Every finding on record at PortagePointe

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice and the residents' assessed needs for three Residents (#5, #6, #7) of three reviewed for quality of care, resulting in actual harm to Resident #5 after an infection in the toe required amputation.Findings include:Resident #5 (R5)Record review indicated R5 was admitted on [DATE] with diagnoses including multiple sclerosis (MS), congestive heart failure, osteoarthritis, thrombophilia, atrial fibrillation, hyperlipidemia, and quadriplegia.During a phone interview on 8/18/26 at 11:55 AM, complainant B stated R5 has chronic issues with his feet due to MS and toe curvature. Complainant B reported the facility had not been trimming R5's toenails, and some CNAs were not washing his feet during showers because they were not taught to do so. Complainant B stated, due to the lack of nail trimming, one toenail punctured the skin of an adjacent toe, causing a previous infection. Complainant B stated the facility had placed cushioned bandages on R5's right second toe but did not feel staff were monitoring or changing the dressing appropriately. Complainant B was unsure how much time passed before a CNA noted the bandage had come off during a shower and that the toe did not look good. R5 was subsequently sent to the emergency department, where MRI findings indicated osteomyelitis of the right second toe requiring amputation.Review of nail care documentation revealed R5 had not had his toenails trimmed within the past 30 days.At 12:57 PM on 8/18/26, the DON reported the facility does not employ a certified wound nurse and relies on the hospital wound department when deemed necessary. Otherwise, facility nursing staff perform wound care.At 1:19 PM on 8/18/26, R5 stated nurses apply foam dressings to his toes to prevent injury. R5 reported he believed something was occurring under the dressing but did not feel nurses were removing it to assess beneath. R5 stated he felt something was wrong long before it was found.Record review revealed a skin assessment, dated 4/2/26, which documented a scab on the right dorsum second (toe) digit measuring 0.2 x 0.3 cm. There was no documentation indicating the physician was notified of the new wound. Skin assessments on 4/16/26, 4/23/26, and 4/30/26 documented ongoing changes to the same site, including deterioration and the initiation of foam dressings, without documentation of physician notification. Subsequent assessments on 5/7/26 and 5/14/26 documented changes in wound size and deterioration, again without evidence of physician notification. The 5/21/26 assessment documented worsening pain and redness, neither of which had been previously reported, with no documentation of physician notification.On 5/28/26, R5 was sent to the emergency department. ED documentation described significant erythema, edema, pain, and MRI findings suspicious for osteomyelitis. R5 was admitted , received intravenous antibiotics, and was evaluated by a general surgeon. On 5/30/26, the surgeon recommended amputation of the right second digit, which was completed the same day.A skin assessment dated [DATE] did not document the new amputation. Instead, it listed the right second digit scab as resolved and noted a dressing on the surgical site that was not removed.Resident #6 (R6)Record review indicated R6 was admitted on [DATE] with diagnoses including prediabetes, chronic venous hypertension with ulcer of the right lower extremity, and chronic B cell lymphocytic leukemia. R6 had active wound treatment orders for wounds to the right medial and lateral interior ankle and right medial lower leg.On 8/18/26, observation of RN A performing wound care revealed multiple infection control and hand hygiene deficiencies. RN A placed supplies directly on the foot of R6's bed without a barrier, failed to don a protective gown before removing dressings, and changed gloves between steps without performing hand hygiene. RN A also touched her phone and reached into her pocket while gloved, then continued wound care without changing gloves.Per CDC Hand Hygiene for Healthcare Workers (2/27/24), hand hygiene must be performed before donning gloves and immediately after glove removal.During interview at 2:53 PM, RN A acknowledged the lapses and stated Sorry. RN A did not offer any explanation as to why Enhanced Barrier Precautions (EBP) were not used, why they did not change gloves appropriately, or perform hand hygiene.R6's EMR did not contain an order for EBP, nor was EBP noted in their care plan.During an interview on 8/18/26 at 3:10 PM, the DON stated the facility does not require orders for EBP and the Infection Preventionist can initiate them. The DON stated they expected nurses to complete skin assessments fully. When asked about the absence of documentation showing physician notification of wound changes, the DON stated nurses may have direct messaged the physician but could not provide evidence of such communication.Resident #7 (R7)Record review indicated R7 was admitted on [DATE] with peripheral vascular disease and had multiple wounds, including to the left posterior elbow, digits of both hands, both forearms, left medial foot, and left elbow. R7's care plan dated 5/8/26 stated staff assessed for EBP but noted the resident did not have a history of MDROs and that standard precautions were in place.Per CMS guidance, staff must wear gown and gloves during high contact care such as wound care for residents with chronic wounds, regardless of MDRO status.During interview at approximately 3:45 PM on 8/18/26, IP C stated they performed a risk versus benefit assessment and determined full EBP was not required because R7 did not have an MDRO. Review of the facility's policy titled LTC Actual Alteration in Skin Integrity Protocol, revised 1/12/26, stated: Report any alteration in skin integrity to the physician, including any signs of drainage, odor, erythema, or necrosis.

This deficiency pertains to Intake #2673210Based on interview and record review, the facility failed to protect the rights of five Residents (#2, #3, #4, #30, & #62) of five residents reviewed for abuse to be free from abuse by a staff member. This deficient practice resulted in feelings of fear, intimidation, frustration, and/or pain for Resident #3, Resident ^#4, and Resident #30.Findings include:The facility submitted a Facility Reported Incident (FRI) to the State Survey Agency on 11/7/25 after four Certified Nurse Aides (CNAs) independently reported concerns regarding the care provided by CNA B. The allegations described a recurring pattern of neglectful care and resident mistreatment and included rough physical handling of residents, failure to provide bathing and showering, prolonged failure to respond to resident call lights, extended absences from the assigned work area resulting in delayed care, failure to cleanse residents following bowel movements, and the use of inappropriate transfer techniques. The FRI identified Resident #2 (R2), Resident #4 (R4), Resident #30 (R30) and Resident #62 (R62) as residents affected by the alleged abuse and documented CNA B had previously been suspended following an allegation of elder abuse.The facility's investigative findings concluded the allegations were substantiated. The investigation documented multiple residents consistently demonstrated agitation, fear, or emotional distress when CNA B was assigned to provide their care and determined there was an identifiable pattern of elder neglect and mistreatment. The facility investigation findings read, in part: .the facility identifies a pattern of concerns. It is identified that multiple elders [residents] in [name of facility unit redacted] don't respond in a positive way when [CNA B] is working, they become agitated or upset when he is caring for them. Facility has completed full investigation and SUBSTANTIATES/VERIFIES [sic] elder NEGLECT [sic] and MISTREATMENT [sic] by [CNA B].During the survey, independent interviews with four CNAs who worked directly with CNA B revealed consistent, mutually corroborative accounts describing rough resident handling, failure to provide necessary care, refusal to honor resident requests, disregard for resident dignity, delayed responses to resident needs, and abusive interactions that caused observable pain, fear, and emotional distress. Although each CNA described separate incidents occurring over different periods of time, their statements demonstrated a consistent pattern of conduct involving multiple residents. Each CNA described separate incidents and their statements demonstrated a consistent pattern of conduct involving multiple residents.During an interview on 7/22/26 at 9:00 AM, CNA F described observing R3 confined on a commode while repeatedly pleading to be assisted off the toilet. After hearing R3 loudly state, I want to get out, let me up, CNA F entered the bathroom and observed CNA B holding a cellular telephone in one hand and holding down R3 on the commode with the other hand. CNA F completed the resident's toileting care after intervening. CNA F further reported witnessing CNA B refuse R30's request to wear a T-shirt, telling the resident he would wear a gown because it was easier, despite the resident's expressed preference. After CNA F honored R30's request, the resident appeared relieved and thankful. CNA F additionally described assisting CNA B with toileting R62, during which CNA B attempted to pull the resident's clothing up after a bowel movement without cleansing the resident. CNA F intervened to provide the required perineal care because CNA B didn't want to be bothered cleaning the resident. CNA F further reported repeatedly observing residents request assistance or care that CNA B either ignored or refused to provide.On 7/22/26 at 10:58 AM, CNA G similarly described repeated failures by CNA B to provide required care. While monitoring R3 through an auditory resident monitoring device, CNA G heard R3 repeatedly request assistance to use the bathroom and heard CNA B tell the resident he was not taking her to the bathroom. CNA G also reported R2 disclosed CNA B handled him roughly and man-handled him during care, a concern she reported to the Nursing Home Administrator (NHA). CNA G further described persistent failures by CNA B to respond to resident call lights, requiring other staff members to routinely assume responsibility for CNA B's assigned residents to ensure essential care needs were met.CNA C was interviewed on 7/22/26 at 12:02 PM. CNA C described CNA B as consistently rude, abrupt, and inappropriate in his interactions with residents. CNA C reported repeatedly observing CNA B forcefully push R30's contracted lower extremities onto a positioning wedge despite the resident screaming in pain and pleading for him to stop. According to CNA C, CNA B continued despite the resident's obvious discomfort. Following these incidents, CNA C said R30 became fearful other caregivers would similarly force his legs during care and repeatedly requested staff not push on his contracted extremities because he feared they would hurt him. CNA C additionally described CNA B refusing resident requests for assistance, including denying a resident's request for food while remaining seated using his cellular telephone, and routinely ignoring resident call lights.On 7/22/26 at 2:17 PM, CNA H independently corroborated CNA C's observations involving R30, describing the resident as being in obvious pain when CNA B forcefully manipulated his contracted lower extremities. CNA H reported R30 described CNA B as rough and abusive and characterized CNA B's interactions with residents as lacking compassion and patience. CNA H further witnessed CNA B transfer R4 by lifting the resident from a wheelchair and throwing him onto the bed despite the resident requiring a mechanical sit-to-stand lift for safe transfers. Although R4 was largely nonverbal because of cognitive impairment, CNA H observed what he described as obvious fear and terror in the resident's facial expressions during the transfer.CNA B did not respond to the surveyor's request for an interview. However, the facility's investigation documented an interview conducted on 11/10/25 during which CNA B admitted failing to cleanse R62 following a bowel movement while denying the remaining allegations. CNA B attributed his conduct to stress and distraction.On 7/23/26 at 8:47 AM, the NHA subsequently reported CNA B asserted during the interview, he could no longer provide appropriate resident care and attempted to voluntarily resign during the investigation. The facility rejected the resignation and immediately terminated his employment after concluding the allegations of neglect and mistreatment were substantiated. The NHA further stated the investigation determined CNA B's actions represented a willful, patterned, and conscious course of conduct. The NHA conveyed she was told by CNA B during questioning that he was burned out.Review of the medical records of R2, R3, R4, R30, R62 revealed that despite substantiating abuse involving multiple residents, the facility failed to conduct a comprehensive post-incident assessments to determine the full extent of resident harm. Record review failed to identify timely head-to-toe skin or injury assessments for the affected residents following the initial abuse allegations on 11/7/25. The only subsequent physical finding identified was a skin assessment completed for R62 on 11/12/25 documenting new bruising of the upper outer arm that had not been present during the previous assessment conducted on 11/5/25. Additionally, the facility failed to complete psychosocial or trauma assessments, initiate supportive interventions, revise resident care plans, increase monitoring, or implement individualized measures to address the physical and emotional impact of the substantiated abuse. These omissions persisted despite the facility's own determination that multiple residents had been subjected to a repeated pattern of abuse, neglect, and mistreatment.The policy titled LTC Breech of Elder's Rights dated as last revised 5/13/26 read, in part: . Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish (includes the deprivation by an individual, including a caretaker, of goods or services necessary to attain or maintain physical, mental and psychosocial well being).Mistreatment: Means to handle an Elder roughly or wrongly.Neglect: The failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. This home will not condone abuse of any type by anyone including staff members.The policy titled LTC Suspicion of Abuse Protocol dated as last revised 5/13/26 read, in part: .Perform a thorough nursing physical examination.Following any abuse allegation, Elders will be assessed for psychosocial harm by the Social Worker/ Social Work Designee. If found, appropriate interventions and care plan updates will be put in place for the Elder.Document the Elder interview and assessment in the nursing notes.

Based on observation, interview, and record review, the facility failed to transcribe a physician's order for a decrease in medication dosage for one Resident (#8) of one resident reviewed for physician's orders. This deficient practice resulted in harm when the resident was not administered medication necessary to treat a medical condition which caused Resident #8 unnecessary emotional anguish and significant stomach pain.Findings include:Resident #8 (R8)Review of R8's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 4/16/26, with diagnoses including gastro-esophageal reflux disease (GERD) [stomach acid backflow into the throat], anxiety, and depression. R8 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of intact cognition.During an observation and interview on 7/21/26 at 9:42 a.m., R8 had tears in her eyes and tears running down her face and reported, I am in pain currently due to the nurse taking my stomach pill away. Resident was noted to start visibly shaking and crying as she sat in her wheelchair in the dining/living room area.Review of the Medication Administration Record (MAR) revealed R8 had not received any medication for GERD from July 15th thru July 21st.Review of physician order summary dated 7/15/26, read in part Pantoprazole sodium oral tablet.40mg (milligrams).created date 7/15/26.order by: [physician's name] reason for discontinue: decrease dose.Review of R8's progress notes revealed the following: 7/21/26 at 13:51 (1:51PM) Elder (resident) complaining of heartburn and stomach upset earlier today before breakfast.She asked about her Protonix(C) [40mg 1 tablet by mouth daily], I looked in her orders/discontinued order, found that it was discontinued. Elder was upset, she did not remember that and was not aware that it was discontinued.@10:20 EA (elder associate [Certified Nurse Aide (CNA)] notified me that someone brought [R8] an OTC [over the counter] Prilosec(C). [R8] states she took one OTC Prilosec(C) 10mg tablet. Asked elder who brought the medication in. She states, does it matter, the doctor hasn't got back to you anyway. When the doctor gets the order, I won't take another one today. I will take the ordered one tomorrow. 7/22/26 4:14 AM.Subject Pantoprazole [medication to treat GERD].Elder was requesting to have this medication this morning d/t [due to] having stomach upset, nausea, and heartburn. I let elder know that this medication was discontinued on 7/15/26.In the note of that discontinued medication it said decrease dose. The policy titled Medication Events last revised 11/18/25, read in part .Medication events is any event that may cause or lead to inappropriate mediation used or patient harm. This include, but is not limited to the following: medication error.Review of a document titled Medication Error dated 7/21/26 read in part .Person preparing report: [Director of Nursing's name] .Previous order for Protonix (C) was dc'd (discontinued) instead of decreased.An interview was conducted on 7/22/26 at 9:30 a.m., the Director of Nursing (DON) reported, There was a medication error yesterday.the resident had a friend bring in medication for her GERD.the physician had ordered the medication to be reduced from 40mg to 20mg, and it was missed.the medication was discontinued.During an interview on 7/22/26 at 10:04 a.m., R8 reported I was hurting so badly yesterday that I called a friend, and she brought me in some of the medication.I couldn't take the pain anymore.During an interview on 7/23/26 at 11:33 a.m., the Nursing Home Administrator (NHA) acknowledged the medication error had occurred which caused a delay in treatment of R8's GERD.The policy titled Medication Events last revised 11/18/25, read in part .Medication events is (sic) any event that may cause or lead to inappropriate mediation used or patient harm. This include, but is not limited to the following: medication error.

Based on interview and record review, the facility failed to ensure the Medical Director or a designated representative attended the Quality Assessment and Assurance (QAA) / Quality Assessment Performance Improvement (QAPI) committee meetings at least quarterly. This deficient practice had the potential to affect all 57 residents residing in the facility. Findings include:A review of the facility's QAPI/QAA committee meeting attendance records on 7/22/26 revealed that the facility Medical Director or an approved clinical designee had not signed or been documented as in attendance at any QAPI committee meeting since 3/10/26, creating a gap in mandatory quarterly attendance.During an interview on 7/23/26 at 11:12 AM, the Nursing Home Administrator (NHA) and Registered Nurse (RN) P confirmed that the Medical Director had not attended any of the bi-monthly QAPI committee meetings since March of 2026. The NHA stated that the Medical Director was no longer serving in that role due to personal reasons. The NHA further verified that the facility had not appointed or utilized a designee to represent the Medical Director or provide medical leadership during the meetings held after 3/10/26The policy titled LTC Quality Assessment Performance Improvement dated as last revised 5/6/24 read, in part: . [name of facility redacted] will maintain a Quality Assessment Performance Improvement (QAPI) program, with participation from the Interdisciplinary Team (IDT) members. The IDT group is known as the Quality Assessment Assurance Committee (QAA). The QAA Committee consists of the Medical Director. The Medical Director or his or her designee; the designee may not be another required member of the committee, but may be someone such as a nurse practitioner, physician assistant, etc. who has knowledge of the facility's policies, procedures, and practices so that he/she can fully participate and can add value to the QAA Committee comparable to the Medical Director.

