the steam table and will re-educate staff. On 10/09/24 at 11:29 AM, Dietary Staff R, placed cooked food items in the food delivery carts for the 400 and 500 building. It was noted Dietary Staff R temped the chicken at 150 degrees F and the hamburger patties and baked potatoes were not temped before being placed in the cart. Both carts left the main kitchen at 11:40 AM On 10/09/24 at 12:01 PM, the 400 building cart was temped by Dietary Staff L. The hamburger patties were 113 degrees F, and the chicken was 130 degrees F. Dietary staff stated the temperatures were fine and served the food to the residents. On 10/09/24 at 11:45 AM, Dietary Staff F in building 500, received the food delivered in an insulated container, plates stored right side up. Several bowls of pears with food coloring and multiple plates of unknown cake sat on the counter, all uncovered. Dietary Staff F picked up thermometer and that was resting on the non-sanitized counter and placed the thermometer into the gravy, temperature was 142 degrees F. She then temped the potatoes, chicken strips and cauliflower without sanitizing the thermometer between foods. Dietary staff F measured the pears at 62 degrees F. She stated she measured the pears at 11:10 AM at 36 degrees and left all the food uncovered. When asked by the surveyor at 12:00 PM. Dietary Staff F sanitized thermometer and measured gravy at 122 degrees F, chicken strips at 118 degrees F, potatoes at 160 degrees F, cauliflower at 122 degrees F and chicken was at 140 degrees F. On 10/09/24 at 12:22 PM, Dietary Staff G delivered the test tray to survey team and temped the foods. Chicken measured at 122 degrees F, cauliflower at 110 degrees F, potatoes at 126 degrees F and pears at 40 degrees. He reported he did not know what temp the appropriate food temps would be. On 10/09/24 at 12:30 PM, Administrative Staff A and Dietary Manager D discussed the above information regarding multiple complaints from residents about the palatability of food as it related to temperatures. Confirmed the temperatures were a concern. The facility's policy Food Preparation and Handling dated 01/01/24 documented timely food distribution is essential to ensure food and beverages are served at proper temperatures. All foods will be held at temperatures between 41 degrees F and 135 degrees F, outside the danger zone of temperatures. The temperature of foods will be periodically monitored and documented throughout the meal service to ensure proper hot or cold holding temperatures are maintained. The facility failed to ensure that meals were served at a safe and appetizing temperature. Residents complained of cold food temperatures at meals. This deficient practice placed the residents at risk for risks related to impaired nutrition.

The facility reported a census of 34 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility. Findings included: - Observation of the small dining room kitchen and food storage areas on 10/07/24 at 09:10 AM, revealed the following areas of concern: One sealed bag of French toast, approximately half used, without open date or label. One carton of opened ice cream, without an open date. One unsealed bag of English muffins, without an open date. One sealed bag of bagels, raisin toast, waffles, omelets, and pancakes, without an open date. One bottle of strawberry syrup dated 08/20/24, with no expiration date noted. Two open bottles of electrolyte drink for residents, without an open date. One twelve ounce plastic cup filled with a smoothie, unsealed and without a date or label. One opened container of half and half cream, without open date. Observation of facility main kitchen on 10/07/24 at 09:20 AM, revealed the following areas of concern: One half of pie that was partially uncovered and cookies on a plate in an open storage cart, without open date or label. One unsealed 10 pound bag of spaghetti noodles approximately three pounds left, without open date. Two opened sealed bags of noodles, without open date. One opened sealed bag of raspberry gelatin, vanilla wafers, brown sugar, pancake mix, cake mix and dried mash potatoes, all without open date. One opened bag of almonds and raisons, without open date or label. One opened unsealed frozen beef patties, without open date. One opened unsealed bag of tater tots and egg rolls, without open date. Opened sealed chicken tenders, frozen pizzas, and waffles, without open date. One bag of cooked pasta sealed, without open date or label. Three bags of opened cheese, without open date. One bag of lunch meat, without open date. One bag of salami with dried brown, green colored edges, without open date. Two bags of shredded cheese, without open date. Several bags of sealed produce tomatoes, onions and lettuce that was opened, without open date. On 10/07/24 at 09:35 AM, interview with Dietary Manager D revealed she expected staff to label and date opened food items and confirmed the above concerns identified with kitchen and freezer storage, which included undated and unsealed items and noted that was unacceptable. On 10/08/24 at 08:45 AM thru 09:05 AM, Dietary Staff G lacked proper hand hygiene in the small kitchen while he served breakfast to the residents. Dietary Staff G was observed touching his face, removed soiled breakfast dished from tables, then assisted other resident with pouring coffee, serving their breakfast meal, and taking orders without washing his hands. 09:06 AM, Dietary Staff G performed hand hygiene, then was observed to removed soiled dishes, touched his face, and rubbed his nose, then he picked up a resident's napkin and she wanted it back and he gave it to her. He then retrieved the sealed bag of dish cloths from laundry, opened them up and put them away. No hand hygiene observed. On 10/08/24 at 09:48 AM, Dietary Manager D, confirmed she expected all staff to complete proper hand hygiene and confirmed it was a concern of the lack of hand hygiene that was observed. On 10/09/24 at 11:19 AM, observed the following concerns during kitchen tour. The two ovens contained several areas of bubbled burned food debris on the bottom of the inside. Three large fry pan contained multiple scratches in the cooking surface. Several cutting boards had multiple scratches and several gouges noted on both sides of the board. On 10/09/24 at 11:19 AM, Dietary Manager D, confirmed the kitchen equipment was a concern. The facility's policy Hand Hygiene dated 01/01/24, documented consistent use by staff of proper hand hygiene practices and techniques is critical to prevent the spread of infections. Alcohol based hand rubs cannot be used in place of proper hand washing techniques in food service setting. The facility's policy Food Preparation and Handling Policy dated 01/01/24, documented the facility will store, prepare, distribute and serve food in accordance with professional standards for food service safety. Any food handlers will perform hand hygiene regularly in a designated hand washing sink during shift and in particular; after handling waste food or refuse and between different tasks. A label will be affixed to container of opened food with following information: Name of the food item and date food was placed in container. The Food-Supply Storage-Food and Nutrition Services Policy dated 07/09/20 revealed food that had been opened or prepared, were to be placed in an enclosed container, dated, labeled, and stored properly. The facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility.

The facility reported a census of 34 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to the maintaining a sterile (free from germs or microorganisms) field with a peripherally inserted central catheter (PICC-a form of access directly into the bloodstream via a vein that can be used for a prolonged period of time) dressing change for Resident (R) 238 and Dietary Staff G lacked proper hand hygiene during dining room service. Additionally, staff improper hand hygiene with catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. The facility failed to set up enhanced barrier precautions (a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes) (EBP). The facility failed to provide respiratory care consistent with professional standards of care for R13, regarding the use and cleaning of the nebulizer equipment and R3, R4, and R31's oxygen supplies were not stored in a clean manner. This deficient practice had the potential to spread possible infections to the residents in the facility. Findings included: - On 10/07/24 at 07:44 AM, observed R13's nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs) intact on machine at 07:57 AM, Licensed Nurse (LN) K took nebulizer into the bathroom, rinsed with water, added medication, and initiated breathing treatment. On 10/08/24 at 02:48 PM, observations of R13's nebulizer revealed an intact nebulizer sitting on the machine on the arm of the chair. On 10/09/24 at 07:18 AM, R13's intact nebulizer sat on the machine on the arm of the chair. On 10/09/24 at 08:18 AM, LN K identified the nebulizer sat intact on the nebulizer machine and stated that at the completion of a nebulizer treatment any of the nursing staff (LN, Certified Medication Aide [CMA] or Certified Nurse Aide [CNA]) could discontinue the treatment. LN K further stated it was the expectation that the staff member that discontinued the treatment would disassemble the nebulizer and rinse it out with tap water then leave the components on a paper towel to air dry until the next treatment. On 10/07/24 at 11:00 AM an oxygen concentrator was noted in R31's room, next to bathroom door, with no date on the tubing or humidifier bottle, which was filled halfway with a cloudy liquid. The nasal cannula was wrapped around the concentrator and hanging on the top. On 10/07/24 at 11:23 AM, R3's oxygen tubing was not labeled with a date and nasal cannula was laying on the floor in her room. On 10/08/24 at 08:45 AM thru 09:05 AM, Dietary Staff G lacked proper hand hygiene in the small kitchen while he served breakfast to the residents. Dietary Staff G was observed touching his face, removed soiled breakfast dished from tables, then assisted other resident with pouring coffee, serving their breakfast meal, and taking orders without washing his hands. 09:06 AM, Dietary Staff G performed hand hygiene, then was observed to removed soiled dishes, touched his face, and rubbed his nose, then he picked up a resident's napkin and she wanted it back and he gave it to her. He then retrieved the sealed bag of dish cloths from laundry, opened them up and put them away. No hand hygiene observed. On 10/08/24 at 09:06 AM R12 was assisted to dining area by staff in wheelchair. She was barefoot and her right leg had open wounds with drainage dripped down her leg and dried drainage noted on bottom of her right foot. On 10/08/24 at 09:48 AM, Dietary Manager D, confirmed she expected all staff to complete proper hand hygiene and confirmed it was a concern of the lack of hand hygiene that was observed. On 10/08/24 at 10:48 AM, Administrative Nurse C confirmed that lack of proper handwashing of the dietary staff is a concern, On 10/08/24 at 12:25 PM, Certified Nurse Aide (CNA) J reported the only way to understand which residents is on EBP, is if there is a bag on the outside of their door that has gowns placed in them. CNA J reported is a resident had a wound, Foley catheter or an infection they will have EBP. CNA J reported she had never observed signage on any resident's door for any type of precautions. On 10/08/24 at 01:10 PM, with Administrative Nurse C, observed R4's oxygen tubing noted coiled on top of concentrator, no bag, no date. On 10/08/24 at 01:10 PM, Administrative Nurse C stated that the expectation was that at the completion of a nebulizer treatment, then LN would disassemble the nebulizer and rinse the components with tap water then set on a paper towel to dry until the next treatment. Additionally, stated that nebulizers should be cleaned with a vinegar/water solution every night and then stowed in a manner which prevented contamination of the equipment. Administrative Nurse C reported that all oxygen tubing (and oxygen/cpap/nebulizer) should be changed on the first and 15th of every month and dated. Oxygen/ continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep airway open during sleep)/nebulizer tubing should be stowed in a bag or in a manner in which prevents contamination of the device. On 10/08/24 at 02:30 PM, Administrative Nurse B, was observed completing the sterile dressing change on Resident (R) 238's PICC line. Administrative Nurse B placed supplies on a sanitized area, applied facemask, removed old PICC dressing, removed gloves and performed hand hygiene. She opened supplies and set area, applied sterile gloves, during the dressing change, Administrative Nurse B contaminated the sterile field when she touched the outside of the package twice when it packaged folded closed. Administrative Nurse B confirmed she should have not touched the outside of the package with her sterile glove. On 10/09/24 at 07:30 AM, Certified Medication Aide (CMA) M completed Foley catheter care for R13 no concerns with cleaning of area, CMA M removed her gloves and did not perform hand hygiene when she re-applied gloves to apply clobetasol ointment (is an ointment you can rub on your skin to reduces swelling, redness, itching and rashes) to affected areas on skin. On 10/09/24 at 08:10 AM, CMA M confirmed that gloves were changed, but no hand hygiene was performed. On 10/09/24 at 09:30 AM, LN K reported EBP baskets are hung outside the resident's door to let the staff know. She reported that if a resident is on a true precaution a personal protective equipment (a term used to describe the clothing, gear, and equipment that protects people from hazards that can cause injury or illness in the workplace or medical setting) (PPE) bag would be hung on the resident's door and a set up for laundry and trash would be placed in the resident's room. LN K reported that she had forgot to place R12's EBP bag outside her room a couple of days ago as the ulcers on her right leg had weeping drainage. On 10/09/24 at 12:45 PM, Administrative Nurse C revealed once gloves were contaminated and removed, hand hygiene needed to be performed. On 10/09/24 at 02:09 PM, Administrative Nurse C reported that the EBP basket was hung outside of the resident's door and that is how staff knew if a resident was on EBP. She reported there was no sign placed as that would be a dignity concerns. Administrative Nurse C revealed she was unsure if R12 required EBP as the wounds were chronic and did confirm the wounds did have drainage the past two days. Administrative Nurse C confirmed that R12 having drainage from wounds from legs and being mobile in hallway and dining room not wearing socks, shoes, or dressings was a concern. On 10/09/24 at 03:30 PM, Administrative Nurse B reported that R12 may not need EBP as she had chronic wounds which may not require EBP. Administrative Nurse B confirmed R12's wounds on both legs had drainage secreting from the open areas the past two days. The facility's Nebulizer Treatment Policy dated 01/01/24, documented that after each use, staff would rinse the nebulizer cup and mouthpiece/mask with warm water and set the components on a paper towel to air dry. The facility's policy PICC/Midline dated 06/2024, documented dressings will be changed every seven days or when dressing seal is compromised. This is done using sterile technique by a Registered Nurse only. The facility's policy Oxygen Administration dated 01/01/24, lacked documentation on labeling equipment and proper storage. The facility's policy Enhanced Barrier Precautions dated 04/01/24, documented EBP are implemented as one intervention to reduce transmission of resistant organisms that employs targeted PPE use during high contact residents care activities. Chronic wounds may include venous stasis ulcers (open sores can occur when the veins in your legs do not push blood back up to your heart as well as they should). If a wound could serve as a reservoir for multiple drug resistant organism (MDRO-common bacteria that have developed resistance to multiple types of antibiotics) colonization or a portal for infection, then EBP should be followed. The facility failed to maintain an effective infection control program related to improper cleaning and storage of respiratory equipment, lacked proper hand hygiene during dining room service and after removal of soiled gloves, improper sterile technique during PICC dressing change and lacked placing a resident on EBP with draining wounds to prevent cross contamination in the facility.

