Every finding on record at Pine Creek Manor Skilled Nursing & Rehab Center

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 04/28/2026 at 8:50 AM an interview with Dietary Manager (DM) E regarding date marking found a receive date and open date should be marked on food items.On 04/28/2026 at 8:52 AM observed cut carrots wrapped in plastic with a facility marked date of 4/15 in the two-door refrigerator located in the dry storage room. Further observation found chopped carrots wrapped in plastic with a number four written on the outside. DM E discarded the items.On 04/28/2026 at 8:54 AM observed two containers of sliced tomatoes in plastic packages with no facility marked date. An interview at this time with DM E found they did not see a date and indicated they are supposed to be labeled. DM E discarded the items.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.On 04/28/2026 at 8:55 AM an interview with DM E found they clean the inside of the refrigerators themselves at least once a week.On 04/28/2026 at 8:59 AM observed dried yellow residue in the bottom interior surface of the refrigerator under the bottom rack in the one door reach in refrigerator. An interview at this time with DM E found they clean refrigerators mostly on Mondays and there are daily checks.On 04/28/2026 at 9:29 AM observed metal shavings accumulated next to the blade of the can opener. DM E acknowledged the metal shavings in the can opener and indicated they would run it through the dishwasher.On 04/28/2026 at 9:55 AM an interview with DM E found maintenance handles the cleaning of the ice machine and ice scoop holder. Upon observation, the ice scoop holder contained a pool of water with brown debris floating at the bottom. DM E acknowledged the water and removed the holder to be cleaned.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 04/28/2026 at 9:31 AM observed a spatula stored in the utensil drawer with brown stained discoloration on one side and gouges indicating deterioration along the base with sections of rubber removed. DM E discarded the item.According to the 2022 FDA Food Code section 4-202.11 Food-Contact Surfaces, (A) Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; Pf (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; Pf.On 04/28/2026 at 11:54 AM observed three cracked and broken tiles near the floor drain adjacent to the dishwasher in the kitchen. The tiles were loose and able to shift when touched creating an uneven surface.According to the 2022 Food Code, section 6-201.11 Floors, Walls, and Ceilings, Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE.On 04/28/2026 at 12:31 PM observed [NAME] F on the tray line plating potato wedges with a gloved hand. [NAME] F was then observed opening a door and opening the one compartment reach in refrigerator before returning to the tray line and using both hands to break apart rolls and using the right hand to plate fries, all while still wearing the original pair of gloves.According to 6the 2022 Food Code, section 3-304.15 Gloves, Use Limitation, (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.P.

Based on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include:On 04/28/2026 at 10:20 AM observed a hand sink with an inoperable hot water faucet in the laundry washing room. An interview with Laundry Aid (LA) H at this time found staff do not use the sink, and it has no warm water. On 04/28/2026 at 10:24 AM observed a utility sink located next to the hand sink in the laundry washing room with linens piled inside the basin. An interview with LA H at this time found the sink is not used, and the basin is used to store rags. Further observation found the sink had no drain line, and water was observed discharging directly onto the floor when turned on.On 04/28/2026 at 11:04 AM observed a shallow pool of cloudy water in the bowl of the hopper in the soiled utility room. A black, grey residue was observed on the interior and around the rim of the bowl. The flush apparatus was observed off.On 04/28/2026 at 11:07 AM observed discolored brown water discharging from the two compartment utility sink in the soiled utility room for a few seconds before running clear.On 04/28/2026 at 1:25 PM an interview with Maintenance and Housekeeping Supervisor (MHS) G was conducted regarding water management. When asked if they are involved in water management MHS G indicated yes. When asked about control measures taken, MHS G stated they flush toilets once a week, flush faucets twice a week, and flush the boilers once a week. When asked about utility sinks and shower rooms, MHS G indicated they flush those as well.On 04/28/2026 beginning at 1:29 PM a tour was conducted with MHS G.On 04/28/2026 at 1:29 PM observed a hand sink with an inoperable hot water faucet in the laundry washing room. MHS G indicated they would have to change the cartridge.On 04/28/2026 at 1:29 PM observed a utility sink located next to the hand sink in the laundry washing room. When the lack of a drain line was pointed out, MHS G indicated they would get it repaired.On 04/28/2026 at 1:31 PM an interview with MHS G found they send samples in for legionella but have not yet done it this year. When asked if chlorine is monitored, MHS G indicated no.On 04/28/2026 at 1:34 PM an interview with MHS G regarding the water management team found it includes the Nursing Home Administrator (NHA), the previous Director of Nursing (DON) and Maintenance. When asked how often the team meets, MHS G indicated once a month. When asked if there was an annual review, MHS G indicated they meet during the monthly meetings. On 04/28/2026 at 1:50 PM observed the hot water handle missing from the mop sink in the soiled utility room. MHS G indicated they were unaware the hot water faucet was inoperable. Further observation of the room found the hopper flush apparatus off at the fixture. During an interview at this time, MHS G stated they had turned it off and had not turned it back on. On 04/28/2026 at 1:53 PM observed the two compartment sink in the soiled utility room. In an interview at this time when asked if the faucet is flushed MHS G indicated they flush it weekly. When informed discolored water was observed coming from faucet MHS G stated the sink is not used frequently and the water line contains galvanized piping.On 04/28/2026 at 2:00 PM observed a spray hose on the wall next to the hand sink in the south shower room. An interview with MHS G at this time found the staff do not use the spray hose. When asked if MHS G flushed the hose, MHS G indicated yes. On 04/28/2026 at 2:41 PM an interview with Nursing Home Administrator (NHA) who also serves as the Director of Nursing was conducted regarding water management. When asked about team members, NHA indicated maintenance takes care of water management. When asked if there was an annual review, NHA indicated it was a part of the emergency book they reviewed in January.On 04/28/2026 at 2:50 PM an interview was conducted with MHS G. When asked about certain fixtures throughout the facility missing from the flushing log, MHS G indicated they are still being flushed, and that they should add them to the log.Record review of the facility provided document titled Healthcare Facility Water Management Program Checklist dated 11/17/2021 includes Identify areas where biofilms may be present and areas where opportunistic pathogens of premise plumbing may grow and spread. Listed items include, Identify areas of stagnation (dead legs, vacant units/rooms, ect.). Identify areas with no residual disinfectant. Identify areas of commodes and hoppers. The program includes checklists for setting control limits for control measures, Set control limits for control measures that will be monitored. The water management program does not include identified areas where Legionella could grow and spread, or a description of control limits set for control measures in place.Record review of the facility provided document titled Water Management Program dated 11/1/2022 states, A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. The program indicates a risk assessment will be completed and states Based on risk assessment, control points will be identified. The list of identified points shall be kept in the water management program binder. The program also includes verbiage regarding the team, The effectiveness of the water management program shall be evaluated no less than annually.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of the premises as well as proper storage of clean and sanitary supplies. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 04/28/2026 at 9:44 AM observed a mop sink in the soiled linen room with the hot water faucet missing. When the cold water faucet was turned on, water was observed leaking from the vacuum breaker.On 04/28/2026 at 9:49 AM observed the two-compartment utility sink in the soiled linen room with a chemical pre-dispensing system in place and the faucet left on. This set up puts undue back pressure on the faucet's internal atmospheric vacuum breaker (AVB), which can compromise the integrity of the mechanism.On 04/28/2026 at 10:00 AM observed the outdoor waste receptacle in an enclosure with debris scattered around the unit, including matted cardboard and leaves accumulated behind it. The side sliding door of the receptacle was open, and flies were observed entering and exiting the waste receptacle. Further observation found rolling chairs, plastic bags, and other debris outside of the enclosure along the concrete wall.On 04/28/2026 at 10:20 AM observed a hand sink with an inoperable hot water faucet in the laundry washing room. An interview with Laundry Aid (LA) H at this time found staff do not use the sink, and it has no warm water. LA H indicated when they need to wash their hands they go outside of the room.On 04/28/2026 at 10:24 AM observed a utility sink located next to the hand sink in the laundry washing room with linens piled inside the basin. An interview with LA H at this time found the sink is not used, and the basin is used to store rags. Further observation found no drain line from the basin, and water was observed discharging directly onto the floor when turned on.On 04/28/2026 beginning at 10:55 AM an individual tour of the facility was conducted.On 04/28/2026 at 10:56 AM observed the shower bed with a sticky orange substance and black particulates beneath the mat in the north shower room. Further observation found yellow and brown discolored water pooled beneath the shower bed within the collection mat.On 04/28/2026 at 10:59 AM observed brown dried residue on the back side of the shower room chair within the netted material in the north shower room.On 04/28/2026 at 11:04 AM observed a shallow pool of cloudy water in the bowl of the hopper in the soiled utility room. A black, grey residue was observed on the interior and around the rim of the bowl.On 04/28/2026 at 11:10 AM observed several floor tiles missing and the mastic exposed in the soiled utility room between the hopper and mop sink.On 04/28/2026 at 11:15 AM observed the kick plate of the bathroom door peeling from the door in resident room [ROOM NUMBER].On 04/28/2026 at 11:15 AM observed a portion of tiles missing along the perimeter at the floor wall junction above the floor molding in the bathroom of resident room [ROOM NUMBER].On 04/28/2026 beginning at 1:29 PM a tour was conducted with Maintenance and Housekeeping Supervisor (MHS) G.On 04/28/2026 at 1:29 PM observed a hand sink with an inoperable hot water faucet in the laundry washing room. MHS G indicated they would have to change the cartridge.On 04/28/2026 at 1:44 PM an interview with MHS G regarding cleaning of equipment found Certified Nurse Aid (CNAs) are responsible for cleaning shared equipment in the shower rooms and housekeeping cleans the rooms daily.On 04/28/2026 at 1:50 PM observed the hot water handle missing from the mop sink in the soiled utility room. MHS G indicated they were unaware the hot water faucet was inoperable. Further observation of the room found the hopper flush apparatus off at the fixture. MHS G stated they had turned it off and had not turned it back on, and staff dump mop buckets down which helps flush it. MHS G indicated they reglaze the hopper occasionally. On 04/28/2026 at 2:03 PM observed a black residue along the base of the toilet in south shower room. MHS G acknowledged the condition and indicated they could recalk.On 04/28/2026 at 3:00 PM observed outdoor waste receptacle with MHS G. In an interview at this time when asked frequency of pick up, MHS G indicated trash is picked up every day. When asked about chairs outside of enclosure, MHS G indicated someone probably pushed them out yesterday when they were not there. Further observation found the side sliding door open. When asked if it is usually left open, MHS G indicated they try to keep it closed. When asked about debris along the outside, MHS G indicated they had not gotten a chance to clean up today.

