Every finding on record at Quail Run Health Care Center

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN-form CMS-10055) or a denial letter at the initiation, reduction or termination of Medicare Part A services and Notice of Medicare Non-Coverage (NOMNC-form CMS-10123, a notice that indicates when care is set to end from a skilled nursing facility) for two sampled residents (Resident #39 and Resident #62) This affected two of the 14 sampled residents. The facility census was 55.The facility was unable to provide a SNF/ABN policy when requested. 1.Review of Resident #62's Electronic Medical Record (EMR) showed:-Medicare Part A last day of coverage 01/04/2026;-SNF/ABN form provided to resident;-Resident signed form 01/05/2026;-The resident was unable to appeal Medicare A discharge. 2.Review of Resident #39's EMR showed:-Medicare Part A last day of coverage 02/16/2026;-SNFABN provided to resident/representative;-SNFABN form signed by resident/representative on 02/26/2026;-The resident or representative was unable to appeal Medicare A discharge. During an interview on 04/02/2026 at 4:00P.M., the Social Services Designee (SSD) said:-A weekly Inter Disciplinary Team meeting happens weekly to determine which residents will lose covered days soon;Residents should be notified prior to loss of coverage;-Some Insurance companies do not notify facility until day of stoppage of coverage, even if on a weekend. During an interview on 03/27/2026 at 11:00A.M., the Administrator said that SNFABNs are completed by SSD and is not sure why it was not completed prior to end of services/coverage.

Based on observation, interview, and record review the facility failed to ensure resident's who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene when the facility failed to ensure proper perineal care was provided to three (Resident's #1, #42, and 54) of 14 sampled resident's. The facility census was 55. Review of the facility policy titled, Perineal Care, dated February 2018, showed: - The purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; - For the female resident: wet a washcloth and apply soap or skin cleansing agent, separate labia and wash area downward from front to back, continue to wash the perineum moving from inside to outward toward the thighs, rinse perineum thoroughly in the same direction using fresh water and a clean washcloth, have resident turn to side, rinse washcloth and apply soap or skin cleansing agent, wash and rinse the rectal area thoroughly wiping from the base of the labia towards and extending over the buttocks; - For the male resident: wet a washcloth and apply soap or skin cleansing agent, wash perineal area starting at the urethra and working outward, wash and rinse urethral area using a circular motion, continue to wash the perineal area including the penis, scrotum, and inner thighs, thoroughly rinse the perineal area in the same order using fresh water and a clean washcloth, have resident turn to side, rinse washcloth and apply soap or skin cleansing agent, wash and rinse the rectal area thoroughly including the area under the scrotum, the anus, and the buttocks; - The facilities policy did not address the use of disposable cleansing wipes. 1. Review of Resident #1's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 03/10/26, showed: - The resident was cognitively intact; - The resident required assistance with toileting and dressing; - The resident had diagnoses of depression, muscle weakness, and cognitive communication deficit. Review of the resident's care plan, dated 03/06/26, showed: - The resident was occasionally incontinent of bowel; - The resident was occasionally incontinent of urine; - The resident required assistance with activities of daily living due to a mobility deficit. Observation on 03/26/2026 at 1:52 P.M. showed: - Certified Nursing Assistant (CNA) C and Nursing Assistant (NA) D performed perineal care for the resident; - The resident's perineal appeared to be red from moisture sitting on the skin too long; - NA D used a disposable cleansing wipe to clean bowel movement off of the resident, folded the cleansing wipe and used it again to clean more bowel movement off of the resident; - NA D used a disposable cleansing wipe to clean bowel movement off of the resident, folded the cleansing wipe and used it again to clean more bowel movement off of the resident. During an Interview on 03/26/2026 at 2:09 P.M. NA D said disposable cleansing wipes could be folded up to four times while cleaning bowel movement off of a resident but he/she usually did not fold the cleansing wipes more than twice. During an Interview on 03/27/2026 at 9:25 A.M. Certified Medication Technician (CMT) A said disposable cleansing wipes should not be folded and used again when providing perineal care to residents. During an Interview on 03/27/2026 at 9:22 A.M. Licensed Practical Nurse (LPN) B said disposable cleansing wipe should only be used once while providing perineal care to residents. During an Interview on 03/27/2026 at 10:32 A.M. LPN C said disposable cleansing wipes should not be folded and reused while providing perineal care for residents. During an Interview on 03/27/2026 at 11:01 A.M. the Director of Nursing (DON) said while cleaning bowel movement off of a resident disposable cleansing wipes should not be folded and reused. 2. Review of Resident #42's Comprehensive MDS, dated [DATE] showed: - Cognitive skills severely impaired. - Physical behavior directed at others and verbal behaviors directed at others occurred one to three days; - Other behaviors not directed at others occurred one to three days. - Upper and lower extremities impaired on both sides; - Dependent on staff for toilet use, dressing, personal hygiene and transfers; - Always incontinent of bowel and bladder; - Diagnoses included stroke, psychotic disorder (a mental condition where a person loses touch with reality) and schizophrenia (a long-term mental illness where a person has trouble telling what is real and what is not). Review of the resident's care plan, revised on 02/11/26 showed: - The resident had bowel incontinence related to immobility. Interventions included checking the resident every two hours and assist with toileting as needed. Provide peri care after each incontinent episode. - The resident had an activity of daily living (ADLs) self-care performance deficit related to stroke. The resident is not toileted. The resident is a check and change. Observation on 03/25/26 at 9:27 A.M., showed: - CNA A and the Activity Director used the mechanical lift and transferred the resident from the Broda chair (a type of reclining geri chair) to his/her bed; - CNA A wiped down each side of the resident's groin and used a different wipe each time; - CNA A did not separate and clean all of the skin folds; - The resident urinated during the peri care; - After the resident finished, the Activity Director wiped down each side of the groin with a different wipe each time; -The Activity Director did not separate and clean all the skin folds or all areas of the skin where urine had touched; - CNA A and the Activity Director turned the resident side to side and removed the wet incontinent brief and placed a clean one on the resident and fastened it; - CNA A and the Activity Director did not clean the buttocks. During an interview on 03/26/26 at 2:51 P.M., CNA A said: - He/She should have separated and cleaned all areas of the skin where urine had touched; - He/She should have cleaned the front skin folds and the buttocks. During an interview on 03/26/26 at 3:15 P.M., the Activity Director said: - He/She should have separated and cleaned all areas of the skin where urine had touched; - The front should be cleaned the front because that's where the urine was and should have cleaned the buttocks. 3. Review of Resident #54's Quarterly MDS, dated [DATE] showed; - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Dependent on staff for toilet use, personal hygiene, and transfers; - Frequently incontinent of urine; - Occasionally incontinent of bowel; - Diagnoses included neurogenic bladder (a dysfunction that results from interference with the normal nerve pathways associ8ated with urination), anxiety, depression, bipolar disorder ( a mental health condition that causes extreme mood changes), paraplegia (a person cannot feel or move the lower half of their body) and quadriplegia (a condition where a person cannot move or feel both arms and both legs). Review of the resident's care plan, revised on 03/23/26 showed: - The resident had an ADL self-care performance deficit related to disease process paraplegia; -The interventions included the resident is occasionally incontinent of urine; -Required the assistance of two staff for the use of the sit to stand (a mechanical lift that allows a resident who can bear weight to transfer from a sitting position to standing position); -The resident used a motorized wheelchair; - The resident had a neurogenic bladder with occasional bladder incontinence related to cervical myelopathy (a condition where the spinal cord in the neck is compressed). Observation on 03/25/26 at 3:25 P.M., showed: - CNA B and NA D used the sit to stand mechanical lift and transferred the resident from his/her motorized wheelchair to bed; - CNA B and NA D turned the resident onto his/her side; - CNA B used one wipe and with the same area of the wipe, cleaned both sides of the resident's buttocks and wiped from front to back; -CNA B and NA D turned the resident onto his/her back; - CNA B wiped down each side of the groin and used a different wipe each time; - CNA B used a new wipe and with the same area of the wipe and cleaned the front skin folds; -CNA B did not separate and clean all the skin folds. During an interview on 03/25/26 at 3:39 P.M., CNA B said: - He/She should not have used the same area of the wipe to clean different areas of the skin; - It should have been a single wipe per area; - He/She should have separated and cleaned all the skin folds where urine had touched. During an interview on 3/27/26 at 10:40 A.M., the DON said: - Staff should separate and clean all the skin folds, including the buttocks and after the resident had urinated, should have made sure to clean all areas of the skin where urine had touched; - Staff should not fold the wipe and should not use the same area of the wipe to clean different areas of the skin.