The facility reported a census of 38 residents with two residents reviewed for risk of elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without knowledge of staff). Based on observation, interview, and record review, the facility failed to provide adequate supervision and a safe environment, as free of accident hazards as possible, to prevent the elopement of cognitively impaired and independently mobile Resident (R)1. On 03/31/24 at approximately 11:30 AM, R1 attempted to exit the front door of the house she resided in without success, and then exited the house into the gated courtyard, followed by staff. R1 was agitated and voiced she wanted to leave. After sitting outside for approximately 45 to 60 minutes with staff, the staff accompanied R1 inside the main building. On 03/31/24 at 03:00 PM, the staff attempted to take R1 back to the house without success. On 03/31/24 at 04:49 PM, R1 exited the front entrance of the building when she was let out by a visitor. The staff was not aware R1 eloped until 05:00 PM when a Certified Nurse Aide (CNA) looked out a window and saw R1 outside in the parking lot area in front of the house, by herself, 11 minutes later. This deficient practice placed R1 in immediate jeopardy. Findings included: - The Medical Diagnosis tab in the electronic medical record (EMR) for R1 included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and amnesia (loss of memory caused by brain damage or severe emotional trauma). The Admission Minimum Data Set (MDS) dated [DATE], assessed R1 with a Brief Interview of Mental Status (BIMS) score of three, indicating severe cognitive impairment, and was independent with transfers. R1 did not require any mobility devices and could walk 150 feet in corridor independently. The Cognitive Loss/Dementia Care Area assessment dated [DATE], revealed R1 had dementia and short-term and long-term memory loss. The Quarterly MDS dated [DATE], assessed R1 with a BIMS score of three, did not require any mobility devices, and did not wander. The Care Plan dated 02/22/24, revealed R1 had impaired cognitive function related to dementia and was unable to find her room or go to meals without reminders, cues, or assistance from staff. The Elopement Evaluation dated 02/21/24, revealed R1 wandered, making her score a one, that indicated she was a risk for elopement. The Progress Note dated 03/31/24 at 11:49 AM, revealed R1 became agitated and left the house she resided in and went to the main building. R1 refused to return to her house. The Progress Note dated 03/31/24 at 12:37 PM, revealed R1 continued to refuse to return to her house and remained in the main building. The Progress Note dated 03/31/24 at 12:42 PM, revealed R1 told Licensed Nurse (LN) H and Certified Nurse Aide (CNA) M she did not know what was going on and was leaving. R1 tried to leave by the front door, then went to patio door, and went to the main building followed by a CNA. (This note was a follow-up note to 03/31/24 at 11:49 AM). The Progress Note dated 03/31/24 at 02:58 PM, revealed at approximately 11:30 AM, a Certified Medication Aide (CMA) from R1's house alerted LN G that R1 was out in the courtyard trying to leave. LN G went outside and R1 told LN G everyone was trying to make her do things she did not want to do, like go back over there and pointed to her house. LN G tried to get R1 to go inside the main building to have lunch and R1 said she was not going to go anywhere but right here, and pointed to the chair she sat in. While outside, R1 talked on the phone for approximately 30 minutes with a family member, sat outside a while longer, then agreed to go with LN G inside the main building for lunch. After lunch and after she watched some television, LN G walked with R1 back to her house at 03:00 PM. R1 did not want to stay there and agreed to go back to the main building. R1 returned to the main building and sat by the nurse's station as she watched television. The Progress Note dated 03/31/24 at 06:30 PM, revealed at approximately 04:42 PM, LN G observed R1 in a recliner by the nurse's station watching television. At approximately 05:00 PM, a staff member called from R1's house reporting R1 was seen outside in the parking lot in front of the house she resided in. LN G then immediately ran out of the door to look for R1 and when approaching R1's house she saw R1 walking on the street towards the house, carrying her phone. LN G asked R1 where she was going and R1 responded I don't know, but not back there, and pointed to the house she resided in. When asked if she wanted to go back to the main building, R1 responded Sure and grabbed LN G's hand. On 04/08/24 at 11:30 AM, observation with Administrative Staff A of the area R1 traversed after she exited the facility revealed a downhill paved driveway to the street. The area lacked a sidewalk from the main building to the side of the house where she was found in the parking lot in front of. The parking lot was approximately 360 feet from the front entrance when walking from the entrance, down the paved driveway, along the street, and to the paved parking lot area where she was found. On 04/08/24 at 11:35 AM, Administrative Staff A stated she observed the camera footage which showed a visitor let R1 out the front entrance, however the camera did not reveal if she walked through the grass or on the street. Administrative Staff A stated a staff member went in a room of the house and saw R1 walk by, then told the nurse immediately and staff met her out in the parking lot in front of the house. On 04/08/24 at 02:40 PM, observed R1 on her bed in her room of the house with a Wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without a staff escort) in place to her right ankle. On 04/08/24 at 02:41 PM R1 stated she would like to go somewhere else but could not state where, could not recall going outside, and stated if she wanted to go outside, she would look both ways and go out. R1 stated she had a bad memory and could not recall everything. On 04/08/24 at 03:55 PM, LN G stated she was on duty when R1 eloped. LN G stated R1 was brought over to the main building around 11:30 AM and was told R1 refused to go back to her house. LN G stated she visited with R1 outside in the courtyard after she talked on the phone with a family member, and R1 did not want to go back to her house because they would not let her do things over there such as go out the front door. LN G stated it was probably 45 minutes before she could persuade R1 to come inside the main building and have lunch. LN G stated she ate with R1 and then took her to the living room area where she sat in a chair and watched television. LN G stated then around 03:00 PM she attempted to take R1 back to her house and R1 wanted nothing to do with the staff there, so she brought R1 back to the main building. LN G stated she last saw R1 at approximately 04:40 PM in the living room area where R1 watched television. LN G stated at 05:00 PM, she received a call that R1 was in the parking lot in the front of R1's house. On 04/08/24 at 04:33 PM, CNA M stated on 03/31/24 she was on duty from 06:00 AM to 06:00 PM and was assigned to the house R1 resided in. CNA M stated in the morning R1 was upset and very agitated and would not calm down, and R1 went to the main building for the day. CNA M stated she was in another resident room in the house R1 resided in and seen R1 through the window walking around outside. CNA M stated she called the nurse because R1 had been acting weird towards her on that day. CNA M stated the day before, R1 packed her belongings, would not give a reason why, and she seemed upset but did not mention leaving. On 04/09/24 at 09:03 AM, CNA N stated the day R1 eloped she was on duty assigned to a different house from where R1 resided. CNA N stated on 03/31/24, she saw R1 in the courtyard with CNA M who attempted to get her to go back inside. CNA N stated R1 had her fist balled up and was saying I need to get out of here. CNA N stated R1 wanted nothing to do with CNA M, so she took over and took R1 to the benches and talked with R1 for a bit. CNA N stated she was able to calm R1 down a little bit and CNA O took over and sat with her. CNA N stated it was around lunch time when that occurred, she would come out and check to make sure all was okay. CNA N stated the staff took R1 inside the main building for lunch. CNA N stated she had not seen R1 try to leave, go out the doors, or wander before. On 04/09/24 at 09:32 AM, CNA O stated she was not on duty when R1 eloped but had worked the shift prior to the incident on 03/31/24. CNA O stated CNA M had her go out to the courtyard to try and get R1 back in the house around lunchtime. CNA O stated she talked to R1 and was with her for about an hour before R1 went inside to eat lunch. CNA O stated she was off duty at 01:00 PM and saw R1 just coming back from lunch and sat in a recliner to watch television. CNA O stated R1's behaviors were a change, and she did not seem to be an elopement risk until that day. On 04/09/24 at 09:42 AM, LN H stated he was on duty on 03/30/24 and 03/31/24 and the staff did not report to him that R1 packed her belongings. LN H stated on 03/31/24 he sat at a table with CNA M when R1 came out and said she was tired of this, and she was leaving. LN H stated R1 tried to get out the front door and could not, then walked out to the courtyard and told someone staff was trying to kill her. LN H stated CNA M followed her and thought R1 yelled at her to get away from her. LN H stated he had not heard R1 talk about leaving, attempt to leave, or pack her belongings when he was on duty, and she would wander around the house but did not attempt to go outside before this incident. LN H sated he thought R1 needed a Wanderguard on, however, he did not tell anyone that or tell the charge nurse LN G. LN H stated he left at 02:00 PM on 03/31/24 when his shift ended. On 04/09/24 at 01:22 PM, Administrative Nurse D stated residents who wander were reviewed in a weekly meeting and R1 had not displayed any exit seeking behaviors or wandering. Administrative Nurse D stated she expected the staff to follow the policy with R1's exit seeking behaviors and should have placed a Wanderguard on her. On 04/09/24 at 01:47 PM, CNA P stated on 03/31/24 and around 04:30 PM to 04:45 PM, she observed R1 as she sat by the nurse's station watching television. CNA P stated she asked R1 how she was and R1 stated she would be better if she got out of here. CNA P stated she went back to get R1 around 04:55 PM and she was gone, which was the time when everyone was saying she was gone, had eloped, and found her at the other building. CNA P stated R1 had not come to the dining room before she eloped. The Employee Notice of Disciplinary Action dated 04/04/24 revealed proper procedure for elopement risk or someone demonstrating exit seeking behaviors was to apply a Wanderguard bracelet. That information could be found in the elopement policy. The facility's policy Elopement Management dated 06/01/23, revealed for prevention of elopement, staff would be educated on never leaving a resident that is actively seeking elopement from the facility until the resident is no longer exit seeking. Staff would be educated to report unusual behaviors to the supervisor immediately and general interventions to be used with residents seeking to elope from the facility. The policy indicated when a risk of elopement was determined, an interdisciplinary plan of care would be established for the resident and may include door alarms, frequent checks by nursing staff, social work consultation, Wanderguard system in place, and resident-centered life enhancing engagement in activities in attempt to decrease wandering activity. The facility failed to provide adequate supervision and a safe environment to cognitively impaired R1, who had exit seeking behaviors, and/or apply a Wanderguard bracelet to her. R1 eloped from the facility on 03/31/24 at 04:49 PM for 11 minutes without staff knowledge. On 04/09/24 at 02:07 PM, Administrative Staff A was provided the Immediate Jeopardy template and notified of the facility's failure to provide adequate supervision when R1 was upset, attempting to exit the facility, and voiced she wanted to leave, and eloped from the facility on 03/31/24 at 04:49 PM, placed R1 in immediate jeopardy. The immediate jeopardy was determined to first exist on 03/31/24 at 04:49 PM and the surveyor verified the facility identified and implemented corrective actions completed on 04/02/24 at 03:00 PM, when the facility completed the following: 1. R1 placed on one-to-one observation following the elopement until she went to bed and LN G educated the visitor about not letting others out without speaking to the nurse first, on 03/31/24. 2. An elopement assessment completed, care plan updated, and a Wanderguard bracelet placed on R1 on 04/01/24 at 08:30 AM. 3. An elopement action plan completed on 04/01/24 at 08:30 AM. 4. A Root Cause completed on 04/01/24 at 08:30 AM for R1 which determined she was on isolation for COVID prior to the day of the incident. 5. On 04/01/24 at 09:00 AM the facility medical director, who was also R1's primary care physician, contacted and reviewed the action plan, root cause, policy changes, education plans and advised to place a sign on the exit doors to keep visitors from allowing exit advising them to see the nurse for assistance before opening the door. 6. The facility contacted the resident representative to inform about care plan updates with interventions to new elopement risks on 04/01/24 at 09:00 AM. 7. A full audit on elopement assessments completed and updated pictures placed at all nurse's stations for all residents with identified elopement risks to educate all staff and all agency staff of residents at risk on 04/01/24 at 09:00 AM. 8. All staff provided immediate education on elopement policy update on 04/01/24 at 09:00 AM. 9. Signs placed on all exit doors on 04/01/24 at 10:00 AM: Elopement Risk - do not open the door for someone you do not know or allow someone to follow you out the door unless they are with your party. For assistance please call [specified number] and a nurse will come to assist you. Thank you for keeping our resident's safe. 10. Elopement Drill completed on 04/02/24 to test staff competency of elopement policy and procedure with an incident after action plan completed. On 04/02/24 at 11:00 AM a new intervention to add sign to the gate exits: Make sure gate is closed behind you, if you find the gate door open notify a nurse immediately. 11. All staff educated on non-pharmacological approaches to support individuals living with dementia, maintain isolation precautions, interventions to help prevent behaviors and exit seeking, Abuse, Neglect, and Exploitation policy, and updated policy for resident isolation procedures on 04/02/24 at 03:00 PM. Due to the corrective action implemented prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J scope and severity.