Based on observation, interview, and record review, the facility failed to clean and maintain kitchen equipment in accordance with professional standards for food safety for all residents served in the dining room.Findings include: During an observation on 7/22/26 at 11:02 a.m., the double ovens were inspected in the main dining room of the facility. The interior visibility of the top oven was impaired due to significant grease accumulation on the glass. When opening the oven, it was noted that the door and oven window had a brown baked on layer covering the oven door. The debris on the oven door was flaking off. The inside walls of the top oven were dirty with burnt on debris and ash on the bottom of the oven. When opening the bottom oven door, it was noted the hinge on the left side of the oven was broken. The inside of the bottom oven was also dirty, and gray ash was noted on the floor of the bottom oven.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. An interview was conducted on 7/22/26 at 11:32 a.m., with Dietary Staff M. When queried about dietary cleaning logs Dietary Staff M reported, We do not have any cleaning logs that I am aware of, usually Dietary Manager O tells us to clean things.we have some blank cleaning logs in the dining pantry room which doesn't look good.During an observation and interview on 7/22/26 at 11:55 a.m., Dietary [NAME] N reported, I use the ovens in the dining room to keep the food warm.I don't know when the ovens have been cleaned last.I hate to say it but I believe the ovens have not been cleaned since last September and the ovens should be cleaned weekly. Dietary [NAME] N was observed turning the oven on and setting the temperature in order to keep the food warm.During an observation and interview on 7/22/26 at 12:04 p.m., when queried about the use and cleaning of the ovens in the dining room, Dietary Manager O reported, We do not use the ovens. When the oven door was opened, it was noted to contain a large sized disposable tin pan filled with macaroni and cheese. Dietary Manger O reported, Oh God, I didn't know we were using the ovens.the top and bottom oven are dirty, and the bottom oven door isn't working right.the hinge appears to be broken.According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.During an observation and interview on 7/22/26 at 12:19 p.m., Nursing Home Administrator (NHA) walked into the kitchen area in the dining room to inspect the ovens. The NHA observed the ovens with this surveyor and reported, The top and bottom ovens are dirty.the bottom oven door is broken.Review of facility policy titled LTC Equipment Sanitation Procedure last revised 1/29/26, read in part .To ensure the prevention of transmission of food borne illness, strict procedures for individual equipment sanitation will be followed. A cleaning schedule is established ad specific guidelines for cleaning equipment are to be followed.Equipment: ovens Frequency [ovens are to be cleaned] once per month or more frequently if needed.

Based on interview and record review, the facility failed to issue requisite written notification of transfer, provide mandated bed-hold information, and submit notification of transfer to the Office of the State Long-Term Care Ombudsman for one Resident (#11) of three residents reviewed for hospitalizations.Findings include:Resident #11 (R11) was admitted to the facility 9/18/24 with a primary diagnosis of dementia with psychotic disturbance. R11 was determined to be incompetent regarding independent treatment decisions, necessitating a court-appointed legal guardian.R11 was transferred to the acute care hospital emergency department following an in-facility fall on 5/1/26. A comprehensive audit of R11's electronic health record (EHR) revealed an absence of both the written notification of transfer and the mandated bed-hold acknowledgement form.On 7/21/26 at 3:58 PM, the Director of Nursing (DON) explicitly verified the omission, stating that while R11 was transferred to the emergency department 5/1/26, the required transfer and bed-hold documentation had not been executed.A review of the facility's Ombudsman reporting logs confirmed R11's transfer to the emergency department on 5/1/26 was excluded from Ombudsman notifications. On 7/23/26 at 7:31 AM, the DON confirmed the Ombudsman was not apprised of the transfer, attributing the omission to the initial failure to generate the written notification of transfer documentation. The DON acknowledged that while these notices represent standard facility operating procedure, they could not identify the systemic or individual failure that caused the omission for R11 on 5/1/26.The policy titled LTC Transfer dated as last revised 3/9/23 read, in part: .Elders may be transferred to another unit within the hospital on a temporary basis to meet their urgent medical needs. The Elder, family or legal representative will be notified if the elder is transferred off the unit for further medical care. A transfer sheet will accompany the elder when they are transferred to another unit.Notice to the office of the State Ombudsman of transfers and discharges will be sent at least once a month. Prior to any transfer, and upon transfer, the elder must receive bed hold information.

Based on observation, interview, and record review, the facility failed to secure a physician order for the use and application of splint/protective devices for one Resident (#45) of two residents reviewed for limited mobility.Findings include:Resident #45 (R45)Review of R45's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 8/16/06 with diagnoses including non-Alzheimer's dementia, aphasia and seizure disorder or epilepsy.Review of R45's care plan last revised 2/3/26 read in part, The Elder [resident] has an ADL (activities of Daily Living) self-care performance deficit r/t (related to) Limited ROM (range of motion).Please apply blue positions splint in the right hand after AM cares. If unable to position splint, OK to use a washcloth, Splint can stay on throughout the day. This is to help prevent skin breakdown.R45 was noted to be without a splint on his contracted right hand on 7/21/26 at 12:03 PM and 7/23/26 at 7:55 AM and 8:50 AM.An interview was conducted on 7/23/26 at 9:46 AM and Occupational Therapist (OT) K reported, There should be something in his contracted hand to protect his skin integrity and prevent the contracture from worsening.I believe it is a standard of practice to use a splint or device such as a rolled washcloth in his hand.An interview was conducted on 7/23/26 at 10:09 AM Restorative Aide/Physical Therapy Assistant L reported, He is supposed to have rolled washcloths or splints in his hand during the day.His hands are very stiff, but his right hand is much worse than the left hand.During an interview on 7/23/26 at 11:27 AM the Director of Nursing (DON) reported, I cannot find a physician's order for the use of a splint or any device to prevent the contractures from worsening.[R45's] hands are very contracted and he needs to have something to prevent them from worsening.Review of policy titled LTC Supportive/Restorative/Rehabilitative Services last revised 3/26/18, read in part The staff will obtain self-help devices as needed for the elder [resident]including but not limited to.splints.During an interview on 7/23/26 at 11:33 AM the Nursing Home Administrator (NHA) acknowledged the concern regarding the lack of a physician order for a splint or other device for R45 and no splint or other device being used for R45.

Based on interview and record review the facility failed to ensure communication/documentation occurred for coordination of hospice services for to one Resident (#6) of one resident reviewed for hospice services.Findings include:Review of R6's Minimum Data Set (MDS) assessment dated [DATE] revealed admission to the facility on [DATE] with diagnoses including cerebral palsy, quadriplegia (partial or total loss of motor and sensory function in all four limbs), and malnutrition. MDS Section O: Special Treatments, Procedures, and Programs revealed R6 was receiving hospice care.During an interview on 7/21/26 at 2:43 p.m., Certified Nurse Aide (CNA) J was asked about a logbook or documentation of hospice care and services provided to R6 that would be available to staff. CNA J reported I am unaware of any documentation about hospice care.there is no communication book that I have ever seen. I don't know what hospice does for [R6}.During an interview on 7/21/26 at 3:06 p.m., the Director of Nursing (DON) reported, There is no documentation from hospice that the floor staff have access to.the floor staff cannot review the services hospice provided or the care plan from hospice.we do not have any communication sheets from hospice that are in a log book or binder.An interview was conducted on 7/21/26 at 3:27 p.m., with the DON and the Nursing Home Administrator (NHA). The NHA reported, There is no staff member at the facility coordinating with hospice.Review of policy titled LTC Portage Pointe Hospice Policy last reviewed 2/16/18, read in part .Hospice and [facility name] shall communicate with one another regularly for each hospice elder [resident] Each party is responsible for documentation such communications .to ensure that the needs of hospice elders are met 24 hours a day.Hospice must develop and maintain a system of communication.hos pie shall promote open and frequent communication with [facility name] and shall pro [NAME].sufficient information to ensure the provision of.services under this agreement is in accordance with the hospice elders plan of are, assessments, treatment planning and care coordination.During an interview on 7/23/26 at 11:32 a.m., the Nursing Home Administrator (NHA) acknowledged the lack of communication between hospice and facility staff and the absence of documentation of services.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: A. Failure to properly label and date food products. B. Failure to ensure expired foods were discarded on or before the identified expiration date. C. Failure to ensure high temperature dish machines were routinely tested for proper sanitizing of food contact surfaces. These deficient practices had the potential to result in food borne illness among any or all the 56 residents in the facility. Findings include: The following were observed during the initial kitchen tour on [DATE] at 3:50 p.m. with Kitchen Manager (KM) C [NAME] House - 13 expired foods located in three refrigerators Delaware House - Four expired foods and three Potentially Hazardous Foods (PHF) not labeled with an open date located in the white refrigerator Bath House (currently used as storage and room for kitchen that is under construction) - 3 PHF not labeled with an open date located in the white refrigerator Wiona House - One expired food and One food not labeled with an open date located in the refrigerator Medora - One expired food located in the refrigerator. An interview was conducted with KM C who confirmed all opened food products should be labeled with a use-by date and expired items should be discarded. The Food and Drug Administration (FDA) 2022 Food Code states: ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking (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; (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 [DATE] at 7:15 a.m., the high-temperature dishwasher in the Pewabic Kitchen was observed for appropriate sanitation temperatures. KM C stated that this dishwasher does not get to the correct wash temperature, Our [Company Name] representative said if this strip turns black then it was fine despite the temperature it is saying on the dish machine. A sanitization strip was placed on a clean plate and KM C began a cycle. The final rinse temperature was 137 degrees Fahrenheit ( F), and the sanitization strip did not turn black to indicate that the dishes was properly sanitized. On [DATE] at 12:15 p.m. Dietary Aide (DA) D was observed using the Pewabic dish machine. DA A was first observed taking a pitcher and scooping out water in the bottom of the dish machine. Then placing dishes into the machine, closing the door and having to hold the door shut so the dish machine would run. A towel was observed near the bottom of the dish machine to collect water. The final rinse temperature of the dish machine was 117 F. The FDA 2022 Food Code states: ,d+[DATE].11 Hot Water and Chemical. After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: (A) Hot water manual operations by immersion for at least 30 seconds and as specified under S ,d+[DATE].111; P (B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under SS ,d+[DATE].15, ,d+[DATE].112, and ,d+[DATE].113 and achieving a UTENSIL surface temperature of 71 C (160 F) as measured by an irreversible registering temperature indicator.

Based on interview and record review, the facility failed to ensure the dietary department was provided with sufficient and properly trained staff to carry out the functions and duties of the nutritional services department. This deficient practice has the potential to result in inadequate nutrition for all 56 residents. Findings include: On 5/28/25 at approximately 12:50 PM, an interview with Kitchen Manager (KM) C was conducted. It was learned KM C had not completed the Certified Dietary Manager's (CDM) exam and had been in this position for over a year. KM C stated he had completed the CDM coursework but was waiting to schedule his exam date. KM C confirmed he is completing resident nutritional assessments despite not taking his exam. The FDA Food Code 2017 states: Knowledge 2-102.11 Demonstration. Based on the RISKS inherent to the FOOD operation, during inspections and upon request the PERSON IN CHARGE shall demonstrate to the REGULATORY AUTHORITY knowledge of foodborne disease prevention, application of the HAZARD Analysis and CRITICAL CONTROL POINT principles, and the requirements of this Code. The PERSON IN CHARGE shall demonstrate this knowledge by: (A) Complying with this Code by having no violations of PRIORITY ITEMS during the current inspection; Pf (B) Being a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM;Pf or (C) Responding correctly to the inspector's questions as they relate to the specific FOOD operation. The areas of knowledge include: (11) Explaining correct procedures for cleaning and SANITIZING UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT; 2-102.12 Certified Food Protection Manager (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. (B) This section does not apply to certain types of FOOD ESTABLISHMENTS deemed by the REGULATORY AUTHORITY to pose minimal risk of causing, or contributing to, foodborne illness based on the nature of the operation and extent of FOOD preparation. 2-102.20 Food Protection Manager Certification. (A) A PERSON IN CHARGE who demonstrates knowledge by being a FOOD protection manager that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for Food Protection-recognized accrediting agency as conforming to the Conference for Food Protection Standards for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with 2-102.11(B). (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection recognized accrediting agency as conforming to the Conference for FOOD Protection Standards for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with S2 102.12.

Based on observation, interview and record review, the facility failed to implement its policy and procedure related to monitoring food brought in by visitors for residents and stored in refrigerators. This failure allowed unmarked and out dated food to be present in the refrigerator units potentially contributing to illness of any or all 56 residents using the units to store food. Findings include: On 5/27/25 at 3:50 p.m. an initial kitchen tour was conducted with Kitchen Manager (KM) C. The following items were observed throughout the tour: A. A glass pickle jar containing pickles and no label with a name, date, or any other identifying information B. Two health shakes, not purchased by the facility and no label with a name, date, or any other identifying information. An interview was conducted with KM C who confirmed that items brought into the facility should contain the residents name and date they were brought into the facility. Review of the facility's LTC (long term care) Food Brought in from Outside Sources Revised 1/13/23 read, in part, .Family/friends are to inform the nurse and/or elder associates of any food or beverages brought into the House for elder consumption .Perishable food from outside sources should be stored in the refrigerator. The items is to be labeled with the Elder's name, and date. Prepared food items are to be discarded within 72 hours if not consumed. Shelf stable food items will be stored for up to 7 days .

Based on interview and record review, the facility failed to ensure physician orders were in place for a resident with a foley catheter (a tube inserted through the urethra to drain urine out of the body from the bladder) for one Resident (#26) of two residents reviewed for catheter care resulting in the potential for unnecessary catheter usage and increased potential for urinary tract infection. Findings include: Resident #26 (R26) Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: history of Urinary Tract Infections (UTI), Alzheimer's Disease, dementia, and anxiety disorder. MDS Section C revealed R26's cognitive skills were severely impaired and R26 rarely or never made decisions. During a phone interview on 5/27/25 at 2:09 p.m., Family Member (FM) B reported she was the responsible party for R26 and the facility did not call her to obtain permission for the foley catheter to be placed in R26's bladder. FM B stated, I want to call the facility right away to find out why (R26) has a catheter. During an interview on 5/29/25 at 8:33 a.m., the Director of Nursing (DON) acknowledged the physician was not called to obtain doctors orders to insert a catheter into R26, and conceded there was no diagnosis that would necessitate the use of a urinary catheter. The DON acknowledged the responsible party for R26 was not notified. The DON reported Registered Nurse (RN) A had inserted the catheter into R26 and should have called the physician to obtain an order for the insertion of the catheter. During a phone interview on 5/29/25 at 8:53 a.m., RN A reported, R26 was seeping urine, and I decided to put the catheter into the resident. RN A acknowledged she did not call the physician and did not call the responsible party. Review of facility policy titled Long Term Care (LTC) Indwelling Catheter Maintenance and Care last revised 3/5/24, read in part .These guidelines are related to .appropriate use of indwelling catheters .insert catheters only for appropriate indications. Avoid use of urinary catheters in elders for management of incontinence .confirm provider's (physician) order. Confirm appropriate diagnosis for insertion of foley catheter .