Based on observation, interview, and record review the facility failed to ensure a safe, clean, comfortable, and homelike environment, ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk when the facility failed to ensure that flooring, baseboards, and windows were in good repair for two residents (Resident #11 and #18). Failed to allow one resident (Resident #29) to sit where he/she would like during meals in the dining room with a broken window in view of all residents, and when the facility staff served Resident #28 a peanut butter and jelly sandwich in a plastic bag rather than on a plate, and when the facility failed to ensure the small shower room on the North hall was repaired in a timely manor for all resident's on the North hall. The facility census was 55. Review of the facilities Homelike Environment policy, dated February 2021, showed: - Residents were provided with a safe, clean, comfortable and homelike environment. - The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. 1. Review of Resident #18's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 3/19/26, showed: - The resident was cognitively intact; - The resident used a walker to assist with walking; - The resident had diagnoses of repeated falls, presence of right artificial hip, and hypertension (high blood pressure). Review of the resident's care plan, dated 2/27/26, showed: - The resident required minimal assistance with completing activities of daily living; - The resident was grieving due to having to sell the home he/she resided in for 20 years to finically support his/her admission to the facility. It was important to help facilitate the resident's adjustment to new home at the facility. Observation on 03/24/2026 at 10:30 A.M. showed: - The flooring in the resident's room had chips in the tile flooring near the resident's bed and bathroom; - There were no baseboards in the resident's room. During an interview on 03/24/2026 at 9:20 A.M. the Maintenance Supervisor said: - A Rehab project started on the north hall resident rooms in November of 2025 where all of the baseboards were removed from the resident rooms and resident bathrooms; - He had been asking for several months when the work would be completed but had not received an answer from administration. During an interview on 03/24/2026 at 10:33 A.M. the resident said: - The floor needed fixed, he/she stubbed his/her toe on the chipped flooring in his/her room; - The baseboards in his/her room had been missing since he/she moved into the facility in September of 2025. Observation on 03/24/2026 at 1:06 P.M. showed a large crack in the middle of the glass on the door in the dining room that goes outside to the patio. During an interview on 03/25/2026 at 2:00 P.M. the resident said: - The window in the dining room had been cracked since he/she moved into the facility in September of 2025; - He/she would not touch the window because he/she was afraid it might break. During an Interview on 03/27/2026 at 11:01 A.M. the Administrator in Training said: - Flooring in resident rooms had been chipped for approximately a year; - Baseboards in resident rooms had been removed for approximately a year; - An outside contractor was putting in the new flooring in the resident rooms. Observation on 03/27/2026 at 10:22 A.M. showed the small shower room on the north hall was unable to be used due to a broken shower handle. During an interview on 03/27/2026 at 10:29 A.M. Resident #18 said, it was inconvenient to wait and made the process for showers very slow. It would have been nice to have two working showers on the north hall so more than one resident could take a shower at a time. During an interview on 03/27/2026 at 10:32 A.M. LPN C said: - The small shower on the north hall had been broken for over a year; - Only having one functioning shower room on the north hall made it difficult to get all of the resident's showers done in a timely manor. During an interview on 03/27/2026 at 11:01 A.M. the Administrator in Training said: - The handle in the small shower room had been broken for approximately a year and a half; - There were other maintenance projects that were placed ahead of getting the small shower on the north hall fixed. -He said he hadn't heard any complaints about their only being one shower on that hall but was aware that there was only one working for an extended amount of time. 2. Review of Resident #52's Comprehensive MDS dated [DATE], showed: -No cognitive impairment; -Dependent on staff for assist with mobility and transfers; -Diagnoses included arthritis, diabetes and depression. Review of Resident's care plan dated 03/06/2026, showed: -Resident at risk for depression due adjusting to her new living arrangements at the facility; -Resident will be continuously monitored to ensure he/she has the resources in place to address depression and mental health concerns; -Resident to take anti-depressant medication as prescribed; -No specific interventions, goals, activities or psychosocial interventions for depression. During an interview on 03/25/2026 at 08:30A.M., resident said: -He/she would like curtains open during the day, but there are other residents that sit in the courtyard, and he/she does not want to be looked at; -A sheer curtain or opaque window cling would be acceptable coverage to keep outsiders from looking in; -A window cling would likely not stick to the shattered window; -The window has been shattered since he/she was admitted over a year ago; -Facility staff told him/her the windows were to be replaced soon; -He/she feels forgotten. An observation on 03/25/2026 at 08:30A.M., showed windows with heavy curtains drawn shut, when curtains pulled back, window had greater than five cracks with clear tape. During an interview on 03/27/2026 at 11:00A.M., the Administrator said: -There are ways to have curtains open to allow sunlight and an exterior view while keeping others from looking in; -A broken window in a resident room for over a year is unreasonable; -The facility should replace all broken windows as soon as possible. 3. Review of Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/28/26 showed: Cognitive skills intact. Independent with transfers and toilet use. Occasionally incontinent of urine. Always continent of bowel. Diagnoses included depression, psychotic disorder (a mental health disorder where a person loses touch with reality) and schizophrenia (a long-term mental illness where a person has trouble telling what is real and what is not). Observation and interview on 3/24/26 at 3:36 P.M., showed: There were no baseboards around the entire room including the bathroom. The white toilet seat in the bathroom showed it was significantly worn with the original white finish no longer visible and underlying material exposed. The resident said the staff removed the baseboard about a year ago when they painted the room. It did not bother him/her, and the toilet seat did not bother him/her. During an interview on 3/27/26 at 10:40 A.M., the Administrator in Training (AIT) said: If the white has worn away and underlying material is exposed, it should be replaced. The baseboards have been missing from some of the rooms for about a year. 4. Review of Resident #29's Quarterly Minimum Data Set, dated [DATE], showed:- Resident was cognitively intact;- Diagnoses: coronary artery disease, dementia, and seizure disorder; During an interview on 3/24/26 at 12:35 P.M., the Resident said:- He/she has no choice where he/she can sit in the dining room. All the seats are assigned, and they won't let her choose where he/she can sit. He/she would like to sit with a friend so he/she could talk more at lunch. It makes him/her very frustrated and mad he/she can't sit where he/she wants to each day. Observation in the dining room on 3/24/26 at 12:37 P.M., showed drink cart service for the dining room residents starting. 5. Review of Resident #28's Quarterly MDS, dated [DATE], showed:- No cognitive screening done for resident;- Diagnoses: aphasia (impaired ability to understand or produce speech), stroke, dementia, anxiety disorder, depression and seizure disorder; Observation in the dining room on 3/24/26 at 12:46 P.M., showed:- First meals for lunch coming out of the kitchen for the main dining room.- 12:52 P.M. Resident did not eat his/her lunch, and he/she was offered a peanut butter and jelly sandwich. The resident agreed to having the substitute and it was delivered to the resident in a plastic bag without a plate. Observation in the dining room on 3/24/26 at 12:37 P.M., showed:- Drink cart service for the dining room residents started.- NA (B) delivered a food tray to a resident without saying a word to the resident or asking if he/she needed anything to go with his/her meal. NA (B) just placed the dishes on the table and immediately turned his/her back to the table and went back to get another resident's food order.- 1:10 P.M. Three eight-foot-high food carts with dirty dishes are taken to the main dining room and stored at the front center of the room less than 15 feet from residents eating. Observation in the kitchen on 3/26/25 at 7:10 A.M., showed pre-made peanut butter and jelly sandwiches made on 3/25/26 in plastic bags in a plastic container sitting on the counter. The use by date was 3/28/26, 4 days after being made. Observation of the main dining room on 3/24/26 at 12:30 P.M., showed the exit door window in the dining room has two large cracks in the window, three feet by one foot in diameter. - A sign posted showing lunch is to be served a noon; -21 residents assembled at various tables throughout the dining room. -No drinks had been served, no condiments were on any of the tables, there were no place settings on the tables, there were no napkins or silverware available and there were no decorations or centerpieces on any of the tables. During an interview on 3/27/26 at 10:45 A.M., the Administrator said:- Breakfast starts at 8:00 A.M. in the main dining room and she would not expect residents to have to wait until 8:40 A.M. to be served.- She would expect alternate food items for meals to be made to order and not prepared the day before.- She would not expect sandwiches to be served in plastic bags to residents during the meal;

Based on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge for six residents (Resident #11, #63, #64, #65, #66 and #67). This affected six of 14 residents sampled. Facility census was 55. Resident policy on the management of discharged resident fund accounts not provided;1. Review of the facility's Accounts Receivable Aging Report, dated 3/24/26, showed:- Resident #11 discharged on 7/4/23 and had an outstanding credit of $176.38 to his/her private pay account. - Resident #63 discharged on 1/3/25 and had an outstanding credit of $2,697.40 to his/her patient liability account.- Resident #64 discharged on 1/19/25 and had an outstanding credit of $923.68 to his/her patient liability account.- Resident #65 discharged on 2/3/24 and had an outstanding credit of $885.24 to his/her private pay account.- Resident #66 discharged on 8/9/24 and had an outstanding credit of $26.05 to his/her patient liability account.- Resident #67 discharged on 5/27/23 and had an outstanding credit of $717.08 to his/her patient liability account. During an interview on 3/25/26 at 10:00 A.M., the Business Office Manager (BOM) said:- The facility switched accounting systems in July 2024 and this has caused some reconciliation delays with discharged resident accounts.- Resident #11 was reviewed and Medicare was informed of the outstanding credit balance through the submission of a TPL form dated 3/25/26.- Resident #63 did not have a TPL form submitted at the time of discharge. The corporate office was notified of the outstanding credit balance on 12/8/25 but no response has been received. This issue is ongoing and being following up by the BOM.- Resident #64 is due a refund of $923.68 and a request was sent to the corporate office for approval on 3/25/26.- Resident #65 is due a refund of $885.24 and a request was sent to the corporate office for approval on 12/6/25. - Resident #66 requires a TPL form to be submitted and a request for corporate approval was submitted 3/25/26.- Resident #67 is due a refund of $717.08 and a request was sent to the corporate office for approval on 12/12/25.During an interview on 3/26/26 at 9:30 A.M., the BOM and Corporate Accountant said that the expectation is that residents upon discharged have their accounts reconciled within 30 days.During an interview on 3/27/26 at 8:15 A.M., the Administrator said that when residents discharge or expire their accounts should be reconciled within 30 days.