The facility reported a census of 41 residents with six sampled, including three residents reviewed for physician ordered therapeutic/mechanically altered diets. Based on observation, record review, and interview, the facility failed to prevent neglect when they failed to provide Resident (R)1 with a therapeutic diet and 100% supervision during oral intake. R1 had dysphagia (swallowing difficulty) and was at risk for aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident) following a cerebrovascular accident (CVA - [stroke] sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). Due to these failures and lack of staff knowledge on providing the correct altered diet/fluids to residents, R1 attended a facility activity/party on [DATE], where she consumed hard shell candy pieces within reach of where staff placed her, and staff served her a cupcake and a non-thickened liquid. Although staff were in the area, they did not provide 100% supervision to the resident while eating and neglected to identify she had received non-thickened liquids until the cup was empty and only ice remained. R1 choked/aspirated, made a gurgling sound, had difficulty breathing, mouth sweep and suctioning were unsuccessful, and R1 became unresponsive and ashen in color with blue tinting to her lips and fingernails. The staff initiated cardiopulmonary resuscitation (CPR - emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning, etc.) and called 911. Emergency Services took over and transferred her to the hospital where she later died . This deficient practice resulted in R1's death and placed five other residents who received a therapeutic diet/mechanically altered consistency diet in immediate jeopardy. Findings included: - The hospital Progress Note dated [DATE] for R1 revealed an assessment of dysphagia with aspiration. The hospital Admission Physician Orders dated [DATE] for R1 included a diagnosis of post CVA. The Minimum Data Set (MDS) tab revealed R1 entered the facility on [DATE]. The Baseline Care Plan dated [DATE] revealed R1 required one-person physical assistance support for eating and required a mechanical soft diet, meat with gravy, nectar thick liquids, ate in the dining room, used a weighted utensil/straw, and was at risk for swallowing and chewing problems. The hospital Discharge Instructions dated [DATE] for R1 revealed a diet order of mechanical soft, nectar thick liquids, gravy on meat, 100% supervision during meal per Speech Therapy, and included R1 would aspirate (inhaling liquid or food into the lungs) if the meat was dry. The Functional Abilities and Goals - Admission assessment dated [DATE] revealed the resident required supervision or physical assistance for eating. The Orders tab for R1 included a diet order dated [DATE] for mechanical soft, level 2 texture (food to avoid included but were not limited to dry or chewy cakes, cookies, and chewy candies and allowed food items included moist cakes or slurried cakes), nectar consistency, and lacked R1 required 100% supervision. The Admission Summary Progress Note dated [DATE] at 04:07 PM revealed R1's diet was mechanical soft, meat with gravy, nectar thick liquids, one to one with meals, had weighted utensils and straw, medications to be crushed with applesauce, and she was alert with mild confusion. The Speech Therapy Evaluation and Plan of Treatment dated [DATE] revealed R1 had a diagnosis of dysphagia following other cerebrovascular disease and had decreased safety during oral intake, with a history of dysphagia and aspiration. The BIMS [Brief Interview of Mental Status] Evaluation Progress Note dated [DATE] at 04:22 PM revealed a score of three indicating severe cognitive impairment. The facility Timeline of Events for [DATE] revealed the following: 1. At 01:55 PM, Activity Staff Z was making cherry limeades for the activity party in the dining room. Consultant Therapy Staff GG brought R1 to the dining room in her wheelchair, and Certified Nurse Aide (CNA) M was assisting in the dining room area. 2. At 01:58 PM, CNA M and Activity Staff Z passed out drinks that Activity Staff Z made for the activity, all resident in the activity were served a cherry limeade in a plastic cup. 3. At 02:09 PM, Administrative Nurse D passed out cupcakes to the residents that wanted one and Activity Staff Z passed out straws. 4. At 02:24 PM, Administrative Nurse D checked on R1 who was vocalizing at that time. 5. At 02:25 PM, Administrative Nurse D went back to check on R1 and Certified Medication Aide (CMA) R helped R1 at that time. 6. At 02:26 PM, Administrative Nurse D and CMA R helped R1 who had increased mucus at that time. 7. At 02:29 PM, Administrative Nurse D and CMA R continued to assist R1 with napkins and mucus. 8. At 02:32 PM, Administrative Nurse D and CMA R continued to assist R1. 9. At 02:37 PM, CMA R and CMA S took R1 out of the dining room and to Licensed Nurse (LN) G to be assessed. Administrative Nurse D and Dietary Staff BB stayed in the dining room. 10. At 02:38 PM, R1 was at the nurse's station. 11. At 02:40 PM, staff went to get the suction machine. 12. At 02:41 PM, staff arrived with the emergency suction machine cart. 13. At 02:43 PM, LN G and Consultant Therapy Staff II assisted R1 to the floor and attempted mouth sweeps on R1, with R1's head turned to the side. 14. At 02:44 PM, Consultant Therapy Staff II started CPR. 15. At 02:50 PM, Emergency Medical Services (EMS) arrived and took over CPR. 16. At 03:15 PM, EMS left the building with R1 after return of cardiac rhythm and pulse. 17. At 06:04 PM, staff contacted the hospital and hospital nurse explained the DPOA (Durable Power of Attorney) desired to cease treatment at the hospital and R1 expired. The Progress Note dated [DATE] at 03:59 PM revealed a staff member brought R1 to the nurse stating she was at the facility activity/party when R1 was given thin liquids to drink and started choking, possibly aspirating. When the nurse began assessment, R1 was not responding and her color began to change to ashen, eventually blue in her lips and nail beds. The nurse attempted to suction R1 to remove any fluid without success and R1 went completely unresponsive at that time. The staff helped lower R1 to the floor, the staff started CPR right away. R1 lacked a pulse and air exchange, CPR continued, and the staff notified 911. CPR continued until EMS arrived. The facility Witness Statement dated [DATE] by CNA M revealed on [DATE] she had asked Activity Staff Z if there was anything she could do to help in the dining room and he had told her to pass out some drinks, so CMA M did. After passing out a couple of drinks and talking to a few residents, CMA M left the dining room to go to her assigned work area. The facility Witness Statement dated [DATE] by Administrative Nurse D revealed on [DATE] she arrived (lacked what time) to the dining room to assist Activity Staff Z with the activity and asked what needed done. Most of the resident's had drinks at that time, Administrative Nurse D gave out a couple then passed out cupcakes, then assisted a resident to eat and drink. At some point Dietary Staff BB came out with the fruit and meat trays and started to serve the residents. Activity Staff Z asked R1 what she wanted and Dietary Staff BB said she was on a special diet and could not have the fruit, but she could get her a fruit cup, and Administrative Nurse D continued to serve the other residents. While on the south side of the dining room serving residents, Administrative Nurse D heard someone coughing with a moist/wet cough and saw that it was R1. Administrative Nurse D stated she went over to R1 and at some point, CMA R came over to help R1, too. R1 was coughing and talking and calmed down after a while, and Administrative Nurse D asked CMA R, if she was back to normal status and CMA R responded maybe but did not look too sure about it. Administrative Nurse D then told CMA R to take her to the nurse's station to be checked by the nurse while Administrative Nurse D stayed with the other residents. Then, CMA S came to the dining room and said the staff needed Administrative Nurse D immediately, and when arrived at the nurse's station, the staff there was trying to get R1 out of her wheelchair. The staff got R1 to the floor, she was unresponsive, 911 notified, and CPR started. CPR continued until EMS arrived and took over and they achieved a cardiac rhythm and transported her out via gurney. The facility Witness Statement dated [DATE] by CMA R revealed on [DATE] she went to the dining room (lacked what time) to assist with the activity/party, noticed R1 gurgling, and notified Administrative Nurse D who was present in the dining room. CMA R sat with R1 and talked to her asking if she could breathe at that time and R1 said she could. CMA R asked again a couple of minutes later if she could breathe again and R1 stated it was tough. CMA R notified Administrative Nurse D, who instructed her to take R1 to the charge nurse on duty. R1 started changing colors and another staff went to get the emergency cart the proceeded to get her out of the chair. CMA R called 911 and the staff started CPR as another staff member went and got Administrative Nurse D. The facility Witness Statement dated [DATE] by Dietary Staff BB revealed on [DATE] there was an activity/party which started at 02:00 PM and dietary was providing fruit, cookies, and meat/cheese trays, and was running behind. Dietary Staff BB entered the area at about 02:30 PM and at that time R1 had a cup and a cupcake wrapper in front of her, and Administrative Nurse D and CMA S were helping out Activity Staff Z. Activity Staff Z asked R1 if she would like any fruit and Dietary Staff BB informed Activity Staff Z that R1 was not allowed that on her diet, but she could get her some canned fruit. The facility Witness Statement dated [DATE] by CMA S revealed on [DATE] she was helping in the dining room when R1 started gurgling and after a while, Administrative Nurse D asked to take R1 down to the charge nurse on duty. When CMA S noticed R1 was changing color, she ran for the emergency cart and when returned staff were attempting to get R1 out of the wheelchair. Another staff called 911 and CMA S went to get Administrative Nurse D who was in the dining room. CMA S took EMS when they arrived to R1, and the staff were performing CPR. The facility Witness Statement dated [DATE] by Consultant Therapy Staff II revealed on [DATE] around 02:30 PM, she walked out of the therapy room and heard she's not breathing so then handed her patient over to Consultant Therapy Staff GG and went to help. Consultant Therapy Staff II helped lower R1 to the floor, swept her mouth twice to see if anything was blocking her airway and CPR initiated. LN G used the suction machine, however, was unsuccessful. LN G used an Ambu bag (handheld device used to provide ventilation to patients her are not breathing) and could not get it sealed around R1's mouth. Consultant Therapy Staff II gave mouth to mouth several times. R1 had a sticky, light red fluid that came out and the staff turned her head to get the fluid out. During this time R1 was unresponsive and turning blue. EMS arrived and took over and stated R1 had a pulse after they gave her medication and CPR, then transported her to the hospital. The facility Witness Statement dated [DATE] by LN G revealed on [DATE], staff brought R1 to the nurse's station. R1 had been at the facility activity/party where she was given thin liquids. R1 was not responding when assessment began, her skin color became ashen, then blue. LN G ran to get the suction machine to try and remove any fluids from R1's airway without success. CPR started, R1 had no pulse or air exchange, 911 notified, and CPR continued until EMS arrived. The hospital records where R1 transferred to on [DATE] revealed she was unresponsive, cyanotic (bluish or purplish discoloration of the skin), and receiving treatment with a LMA (laryngeal mask airway - used as a temporary method to maintain an open airway), bagging (providing breathes with use of a device), and she had poor air movement with coarse breath sounds (crackling, bubbling sound that presents with excessive fluid in the lungs which could be caused by aspiration). At 03:33 PM, the family reported she had a DNR (do not resuscitate) and requested comfort measure. R1's time of death was at 03:55 PM. On [DATE] at 10:05 AM, Administrative Staff A stated the facility Timeline of Events was done using the facility cameras. On [DATE] at 10:50 AM Administrative Staff A stated R1 did receive a cupcake at the activity/party on [DATE] and her diet order included 100% supervision with meals. On [DATE] at 11:01 AM Administrative Nurse D stated she was generally supervising the dining room area on [DATE] and was in the vicinity of R1. On [DATE] at 11:09 AM, CNA M stated she was in the dining room for the activity on [DATE] and Activity Staff Z asked her to help pass out drinks. CNA M stated she gave R1 a limeade from the table and that she had never provided cares to her before as R1 was in a different area of the facility than where she had been assigned to. CNA M stated she was not sure what kind of diet R1 was on. CNA M stated there were packages of what looked like hard shell candies on the table and that R1 had some in front of her, however, she did not know if R1 had opened them or not and had not observed R1 take a drink while there. On [DATE] at 11:40 AM, Activity Staff Z stated he put the activity/event together and had left at 02:28 PM on [DATE]. Activity Staff Z stated Administrative Staff A had brought cupcakes and hard-shell candies for the party and placed the candies on the tables where the residents would sit. Activity Staff Z stated he placed cupcakes on plates and Administrative Nurse D and CMA S passed them out. Activity Staff Z stated he recalled R1 sat in the dining room with the hard-shell candies in front of her and did not know if she opened them or not. Activity Staff Z stated he passed out a few drinks, mainly pouring them, and did not know if any of the residents in the dining room required thickened liquids, and he did not know R1's diet orders. Activity Staff Z stated he left at 02:28 PM and at that time heard Dietary Staff BB and Administrative Nurse D talking about R1's liquids were supposed to be thickened. R1 had already ate her cupcake and she had the hard candies and a drink in front of her. On [DATE] at 01:19 PM, Consultant Therapy Staff HH stated R1 was an aspiration risk based on the swallow study done at the hospital, prior to admission to the facility. Consultant Therapy Staff HH stated R1 admitted to the facility on a dysphagia level two diet, ground meat, mechanical soft, nectar thick liquids, and 1:1 supervision and she did not change any of the admission diet orders for R1. Consultant Therapy Staff HH stated according to the dysphagia diet guidelines used by the facility, would need to double check, typically the cupcake would need to be slurried, cakes should be moist, sometimes the frosting could do that, and stated it was a fine line and depended on how moist or soft the cupcake, if R1 would be able to tolerate it. Consultant Therapy Staff HH stated she would not have recommended the hard-shell candies due to the outer candied shell could pose a risk if not chewed well. On [DATE] at 02:26 PM, Dietary Staff BB stated she saw R1 in the dining room on [DATE] and she had a cup in front of her and did not see if it was empty or not, an empty cupcake wrapper, and a little box with hard-shell candies that was opened in front of R1. Dietary Staff BB stated R1 had a mechanical soft dysphagia level two diet, and as long as the cupcake had enough frosting and was a moist cake, then it would be appropriate for her. Dietary Staff BB stated she did not see the cupcakes and probably would not have given her the candies. Dietary Staff BB stated there were nursing staff present in the dining room, however not with R1 at the table. Dietary Staff BB stated Activity Staff Z was getting ready to give her some fresh fruit, but before she answered, she told Activity Staff Z she could get R1 a fruit cup. When she returned to the dining room, CMA S and CMA R checked on R1, debated on if they should call the nurse or take R1 to the nurse, and they decided to take the resident to the nurse. Dietary Staff BB stated the nursing staff would have to look at a resident's care plan to determine their diet and the dietary staff had a spreadsheet for the different diets due to lack of access to the care plans. On [DATE] at 02:45 PM, Administrative Staff A stated she had put the hard-shell candies in a small purple box that had a butterfly on top, like fun size, as center pieces on the tables for the party around 01:00 PM, after lunch, when Activity Staff Z set up the tables and made the cupcakes. On [DATE] at 03:51 PM, Administrative Nurse D stated she did not observe R1 take any drinks however she had a cup in front of her at the activity/party on [DATE], and it only had ice in it when she observed it. It was approximately a 12-ounce plastic cup, and there was evidence R1 ate the candies due to colors of the candies on the tablecloth where she touched it after putting them in her mouth, and the box was empty. Administrative Nurse D stated it was okay for R1 to have the candies since they melt in your mouth. Administrative Nurse D stated R1's liquids were to be thickened, and thickened liquids would not have ice in them. Administrative Nurse D stated she did not know if R1 required supervision with oral intake, and when checking the care plan, Administrative Nurse D stated the care plan did not reveal she required supervision for meals. Administrative Nurse D stated 100% supervision at meals would indicate the resident should have somebody sitting there with them and the 100% supervision should have been included in her diet order. Administrative Nurse D stated staff should have provided supervision at the party when R1 had food and fluids. Prior to serving R1, the staff should have checked the care plan and orders. On [DATE] at 06:43 PM, CMA R stated when she entered the dining room on [DATE], R 1 had a cupcake, a little box of hard-shell candies, and what she thought was fruit punch, and later staff passed out the cookies. CMA R stated she did not see R1 drink from the cup, but it only had ice in it when it was later observed. CMA R stated she did not see R1 eat the candies or the cookie, however the cookie did not have any bites gone from it when she removed R1 away from the table. CMA R, who had cared for R1 before, stated at the time she knew R1 was to have chopped ground meat moistened with gravy and thickened liquids. CMA R stated she said something to Administrative Nurse D, after noticing R1 having some problems, that it looked like there was regular (thin) liquids in R1's cup and had not noticed it before that time. CMA R stated she sat by R1 and asked her one last time about her breathing and R1 stated it was really hard to breathe, so she alerted Administrative Nurse D who told her to take R1 to the nurse. CMA R stated R1 required supervision, when she came out for meals, staff was always to be with her, and when CMA R got to the dining room on [DATE], no staff were with R1, at that time. CMA R stated Administrative Nurse D and CMA S were meandering around the residents in the area. On [DATE] at 01:54 PM, third attempt made to contact LN G for interview, without success. Review of the facility video footage dated [DATE] from 01:45 PM until 02:37 PM with Administrative Staff A revealed the following: At 01:48 PM, purple boxes sat on the tables in the area of the dining room for the activity/party. At 01:55 PM, Consultant Therapy Staff GG brought R1 to the table via wheelchair for the activity/party, and the box of candies were in front of her on the table. R1's back was to the facility camera. At 1:58 PM, CNA M provided R1 a cup of fluids from the table where Activity Staff Z was making the cherry limeades. R1 grabbed the cup and tilted her head back, which appeared that she took a drink from the cup. At 01:59 PM, R1 appeared to take another drink, CNA M was at the table where the resident sat, then exited the area at 02:01 PM. At 02:02 PM, Activity Staff Z and Administrative Nurse D entered the activity/party area, R1 lacked supervision by staff. At 02:05 PM R1 moved her upper body forward and back, her back still to the facility camera. At 02:08 PM, Administrative Nurse D gave R1 a cupcake. At 02:13 PM, CMA R patted R1 on the back. At 02:21 PM, Activity Staff Z and Dietary Staff BB appeared to be talking to each other in the area of the activity/party behind R1. At 02:25 PM, Administrative Nurse D sat down by R1, CMA R rubbed R1's shoulders, then Administrative Nurse D got up from the table. At 02:26 PM, Administrative Nurse D handed CMA R a napkin, who then bent over R1, however, R1's back was still to the facility camera, obstructing view of what CMA R did with the napkin. At 02:27 PM, CMA R patted R1 on the shoulders while Administrative Nurse D was on the right side of R1. At 02:30 PM, CMA R remained with R1. At 02:31 PM, CMA R got another napkin and returned to R1, however unable to see what she did with the napkin. At 02:33 PM, R1 made a motion with her hand, Administrative Nurse D checked on her and walked away. At 02:34 PM, CMA R stood beside R1 and patted her on the back, rubbed her back/neck area with gentle pats. At 02:35 PM, CMA R stood up again, and continued to rub R1's back. At 02:36 PM, CMA R left R1 to throw something away and then returned to R1. At 02:37 PM, CMA R leaned over R1, moved her away from the table and towards the exit doorway of the dining room, walked away, and CMA S moved R1 in her wheelchair out of the dining room. The facility Level Two ground food guideline, undated, revealed that food to avoid included dry or chewy cakes, cookies, and chewy candies and allowed food items included moist cakes or slurried cakes. The facility policy Thickened Liquids - Preparing and Serving undated, revealed thickened liquids will be served when ordered by the resident's physician. On [DATE] at 11:20 AM, Administrative Staff A was provided a copy of the IJ template and notified the facility failure to prevent neglect with the failure to provide therapeutic and/or mechanically altered diets as ordered, and failure to provide supervision/assistance for R1 while she ate, due to her dysphagia and risk for aspiration, placed R1 in immediate jeopardy Due to this failure, R1 subsequently choked/aspirated at the facility activity on [DATE], after staff noted she began making a gurgling sound and had difficulty breathing. The staff implemented a mouth sweep and suctioning of R1, which were unsuccessful, then began CPR when R1 became unresponsive and ashen in color, with blue tinting to her lips and fingernails. The facility emergency medical transferred R1 to a local hospital, where she subsequently died . The facility identified and implemented the following corrective measure on [DATE] at 04:00 PM: 1. On [DATE] at 05:30 PM, the facility implemented an immediate intervention for a dietary team member to be present at all activities if food/drinks were served. Dietary Staff BB would review the activities calendar and prepare the food/drinks for activities. The facility updated the list of mechanically altered diets/fluids. 2. On [DATE] at 05:30 PM, the facility completed immediate education and review on the care plan policy with all nursing staff. 3. On [DATE] at 05:30 PM, the facility completed immediate education on abuse, neglect, and exploitation to all staff. 4. On [DATE] at 05:30 PM, the facility completed immediate education on diet/food consistency/thickened liquids to all nursing and dietary staff. 5. On [DATE] at 01:00 PM, the facility contacted the Medical Director to review the investigation, reporting summary, action plan, and the new dysphagia diet policy. 6. On [DATE] at 04:00 PM, the facility revised the Dysphagia Care policy and completed education to all nursing and dietary staff. The surveyor verified the implementation of the above corrective actions onsite on [DATE] at 03:30 PM. Due to the implemented corrective actions prior to the surveyor's arrival onsite, the deficient practice was deemed past-noncompliance and existed at a J scope and severity.