Based on interview and record review the facility failed to ensure timely physician response to Medication Regimen Review (MRR) pharmacy recommendations for two Residents (R19 and R52) of five residents reviewed for MRR. This deficient practice has the potential to result in medication irregularities, excessive dosage, side effects, and adverse reactions. Findings include: Resident #19 (R19) A review of R19's Minimum Data Set (MDS) assessment, dated 12/5/23, revealed admission to the facility on [DATE], with active diagnoses that included: progressive neurological conditions, heart failure, hypertension, multiple sclerosis, anxiety, chronic pain, and depression. R19 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. A review of care plan for R19 read in part, . medications sertraline (zoloft) and bupropion (wellbutrin) (psychotropic medications) used simultaneously may increase risk of side effects. A review of R19's monthly MRR by a Registered Pharmacist (RPh) G, dated January 2024, read in part, A Federal Regulation requires Gradual Dose Reduction (GDR) attempts of psychotropic medications in two separate quarters within the first year . RPh G asked the physician to: Please evaluate if a Gradual Dose Reduction can be attempted for R19 at this time. Physician did not sign the MRR until March of 2024. During a phone interview at 10:08 a.m., RPh G said recommendations for MRR are provided to physician for review every month. RPh G provided a Pharmacy Procedure, titled Drug Regimen Review Procedure, to the facility read in part: The pharmacist will complete each of the resident's MRR every month .any irregularities will be available for review by the medical director and must consistently demonstrate a timely and appropriate response from the attending physician. During an interview on 5/8/24 at 10:39 a.m., the Nursing Home Administrator NHA acknowledged the facility did not have a policy for MRR and the Drug Regimen Review Procedure was a Pharmacy procedure given to the DON by the Pharmacist. During the same interview the Director of Nursing DON said, the facility never put a policy together for MRR or timeframe's for physician response regarding MRR. 35103 Resident 52 (R52) A review of R52's MDS assessment, dated 1/30/2024, revealed R52 was admitted to the facility on [DATE], with active diagnoses that included: non-traumatic brain dysfunction, diabetes mellitus, other fracture, Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, depression. and adjustment disorder with mixed disturbance of emotions and conduct. R52 scored 11 of 15 on the BIMS reflective of moderately impaired cognition. A review of R52's monthly MRR prepared by RPh G, dated September 2023, and submitted For Physician Review and Signature, read in part, A Federal Regulation F-758 requires gradual dose reduction attempts of psychotropic medications in two separate quarters within the first year of use and annually thereafter, unless clinically contraindicated. Please evaluate if a gradual dose reduction can be attempted for this elder (R52) at this time. Physician H declined the recommended GDR with a signature dated 11/21/23; approximately 2 months later. Another review of R52's MRR recommendation For Physician Review and Signature, dated December 2023 and prepared by RPh G read in part: Periodic review of full anti-coagulation is recommended for patients without a specified end-date following acute DVT (deep vein thrombosis)/PE (pulmonary embolism) treatment. Elder currently takes xarelto (anticoagulant medication) 20 mg (milligrams) PO (by mouth) Q (every) daily. Her diagnosis list includes acute embolism and thrombosis of unspecified deep veins of right lower extremity (date of event unknown to writer) Please assess if indefinite full anti-coagulation is still indicated. Physician H replied indefinite anticoag (anticoagulation) indicated, signed, and dated 3/1/24; approximately 3 months following RPh G's written recommendation. During an interview on 5/07/24 at 2:40 p.m., when asked if there was a reason for the delay in signing of the pharmacy recommendations for December 2023 and September 2023, Physician H asked to look at the specific documents and stated, I don't know (why there was a delay). I am not in the habit of sitting on those things. He did then state, if they came to my folder here at the long-term care facility, I am here twice a week and I would have signed them. Physician H said if the documents had been sent to his office, that may have resulted in a delay. During a telephone interview on 5/8/24 at 9:58 a.m., the Nursing Home Administrator (NHA) was asked what she considered timely, per the MRR policy, for the physician to address pharmacy recommendations? The NHA said she would expect them addressed by the time the physician next sees them. When asked directly if waiting for two to three months would be considered timely for the physician to sign the pharmacy recommendations, the NHA stated, No that is not timely. The NHA said one month would be considered timely in her estimation. Review of the Drug Regimen Review Procedure, unsigned and undated, revealed the following, in part: . When requested, the attending physician/mid-level practitioner must document in the resident's medical record that an identified irregularity has been reviewed, and what if any action has been taken to address it. The method for notification of irregularities will be determined by the consultant pharmacist and facility, but must consistently demonstrate a timely and appropriate response from the attending physician/mid-level practitioner .

Based on observation, interview and record review, the facility failed to 1. Identify and implement corrective action in response to the mechanical dish machine's failure to demonstrate proper sanitizing, 2. Ensure proper air gaps were installed to avoid waste water backflow, 3. Ensure outdated time/temperature controlled food was was not accessible for use, 4. Ensure food trays being prepared for meal service did not become contaminated, 5. Demonstrate proper testing of sanitizing solution for meal preparation conutertops, and 6. Ensure dirty dishes and untensils following meal service were properly stowed in accordance with professional standards for food service safety potentially resulting in food borne illness among any and all 59 residents. Findings include: On [DATE] at approximately 3:00 PM, the three compartment sink in the Medora kitchen was observed to have all three sink compartments draining directly to the sanitary sewer, without an air gap or air break to prevent the back flow of contaminated waste water into the sinks. On [DATE] at approximately 9:00 AM the high temperature under- the- counter dish machine was observed to have the drain line directly connected horizontally to the waste trap T of the adjacent three compartment sink. This direct connection could force waste water into the three compartment sink or allow waste water to gain entrance to the dish machine, un-noticed. The FDA Food Code 2017 states: ,d+[DATE].11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, 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. On [DATE] at approximately 8:00 AM, a container of Ham soup base was observed in one of the residential type refrigerators in the Medora kitchen. The soup base container had a facility placed sticker which identified the product to have been received on [DATE]. No expiration date was located. On the bottom of the container was a [NAME] calendar code (0063) which identified the product as having been manufactured on [DATE]. The vendor's product life is known to be 360 days for the product, which would have then expired on [DATE]. An interview with Kitchen Manager (KM) A and Cook B was conducted on [DATE] at approximately 10:30 AM and it was learned the facility did not have a system to address products delivered to the kitchen without expiration dates, by vendors. KM A stated he was not aware of how the [NAME] calendar worked or how the dating system on the bottom of the containers were to be read and expired food identified. The FDA Food Code 2017 states: ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking (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: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf 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. Pf On [DATE] at approximately 12:15 PM, two resident trays were observed on the counter adjacent to the hand sink in the Delaware dining room. As the hand sink was used, water was observed splashing onto the trays which had been set up with beverages and utensils. The FDA Food Code 2017 states: ,d+[DATE].11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts ,d+[DATE] - ,d+[DATE]. On [DATE] at 7:30 AM an interview was conducted with Cook C. It was learned during this interview the facility uses soap and water in the wiping rag buckets, used for wiping counter tops. A spray bottle containing a quaternary ammonium (aka Quat)) sanitizing solution is then used to sanitize the counter tops. On [DATE] at approximately 8:45 AM, an interview was conducted with KM A and Cook B regarding the testing of the Quat solution in the spray bottles. Cook B demonstrated the testing by pouring out a sample from a spray bottle into a small glass. Using test strips QT 40, the strip was dipped into the solution and held for 10 seconds then reported to be in excess of 300 PPM (Parts Per Million). Cook B was requested to measure the temperature of the solution, which was then reported to be 92 F. A review of the package directions for the QT 40 strips, directed the user that the acceptable temperature range for accuracy of the strips was between 65 F and 75 F) KM A and Cook B stated they were not aware of that restriction of the use of the strips. On [DATE] between 1:00 PM and 2:00 PM, and following each of the meals on [DATE] and [DATE], soiled resident meal dishes, pans from cooking and other preparation cookware were observed to be piled on the raised counter near the two compartment sink and under-the-counter dish machine in the [NAME] Dining room. These soiled dishes were accessible to residents and guests visiting the facility and the dining room. The FDA Food Code 2017 states: ,d+[DATE].13 Drainboards. Drainboards, UTENSIL racks, or tables large enough to accommodate all soiled and cleaned items that may accumulate during hours of operation shall be provided for necessary UTENSIL holding before cleaning and after SANITIZING.

Based on observation, interview and record review, the facility failed to provide an environment which was safe, functional and sanitary for residents, staff and visitors, as evidenced by the failure to provide adequate kitchen facilities for the storage, preparation and delivery of food for all 59 residents. This deficient practice resulted in kitchen space which was not equipped with food service equipment and space to meet minimum standards to provide for the dietary needs of the residents and had the potential to result in negative environmental impacts to residents, employees and visitors due to lack of appropriate ventilation, space and storage needs. Findings include: On 5/6/24 at 1:45 PM then throughout the remaining survey time (5/6/24 to 5/8/24), the dietary facilities were observed to be inadequate and dysfunctional for the storage, preparation and delivery of food. This deficient practice has the potential to affect all 59 residents. Observations included: 1. The main preparation kitchen had been located in an originally designed and constructed [NAME] household kitchen/dining identified by the facility as the Medora household. Food was prepared in this space for all five households of the facility. This kitchen space originally included space for dining, now designated for refrigerator/freezer and mixing equipment. 2. The main kitchen lacked minimum approved equipment, including commercial cooking/baking ovens, refrigeration units, and appropriate storage space in accordance with design standards. Four of the refrigeration/freezer units were non-commercial construction. 3. The small three compartment sink had waste lines directly connected to the sanitary sewer lines, lacking the required air gaps from the rinse and sanitize compartments. 4. The small three compartment sink did not have compartments large enough to handle the large baking and cooking dishes. 5. The preparation kitchen did not have a food preparation sink to allow staff to properly wash produce and other foods needing to be washed prior to service. 6. The under-the-counter dish machine waste line was not installed according to manufacturer's requirements. 7. Counter tops in Medora kitchen had been replaced with non-commercial plastic laminate (Formica) covered tops. 8. The [NAME] dining room kitchen, which had also been designed and constructed as an [NAME] household kitchen was being used for cooking the hot food prior to distributing to the other households. This kitchen did not have adequate space to store soiled dishes from the cooking process as well as the dishes being returned to area required to be washed in the under-counter dish washer. Cooking equipment, returning soiled resident meal dishes and utensils were observed piled on the raised counter, over the two compartment sink facing the dining room where residents ate their meals. 9. The two compartment kitchen sink in the [NAME] Dining room was observed to be discolored, stained and pitted, and unable to be cleaned. 10. The [NAME] dining room staff were removing wet dishes from the dish machine and placing them on wheeled carts, located over a carpeted area making it wet and unable to be properly cleaned. 11. The interior of the sink base cabinet for the two compartment sink in the [NAME] dining room was deteriorating and in poor condition. 12. The facility had placed temporary vertical fabric covered barriers in the [NAME] dining room to segregate the area used to drain and dry wet dishes on the racks and the dining room area. This removed approximately 120 square feet (10' x 12') of useable dining room space. These temporary barriers had been in place since July 2023. 13. The dish machine in the [NAME] Dining room was observed to be leaking onto the floor when operating and opened following a cycle of use. An interview with Cook C on 5/7/24 at approximately 9:15 AM confirmed this condition had been an ongoing problem for months. 14. The kitchen was not provided with a designated housekeeping closet, including a mop sink, mop storage area and cleaning chemical storage. On 5/8/24 at approximately 10:20 AM, an interview was conducted with Cook C concerning the functionality of the space and equipment in the [NAME] kitchen/dining room. Cook C stated the ovens don't always work correctly, making it difficult to properly heat food, and though, food preparation was conducted in the Medora kitchen, all cooking, for the entire population of residents occurred in the two small non-commercial style ovens. Cook C also stated there was not adequate space to store the soiled dishes coming back from the residents' meals. Cook C continued that the small under counter dish machine leaked water onto the floor regularly, and staff were required to conduct all dish washing activities for cooking equipment and residents' soiled dishes in the machine. Cook C also shared that there was not an acceptable location to place racks of wet dishes after being removed from the dish machine. Cook C stated placing the wet trays on the wheeled carts behind a temporary make-shift wall, and allowing them to drip and dry over carpeting, deemed inappropriate. These same sentiments were shared by Kitchen Manager A and the Nursing Home Administrator. On 5/6/24 at approximately 2:30 PM an interview with the Nursing Home Administrator (NHA) was conducted concerning the kitchen facilities. The NHA confirmed the facility had agreed to the commencement of the construction of new kitchen facilities, following the previous year's survey. The NHA confirmed that contracts had not been signed or any construction begun to correct the same issues as identified during the previous survey and documented on the current survey.