Based on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety when facility staff failed to observe proper handwashing procedures in the kitchen, failed to monitor food items for expiration dates, failed to properly label food items, and failed to properly monitor food cooking and serving temperatures. This affected all residents in the facility. The facility census was 55. Review of facility policy titled, Refrigerators and Freezers, revised November 2022, showed:- This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines;- Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures;- Monthly tracking sheets include time, refrigerator temperature and initials;- Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening;- All food is appropriately dated to ensure proper rotation by expiration dates. Received dates are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated once food is opened; - Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates. Review of facility policy titled. Food Preparation and Service, revised November 2022, showed:- Danger Zone means temperatures above 41 degrees ( ) and below 135 that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness;- Potentially Hazardous Food (PHF) means food that requires time/temperature control for safety to limit the growth of pathogens. Examples of PHF foods include ground beef, poultry, chicken, seafood, cut melon, unpasteurized eggs, milk, yogurt and cottage cheese; - Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of foodborne illness;- Food preparation staff need to adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness;- Proper hot and cold temperatures are maintained during food distribution and service;- Jewelry is worn minimally for food and nutrition services staff.Review of facility policy titled, Handwashing/Hand Hygiene, revised October 2023, showed:- Hand hygiene is required immediately after glove removal;- The use of gloves does not replace hand washing/hand hygiene;- Perform hand hygiene before applying non-sterile gloves.Observation in the kitchen on 03/24/26 at 9:00 A.M., showed:Dry Storeroom:- Freezer log missing temperature checks on 3/22 and 3/23/26 evening shift. Unable to located refrigerator thermometer;Vestibule next to Dry Storeroom:- Two stand-up refrigerators missing temperature checks on 03/22 and 03/23/26 evening shift;- Two jugs of tea made 03/21/26 expired;- Chicken salad spread container, 5 pounds, opened 03/20/26 and not re-sealed;- Meat, unknown, in metal pan in refrigerator defrosting without any labeling;- 16-ounce original plastic container of fresh strawberries with no date contains three moldy strawberries;Main Kitchen Area:- Refrigerator missing 03/09, 03/10, 03/20, 03/23/26 temperature log entries for evening shift;- Refrigerator missing 03/05, 03/09, 03/10, 03/17, 03/20/26 temperature log entries for day shift;- Meat, unknown, in metal pan defrosting in refrigerator without any labeling;- Leftover cooked sausage in refrigerator expired 03/23/26;- Chicken pot pie in refrigerator dated 03/21/26 expired;- Leftover rice pilaf in refrigerator dated 03/19/26 expired;- Freezer temperature log missing entries for 03/05, 03/09, 03/10, 03/15, 03/17, 03/20/26 day shift:- Freezer temperature log missing entries for 03/09, 03/10/26 evening shift;- Freezer has Styrofoam cup of ice cream covered and not labeled or dated.Observation in the kitchen on 03/26/26 at 7:00 A.M., showed:- Meat defrosting in a pan in the refrigerator with no date other than the received date of 02/10/26;- Refrigerated Pimento Cheese Spread in a five-pound container with a use by date of 02/20/26 expired;- Peanut Butter and Jelly sandwiches made on 03/25/26 with a use by date of 03/28/26 which is four days after initially made. These items were stored in a plastic open container sitting on a kitchen counter;- Breakfast menu for the day showed French Toast, Farina, Oatmeal, and Sausage patties;- At 7:27 A.M. Oatmeal completed cooking on the stove and transferred to the steam line by Dietary [NAME] (A). No temperature check taken on completed food item;- Dietary [NAME] (A) changed gloves after working with pork sausage and did not wash hands between glove change;- At 7:50 A.M. First batch of 17 pieces of French Toast completed, temperature check done with a reading of 190 and placed on steam line;- At 8:35 A.M. Dietary [NAME] (A) wearing gloves goes into the Dietary Manager (DM) office and picks up a book and returns to kitchen area and stacks food plate covers. Changes gloves without handwashing and then continues to work with food from the steam line and filling plates;- At 8:38 A.M. First food trays are loaded onto hall carts with no temperatures taken at the steam line;- At 8:45 A.M. Dietary [NAME] (A) changes gloves in kitchen and does not handwash between glove change. During an interview on 03/26/26 at 3:15 P.M., the DM said:- Food temperatures should be taken right before serving to residents from the steam line and when foods are completely cooked. If multiple batches of a product are being made such as French toast, the cook should take the temperature of each batch when it's completed cooking. The reason French Toast needs temperature checked is because of the eggs used to make the product;- The serving temperature to halls should be 165 for hot foods and 41 to 43 for cold foods;- Gloves should be changed whenever you leave the kitchen and return of whenever they are soiled or contaminated. Staff should always wash their hands between glove changes;- Expired food items should be discarded as soon as they are expired;- Leftovers are good for three days. If a food item is prepared on 03/23/26 then it would be discarded on 03/26/26; - Every refrigerator and freezer should have a thermometer for staff to record temperatures daily. Currently there are four missing thermometers, and they were likely taken recently by a disgruntled ex-dietary employee;- Missing temperatures in the refrigerator and freezer temperature logs are due to new employees and training that is ongoing.During an interview on 03/27/26 at 10:45 A.M., the Administrator said:- Temperatures should be taken on food items before meal service and at the last tray that is served. When dietary staff finished cooking a food item it should be temperature checked prior to going to the steam line;- Kitchen staff should wash their hands between gloves changes in the kitchen;- Items in the refrigerator and freezer should be properly labeled with expiration dates;- Temperature checks should be done in the morning and evening on all refrigerators and freezers and there should be a thermometer available in each location for staff to utilize;- Leftovers should be thrown away immediately after they have been there for three days;- Expired items should be thrown away immediately when they expire.

Based on observation, interview and record review, facility staff failed to ensure prepared food items were served at a safe and appetizing temperature to residents, failed to monitor the internal temperature of hot food items held on the steam table, failed to offer a variety of meal substitutions to residents, and failed to utilize preparation and hot storage methods that preserved and enhanced the palatability of food items. The facility census was 55.Review of facility policy titled, Food Preparation and Service, revised November 2022, showed:- Internal cooking temperature for raw eggs was 145 degrees ( ) Fahrenheit;- Proper hot and cold temperatures are maintained during food distribution and service;- The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff;- The danger zone for food temperatures is above 41 and below 135 . This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness;- Policy provided did not cover required serving temperatures to residents;1. Review of Resident #57's Quarterly Minimum Date Set (MDS, a federally mandated assessment tool completed by facility staff), dated 03/05/26, showed:- Resident was cognitively intact;- Diagnoses: dementia, depression, and psychotic disorder;During an interview on 03/26/25 at 9:15 A.M., the resident said:-The coffee was cold this morning;-Staff brought him/her three half-filled coffee mugs of lukewarm coffee instead of just filling his/her large insulated cup;-The amount of milk he/she got for breakfast was not enough for a bowl of cereal;-The French Toast and sausage was lukewarm and it feels like the kitchen staff don't care how they serve the hall trays;- It was not an enjoyable meal for him/her. 2. Review of Resident #11's Quarterly MDS, dated [DATE], showed:- Resident was cognitively intact;- Diagnoses included: Depression, psychotic disorder, and schizophrenia. During an interview on 03/24/26 at 3:38 P.M., the resident said:- He/She eats in the dining room;- The meat especially the pork is tough;- If he/she does not like the main course the staff always offers a peanut butter and jelly sandwich, there are very few alternatives to choose from that are fresh;- The food is not seasoned well and sometimes the food temperature is too hot and it makes it hard to eat;- He/She would prefer his/her food at the proper temperature so he/she can eat it.3. Review of Resident #18's Quarterly MDS, dated [DATE], showed: - Resident has moderately cognitive impairment;- Diagnoses included: Obstructive uropathy (blockage of the urinary tract), diabetes, and depression; During an interview on 03/24/26 at 10:34 A.M., the Resident said:- He/She normally eats in his/her room and the food is cold half the time it is served. There's not much variety with very few alternative options unless you want peanut butter and jelly. Eating cold food is not very appetizing and disappointing. 4. Review of Resident #4's Quarterly MDS, dated [DATE], showed:- Resident was cognitively intact;- Diagnoses included: Obstructive uropathy and diabetes;During an interview on 03/24/26 at 10:39 A.M., the Resident said:- He/She eats in his/her room and when the food is delivered it's barely warm. He/She has had to ask staff to warm up his/her meal at various occasions and would much prefer for the food to arrive hot so he/she could eat when it arrives instead of having to wait an additional five to 10 minutes before the tray comes back to the room. Record review of alternate food items for each meal on 03/24/26 showed residents could request a deli meat sandwich, grilled cheese, peanut butter and jelly sandwich, chips, or cottage cheese.Record review of recipe card on 03/26/26 at 7:00 A.M., showed: French Toast (non-applicable steps omitted):- 1 2/3 Tablespoons of cinnamon.- Optional: Powdered sugar sprinkled on each serving of completed French Toast.Observation in the dining room on 03/24/26, showed:- 12:46 P.M. Resident offered a peanut butter and jelly sandwich as the only option for a meal substitute. Resident received a sandwich in a bag for their substitute menu item.- 12:53 P.M. Resident offered a peanut butter and jelly sandwich as the only option for a meal substitute. Resident received a sandwich in a bag for their substitute menu item.- 1:06 P.M. Resident offered a peanut butter and jelly sandwich as the only option for a meal substitute. Resident received a sandwich in a bag for their substitute menu item.Observation in the kitchen on 03/26/26 at 7:30 A.M., showed:- Peanut butter and jelly sandwiches made on 03/25/26 with a use by date of 03/28/26 which is four days after initially made. These items were stored in a plastic open container sitting on a kitchen counter;- At 7:38 A.M. First batch of French Toast (17 slices) was completed, temperature checked showed 190 and placed in a metal container on the steam line;- At 7:49 A.M. Second batch of French Toast (17 slices) was completed by Dietary [NAME] (A) and temperature checked over 165 df and placed on a piece of parchment paper on top of the first batch of French Toast on the steam line;- At 7:59 A.M. Dietary [NAME] (A) preparing a third batch of French Toast grabbed the cinnamon spice bottle and tipped it over the liquid mixture he/she had prepared for dipping the bread. No measurement was taken and less than one teaspoon came out of the container and into the mixture; - At 8:02 A.M. Third batch of French Toast (17 slices) was completed by Dietary [NAME] (A) and not temperature checked. It was placed on a piece of parchment paper on top of the other two batches on the steam line in a metal container which is shut and keeps the heat and condensation from escaping the container;- At 8:10 A.M. Dietary [NAME] (A) finished fourth batch of French Toast (17 slices) and did not take a temperature of finished food product. This batch was placed on a piece of parchment paper on top of the other three batches on the steam line. The steam line now has 72 pieces of French Toast in one metal contained on the steam line. Dietary [NAME] (A) did not utilize the oven which was empty for a holding area for the breakfast food items; - At 8:52 A.M. Last hall tray goes out of kitchen with test tray loaded on the bottom shelf. No temperature checks of the food items on the steam line were observed.- At 9:00 A.M. Last hall tray delivered, test tray consisted of oatmeal, French toast, and a sausage patty. Temperatures taken showed: French Toast 113.5 , expected temperature 120.0 , Sausage patty 105.2 , expected temperature 120.0 ; - French toast was soggy, lukewarm and had very little flavor, with no taste of cinnamon when eaten plain without any condiments; - The sausage was cold to the taste.During an interview on 03/26/26 at 3:15 P.M., the Dietary Manager (DM) said:- Currently staffing in the kitchen was one cook missing but there is enough staffing to provide service to the residents daily. She fills in for the missing cook until a new one is hired;- The French Toast was soggy for breakfast on 03/26/26 because Dietary [NAME] (A) did not utilize the oven to keep the multiple batches of French toast hot and free from steam line condensation;- Powdered Sugar is stocked in the kitchen for meal preparation. She is not sure why Dietary [NAME] (A) did not follow the guidance on the recipe card which allowed for optional use of powdered sugar sprinkled on the French Toast. When she makes French toast for the residents, she makes half the batch with powdered sugar and half the batch with extra cinnamon for higher quality and taste;- She has tried to guide and teach Dietary [NAME] (A) how to improve service, but he/she does not take direction well and is resistant to change in the kitchen;- Whenever spices are used in a recipe they should be measured out and added exactly as stated for the recipe; - Food temperatures should be taken right before serving to residents from the steam line and when foods are completely cooked. If multiple batches of a product are being made such as French toast, the cook should take the temperature of each batch when it's completed cooking. The reason French Toast needs temperature checked is because of the eggs used to make the product;- The serving temperature to halls should be 165 for hot foods and 41 to 43 for cold foods.During an interview on 3/27/26 at 10:45 A.M., the Administrator said: - Food items should be served per state and federal regulations for temperatures and sausage patties served at 105 are too cold to be served as a hot food item;- Temperature of food items should be taken prior to service to residents and before the last tray is served;- The DM is responsible for monitoring the kitchen staff during food preparation and should train, guide, and re-direct kitchen staff as needed;- Residents should not expect to receive soggy French Toast for breakfast; - Alternate food items should be made to order for residents and not pre-made or served in a plastic bag.