Based on observation, interview, and record review, the facility failed to formulate an Advance Medical Directive (AMD- the written instruction relating to the provision of health care) for one (R7) of five residents reviewed for Advance Directives. Findings include: On 04/28/2026 at 12:22 P.M., a record review of the Electronic Health Record (EHR) revealed R7 had a code status of Full Code with an admit date of 06/03/2025 and a diagnosis of Acute Cystitis without Hematuria, Schizophrenia, Diabetes and Peripheral Vascular Disease, Unspecified. Record review also revealed that R7 had a legal guardian. On 04/29/2026 at 11:20 A.M., Social Worker (SW) A was interviewed to discuss the formulation of a written Advanced Directive for R7. SW A was queried as to the expectations of Advance Directives for long term care residents within the facility. SW A stated, All residents should have documentation of an Advance Directive being offered. I should have documentation of an Advanced Directive for R7 but I don't. I do not have written documentation from R7's guardian.On 04/29/2026 at 2:15 P.M., the Nursing Home Administrator (NHA)/Director of Nursing (DON) was interviewed regarding an Advance Directive for R7. The NHA/DON stated, I looked, we don't have one for R7. I'll contact the guardian. Queried as to the expectations of Advance Directives; the NHA/DON stated, There should be documentation of the offer for an advance directive for all residents. Further record review revealed the lack of written documentation of R7's legal representative being offered education and the opportunity to formulate an Advanced Directive.Review of the facility policy on Advanced Directives entitled, Residents' Rights Regarding Treatment and Advance Directives date revised- 01/07/2026, read in part: . Any decision making regarding the resident's choices will be documented in the medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan that includes and supports the dementia care needs for one (R7) of one resident reviewed for care planning resulting in the potential to limit R7's highest practicable physical, mental, and psychosocial well-being.Findings include: On 04/28/2026 at 12:22 P.M., a record review of the Electronic Health Record (EHR) revealed R7 was admitted to this facility on 06/03/2025 with a diagnosis of Acute Cystitis without Hematuria, Schizophrenia, Diabetes and Peripheral Vascular Disease, Unspecified.Record review of the (EHR) revealed a care plan dated: 2/26/26 without a Dementia diagnosis, goal, focus or interventions for this diagnosis within the care plan. Record review of R7's Care Plan dated 02/26/2026 revealed Focus: I HAVE DIAGNOSIS OF SCHIZOPHRENIA; MAY EXHIBIT SYMPTOMS OF DELUSIONS, DISORGANIZED THINKING, FLAT AFFECT, HALLUCINATIONS, SOCIAL WITHDRAWL, DEPRESSION, ABNORMAL MOTOR BEHAVIORS, IMPULSIVE, HYPERVERBAL, HIGH ENERGY, EUPHORIA; SADNESS, HOPELESSNESS, LOSS OF INTEREST.Further review of the (EHR) revealed a Minimum Data Set (MDS) dated : 03/12/2026 also lacked the identification of a diagnosis of Dementia for R7. The Minimum Data Set (MDS) is used to assess the resident's clinical condition, cognitive and functional status, and use of services.On 04/29/2026 at 11:30 A.M., Social Worker (SW) D was interviewed by telephone and provided documentation of a 3878 PASARR Level II Dementia Exemption dated 9/10/25. On 04/29/2026 at 11:42 A.M., Social Worker (SW) A was interviewed to discuss the lack of documentation regarding a Diagnosis of Dementia in the care plan or the Minimum Data Set (MDS) despite a Dementia exemption from the State Agency and the reference of Dementia in progress notes by the Medical Director. SW A stated, I don't see a diagnosis for Dementia. Record review of R7's Psychiatric Evaluation dated 04/20/2026 also has no mention of a Dementia diagnosis. On 04/29/2026 at 2:00 P.M., the Nursing Home Administrator (NHA)/Director of Nursing (DON) was interviewed regarding the lack of documentation within the care plan to address a Dementia diagnosis for R7 and the lack of information noted for Dementia in the MDS dated [DATE]. The NHA stated, I'm checking with the Medical Director because I don't see it either. Queried if a Dementia diagnosis should be included in a comprehensive care plan. The NHA stated, Yes.On 04/29/2026 at 2:30 P.M., the Minimum Data Set Coordinator (MDS Coordinator) B was interviewed regarding the lack of Dementia Diagnosis across relevant information within the care plan and Electronic Health Record. MDS Coordinator B stated, I don't see a Dementia diagnosis in our system.On 04/30/2026 at 12:15 P.M., Medical Director C was interviewed and stated, R7 has a multifactorial impaired mental status. Medical Director C confirmed that R7 has a diagnosis of Dementia. When queried about the lack of information in the MDS and Care Plan denoting the Dementia diagnosis in the Electronic Health Record, Care Plan and Minimum Data Set, Medical Director C stated, R7 has Dementia with no change in condition since admittance to the facility.Further record review revealed the lack of documentation of R7 and or the legal representative being a part of establishing the expected goals of a dementia care plan and lacks the parameters of an outcome of care for dementia, the amount, frequency, and duration of dementia care related to the effectiveness of a plan of care for Dementia. R7's individualized dementia care needs are not addressed or being met through the care planning process. The facility has not developed a care plan to address the problems/risks of dementia identified by the Medical Director and provided in the PASARR determination.

Based on observation, interview, and record review the facility failed to provide 80 square feet of space per resident in 10 (102, 103, 107, 109, 110, 111, 112, 113, 116, and 117) resident Medicare or Medicaid rooms. Findings include:On 4/30/2026 at 10:15 AM, a review of the facility's room documentation and measurements determined the following residents' rooms were undersized, providing the following square feet of floor space per resident:RM# SQ. FT. ROOM # OF BEDS # OF Residents102 215 3 2 103 210 3 2107 220 3 3109 213 3 3110 217 3 2111 217 3 2112 210 3 3113 212 3 2116 224 3 2117 213 3 2On 04/28/26, during the recertification survey, observations of resident rooms were made. There were no complaints verbalized by residents regarding room size.On 4/30/2026 at 2:19 PM, the Nursing Home Administrator (NHA) was interviewed, and acknowledged they had rooms that did not meet the square footage regulations.