Based on observation, interview, and record review, the facility failed to ensure timely monitoring of blood glucose and administration of glucagon (emergency blood glucose elevating medication) for one Resident (R59) of five residents who were prescribed insulin and/or other blood glucose lowering medications. This deficient practice resulted in a delay in treatment for severe hypoglycemia (low blood sugar), and the potential for adverse neurological and physical outcomes for R59. Findings include: Review of R59's Minimum Data Set (MDS) assessment, dated 2/2/24, revealed R59 was admitted to the facility on [DATE] with active diagnoses that included: stroke, end stage renal disease (ESRD), diabetes mellitus, and hemiplegia (paralysis of one side of the body). R59 scored 12 of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderate cognitive impairment, with the ability to understand others and be understood by others. Review of R59's care plans revealed the following focus and interventions: Endocrine: The Elder has Diabetes Mellitus type II, date initiated: 2-23-2023 . Report to RN any s/sx (signs/symptoms) of hypoglycemia: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, etc., date initiated: 2/23/2023. Review of R59's Physician Order Recap Report found no physician prescribed order for the injection of glucagon for treatment of severe hypoglycemia, when R59 was unable to ingest food or drink. Review of LTC (Long-Term Care) Standing Orders - [Facility Name], last revised 1/11/2024, revealed the following, in part: Hypoglycemic Reaction: Follow [Facility Name] Hypoglycemic Protocol. Review of the facility LTC Hypoglycemic Protocol, last revised 3/9/2018, revealed the following, in part: Expected Outcome: Elder's blood sugar will remain in the target goal range. Elder complications from blood sugar changes will be minimized or managed. Assessment: Check the elder's medical record for their target (goal) blood glucose range. If no target has been established, assume 70 mg/dl (milligrams per deciliter) as the lower threshold of the target . Assess the elder with a change in condition for the following . Severe hypoglycemia: Symptoms may include loss of consciousness, inability to awaken, seizure activity or disoriented behavior with inability to take oral carbohydrate . Interventions: . Treatment of Severe Hypoglycemia: 1. Recognize signs/symptoms of severe hypoglycemia. Check blood glucose via home's monitor and if < (less than) target blood sugar [70 mg/dl] then: - administer 25 gms (grams) of 50% Dextrose intravenously or - administer 1 mg of glucagon via IM (intramuscular) (if unable to obtain venous (IV) access) - notify MD - Check blood glucose 15 minutes after carbohydrate administration - repeat treatment until blood glucose is within target range . Review of R59's progress notes revealed the following, in part: Focus: hypoglycemic (low blood glucose). This evening shift (3/16/24), around 1640 (4:40 p.m.) staff was aware elder (R59) was lethargic and less responsive. This nurse was notified. Elder (R59) briefly opened eyes and closed them, but unable to respond to staff after saying her name loudly and physical stimulation. Elder had secretions in her mouth and throat, audible gurgling, unable to clear secretions, and mouth breathing. VS (vital signs) at 1700 (5:00 p.m.): T (temperature) 97.0, BP (blood pressure) 195/81, P (pulse) 71, O2 (oxygen saturation) 80% RA (on room air), R [respirations 28 (labored)]. HOB (head of bed) elevated. O2 NC 2L (supplemental oxygen applied via nasal cannula at 2 liters). Morphine 0.25 ml (milliliters given) at 1723 (5:23 p.m.). Shallow oral suction with [NAME], unable to hear lung sounds over audible gurgling. BG (Blood Glucose) 23 (severe hypoglycemia) at 1734 (5:34 p.m.) (assessed 54 minutes after finding R59 lethargic and less responsive). Standing order IM glucagon injection at 1740 (5:40 p.m.), elder unable to take anything PO (by mouth). BG 40 at 1751, standing order IM glucagon injection at 1755 (5:55 p.m.). Elder more alert, continues to open eyes briefly, moves head to voice. Doesn't answer yes/no questions, not safe to swallow. Called [Physician H] at 1809 (6:09 p.m.). BG 72 at 1813, he (Physician H) ordered, give another IM glucagon injection and call back with BG update . IM glucagon injection at 1823 . BG 94 at 1840 . During an interview on 5/7/24 at 2:27 p.m., when asked when blood sugar should be assessed when finding a diabetic resident (such as R59) lethargic and unresponsive, Registered Nurse (RN) I said blood sugar should be considered a vital sign and should be assessed with other vitals during a period of decline to determine the cause of the resident's change in condition. RN I said glucagon should be administered promptly after identifying that the blood sugar was low, and the resident was unable to consume foods or beverages (was unresponsive). Observation of the [Hall Name] on 5/8/24 at 7:40 a.m., with RN K found no emergency glucagon in the medication storage cabinet located on the Hall. When asked if any residents may need emergency glucagon, RN K stated, I do have residents who may need glucagon as a standing order. There was none in the cabinet in [different Hall Name] . RN K said she did not know where the glucagon was stored. The Director of Nursing (DON) approached during this interview and reported that there were two emergency glucagon kits in the facility: one each in two of five facility halls. During an interview on 5/8/24 at 8:41 a.m., the DON was asked about the lack of glucagon on all facility halls that housed diabetic residents. The DON stated, We will have them in all of the halls. And I agree with you they should be in all the halls. The DON acknowledged that only two of five halls in the facility had glucagon readily available, and with a resident in the past several months needing three injections of glucagon to raise their blood glucose levels sufficiently, they (emergency glucagon) should be on all the halls and the nursing staff should know where they are located. During a telephone interview on 5/8/24 at 9:27 a.m., RN J confirmed she was providing care to R59 on 3/16/24 when R59 was found lethargic and unresponsive. RN J stated, [R59] was breathing really heavy that day. She was less awake this time. She has had exacerbations of . heart failure - we tried morphine to help with her tachypnea (rapid, labored breathing). It was right at supper time, and it was chaotic. I called the other nurse (on duty on another hall) and she said, 'Did you check her sugar?' I said, 'Oh no, I did not. RN J confirmed R59's blood glucose was 23 mg/dL (milligrams per deciliter) (severe hypoglycemia) when first assessed 54 minutes after being found lethargic and unresponsive. When asked where emergency glucagon was found to administer to R59, RN J stated, I looked in [Hall Name] and there was none (hall were R59 resided) . I called the other nurse, and she ran to [Another Hall Name] and she had two or three of them (emergency glucagon kits). We had three total (that they found in the facility) . We had refill request sheets, and I did one for a couple of emergency glucagon kits for each house. I have never needed to provide glucagon . I did give her three injections. First off, we gave the first one and I was trying to find the policy with all of the details, and I waited another 10-15 minutes checked her sugar it was 43, then I called Physician H, and he gave me the order to give her the third one at a certain time . It took a while to find the glucagon and set it up with the kit . During an interview on 5/7/24 at 1:47 p.m., the Nursing Home Administrator (NHA) was asked if she understood this Surveyor's concern with the delay in blood sugar monitoring and administration of emergency glucagon to raise R59's blood glucose levels after R59 was found lethargic and less responsive. The NHA agreed the delay in assessment and the delay in administration of glucagon to R59, on 3/16/24, after being found with severe hypoglycemia (low blood sugar) was a concern. The NHA stated, I would be concerned if you were not concerned. The NHA said she would expect glucagon be administered within 10 minutes of finding a diabetic resident lethargic and unresponsive.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to properly store food at proper temperature while waiting to be served. 2. Failing to properly store clean dishes, cooking equipment and utensils. 3. Failing to ensure one dish machine was operating according to manufacturer's standards. 4. Failing to dispense hand towels in a sanitary manner to prevent cross contamination. 5. Failing to maintain cooking equipment in a clean condition. 6. Failing to maintain drawer storage areas for utensils in a clean condition. 7. Failing to properly post signage at all handwash sinks in the kitchens and dining rooms. 8. Failing to provide appropriate shielded lighting fixtures over food preparation and service areas. 9. Failing to maintain cooking equipment, food preparation surfaces and freezers in good repair. 10. Failing to provide a three compartment sink for the washing, rinsing and sanitizing of food contact surfaces. 11. Failing to provide minimum operating and commercially approved equipment for cooking, refrigeration and preparation activities. These deficient practices have the potential to result in food borne illness among any and all 59 residents of the facility. Findings include: 1. On 5/16/23 between approximately 12:10 PM and 12:45 PM, the noon meal was observed being served to residents in four different locations. These included the Franklin, Pewabic, [NAME], and Delaware (as named by the facility) dining rooms and associated kitchen stations. Stainless steel pans of egg salad sandwiches were observed in each of the kitchen areas. The internal temperature of the sandwiches, focusing on the egg salad filling, was measured with a metal probe thermometer. Temperatures varied between 55 F and 77 F. At 12:30 PM, on the [NAME] unit, the sandwiches in the pan were measured to be 62 F. An interview with Certified Dietary Aid (CNA) D was conducted at this time and stated she received food from the dietary department and was responsible for serving it to the residents. Staff D also stated she had measured the temperature just 2 minutes before and recorded the sandwiches were at 38F. When asked how it was possible for the temperature to increase 24 degrees, Staff D stated I don't know'. At approximately 12:35 PM the temperature of egg salad sandwiches in the Delaware kitchen were measured using the same metal stem thermometer. The egg salad filling was measured to be 57 F. At approximately 12:40 PM sandwiches in the Franklin unit were measured at 59 F. At 12:50 PM, the temperatures of the sandwiches were confirmed with Dietary Manager (DM) A. DM A stated I don't know how that happened. DM A acknowledged it was unlikely the temperature of the sandwiches had increased and the sandwiches most likely left the main kitchen above the maximum holding temperature of 41 F. The FDA Food Code 2017 states: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54 C (130 F) or above; 2. On all days of the survey, 5/16/23 through 5/18/23, clean dishes, cups, drinking glasses and cooking equipment were observed being stored on four wire racks in the Franklin dining room adjacent to the hand sink and near the windows, over a carpet floor. On 5/17/23 at 10:30 AM, an interview was conducted with Cook B regarding the storage of clean equipment in the dining room. Cook B stated that the dishes were removed from the dish washer, then taken to the racks to drain, dry and store until needed again. Cook B stated that there was no other location where these clean dishes could be stored, as the kitchen area was too small to accommodate this function. The FDA Food Code 2017 states: 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; 3. On 5/17/23 at approximately 10:40 AM, observations of the the dish machine operation, in the [NAME] kitchen were made. Five cycles were operated at this time, with none of the wash cycles, during this observation period, reaching the minimum threshold of 150 F, varying between 138 F and 143 F. An interview was conducted with Staff D, at this time, who stated they had to run water at the adjacent sink for a long period of time to get hot water. Additionally, Staff D stated the vendor had told them that it did not matter if the wash temperature did not reach 150 F, as long as the final rinse reached 180 F. A review of the manufacturer's stamp specification plate, mounted at the bottom of the dish machine was conducted. The specifications for the machine, by the manufacturer, stated the minimum wash temperature was 150 F. A review of the log book, kept by the facility for recording the testing of the dish machine, revealed sporadic examples of the irreversible color indicator failing to show the dish machine was properly sanitizing food contact surfaces in this machine. The FDA Food Code 2017 states: 4-501.15 Warewashing Machines, Manufacturers' Operating Instructions. (A) A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions. 4. On all days of the survey, May 16 to 18, 2023, hand towels were observed next to hand sinks in all kitchen/dining rooms. The hand towels were rolls, standing vertically on upright holders, and subject to splash from the sinks, and other sources of contamination. No wall mounted, sanitary dispensers were observed for food service staff to dry their hands in a sanitary manner. The FDA Food Code 2017 states: 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; 5. On 5/18/23 bewteen 8:30 AM and 9:30 AM, observations were conducted of all kitchen areas. The interior of the ovens in the Medora, Franklin, [NAME] and Delaware kitchens were observed to have grease and grime burned to the bottom and front doors of the units. Caulked seals behind the sinks, between the 4 back splash and counter tops were observed to be blackened with mold like substance. This was observed in the Franklin, Medora, [NAME], Pewabic and Delaware kitchens and hand sinks. The FDA Food Code 2017 states: 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 6. On 5/18/23 bewteen 8:30 AM and 9:30 AM, observations were conducted of all kitchen areas. Drawers with plastic dividers, used to store food service utensils were observed to be dirty. These observations were made on the [NAME] and Delaware units. The FDA Food Code 2017 states: 4-602.13 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues 7. On 5/18/23 bewteen 8:30 AM and 9:30 AM, observations were conducted of all kitchen areas. None of the hand sinks, used by food service staff, in any of the kitchens, were provided with proper signage directing staff to wash their hands. The FDA Food Code 2017 states: 6-301.14 Handwashing Signage. A sign or poster that notifies FOOD EMPLOYEES to wash their hands shall be provided at all HANDWASHING SINKS used by FOODEMPLOYEES and shall be clearly visible to FOOD EMPLOYEES. 8. On all days of the survey, all kitchens in all units were observed to have Pendant type light fixtures hanging from the ceiling, directly over the food preparation and service areas. These light fixtures were glass, with no protective shield surrounding the glass to prevent them from breakage and glass falling onto the food preparation and service areas. This was observed in the Franklin, Medora, Pewabic, Delaware, and [NAME] kitchen units. The FDA Food Code 2017 states: 6-202.11 Light Bulbs, Protective Shielding. (A) Except as specified in (B) of this section, light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas wherethere is exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; or unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. 9. On 5/18/23 between 8:00 AM and 11:00 AM, observations were made of kitchen equipment and food preparation surfaces. The white horizontal chest freezer, located in the Medora kitchen was observed to be in poor condition, with broken seals, cracked and broken plastic areas on the lid and main chest areas. The Corian-like countertop in the Medora kitchen was observed to have a major break, running from the front to the back of the counter, directly adjacent to the undercounter oven. Cracks in the counter were also observed near the residential stove/oven as well in a corner area of the counter. The fiberglass roping oven door seals were observed to be ripped, torn or otherwise in poor condition. This was observed on the residential type ovens in the Franklin, Medora, [NAME] and Delaware kitchen units. The two compartment composite constructed sinks in the Franklin, Medora and Delaware kitchens were pitted, stained and uncleanable. The hand sink in the Franklin dining room did not drain appropriately, with water standing in the bottom and splashing onto the adjacent surfaces when being use. The FDA Food Code 2017 states: 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 10. On 5/16/23 at approximately 12:15 PM, during the initial tour of the dietary department, it was observed that staff did not have access to a three compartment sink for the washing, rinsing and sanitizing of food contact surfaces. An interview at this same time with DM A confirmed that the dietary department did not have a three compartment sink. The FDA Food Code 2017 states: 4-301.12 Manual Warewashing, Sink Compartment Requirements. (A) Except as specified in (C) of this section, a sink with at least 3 compartments shall be provided for manually washing, rinsing, and SANITIZING EQUIPMENT and UTENSILS. (B) Sink compartments shall be large enough to accommodate immersion of the largest EQUIPMENT and UTENSILS. If EQUIPMENT or UTENSILS are too large for the WAREWASHING sink, a WAREWASHING machine or alternative EQUIPMENT as specified in (C) of this section shall be used. 11. On 5/16/23 at 1:30 PM an interview with DM A was conducted. It was learned that the green house style residential kitchen on the Medora unit had been converted into the main food preparation kitchen for the entire facility resident population. The facility was not provided with the minimum equipment necessary to operate a commercial kitchen. Included in these deficient operational necessities were: A. Proper cooking equipment. All cooking equipment consisted of stoves/ovens which were residential type, not designed for commercial food preparation. B. Dish washing equipment was not sufficient for the operations. There was not a three compartment sink, for the washing, rinsing and sanitizing of large food service equipment, the single compartment under counter dish washers did not have the capacity to accommodate all dish washing activities. C. Refrigeration units included four upright residential type refrigerator/freezer units in the Medora kitchen; each household (Franklin, Delaware, Pewabic and [NAME]) had only residential type refrigerator/freezer units; the large chest freezer in the Medora (main) kitchen was a non-commercial type unit, with non of the aforementioned equipment meeting the NSF (National Sanitation Foundation) standards for food service safety. D. Proper storage of single service food service materials was haphazard in the Medora kitchen, using tables and any other horizontal surface to place packages and cartons. E. Food preparation equipment, including stand up mixers were in among storage of paper products and one adjacent to a hand sink in the Medora kitchen.

Based on observation, interview and record review, the facility failed to provide an environment which was safe, functional and sanitary for residents, staff and visitors, as evidenced by the failure to provide adequate kitchen facilities for the storage, preparation and delivery of food for all 59 residents. This deficient practice has resulted in kitchen space which is not equipped with minimum standard food service equipment and space to provide for the dietary needs of the residents and has the potential to result in negative environmental impacts to residents, employees and visitors due to the lack of appropriate ventilation, space and storage needs. Findings include: On 5/16/23 at 11:45 AM, the dietary facilities were observed to be dysfunctional and unsanitary for the storage, preparation and delivery of food to residents. Observations included: 1. The main preparation kitchen had been located in an [NAME] household kitchen/dining room designed space identified by the facility as the Medora household. Food was prepared in this space for all five households of the facility. This kitchen space originally included space for dining, now designated for refrigerator/freezer and mixing equipment, 2. The main kitchen lacked minimum approved equipment, including commercial cooking and baking ovens, refrigeration units, appropriate storage space in accordance with design standards. Four of the refrigeration/freezer units were non-commercial construction, and one chest freezer was a non-commercial residential type in poor condition. Counter tops were constructed of residential type Corian material which was cracked and broken. Food service supplies, including paper goods, disposable utensils, and other equipment was stacked on tables in the area which was originally planned, designed and constructed as a resident dining room. 3. Lighting over the cooking area consisted of hanging pendant type light fixtures, with glass globes and bulbs which were not properly shielded against breakage. 4. The hand wash sink for the Medora kitchen was located in the designated storage area and not the food preparation area. There were not hand towel dispensers, rather, rolls of paper towel situated on vertical household holders which required staff to contact the entire roll with wet hands in order to tear off the towels. 5. There was no exhaust ventilation to capture and remove the excessive steam emanating from the under the counter type single compartment dish washer. There was no fresh make up air for the food service area. 6. Non commercial equipment, not meeting NSF (National Sanitation Foundation), or equivalent, standards were used throughout the kitchen, including mixers, ovens, and cooling units. 7. The kitchen was not provided with a designated housekeeping closet, including a mop sink, mop storage area and cleaning chemical storage. On 5/17/23 at approximately 3:45 PM, an interview was conducted with Cook B in the Medora preparation kitchen. The functionality of the kitchen was discussed, with Cook B stating that the kitchen was not functional. Cook B referenced the lack of commercial kitchen equipment, including refrigeration, dish washing, ventilation and storage, as well as the lack of a three compartment sink, food preparation tables/surfaces, hand washing and housekeeping (mops, chemicals, sinks, etc) facilities. On 5/18/23 at approximately 10:45 AM, an interview was conducted with Cook L in the Franklin kitchen. Cook L was asked about using the kitchen for preparation, storage and service to the residents. Cook L described the lack of usable area, pointing to the counter tops and stated there was less than 36 of space to conduct any preparation activities. The rest was consumed by table top [NAME]-[NAME] devices used to hold hot food. With respect to the storage of clean dishes, cooking equipment and utensils, Cook L pointed at the rolling racks, on wheels, located in the dining room, and explained that the clean dishes, after being removed from the dish machine, had to drain, dry and be stored in the dining room due to the lack of any other space available for such purpose. On 5/17/23 at 10:30 AM, an interview was conducted with the non-certified Dietary Manager (DM) A regarding the functionality of the kitchen. DM A acknowledged dietary staff had many problems with using the allocated space for the preparation, storage, and service of the residents' food needs. DM A acknowledged the lack of approved equipment and lack of meeting the minimum standards for the operation of a dietary department. DM A explained that the nursing home dietary functions had been totally disassociated with the attached acute care hospital's dietary department and the hospital's kitchen facilities were no longer accessible to the nursing home. On 5/18/23 at 11:30 AM, an interview with the Nursing Home Administrator (NHA) was conducted. The NHA stated the facility had been planning to construct new kitchen facilities for over two years, but nothing had occurred to commence the construction project.