Based on observations, interviews, and record review, the facility failed to label and date medications and biologicals stored within the North medication room. The staff failed to date an opened bottle of Lorazepam (used to treat anxiety) for one of the 14 sampled residents, (Resident #16), and failed to label four house stock insulin pens, and failed to date an opened bottle of house stock melatonin (a medication used for insomnia). The facility census was 55. The facility did not provide a policy for labeling and dating of medications. 1. Observation and interview on 03/25/26 at 12:37 P.M., of the North medication room showed: - Resident #16 had an opened bottle of Lorazepam 2 milligram per milliliter (2 mg/ml). It was filled on 2/13/26. The box said to discard 90 days after opening; - Licensed Practical Nurse (LPN) A said it should have been dated when it was opened; - Four Levemir (long acting) insulin pens were in a clear plastic cup and did not have pharmacy label to indicate if they were house stock or if they belonged to a resident; - LPN A said they were house stock and should have a pharmacy label on them. During an interview on 3/27/26 at 10:40 A.M., the Director of Nursing (DON) said: - The insulin pens should have a label on them to indicate who they belonged to, even if they were used for house stock; - The Lorazepam should have been dated when it was opened. 2. Observation on 03/26/2026 at 2:46 P.M. showed the south medication cart had an opened bottle of over the counter (OTC) 3milligram (mg) melatonin that did not have a date indicating when the bottle was opened. During an Interview on 03/26/2026 at 2:46 P.M. Certified Medication Technician (CMT) B said house stock of OTC medications should have the date written on the bottle indicating the day the bottle was opened. During an interview on 03/27/2026 at 9:25 A.M. CMT A said house stock of OTC medications should have the date written on the bottle indicating the day the bottle was opened. During an interview on 03/27/2026 at 9:22 A.M. LPN B said house stock of OTC medications should have the date written on the bottle indicating the day the bottle was opened. During an interview on 03/27/2026 at 10:32 A.M. LPN C said house stock of OTC medications should have the date written on the bottle indicating the day the bottle was opened. During an interview on 03/27/2026 at 11:01 A.M. the DON said house stock of OTC medications should have the date written on the bottle indicating the day the bottle was opened.

Based on interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to maintain the highest practicable physical well-being of the residents when no annual training records were found for licensed nurses. The facility census was 55. The facility did not provide a policy for competencies for the licensed nurses. During an interview on 03/25/26 at 12:56 P.M., Licensed Practical Nurse (LPN) A said:- He/She has worked at the facility for about three weeks;- He/She remembered an in-service on gait belt (a special belt placed around the resident's waist to provide a handle to hold onto during a transfer) training;- He/She had completed online training for dementia care, abuse/neglect, infection control, communication, catheter care, peri care, and transfers;- He/She had not completed any competencies. During an interview on 03/25/26 at 3:14 P.M., LPN D said:- He/She has worked at the facility for about four or five months;- He/She had completed in-services on the computer for abuse/neglect, infection control, communication, dementia care, behaviors, transfers, catheter (sterile tube inserted into the bladder to drain urine) and per care;- He/She had not completed any competencies. During an interview on 03/26/26 at 03:08 P.M. the Regional Nurse Consultant (RNC) said the facility has not had any of the licensed nurses do any competencies. During an interview on 03/27/26 at 10:40 A.M., the Director of Nursing (DON) said the licensed nurses should have been doing competency skills during their orientation.

Based on observation, interview, and record review, the facility failed to ensure they developed and implemented a comprehensive person-centered plan of care which included measurable objectives and timeframes to address and meet each resident's specific medical, nursing, mental, and psychosocial needs when the facility staff failed to ensure call light within reach and ensure anti-slip material in place to ensure safety (Resident #8); when the facility had conflicting information regarding discharge planning in resident's current care plan (Resident #10); when the facility failed to develop a plan of care regarding resident wandering or exit seeking behavior and when the facility failed to initiate a care plan for a resident that required meal intake in a specific location that was not the public dining room or personal room (Resident #37) and additionally when the facility failed to initiate or implement life-enriching activities for a resident diagnosed with depression (Resident #52). This affected four of 15 sampled residents the facility census was 56. 1.Review of Resident #8's Quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff) dated 02/12/2026, showed:-Moderate cognitive impairment;-Incontinent of bowel and bladder;-Maximum assist with transfers related to hemiplegia (inability to use one side of the body);-Diagnoses included: heart failure, stroke and diabetes mellitus (metabolic disease). Review of the resident's care plan dated 02/06/2026, showed:-Dependent on staff for meeting emotional, intellectual, physical, and social needs;-Staff to ensure resident's call light is within reach;-Resident required (Dysem), an anti-slip material to be placed in his/her wheelchair to help prevent falls);-No goals or staff interventions to help prevent skin breakdown/skin injury related to resident's incontinence or immobility. Observation on 03/24/2026 at 09:52A.M., showed:-Resident seated in his/her Broda chair (a wheelchair used to assist with positioning and pressure reduction);-Call light attached to shirt at shoulder level to resident's non paralyzed side;-Resident unable to move opposite limb to reach call light to alert staff of needs. Observation on 03/25/2026 at 1:12P.M., showed resident in room, seated in Broda chair, call light laying across bed behind resident out of his/her reach. Observation on 03/26/2026 at 02:22P.M., showed:-Resident lying in bed, watching television;-Call light attached to calendar, hung from wall, on resident's paralyzed side, out of reach;-No Dysem in resident's wheelchair. During an interview on 03/27/2026 at 09:50A.M., Licensed Practical Nurse B said that residents that have Dysem care planned, as a safety intervention should have product in place, as well as the nurses check for placement each day and chart if in place or missing. 2. Review of Resident #10's comprehensive MDS dated [DATE], showed:-Resident cognitively intact;-Independent with mobility, ambulation and ADLs (Activities of Daily Living);-Diagnoses included Bipolar, cancer, heart disease and high blood pressure. Review of resident's care plan dated 02/26/2026, showed:-Resident at risk for urinary retention and is perform intermittent self-catheterization (a tube temporarily placed in the bladder to drain urine and then removed) twice daily with minimal assist from staff;-Resident is unable to make sound decisions or live independently;-Resident to be satisfied with current living arrangements at facility;-Wishes to be discharged to the community upon successful completion of treatment (dated 12/2024);-Resident will be able to verbalize/communicate required assistance post-discharge and the services required to meet needs before discharge. Review of the Physician's Order Set dated 03/24/2026 showed no orders for intermittent catheterization by staff or by resident. A catheterization requires a physician order and aseptic technique (a set of specific practices used in healthcare to prevent contamination and maintain sterility). 3.Review of Resident 37's Quarterly MDS dated [DATE], showed:-Severe cognitive impairment;-Wandering behavior not displayed;-Supervision and intermittent assist from staff required for meal intake;-Diagnoses included cancer, pneumonia, tremors and hearing loss. Review of resident's care plan dated 12/02/2025, showed:-Dependent on staff for meeting emotional, intellectual, physical, and social needs;-Resident often wandered and had exit seeking behaviors; -Potential fluid deficit related to poor intake and dementia;-Swallowing problem related to pocketing food in cheek and delayed swallowing;-No interventions or indications that resident needs to be assisted with meals in hallway; Review of resident's physician order set dated 03/25/2026, showed no orders for wander guard (a specialized electronic system that prevents residents with dementia from wandering into danger.) Observation on 03/24/2026 at 09:11A.M., showed resident assisted by facility staff at south nurse's station, wander guard bracelet in place to right ankle. Observation on 03/25/2026 at 08:30A.M., showed resident being assisted with meal by facility staff at south nurse's station, wander guard bracelet in place to right ankle. Observation on 03/25/2026 at 12:53P.M., showed resident being assisted with meal by facility staff at south nurse's station, wander guard bracelet in place to right ankle. During an interview on 03/27/2026 at 09:50A.M., the Activity Director (AD) said:-The resident should not be made to eat alone in the hallway, that resident's family/representative wants him/her to have meals in the hallway;-Eating in hallway should be care planned as a preference;-He/She is able to input and edit care plans. 4. Review of Resident #52's Comprehensive MDS dated [DATE], showed:-No cognitive impairment;-Dependent on staff for assist with mobility and transfers;-Diagnoses included arthritis, diabetes and depression. Review of Resident's care plan dated 03/06/2026, showed:-Resident at risk for depression due adjusting to her new living arrangements at the facility (initially dated 03/21/2025);-Resident will be continuously monitored to ensure he/she has the resources in place to address depression and mental health concerns;-Resident was grieving the loss of his/her independence;-No specific interventions, goals, activities or psychosocial interventions for depression;-No mention of resident preferences such as food, activities, time of rising, books, television, etc. During an interview on 03/25/2026 at 08:30A.M., the resident said:-He/She preferred not to get out of bed as it caused increased pain;-He/She received a monthly activities calendar dropped off to him/her;-The staff provided activity and puzzle books intermittently, all the ones he/she currently had were all completed;-He/She would be willing to get out of bed and go to one previously agreed upon group activity per week;-He/She felt forgotten. During an interview on 03/27/2026 at 09:50A.M., the Activity Director (AD) said:-He/She can implement and make changes to resident care plans;-All residents have activities categories with personal preferences in their care plans;-To know the resident feels forgotten makes him/her feel heart broken. During an interview on 03/27/2026 at 10:40A.M., the Director of Nursing said:-Residents that require isolation with meals should have that intervention on his/her care plan;-Dysem is obtained from therapy staff and should be in place at all times;-Baseline care plans are formulated from staff assessments and comprehensive care plans are formulated after care conference meetings with the interdisciplinary team (IDT);-Residents that are incontinent of bowel or bladder are at risk for skin integrity impairment;-A physician order is required for wander guards and placement of wander guard should be in care plan;-Call lights should be within reach of each resident when in his/her own room. During an interview on 04/02/2026 at 4:00P.M., the Social Services Designee (SSD) said:-All residents should have an activities category, including personal preferences on their care plans;-The AD inputs most activities and preferences, but upon admission, SSD does a thorough assessment with resident and family members;-Wander guards are supposed to have a physician order and be in the resident's care plan as an intervention to maintain safety; -If an intervention such as Dysem is care planned, then that intervention should be in place;-It is not reasonable that a resident has a goal to be comfortable and adjusted in new environment for over 12 months without any additional interventions; -Residents that are incontinent of bowel or bladder are at risk for skin integrity impairment and that interventions such as checking resident for soiling every 2 hours and repositioning should be care planned;-Quarterly IDT meetings are held and care plans are amended within two weeks of meeting date;-SSD, MDS Coordinator, AD and dietary manager are the only staff that are able to make changes to care plans. During an interview on 04/02/2026 at 4:15P.M., the MDS Coordinator said:-All care planned interventions should be in place;-Care plans and MDS assessments are completed per regulations;-The care plan and MDS assessments should accurately reflect each other;-After an MDS assessment or care conference, the care plan is required to be updated within 14 days.