Based on observation, interview, and record review, the facility failed to: 1. Ensure pans were cleaned before stacking; 2. Properly date-label and store food in the kitchen; and 3. properly store ladles. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: On 3/10/25 at 8:45 AM an initial tour of the kitchen was performed with Dietary Manager (DM) F, the following was observed: 1. Five sheet trays were heavily soiled and stored with clean pans in the clean pot/pan storage area. DM F agreed the sheet trays were heavily soiled and said they should not be used and stated, We need new ones. 2. Six large soup ladles were observed hanging from the side bracket of the hood vent. DM F said the ladles should not be hanging from the vent. In the dry food storage room: 1. One opened frosting can not dated. 2. One family sized bag of potato chips opened not dated. 3. One box of instant mashed potatoes box opened not dated. DM F agreed all opened items should be dated and stored properly. On 3/13/25 at 8:51 AM the Nursing Home Administrator was interviewed and said the expectation is for food to be stored correctly and for heavily soiled uncleanable kitchen items to be discarded and replaced. A review of the facility policy titled Date Marking for Food Safety date implemented 11/1/2022 and revealed in part; The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. A review of the facility policy titled Food Safety Requirements date implemented 10/26/22 revealed in part; All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. a. Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment. b. Clean dishes shall be kept separate from dirty dishes. c. Staff shall wash hands prior to handling clean dishes, and shall handle them by outside surfaces or touch only the handles of utensils. d. Staff shall adhere to safe hygienic practices to prevent contamination of foods.

Based on observation, interview, and record review the facility failed to ensure a urinary catheter drainage bag was maintained in a dignified manner for one resident (R97) of two residents reviewed for urinary catheters and dignity covers, resulting in the potential for embarrassment. Findings include: On 03/10/25 at 09:15 AM, an observation of R97's foley catheter bag was observed outside of the room, visible from the hallway. The foley catheter drainage bag had dark amber urine. The urinary drainage bag was without a dignity cover (a bag used to cover a urine drainage/collection bag, so urine is not visible). R97 was observed in bed laying on their back, wearing pants and no shirt. R97 was asked how long they've been at the facility. R97 said, Not long, I'm here for therapy because my legs don't work. R97 was asked about care at the facility and their foley catheter bag not covered. R97 said, It is what it is .I can't do anything about that. On 03/10/25 at 10:30 AM, Nurse D was interviewed and asked why R97 did not have a dignity bag cover. Nurse D was unable to explain why R97 did not have a dignity cover on at the time of the observation. A review of R97's electronic medical record revealed an admission to the facility on [DATE] with the diagnoses of Retention of Urine, Emphysema, Psychoactive Substance use, Morbid Obesity and UTI. A review of R97's BIMS (Brief Interview for Mental Status) dated 03/04/2025, revealed a score 15 out of 15 (cognitively Intact). A review of R97's care plan dated 02/26/2025 noted the following: Problem: I have a self-care deficit r/t [related to]: Decreased Mobility, Morbid Obesity, Weakness of Musculoskeletal System, Emphysema and Retention of Urine. Bladder Function: Indwelling Foley Cath. Problem: Indwelling Catheter .Resident requires an indwelling urinary catheter r/t: Retention of urine. Approach Start Date 02/26/2025 .Store collection bag inside a protective dignity pouch. Further review of the progress notes and care plan revealed no evidence of the R97 removing the catheter dignity bag. On 03/13/25 at 10:49 AM, Unit Manager A was interviewed and queried about R97's foley catheter bag being without a dignity cover. Unit Manager A said, [R97] takes the bag cover off. On 03/13/25 at 12:10 PM, The Director of Nursing (DON) was interviewed and asked about R97's foley catheter bag being without a dignity cover. The DON stated that the resident (R97) should have a dignity bag cover. A review of the facility's policy Catheter Care dated 11/1/2022 revealed the following: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: 1. Catheter care will be performed every shift and as needed by nursing personnel. 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use.

Based on observation, interview, and record review the facility failed to ensure an indwelling foley catheter was secured for one resident (R37) of two residents reviewed for catheter care with the potential to cause irritation and/or trauma. Findings include: On 3/11/25 at 1:28 PM, R37's foley catheter was observed with Licensed Practical Nurse (LPN) E. R37 was observed with no leg strap attached to the catheter. When LPN E was queried regarding the leg strap LPN E said the leg bag should have been attached with a strap. On 3/11/2025 at 2:25 PM, the Nursing Home Administrator (NHA) was interviewed and said residents should have leg straps when they have a catheter. The NHA explained leg straps are used to secure the catheter to prevent the catheter from being pulled out. Record review of R37 Electronic Medical Record (EMR) revealed R37 was admitted on [DATE] with diagnoses of Acute pyelonephritis, Dementia, Pressure ulcer of right heel, Pressure ulcer of left heel, Pressure ulcer of sacral region stage 4, Urinary tract infection, and schizoaffective disorder bipolar type. Review of R37's Admission assessment dated [DATE] for Minimum Data Set for Brief Interview for Mental Status was severely impaired. Review of the facility policy titled, Catheter Caredated: 11/1/2022 revealed the following: It is the policy of the facility to ensure that residents with indwelling catheter receive appropriate catheter care. In accordance with the policy, it is noted leg bags will be attached to resident's thigh or calf making sure to have slack on the tubing to minimize pressure and tension.

Based on observation, interview and record review the facility failed to ensure professional standards of practice for oxygen administration for one (R7) of one resident reviewed for oxygen administration resulting in a R7 receiving supplemental oxygen therapy without a healthcare provider order. Findings include: On 03/10/25 at 10:45 AM, R7 was observed in bed on their back wearing a gown. Their left arm was bent at the elbow toward their chest. R7 was soft spoken and was able to answer basic questions. R7 was wearing supplemental oxygen via nasal canula (a device that delivers extra oxygen through a tube and into the nose). R7's oxygen was at three liters per minute. The oxygen tubing was not labeled with a date. On 03/10/25 at 01:28 PM, R7 was observed wearing oxygen via nasal canula with oxygen at three liters per minute. The oxygen tubing was not labeled with a date. On 03/11/25 at 08:38 AM, R7 was observed in bed with his eyes closed wearing a gown. R7 was observed wearing supplemental oxygen via nasal canula at 3.5 liters. The oxygen tubing was not labeled with a date. A review of R7's electronic medical record revealed an initial admission of 04/25/2024 and the diagnoses of Chronic Obstructive Pulmonary Disease, Anxiety, Schizoaffective Dementia, Depression, Contracture of muscle, multiple sites, Seizure, Stroke, Traumatic Brain Injury, and Heart Failure. A review of R7's BIMS (Brief Interview for Mental Status) dated 02/01/2025, revealed a score 9 out of 15 (Moderately Impaired). A review of R7's care plan revealed the following: Problem Start Date: 04/25/2024: COPD: Approach: Monitor oxygen saturation via pulse oximetry as ordered. A review of R7's care plan did not address supplemental oxygen therapy. A review of R7's electronic medical record physician orders did not reveal an order for oxygen therapy. On 03/11/25 at 11:04 AM, Unit Manager A was interviewed and queried about R7 receiving oxygen therapy at 3-3.5 liters and not finding an order in the electronic medical record for oxygen therapy. Unit Manager A said, I forgot to enter the oxygen order. On 03/13/25 at 12:08 PM, The Director of Nursing (DON) was interviewed and queried regarding R7 receiving oxygen therapy without a physician order. The DON said that they should have a physician order to receive oxygen. A review of the facility's policy Consulting Physician/Practitioner Orders dated 11/01/2022 revealed the following: Policy: The attending physician shall authenticate orders for the care and treatment of assigned residents. Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record.

Based on observation, interview, and record review the facility failed to provide 80 square feet of space per resident in three resident rooms resulting in the potential interference with care provided and resident dissatisfaction with their living environment. Findings include: On 3/10/25 at 11:30 AM, the following rooms were observed and review of facility census count sheet dated 3/10/25 revealed the following resident rooms did not provide 80 square feet of floor space per resident. RM# SQ. FT. BEDS Residents 103 210 3 3 109 213 3 3 117 213 3 3 On 3/13/25 at 11:00 AM, the Nursing Home Administrator was interviewed, and they acknowledged they had rooms that did not meet the square footage regulations.