Based on interview and record review, the facility failed to implement their abuse policy to ensure timely reporting of allegations of potential abuse for four Residents (R2, R5, R6, and R9) out of nine sampled residents reviewed for abuse. This deficient practice resulted in a delay in reporting of potential abuse allegations to the State Agency and the possibility of continued resident mistreatment. Findings include: The following Facility Reported Incidents (FRIs), and associated Residents, were investigated during an abbreviated survey on 4/26/23. R2 Review of a facility Investigation File revealed R2 had an unwitnessed fall with major injury (pelvic fracture and head laceration) that occurred on 8/12/22 at 9:15 p.m. Review of an 8/13/22, 8:53 a.m. typed timeline, completed by the NHA, revealed the following: [Nursing Home Administrator (NHA)] notified by [on-call manager] on 8/13/22 at 8:53 a.m., of [R2's] fall and ED (emergency department) visit . Elder's fall occurred prior evening 8/12/22 around 9:00 p.m., Elder returned from ED at 2:30 a.m. on 8/13/22. [NHA] submitted [State Agency] 2-hour report via app (application) on cell phone at 9:45 a.m. (on 8/13/22) . The 24-hour report was submitted on 8/14/23 at 4:16 p.m. During an interview on 4/26/23 at 1:13 p.m., when asked when potential allegations of abuse were to be reported to the State Agency, facility Supervisor J stated, Abuse needs to be reported immediately. Supervisor J acknowledged there was a 2-hour time limit from the time of the event for the incident/allegation to be reported. When asked about the delay in reporting of R2's unwitnessed fall with pelvic fracture and head laceration that required ED evaluation and treatment, Supervisor J confirmed they had reported the incident the following morning (8/13/22) to the NHA. R5 Review of the incident Investigation Summary submitted to the State Agency revealed R5 had an unwitnessed fall with transfer to the ED on 4/3/23 at 5:00 p.m. The summary noted, .NHA was notified at 2117 (9:17 p.m.) (more than four hours later) that elder was in wheelchair in doorway of her room and fell . Fall unwitnessed but nurse heard fall from dining room and responded to assist elder . The 2-hour report for potential abuse/serious bodily injury was submitted at 4/3/23 at 10:01 p.m. R6 Review of the incident Investigation Summary submitted to the State Agency revealed R6 had an unwitnessed fall with a right femoral neck fracture (hip fracture) on 2/3/23 at approximately 9:30 p.m. A 24-hour report was submitted on 2/6/23 at 2:46 p.m.; three days later. During an interview on 4/26/23 at 4:17 p.m., the NHA in the presence of the Director of Nursing (DON), confirmed reporting of this incident involving R6 to the State Agency was completed late, and not within a 2-hour or a 24-hour period. R9 Review of the incident Investigation Summary submitted to the State Agency revealed R9 was found with the imprint of a hand on the left hip, discovered on 4/10/23 at 3:16 a.m. during night shift. The Summary noted the NHA and DON assessed the marking on 4/10/23 at 11:00 a.m., and the marking appeared to be that of a right hand. The NHA documented in the summary, . 2-hour report was not done because NHA was not notified at the time the markings were found (3:16 a.m.) . The incident was initially reported to the State Agency on 4/10/23 at 12:21 p.m. During an interview on 4/26/23 at 4:00 p.m., the NHA confirmed she did not complete a 2-hour potential abuse report to the State Agency. Review of the facility LTC (Long Term Care) Breech of Elder's Rights policy, last revised 3/8/23, revealed the following, in part: .All members of the healthcare team, volunteers, family members, and others are encouraged to report any incidents of abuse or suspected abuse immediately to the Manager on call and to licensed staff on duty, ultimately to be reported to the Nursing Home Administrator immediately . If the manager on call is not the Nursing Home Administrator, the manager who is on call will immediately notify the Nursing Home Administrator . Failure to comply with keeping the Elder safe and/or immediate reporting will result in corrective action . 9. All incidents/allegations involving suspected abuse will be reported to the manager on call immediately and then to the Administrator, but no later than 2 hours after the allegation is made. The Administrator will have the nurse initiate LTC Suspicion of Abuse protocol. The Administrator will complete a 2-hour notification to the State of [Name], initiate investigation, and complete a 24-hour report to the State of [Name] . During an interview on 4/26/23 at 3:39 p.m., the NHA, DON, and Assistant Director of Nursing (ADON) were asked to review the timeframes of the eight FRIs reviewed during the abbreviated survey, and the timeliness of reporting allegations of potential abuse. The DON acknowledged the facility management team believed the 2-hour reporting timeframe began when the abuse coordinator/NHA was notified by facility staff of each incident. They were unaware the 2-hour timeframe began when the incident was discovered by facility staff. The NHA acknowledged the absence of, or late submission of the above potential abuse allegation reports to the State Agency.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and active/functioning door alarms to prevent the elopement of one Resident (R1), out of eight residents reviewed for safety and supervision. This deficient practice resulted in R1's unsupervised and unobserved elopement from the building and the potential for injury due to decreased safety awareness. Findings include: Review of R1's Minimum Data Set (MDS) assessment, dated 6/14/22, revealed R1 scored 3 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severely impaired cognition. R1 ambulated independently and wore a code alert bracelet (alarmed bracelet) to prevent unnoticed elopement from the facility. R1 had the following active diagnoses, in part: Alzheimer's disease, dementia, and history of falling. Review of the Incident Summary submitted to the State Agency on 7/3/22 at 9:00 p.m., revealed the following, in part: . On Saturday 7/2 around 11:32 a.m., [Nursing Home Administrator (NHA)] was notified that R1 had eloped from the facility. Upon interviewing Elder Associate [(CNA) D], [CNA D] states that R1 had been at the emergency exit in [facility hall] multiple times that morning pushing on the door to get out and the door was alarming. [CNA D] put her key into the lock to shut off the alarm. Later, [CNA D] was sitting in the [facility hall] nurses office and was informed that Elder [Resident Name] who was out on the Delaware patio saw R1 walking in the parking lot outside of [Name of Unit] house and he waved for [CNA I] Elder Associate to come and help. [Resident Name] reported to [CNA I] that R1 was out walking and [CNA I] jumped the fence from the [Name of Unit] garden and got R1, bringing her back into the facility. R1's code alert alarmed when coming back into the facility indicating that the code alert was working When the [Name of Unit] emergency door was assessed after the incident, the light was green which indicates the door was not locked. Door subsequently locked by Assistant Director of Nursing (ADON)/Registered Nurse (RN) and light noted to be red . Review of R1's Progress Notes revealed the following 7/2/22 at 12:15 p.m. Nurse Note: Elder was found an estimated 150 ft outside of [Name of Unit] house at 1125 (11:25 a.m.) Elder on patio notified [CNA I], EA (Elder Associate) who walked Elder (R1) back to the front of the building. When briefing about the situation, elder (R1) had set off alarm to emergency door and [CNA D] EA, unlocked door to turn alarm off. EA (CNA D) reports that she thought she re-locked the door, but it was unlocked when inspected. Elder's (R1's) code alert went off when returning to the building, so that is intact and in working condition . During an interview on 4/25/23 at 11:56 a.m., CNA D confirmed R1's had activated the exit door alarm on 7/2/22 in the unit she was working on. CNA D stated, It was beautiful (outside), and she (R1) was trying to get out. The (door) alarm went off. I put the key in the door (lock) to turn the alarm off and I took her (R1) back to [her unit] . She (R1) had come back down (to CNA D's unit), and I did not turn it (the door alarm) back to the red light (to show the alarm was active). It was my fault . [R1] came back (to the exit door) and I had not turned the alarm back on . During an observation on 4/25/23 at approximately 12:05 p.m., CNA D demonstrated how the exit alarm had been disabled with a key on 7/2/22 turning the light green and reactivated with a turn of the key to a red light. An Emergency Exit Door Lock Monitoring tool was placed on the wall next to the door with staff signatures present to show door lock assessments were being completed. A red card was visible over the light, that required staff to move the card to assess the color of the light. Review of the facility LTC Missing Elders - Elopement policy, last revised 2/28/23, revealed the following, in part: The safety of every Elder is of prime concern to the organization . Procedure . Every exit door is to be checked to determine that they are locked and if there is any evidence that the Elder may have exited by any of these doors . The facility self-identified the deficiency and re-educated all facility staff on 7/5/22 regarding the importance of relocking the emergency doors when turning off the exit alarm and how to do this. Education was provided to staff via email and further education was provided during NHA rounds. An Emergency Exit Door Lock Monitoring tool was placed in each house (unit). Tool provided instructions to staff to check that emergency doors are locked and that this should be done twice per shift, once in the first half of the shift and once in the second half of the shift. Monitoring tool also provided re-education that the door is locked when the red light is on and instructs staff to complete the tool upon each check. NHA randomly spot-checked tool to ensure it was being completed and to continue to educate staff. NHA checks of tool completion were done approximately twice per week. Intervention also included placement of red card over lock/light so that staff are required to physically go to the emergency door lock to see the light and lift the sign to check the color of the light. Monitoring tool was placed next to the lock so staff could document their lock check at the time of checking the lock. NHA twice weekly checks of monitoring tool completion noted staff were completing door checks and monitoring tool as required. No additional resident elopements occurred since R1's elopement on 7/2/22. The facility was determined to be compliant with the requirements of Past Noncompliance at F689 as of 7/25/22 following review of the deficiency identification, immediate action to correct the deficiency, education of staff, and continued monitoring to ensure compliance.

Based on interview and record review, the facility failed to ensure the physician conducted a timely medical review for one Resident (#200) out of one resident reviewed for physician services. This deficient practice resulted in harm when the physician did not respond to faxed documentation related to Resident #200 change of condition. This resulted in deterioration of Activities of Daily Living (ADLs), weight loss, decreased oral intake, somnolence (sleeping for unusually long periods, and unexpected death. Findings include: Review of Complaint Intake Number: MI 763, filed [DATE], read in part, a recent resident death may be at fault of (nursing home) staff. This is a summary of the allegation . Her physician prescribed a high increase of a [MEDICATION NAME] (a powerful synthetic opioid [MEDICATION NAME] that is similar to [MEDICATION NAME] but is 50 to 100 times more potent), about a week and a half ago. Before the dose increase, the resident reportedly ate 51%-75% of meals and drank (up) to 2500 cc of fluids After the dose adjustment she began not eating, not drinking, not using the restroom appropriately, sleeping up to 20 hours per day .The resident has since passed away . Review of Resident #200's Minimum Data Set (MDS) assessment, reference date [DATE], revealed the following major Diagnoses: [REDACTED]. The same MDS assessment showed Resident #200 required only supervision with bed mobility, transfers, ambulation, and eating. Resident #200 was 60 inches (five feet) tall, and weighed 108 pounds, with a documented significant weight loss. The MDS assessment Prognosis Sectionindicated Resident #200 did not have a condition or chronic disease that would result in a life expectancy of less than 6 months. Review of Resident #200's Progress Note, written by Registered Nurse (RN) W on [DATE] at 11:03 a.m., revealed: .MEMO to MD (Physician/Medical Director DD ) faxed today: Since [MEDICATION NAME] increased from 12 mcg to 25 mcg on ,[DATE], elder has the following changes: Refuses food and fluids frequently, looks around often staring but seldom verbal, weight loss of 7.4 lbs. (pounds) since [DATE], confusion with simple commands, unsteady gait, refusing medications, despite crushing. Attached weights, MAR (Medication Administration Record), progress notes, and May PRN (as needed) MAR. Request MD to review and advise, consider reducing [MEDICATION NAME] back to 12 mcg and scheduling [MEDICATION NAME] (narcotic pain medication) ,[DATE] times daily vs (versus) PRN. Behavioral issues are previously noted on days elder did not receive [MEDICATION NAME]. Faxed. During an interview on [DATE] at 12:59 p.m., the Nursing Home Administer (NHA) and the Director of Nursing (DON) were asked for all documentation to show the facility had addressed the nurses' repeated concerns with Resident #200's decline in condition (nurse progress notes) with the increased [MEDICATION NAME] dose on [DATE]. In addition, a copy of RN W's facsimile, sent to Physician DD on [DATE], was requested to provide evidence of Physician DD's actions to address RN W's specific request to decreased Resident #200's [MEDICATION NAME] dosage. The last pharmacy PRN medication review FOR PHYSICIAN REVIEW AND SIGNATURE, dated [DATE], was not completed by Physician DD. The Pharmacist' s review required the physician, in order to continue PRN medication use, to directly examine/assess Resident #200 and to document the risk versus benefit with continued use. Review of the last physician progress notes [REDACTED].#200's death on [DATE], occurred on [DATE], by Nurse Practitioner (NP) EE who performed an audiovisual (video) visit. All physician progress notes [REDACTED]. The last time Physician DD examined Resident #200 was on [DATE] per the physician progress notes [REDACTED]. During an interview on [DATE] at 2:06 p.m., the NHA and DON were again asked for RN W's facsimile to Physician DD, the DON stated, That's the piece we cannot find . It was in a folder and must have gotten shredded when she (Resident #200) was discharged (death). Regarding communication with Physician DD, the DON stated they had tried to communicate by calls to cell phone, home and office, as well as two emails, but did not get a reply. The DON said there was an IDT (Interdisciplinary Team) meeting on [DATE] where Physician DD, although not present, was notified of Resident #200's status. The DON confirmed she had taken the minutes of the meeting. Evidence of when, how, and what was communicated to the physician in regard to Resident #200's change in condition, was requested. The DON provided no additional evidence to show Physician DD was aware and addressed Resident #200's significant change in condition. Review of Resident #200's Nursing Progress Notes revealed the following nursing concerns: [DATE] - very lethargic this shift .only accepted about 80 ml (milliliters) of fluid this shift. The increase in elder ' s [MEDICATION NAME] seems to have contributed to elder ' s change in behavior . [DATE] - Elder would not stand or move. Elder would not respond (sic) to staff, she would look in direction if touched but, would not verbally respond (sic) to questions . [DATE] - .refuses to eat .pushed food around plate, takes occasional sips of liquids .refused medications .ambulating independently in hallway, weaving slightly . [DATE] - Elder sleepy, doesn't talk much. Elder spits out PO (oral) medications a couple of times then held them in mouth for several minutes .somewhat unsteady on feet. During an interview on [DATE] at approximately 2:10 p.m., the NHA and DON were asked why further action was not taken, when Physician DD did not respond to RN W's faxed concerns? The NHA and DON did not respond. When asked about Physician DD's schedule for resident visits, the NHA indicated Physician DD had not provided the facility a set schedule, and therefore they never knew when to expect him in the building. The NHA continued to explained that Physician DD had not been in the facility since the beginning of Covid-19 to perform resident visits. During a telephone interview on [DATE] at 6:04 p.m., RN W confirmed she had sent a facsimile herself to Physician DD on [DATE] at approximately 11:00 a.m., regarding her concern with Resident #200' s potential over-sedation and included additional documents to support her clinical concern with over sedation. RN W further explained when faxes were sent to physician offices, there was a file folder in each house (living area), with a log sheet to record incoming and outgoing faxes. RN W indicated Physician DD never responded to her concerns regarding Resident #200 on [DATE]. Review of facility's LTC parameters for Notification of Physician by Nursing Staff policy, approved [DATE], read in part, The physician is to be notified in at least the following situations: 1. Any significant change in condition. 2. Any change in condition that may affect the current level of care the elder is receiving .7. Any side effect of new medication or treatment .