The facility reported a census of 41 residents with six sampled, including three residents reviewed for physician ordered therapeutic/mechanically altered diets. Based on observation, record review, and interview, the facility failed to provide Resident (R)1 with a therapeutic diet and 100% supervision during oral intake. R1 had dysphagia (swallowing difficulty) and was at risk for aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident) following a cerebrovascular accident (CVA - [stroke] sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). Due to these failures and lack of staff knowledge on providing the correct altered diet/fluids to residents, R1 attended a facility activity/party on [DATE], where she consumed hard shell candy pieces within reach of where staff placed her, and staff served her a cupcake and a non-thickened liquid. Although staff were in the area, they did not provide 100% supervision to the resident while eating and neglected to identify she had received non-thickened liquids until the cup was empty and only ice remained. R1 choked/aspirated, made a gurgling sound, had difficulty breathing, mouth sweep and suctioning were unsuccessful, and R1 became unresponsive and ashen in color with blue tinting to her lips and fingernails. The staff initiated cardiopulmonary resuscitation (CPR - emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning, etc.) and called 911. Emergency Services took over and transferred her to the hospital where she later died . This deficient practice resulted in R1's death and placed five other residents who received a therapeutic diet/mechanically altered consistency diet in immediate jeopardy. Findings included: - The hospital Progress Note dated [DATE] for R1 revealed an assessment of dysphagia with aspiration. The hospital Admission Physician Orders dated [DATE] for R1 included a diagnosis of post CVA. The Minimum Data Set (MDS) tab revealed R1 entered the facility on [DATE]. The Baseline Care Plan dated [DATE] revealed R1 required one-person physical assistance support for eating and required a mechanical soft diet, meat with gravy, nectar thick liquids, ate in the dining room, used a weighted utensil/straw, and was at risk for swallowing and chewing problems. The hospital Discharge Instructions dated [DATE] for R1 revealed a diet order of mechanical soft, nectar thick liquids, gravy on meat, 100% supervision during meal per Speech Therapy, and included R1 would aspirate (inhaling liquid or food into the lungs) if the meat was dry. The Functional Abilities and Goals - Admission assessment dated [DATE] revealed the resident required supervision or physical assistance for eating. The Orders tab for R1 included a diet order dated [DATE] for mechanical soft, level 2 texture (food to avoid included but were not limited to dry or chewy cakes, cookies, and chewy candies and allowed food items included moist cakes or slurried cakes), nectar consistency, and lacked R1 required 100% supervision. The Admission Summary Progress Note dated [DATE] at 04:07 PM revealed R1's diet was mechanical soft, meat with gravy, nectar thick liquids, one to one with meals, had weighted utensils and straw, medications to be crushed with applesauce, and she was alert with mild confusion. The Speech Therapy Evaluation and Plan of Treatment dated [DATE] revealed R1 had a diagnosis of dysphagia following other cerebrovascular disease and had decreased safety during oral intake, with a history of dysphagia and aspiration. The BIMS [Brief Interview of Mental Status] Evaluation Progress Note dated [DATE] at 04:22 PM revealed a score of three indicating severe cognitive impairment. The facility Timeline of Events for [DATE] revealed the following: 1. At 01:55 PM, Activity Staff Z was making cherry limeades for the activity party in the dining room. Consultant Therapy Staff GG brought R1 to the dining room in her wheelchair, and Certified Nurse Aide (CNA) M was assisting in the dining room area. 2. At 01:58 PM, CNA M and Activity Staff Z passed out drinks that Activity Staff Z made for the activity, all resident in the activity were served a cherry limeade in a plastic cup. 3. At 02:09 PM, Administrative Nurse D passed out cupcakes to the residents that wanted one and Activity Staff Z passed out straws. 4. At 02:24 PM, Administrative Nurse D checked on R1 who was vocalizing at that time. 5. At 02:25 PM, Administrative Nurse D went back to check on R1 and Certified Medication Aide (CMA) R helped R1 at that time. 6. At 02:26 PM, Administrative Nurse D and CMA R helped R1 who had increased mucus at that time. 7. At 02:29 PM, Administrative Nurse D and CMA R continued to assist R1 with napkins and mucus. 8. At 02:32 PM, Administrative Nurse D and CMA R continued to assist R1. 9. At 02:37 PM, CMA R and CMA S took R1 out of the dining room and to Licensed Nurse (LN) G to be assessed. Administrative Nurse D and Dietary Staff BB stayed in the dining room. 10. At 02:38 PM, R1 was at the nurse's station. 11. At 02:40 PM, staff went to get the suction machine. 12. At 02:41 PM, staff arrived with the emergency suction machine cart. 13. At 02:43 PM, LN G and Consultant Therapy Staff II assisted R1 to the floor and attempted mouth sweeps on R1, with R1's head turned to the side. 14. At 02:44 PM, Consultant Therapy Staff II started CPR. 15. At 02:50 PM, Emergency Medical Services (EMS) arrived and took over CPR. 16. At 03:15 PM, EMS left the building with R1 after return of cardiac rhythm and pulse. 17. At 06:04 PM, staff contacted the hospital and hospital nurse explained the DPOA (Durable Power of Attorney) desired to cease treatment at the hospital and R1 expired. The Progress Note dated [DATE] at 03:59 PM revealed a staff member brought R1 to the nurse stating she was at the facility activity/party when R1 was given thin liquids to drink and started choking, possibly aspirating. When the nurse began assessment, R1 was not responding and her color began to change to ashen, eventually blue in her lips and nail beds. The nurse attempted to suction R1 to remove any fluid without success and R1 went completely unresponsive at that time. The staff helped lower R1 to the floor, the staff started CPR right away. R1 lacked a pulse and air exchange, CPR continued, and the staff notified 911. CPR continued until EMS arrived. The facility Witness Statement dated [DATE] by CNA M revealed on [DATE] she had asked Activity Staff Z if there was anything she could do to help in the dining room and he had told her to pass out some drinks, so CMA M did. After passing out a couple of drinks and talking to a few residents, CMA M left the dining room to go to her assigned work area. The facility Witness Statement dated [DATE] by Administrative Nurse D revealed on [DATE] she arrived (lacked what time) to the dining room to assist Activity Staff Z with the activity and asked what needed done. Most of the resident's had drinks at that time, Administrative Nurse D gave out a couple then passed out cupcakes, then assisted a resident to eat and drink. At some point Dietary Staff BB came out with the fruit and meat trays and started to serve the residents. Activity Staff Z asked R1 what she wanted and Dietary Staff BB said she was on a special diet and could not have the fruit, but she could get her a fruit cup, and Administrative Nurse D continued to serve the other residents. While on the south side of the dining room serving residents, Administrative Nurse D heard someone coughing with a moist/wet cough and saw that it was R1. Administrative Nurse D stated she went over to R1 and at some point, CMA R came over to help R1, too. R1 was coughing and talking and calmed down after a while, and Administrative Nurse D asked CMA R, if she was back to normal status and CMA R responded maybe but did not look too sure about it. Administrative Nurse D then told CMA R to take her to the nurse's station to be checked by the nurse while Administrative Nurse D stayed with the other residents. Then, CMA S came to the dining room and said the staff needed Administrative Nurse D immediately, and when arrived at the nurse's station, the staff there was trying to get R1 out of her wheelchair. The staff got R1 to the floor, she was unresponsive, 911 notified, and CPR started. CPR continued until EMS arrived and took over and they achieved a cardiac rhythm and transported her out via gurney. The facility Witness Statement dated [DATE] by CMA R revealed on [DATE] she went to the dining room (lacked what time) to assist with the activity/party, noticed R1 gurgling, and notified Administrative Nurse D who was present in the dining room. CMA R sat with R1 and talked to her asking if she could breathe at that time and R1 said she could. CMA R asked again a couple of minutes later if she could breathe again and R1 stated it was tough. CMA R notified Administrative Nurse D, who instructed her to take R1 to the charge nurse on duty. R1 started changing colors and another staff went to get the emergency cart the proceeded to get her out of the chair. CMA R called 911 and the staff started CPR as another staff member went and got Administrative Nurse D. The facility Witness Statement dated [DATE] by Dietary Staff BB revealed on [DATE] there was an activity/party which started at 02:00 PM and dietary was providing fruit, cookies, and meat/cheese trays, and was running behind. Dietary Staff BB entered the area at about 02:30 PM and at that time R1 had a cup and a cupcake wrapper in front of her, and Administrative Nurse D and CMA S were helping out Activity Staff Z. Activity Staff Z asked R1 if she would like any fruit and Dietary Staff BB informed Activity Staff Z that R1 was not allowed that on her diet, but she could get her some canned fruit. The facility Witness Statement dated [DATE] by CMA S revealed on [DATE] she was helping in the dining room when R1 started gurgling and after a while, Administrative Nurse D asked to take R1 down to the charge nurse on duty. When CMA S noticed R1 was changing color, she ran for the emergency cart and when returned staff were attempting to get R1 out of the wheelchair. Another staff called 911 and CMA S went to get Administrative Nurse D who was in the dining room. CMA S took EMS when they arrived to R1, and the staff were performing CPR. The facility Witness Statement dated [DATE] by Consultant Therapy Staff II revealed on [DATE] around 02:30 PM, she walked out of the therapy room and heard she's not breathing so then handed her patient over to Consultant Therapy Staff GG and went to help. Consultant Therapy Staff II helped lower R1 to the floor, swept her mouth twice to see if anything was blocking her airway and CPR initiated. LN G used the suction machine, however, was unsuccessful. LN G used an Ambu bag (handheld device used to provide ventilation to patients her are not breathing) and could not get it sealed around R1's mouth. Consultant Therapy Staff II gave mouth to mouth several times. R1 had a sticky, light red fluid that came out and the staff turned her head to get the fluid out. During this time R1 was unresponsive and turning blue. EMS arrived and took over and stated R1 had a pulse after they gave her medication and CPR, then transported her to the hospital. The facility Witness Statement dated [DATE] by LN G revealed on [DATE], staff brought R1 to the nurse's station. R1 had been at the facility activity/party where she was given thin liquids. R1 was not responding when assessment began, her skin color became ashen, then blue. LN G ran to get the suction machine to try and remove any fluids from R1's airway without success. CPR started, R1 had no pulse or air exchange, 911 notified, and CPR continued until EMS arrived. The hospital records where R1 transferred to on [DATE] revealed she was unresponsive, cyanotic (bluish or purplish discoloration of the skin), and receiving treatment with a LMA (laryngeal mask airway - used as a temporary method to maintain an open airway), bagging (providing breathes with use of a device), and she had poor air movement with coarse breath sounds (crackling, bubbling sound that presents with excessive fluid in the lungs which could be caused by aspiration). At 03:33 PM, the family reported she had a DNR (do not resuscitate) and requested comfort measure. R1's time of death was at 03:55 PM. On [DATE] at 10:05 AM, Administrative Staff A stated the facility Timeline of Events was done using the facility cameras. On [DATE] at 10:50 AM Administrative Staff A stated R1 did receive a cupcake at the activity/party on [DATE] and her diet order included 100% supervision with meals. On [DATE] at 11:01 AM Administrative Nurse D stated she was generally supervising the dining room area on [DATE] and was in the vicinity of R1. On [DATE] at 11:09 AM, CNA M stated she was in the dining room for the activity on [DATE] and Activity Staff Z asked her to help pass out drinks. CNA M stated she gave R1 a limeade from the table and that she had never provided cares to her before as R1 was in a different area of the facility than where she had been assigned to. CNA M stated she was not sure what kind of diet R1 was on. CNA M stated there were packages of what looked like hard shell candies on the table and that R1 had some in front of her, however, she did not know if R1 had opened them or not and had not observed R1 take a drink while there. On [DATE] at 11:40 AM, Activity Staff Z stated he put the activity/event together and had left at 02:28 PM on [DATE]. Activity Staff Z stated Administrative Staff A had brought cupcakes and hard-shell candies for the party and placed the candies on the tables where the residents would sit. Activity Staff Z stated he placed cupcakes on plates and Administrative Nurse D and CMA S passed them out. Activity Staff Z stated he recalled R1 sat in the dining room with the hard-shell candies in front of her and did not know if she opened them or not. Activity Staff Z stated he passed out a few drinks, mainly pouring them, and did not know if any of the residents in the dining room required thickened liquids, and he did not know R1's diet orders. Activity Staff Z stated he left at 02:28 PM and at that time heard Dietary Staff BB and Administrative Nurse D talking about R1's liquids were supposed to be thickened. R1 had already ate her cupcake and she had the hard candies and a drink in front of her. On [DATE] at 01:19 PM, Consultant Therapy Staff HH stated R1 was an aspiration risk based on the swallow study done at the hospital, prior to admission to the facility. Consultant Therapy Staff HH stated R1 admitted to the facility on a dysphagia level two diet, ground meat, mechanical soft, nectar thick liquids, and 1:1 supervision and she did not change any of the admission diet orders for R1. Consultant Therapy Staff HH stated according to the dysphagia diet guidelines used by the facility, would need to double check, typically the cupcake would need to be slurried, cakes should be moist, sometimes the frosting could do that, and stated it was a fine line and depended on how moist or soft the cupcake, if R1 would be able to tolerate it. Consultant Therapy Staff HH stated she would not have recommended the hard-shell candies due to the outer candied shell could pose a risk if not chewed well. On [DATE] at 02:26 PM, Dietary Staff BB stated she saw R1 in the dining room on [DATE] and she had a cup in front of her and did not see if it was empty or not, an empty cupcake wrapper, and a little box with hard-shell candies that was opened in front of R1. Dietary Staff BB stated R1 had a mechanical soft dysphagia level two diet, and as long as the cupcake had enough frosting and was a moist cake, then it would be appropriate for her. Dietary Staff BB stated she did not see the cupcakes and probably would not have given her the candies. Dietary Staff BB stated there were nursing staff present in the dining room, however not with R1 at the table. Dietary Staff BB stated Activity Staff Z was getting ready to give her some fresh fruit, but before she answered, she told Activity Staff Z she could get R1 a fruit cup. When she returned to the dining room, CMA S and CMA R checked on R1, debated on if they should call the nurse or take R1 to the nurse, and they decided to take the resident to the nurse. Dietary Staff BB stated the nursing staff would have to look at a resident's care plan to determine their diet and the dietary staff had a spreadsheet for the different diets due to lack of access to the care plans. On [DATE] at 02:45 PM, Administrative Staff A stated she had put the hard-shell candies in a small purple box that had a butterfly on top, like fun size, as center pieces on the tables for the party around 01:00 PM, after lunch, when Activity Staff Z set up the tables and made the cupcakes. On [DATE] at 03:51 PM, Administrative Nurse D stated she did not observe R1 take any drinks however she had a cup in front of her at the activity/party on [DATE], and it only had ice in it when she observed it. It was approximately a 12-ounce plastic cup, and there was evidence R1 ate the candies due to colors of the candies on the tablecloth where she touched it after putting