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for the facilities census of 40 residents and its staff resulting in an increased chance of harm. Findings include: On 1/9/24 between 11:30 AM and 1:23 PM, during an environmental tour of the facility the following observations were made: The ice machine's door was observed cracked, glued, and separated in several areas. The exterior service entry doors were observed with a 1 inch gap on the vertical center seal allowing daylight to shine through the opening. The toilet and sink surround in resident room [ROOM NUMBER] was observed cracked and in poor condition. The radiator's protective grates in resident room [ROOM NUMBER] were observed damaged and with portions missing. Additionally, in this room drawer handles were observed missing on the furniture. The south shower room exhaust fan was observed not functioning. The north shower room exhaust fan was observed not functioning. Additionally, in this room an unprotected toilet plunger was observed stored on the floor, and the wall mounted nurse call device's pull cord was observed hanging 28 inches above the floors surface. In the soiled utility room the hopper and two compartment sink were observed soiled, and the tile flooring was observed cracked, damaged and with several sections missing. On 1/9/24 at 12:24 PM, the surveyor inquired with the Maintenance Director, staff A, on how the facility communicates its maintenance requests to the maintenance department to which they replied, we have book at the nurse's station that I check throughout the week. On 1/9/24 at 12:38 PM, upon record review by the surveyor and staff A of this book titled, Maintenance requisition/call light/ repair log revealed the last documented maintenance request was made on 10/17/23. At this time the surveyor inquired with staff A on if they thought this book was being consistently utilized to communicate maintenance requests to the maintenance department to which they replied, Not really, and I'm the only one in maintenance. Most people just tell me things and I go and do them, or I try to get the parts ordered for them if it's something I don't already have. On 1/9/24 between 1:37 PM and 2:03 PM, during a tour of the laundry room and its support spaces the following observations were made: An accumulation of dust and debris was observed on top of both washing machines, underneath and behind both dryers, and on the radiator grates. A portion of the exposed ceiling near the clean linen folding table was observed actively leaking into the laundry room. On 1/9/24 at 1:44 PM, the surveyor inquired with the Maintenance Director, staff A, on if they were aware of the current state of the roof leak to which they replied, No. It must have just started. It looks like the seal around the vent needs to be redone. On 1/9/24 at 1:57 PM, three fitted bed sheets were observed with dark colored stains in the clean linen room. At this time the surveyor inquired with staff A on if these items met the facility's cleanliness expectations prior to providing them to residents to which they replied, they have been washed, but we need to order some new sheets. This is as clean as we can make them.

Based on interview and record review, the facility failed to ensure a Registered Nurse was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergency or routine care and unmet care needs that could cause negative outcomes, affecting all 40 residents who resided in the facility. Findings include: On 1/9/2024 at 10:40 A.M. review of the staffing schedule with Activities/Scheduler D for the following dates revealed there was no scheduled RN coverage or replacement: September 2nd, 3rd, 14th, 19th, and 20th. (2023) October 6th, 10th, 12th, 22nd, and 28th. (2023) November 1st, 3rd, 6th, 11th, 13th, and 17th. (2023) December 1st. (2023) On 1/9/2024 at 12:00 P.M. the NHA/DON said during an interview the facility currently had a total of three Registered Nurses (RN) working and one of the RN's was on leave of absence (LOA). The NHA/DON said the facility did not utilize pool or Agency staff, providing consistent RN coverage was difficult, and NHA/DON periodically came in and worked as RN. When asked why the facility had not hired anyone the NHA/DON indicated RNs were hired but quit. No evidence of that information was provided or presented during the survey. On 1/9/2024 at 4:00 P.M. a review of the Facility Assessment updated 8/2023, revealed, Staffing: the facility required a minimum of two Licensed nurses per shift to meet the needs of the residents. On 1/9/2024 at 4:05 P.M. the NHA/DON acknowledged there was a problem with staffing and the facility expected some concerns.

Based on observation, interview, and record review the facility failed to provide intact linen for three residents (R13, R28, and R9) of 10 residents reviewed for bed linen, resulting in a less than optimal homelike environment. Findings include: R13 On 1/7/24 at 10:34 AM, R13 was observed lying in the bed. The bed linen was observed to have holes. The holes measured approximately the size of a quarter to the size of a baseball. The linen had threadbare areas that were frayed and revealed the color of the mattress underneath. R28 On 1/7/24 at 10:37 AM, R28 was observed lying in the bed. The bed linen was observed to have threadbare patches. The patches were thin and revealed the mattress. There were surrounding holes which were approximately the size of a quarter. R9 On 1/7/24 at 12:15 PM, R9 was observed lying on a bariatric bed. The bed linen was observed with threadbare areas. One area measured approximately the size of a basketball. Other areas measured approximately the size of a dime and a quarter. The fitted sheet was threadbare and the mattress was visible through the fabric. The fabric was frayed. On 1/7/24 at 10:40 AM, during an interview with Maintenance Director (MD) A, who was present during the observation, inspected the sheets and said they needed to be replaced. MD A said the worn sheets needed to be disposed of. 15194 On 1/8/2024 at 10:00 A.M. during an observation with MD A concerning the worn linen, R9 gestured and pointed to the worn areas in the fitted (bottom) sheet on his bed. Also, MD A observed R13 and R28s' linen with worn areas in their fitted sheets. MD A stated, linen had been brought out for the nursing staff to change the resident's bed on 1/7/24, but he did not know why the sheets were not changed. A subsequent observation of the back up linen was conducted with MD A and Laundry Aide B. During the observation, there appeared to be insufficient bariatric (extra large) bed linen. MD A stated, the bottom of the regular sheets were stretched and used on the bariatric beds in the facility. When asked how much linen the facility had available, and when the last time the facility ordered linen for the bariatric beds, MD A was not sure but would check with the NHA/DON. On 1/8/2024 at 10:30 A.M., MD A said the facility was previously informed about the linen and would try to find a requisition. On 1/8/2024 at 10:32 A.M. during an interviw, the NHA/DON had no knowledge of when the last time linen was ordered for the facility. On 1/8/2024 at 11:00 A.M. a requisition was presented dated 10/18/23 from a local vender, but the requisition did not identify linen was ordered. On 1/8/2024 at 11:40 A.M. the NHA/DON was interviewed regarding the ordering of linen for the facility. The NHA/ DON had not ordered any linen since working at the facility, and said the corporate office would have the information. Prior to exiting the facility on 1/9/2024 at 5:30 P.M., no additional information was provided concerning when the facility ordered linen for the resident's beds.

Based on interview and record review, the facility failed to revise/update a care plan for one resident (R6) out of two residents reviewed for skin conditions, resulting in the potential for lack of skin treatment. Findings include: A review of R6's EMR (Electronic Medical Record) revealed R6 was admitted to the facility 6/10/21. R6 had the following medical diagnoses: Psoriasis, Dementia, and Paranoid Schizophrenia. A review of R6's Quarterly MDS (Minimum Data Set) dated 12/24/23 revealed R6 was unable to complete the Brief Interview of Mental Status (BIMS). According to the MDS, R6 was receiving ointments for her skin. A review of R6's care plan dated 9/26/23 revealed, Resident has rash (Psoriasis) related to dry skin on right side of face / right ear .Resident's rash(es) will heal without complications .Treat rash per Physician order: Silvadene Cream each shift. A review of a nursing progress note dated 9/13/23 revealed, Recurrent rash on resident's right side of face, near the temple, is exacerbated. Physician ordered silvadene cream twice daily until resolved. A review of a nursing progress note dated 11/10/23 revealed, Writer notified Physician that resident Psoriasis was not resolving with silvadene so new orders were received to apply Betamethazone cream twice a day. New orders placed in EMAR. According to the care plan which was initiated 9/26/23, Silvadene was documented as the treatment for R6's Psoriasis, but there was no update to the care plan to reflect the new order placed (start date of 11/10/23). On 1/9/24 at 1:26 PM during an interview, the Nursing Home Administrator (NHA)/ Director of Nursing (DON) said when there is an update to the resident's care, there should be an update made to the order and care plan. A review of the facility's policy titled, Comprehensive Care Plans with a date of 10/26/22 revealed, The comprehensive care plan will include measurable objectives and timeframes to meet the resident ' s needs as identified in the resident ' s comprehensive assessment. The objectives will be utilized to monitor the resident ' s progress. Alternative interventions will be documented, as needed.

Based on observation, interview, and record review the facility failed to ensure an appropriate outlet extender for durable medical equipment (oxygen concentrator) was used for one resident (R31) of five residents reviewed for accidents, resulting in the potential for nonfunctioning medical equipment and an unsafe electrical connection. Findings include: On 1/7/24 at 12:14 PM during an observation, R31 was observed in bed wearing oxygen by nasal cannula (NC). The nasal cannula was attached to an oxygen concentrator delivering oxygen at 1.5 liters per minute. On 1/7/24 at 12:15 PM during an interview with R9 (R31's roommate), R9 reported that an outlet extender device had been loaned to R31 by R9's son. On 1/7/24 at 12:40 PM during an observation of R31's room, an outlet extender with three ports was observed plugged into the wall electrical outlet. The oxygen concentrator was plugged into the outlet extender. On 1/7/24 at approximately 1:30 PM during observation and interview, Maintenance Director (MD) A pointed to the label UL (Universal Laboratories) stamp on the outlet extender and explained that UL indicated the outlet extender is safe to use. On 1/8/24 at approximately 10:00 AM, MD A was interviewed and reported being unaware of the specific numbers for outlet extenders required for durable medical equipment. On 1/8/24 at 4:00 PM, MD A confirmed the device did not have the specific code that indicated it was safe for the use of durable medical equipment. MD A stated, the device was illegal. On 01/09/24 4:03 PM the NHA/DON and Registered Nurse (RN) E were interviewed and acknowledged that an outlet extender should not be used for durable medical equipment. Review of the facility's policy titled Electrical Safety dated October 1, 2022, documented the following: Power strips used in a patient care vicinity: I. Must not be used for patient-care equipment (i.e. beds, air mattress, concentrators, or other medical equipment). II. Must be UL approved in accordance with NFPA (National Fire Protection Association) 99 (2012) edition. III. Must be tested by the maintenance department prior to use.