Based on interview and record review, the facility failed to ensure that pain management was safely provided consistent with professional standards of practice for one Resident (#200) of four reviewed for pain management. This deficient practice resulted in harm with potential over sedation of Resident #200 with multiple pain medications, including [MEDICATION(S)]. Findings include: According to Complaint Intake Number: MI 763, filed [DATE], read in part, a recent resident death may be at fault of (nursing home) staff. This is a summary of the allegation . Her physician prescribed a high increase of a [MEDICATION(S)] patch (a powerful synthetic opioid [MEDICATION(S)] that is similar to [MEDICATION(S)] but is 50 to 100 times more potent), about a week and a half ago. Before the dose increase, the resident reportedly ate 51%-75% of meals and drank (up) to 2500 cc of fluids After the dose adjustment she began not eating, not drinking, not using the restroom appropriately, sleeping up to 20 hours per day .The resident has since passed away . According to Resident #200 ' s Minimum Data Set (MDS) assessment, reference date [DATE], revealed the following major Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The same MDS assessment showed Resident #200 required only supervision with bed mobility, transfers, ambulation, and eating. Resident #200 was 60 inches (five feet) tall, and weighed 108 pounds, with a documented significant weight loss. The MDS assessment Prognosis Section indicated Resident #200 did not have a condition or chronic disease that would result in a life expectancy of less than 6 months. On [DATE] at 12:59 p.m., Nursing Home Administrator (NHA) and Director of Nursing (DON), in the presence of a second Surveyor, were interviewed regarding the complaint investigation, filed [DATE], involving Resident #200 unexpected death. Resident #200's Progress Note, written by Registered Nurse (RN) W on [DATE] at 11:03 a.m., was read aloud, Note Text: MEMO to MD (Physician DD )faxed today: Since [MEDICATION(S)] patch increased from 12 mcg to 25 mcg on ,d+[DATE], elder has the following changes: Refuses food and fluids frequently, looks around often staring but seldom verbal, weight loss of 7.4 lbs. (pounds) since [DATE], confusion with simple commands, unsteady gait, refusing medications, despite crushing. Attached weights, MAR (Medication Administration Record), progress notes, and May PRN (as needed) MAR. Request MD to review and advise, consider reducing [MEDICATION(S)] back to 12 mcg and scheduling [MEDICATION(S)] (narcotic pain medication) ,d+[DATE] times daily vs (versus) PRN. Behavioral issues are previously noted on days elder did not receive [MEDICATION(S)]. Faxed. The NHA and DON were asked to provide a copy of RN W's facsimile as noted above, sent to Physician DD on [DATE], and to indicate Physician DD's response to RN W ' s request for a decreased in Resident #200 ' s [MEDICATION(S)] dose. When asked the DON confirmed Resident #200 was not considered end-of-life, not receiving comfort care, nor on hospice prior to her death on [DATE]. The NHA and DON were asked to show how the facility had monitored the increased [MEDICATION(S)] dose which doubled from 12.5 mcg to 25 mcg on [DATE]. During the same interview this Surveyor asked and showed the NHA and DON the last PRN medication review FOR PHYSICIAN REVIEW AND SIGNATURE, dated [DATE], which was not addressed (left blank) by Physician DD. The Pharmacist's review required the physician, in order to continue PRN medication use, to directly examine/assess Resident #200 and to document the risk versus benefit with continued use. Neither the NHA or DON responded, and both took Resident #200's closed medical record and left the room, suspending the interview. On [DATE] at 2:06 p.m., the NHA and DON returned to continue the interview. When asked for RN W's facsimile to Physician DD on [DATE], the DON stated, That's the piece we cannot find . This Surveyor expressed concerns with potential over-sedation after reading several sections of Resident #200's nursing progress notes to the NHA and DON, which included the following: [DATE] - new [MEDICATION(S)] dose (from 12.5 mcg to 25 mcg) [DATE] - [MEDICATION(S)] PRN administered [DATE] - very lethargic this shift .only accepted about 80 ml (milliliters) of fluid this shift. The increase in elder ' s [MEDICATION(S)] patch seems to have contributed to elder ' s change in behavior . [DATE] - Elder would not stand or move. Elder would not respond (sic) to staff, she would look in direction if touched but, would not verbally respond (sic) to questions . [DATE] - .refuses to eat .pushed food around plate, takes occasional sips of liquids .refused medications .ambulating independently in hallway, weaving slightly . [DATE] - Elder sleepy, doesn ' t talk much. Elder spits out PO (oral) medications a couple of times then held then in mouth for several minutes .somewhat unsteady on feet. This Surveyor expressed concern with almost daily clinical notes, from multiple nurses, that indicated signs of potential over-sedation without any other facility notification to the physician for intervention for Resident #200. The NHA and DON were asked what the protocol was if a physician does not respond to a nurse's notification of a significant change in condition. The NHA said the nurse can call the on-call physician at the hospital and/or send the resident to the emergency room for evaluation (which was not done for Resident #200). When asked why further action was not taken, when Physician DD (also facility Medical Director) did not respond to RN W's faxed concerns, the NHA and DON did not respond. When asked to collectively review Resident #200's electronic medical record for vital signs, the record showed the last complete set of vitals was documented on [DATE]. No oxygen saturation assessments were documented for Resident #200 during this time. When asked if this was a concern, especially during the Covid-19 pandemic when all resident vital signs were assessed at least daily, the NHA and DON both acknowledged the concern with omission of vital sign information from [DATE] to [DATE] for Resident #200, which would have been relevant for narcotic medication management for pain. Review of Nursing 2016 Drug Handbook for [MEDICATION(S)] indicated the following nursing considerations: Monitor circulatory and respiratory status and urinary function carefully. Drug may cause respiratory depression, [CONDITION(S)], urine retention, nausea, vomiting .or altered level of consciousness . Review of Resident #200's [DATE] at 7:10 a.m. progress note, read in part: Action: (Administered) [MEDICATION(S)] ,d+[DATE] mg PO (oral) 1 (tablet) at 7:10 (a.m.) . Review of Resident #200's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #200 ' s Nurse Practitioner ' s (NP) EE ' s progress note from an audiovisual visit on [DATE] read in part, Over the last month, the patient has had improved pain management with her patch. She continues to have pain, but again it is improving. She tells me her pain is mainly in her lower back . At the time of this visit Resident #200 was receiving the following physician ordered medications, in part: [MEDICATION(S)] (antidepressant), [MEDICATION(S)] (antipsychotic), [MEDICATION(S)] (benzodiazepine), [MEDICATION(S)] ,d+[DATE] (narcotic pain medication), [MEDICATION(S)] patch 5% (pain medication), [MEDICATION(S)] (antipsychotic), lorazepam (benzodiazepine), and [MEDICATION(S)] (pain medication). Review of NP's EEs, [DATE] new order, read, Increase to [MEDICATION(S)] 25 mcg patch from 12 mcg patch. During a telephone interview on [DATE] at 6:04 p.m., RN W confirmed her concerns with potential over-sedation of Resident #200. RN W notified Physician DD by facsimile on [DATE] at approximately 11:00 a.m., and did not receive a response prior to the end of her shift. Her concerns were noted in the nursing progress note, and communicated during report to the oncoming afternoon shift. RN W said Resident #200 was not her regular self, not eating, not drinking, sleeping excessively, and she had gone from being independent with ADLS (Activities of Daily Living) to being totally dependent on staff in a short period of time. RN W said she knew Resident #200 well, because she had provided care for her in a previous facility, as well as this facility. RN W returned to work on [DATE] and learned Resident #200 was then deceased . Upon review of [DATE]'s progress notes, RN W said the progress note did not support CNA documentation of Resident #200's total dependence on staff for ADLs immediately prior to her death. Review of facility's LTC parameters for Notification of Physician by Nursing Staff policy, approved [DATE], read in part, The physician is to be notified in at least the following situations: 1. Any significant change in condition. 2. Any change in condition that may affect the current level of care the elder is receiving .7. Any side effect of new medication or treatment .

Based on observation, interview, and record review, the facility failed to ensure training with competency and monitoring of staff use of the mechanical lift, for 10 Residents (#2, 5, 12, 24, 27, 29, 31, 32, 40, 55) that required dependent mechanical lift transfers. This deficient practice resulted in Resident #24's fall from a lift requiring emergency care, when an inappropriate sling size was used for the resident's transfer, and immediate jeopardy, with the potential for serious bodily harm or death, for all 10 residents who required dependent mechanical lift transfers. The immediate jeopardy began on 1/29/19 at 10:30 a.m., when Resident #24 fell from a too large sling, while being transferred from the toilet by mechanical lift. The Administrator (NHA) was notified of the immediate jeopardy on 2/1/19 at 8:15 a.m., and the request was made for an abatement plan. The immediate jeopardy was removed on 2/1/19 at 11:50 a.m., when the facility received acceptance of, and began implementation of its Plan of Removal for Immediate Jeopardy, that included: -Proper assessment of the 10 potentially affected Residents, with a licensed Registered Nurse (RN) -Training of all nurses and Certified Nurse Aides (CNAs), who work with mechanical lifts -Assure all staff, who work with mechanical lifts are competent prior to transferring any resident with the mechanical lift -Development of a policy to include frequency of assessment and re-assessment of any resident who uses a mechanical lift, for the proper sling size Noncompliance remained at a level of no actual harm with the potential for more than minimal harm, until confirmation of completion of the abatement plan, and verification of the facility process to ensure resident safety, has been completed. Findings include: According to the Minimum Data Set (MDS) assessment, dated 11/27/18, Resident #24 was severely cognitively impaired, and required extensive assistance of 2 staff for transfers. Resident #24 had [DIAGNOSES REDACTED]. On 1/29/19 at 10:30 a.m., CNA A was transferring Resident #24, from the toilet, using a large hygiene sling with the dependent full mechanical ceiling lift, when Resident #24 fell backward from the sling, to the floor, hitting her head on the tile floor, according to CNA A, at the time of the incident. Resident #24 was transferred to the emergency room for evaluation, after placement of a neck immobilizer. The sling used for transfer, was observed in the room immediately following the fall, and did not have a colored tag on it and its label was worn illegible. The sling had a blue strap down the back. During an interview on 1/29/19 2:02 p.m., when asked how she knew what size sling to use with Resident #24, CNA A stated, (Resident #24) uses a large. It's in her care plan. Look, you can see how long it is. It's a large. The blue strap on the back means large. When asked how she knew if the sling fit correctly, CNA A said, It fit how it usually fits, I didn't think anything was wrong. CNA A confirmed the waist/vest strap on the sling was usually loose to Resident #24's body, leaving about 3 inches space. During an interview on 1/29/19 at 11:40 a.m., the Administrator (NHA) was asked for any and all policies regarding mechanical lifts, slings, and transfers. On 1/29/19 at 1:08 p.m., the NHA confirmed there were no policies available regarding sling size, transfer or lifts. The NHA also confirmed there were two total lift slings in use at the facility; one for general transfers, which was a full sling, and one, a hygiene sling, without a bottom, used for toileting and other hygiene. The hygiene sling had a top vest strap, a strap under the thighs, and a waist strap, within the vest area, leaving the bottom side open for toilet access. During an interview on 1/29/19 at 3:25 p.m., the NHA confirmed she entered the sling size as large in Resident #24's care plan on 12/14/17. The NHA was asked how she came to the sling size decision, and responded, It's based on weight. It must have been somewhere else in the chart. The source document the NHA referred to, was requested from the NHA at that time, but not received. The NHA confirmed no direct individual fitting was done for any residents, in determining sling size. The NHA provided a list of ten residents in the facility who used the dependent mechanical lift for transfers, and confirmed the process of sling size selection was the same for all ten residents. The (brand) Sling Selection Chart, not dated, revealed, .Universal Sling .Medium Yellow 110-190 pounds .The following assessment criteria should be used as a guideline for Ultra Sing fitting only. Direct fitting to the patient remains the most reliable method. Resident #24's weight was 180.6 pounds on 1/20/19, according to the electronic medical record (EMR). Resident #24's care plan, dated 12/14/17, revealed a large sling for use with transfers. According to the EMR, Resident #24 weighed 194.8 pounds on 11/16/17, the last recorded weight prior to the care plan entry on 12/14/17, for sling size. The weight difference between 11/16/17 and 1/29/19, was 14.2 pounds. No re-assessment of sling was done during that time. During an interview on 1/29/19 at 1:08 p.m., the NHA was asked if there were guidelines for the using the lift slings, and responded, No. When asked for a policy regarding sling use and the facility mechanical lifts, the NHA stated, No we don't have any policy for the lifts or slings. For transfers there is a policy for level of assistance, but not for the slings. When asked if Resident #24's care plan dated 12/14/17, was the last assessment of Resident #24's sling size, the NHA confirmed it was. During an interview on 2/01/19 at 9:11 a.m., with the NHA confirmed no further sling assessment was done, following Resident #24's weight loss from 11/17 to 1/19, stating, It was gradual and not significant. If there was a policy in place maybe it would have been done. The NHA said she understood that lack of reassessment was a problem. On 1/29/19 at 4:20 p.m., observation was made of a transfer with full lift and hygiene sling, of Resident #55, from the bed to a chair, by CNAs C and D. The sling had a yellow tab, designating Medium. CNA C applied the waist strap to the lift using the fourth loop. When asked how she knew what loop to use, CNA C state, Everybody does it differently. I don't know if there is one right or wrong way. When asked if two people are ever required for transfer, CNA C stated, It depends on the resident. Sometimes (Resident #24) is combative and I would never use one (CNA) with that. According to the MDS assessment, dated 12/4/18, Resident #27 was severely cognitively impaired, with [DIAGNOSES REDACTED]. On 1/29/19 at 4:50 p.m., observation was made of a transfer with full lift and hygiene sling, of Resident #27, from the bed to a chair, by CNAs E and F. The sling size was extra large, as indicated by the black tab attached. CNA F was asked why he chose the lower loops for lift attachment, and said that keeps the resident sitting upright. When Resident #27 was lifted off the bed, his position was half reclined, not upright. The sling waist/vest strap was very loose leaving 8-10 inches between the sling and the body. Resident #27 was not supported in the sling and hung very low below the sling. When asked who decides what sling size to use, CNA E stated, I think (the NHA) does that. The document Hygiene Vest, not dated, revealed, Hygiene Vest .are designed for safe and comfortable lifting to and from the toilet. The vest offers almost fully upright sitting, and provides functional and safety advantages. The Hygiene Vest works well in complicated situations .The vest section firmly supports the upper body during lifting .Our smart guide can help you find a suitable sling for the lifting needs at your facility or for a specific patient. Remember that the more information you fill in, the more relevant your result becomes. Obviously, the guide does not replace an individual fitting, which we always recommend . During an interview on 1/29/19 at 1:38 p.m., the NHA was asked for any manufacturer information in house, for the lifts in the facility, and responded, No, we don't have any information in house on the lifts. During an interview on 2/01/19 at 9:33 a.m., The DON and NHA were asked if there was a policy in place, would the inaccurate sling size have been caught and re-assessed. The NHA stated, It could have. During a phone interview on 1/29/19 at 1:31 p.m., the education nurse, Registered Nurse (RN) B, was asked about the training provided to CNAs regarding lift use, transfers and slings, and said she provided classroom orientation for two days to new CNAs, then the CNA was assigned to a mentor, determined by the NHA, on the floor to complete competencies. RN B said the materials used in the classroom settings did not include any manufacturer guidelines or materials, for the lifts and slings. RN B also said she did not monitor or confirm CNA competency following training, adding the mentoring CNA signed off on the orienting CNA's competency sheet. When asked if CNAs are trained to assess someone else's competency, RN B said no. RN B also confirmed there was no training for the mentor role. During an interview on 1/29/19 at 1:38 p.m., the NHA was asked the criteria for appointing CNA mentors, and stated, (CNAs) shadow with the most senior (CNA) on shift. The NHA also confirmed there was no manufacturer guidelines or printed information in house, used in training. When asked how the training was created, the NHA stated, There is a 1:1 return demonstration. When asked what information was used for the training process, the NHA stated, I came up with my own training sheet. CNA A's orientation and competencies were requested at this time, as well as any manufacturer guidelines and information, from the NHA. CNA A's Core Competency for (brand) lift system, dated 2/22/13, revealed Reads the Sling Application Golden Rules & transfer guides prior to transferring elder., initialed on 2/22, signed by CNA A on 2/22/13. The Sling Application Golden Rules guide was requested from the NHA. The document showed all applications with a taught waist/vest strap, close to the body. The document Sling Application Golden Rules, dated 12/7/06, revealed, Proper training in sling application involves hands on instruction from a qualified mentor for both the lift and sling being used. Sling application may also be reviewed from (brand) lift In-service videos. During an interview on 1/29/19 2:02 p.m., CNA A was asked how long she worked at the facility and if she ever mentored any new CNAs and responded, I've worked here 6 years, and yes, I've trained new CNAs. CNA A denied having training in mentoring others.