Based on observation, interview and record review, the facility failed to treat residents with dignity and respect with dining when the facility allowed one resident (Resident #24) to eat a meal in his/her room while setting next to his/her soiled bed and when staff stood to assist four residents (Resident #1, #8, #22, #42) with eating while in the dining room. This affected five of 15 sampled residents. The facility census was 55.Review of the undated facility policy titled, Resident Rights, showed:-Residents have the right to a dignified existence;-Residents have the right to personal privacy, including accommodations;-Residents have the right to be free from involuntary seclusion;-The facility shall care for its residents in a manner that promotes enhancement of each resident's quality of life. 1. Review of Resident #24's Quarterly Minimum Data Sheet (MDS), a federally mandated resident assessment tool completed by facility staff, dated 02/12/2026, showed:-Mild cognitive impairment;-Moderate assistance required for toileting, hygiene, and lower body dressing;-Frequently incontinent of bowel and bladder;-Diagnoses included Schizophrenia, Alzheimer's Dementia, overactive bladder, and urinary incontinence. Review of the resident's care plan dated 03/17/2026, showed:-Resident had an Activities of Daily Living (ADL) self-care performance deficit and activity intolerance;-Resident was dependent on nursing staff for assist with all ADL's.-Resident wished to be satisfied with current living situation;-Staff were supposed to allow the resident to make some decisions about treatment and care; Observation of the resident on 03/24/2026 at 08:35A.M. showed:- He/She was in his/her room in a wheelchair;-The resident did not have pants or underpants or an incontinent brief on;-The resident's bed and linens were saturated with urine. Observation on 03/24/2026 at 10:04A.M., showed:-He/She sat in a wheelchair in his/her room;-The resident was sitting next to his/her soiled bed; the bed linens were saturated with urine; - A strong odor of urine present;-The resident's eaten meal tray was on the bedside table next to bed;-The resident had consumed meal while sitting next to a saturated bed of urine. During an interview on 03/27/2026 at 09:20 A.M., Nursing Aid (NA) A said: -The resident's meal tray should not have been delivered to the resident since he/she had been incontinent and required assist with toileting; -Staff should have removed the meal tray, assisted resident with incontinence care and dressing;-The staff should have cleaned the resident's soiled bed, warmed the meal and then served the meal;-It is not reasonable for the resident to eat his/her meal next to his/her soiled bed. During an interview on 03/27/2026 at 09:50 A.M., Licensed Practical Nurse (LPN) A said:-The resident's meal tray should have not been delivered to the resident when he/she was next to his/her soiled bed; -The meal should have been removed and the resident assisted with getting soiled areas cleaned;-The resident should have been offered meal; -The resident eating a meal next to a soiled bed was un-dignified. During an interview on 03/27/2026 at 10:15A.M., the Assistant Director of Nursing (ADON) said:-Residents should not have to eat meals next to a soiled bed; -Staff should have assisted the resident with hygiene, grooming and dressing;-Staff should have cleaned up the resident's soiled bed, warmed the resident's food and served resident after clean-up was completed. 2. Observation on 03/24/2026 from 12:51P.M. through 1:15P.M., showed staff members standing to feed residents in the dining room:-RN C standing to feed Resident #8;-RN C standing to feed Resident #1;-NA B standing to feed Resident #8;-NA A standing to feed Resident #8;-RN C standing to feed Resident #22;-NA A standing to feed Resident #42. During an interview on 03/24/2026 at 2:35P.M., NA B said that staff should be seated when assisting residents with meals but there are not enough chairs in dining room for all staff to sit while feeding residents. During an interview on 03/27/2026 at 09:30A.M., the Activities Director/CNA said that staff should not stand to feed residents, they should be at resident's eye level so residents can see and interact with staff. During an interview on 03/27/2026 at 09:50A.M., LPN B said staff are supposed to sit at eye level when assisting residents to eat. During an interview on 03/27/2026 at 10:40A.M., the DON said staff should be seated when assisting residents with meals to maintain eye contact and interact with each other.

Based on interview and record review, the facility failed to allow one resident (Resident #1) to return to the facility without a documented reason in the medical record as to why the resident's needs could not be met. This affected one resident of three sampled residents. The facility's census was 32. Review of the facility provided policy titled, Transfer or Discharge Notice, dated March 2025 showed:-When a resident is sent to an acute care setting, this is considered a transfer, not a discharge, because the resident's return is generally expected; -If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility, not the reason for the initial transfer; -If the facility does not permit a resident's return to the facility, based on inability to meet the resident's needs, the facility will notify the resident, and/or his/her representative in writing, including notification of appeal rights;-Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge.1. Review of Resident #1's Level 1 Nursing Facility Pre-admission Screening for Mental Illness/Mental Retardation or Related Condition (PASRR) dated 2/17/2015 showed:-He/She had manic (abnormally elevated mood and activity) and depressive (deep sadness) episodes; -He/She had serious problems in level of function; -He/She received intense Psychiatric treatment in the past two years; -He/She often called the crisis hotline threatening to harm self if he/she did not get what he/she wanted; -He/She had problems getting along with others and needed redirection; Review of Resident #1's preadmission packet dated 12/3/2025 at 12:22 PM showed:-The resident's guardian was the Public Administrator; -Diagnoses of anxiety, diabetes, Schizophrenia, Bipolar disorder, depression, anxiety and obesity.Review of the resident's pre-admission care plan dated 12/3/25 at 1:20P.M, showed:-He/She became angry quickly if things did not go his/her way; -He/She made threats; -He/She had suicidal thoughts, with no specific plan; -He/She was deemed safe for admission to a skilled facility; -He/She was at risk for aggression, anxiety, and irritability; trouble getting along with others and picked at his/her skin; -He/She may display high and low emotions; -He/She needed assistance with care, as he/she was unable to stay on task; -Due to his/her size and behaviors, he/she required 2 staff assistance for care. Review of the resident's Face Sheet showed:-The resident was admitted to the facility on [DATE]; -The resident was discharged on 12/7/25 at 6:30 P.M.; -Public Administrator as guardian; -Diagnoses of anxiety, obesity, depression, diabetes, Schizophrenia (a brain disorder leading to a break from reality, disorganized thinking and reduced emotional expression) and Bipolar Disorder (a mental illness causing an extreme shift in mood, energy and activity), restlessness and agitation.Review of the resident's nurse progress notes showed:-On 12/06/2025 at 12:02 P.M. He/She was very anxious, had been back and forth to the nurses station requesting things; -The resident requested hospice be called twice; -Hospice encouraged the use of his/her antianxiety medication; -On 12/06/2025 at 4:13A.M. staff reported he/she was using the call light frequently for minor issues; -When the resident's call light was answered, the resident would attempt to pull staff into the bed with him/her; -The staff were instructed to provide care in pairs.-On 12/07/2025 6:34 P.M. the resident returned from a smoke break; -He/She requested hospice be called; -The resident reported he/she was having a mental and physical crisis; -He/She said he/she was having chest pain that went down the left arm, and he/she was going to hurt him/herself and everyone sitting/standing around him/her; -911 was called; -He/She began throwing things when Emergency Medical Services (EMS) arrived; -EMS de-escalated the situation and the resident was transferred to a local hospital. During an interview on 12/23/24 at 12:08 P.M. the Public Administrator for Resident #1 said:-The facility admitted the resident on 12/5/25; -He/She was sent to the hospital on [DATE]; -On 12/9/25 at 9:35 A.M. a Social Worker from the hospital called the Public Administrator's office and said the facility would not accept the resident back; -At 1:21 P.M. on 12/9/25 the office received a formal notice of discharge;-On 12/23/25 the resident remained at the hospital, and he/she continued to look for placement. During an interview on 1/6/26 at 11:12 A.M. the hospital Social Service worker said:-Resident #1 was admitted to the hospital on [DATE]; -The resident was admitted for chest pain, but had some suicidal/homicidal ideation; -Social Services from the facility called the hospital on [DATE] and said they would not re-admit the resident; -The afternoon of 12/9/25 the facility Social Service Designee delivered a letter that said they would not accept the resident for re-admission. During an interview on 1/6/26 at 1:23 P.M. the Administrator said:-The resident made verbal threats to harm his/her roommate; -Any behaviors, threats to others or self should have been charted; -She would expect threats to others or self to be documented; -The hospital treated the resident for an irregular heart rate and wanted to send the resident back to the facility; -We said the resident could not return, because he/she needed to see psychiatry for behaviors; -She did not believe an entire preadmission packet was sent prior to the resident being admitted ; -The facility was not aware of his/her previous behaviors prior to admission; -The Director of Nursing reviewed the preadmission packet and deemed the resident was appropriate for admission; -She felt other residents would not be safe based on behaviors at the time the resident was sent out, if the resident was allowed to return. Intake 2689104Intake 2699939