Based on observation, interview and record review, the facility failed to consistently post nurse staffing information that was readily accessible for all 40 residents as well as visitors and vendors in the facility, resulting in necessary staffing information not being available to residents and visitors. Findings include: On 1/7/2024 at 8:30 A.M., upon entering the facility a document titled Daily Staff Report was observed dated 1/6/2024 was posted in the front lobby above the sign in area of the facility. At 5:15 P.M. the same dated (1/6/2024) Nursing Staffing Report was posted. On 1/8/2024 at 12:30 P.M. during an observation, and upon leaving the facility at 5:30 P.M. the Nurse Staffing Report remained dated 1/6/2024 and had not been updated or changed. On 1/9/2024 at 10:49 A.M. during an interview with Activities/Scheduler D concerning who was responsible for posting the Nurse Staffing information. Activities/Scheduler D confirmed it was the responsibility of the Activities/Scheduler. Activities/Scheduler D explained the posting information on 1/7/24 was not posted because at the time there was assistance needed to pass the meal trays. Activities/Scheduler D confirmed the daily schedule posting was forgotten until the surveyor was observed attempting to review the area where the daily schedule posting normally hung.

Based on observation and record review, the facility failed to provide 80 square feet of space per resident in 10 of 15 multiple resident rooms resulting in potential interference with care provided and resident dissatisfaction with their living environment. Findings include: On 01/9/24 at 11:10 AM, observations of the following rooms and review of the facility bed count sheet, most recent dated 8/2/21 revealed the following resident rooms did not provide 80 square feet of floor space per resident. MEDICARE/MEDICAID ROOMS: RM # SQ. FT. BEDS 102 215 3 103 210 3 107 220 3 109 213 3 110 217 3 111 217 3 112 210 3 113 212 3 116 224 3 117 213 3 The health and safety of the residents were not affected by the room size. Interviews of the residents revealed no problems with their rooms.

Based on interview and record review the facility failed to ensure Pneumococcal immunizations were received for one residents (R603) out of five reviewed for immunizations, resulting in placing an immune compromised resident at risk for pneumonia. Findings include: Resident #603 Review of an admission record revealed, Resident #603(R603) admitted to the facility 9/15/21 with pertinent diagnoses which included Dementia and Type 2 Diabetes. Review of a Minimum Data Set (MDS) assessment, with a reference date of 5/4/23 revealed R603 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15 out of 15. Review of Flu and Pneumonia Vaccine Consent form revealed R603 guardian consented for the pneumonia vaccine on 9/21/22. Review of R603's Physician orders and MAR for September 2022 revealed there was no order or documentation of administration of Pneumococcal vaccine. In an interview on 8/24/23 at 1:43 p.m., the Director of Nursing (DON) reported R603 did not receive the pneumonia vaccine. In an interview on 8/24/23 at 1:48 p.m., the Nursing Home Administrator (NHA) reported R603 did not receive the pneumonia vaccine. The NHA reported they reviewed the records and MDS and there is no documentation that R603 received the pneumonia vaccine. Review of a Pneumococcal Vaccination policy with a implemented date of 11/1/22 revealed, It is our policy to offer our residents, staff, ad volunteer workers immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations . Policy Explanation and Compliance Guidelines: 1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. 2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders . 12. The resident's medical record shall include documentation that indicates at a minimum, the following: a. The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization. b. The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal .

Based on observation, interview, and record review the facility failed to maintain backflow protection at the kitchen three compartment sink, resulting in the potential for cross-contamination. This deficient practice has the potential to affect all 46 residents who reside in the facility. Findings Include: On 10/18/22 at 11:30 AM during an observation in the kitchen, the main drain line of the three compartment sink was observed to be directly connected to the floor drain leading to the sewage system, and not provided with an air gap to prevent the potential backflow of solid, liquid, or gas contaminants. During an interview on 10/19/22 at 1:10 PM with Corporate Director of Maintenance (CDM) H, when asked if the drain lines should have an air gap he said, Yes. Record review of the 2013 Michigan Modified FDA (Food Drug Administration) Food Code Section 5-402.11 Backflow Protection.a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment or utensils are placed.