them in her mouth, and the box was empty. Administrative Nurse D stated it was okay for R1 to have the candies since they melt in your mouth. Administrative Nurse D stated R1's liquids were to be thickened, and thickened liquids would not have ice in them. Administrative Nurse D stated she did not know if R1 required supervision with oral intake, and when checking the care plan, Administrative Nurse D stated the care plan did not reveal she required supervision for meals. Administrative Nurse D stated 100% supervision at meals would indicate the resident should have somebody sitting there with them and the 100% supervision should have been included in her diet order. Administrative Nurse D stated staff should have provided supervision at the party when R1 had food and fluids. Prior to serving R1, the staff should have checked the care plan and orders. On [DATE] at 06:43 PM, CMA R stated when she entered the dining room on [DATE], R 1 had a cupcake, a little box of hard-shell candies, and what she thought was fruit punch, and later staff passed out the cookies. CMA R stated she did not see R1 drink from the cup, but it only had ice in it when it was later observed. CMA R stated she did not see R1 eat the candies or the cookie, however the cookie did not have any bites gone from it when she removed R1 away from the table. CMA R, who had cared for R1 before, stated at the time she knew R1 was to have chopped ground meat moistened with gravy and thickened liquids. CMA R stated she said something to Administrative Nurse D, after noticing R1 having some problems, that it looked like there was regular (thin) liquids in R1's cup and had not noticed it before that time. CMA R stated she sat by R1 and asked her one last time about her breathing and R1 stated it was really hard to breathe, so she alerted Administrative Nurse D who told her to take R1 to the nurse. CMA R stated R1 required supervision, when she came out for meals, staff was always to be with her, and when CMA R got to the dining room on [DATE], no staff were with R1, at that time. CMA R stated Administrative Nurse D and CMA S were meandering around the residents in the area. On [DATE] at 01:54 PM, third attempt made to contact LN G for interview, without success. Review of the facility video footage dated [DATE] from 01:45 PM until 02:37 PM with Administrative Staff A revealed the following: At 01:48 PM, purple boxes sat on the tables in the area of the dining room for the activity/party. At 01:55 PM, Consultant Therapy Staff GG brought R1 to the table via wheelchair for the activity/party, and the box of candies were in front of her on the table. R1's back was to the facility camera. At 1:58 PM, CNA M provided R1 a cup of fluids from the table where Activity Staff Z was making the cherry limeades. R1 grabbed the cup and tilted her head back, which appeared that she took a drink from the cup. At 01:59 PM, R1 appeared to take another drink, CNA M was at the table where the resident sat, then exited the area at 02:01 PM. At 02:02 PM, Activity Staff Z and Administrative Nurse D entered the activity/party area, R1 lacked supervision by staff. At 02:05 PM R1 moved her upper body forward and back, her back still to the facility camera. At 02:08 PM, Administrative Nurse D gave R1 a cupcake. At 02:13 PM, CMA R patted R1 on the back. At 02:21 PM, Activity Staff Z and Dietary Staff BB appeared to be talking to each other in the area of the activity/party behind R1. At 02:25 PM, Administrative Nurse D sat down by R1, CMA R rubbed R1's shoulders, then Administrative Nurse D got up from the table. At 02:26 PM, Administrative Nurse D handed CMA R a napkin, who then bent over R1, however, R1's back was still to the facility camera, obstructing view of what CMA R did with the napkin. At 02:27 PM, CMA R patted R1 on the shoulders while Administrative Nurse D was on the right side of R1. At 02:30 PM, CMA R remained with R1. At 02:31 PM, CMA R got another napkin and returned to R1, however unable to see what she did with the napkin. At 02:33 PM, R1 made a motion with her hand, Administrative Nurse D checked on her and walked away. At 02:34 PM, CMA R stood beside R1 and patted her on the back, rubbed her back/neck area with gentle pats. At 02:35 PM, CMA R stood up again, and continued to rub R1's back. At 02:36 PM, CMA R left R1 to throw something away and then returned to R1. At 02:37 PM, CMA R leaned over R1, moved her away from the table and towards the exit doorway of the dining room, walked away, and CMA S moved R1 in her wheelchair out of the dining room. The facility Level Two ground food guideline, undated, revealed that food to avoid included dry or chewy cakes, cookies, and chewy candies and allowed food items included moist cakes or slurried cakes. The facility policy Thickened Liquids - Preparing and Serving undated, revealed thickened liquids will be served when ordered by the resident's physician. On [DATE] at 11:20 AM, Administrative Staff A was provided a copy of the IJ template and notified the facility failure to provide therapeutic and/or mechanically altered diets as ordered, and failure to provide supervision/assistance for R1 while she ate, due to her dysphagia and risk for aspiration, placed R1 in immediate jeopardy Due to this failure, R1 subsequently choked/aspirated at the facility activity on [DATE], after staff noted she began making a gurgling sound and had difficulty breathing. The staff implemented a mouth sweep and suctioning of R1, which were unsuccessful, then began CPR when R1 became unresponsive and ashen in color, with blue tinting to her lips and fingernails. The facility emergency medical transferred R1 to a local hospital, where she subsequently died . The facility identified and implemented the following corrective measure on [DATE] at 04:00 PM: 1. On [DATE] at 05:30 PM, the facility implemented an immediate intervention for a dietary team member to be present at all activities if food/drinks were served. Dietary Staff BB would review the activities calendar and prepare the food/drinks for activities. The facility updated the list of mechanically altered diets/fluids. 2. On [DATE] at 05:30 PM, the facility completed immediate education and review on the care plan policy with all nursing staff. 3. On [DATE] at 05:30 PM, the facility completed immediate education on abuse, neglect, and exploitation to all staff. 4. On [DATE] at 05:30 PM, the facility completed immediate education on diet/food consistency/thickened liquids to all nursing and dietary staff. 5. On [DATE] at 01:00 PM, the facility contacted the Medical Director to review the investigation, reporting summary, action plan, and the new dysphagia diet policy. 6. On [DATE] at 04:00 PM, the facility revised the Dysphagia Care policy and completed education to all nursing and dietary staff. The surveyor verified the implementation of the above corrective actions onsite on [DATE] at 03:30 PM. Due to the implemented corrective actions prior to the surveyor's arrival onsite, the deficient practice was deemed past-noncompliance and existed at a J scope and severity.

The facility had a census of 44 residents. The sample included 4 residents. Based on observation, record review and interview, the facility failed to provide the necessary care and services for 1 of 4 sampled residents reviewed for adequate assessments. Resident #1 admitted to the facility with a dressing on his/her left lower forearm, lacked physician orders [REDACTED]. The facility also failed to report to the physician the resident's complaints of left wrist pain, after a fall, swelling with bruising and inability to move his/her fingers, and the resident requested an x-ray, (16 hours after the fall). (#1) Findings included: - Resident #1's hospital history and physical, dated 9/17/16, revealed the resident had [DIAGNOSES REDACTED]. Resident #1's admission (MDS) Minimum Data Set assessment, dated 9/27/16, recorded a (BIMS) Brief Interview for Mental Status score of 15, indicated intact cognition, and he/she required extensive assistance of 2 staff for bed mobility, transfers, toileting, and limited assistance of 1 staff for personal hygiene. The MDS indicated the resident had unsteady balance, only able to stabilize with human assistance, he/she ambulated with walker or wheelchair. The MDS documented the resident had a skin tear on admission. The (CAA) Care Area Assessment for (ADLs) Activities Daily Living, dated 10/3/16, indicated the resident required limited to extensive staff assistance of 1-2 with his/her ADLs. The CAA recorded the resident could pivot transfer, or at times used the sit to stand lift for transfers, and was currently working with (PT) Physical Therapy and (OT) Occupational Therapy. The 9/20/16 admission temporary care plan instructed staff to assist the resident with his/her toileting needs, and provide the resident with a call light with instructions on using it. The temporary care plan lacked documentation of the dressing or treatment to the resident's left lower arm skin tear. The admission care plan also instructed staff to assist with transfers and mobility as he/she recently had fallen at home resulting in a left [MEDICAL CONDITION]. The Hospital discharge instructions, dated 9/20/16, documented the resident had an allergy to [MEDICATION NAME] TAO as of 8/14/02 and lacked instructions for staff to change the dressing to the resident's left forearm. Nursing Note dated 9/20/16 at 1:25 PM, recorded the resident had an intact dressing to his/her left lower arm and purple areas to his/her left elbow and hand and lacked documentation of an assessment of the skin under the dressing. Review of the September 2016 (TAR) Treatment Administration Record revealed no documentation staff provided treatment to the resident's left lower forearm skin tear from September 20-30, 2016. Nursing note dated 10/2/16 at 8:20 AM, (12 days after admission) indicated staff removed the dressing from the resident's left forearm, cleansed the wound, applied an ABD (a highly absorbent dressing that provides padding and protection for large wounds, measuring 5 inches x 9 inches) dressing and 2 x 3 cm non-adhering pad to areas on the left lower forearm and applied Coban (self-adhering wrap a thin, lightweight, breathable, elastic support) to secure the dressing. The note further revealed when staff removed the previous dressing, they noted an odor with a small amount of tannish to light yellow with serosanguinous (semi-thick reddish) drainage and the medical record lacked a physician's orders [REDACTED]. The medical record lacked evidence staff notified the physician regarding the status of the resident's left forearm wound. The resident's physician standing order instructed staff to implement the facility's wound protocol for treatment of [REDACTED]. The 10/5/16 at 9:59 AM, nurse's notes revealed staff removed the dressing from the resident's lower left arm, which continued to be red and abraded. The note indicated staff cleansed the wound with Normal Saline ([MEDICATION NAME] and the most commonly used wound irrigation), applied [MEDICATION NAME] TAO to the wound, then Tesla (non- adhesive dressing) and wrapped the wound with Coban. The note indicated the old dressing had a small to moderate amount of serosanguinous, yellow/green drainage. The medical record lacked a physician's orders [REDACTED]. The 10/6/16 at 9:59 AM, nurse's notes indicated staff changed the dressing to the resident's left lower arm, due to the resident's complaint of itching to the upper area of left lower forearm. The note indicated the previous dressing had a small to moderate amount of thick, serosanguinous yellow/green drainage to both the upper and lower open areas. The note indicated staff cleansed the wounds with Normal Saline, applied [MEDICATION NAME] TAO, and [MEDICATION NAME] to the wound. The same note indicated at 12:52 PM, the resident's physician, wrote a new order for staff to change the dressing daily to the left arm. The medical record revealed no specific dressing instructions except to change the dressing daily and did not instruct staff to apply [MEDICATION NAME] TAO to the skin tear (17 days since the resident admitted before staff obtained a physician's orders [REDACTED]. Review of the nurse's notes indicated staff continued to apply [MEDICATION NAME] TAO to the resident's skin tear on his/her left lower arm daily from 10/5/16-10/9/16. The 10/9/16 at 1:18 PM, nurse's notes indicated staff changed the dressing to the resident's left lower arm and the previous dressing had blood and yellow/green tinged drainage with the resident stating his/her arm was burning. The note indicated staff administered Tylenol (pain medication), 325 (mg) milligrams, 2 tabs, by mouth, for pain at approximately 12:15 PM. Nursing note dated 10/10/16 at 1:01 AM, documented the the resident complained of pain to his/her left arm with the dressing intact. At 10:08 AM, staff noted a foul odor upon removal of the previous dressing to the resident's lower left arm. The area appeared superficial with a dry appearance and the lower area of the left arm, near the wrist area, remained open. The noted indicated staff applied [MEDICATION NAME] TAO and [MEDICATION NAME] to the area and wrapped the area with Coban. At 10:11 AM, the note indicated the resident's physician advised staff the resident was not to have [MEDICATION NAME] TAO to arms or any part of his/her body as the resident was very allergic to [MEDICATION NAME] TAO. The note further indicated staff rewrapped the resident's arm as the arm was weeping (the seeping of an open or healing wound, either of serum or pus, sometimes accompanied by a strong smell). Review of the resident's September, October and November 2016 (TAR) Treatment Medication Records and (MAR) Medication Administration Records revealed documentation of the resident's allergy to [MEDICATION NAME], since admission. The 10/11/16 at 12:21 PM, nurse's note recorded new physician orders [REDACTED]. The 10/12/16 at 10:50 AM, nurse's notes recorded staff change the resident's left arm dressing which revealed the previous dressing had a small to moderate amount of thick, light green/yellow drainage on it, with a foul odor. The note further indicated staff notified the resident's physician and received a new order to cleanse the wound with Normal Saline, apply Xeroform and cover with [MEDICATION NAME] and Coban. The 10/12/16 physician's office visit revealed documentation of the resident's skin tear after an allergic reaction to his/her left forearm. The note indicated reactive [MEDICAL CONDITION] to the resident's left elbow, and lower forearm had improved. The note further indicated the resident was very upset about the lesion on his/her left arm, and complained of left arm pain. The 10/17/16 physician's orders [REDACTED]. to allow free passage of exudates in to a secondary dressing) to replace the Xeroform. The 10/20/16 physician order [REDACTED]. The 10/20/16 physician's visit indicated the resident's arm wound showed improvement with dressing only to the distal area of the arm. The note instructed staff to continue the same dressing, leaving the distal area open, and indicated the proximal wound was healing. The 11/2/16 at 7:08 AM, nurse's note recorded at approximately 3:02 AM, the resident's call light came on and staff found the resident seated on the floor next to his/her bed, with blood on the left forearm and hand. The note indicated the resident stated he/she had taken himself/herself to the bathroom and fell when he/she tripped on his/her shoes. The note indicated the resident stated I knew better but I sat up and saw the toilet and said to myself that is not that far away, I think I can make it. I got in there fine and when I came out I had the problem, I stepped on my shoes, and lost my balance. Staff noted skin tears to the resident's left elbow approximately 3 (cm) centimeter x 1 cm, left forearm 3 cm, left hand 2nd finger 1.5 cm V-shaped, 3rd finger 2 cm and also noted a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to the inner aspect of the left forearm. The note indicated the resident able to move his/her wrist up/down and back/forth, make a fist and wiggles his/her fingers. The note indicated staff applied ice to the area, cleansed the skin tears, and applied steri-strips applied with a protective dressing on top. The note indicated staff notified the resident's physician by fax with no physician's response to the fax. The 11/2/16 at 3:18 PM, (approximately 12 hours after the fall) nurse's note documented the resident's wrist had a purple/discolored area and appeared raised. The note indicated staff had administered Tylenol 1 tab, by mouth, per resident's request at 9:30 AM for complaint of wrist discomfort. The note indicated at 3:25 PM, staff administered Tylenol 1 tab, by mouth, for complaint of discomfort to left forearm. The 11/2/16 at 3:48 PM, nurse's notes indicated the physician instructed staff to perform neuro checks per protocol and monitor wound carefully. The 11/2/16 at 6:50 PM, nurse's note record staff sent a fax to the resident's physician regarding the resident complaining of left wrist