Based on interviews and record review, the facility failed to ensure ten of eleven sampled residents who participated in a group meeting, knew who the Grievance Official was and how to file a grievance. The facility census was 56. Review of the facility's undated policy for grievances, showed, in part: - Residents have the right to voice grievances to facility or other agency that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal; - Such grievances include those with respect to care and treatment which is furnished as well as that which has not been furnished, behavior of staff and other residents; and other concerns regarding their Long Term Care facility stay; - Residents have the right to and the facility must make prompt efforts by facility to resolve grievances residents may have; - The facility must make information on how to file a grievance or complaint available to the residents; - The facility must establish a grievance policy to ensure prompt resolution of all grievances regarding residents' rights; - Upon request, provider must give a copy of grievance policy to residents. Grievance policy must include: notifying resident of right to file grievances orally; contact information of grievance official; reasonable expected time frame for completing review of grievance; right to obtain written decision regarding grievance; contact information of independent entities with whom grievances may be filed; - Identifying Grievance Official responsible for overseeing grievance process, receiving and tracking grievances through conclusion, leading investigations by facility, maintaining confidentiality of all information associated with grievances, issuing written grievance decisions to resident, and coordinating with agencies as necessary in light of specific allegations; - Ensuring all written grievance decisions include date grievance was received, summary statement of the grievance, steps taken to investigate grievance, a summary of pertinent findings or conclusions regarding resident's concerns, a statement as to whether grievance was confirmed or not confirmed and any corrective actions taken or to be taken by facility as a result of grievance, and date written decision was issued. Review of the facility's undated policy for resident rights showed, in part: - Residents have a right to a dignified existence, self determination and communication with and access to persons and services inside and outside the facility. This facility shall protect and promote the rights of each resident which shall include the following rights: - A resident has the right to exercise his/her rights as a resident of the facility and as a citizen or resident of the United States; - A resident has the right to voice grievances with respect to treatment or care that is, or fails to be furnished, without discrimination or reprisal for voicing grievances and prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents. 1. Review of the resident council meeting minutes showed: - 8/26/24 - the minutes did not indicate what resident rights had been reviewed or discussed or if the residents knew how to file a grievance; - 10/1/24- the minutes did not indicate what resident rights had been reviewed or discussed or if the residents knew how to file a grievance; - 10/29/24 - the minutes did not indicate if the resident rights had been reviewed or discussed or if the residents knew how to file a grievance. During a group meeting on 11/6/24 at 3:01 P.M., ten of the 11 alert and oriented residents who attended said they did not know who the Grievance Official was and did not know how to file a grievance. During an interview on 11/5/24 at 12:44 P.M., the Activity Director said: - He/she had been in the current position since September; - He/she set up the resident council meetings; - They discussed the resident's concerns at the meetings. During an interview on 11/7/24 at 5:06 P.M., the Administrator said the residents should know who the Grievance Official was and how to file a grievance. During an interview on 11/7/24 at 5:06 P.M., the Regional Quality Assurance (QA) Nurse said he/she addressed grievances with the residents back in April and discussed the process with them.

Based on observation and interviews the facility failed to maintain accommodation of needs when the facility staff did not ensure two of 14 sampled resident (Resident #46 and #39), had their call lights within reach while they were in their rooms. The facility census was 56. The facility did not provide a policy regarding call light use. 1. Review of Resident #46's Quarterly minimum data set (MDS, a federally mandated assessment completed by the facility staff) date 10/17/24 showed: - The resident had a Brief Interview for Mental Status (BIMS) score of 0, indicating sever cognitive impairment; - Diagnoses included: Dementia (a disease that affect the brain that causes memory loss and impairs reasoning), weakness and anxiety; - The resident used a walker for mobility; - The resident required the assistance of one staff for bed mobility, toileting, and showering. Review of the resident's undated comprehensive care plan does not address call light use. Observation on 11/4/24 at 9:34 A.M. showed: The resident was in bed with the head of bed raised; - The resident's bed was pushed with the left side of the bed against the wall; - The residents call light was plugged into the wall and was lying on the floor behind the residents bed; - The resident was not able to reach the call light; - Certified Nurses Aide (CNA) D entered the resident's room, removed the resident's breakfast tray and then left the room without giving the resident his/her call light. Observation on 11/5/24 at 10:32 A.M. showed: - The resident was in his/her bed; - The residents call light was lying behind the residents bed, on the floor at the foot of the bed. Observation on 11/6/24 at 2:45 P.M. showed: -The resident was in his/her bed; - The bed was pushed with the left side against the wall; - The resident call light was behind the bed, lying on the floor at the foot of the bed; - The resident was unable to reach the call light. 2. Review of Resident #39's Quarterly MDS, dated [DATE] showed: - He/She had a BIMS score of 0, indicating severe cognitive impairment; - Diagnoses included: Stroke, heart disease and schizophrenia ( a disorder that affects a persons ability to think, feel and behave clearly). - The resident was dependent on staff for toileting, personal hygiene, and transfers; - The resident was incontinent of bowel and bladder. Review of the resident's undated comprehensive care plan directed the facility staff to keep the resident's call light within arms length. Observation on 11/4/24 at 10:11 A.M. showed: - CNA D and Nurse Aide (NA) A enter the residents room with the resident in his/her wheel chair; - The resident's head of bed was elevated and the resident's call light cord was draped across the frame of the head board with the call light resting on the floor; - The staff assist the resident to bed and provided incontinent care; - The staff covered the resident with his/her blanket, turned the light out and left the resident's room; - The staff did not pick up the resident's call light and did not provide it to him/her. Observation on 11/5/24 at 10:36 A.M. showed: - The resident was in bed with the head of bed elevated; - The resident's call light cord was draped across the bed frame at the head of the bed with the call light resident on the floor under the bed. During an observation on 11/6/24 at 2:43 P.M. showed: - The resident was in bed with the head of bed elevated; - The resident's call light cord was draped across the bed frame at the head of the bed with the call light resident on the floor under the bed. During an interview on 11/7/24 at 7:34 A.M. CNA D said he/she should have made sure the resident's call light was in reach at all times. During an interview on 11/7/24 at 5:06 P.M. the Director of Nurses said: - She expected the staff to ensure the resident had their call lights within reach while in their rooms and in bed; - She did not expect staff to provide cares and not provide the resident with his/her call light; - Call lights should be in reach at all times and should not be on the floor or under the bed.

Based on observations, interviews, and record review, the facility failed to ensure staff provided services that met professional standards of quality of care when staff failed to obtain an order for a resident to go to dialysis ( a procedure that removes waste products and excess fluid form the blood when the kidneys are no longer functioning properly) which affected one of the 14 sampled residents, (Resident #49). Additionally, the facility failed to monitor the settings of the low air loss mattress (an air mattress with tiny holes that helps prevent and treat pressure wounds and regulate skin temperature and moisture levels) which affected two residents, (Resident #21 and #30). The facility census was 56. Review of the facility's policy for medication orders, dated 2001, showed: - The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders; - A current list of orders must be maintained in the clinical record of each resident. 1. Review of Resident #49's care plan, reviewed on 4/24/24 showed the care plan did not address the resident going to dialysis. Review of the resident's Quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 7/20/24 showed: - Cognitive skills severely impaired; - Independent with toilet use, dressing and transfers; - Always continent of bowel and bladder; - Diagnoses included stroke and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing) and diabetes mellitus. Review of the resident's physician order sheet (POS) dated November 2024 showed the resident did not have a physician's order to go to dialysis. During an interview on 11/7/24 at 9:55 A.M., the MDS/Care Plan Coordinator said the resident's care plan should address if the resident goes to dialysis. During an interview on 11/7/24 at 10:53 A.M., Licensed Practical Nurse (LPN) D said the resident should have an order to go to dialysis. During an interview on 11/7/24 at 5:06 P.M., the Director of Nursing (DON) said: - The care plans should be comprehensive and should include if the resident went to dialysis; - There should be a physician's order for the resident to go to dialysis. 2. Review of the undated manufacturer's guidelines for the Drive low air loss mattress showed: - Adjust the dial to correspond to the resident's appropriate weight setting or comfort level. Review of Resident #21's care plan, revised 5/15//24 showed: - The resident had the potential for skin injury; - Provide a low air loss mattress with proper functioning. Review of the resident's Significant change in MDS, dated [DATE] showed: - Cognitive skills moderately impaired; - Upper and lower extremities impaired on both sides; - Dependent on staff assistance for eating, oral care, showers, dressing, personal hygiene, transfers and toilet use; - Always incontinent of bowel and bladder; - Weight - 160 pounds. No weight gain or weight loss; - Had one Stage III pressure ulcer (a full thickness of skin loss, exposing the subcutaneous tissues, presents as a deep crater with or without undermining adjacent tissue) on admit; - Diagnoses included non traumatic brain dysfunction (brain damage caused by internal factors rather than an external physical force), congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), anxiety, cerebral palsy (CP, abnormal brain development or damage to the developing brain that affects a person's ability to control their muscles) and dementia (inability to think). Observation on 11/4/24 at 9:23 A.M., showed the Drive low air loss mattress was set on 300 pounds. Observation on 11/4/24 at 9:47 A.M., showed Nurse Aide (NA) B and Certified Nurse Aide (CNA) C provided incontinent care and the resident did not have a pressure ulcer on his/her buttocks. Review of Resident #21's weight on 11/7/24 at 11:30 A.M., showed: - 10/4/24 - 151.6; - 11/3/24 - 147.8. Observation on 11/7/24 at 11:36 A.M., showed the low air loss mattress was set on 280 pounds. Review of the resident's POS, dated November 2024 showed the resident did not have a physician's order for the low air loss mattress or what the settings should be set on. 3. Review of the undated manufacturer's guidelines for the Proactive low air loss mattress, showed: - Users can adjust air mattress to a desired firmness according to the resident's weight or the suggestion from a a health care professional. Review of Resident #30's care plan, reviewed 3/22/24 showed it did not address the use of the low air loss mattress or what the settings should be. Review of the resident's Quarterly MDS, dated [DATE] showed: - Short term and long term memory problems; - Cognitive skills severely impaired; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for eating, oral care, toilet use, showers, dressing, personal hygiene and transfers; - Always incontinent of bowel and bladder; - Diagnoses included dementia, anxiety, traumatic brain injury (TBI, a sudden injury that causes damage to the brain), depression and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness and social interactions). Observation on 11/4/24 at 2:52 P.M., showed the low air loss mattress was set on 230 pounds. Review of the resident's weight on 11/7/24 at 11:28 A.M., showed: - 10/1/24 - 153.1 pounds; - 11/2/24 - 154.4 pounds. Observation on 11/7/24 at 11:36 A.M., showed the low air loss mattress was set on 230 pounds. Review of the resident's POS, dated November 2024 showed the resident did not have a physician's order for the low air loss mattress or what the settings should be set on. 4. During an interview on 11/6/24 at 10:32 A.M., LPN B said: - The nurses monitor the low air loss mattresses to make sure the settings are correct; - He/she just visually checks it and does not think it is documented anywhere; - Hospice (end of life care) sets up the low air loss mattresses. During an interview on 11/7/24 at 7:09 A.M., LPN A said: - The nurses check the settings each shift; - When they had paper charting, it was written in the books; - He/she just remembered what the settings should be; - Should look on the POS for the orders for the low air loss mattress and for what the settings should be set on. During an interview on 11/7/24 at 10:53 A.M., LPN D said: - The nurses monitor the settings on the low air loss mattress; - He/she did not know what settings they should be set on; - He/she did not know how often they should be checked. During an interview on 11/7/24 at 5:06 P.M., the Regional Quality Assurance (QA) nurse said: - There should be a physician's order to indicate the weight of the resident and it would be per manufacturer's guidelines; - The nurses should be checking them to ensure they are on the correct setting.