This citation has two deficient practice statements, A and B: A: Based on observation, interview, and record review, the facility failed to ensure one Resident (#24) was transferred safely using a mechanical lift, and failed to adequately assess proper mechanical lift sling size for 10 (#2, 5, 12, 24, 27, 29, 31, 32, 40, 55) residents who required dependent mechanical lift transfers. This deficient practice resulted in Resident #24's fall from a lift requiring emergency care, when an inappropriate sling size was used for the resident's transfer, and immediate jeopardy, with the potential for serious bodily harm or death, for all 10 residents who required dependent mechanical lift transfers. The immediate jeopardy began on 1/29/19 at 10:30 a.m., when Resident #24 fell from a too large sling, while being transferred from the toilet by mechanical lift. The Administrator (NHA) was notified of the immediate jeopardy on 2/1/19 at 8:15 a.m., and the request was made for an abatement plan. The immediate jeopardy was removed on 2/1/19 at 11:50 a.m., when the facility received acceptance of, and began implementation of its Abatement Plan for Removal of Immediacy, that included: -Proper assessment of the 10 potentially affected Residents, with a licensed Registered Nurse (RN) -Training of all nurses and Certified Nurse Aides (CNAs), who work with mechanical lifts -Assure all staff, who work with mechanical lifts are competent prior to transferring any resident with the mechanical lift -Development of a policy, to include frequency of assessment and re-assessment of any resident who uses a mechanical lift, for the proper sling size Noncompliance remained at a level of no actual harm with the potential for more than minimal harm, until confirmation of completion of the abatement plan, and verification of the facility process to ensure resident safety, has been completed. Findings include: According to the Minimum Data Set (MDS) assessment, dated 11/27/18, Resident #24 was severely cognitively impaired, and required extensive assistance of two staff for transfers. Resident #24 had [DIAGNOSES REDACTED]. During an interview on 1/29/19 at 10:30 a.m., at the scene of the incident, CNA A said she was transferring Resident #24, from the toilet, using a large hygiene sling with the dependent full mechanical ceiling lift, when Resident #24 fell backward from the sling to the floor, hitting her head on the tile floor. This Surveyor observed Resident #24 transferred to the emergency room for evaluation, after placement of a neck immobilizer. During an interview on 1/29/19 at 11:40 a.m., the Nursing Home Administrator (NHA) was asked for any and all policies regarding use of mechanical lifts, slings, and transfers. On 1/29/19 at 1:08 p.m., the NHA confirmed there were no policies available regarding sling size, transfer or lifts. The NHA also confirmed there were two total lift slings in use at the facility; one for general transfers, which was a full sling, and one, a hygiene sling, without a bottom, used for toileting and other hygiene. The hygiene sling had a top vest strap, a strap under the thighs, and a waist strap, within the vest area, leaving the bottom side open for toilet access. During an interview on 1/29/19 at 3:25 p.m., the NHA confirmed she entered the sling size as large in Resident #24's care plan on 12/14/17. The NHA was asked how the sling size decision was made, and responded, It's based on weight. It must have been somewhere else in the chart. The source document the NHA referred to, was requested from the NHA at that time, but not received. The NHA confirmed no direct fitting was done for any residents, in determining sling size. The NHA provided a list of ten residents in the facility that used the dependent mechanical lift for transfers, and confirmed the process of sling size selection was the same for all ten residents. The (brand) Sling Selection Chart, not dated, revealed, .Universal Sling .Medium Yellow 110-190 pounds .The following assessment criteria should be used as a guideline for Ultra Sling fitting only. Direct fitting to the patient remains the most reliable method. Resident #24's weight was 180.6 pounds on 1/20/19, according to the electronic medical record (EMR). The sling used for transfer, was observed in the room immediately following the fall, and did not have a colored tag on it and its label was worn illegible. The sling had a blue strap down the back. During an interview on 1/29/19 2:02 p.m., CNA A was asked how she knew what size sling to use with Resident #24, CNA stated, (Resident #24) uses a large. It's in her care plan. Look, you can see how long it is. It's a large. The blue strap on the back means large. When asked how she knew if the sling fit correctly, CNA A said, It fit how it usually fits, I didn't think anything was wrong. CNA A confirmed the waist/vest strap on the sling was usually loose to Resident #24's body, leaving about 3 inches space. Resident #24's care plan, dated 12/14/17, revealed a large sling for use with transfers. On 1/29/19 at 4:20 p.m., observation was made of a transfer with full lift and hygiene sling, of Resident #55, from the bed to a chair, by CNAs C and D. The sling had a yellow tab, designating Medium. CNA C applied the waist strap to the lift using the fourth loop. When asked how she knew what loop to use, CNA C stated, Everybody does it differently. I don't know if there is one right or wrong way. When asked if two people are ever required for transfer, CNA C stated, It depends on the resident. Sometimes (Resident #24) is combative and I would never use one (CNA) with that. According to the MDS assessment, dated 12/4/18, Resident #27 was severely cognitively impaired, with [DIAGNOSES REDACTED]. On 1/29/19 at 4:50 p.m., observation was made of a transfer with full lift and hygiene sling, of Resident #27, from the bed to a chair, by CNAs E and F. The sling size was extra large, as indicated by the black tab attached. CNA F was asked why he chose the lower loops for lift attachment, and said that keeps the resident sitting upright. When Resident #27 was lifted off the bed, his position was half reclined, not upright. The sling waist strap was very loose leaving 8-10 inches between the sling and the body. Resident #27 was not supported in the sling and Resident #27's bottom and most of his back hung very low below the sling. When asked who decides what sling size to use, CNA E stated, I think (the NHA) does that. The document Hygiene Vest, not dated, revealed, Hygiene Vest .are designed for safe and comfortable lifting to and from the toilet. The vest offers almost fully upright sitting, and provides functional and safety advantages. The Hygiene Vest works well in complicated situations .The vest section firmly supports the upper body during lifting .Our smart guide can help you find a suitable sling for the lifting needs at your facility or for a specific patient. Remember that the more information you fill in, the more relevant your result becomes. Obviously, the guide does not replace an individual fitting, which we always recommend . During an interview on 1/29/19 at 1:08 p.m., the NHA was asked if there were guidelines for the using the lift slings, and responded, No. When asked for a policy regarding sling use and the facility mechanical lifts, the NHA stated, No we don't have any policy for the lifts or slings. For transfers there is a policy for level of assistance, but not for the slings. When asked if Resident #24's care plan dated 12/14/17, was the last assessment of Resident #24's sling size, the NHA confirmed it was. According to the EMR, Resident #24 weighed 194.8 pounds on 11/16/17, the last recorded weight prior to the care plan entry on 12/14/17, for sling size. The weight difference between 11/16/17 and 1/29/19, was 14.2 pounds. No re-assessment of sling was done during that time. During an interview on 1/29/19 at 1:38 p.m., the NHA was asked for any manufacturer information for the lifts in the facility, and responded, No, we don't have any information in house on the lifts. During an interview on 2/01/19 at 9:11 a.m., the NHA confirmed no further assessment was done, following Resident #24's weight loss from Nivember (YEAR) to (MONTH) 2019, stating, It (Resident #24's weight loss) was gradual and not significant. If there was a policy in place maybe it would have been done. The NHA said she understood that lack of reassessment was a problem. During an interview on 2/01/19 at 9:33 a.m., The DON and NHA were asked if there was a policy in place, would the inaccurate sling size have been caught and re-assessed. The NHA stated, It could have. B: Based on interview and record review, the facility failed to provide adequate supervision and assistive devices to prevent falls for three Residents (#3, 7 and 43), of 17 reviewed for falls. This deficient practice resulted in the potential for injury, related to falls. Findings include: Resident #3 Review of an Incident Review form regarding a 10/27/18, 9:45 a.m. unassisted, unobserved fall for Resident #3 revealed: Elder (Resident #3) found sitting on the floor (in elder bathroom) .Pants were down around .knees .States .trying to flush the toilet, to clean up. Review of a Fall Statement: Nurse, completed by Registered Nurse (RN) CC regarding the 10/27/18 unwitnessed fall revealed the following: Was the care plan being followed? (Care Plan) States not to leave unattended on toilet . Review of IDT (Interdisciplinary Team) Progress Note, dated 10/31/18, read, in part: Elder (Resident #3) was discussed .(regarding) recent fall while in bathroom. (Resident #3) had displaced himself from the toilet while flushing. Elder was being intermittently supervised while having a BM (bowel movement) but ultimately got himself off the toilet and onto the floor . Review of Resident #3's ADL (Activities of Daily Living) Care Plan revealed the following intervention dated 5/7/18: Do not leave unattended on toilet. On 2/5/19 at 1:30 p.m. Registered Nurse (RN)/MDS V was interviewed regarding Resident #3's care plan and bathroom supervision. RN V confirmed Resident #3 should not have been left unsupervised on the toilet per the care plan. This Surveyor was directed to RN V by the NHA, in the absence of the DON. Review of the facility LTC (Long Term Care) Falls Prevention policy, last revised 11/16/2017, read, in part: .Specific interventions, based on the Elder's needs, are to be documented in their care plan . On 2/5/19 at 2:06 p.m. CNA Z stated, I should (have) stayed there with (Resident #3). If I stay there with (Resident #3), I cannot get my work done .I don't know who (facility staff) talked to me, but they said not to leave (Resident #3) unattended on the toilet .They didn't need to tell me anything. I should have known better. Resident #7 Review of a 1/8/19 Nursing Progress Note revealed the following: .Elder on the toilet, unresponsive, drooling, pale an diaphoretic (sweating). Was told by associate (Certified Nurse Aide (CNA)), that (CNA) was putting her on the toilet and when she stood up she squealed and then started to go limp so (CNA) lowered her to the toilet seat. Review of Resident #7's ADL care plan revealed the following interventions: This elder requires extensive assistance by two staff for toileting, Initiated 3/9/17 .Elder needs extensive assist with transfers .Initiated 7/8/2016 . Review of a 1/12/19 Weekly Skin Observation for Resident #7 revealed the following: R. (right) top of foot to lateral side of R. foot has irregular shaped multi-colored bruise roughly measuring 7.5 cm x 7.5 .Bruise to R. mid back also multi-colored; 1.1 cm x 1.1 cm . Review of a 1/15/19 Progress Note included the following: This writer (NHA) along with (RN/MDS V) following up on bruises on (Resident #7's) right foot and lower back from skin assessment documented on 1/12/19 .(Resident #7) had episode on 1/8/19 became unresponsive during the toilet transfer while being transferred with (CNA Y). (Resident #7) did not fall, but may have injured her foot at this time. A (two-person mechanical lift) was required to transfer her from the toilet back to .bed. Since this episode (Resident #7) has refused to transfer out of bed . On 2/6/19 at 6:18 a.m. CNA Y was interviewed by telephone regarding Resident #7's unresponsiveness on 1/8/19. CNA Y stated, I took (Resident #7) by the hand and stood her up and she started cocking her head, and she let out a squeal .(Resident #7) started going down (falling) .Eventually (Resident #7) was sitting on the toilet .The bruise in the middle of her back could have been from the spout on the back of (the) toilet - because (Resident #7) was leaning on it real hard, and I was trying to keep her from falling off the toilet .I did not have a gait belt on her that morning. I know it is against the rules . Review of the facility LTC (Long Term Care) Falls Prevention policy, last revised 11/16/2017, read, in part: Use gait belts for all transfers and ambulation for Elders requiring assistance . Resident #43 Resident #43's Face Sheet dated 2/6/19, revealed the Resident had [DIAGNOSES REDACTED]. Resident #43's MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03, indicative of severe mental impairment. The Care Plan, revised on 12/27/18 revealed Resident #43 had limited to no safety awareness and as an intervention, motion detector alarm activated to remind elder not to get out of bed by herself and bed alarm on when in bed. According to an (undated) Incident Review, on 1/6/19 at 7:06 a.m., Resident #43 was found sitting by her bed on the floor facing the closet .Her bed alarm was not sounding. A motion detector was underneath elder's left leg and began to sound when elder was moved . In the same document, were alarms on? No. A Progress Note dated 1/9/19, written by RN V, revealed, Alarms were not being used as care plan states at the time of this fall. An interview was conducted on 02/06/19 at 12:35 p.m. with CNA DD, who stated, I was with another resident when I heard she had fallen. CNA EE had just been in there, it was minutes before she fell , and turned the bed alarm off because the resident had attempted to get up. I don't think she turned it back on. A phone interview was conducted on 2/6/19 at 1:05 p.m. with CNA EE, who stated, I heard the alarm go off and when I went in, her legs were out of the bed. This was right at change of shift, and we had already been given our assignments . I told her (Resident #43) she'd have to wait a few minutes and (CNA DD) would be right in, and I put her legs back into bed. I slid the reset switch for the floor alarm, it's a sensor beam that you slide, and when you slide it all the way, it automatically resets. To be truthful, it was dark in there, and I pushed a button for the bed alarm, but it must have not reset but got shut off. I didn't have a light on, so I'm not sure which button I pushed.