pain and (OT) Occupational Therapy reported a large hematoma to the resident's left wrist with cold rice pack and elevation of the extremity. The note further recorded the resident requested an x-ray and the note indicated staff sent another fax to the resident's physician asking for an x-ray of the left wrist due to pain related to a recent fall. Review of the November 2016 MAR indicated [REDACTED]. The 11/3/16 at 1:04 PM, nurse's note indicated staff received a physician's orders [REDACTED]. The note further indicated at 1:52 PM, staff noted swelling and purple discoloration to his/her left inner wrist and left hand and the resident complaining of discomfort to the area. The note documented staff administered Tylenol, as ordered, at 7:30 AM. Review of the November 2016 (MAR) Medication Administration Record [REDACTED]. The note documented the resident left the facility at 2:36 PM, with transportation staff to the hospital for the x-ray. The 11/3/16 x-ray reported a fracture in three areas of the resident's left wrist. The 11/3/16 at 7:09 PM, nurse's note documented the resident returned to the facility after surgical repair of the left wrist fracture splinted and new physician's orders [REDACTED]. The 11/4/16 at 1:33 AM, nurse's notes indicated the resident had bruising to his/her left fingers/hand with splint and ace wrap intact to the resident's left arm and resident used a sling for comfort. The 11/8/16 physician visit indicated the resident's left wrist was re-splinted due to the skin tears on the resident's left lower arm were not healed enough for a cast. The 11/11/16 at 11:44 AM, nurse's note indicated the resident returned from the physician's office with a cast on his/her left forearm. The 11/28/16 at 4:10 PM, social service notes indicated a phone call at approximately 2:00 PM, from the resident's family member revealed he/she believed the initial dressing to the left arm skin tear, when the resident arrived at the facility was not removed or examined for 7 days. The family member also stated the resident had a medication error and received a topical treatment of [REDACTED]. The family member also stated when the resident fell in his/her room, the family member believed the facility did not follow proper protocol when it took 2 days for the facility to obtain an x-ray for the resident. review of the resident's medical record revealed [REDACTED]. During an interview on 12/6/16 at 12:35 PM, the resident stated when he/she fell at the other nursing home, he/she tried to tell the nurses his/her arm was broken and staff told him/her it was only bruised. The resident stated he/she complained of wrist pain right after the fall and staff gave him/her Tylenol for the pain, which did help some. The resident stated he/she was having more pain in his/her left wrist especially after it started to swell, turned black/blue and was misshapen. On 12/6/16 at 1:30 PM, Nurse Aide B stated the resident fell and broke his/her wrist when the resident got up to the bathroom, on his/her own, and was supposed to call for assistance. On 12/6/16 at 1:45 PM, Nurse C stated he/she worked the day shift, after the resident fell during the night, and was told in shift report the resident complained his/her wrist hurt but could do complete (ROM) range of motion with his/her left wrist. Nurse C stated if he/she had been working when the resident fell he/she would have put ice on the wrist and if the resident continued to complain of pain, he/she would have called the doctor's office. Nurse C stated he/she remembered the resident's wrist was obviously swollen and bruised. Nurse C further stated if a new resident admitted to the facility with a dressing intact, he/she would have removed the dressing to see what was under the dressing and then called to the physician's office to get an order for [REDACTED]. TAR. On 12/6/16 at 2:20 PM, Administrative Nurse A stated staff changed the resident's left lower arm dressing daily from his/her admitted , as Administrative Nurse A had helped changed the dressing at times and verified staff did not document the daily dressing changes. Administrative Nurse A verified the physician's orders [REDACTED]. Administrative Nurse A stated he/she would expect the nurses to remove a dressing on admission to the facility, unless the physician ordered otherwise not to remove the dressing. Administrative Nurse A stated the night nurse had informed him/her when the resident fell on [DATE], during the night shift, and the resident had full ROM in his/her wrist at the time staff assessed the resident, immediately after the fall. Administrative Nurse A stated he/she would expect the nurses to call the resident's physician or the emergency room if a resident fell and was complaining of pain in an extremity with bruising and swelling, instead of faxing the physician and waiting for a reply the next day. On 12/6/16 at 3:35 PM, Physician D stated he/she assessed the resident in the emergency room after the resident's fall. Physician D stated just by looking at the resident's wrist a person could tell it was broken. Physician D stated the resident should have been seen much sooner, as the resident was unable to move his/her fingers due to the swelling, bruising and dislocation. The 2/2016 facility's skin protection policy indicated each resident would be evaluated when the resident moved in to the facility, return from another health care facility, after a significant change in condition, quarterly and annually with MDS process for the potential of having a skin injury or breakdown. The policy indicated residents who have a potential for skin breakdown or increased breakdown will have interventions designated on the individual care plan based on needs and preferences. All nursing staff shall be responsible for the reporting of any abnormal skin conditions. The policy indicated the charge nurse would complete a skin incident form, contact the resident's responsible party and physician, initiate treatment orders, and designate action to prevent any further similar situations. The 2/2016 facility's physician notification protocol stated the physician should be informed at the time of an event of any fall with any suspected serious injury. The facility failed to document dressing changes on Resident #1's left lower forearm, until 12 days after admission to the facility and after the wound had a foul odor. The facility failed to review Resident #1's medical history for allergies and the resident developed an allergic reaction to the ointment used for the daily dressing changes to the resident's left forearm. The facility failed to obtain physician orders [REDACTED].

The facility had a census of 40 residents. The sample included 6 residents. Based on observation, interview and record review the facility failed to provide an environment to prevent accidents for 3 of 3 residents reviewed for falls. Resident #6 had 2 falls, without identification of a root cause analysis, or implementation of appropriate interventions. Resident #3 had multiple falls, related to toileting, and the facility failed to identify and implement a toileting plan specific to his/her needs. Resident #2 had 3 falls without identification of a root cause analysis, or implementation of an appropriate intervention to prevent future falls, and the resident fell and sustained a fracture of his/her hip. Findings included: - Resident #2's quarterly (MDS) Minimum Data set assessment, dated 8/25/15, indicated the resident had severe cognitive impairment with short and long term memory problems, severely impaired cognitive skills for decision making, and exhibited inattention, disorganized thinking, altered level of consciousness, and psychomotor retardation behaviors. The MDS further indicated the resident required extensive assistance from 2 staff for bed mobility, transfers and toilet use, his/her balance unsteady and only able to stabilize with staff assistance, had no (ROM) Range of Motion impairment, and used a walker and a wheelchair as an assistive device. The MDS further indicated the resident was always incontinent of urine, had no falls, and received antipsychotic and antibiotic medications. The 8/15/15 initial care plan (upon return from the hospital) instructed staff to provide assistance of 1 staff to complete (ADLs) Activities of Daily Living, to check frequently for needs, and informed staff the resident remained confused, overwhelmed, and ambulated with a cane. The 8/26/15 care plan instructed staff to encourage the resident to call for staff assistance, check for his/her needs, and to remind the resident to toilet on a prompted schedule and as needed. The care plan further instructed staff to encourage use of assistive devices, provide 1 to 2 staff assistance with ambulation, and to respond to restlessness by offering toileting, nutrition, hydration and position changes. The 10/18/15 care plan update instructed staff to provide toileting, position changes, 15 minute visual checks, assess for pain, and staff rearranged his/her room. The 10/20/15 care plan instructed staff to provide toileting, position changes, assistance with ambulation, and 15 minute visual checks. The 9/26/15 at 1:07 AM, nurse's note indicated staff found the resident sitting on the floor, with his/her legs crossed, in front of the recliner, with no apparent injuries. The 9/26/15 facility investigation indicated the resident tended to sit close to the edge of any chair, staff reminded him/her to move his/her hips back, but then moments later, the resident moved back to the edge. The investigation concluded he/she must have slipped off his/her chair, and staff possibly needed to place a piece of mat in the chair to keep him/her from sliding off. The investigation further indicated the resident required 1:1 supervision to prevent falls. The 10/8/15 at 3:23 PM, nurse's note indicated the resident was alert, confused, and disoriented, and staff used a mechanical sling lift to transfer and toilet the resident. The 10/18/15 at 2:46 AM, nurse's note indicated staff found the resident lying face down between his/her bed and the wall register, saying help me, help me. The note indicated staff asked the resident what happened, and he/she stated I tried to get up. The note indicated the resident sustained [REDACTED]. The 10/18/15 facility investigation indicated the resident attempted to get him/herself out of bed, had a steady decline, and the only way to prevent falls was to have 1:1 supervision. The investigation further indicated staff would continue 15 minute checks. The 10/21/15 at 12:44 PM, nurse's note indicated staff found the resident lying on the floor on his/her back, and the resident complained of severe left pain hip. The 10/21/15 facility investigation indicated the resident's fall out of bed was an unknown cause, and nothing would prevent the resident from falling except 1:1 supervision, due to his/her declining cognition. The 10/21/15 imaging report indicated the resident had a displaced fracture of the left femoral neck (hip). On 11/3/15 at 2:34 PM, observation revealed the resident sested in a recliner in the commons living area, on the edge of the seat. Further observation revealed no mat or device in the recliner to prevent the resident from sliding out. Continued observation revealed the resident often had a rocking motion with the appearance of trying to stand, while seated on the edge of the recliner. (staff observed to provide 15 minute checks) On 11/3/15 at 2:40 PM, Nurse Aide C stated the resident had a dramatic decline over the past few months. Nurse Aide C stated the resident used to walk by him/herself, needed very little help, and now received total care. Nurse Aide C stated the resident was sent to the hospital for foaming at the mouth, and when he/she was brought back, he/she was restless and would walk 24/7, and 1 day he/she just stopped. Nurse Aide C stated staff tries to visit with the resident when he/she scoots to the edge of the chair, and provided 15 minute checks. On 11/4/15 at 1:52 PM, Medication Aide D verified staff had moved some things out of the resident's room before his/her last fall. Medication Aide D further verified he/she had just laid the resident down when he/she fell out of bed and sustained the hip fracture. Medication Aide D stated sometimes the resident had a habit of sitting up in bed prior to his/her fall. Medication Aide D further stated the resident had a habit of talking, and he/she does not do much of that anymore. On 11/4/15 at 4:25 PM, Administrative Nurse E verified staff had not provided the resident with 1:1 supervision, and the facility does not provide 1:1 supervision for any of the residents. The facility's 12/13 Fall Management policy instructed staff the interdisciplinary team will review the fall occurrences at the weekly risk management meeting to determine possible causes of the resident's falls. The facility failed to evaluate root cause analysis and provide timely and effective interventions to prevent falls, and Resident #2 had a fall from his/her bed, and sustained a fractured hip. - Resident #6's annual (MDS) Minimum Data set assessment, dated 7/14/15, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 2, displayed disorganized thinking behaviors, required extensive assistance from 1 staff for dressing, toilet use and personal hygiene, and required limited assistance from 1 staff for bed mobility and transfers. The MDS indicated the resident's balance not steady, only able to stabilize with staff assistance, used a walker, was frequently incontinent bladder, had no falls, and received a diuretic medication. The 7/14/15 fall (CAA) informed staff the resident had a potential for falls related to his/her dementia and the need for assistance from staff. The 7/27/15 care plan informed staff the resident had a potential for falls related to a history of falls. The care plan instructed staff to encourage activities in the commons area, provide a partial rail to the bed to aide in mobility, keep the walker within reach, ambulate with a 4 wheeled walker, and provide frequent visual checks. The 9/16/15 at 8:10 AM, nurse's note indicated, at 10:15 PM, staff found the resident lying on his/her right side, with the walker tipped, and blood on the floor. The note indicated staff found a skin tear to the resident's thumb and a laceration on his/her chin. The note further indicated the resident was awake most of the night and watched television in the commons area of the facility. The 9/16/15 facility investigation indicated the resident attempted to get up on his/her own, and had both of his/her legs in the same pant leg. The investigation concluded the resident had increased confusion and altered thought process and needed to be observed constantly by staff. The investigation further indicated staff would offer toileting and to encourage the resident to visit in the commons area. The 9/21/15 at 7:43 AM, nurse's note indicated staff heard a noise and found the resident sitting on the floor beside his/her bed. The note indicted the resident had blood dripping from his/her ear onto his/her arm, and the resident went to the emergency room and received 11 sutures to his/her ear. The 9/21/15 facility investigation indicated the resident did not use his/her call light, got up unassisted, fell and hit his/her ear due to increased confusion, forgetfulness, and restlessness. The investigation indicated the resident needed 1:1 supervision, and to continue 15 minute visual checks, keep his/her bed in low position, and to offer toileting. The 9/21/15 hospital discharge instructions indicated the resident was treated for [REDACTED]. On 11/4/15 at 11:13 AM, observation revealed the resident seated in a recliner in the commons area of the facility, with his/her eyes closed. Further observation revealed the resident opened his/her eyes, and scooted to the edge of the recliner, and staff immediately assisted him/her to the wheelchair. The resident then independently propeled him/herself throughout the facility. On 11/3/15 at 4:25 PM, Nurse F verified staff watch for the resident's agitation level, and administer medications as needed. Nurse F further stated sometimes he/she will focus on just propelling around the facility. On 11/4/15 at 12:18 PM, Nurse A verified staff provide frequent checks on the resident, and he/she has anti tip brakes in case he/she self-transfers. On 11/4/15 at 4:25 PM, Administrative Nurse E verified staff had not provided 1:1 supervision to the resident and was not an appropriate or feasible intervention. The facility's 12/13 Fall Management policy instructed staff the interdisciplinary team will review the fall occurrences at the weekly risk management meeting to determine possible causes of the resident's falls. The facility failed to provide a thorough investigation and identify root cause analysis of Resident #6's falls and provide appropriate interventions. - Resident #3's admission (MDS) Minimum Data set assessment, dated 5/20/15, indicated the resident had moderate cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 9, had an altered level of consciousness, behaviors, and required