Based on observation, interview and record review the facility failed to ensure the safety of a cognitively impaired resident (R607) when she walked out of the facility without authorization or supervision at 8:30 PM during a winter advisory without a coat or boots on resulting in Immediate Jeopardy when R607's condition and location were unknown until Emergency Medical Services (EMS) returned R607 to the facility at approximately 11:30 PM that evening. This deficient practice placed R607 and 3 other residents who were assessed to be cognitively impaired and 'at risk for elopement' (an unauthorized departure from the facility) at risk for serious harm, injury and or death from hazards outside the facility. Findings: On 2/10/22 at 9:23 AM, R607's Responsible Party (RP) said that on 2/3/22 at approximately 8:30 PM, R607 was found walking on the sidewalk in the snow with only a t-shirt and slippers on by a 'Good Samaritan'. R607's RP said the 'Good Samaritan' called the police and located R607's family members and RP by using Social Media. R607 was transported by EMS to the local hospital and then returned to the facility. R607's RP said the facility had never notified her that R607 had walked out of the facility unsupervised and still had not contacted her to discuss the incident. On 2/10/22 at 9:30 AM, during a phone interview with 'Good Samaritan' (GS) J she said on 2/3/22 at approximately 8:30 PM she was driving home and saw a woman (R607) walking on the side walk in the snow with only a T-shirt, sweat pants, and slippers with no backs on. GS J said that R607 kept saying she was Going to see her Momma, and gave her the address to the house. GS J said she was then able to locate R607's family members on social media, contacted them and then called '911'. GS J identified where she found R607, which was approximately .4 miles from the facility on a two-way 4 lane road with a posted speed limit of 45 mile per hour. According to the local weather report on 2/3/2022 at 8:30 PM the temperature was 23 Fahrenheit (F) with a wind chill that made it feel like 17 F, and 7.5 inches of snow had fallen in the area throughout the day. On 2/10/22 at 9:40 AM R607 was observed independently ambulating throughout the facility dressed in a T-shirt, sweat pants, and slippers. During interview R607 said she, wants to go see her Momma. According to R607's face sheet she had multiple diagnoses that included [CONDITION(S)], [CONDITION(S)] with behaviors, pseudobulbar affect, [CONDITION(S)] and adjustment disorder. The Annual Minimum Data Set (MDS) with a reference date of 11/30/21 indicated R607 had moderately impaired cognition and required assistance from one staff member for all 'Activities of Daily Living'. A care plan initiated on 11/26/2020 read as follows; Resident has a history of elopement she eloped from previous nursing home. Resident's family reported she has eloped from home on numerous occasions. Resident has to be constantly redirected back to her room to ensure safety. The interventions included; Administer medications as needed, Approach from the front. Walk in step with resident first before redirecting. Convey an attitude of acceptance toward the resident. Maintain a calm environment and approach to the resident. Resident finds comfort in talking with her daughters daily. A review R607's Electronic Medical Record (EMR) revealed no progress notes from 1/24/2022 through 2/03/2022. There is no documentation to support R607 had left the facility unauthorized and without supervision on 2/3/2022 or that she had been returned by EMS. On 2/10/22 at approximately 11:00 AM during an interview Administrator A said on 2/3/22 at approximately 8:30 PM R607 was aggressively pushing on the front door to get out of the facility and Certified Nursing Assistant (CNA) E could not redirect her and allowed her (R607) to leave the facility unsupervised. The Administrator said that if the front door is pushed for 15 consecutive seconds it automatically opens. The Administrator could not produce the video of the incident nor could he confirm if 911 had been called by staff. Administrator A could not say what, if any, interventions were taken by staff to re-direct R607's behaviors or return her to the facility at this time. On 2/10/22 at 1:44 PM CNA E said that on 2/3/22 at approximately 8:30 PM, R607 was aggressively attempting to get out of the facility and pushing on the front door. CNA E said, I did not want to struggle with her, so I let her leave. I followed her outside and saw she was headed toward a restaurant and thought she would be OK. CNA E confirmed the front door alarms were sounding and that he reset them after he re-entered the facility without R607. CNA E could not recall if he called 911. CNA E said he was the only CNA in the building that afternoon shift for 46 residents and notified Licensed Practical Nurse (LPN) G that R607 had left the facility. CNA E said that he had been at the facility for less than 90 days and did not recall what the facility's policy was for residents that leave the facility unauthorized. On 2/10/22 at 4:00 PM Licensed Practical Nurse (LPN) D said he was aware that R607 had walked out of the facility on 2/3/22 after aggressively pushing the front door open. LPN D said he was not assigned to R607 and did not attempt to re-direct her, nor did he call 911. LPN D said R607 was returned to the facility by EMS at end of shift change, around 11:30 PM. LPN D said he didn't recall what the facility's policy or protocol was for residents that leave the facility unauthorized. On 2/11/22 at 1:00 PM, LPN G confirmed that he was an agency nurse and assigned to R607 on 2/3/22 during the afternoon shift. LPN G said R607 was focused on leaving the building that night and no one could redirect her. CNA E followed her (R607) out, but returned to the facility without the resident. LPN G said he didn't call 911 or document any progress notes regarding the incident because, There was only three guys on that night. Me, another LPN, and one CNA for 47 residents. It was crazy night, so no I didn't chart anything about it. She (R607) was returned to the facility before my shift ended, and she was alright. According to the Hospital's emergency room records dated 2/3/22 at 9:52 PM, Patient (R607) arrived to the emergency room after being found wandering in the cold. Confusion: At this time patient appears to be at baseline, patient is from nursing home and will be sent back, vital signs are stable and exam is normal. According to the facility's policy for 'Resident Behavior' revised on 11/12/21; Staff shall report and or investigate if need be all cases of missing residents. Policy Interpretation and Implementation 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being mussing to the Charge Nurse, Director of Nursing and Administrator 2. If an employee observes a resident leaving the premises, he/'she should: a. Attempt and or to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. 3. When a departing (a definite elopement) individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Notify the Attending Physician; c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of the Incident/Accident; e. Document the event in the resident ' s medical record. 4. If an employee discovers that a resident is missing from the facility, he/she shall: a Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the build and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. e. Code Pink 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident. c. Notify the resident's legal representative (sponsor); d. Notify search teams that the resident has been located; e. Complete an incident report; and f. Document relevant information in the resident ' s medical record. The Administrator (A) was notified on 2/11/22 at 9:01 AM Immediate Jeopardy (IJ) had been identified on 2/3/22 at 8:30 PM when the facility failed to ensure the safety of a cognitively impaired resident (R607) when she walked out of the facility without authorization or supervision during a winter advisory without a coat or boots and her condition and location were unknown until Emergency Medical Services (EMS) returned R607 to the facility at approximately 11:30 PM that evening. This deficient practice has the potential to affect all four residents who were assessed to be cognitively impaired and 'at risk for elopement' at risk for serious harm, injury and or death from hazards outside the facility. On 2/11/2022 the State Agency verified the following interventions has been put into place and were effective to remove the immediacy: 1. Identification of Residents Affected or Likely to be Affected: All residents in the facility are 'at risk' for this deficient practice. * The facility Administrator Completed door alarms checks on the main door, North, service entrance and south to ensure the door alarms are working and audible. * All residents were reassessed for elopement those who are at increased risk a picture was taken and put in the elopement book located at the nursing station with their face sheets. Only 3 residents scored high for increased risk for elopement and care plans has been reviewed and updated. * Resident number R 607 was placed on Q 15 minutes checks, assessed by charge nurse and no adverse reactions or ill effects. 2. Actions to Prevent Occurrence/Recurrence: Upon receiving notice of resident # R 607 elopement * The policy on elopement was reviewed by the Administrator and Director of Nursing and deemed it appropriate. * All facility staff education was initiated and is ongoing with a date of compliance 2/12/22. All staff will be in-serviced via phone and in person on the 'elopement policy' and residents who are at increased risk for elopement. Any staff in-service via phone will receive an in-person in-service on next returned scheduled day to work. * Elopement risk assessment will be done for every resident on admission, quarterly, annually and as needed. * Elopement risk assessment will also be completed when any resident are showing any exit seeking behaviors. * The Director of Nursing/Designee will audit all residents who are at increased risk for elopement twice a week for four weeks than monthly/PRN. * Maintenance staff/designee will check twice a day once in the morning and once in the evening to ensure all door alarms are working and audible daily/PRN with no end dates. * Results from the audit will be immediately addressed and reported to the Quality assurance committee monthly for action and follow. * The facility medical director has been notified and received the components of the plan of correction for approval. * The facility also posted an ad on company website for security 24 hours a day 7 days a week. The newly hired security staff will check with the charge nurse on duty to verify if residents are able to sign themselves in and out of the facility. Also, the resident who is at increased risk for elopement binder will be placed at security desk immediately.