BASED ON INTERVIEWS AND RECORD REVIEWS, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND SAFE FOOTWARE DURING A TRANSFER FROM BED IN ONE (#1) OF THREE SAMPLED RESIDENTS REVIEWED FOR FALLS FROM A TOTAL OF 60 FACILITY RESIDENTS RESULTING IN RESIDENT#1 FALLING, SUSTAINING A HIP FRACTURE AND A DECLINE IN PHYSICAL FUNCTIONING. FINDINGS INCLUDE: A REVIEW OF THE MINIMUM DATA SET(MDS) ASSESMENT DATED 10/16/12, SHOWED THAT RESIDENT#1 WAS A [AGE] year OLD WOMAN admitted to the facility on [DATE]. HER [DIAGNOSES REDACTED]. RESIDENT#1'S MDS ALSO REVEALED SHE SCORED A 3 OUT OF 15 ON HER BRIEF INTERVIEW FOR MENTAL STATUS (BIMS), INDICATING SEVERE COGNITIVE IMPAIRMENT. RESIDENT#1 REQUIRED EXTENSIVE PHYSICAL ASSISTANCE OF TWO PEOPLE FOR TRANSFERS. SHE DID NOT WALK BUT USED A WHEELCHAIR WITH EXTENSIVE ASSISTANCE OF ONE PERSON FOR LOCOMOTION ON THE UNIT. HER BALANCE WAS NOT STEADY AND SHE WAS ONLY ABLE TO STABILIZE WITH STAFF ASSISTANCE WHEN MOVING FROM A SEATED TO A STANDING POSITION. SHE HAD FUNCTIONAL LIMITATION IN RANGE OF MOTION TO BOTH UPPER EXTREMITIES. THE CARE AREA ASSESSMENT(CAA) DOCUMENTATION NOTES FROM THE MDS dated [DATE] READ IN PART, UNDER FALLS, "ELDER WITH HISTORY OF FALLS--7/10/12, 8/26/12, AND 10/15/12....ELDER fell AND SUFFERED A COMPRESSION FRACTURE OF HER SPINE IN JULY. SHE WAS NOT AT HER BASELINE FOR AMBULATION YET WHEN SHE fell AND FRACTURED HER LEFT ARM ON 8/26/12. SHE HAS NOT BEEN AMBULATING, BUT HAS BEEN WORKING WITH THERAPY UP TO HER CURRENT TIME. SHE fell AND FRACTURED HER RIGHT ARM ON 10/15/12...THIS ELDER IS AT HIGH RISK FOR FALLS...SHE LACKS INSIGHT FOR SAFETY AND NEEDS." A "DAILY CARE INFORMATION & PLAN" DATED 11/2/12, SHOWED THAT RESIDENT#1 REQUIRED EXTENSIVE ASSISTANCE OF 1-2 PEOPLE FOR TRANSFERS AND AMBULATION USING A GAIT BELT. HER FALL RISK INTERVENTIONS INCLUDED A BED ALARM AND A SEAT BELT ALARM IN HER WHEELCHAIR. THE NURSE NOTES DATED 11/30/12 IN RESIDENT#1'S MEDICAL RECORD, SHOWED THAT AT 4:15 P.M., THE BED ALARM SOUNDED IN RESIDENT#1'S ROOM. SHE WAS FOUND LYING NEXT TO HER BED. RESIDENT#1 COMPLAINED OF LEFT HIP AND LEFT LEG PAIN. SHE WAS TRANSFERRED TO THE EMERGENCY DEPARTMENT WHERE X-RAY REPORTS OF HER LEFT HIP AND PELVIS AND PHYSICIAN DOCUMENTATION DATED 11/30/12, REVEALED NO FRACTURE; [DIAGNOSES REDACTED].#1 AGAIN COMPLAINED OF SEVERE PAIN IN HER LEFT LEG. SHE WAS SENT A SECOND TIME TO THE EMERGENCY DEPARTMENT FOR EVALUATION. PHYSICIAN DOCUMENTATION DATED 12/4/12, READ IN PART, "HAS CONTINUED PAIN AND WOULD LIKE XRAY REPEATED...REVIEWED XRAY...FX (FRACTURE) IS EVIDENT ON FILMS FROM FRIDAY. Diagnosis: [REDACTED]." A POST FALL assessment dated [DATE], REVEALED THAT AT THE TIME OF RESIDENT#1'S FALL, RESIDENT#1'S ALARM(S) WERE SOUNDING AND SHE WAS FOUND TO BE WEARING NON-GRIP SOCKS. IMMEDIATE INTERVENTIONS TAKEN TO PREVENT REOCCURRENCE WERE "A FLOOR MAT, REMIND TO USE GRIPPY SOCKS, REMINDED ELDER TO ALWAYS CALL FOR ASSISTANCE-DO NOT GET UP ON OWN." A COMPUTERIZED NOTE, ENTERED BY REGISTERED NURSE (RN)/ASSISTANT COACH (ASSISTANT DIRECTOR OF NURSING-ADON) "I" ON 11/30/12 READ, "ASKED ELDER HOW SHE fell . SHE STATED THAT SHE WAS IN HER BED AND HEARD A NOISE. SHE GOT UP. SHE ADDED THAT SHE SHOULDN'T HAVE GOTTEN UP. SHE ALSO SAID THAT THE FLOORS WERE SLIPPERY, AND SHE STARTED FALLING." REGISTERED NURSE "I" WAS INTERVIEWED ON 12/19/12 AT 12:10 P.M.. SHE STATED: "YES, I WAS WORKING THAT DAY. WE HEARD AN ALARM RINGING. WE FOUND (RESIDENT#1) ON THE FLOOR BETWEEN HER BED AND HER CLOSET DOOR. SHE TOLD ME SHE HAD HEARD A NOISE AND WAS GETTING UP TO SEE WHAT IT WAS. SHE HAD REGULAR SOCKS ON. SHE WAS HIGH RISK FOR FALLS; SHE SHOULD HAVE HAD SHOES OR GRIPPER SOCKS ON WHILE IN BED. HER SHOES WERE PARKED NEATLY BY HER CLOSET; THAT WAS THE FIRST THING I LOOKED FOR. GRIPPER SOCKS ARE NOT ON HER CARE PLAN BECAUSE IT'S A GIVEN--HIGH RISK RESIDENTS ARE TO HAVE EITHER SHOES OR GRIPPER SOCKS ON WHEN IN BED. (RESIDENT#1) GOT AROUND IN A WHEELCHAIR (WC)--SHE HAS A SEAT BELT ALARM. IF SHE HAD TRANSFERRED HERSELF INTO BED, SHE WOULD HAVE SET THE WC ALARM OFF. ALSO, SHE HAD BEEN IN BED BEFORE THE FALL WITH HER BED ALARM ON--IT WAS SOUNDING WHEN SHE GOT UP. HER SHOES WERE OUT OF HER REACH. SHE COULDN'T HAVE TAKEN HER OWN SHOES OFF AFTER SHE GOT INTO BED. YES, SOMEBODY PUT HER TO BED WITHOUT GRIPPER SOCKS ON." CERTIFIED NURSE AIDE (CNA) "A" WAS INTERVIEWED ON 12/19/12 AT 1:55 P.M. SHE STATED: "I WORKED DAY SHIFT BEFORE (RESIDENT#1) fell . I WENT HOME AROUND 3:00 P.M. NO, I DON'T REMEMBER IF I PUT HER TO BED AFTER LUNCH. SOMETIMES SHE WANTS HER SHOES OFF WHEN SHE LIES DOWN IN BED; OTHER TIMES SHE WANTS THEM LEFT ON. I'D LIKE TO SAY THAT I ALWAYS PUT GRIPPER SOCKS ON HER WHEN I PUT HER TO BED, BUT THAT WASN'T THE CASE. NOW WE DO! SHE HAS THEM ON ALL THE TIME NOW. I JUST ALWAYS TRIED TO MAKE SURE SHE HAD GRIPPER SOCKS ON BUT THAT DAY IT DIDN'T HAPPEN." CERTIFIED NURSE AIDE "C" WAS INTERVIEWED BY TELEPHONE ON 12/19/12 AT 3:42 P.M. SHE STATED: "I WORKED DAY SHIFT THAT DAY. I DON'T REMEMBER PUTTING HER TO BED AFTER LUNCH THAT DAY. TYPICALLY, WHEN I PUT (RESIDENT #1) TO BED, I WOULD LEAVE HER SHOES ON; THAT'S WHAT SHE PREFERRED." CERTIFIED NURSE AIDE "B" WAS INTERVIEWED ON 12/19/12 AT 2:45 P.M. SHE STATED: "I WORKED AFTERNOON SHIFT THAT DAY. I WAS IN 4A WITH A NURSE DOING A 2-PERSON TRANSFER. (RESIDENT#1'S) BED ALARM WENT OFF. I FOUND HER ON THE GROUND. NO, THERE WAS NO CLUTTER; THE FLOORS WERE DRY. THE CALL LIGHT WAS NEXT TO HER BUT SHE NEVER USES IT. SHE WAS SITTING ON THE FLOOR. SHE HAD SOCKS ON; I DON'T KNOW WHAT KIND." REGISTERED NURSE "D" WAS INTERVIEWED BY TELEPHONE ON 12/19/12 AT 3:35 P.M. SHE STATED: "I WAS HELPING (CNA "B") ACROSS THE HALL WITH A LIFT. SHE WENT TO RESPOND TO AN ALARM. SHE FOUND (RESIDENT #1) ON THE FLOOR. (RESIDENT #1) HAD SOCKS ON BUT NOT GRIPPY SOCKS. YES, SHE SHOULD HAVE HAD GRIPPY SOCKS ON. HER SHOES WERE BETWEEN HER BED AND HER CLOSET; SHE COULD NOT HAVE PUT THEM THERE HERSELF WITHOUT SETTING HER ALARM OFF." A PHYSICIAN'S PROGRESS NOTE DATED 12/5/12, READ IN PART, "FAMILY DESIRES NO SURGERY." DURING AN INTERVIEW WITH RN "I" ON 12/20/12 AT 9:00 A.M., SHE STATED: "THERE IS A SIGNIFICANT CHANGE MDS FOR (RESIDENT #1) IN PROCESS RIGHT NOW SECONDARY TO HER BEING BEDBOUND. THE DOCTOR ORDERED NO LIFT TO BE USED FOR TRANSFERS; HE ORDERED A 3-4 PERSON TRANSFER. WE CAN'T DO THAT; IT'S DANGEROUS. SHE WASN'T AMBULATORY BEFORE THIS FALL DUE TO HER ARM FRACTURES; SHE COULDN'T USE A WALKER. THE ONLY CHANGE NOW IS SHE IS BEDBOUND. SURGERY IS STILL IN QUESTION--ANOTHER X-RAY WAS DONE YESTERDAY. WE'RE WAITING TO HEAR FROM THE FAMILY." ( )

BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION FOR ONE RESIDENT (#1) OF FOUR RESIDENTS REVIEWED FOR FALLS FROM A TOTAL OF 60 RESIDENTS IN THE FACILITY. THIS DEFICIENT PRACTICE RESULTED IN HARM TO RESIDENT #1 WHO SUSTAINED A FALL WITH INJURY THAT LED TO HER DEATH. FINDINGS INCLUDE: A REVIEW OF THE FACILITY INVESTIGATION SHOWED THAT RESIDENT #1 WAS A [AGE] year OLD WOMAN ORIGINALLY admitted to the facility on [DATE]. HER [DIAGNOSES REDACTED]. RESIDENT #1'S MOST RECENT MINIMUM DATA SET ((MDS) dated [DATE], REVEALED SHE WAS UNABLE TO COMPLETE THE BRIEF INTERVIEW FOR MENTAL STATUS (BIMS). A STAFF ASSESSMENT FOR MENTAL STATUS WAS DONE INSTEAD AND INDICATED SHE HAD LONG AND SHORT TERM MEMORY PROBLEMS AND WAS MODERATELY IMPAIRED FOR DAILY DECISION MAKING (DECISIONS POOR AND CUES/SUPERVISION REQUIRED). THIS MDS ALSO REVEALED THAT RESIDENT #1 HAD A CONTINUOUS ALTERED LEVEL OF CONSCIOUSNESS (EXAMPLE: LETHARGIC, STUPOROUS) AND AN UNUSUALLY DECREASED LEVEL OF ACTIVITY SUCH AS SLUGGISHNESS, STARING INTO SPACE, STAYING IN ONE POSITION OR MOVING VERY SLOWLY. ACCORDING TO THE MDS, RESIDENT #1'S FUNCTIONAL STATUS INDICATED SHE REQUIRED EXTENSIVE PHYSICAL ASSISTANCE OF TWO OR MORE PEOPLE FOR TRANSFERS. HER BALANCE, WHILE MOVING FROM A SEATED TO STANDING POSITION WAS NOT STEADY, ONLY ABLE TO STABILIZE WITH HUMAN ASSISTANCE. A REVIEW OF RESIDENT #1'S CARE PLAN, CURRENT AT THE TIME OF HER FALL ON [DATE], SHOWED SHE REQUIRED EXTENSIVE ASSISTANCE OF TWO PEOPLE FOR TRANSFERS; SHE WAS NOT TO BE LEFT UNATTENDED IN THE BATHROOM AND SINCE SHE WAS AT RISK FOR FALLS, WAS TO HAVE A TABS ALARM ON WHEN IN HER WHEELCHAIR. A NURSE'S NOTE ENTERED BY REGISTERED NURSE (RN) 'F' REVEALED THAT ON [DATE] AT 8:05 PM, "ELDER fell IN BATHROOM THIS EVENING AS SHE WAS ATTEMPTING TO STAND ON HER OWN." THE NURSE'S NOTE SHOWED AFTER THE FALL, RESIDENT #1 WAS UNABLE TO BEAR WEIGHT AND A PHYSICAL ASSESSMENT SHOWED "A SWOLLEN, BULGED, FIRM AREA TO HER RIGHT ANTERIOR MID THIGH." AFTER CONSULTING HER DURABLE POWER OF ATTORNEY (DPOA) AND THE NURSING SUPERVISOR, RESIDENT #1 WAS TRANSFERRED TO THE EMERGENCY DEPARTMENT. AN X-RAY REPORT DATED [DATE], READ IN PART, "RIGHT FEMUR...THERE IS COMPLETE FRACTURE OF THE DISTAL FEMORAL DIAPHYSIS. LEFT FEMUR...THERE IS FRACTURE OF THE LEFT DISTAL FEMORAL DIAPHYSIS." A NURSE'S ENTRY ON [DATE] READ, "ELDER PASSED AWAY AT 1425 (2:25 PM) TODAY." THE MEDICAL EXAMINER REPORT DATED [DATE], READ IN PART, "(RESIDENT #1) died on [DATE] AFTER SUSTAINING A FALL ON [DATE] WHICH RESULTED IN FRACTURE OF BOTH DISTAL FEMURS....NO AUTOPSY WAS PERFORMED. (RESIDENT #1'S) HEMOGLOBIN DECREASED QUICKLY AFTER THE INJURY. SHE had a history of [REDACTED]. COMPLICATIONS FROM THE INJURY INCLUDE SIGNIFICANT BLOOD LOSS INTO THIGH COMPARTMENTS FROM FEMUR FRACTURE, RISK OF FAT EMBOLISM OR THROMBOEMBOLISM TO LUNGS, AND INCREASED STRAIN ON HER HEART FROM THE ABOVE POTENTIAL COMPLICATIONS. ANY OF THESE FACTORS WOULD HAVE RESULTED IN HER DEATH, WITH THE MAIN CAUSE OF DEATH BEING THE FEMUR FRACTURES. CAUSE OF DEATH: BILATERAL FEMUR FRACTURES." DURING A TELEPHONE INTERVIEW WITH CERTIFIED NURSE AIDE (CNA) 'A' ON [DATE] AT 1:15 PM, SHE STATED, "I BROUGHT (RESIDENT #1) INTO THE BATHROOM. AS SHE WAS SEATED IN HER WHEELCHAIR, I TOOK HER ALARM OFF AND CHANGED HER INTO HER NIGHTGOWN. I FACED HER TOWARD THE GRAB BAR, ABOUT AN ARM'S LENGTH AWAY. THE WHEELCHAIR BRAKES WERE NOT LOCKED. I TURNED TO LOOK FOR HER GAIT BELT; IT WAS ON THE 3 DRAWER COMPARTMENT, UNDER HER CLOTHES AND SOME WASHCLOTHS. I ASSUME SHE REACHED FOR THE GRAB BAR, GRABBED IT AND PULLED HERSELF UP. I LOOKED AND SHE WAS FALLING. BY THE TIME I GOT TO HER, SHE WAS ON THE FLOOR." CNA 'B' WAS INTERVIEWED BY TELEPHONE ON [DATE] AT 1:15 PM. SHE STATED, "I HEARD 'ASSISTANCE NEEDED' ON THE WALKIE-TALKIE. I RAN INTO THE ROOM. REGISTERED NURSE (RN) 'F' WAS COMING DOWN THE HALL; WE ENTERED THE ROOM TOGETHER. (RESIDENT #1) WAS ON THE BATHROOM FLOOR. (CNA 'A') WAS KNEELING ON THE FLOOR BEHIND HER. THE GAIT BELT WAS ON THE WHITE CABINET. THE ALARM WAS NOT GOING OFF." DURING AN INTERVIEW WITH CNA 'E' ON [DATE] AT 2:30 PM, SHE STATED, "I WAS THE SECOND TO THE LAST ONE THERE; (RN 'F', CNA 'B', CNA 'A' AND RN 'D') WERE ALREADY THERE. (RESIDENT #1) WAS ON THE FLOOR. THE GAIT BELT WAS NOT ON HER; IT WAS ON THE 3 DRAWER BIN. A FEW MINUTES EARLIER, I HAD OFFERED TO HELP (CNA 'A') GET (RESIDENT #1) ON THE TOILET; SHE SAID, 'NO, I'M GOOD.'" ON [DATE] AT 2:55 PM, RN 'F' STATED, "I WAS THE FIRST ONE THERE. (RESIDENT #1) AND (CNA 'A) WERE SITTING ON THE FLOOR. (CNA 'A') SAID SHE HAD TURNED TO GET THE GAIT BELT. I DON'T RECALL SEEING THE GAIT BELT. THE TAB ALARM WAS NOT ON (RESIDENT #1); IT WAS ON THE WHEELCHAIR." ALTHOUGH IT COULD NOT BE CONCLUSIVELY DETERMINED IF CNA 'A' WAS ATTEMPTING TO TRANSFER RESIDENT #1 BY HERSELF AT THE TIME OF THIS FALL, OR IF HER INTENTION WAS TO CALL FOR ASSISTANCE ONCE SHE HAD THE GAIT BELT ON RESIDENT #1, CNA 'A' HAD admitted LY TAKEN THE TAB ALARM OFF OF RESIDENT #1, THEN TURNED AWAY SO THAT RESIDENT #1 WAS NOT IN HER LINE OF VISION. AS A RESULT OF INADEQUATE SUPERVISION, RESIDENT #1 fell AND SUSTAINED INJURIES THAT LED TO HER DEATH. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING/HEAD COACH ON [DATE] AT 4:15 PM, SHE STATED, "CNA 'A' HAS BEEN TERMINATED FROM EMPLOYMENT AT THE FACILITY." ( )