limited assistance from 1 staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS further indicated the resident's balance was not steady, but was able to stabilize without staff assistance, used a walker and a wheelchair, occasionally incontinent of bladder, had no falls, and received anticoagulant and diuretic medications. The 5/20/15 fall (CAA) Care Area Assessment indicated the resident had a potential for falls related to back pain and dementia. The 5/14/15 initial care plan instructed staff to provide 1 staff assistance for transfers, and lacked any direction to staff for fall prevention. The 5/25/15 comprehensive care plan instructed staff to provide a 4 wheeled walker with 1 staff assistance, and proper fitting shoes with non-skid soles. The 6/5/15 care plan update instructed staff to provide frequent visual checks. The 5/21/15 at 1:02 PM, nurse's note indicated staff found the resident lying on the floor on his/her right side, and he/she reported pain his/her buttocks. The note further indicated the resident heard the phone ringing and he/she attempted to get out of bed independently without staff assistance, lost his/her balance, fell backwards, and sustained a 3 inch goose egg (large egg shaped bump) to the back of his/her head. The 5/21/15 facility investigation indicated the resident ambulated without calling for assistance, and the facility provided the resident multiple lessons with use of the call light. The 5/25/15 1:43 AM, nurse's note staff found the resident lying on his/her right side in the doorway of the bathroom. The note further indicated the resident had utilized the call light before he/she got without assistance. The 5/25/15 facility investigation indicated staff observed the resident's call light up, but completed a medication pass before assisting the resident, and staff were to encourage the resident to wait for staff assistance. The 6/5/15 at 12:49 PM, nurse's note indicated staff found the resident lying on the bathroom floor, and the resident had self-toileted without calling for assistance. The 6/5/15 facility investigation indicated the resident toileted him/herself during self performed personal care, the resident lost his/her balance, and lowered him/herself to the floor. The investigation indicated staff educated the resident to call for assistance, and the resident was placed on 15 minute checks. The 6/27/15 at 2:52 AM, nurse's note indicated staff found the resident on the floor leaning to his/her left side. The note further indicated the resident had been incontinent of urine, and staff assisted the resident with incontinent cares. The 6/27/15 facility investigation indicated the resident was on an antibiotic for a (UTI) Urinary Tract Infection, and fell because he/she needed to use the restroom. The investigation further indicated the resident required 1:1 supervision to prevent falls, and continued 15 minute checks. The 7/5/15 at 11:48 PM, nurse's note indicated at 9:10 PM, staff found the resident lying on his/her side in front of the closet, and had sustained no injuries. The 7/5/15 facility investigation indicated the resident had a thing about spending time in his/her closet, and found lying in front of the closet door, so was assumed he/she wanted a change of clothing. The investigation indicated staff needed to sit with him/her 24/7, toilet the resident, and to continue 15 minute checks. The 9/11/15 (ER) emergency room record indicated the resident received staples to his/her head laceration, and instructed staff to keep it clean and dry. The 7/13/15 at 3:02 PM, nurse's note indicated staff found the resident on the floor at 6:29 AM, and stated he/she was looking for his/her parents. The 7/13/15 facility investigation indicated staff had taken the resident to the bathroom at 6:00 AM, and the resident had confusion. The investigation indicated staff continued the 15 minute checks. The 8/6/15 at 3:35 AM, nurse's note indicated staff found the resident sitting on the floor in front of the recliner. The note indicated the resident stated 2 different scenarios about the fall, and the resident sustained [REDACTED]. The 8/6/15 facility investigation indicated the resident attempted to get up, was very independent and needed constant supervision. The investigation further indicated staff should continue to offer assistance and provide 15 minute checks. The 9/11/15 at 4:45 PM, nurse's note indicated at 11:10 AM, staff found the resident lying on his/her right side on the bathroom floor, in a pool of blood. The note indicated staff called an ambulance and held pressure at the cranial site where the injury extruded from, and the resident was taken to the emergency room for evaluation and treatment. The 9/11/15 facility investigation indicated the resident ambulated independently, and frequently had confusion, disorientation. The investigation indicated staff continue 15 minute checks, ask the resident for needs with checks, and encourage resident to call for assistance. On 9/12/15 at 5:34 PM, nurse's note indicated at approximately 11:20 AM, staff found the resident lying on the floor in the hall on his/her left side. The note indicated the resident stated he/she was looking for a bathroom, staff assisted the resident to the bathroom, and he/she had a bowel movement. The 9/12/15 facility investigation indicated the resident ambulated into the hall and fell on his/her left side, had confusion, and was looking for a bathroom. The investigation indicated staff should prompt toileting every 2 hours, and to continue 15 minute checks. The 9/18/15 at 1:13 AM, nurse's note indicated staff found the resident on the floor in the hallway without any injury. The 9/18/15 facility investigation indicated the resident ambulated to the hall and fell on his/her left side, and stated he/she wanted to be with other people. The investigation indicated the resident needed 24/7 supervision, and staff placed a silent pad alarm under the resident. The medical record revealed a 3 day bowel and bladder voiding pattern was started on 9/17/15, and completed on 9/19/15. (after 5 falls) On 11/3/15 at 2:13 PM, observation revealed the resident seated in his/her recliner, call light within reach, and a pad alarm in the chair. On 11/3/15 at 4:25 PM, Nurse F verified the resident had a pad alarm to notify staff over the pager system when he/she gets up, used a sit to stand lift, staff peek in quickly, and encourage use of the call light. On 11/4/15 at 1:52 AM, Medication Aide D verified staff try to toilet the resident every 2 hours, but sometimes he/she does not have to go. On 11/4/15 at 4:25 PM, Administrative Nurse E verified 1:1 supervision was not provided to the resident and was not an appropriate or feasible intervention. Administrative Nurse E further verified the facility had not done a bowel and bladder pattern until 9/17/15 even though the resident had multiple falls related to toileting. The facility's 12/13 Fall Management policy instructed staff the interdisciplinary team will review the fall occurrences at the weekly risk management meeting to determine possible causes of the resident's falls. The facility failed to identify Resident #3's root cause of his/her multiple falls related to toileting, and the resident continued to fall.

The facility had a census of 58 residents. The sample included 14 residents, which included 1 reviewed for pressure ulcers. Based on observation, interview and record review the facility failed to provide care and services to prevent the development of pressure ulcers for 1 of 1 residents reviewed for pressure ulcers. (#26) Findings included: - Resident #26's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 5/22/13, indicated the resident had intact cognition and independence with bed mobility, transfers, dressing, required limited assistance with hygiene and supervision with toileting, eating and locomotion. The MDS indicated the resident weighed 118 pounds, received a therapeutic diet, not at risk for pressure ulcers and had pressure relieving devices used on his/her chair and bed. The 8/19/13 significant change MDS indicated the same except the resident now had moderately impaired cognition and required extensive staff assistance with bed mobility, transfers, dressing, hygiene and total assist with toileting. The MDS also indicated the resident was now at risk for pressure ulcers, had 1 Stage 2 pressure ulcer (started 8/16/13), and treatment included a pressure relief device to the chair and bed, repositioning, ulcer care, and dressings. The 11/7/13 MDS indicated the resident cognitively intact, required extensive assistance with (ADLs) Activities of Daily Living, except independent with eating and locomotion. The MDS indicated the resident had 1 stage 2 unhealed ulcer, treatment now also included nutrition. The 8/19/13 (CAAs) Care Area Assessment summary stated the resident had a blister area on his/her left heel and had the potential for pressure areas related to decreased mobility. The 5/28/13 care plan directed the staff to provide a regular diet as ordered, report to the physician if the resident had any weight or appetite changes, offer the resident snacks in the afternoon, and weigh him/her weekly. The care plan lacked interventions for skin assessment or prevention of skin issues. The care plan update directed the staff to assist the resident in putting the bed rail up and making sure it was secure. The 8/16/13 update directed the staff to float the resident's left heel, ensure the resident wore no shoe on his/her left foot and wrap the resident's left heel loosely with Kerlix (a type of bandage wrap). The 8/19/13 care plan directed the staff to encourage, remind and assist the resident with position changes, keep pressure off his/her left heel, use an off-loading boot to left leg, wrap the left heel loosely with Kerlix and when the blister opens wash with [MEDICATION NAME] (a wound cleanser) 2 times per day, apply antibiotic ointment and gauze. The 8/8/13 at 11:42 PM, facsimile indicated the resident fell in his/her room and reported he/she was in the process of getting into bed and when he/she grabbed the bed rail it went down causing the resident to lose his/her balance. The note indicated the resident had mildly reddened skin at the lower back, but no other apparent injuries. The physician ordered the staff to ensure the resident did not bear weight on his/her left leg and to obtain an x-ray of the resident's left hip in 1 week to compare to previous x-rays. The 8/9/13 Radiology report of the resident's left hip x-ray indicated deformity of the inferior pubic ramus (bone in the pelvic area) likely on the basis of a non-displaced fracture. Also minimal displaced [MEDICAL CONDITION] (thigh bone) extending to the hip. Review of the nurse's notes revealed the resident complained of left foot/heel pain on 8/11/13 at 11:55 AM. The note indicated the nurse noted no bruising or redness. The 8/14/13 radiology report indicated a comparison made with prior x-rays indicated post-surgical changes of the left hip, stable non-healed fracture of left femoral fracture and interior left pubic fracture. The 8/16/13 at 9:30 PM nurse's note indicated the staff noted a blister on the resident's left heel, purplish/white, blanched area, surrounded by reddened skin and warm to the touch. The note indicated the blister measured 6 (cm) centimeters by 4.5 cm and the surrounding area reddened from the arch of the foot up the resident's heel to his/her lower ankle, a length of 12.5 (cm) centimeters. The 8/16/13 physician's orders [REDACTED]. (1) Protect and keep pressure off left heel, float heel. (2) Wrap left heel loosely with Kerlix. (3)[MEDICATION NAME](antibiotic), 250 (mg) milligrams by mouth twice daily for 7 days for [MEDICAL CONDITION] (infection of the skin). (4) When the blister becomes open, wash with [MEDICATION NAME] and water, apply antibiotic ointment and gauze dressing. The 8/19/13 (APRN) Advanced Practice Registered Nurse visit note indicated the resident had a large symmetrical blister over the calcareous (heel bone) on the heel of the left foot with areas of dark purple in color and definitely blistered. The 8/19/13 physician's orders [REDACTED]. (2) Consult Physical Therapy for evaluation of the wound and ideas on keeping pressure off. (3) Call the physician if the blister opens or starts draining. The 8/20/13 Nutritional Assessment by the (RD) Registered Dietician indicated the resident weighed 112 pounds, the resident at nutritional risk and recommended the addition of Prosource (a protein supplement) twice daily. The 8/21/13 physician's orders [REDACTED]. The 8/21/13 Physical Therapy assessment indicated no open areas on the wound, and it did not appear infected or "angry". The assessment stated the wound appeared to be resulted from pressure and inactivity. The assessment indicated a recommendation for the left heel to be non-weight bearing at rest, keep the heel supported by pillows. The 8/26/13 at 9:30 AM, nurse's note indicated staff continue to elevate the resident's left leg and the resident wore a pressure reducing boot on his/her left foot. At 11:30 AM, the nurse's note indicated the facility received a physician's orders [REDACTED]. The 9/6/13 physician's orders [REDACTED]. The 9/10/13 physician's visit note stated the blister remained intact to the resident's left heel, but drained. The note stated the resident doing well overall, but indicated the physician unsure of the current best treatment for [REDACTED]. The 9/17/13 Wound clinic note directed the staff to float the resident's heels, use a left off-loading heel boot, keep the dressing dry (may shower keeping wound out of water), cleanse the wound with (NS) normal saline, pat dry, apply vasotex, cover the wound with foam [MEDICATION NAME], secure with Kerlix gauze and tape. The note indicated the resident's heel wound measured 5.3 cm x 6.0 cm and was a stage 3 pressure ulcer. The 9/24/13 physician's orders [REDACTED]. The 10/1/13 wound clinic notes indicated the resident's left heel wound measured 2.0 cm x 2.4 cm. Treatment included debridement (surgically removal of dead tissue), silvergel/[MEDICATION NAME], foam and Kerlix. The 10/8/13 wound clinic notes indicated the resident's left heel wound measured 2.4 cm x 2.2 cm. The 10/15/13 wound clinic notes indicated the wound measured 1.7 cm x 2.2 cm and an additional wound on the lateral heel measured 0.8 cm x 0.6 cm. The physician directed the staff to allow the resident to offload heels with pillows or other device. The 10/22/13 wound clinic notes indicated the resident's heel wound measured 2.1 x 2.1 cm, and the lateral heel wound measured 0.01 cm and both wounds were debrided today. Treatment to include (1) skin barrier of choice, (2) paint with [MEDICATION NAME] swabs, (3) cover with foam, Kerlix and tape, (4) elevate left leg 30 minutes 3 times per day. (5) Dressing changes daily. (6) Keflex (antibiotic), 500 (mg) milligrams, three times daily, for 10 days. (7) Heel off-load boot. The 10/22/13 blood laboratory results indicated values of [MEDICATION NAME] (a body tissue building protein) were 3.5 (3.4-5) and total protein 6.6 (6.4-8.2). The 10/29/13 wound clinic measurements of the left heel wound were 2.2 cm x 1.8 cm and indicated the lateral wound resolved. The 11/5/13 wound clinic measurements of the left heel wound were 1.9 cm x 2.3 cm. The 11/12/13 Wound Care Clinic orders included: float heels, left off-loading heel boot, keep dressing dry - may shower keeping wound out of water. Cleanse wound with NS, pat dry, apply Santyl, cover wound with foam Adaptec, secure with Kerlix gauze and tape. Elevate left leg 30 minutes 3 x /day. Change dressing daily. The left heel stage 3 pressure ulcer wound measured 2.5 cm x 2.0 x 0.3 cm and the wound debrided today. The 11/19/13 Wound Clinic documentation left heel wound measured 2.2 cm x 1.7 cm x 0.2 cm. debrided today. On 11/19/13 at 12:20 PM, observation revealed the resident independently eating lunch. He/She was seated in a wheelchair and wore a heel off-loading boot on the left foot/ankle. On 11/20/13 at 8:03 AM, observation revealed Nurse F provided wound care to the resident's left foot pressure ulcer. Resident was able to stand and pivot with cueing and moderate assistance and wore a heel protector device on the left foot. Further observation revealed Nurse F asked the resident if he/she had any pain in his/her left foot and the resident replied it had not hurt for a long time. Nurse F stated the swelling was less than before and had a small amount of drainage on the dressing and a little slough on the outside of the wound. Nurse F stated the wound clinic had just removed the black center this week and the resident stated the wound was a little tender to touch. Observation revealed the wound was irregular shaped with granulation and slough, approximately 2 cm x 2 cm, with the surrounding skin pink. Nurse F applied Santyl ointment to the wound bed, then applied foam dressing over the heel, then wrapped loosely with Kerlix. Nurse F placed the protective boot with sheepskin on the resident's left ankle/foot. Nurse F stated the facility placed the air mattress about the