This citation pertains to MI 117 and MI 300. Based on observation, interview, and record review, facility staff failed to report a fall with injury for one of three residents (R#41) reviewed for falls, resulting in a delay of assessments, pain management, and transfer to the hospital for treatment of [REDACTED]. On 8/6/19 at 8:55 a.m., R#41 was observed lying in bed alert and able to make needs known through nonverbal communication. R#41 used nonverbal communication through facial expressions, hand gestures, and head nodding. R#41 was observed using her left hand only with the bed side table on the left side of the bed. On 8/6/19 at 9:00 a.m., an interview with R#41 was conducted. R#41 was asked what happened to her leg. R#41 pointed downward at the floor on the left side of the bed. R#41 was asked, was she indicating the bedside table? R#41 nodded her head No. R#41 pushed the bedside table over and used her left hand to point downward at the floor. R#41 was asked, to nod her head yes or no to the questions asked. R#41 was asked, did she fall on the floor; R#41 nodded her head indicating, Yes (head was nodding up and down). R#41 was asked, did you fall from your bed on the floor; R#41 nodded her head indicating, No. (head nodded side to side). R#41 was asked, did someone let you fall; R#41 nodded her head Yes. On 8/6/19 at 9:25 a.m., during an interview with the R#41, she was asked, if her Nurse Aide let her fall. R#41 nodded Yes. R#41 was asked, was she in a wheelchair when she fell on the floor. R#41 nodded her head indicating Yes. The Resident was asked, did someone come to look at your leg when she was on the floor. The resident nodded with a facial expression, No. R#41 was asked, what happened after she fell , R#41 pointed to her bed. R#41 was asked, after you fell , your Nurse's Aide picked you up and then put you back in the bed. R#41 nodded Yes. While leaving out the Resident's room, she made a grunting sound to get my attention and pointed at the light. When R#41 was asked, if she wanted me to turn the light off, she nodded, Yes. On 8/6/18 at 9:37a.m., Activity Director B was interviewed upon entering R#41's room. B was asked, did she work with the Resident often. Activity Director B stated, Yes. Activity Director B was asked, Does the Resident usually know what she wants and answers accurately. Activity Director B stated, She knows what she is talking about. She can't speak but she can let you know what she needs and let you know what happened. She can nod yes or no and is accurate. On 8/6/19 at 10:50 a.m., Nurse C gave a statement. Nurse C was asked if R#41 was a two-person transfer. Nurse C stated, I have been here since (MONTH) of (YEAR) and I have always seen them ( Nurse Aides) use two people to transfer R#41. Nurse C was asked, did he know anything about how the resident sustained [REDACTED]. Nurse C stated, No, I think I talked to her on (MONTH) 27th, because she refused her shower on that day. I always talk to her because she refuses to get out of bed and refuses to take her showers a lot. She was fine then; she was her old self and was not in any pain. Nurse C was asked, when you talk to the Resident, does she understand and answer accurately. Nurse C stated, Oh yeah, she understands everything, she just can't speak. On 8/6/19 at 11:35 a.m., R#41's roommate, 'Resident D was interviewed. Resident 'D' was asked; did you see or hear anything happened to your roommate about two weeks ago that cause her pain and having to go to the hospital. Resident D stated, yes, her Aide was pushing her in the room about 9:30 that evening to put her in the bed. I came back to the room about 8:30 that evening and she wasn't in bed then. We both sat at the same table at dinner time and she was fine acting like her normal self with no pain. After the Aide pulled the curtain, I could hear the Aide getting frustrated trying to put her in the bed. I heard when she fell against the bedside table and hit the floor. I only heard one aide's voice in the room. On 8/6/19 at 9:47 a.m., several unsuccessful attempts made to contact Nurse Aide [NAME] via telephone for an interview. The Director of Nursing (DON) also attempted to contact Nurse Aide [NAME] via telephone, and was unsuccessful. On 8/6/19 at 11:50 a.m., further interview with Resident D she stated, I even asked her the next day after returning from the hospital, did she fall on the floor and she nodded 'Yes'. She understands, and she can nod 'yes' and 'no'. I reported the fall to the DON and the Administrator, and they didn't say anything. Since she fell , the aide does not care for her anymore, she only came in the room one time to pass us some water. When the ambulance came to take her to the hospital about 2:00 that morning, the ambulance drivers asked the aide what happened. The aide told them she didn't know. I told the aide, no, you need to tell them exactly what happened and why she (R#41) is in so much pain. On 8/6/19 at 12:10 p.m., a review of the clinical record revealed R#41 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R#41 had no BIMS, required total assistance from one person for transfers, extensive assistance from one person for bed mobility, and total assistance from one person for all Activity Daily Living (ADLs). R#41 was transferred to the Emergency Department on 7/30/19 at 01:59 for right leg pain. On 8/6/19 at 12:15 p.m., review of the facility's investigation report dated 7/30/19 revealed, R#41 had a Unusual Occurrence documented, complaint of right leg pain, right leg swollen and warm to touch. R#41 was assessed for a pain level of 8 thru 10 on a pain scale 0-10. The Resident was indicating pain by moaning, crying, holding on to the bed rails. The Resident was ordered new pain medication, [MEDICATION NAME] 5/325 mg on 7/30/19 due to the right leg pain. Review of the hospital's 'right leg x-ray' revealed a, Right Femoral Shaft Fracture. A Femoral Shaft Fracture is a break in the shaft of the thigh bone. The femur is the long bone that connects the hip joint to the knee joint. Causes: A healthy femur may break from a forceful impact, such as a from a fall, high -impact sports injury, and a car or motorcycle accident. On 8/6/19 at 12:24 p.m., Nurse A was contacted via telephone for an interview. Nurse A was asked, to make a statement about R#41 fracture leg on the date of 7/29/19. Nurse A stated, I was caring for the Resident on that day from 3:00 p.m., to 11:00 p.m. Nurse A was asked, was the Resident in any pain. Nurse A stated, No, the Resident wasn't in any pain. Nurse Aide [NAME] came and got me about 10:00 that night, and said the Resident was in pain. When I assessed the Resident, it was her right leg that was in excruciating pain. I called the Physician and gave a report and notified the DON. The Physician ordered a stat x-ray on the right leg. I ordered the x-ray, but I left at 11:00 p.m. I gave a report to the Nurse that was coming on the next shift. I gave the Resident something for pain, I believe it was Tylenol. On 8/6/19 at 12:30 p.m., Nurse A stated, The next day I came back to work, the Resident had a cast on her leg. Nurse A was asked, did any one reported that R#41 had a fall. Nurse A stated, No, No one came to me to report a fall. Nurse A was asked, who was the Aide on that day from 3:00 p.m., to 11:00 p.m. Nurse A said the Aide [NAME] was working on my shift that day. Nurse A was asked, was the Aide wearing something on her head that day. Nurse A stated, Yes, she wears something on her head every day. It's something you can get from the wig store. On 8/6/19 at 2:58 p.m., the DON and the Administrator were interviewed. The Administrator and the DON was asked, what was their conclusion of the incident. The Administrator stated, I am not finished with the investigation yet. The Administrator was asked, was the Incident reported to the State of Michigan. The Administrator stated, Yes, I reported on (MONTH) 30th. The Administrator was asked, after reporting the incident, should there have been a five day report? The Administrator stated, I am not finished with the investigation. The Administrator was asked, when was the incident reported to her? The Administrator stated, The same day it was reported to the Nurse. It was told to the Nurse about 10:00 p.m. on 7/29/19, the Resident was having right leg pain. The interviews were conducted back from (MONTH) 27th with no discrepancies. We have not yet interviewed the Certified Nurse Assistant (CENA)E. On 8/6/19 at 3:05 p.m., during a further interview with the DON and the Administrator, the Administrator said, The Resident was interviewed. The Resident was nodding 'Yes' to Pain and 'No' to fall. The Administrator was asked, has anyone approached you or the DON to report the Resident fell . The Administrator stated, The Resident D did approach us and said who had let the Resident fell on the floor. The Administrator stated, We couldn't figure out what CENA (competency evaluated nurse aide) she was talking about. The Administrator was asked, because Resident D stated she had fell on the floor, wasn't that enough to continue the investigation to try to find out which CENA was involved. The DON stated, we have another CENA who wears something on her head too. On 8/6/19 at 3:25 p.m., R#41 was interview in her room with the DON and the Administrator present. R#41 was asked, what happened to cause her fracture. R#41 again pointed downward on the floor. R#41 was asked, did her Aide let her fall while attempting to put her in bed. R#41 nodded, Yes. The DON and the Administrator was asked, do they agree with the interpretation of what happened by the Resident's 'hand gestures'. The DON and the Administrator both said, Yes. On 8/6/19 at 3:40 p.m., review of the Facility's policy titled Abuse Prevention Program documented with no date, Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The seven forms of Abuse: 1. Physical .6. Neglect/Self-Neglect.

Based on interview and record review, the facility failed to ensure the change in condition was assessed and monitored by the attending physician for one (302) of three residents reviewed for a change in condition out of a total of 3 sampled residents. Resident 302 was discovered to have an acute change in mental status necessitating a transfer to an acute care facility (hospital) where her blood sugar was assessed to be excessively elevated at 1000. Findings include: A record review revealed resident 302 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 4/12/18 revealed the resident's Brief Interview Mental Status (BIMS) score of 15/15 indicated an intact mental status. A nurse's note dated 7/25/18 revealed the resident received an additional mental status test identified as, The Sturm Mental Status. The results of the test indicated resident 302 was experiencing mental status changes (confusion, amnesia (mental loss), and loss of alertness) that was not congruent with her most recent BIMS score. Resident 302 was only alert to her name; according to the test results. Doctor (C) was notified and directed the staff to send the resident to the hospital. A record review of the resident's Medication Administration Record [REDACTED]. The order was discontinued via Dr. E on 6-27-18 and changed to Accucheck once a day. The Medication Administration Record [REDACTED]. The resident was not on a sliding scale order for insulin coverage in the month of July. On 8/8/18 at 3:30pm a nurse's note revealed the resident was admitted to the hospital for an outpatient surgical procedure involving her kidneys on 7/16/18. There were new prescriptions ordered to include: [MEDICATION NAME] (pain medication) 50 mg orally twice daily [MEDICATION NAME](antibiotic) 250 mg tabs every 12 hours for 5 days. There were no changes in the insulin dosage for this resident following her outpatient surgical procedure. On 8/8/18 at 4:00pm a record review of the resident's MAR indicated [REDACTED] 7/16- 210; 7/17- 342, 7/18- 304, 7/19-327, 7/20-300, 7/21- 449, 7/22-200, 7/23-429, 7/24-332, 7/25-396. On 8/8/18 at 4:30 pm during an interview with the Don (Director of Nursing) she stated, during a random medical record audit on 7/18/18, I noticed the resident's blood sugar readings were higher than they were prior to surgery (i.e. her highest blood sugar reading was 162). I called Dr. E to see if he wanted to make changes in her insulin dosage or put her on a sliding scale. Dr. E instructed me to just keep monitoring her with the Accuchecks once daily. On 8/8/18 at 4:45pm during an additional interview with the Don, the Don stated, there has been a change of doctors here, this happened when the facility went under new management, (i.e. the official date of new management was (MONTH) 1st). The Don stated, the new medical director, doctor (C), conducted a history and physical on resident 302 because of this change. On 8/8/18 at 5:00 pm following a review of a document entitled, History and Physical (Transfer of Service) dated 7/17/18, under the section of the document entitled Assessment and Plan, number one, read as follows: Type 2 diabetes mellitus, currently stable. We will continue her Accuchecks and HB AIC (measures the amount of glucose in the blood over the previous 2-3 months) and adjust her insulin as needed. On 8/8/18 at 5:15pm, review of a document entitled Interim Orders, dated 7-23-18, indicated the following orders were requested by Dr C: CMP (comprehensive metabolic panel)- this test measures blood sugar levels, kidney and liver function, electrolyte and fluid balance; CBC with diff (complete blood count with differential); Lipid panel (assessment of cholesterol); Vitamin D25; Hemoglobin A1C (measures the amount of glucose in the blood). During a record review it was noted there were no changes made in the frequency of the resident's glucose monitoring, or insulin dosage per Dr. C. after he became the physician of record for this resident. On 8/8/18 at 5:20pm during a phone interview with Dr. C, when questioned about the status of the resident's diabetes and her admission to the hospital. Dr C stated, I don't understand why the blood sugar checks were changed from 3 times a day to once a day. No one contacted me with elevated blood sugars elevated over 225, or blood sugars under 90. It was the other doctor that was leaving the facility that did not care. The communication between the doctors should have been better. The facility staff have been doing a good job, give them a break. On 8/8/18 at 5:30 pm during an interview with the Don, the results of the resident's AIC ordered per Dr. C on 7-23-18 was requested. The Don stated the results were not available, and she would call the lab and ask them to send a copy. On 8/8/18 at 5:40pm the Don was asked to provide a copy of the facility policy and procedure related to blood sugar monitoring. At the time of exit from the facility this information had not been provided nor had a copy of the AIC lab results for 7-23-18.