Based on observation, record review and interviews the facility staff failed to review and update care plans quarterly for two of 14 sampled residents (Resident #36 and #43).The facility census was 56. The facility did not provide a policy for care plan revisions and updates. Review of the undated Resident Right's policy showed: - The resident had the right to participate in their person-centered care plan; - Participate in the development of goals and outcomes of care the care plan; - Request revisions to the person-centered care plan. 1. Review of Resident #36's Quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 8/22/24 showed: - The resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had mild cogitative deficit; - Diagnoses included: Alzheimer's Disease (A disease of the brain that impairs memory and reasoning), urinary incontinence and constipation; - The resident required assistance from one staff to use the toilet, get dressed, and shower; - The resident had verbal behaviors. Review of the resident's care plan showed: - The resident's care plan was last updated 5/4/24; - The resident's care plan did not address his/her verbal behaviors that were assessed for the MDS dated [DATE]. 31102 2. Review of Resident #43's care plan conference summary, dated May 2024 showed: - Two staff attended the meeting; - The form did not indicate if the resident was invited to the care plan meeting or if he/she attended the meeting; - This was the only care plan conference summary provided by the facility. Review of the resident's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Upper extremity impaired on one side; - Required partial to moderate assistance of staff with toilet use, showers, and transfers; - Frequently incontinent of bowel; - Diagnoses included cancer, stroke, diabetes mellitus and hemiplegia (paralysis affecting one side of the body). During an interview on 11/4/24 at 11:31 A.M., the resident said: - He/she had not been invited to a care plan meeting and had not attended a care plan meeting. During an interview on 11/5/24 at at 12:31 P.M., the MDS/Care Plan Coordinator said: - He/she did the nursing component of the MDS; - Social Services invited the residents and the responsible parties to the the care plan meetings. During an interview on 11/5/24 at 3:34 P.M., the Social Services Designee said:- He/she had only been in the current position for three weeks; - Was only able to find one care plan conference summary for the resident; - Residents and responsible parties should be invited to the meetings. During an interview on 11/7/24 at 5:06 P.M., the Director of Nursing (DON) said: - Residents and/or responsible parties should be invited to their care plan meeting; - There should be documentation to indicate who attended the care plan meetings - Care plan should be updated quarterly and as needed in coordination with the MDS assessment schedule.

Based on record review and interviews the facility staff failed to develop a comprehensive person-centered care plan for three of 14 sampled residents (Resident #25, #18, and #49). The facility census was 56. The facility did not provide a care plan policy. Review of the undated Resident Right's policy showed: - The resident had the right to participate in their person-centered care plan; - Participate in the development of goals and outcomes of care the care plan; - Request revisions to the person-centered care plan. 1. Review of Resident #25's Quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 10/2/24 showed: - The resident had a brief interview for mental status (BIMS) score of 12, indicating minimal cognitive deficit; - Diagnoses included: Obesity, urinary incontinence and diabetes type 2 (a disease in which the body does not process blood sugar properly); - The resident was bound to his/her wheelchair; - The resident was incontinent of bowel and bladder; - The resident required assistance of two staff to provide hygiene, bathing, and transfers. Review of the resident's record showed the following: - The resident was admitted to the facility on [DATE]; - The care plan was one page in length, was dated 11/4/24 and addressed a fall the resident had; - The resident did not have a person-centered comprehensive care plan. 31102 2. Review of Resident #18's MDS, dated [DATE] showed: - Cognitive skills intact; - Diagnoses included cancer, seizure disorder, anxiety, chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing) and congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body). Review of the resident's care plan, initiated on 10/14/24 showed the care plan did not address the resident's code status. Review of the resident's physician order sheet (POS), dated November 2024 showed it did not address an order for the resident's code status. Review of the resident's face sheet showed it did not address the resident's code status. During an interview on 11/7/24 at 9:55 A.M., the MDS/Care Plan Coordinator said the resident's care plan should address the resident's code status. During an interview on 11/7/24 at 10:53 A.M., LPN D said: - There should be a physician's order for a resident's code status; - Their code status should be on the face sheet and it should be care planned. During an interview on 11/7/24 at 5:06 P.M., the Director of Nursing (DON) said: - There should be a physician's order for the resident's code status; - The care plan should address the resident's code status. 3. Review of Resident #49's care plan, reviewed on 4/24/24 showed the care plan did not address the resident going to dialysis ( a procedure that removes waste products and excess fluid form the blood when the kidneys are no longer functioning properly). Review of the resident's Quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Independent with toilet use, dressing and transfers; - Always continent of bowel and bladder; - Diagnoses included stroke and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing) and diabetes mellitus. During an interview on 11/7/24 at 9:55 A.M., the MDS/Care Plan Coordinator said the resident's care plan should address if the resident goes to dialysis. During an interview on 11/7/24 at 5:06 P.M., the DON said the care plans should be comprehensive and should include if the resident went to dialysis.

Based on observation and interview, the facility failed to ensure housekeeping and maintenance services was provided to maintain a sanitary, orderly and comfortable interior throughout the facility. The facility census was 56. Review of the facility's Floors policy, revised December 2009, showed in part: -All floors should be cleaned daily; -Floor cleaning procedures are maintained by the house keeping director. Review of the facility's undated house keeping daily cleaning duties showed: -Pull trash; -Dust/mop floors; -Clean toilet; -Dust horizontals; -Clean shower rooms; -Sitting and dining Rooms; -Resident rooms 100 - 119; -Resident rooms 120 - 139. The facilty provided no other policies on cleaning and environment. 1. Observation on 11/04/24 at 9:02 A.M., showed: -room [ROOM NUMBER] with dirt and debris on the floor; -The bathroom floor in room [ROOM NUMBER] was covered with dirt, and was sticky; -The toilet bowl in room [ROOM NUMBER] had brown debris on the sides and will not flush. 2. Observation of the shower room on South Hall on 11/04/24 at 12:10 P.M., showed: -The toilet bowl is covered with brown debris on the sides; -The floor tiles around the toilet are broken and base board is coming away from the wall behind the toilet; -The light cover above the toilet is cracked; -The window blinds are broken by the sink. 3. Observation on 11/04/24 at 2:46 P.M., showed: -The floor in room [ROOM NUMBER] covered with dirt and debris; -room [ROOM NUMBER] smelled of urine; -The back of the stool was not in place. 4. Observation on 11/04/24 at 2:55 P.M., showed room [ROOM NUMBER] with a brown stain on the bathroom ceiling the size of a basket ball. 5. Observation on 11/04/24 at 3:16 P.M., showed the door to the outside smoking area on South Hall with a two inch gap at the bottom and side. 27584 6. Observation on 11/5/24 at 2:23 P.M. and 2:50 P.M., showed the showers across from the nurse's stations by rooms [ROOM NUMBERS] did not have backfow preventers on the shower hoses. During an interview on 11/6/24 at 3:50 P.M., the Maintenance Supervisor said he did not know the shower hoses needed a backflow preventer. 7. Observation on 11/5/24 starting at 2:25 P.M. showed: - The call light cord less than two inch long in the room [ROOM NUMBER]'s bathroom; - No call light cord in room [ROOM NUMBER]'s bathroom; - No call light cord in room [ROOM NUMBER]'s bathroom; - No call light cord in room [ROOM NUMBER]'s bathroom. During an interview on 11/5/24 at 2:42 P.M., the Maintenance Supervisor said all bathroom call lights needed a cord, but some of them have been pulled out. He did not currently have any work orders for call light cords. 8. Observation on 11/6/24 at 3:27 P.M., showed the middle dining room door leading out to the corridor near the copy room would not easily open. Residents attempted to open the door but could not get it opened. The surveyor used significant force with their shoulder on the other side of the door (the door swung into the dining room) to push the door open. Several residents in group mentioned the door could be very difficult to open, so they don't ever use that door. During an interview on 11/6/24 at 3:50 P.M. the Maintenance Supervisor said he did not know the door in the dining room was difficult for residents to open. 44993 9. Observation on 11/4/24 at 9:00 A.M. showed: - The south hall smelled like urine; - Rooms 120, 121, 123, and 125 smelled like urine; - The shared restroom in room [ROOM NUMBER] smelled like urine and the resident had an air freshener sitting on his/her over the bed table; - The floor of the restroom was sticky and had black debris on it. Observation on 11/4/24 at 10:02 A.M. showed room [ROOM NUMBER] a strong urine odor. Observation: 11/4/24 at 10:11 A.M. showed room [ROOM NUMBER] the floor was sticky and the room had a strong urine odor. 10. Observation on 11/5/24 at 7:42 A.M. - The South hall smells like strong urine; - Rooms 120, 121, 123, and 125 smelled like urine. Observation on 11/6/24 at 9:32 A.M. showed: - The South hall smells like strong urine; - Rooms 120, 121, 123, and 125 smelled like urine. Observation on 11/7/24 at 7:15 A.M. showed the South hall smelled like strong urine. During an interview on 11/07/24 at 11:35 A.M., the Maintenance Supervisor said: -He/she is in charge of making repairs in the facility which included repairs to resident rooms, resident bathrooms and shower rooms; -Staff verbally notify him/her if there is a repair that needs to be made; -He/she tries to make repairs as they are reported to him/her; -Sometimes he/she is not aware of repairs that need to be made; -The facility should be in good repair; -The door to the outside smoking area on south hall should not have a gap and should close completely. During an interview on 11/07/24 at 02:41 P.M. the Housekeeping Supervisor said: -The halls and resident rooms should not smell like urine; -He/she expects the floors to be cleaned daily and as needed; -Housekeepers should be using the daily cleaning list; -The floors should not be sticky and dingy; -The facility has had a high turnover in housekeeping staff and are trying to get back on track. During an interview on 11/7/24 at 5:06 P.M., the Administrator said: -He/she expects the facility to be clean and odor free; -He/she expects the building to be in good repair.