time the resident got the pressure ulcer on his/her heel and the resident visited the wound clinic every Tuesday. On 11/19/13 at 1:00 PM, Nurse Aide G stated the resident slept a lot after his/her [MEDICAL CONDITION] and was in a lot of pain. He/She stated staff placed pillows under the resident's legs, provided education, cues, and reminders to the resident to reposition. On 11/20/13 at 4:25 PM, Administrative Nurse A stated the resident did not complain of pain in his/her heel until after she had been to a wedding for 4 hours on 8/10/13. Nurse A stated the staff had placed a footrest on the resident's wheelchair after the 8/8/13 fracture and stated a new air mattress had been placed on the resident's bed approximately 8/23/13. Administrative Nurse A stated the pressure ulcer preventive measures were not listed on the care plan between 8/8/13 (when the resident sustained [REDACTED]. On 11/21/13 at 9:15 AM, Maintenance Staff E stated he/she had no documentation of when the resident's mattress was changed to pressure relieving from a normal foam mattress. On 11/21/13 at 9:25 AM, the resident stated he/she normally wore very comfortable shoes, but for the wedding on 8/10/13, he/she wore dress shoes. The resident stated the shoes did not hurt his/her feet and he/she removed them right away when he/she returned to the facility. On 11/21/13 at 10:06 AM, Nurse F stated the resident had a regular mattress and the staff did not change the mattress or initiate other interventions the day the resident sustained [REDACTED]. Nurse F stated the 8/17/13 nursing notes stated the resident's heels were floated, but nothing was written in the nurse's notes regarding the staff floating the resident's heels between 8/9/13 and 8/17/13. He/She verified the interventions should be on the care plan. Nurse F stated when the resident's heel blister appeared, the physician started him/her [MEDICATION NAME] 10 days for [MEDICAL CONDITION] on 8/16/13, but 3 days later the physician indicated he/she was unsure of the cause of the blister and ordered the heel boot on 8/19/13. On 11/21/13 at 10:00 AM, Physical Therapy Staff H stated the resident moved his/her legs around a lot and "scootched around in bed" and was more confused at that time. On 11/21/13 at 12:40 PM, Medical Practitioner J stated the resident was not very mobile after the fractures and he/she wanted the staff to encourage the resident not to be as active. The facility's 10/2013 Pressure Ulcer Prevention and Management policy stated the policy of this community is that all residents are considered to have some risk for the development of pressure ulcers. A skin assessment will also be conducted at admission and the time a change in the resident's condition is noted. After conducting an inspection of the resident's skin, the nurse will review the care area assessment for pressure ulcers to identify risk factors for the development of pressure ulcers. An immediate plan to reduce a resident's risk of pressure ulcers or to treat an existing pressure ulcer will be developed and implemented. A comprehensive prevention plan must be initiated for all residents who have intact skin and are at risk for developing and/or who already have a pressure ulcer. The comprehensive prevention program includes (1) risk assessment tools. (2) support surface (standard foam mattress are not appropriate for any one with limited mobility and are at risk.) (3) skin care protocols. (4) repositioning schedule. (5) nutritional support. Note - pressure on heels need measures to elevate the heels. Dietary consult requested. Increase protein, Vitamin C 500 mg daily and zinc 220 mg, MVI daily for all stages of pressure ulcers. Ulcer monitoring performed daily independent of the dressing changes. The facility failed to provide care and services to prevent the development of a pressure ulcer for Resident #26, who experienced a decline in mobility due to a fracture in the pelvic area and developed a stage 3 pressure ulcer on his/her left heel, which required care and debridement from a wound clinic, and also developed an open area on the coccyx.

The facility had a census of 58 residents. The sample included 14 residents, of which 3 were reviewed for accidents. Based on observation, interview and record review the facility failed to provide adequate supervision and an environment free of accident hazards to prevent accidents with injury for 1 of 3 sampled residents. (#15) (#39) Findings included: - Resident #15's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 7/2/13, indicated the resident had adequate vision with glasses, severely impaired cognition, and required extensive staff assistance with bed mobility, locomotion, dressing, and total assistance with transfers and toileting. The MDS indicated the resident's balance unsteady, he/she had (ROM) Range of Motion impairment in both legs, used a wheelchair and had no falls. The 9/26/13 quarterly MDS indicated the same except the resident had 1 non-injury fall and 1 minor injury fall. The 7/17/13 care plan directed the staff to use the sit to stand lift for transfers, offer the resident choices, and ensure the call light within his/her reach. The 9/30/13 care plan review summary stated the staff used a mechanical lift for transfers and the resident needed 2 staff assistance with brief standing. The summary indicated the resident very independent and wants to do things for him/herself but will call for assistance with toileting. The 10/1/13 care plan indicated the resident had 2 episodes of falls and the resident rarely attempted to stand on his/her own. The care plan indicated the resident self- propelled his/her wheelchair and the staff were to assist when needed, ensure the call light within reach, use a sling lift for transfers and a commode for toileting. The facility Investigation indicated the staff found the resident, on 9/18/13 at 4:25 AM, on the floor between the bed and the wall mounted heat register, with his/her knees on a pillow and the bed covers under him/her. The resident had a 3 cm x 1.5 cm hematoma to his/her right knee and a 1.5 cm by 0.5 cm hematoma to the back of his/her right elbow. The report indicated the resident stated he/she rolled off the side of the bed and landed on the floor. The investigation report indicated the facility's action/care plan revision directed the staff to move the resident's bed closer to the wall. The 9/26/13 at 11:30 AM, nurse's note for the MDS assessment indicated the resident had severe cognitive impairment and was alert with some daily confusion. The facility investigation stated on 9/26/13 at 2:40 PM, the nurse was walking past the resident's room and saw the lift chair rising to the highest level. The nurse stated before he/she could get to the resident, the resident slid out of the chair and landed on his/her buttocks on the gel cushion and blanket. The facility's investigation indicated the chair control had gotten wedged between the foot rest and the frame of the chair in the rising position. No apparent injuries were noted and the investigation indicated the resident had increased confusion related to a urinary tract infection. The facility's plan of action/care plan revision directed the staff to monitor the resident frequently when in the recliner to ensure the chair controller is in the pouch on the outer side of the recliner. The 11/8/13 at 4:58 PM, nurse's note indicated the staff responded to the call light and the resident calling for help at 1:40 PM. The note indicated the resident was on the floor, with blood on his/her forehead and anterior shins. The note indicated the resident remained alert, talking, and complained of pain with movement. The 11/8/13 facility investigation indicated the resident had been in his/her electric recliner at 1:40 PM, the recliner "button" did not shut off and the resident slid onto the floor. The report indicated the resident received a skin tear and hematoma to the forehead, skin tear to the right hand and he/she had severe pain. The report indicated the staff notified the physician and sent the resident, via ambulance, to the emergency room , where the physician diagnosed tibia and fibula fractures on the resident. The investigation concluded the electric chair controls were improperly handled and the resident had no comprehension of the chair's functioning. The note indicated the facility changed the recliner. Review of the nurse's notes between 9/26/13 and 11/8/13 revealed no indication the staff educated the resident about the use of the recliner controls. On 11/19/13 at 12:55 PM, observation revealed the resident, seated in a wheelchair in his/her room, with the call light in his/her lap and glasses on. Further observation revealed the resident had a bruise on his/her right forehead with 2-3 sutures, a small open area on the back of his/her right hand, thigh to ankle soft brace on his/her left leg, a yellow foam boot on the left foot and an ace wrap below his/her right knee. Observation revealed the recliner in the room was not electric. On 11/20/13 at 7:12 AM, observation revealed the resident in bed with 1/4 bed rails up on both sides. Further observation revealed the head of the bed was approximately 1 foot away from the wall, the foot of the bed was approximately 2 feet away from the wall and the bed was not lower than average height, approximately 2-3 feet from the floor. On 11/20/13 at 9:31 AM, Nurse C stated the risk team discussed the resident's fall on 9/26/13. He/she stated the resident had been using the controls to move the foot rest up or down for his/her comfort. Nurse C stated the electric recliner controls put the foot rest down first then the seat of the chair starts rising. On 11/20/13 at 10:01 AM, Administrative Staff A stated the staff educated the resident to put the control back into the pocket on the side of the recliner, although the resident had severe cognitive impairment He/She stated the recliner was the resident's and as such they could not take it away from him/her and could not disable the electronics or the footrest would not work. He/She stated the recliner was removed after the resident's fall on 11/8/13 because it had blood on it. Administrative Staff A stated the resident is currently using a non-electric recliner, but stated the staff will put the resident's recliner back in his/her room, because it belongs to him/her. He/She stated the facility had not developed directions for the staff to ensure the resident's chair control was in its proper place and not in the seat of the chair. Administrative Staff A stated the facility maintenance staff were in the process of adjusting the other electric recliners in the facility so the cord would not be long enough to get caught down in the chair. On 11/20/13 at 12:46 PM, Nurse Aide D stated the resident had a pocket on the side of his/her recliner, but liked to have the chair control beside him/her in the chair. Nurse Aide D stated the resident would take the control back out of the pocket after staff placed it there. On 11/20/13 at 12:55 PM, Nurse B stated the staff tried to put the remote in the pocket of the recliner, but the resident was able to get it out by himself/herself. On 11/21/13 at 7:35 AM, Administrative Staff A stated the facility had not reported the fall of 9/18/13 due to the resident being able to tell them what happened. On 11/26/13 at 1:45 PM, Physician Q stated he/she was unsure if the resident's cognition level was sufficient enough for him/her to understand the use of the controls for the electric recliner. The facility's 9/2013 Fall Management policy stated the facility would systematically assess, develop and evaluate care plan interventions to mitigate potential harm. Post fall the charge nurse will complete the unusual occurrence report within 24 hours, update the plan of care, notify the physician and resident's representative, and notify the (DON) Director of Nursing and the administrator, of falls resulting in serious harm or injury. The facility lacked a policy for assessment of the resident for the use of electric recliners. The facility failed to ensure Resident #15's electric recliner was not an accident hazard and the resident experienced another fall with injuries from the electric recliner. The facility failed to provide feasible interventions after the resident rolled out of bed and sustained injuries. - Resident #39's admission (MDS) Minimum Data Set 3.0 assessment, dated 8/15/2013, indicated the resident had severely impaired cognition and required extensive assistance on staff with his/her activities of daily living. Continued review revealed the resident had a history of [REDACTED]. The 9/19/2013 and the 10/28/2013 care plan directed the staff to transfer and ambulate the resident with 1-2 staff assistance, and if the resident is unable to stand use the sit to stand lift and assist with transfers. Continued care plan review indicated the resident was a high fall risk and did not understand the need to gain his/her balance before ambulation. The care plan directed the staff to monitor the resident for incontinence every two hours and monitor skin integrity for impairment or breakdown. The 9/14/2013 at 11:15 AM, nurse's notes indicated the staff heard the resident talking in his/her room. The nurse found the resident on the floor near the TV stand and his/her forehead resting on the bench cushion of the window seat. Upon examination, the resident had 3 abrasions on the mid back, 1 open skin tear to the left elbow measuring 4.3 (cm) centimeters x 5.0 cm and a bruise on his/her lower back. The resident was transferred to the emergency room for further care. The 10/06/2013 at 7:30 AM, nurse's notes indicated staff found the resident lying on the floor on his/her right side near the TV stand and window bench with a blanket under his/her head. The nurse's notes revealed the resident had a reddened area to the left mid-back on his/her left side. The resident stated " he/she was going fishing and fell and hit his/her head." The 10/08/2013 at 8:00 AM, nurse's notes indicated the resident had left side and back pain that had increased since a fall on 10/06/2013. The resident presented to the emergency room complaining of pain with movement and deep breathing, and mildly confused. The resident was admitted to the hospital for pain control for fractured ribs and evaluation. The 10/17/2013 untimed nurse's notes indicated the nurse aide heard the resident close his/her door and the nurse aide opened his/her door and turned around and the resident had a fall. No injury except a small scrape to his/her right knee. The 11/04/2013 nurse's notes indicated the resident fell last night and complained of left arm and hip pain and would not roll onto his/her back to assess range of motion. The ambulance transferred the resident to the hospital. The resident was evaluated and did not have any fractures. The 11/15/2013 at 4:12 PM, nurse's notes indicated at 2:45 PM, staff observed the resident laying on his/her left side. The resident was assisted to the wheelchair with 3 staff and was incontinent of bowel. The resident stated he/she was trying to straighten things up. No injuries noted. , The September 2013 facility fall management policy stated the facility would systematically assess, develop and evaluate residents care plan interventions to mitigate potential harm. The policy indicated a fall is defined as " an unexpected descent from a " standing, sitting, or horizontal position " . The fall investigation unusual occurrence investigation report would be completed within 24 hours by the charge nurse. Unusual occurrences are reviewed with the Interdisciplinary team at daily stand up and/or weekly risk management meeting. The Quality Assurance nurse would oversee individual resident fall statistics. Falls would be logged to determine individual and facility trends. Summary of unusual occurrence reports are reviewed by QA meetings. Referrals may also be made to pharmacist, therapy and/or physicians ' for further review. The charge nurse would complete unusual occurrence report, update the care plan as appropriate, notify the physician and resident ' s representative, notify the Director of Nursing and Administrator foe falls resulting in serious harm or injury, and alert staff through change of shift report. On 11/19/2013 at 4:30 PM, observation revealed Nurse Aide N and Nurse Aide O transferred the resident from his/her recliner, with a gait belt and walker, to the wheelchair and transferred to the toilet. On 11/20/2013 at 8:05 AM, observation revealed Nurse Aide L and Nurse Aide P assisted the resident with morning activities of daily living, assisting the resident to dress, and then transferred the resident from the side of his/her bed to the toilet using a sit to stand lift. On 11/21/2013 at 10:05 AM, Nurse A stated the resident had two un-witnessed falls in his/her room with injury and/or hospitalization and staff had not completed a thorough investigation of the fall, including witness statements documenting the resident's fall. The facility failed to provide supervision and assistance for Resident #39 when left unattended in his/her room.