Based on observation, interview and record review the facility failed to provide adequate pain management for one sampled resident (#601) out of eight residents reviewed for pain from a total sample of 14, resulting in uncontrolled pain experienced during wound care. Findings include: On 9/28/17 at 12:05 p.m., coccyx (pressure ulcer on the tail bone) wound care for R#601 was observed with Assistant Director of Nurses (ADON Nurse F). Nurse F entered R#601's room stating, She (R#601) has already been medicated for pain. Nurse F prepared the wound care supplies and with the assistance of the nurse aide, R#601 was turned from her back onto her left side. While being turned R#601 yelled out, Ow, Ow, Ow. Nurse F then proceeded to to remove the old wound dressing from the coccyx, with R#601 continuing to moan out, Ouch. As Nurse F was cleansing the wound,R#601 was heard crying out, It burns. Stop. Ow, Ow, Ow. Oh God it hurts all the way down to the muscle. Observation at this time revealed R#601 with facial wincing and pursed lip breathing (breathing technique with exhaling through tight lips and inhaling through the nose) through the pain. At 12:15 p.m., Nurse F applied a clean dressing to R#601's coccyx pressure wound while R#601 continued to yell out, That's enough. Your hurting me. I'm in pain. Afterward the nurse, along with the nurse aide turned R#601 off of her left side on to her back. At no time during the 10 minute long wound care did NurseF stop the treatment, assess the residents pain level, or assess if the pain medication she had received prior to the wound care was effective, despite R#601 yelling out and requesting the nurse to stop. On 9/28/17 at 1:00 p.m., record review revealed that R#601 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set Assessment ((MDS) dated [DATE] indicated the residents cognition was intact and was totally dependence on staff for activities of daily living. Under Section J-Health Conditions documentation revealed R#601 had no presence of pain. R#601 was admitted on to Hospice services on 7/9/17. Review of the Pain level assessment (with a desired pain level of 0-2, with 0 being least amount of pain and 10 being the greatest pain) dated 9/28/17 (day of the wound care observation) 7 am to 3 pm shift documented the residents pain level was 0 for the shift. Review of the current physician's orders [REDACTED]. Give one tablet per Percutaneus Endoscopic Gastostomy (PEG) tube (feeding tube into the stomach) every 8 hours as needed for pain. Review of the As Needed (PRN) Medication Administration Record [REDACTED]. According to the manufactures guidelines Tylenol takes about 30 to 60 minutes to take effect. There was no order for Tylenol on the current physician's orders [REDACTED]. The Alteration in comfort related to chronic pain, skin impairment, contracture care plan dated 7/18/17 had approaches of Assess pain signs and symptoms: crying, moaning, facial grimacing, guarding and pain complaints .Administer medication per order and assess effectiveness .Notify physician and hospice if pain medication or interventions are ineffective. There was no behavioral care plan that addressed yelling out or moaning as a identified behavior. On 9/28/17 at 1:50 p.m., Nurse F was queried regarding the pain management for R#601. Nurse F said that that she was unsure of when the resident was medicated for pain prior to the wound care, I asked the nurse (who was assigned to administer pain medication to R#601) but she never answered me. Nurse F went on to say that (R#601) always complains of pain and that last week while doing her treatment she screamed and yelled out then too, that's the norm for her. On 9/28/17 at 3:40 p.m., R#601 was asked to rate her pain level during the wound care treatment earlier that day. R#601 rated her pain level at a 9.5 to 10. You could even say at times it went to an 11. On 9/29/17 at 3:00 p.m., The Director of Nursing (DON) was ask about the pain managment for R#601 and stated, We have been working with hospice to get her pain managed. I will have to contact them again to re-evaluated her pain and medications. Review of the Pain Mnagement Guidelines Policy dated 11/30/14 documented, This center strives to improve patient/resident comfort and minimize pain in order to help a resident attain or maintian his or her highest practicable level of well-being.

Based on observation, interview, and record review, the facility failed to ensure that a resident who was at risk for falls was wearing appropriate footwear for one (#209) of five sampled residents reviewed for falls from a total sample of 10, resulting in a fall and hip fracture that required surgical repair. Findings include: On 11-17-15 at 11:35 AM, while sitting in the front lobby, Resident #209 was noted with a bruise on the right arm. Resident #209 verbalized she had a recent fall and hurt her hip, stating, I was trying to dance and fell hurting my hip. I had to go to the hospital and I will have the sutures taken out next week. During the interview, Resident #209 reported she fell during an activity, while dancing unassisted and was wearing fuzzy socks. The resident stated, I wear my fuzzy socks and then wear my shoes--but no one helped me to put my shoes on that day. At 2:30 PM, the resident attended the Group Interview and further expressed that she was unable to dress and put on her shoes alone and that the aides always tell me to do it myself. On 11-18-15 at 9:15 AM, Resident #209's clinical record was reviewed. The resident was readmitted [DATE]. [DIAGNOSES REDACTED]. Review of the nursing home resident assessment and care screening dated 10-26-15 noted that the resident had cognitive patterns described as moderate impairment and described the resident was alert with depressed mood. A plan of care was in place that noted Resident #209 had a history of [REDACTED]. The care plan identified the resident was at risk for falls due to weakness and decreased balance. The resident had poor safety awareness and has been observed by staff getting up without assistance. Care plan approaches were as follows: provide one person limited assist for all transfers, wheelchair for locomotion, remind her frequently not to get up unassisted, use of non-slip footwear at all times, observe for changes in condition that may warrant need for increased supervision and assistance . On 11-18-15 at 10:00 AM, the facility investigation, incident report, and interdisciplinary progress notes dated 10-30-15 were reviewed. According to the progress note dated 10/30/15 at 2:45 PM, it was documented that the nurse was informed that Resident #209 was dancing in the day room at the Halloween party and fell to the floor. The resident complained of right hip pain. The nurse assessed and called the physician who ordered a stat x-ray. At 5:15 PM, the x-ray mobile unit arrived to perform examination and Resident #209 refused and was described as screaming: It hurts and was holding right side of leg. The doctor was notified and ordered transfer to the hospital for evaluation to rule out hip fracture. Pain medication was given at this time as the resident reported a score of 10 (pain scale 10/10). The emergency medical services (EMS) arrived at 6:45 PM and transported Resident #209 to the hospital. At 10:45 PM, the hospital was contacted and the facility was informed that the resident was admitted to the hospital in need of surgery. A review of the hospital radiological report dated 10-30-15 at 9:21 PM revealed the following: Impression: Acute subcapital fracture of the right femoral neck with proximal displacement of the distal fracture fragment (right hip fracture). On 11/18/15 at 11:45 AM, the activity person , employee 'C' was interviewed. Employee 'C' stated, The resident stood unassisted to dance during the party and was wearing fluffy socks when she fell . The employee's written statement for the investigation further revealed: She (resident #209) attended activities--Halloween party on 10-30-15 .wearing her Halloween hat and her fluffy socks .Music was playing and she loves to dance. She locked her chair and began to dance .three times before the fall. The fourth time she .slowly stepped to the right .tripped over her foot and rolled down to the floor. I was behind another resident at the time .when I made it to her she was getting up. I helped her to the wheelchair and asked Do you have pain? .then she said her hip has a little pain in it. That's when I rolled her out to the nurse and told them what happened. Employee C was asked if the resident required assistance while standing and if it was the facility's policy for him to pick residents off of the floor and place them back into the wheelchair after a fall, and Employee C stated, I'm not sure. On 11/19/15 at 11:30 A.M., the Administrator was interviewed. The Administrator stated, All falls/accidents are reviewed and handled by the Interim Director of Nursing. The facility investigation noted the potential cause of the fall was inappropriate footwear (fuzzy socks that had no grips). I plan to in-service all staff on falls and safety. To ensure that residents are wearing appropriate footwear and to ensure nursing staff assess residents prior to moving the resident after a fall. The facility was asked to provide a policy for falls. The policy titled Fall Risk (effective date 11/30/2014) was reviewed. Policy: To identified factors which place the resident at risk for falls and to facilitate the development of interventions to minimize or prevent falls to extent possible, residents will have a fall risk evaluation completed on admission/readmission and quarterly ( )