Based on record review and interviews, the facility failed to ensure staff invoked (activated by verifying incapacity of the resident to make decisions) Durable Power of Attorney (DPOA) prior to allowing a resident to sign his/her Outside of Hospital Do Not Resuscitate (OHDNR) form which affected one of the 14 sampled residents, (Resident #30) and failed to obtain advance directives for code status (whether the resident wished to have cardiopulmonary resuscitation, CPR, if the resident's breathing stops or if the resident's heart stopped beating), which affected Resident #18. The facility census was 56. Review of the facility's policy for advance directives, revised [DATE], showed, in part: - Advance directives will be respected in accordance with state law and facility policy; - Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he/she chooses to do so; - If the resident is incapacitated and unable to receive information about his/her right to formulate an advance directive, the information may be provided to the resident's legal representative; - Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record; - If the resident indicates that he/she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance; - The Attending Physician will provide information to the resident and legal representative regarding the resident's health status, treatment options and expected outcomes during the development of the initial comprehensive assessment and care plan; - The plan of care for each resident will be consistent with his/her documented treatment preferences and/or advance directive; - The Interdisciplinary Team will conduct ongoing review of the resident's decisions making capacity and communicate significant changes to the resident's legal representative. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (RAI); - Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment and care plans; - The Director of Nursing (DON) or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care; - The Staff Development Coordinator will be responsible for scheduling advance directive training classes for newly hired staff members as well as scheduling annual Advance Directive In-Service Training Programs to ensure that our staff remain informed about the residents' rights to formulate advance directive and facility policy governing such rights. 1. Review of Resident #18's Admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE] showed: - Cognitive skills intact; - Diagnoses included cancer, seizure disorder, anxiety, chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing) and congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body). Review of the resident's care plan, initiated on [DATE] showed the care plan did not address the resident's code status. Review of the resident's physician order sheet (POS), dated [DATE] showed it did not address an order for the resident's code status. Review of the resident's face sheet showed it did not address the resident's code status. During an interview on [DATE] at 9:55 A.M., the MDS/Care Plan Coordinator said the resident's care plan should address the resident's code status. During an interview on [DATE] at 10:53 A.M., Licensed Practical Nurse (LPN) D said: - There should be a physician's order for a resident's code status; - Their code status should be on the face sheet and it should be care planned. During an interview on [DATE] at 5:06 P.M., the Director of Nursing (DON) said: - There should be a physician's order for the resident's code status; - The care plan should address the resident's code status. During an interview on [DATE] at 5:06 P.M., the Regional Quality Assurance (QA) Nurse said: - If the resident did not have a physician's order for a code status, they would automatically be a full code. 2. Review of Resident #30's Out of Hospital Do Not Resuscitate (OHDNR) order showed on [DATE], the resident had a mark to indicate his/her signature and the physician signed it on [DATE]. Review of the resident's Significant Change in Condition MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Verbal behavior not directed at others occurred one to three days; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for eating, oral care, toilet use, dressing, personal hygiene, showers and transfers; - Always incontinent of bowel and bladder; - Diagnoses included dementia, anxiety, traumatic brain injury (TBI, a sudden injury that causes damage to the brain), depression and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness and social interactions). Review of the resident's care plan reviewed on [DATE] directed staff to not perform CPR as the resident has a DNR order. Review of the resident's Quarterly MDS, dated [DATE] showed:- The resident had short term and long term memory problems; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for eating, oral care, toilet use, dressing, personal hygiene, showers and transfers; - Always incontinent of bowel and bladder; - Diagnoses included dementia, anxiety, TBI, depression, schizophrenia and post traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of the resident's POS, dated [DATE] showed an order dated [DATE] - Do Not Resuscitate. Review of the resident's face sheet showed: - The resident's responsible party was him/herself; - The resident's code status was Do Not Resuscitate. During an interview on [DATE] at 3:34 P.M., the Social Services Designee (SSD) said: - He/she had only been in the current position for three weeks; - He/she has not done a lot of advance directives yet; - On admission, he/she asked their advance directives; - He/she did their Brief Interview for Mental Status (BIMS) assessment to determine their cognition; - Resident #30 is not alert and oriented and is non-verbal. He/she did not think the resident should be his/her own person. The resident does not have a guardian at this time; - If a resident's BIMS was a three, it would indicate severe cognition. During an interview on [DATE] at 3:50 P.M., the Administrator said: - If the resident had a BIMS of a three, the Interdisciplinary (IDT) team would meet and talk and see if the next of kin would want to pursue guardianship; - Social Services would contact the family and see if they would be the responsible party; - Resident #30 is currently not alert and oriented; - With the resident's BIMS being a three, he/she should not have signed their OHDNR form. During an interview on [DATE] at 10:32 A.M., LPN B said:- Resident #30 is not alert and oriented. He/she cannot talk to you; - He/she did not feel the resident was alert and oriented enough to make legal decisions; - He/she did not feel the resident should be their own person but did not know what to do about something like that. During an interview on [DATE] at 10:53 A.M., LPN B said Resident #30 is not alert and oriented and he/she did not think the resident was capable of making health care decisions. During an interview on [DATE] at 5:06 P.M., the DON said if the resident's BIMS was a three, then the resident should not sign his/her DNR paperwork.

Based on observations, interviews and record review, the facility failed to consider concerns and recommendations of the resident council members concerning issues of resident care and life in the facility and failed to communicate back with the resident council regarding their concerns as reported by ten of the 11 residents who participated in a group interview. This had the potential to affect all residents in the facility. The facility census was 56. Review of the facility's undated policy for grievances, showed, in part: - Residents have the right to voice grievances to facility or other agency that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal; - Such grievances include those with respect to care and treatment which is furnished as well as that which has not been furnished, behavior of staff and other residents; and other concerns regarding their Long Term Care facility stay; - Residents have the right to and the facility must make prompt efforts by facility to resolve grievances residents may have; - The facility must make information on how to file a grievance or complaint available to the residents; - The facility must establish a grievance policy to ensure prompt resolution of all grievances regarding residents' rights; - Upon request, provider must give a copy of grievance policy to residents. Grievance policy must include: notifying resident of right to file grievances orally; contact information of grievance official; reasonable expected time frame for completing review of grievance; right to obtain written decision regarding grievance; contact information of independent entities with whom grievances may be filed; - Identifying Grievance Official responsible for overseeing grievance process, receiving and tracking grievances through conclusion, leading investigations by facility, maintaining confidentiality of all information associated with grievances, issuing written grievance decisions to resident, and coordinating with agencies as necessary in light of specific allegations; - Ensuring all written grievance decisions include date grievance was received, summary statement of the grievance, steps taken to investigate grievance, a summary of pertinent findings or conclusions regarding resident's concerns, a statement as to whether grievance was confirmed or not confirmed and any corrective actions taken or to be taken by facility as a result of grievance, and date written decision was issued. 1. Review of the resident council meeting minutes, dated 8/26/24 showed;- Old business - laundry, call lights, trash in rooms and loud employees; - New business - clothes missing, cold food, and trash piling up in rooms - The form did not indicate how the issues were resolved, who was responsible or if the resolutions were satisfactory with the residents. 2. Review of the resident council meeting minutes, dated 10/1/24 showed:- Old business - clothes missing, cold food, and trash piling up in rooms; - New business - smell of the facility, employees being loud and swearing, dignity issues, information board, cleaner rooms, theft, dirty linens being left on the floor and wheelchairs not being washed; - The form did not indicate how the issues were resolved, who was responsible or if the resolutions were satisfactory with the residents. 3. Review of the resident council meeting minutes, dated 10/29/24 showed: - Old business - smell of facility, employees loud and swearing, dignity issues, information board, cleaner rooms, theft, dirty linens being left on the floor and wheelchairs not being washed; - New business - gazebo lights not working, gazebo door needs fixed, recycle, cold food at dinner and toaster on North; - The form did not indicate how the issues were resolved, who was responsible or if the resolutions were satisfactory with the residents. 4. During the group meeting on 11/6/24 at 3:01 P.M., the residents said: - All 11 residents were not aware of who the Grievance Official was; - Ten of the 11 residents did not know how to file a grievance; - Ten of the 11 residents did not feel like they had any follow up from the staff about their concerns. During an interview on 11/5/24 at 12:44 P.M., the Activity Director said: - He/she had been in the current position since September; - He/she set up the resident council meetings; - They discussed the resident's concerns at the meetings. During an interview on 11/7/24 at 5:06 P.M., the Administrator said: - When residents voice concerns, the concerns should be followed up on the next month; - All grievances should be followed up on; - The residents concerns should be addressed.

Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect, when staff failed to address one resident (Resident #33) by their preferred name of choice, failed to assist one resident with eating lunch (Resident #44) and when the facility staff failed to ensure one resident (Resident #41) was dressed in clean clothing. This affected three out 24 sampled residents. The facility census was 56. Review of the facility's undated Resident Rights Policy showed in part: -Residents have a right to a dignified existence and self-determination; -The facility shall protect and promote the rights of each resident; -The facility shall care for it's residents in a manner that promotes enhancement of each resident's quality of life. 1. Review of Resident #44's Admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 8/18/24, showed: -Severe cognitive impairment; -Maximal assistance with showers and dressing; -Supervision or touching assistance with transfers from chair to bed, mobility from sitting to lying; -Frequently incontinent of urine; -Always incontinent of bowel; -Diagnosis included cancer, stroke, atrial fibrillation (AFib, a heart condition that causes irregular heart beat), high blood pressure and anxiety. Review of the resident's care plan, revised 8/29/24, showed: -The resident has an Activities of Daily (ADL) self-care performance deficit; -The resident has impaired cognitive function; -The resident is dependent on staff for meeting emotional, intellectual, and physical needs; -The resident has impaired visual function. Observation on 11/4/24, at 12:54 P.M., showed: - Nurse Aide (NA) A assisted the resident to the dining room; -The resident was using a walker and NA assisted the resident into a chair that sat approximately 12 inches from the table; -NA A did not assist the resident in moving his/her chair closer to the dining room table; -The resident leaned forward in the dining room chair but could not move the chair closer to the table; -The resident was still setting approximately 12 inches away from the table; -The resident was served lunch; -The resident picked up a fork and began eating; -The food dropped off the fork and landed on the table and onto the resident's lap; -Flies were landing on the food that was dropped on the table; -The resident sat his/her fork down and started to lick the table; -The resident licked the table and used his/her mouth to eat the food that had been dropped on the table; -NA A was in the dining room passing trays; -The flies were still landing on the food that was dropped on the table by the resident; -The resident continued to use his/her mouth and tongue to eat directly off of the table; -No staff assisted the resident with his/her meal. 2. Review of Resident #41's Quarterly MDS dated [DATE], showed: -Severe cognitive impairment; -Supervision with showers and dressing; -Supervision with personal hygiene; -Frequently incontinent of urine and bowel; -Diagnosis included dementia, anxiety and bipolar disorder (a mental illness that causes extreme mood swings). Review of the resident's care plan, revised 7/10/24, showed: -Requires assistance with ADLs related to dementia; -Visually impaired; -The resident will not suffer any loss of dignity due to memory loss. Observation on 11/4/24, at 01:18 P.M., showed: -The resident walked into the dining room and sat in a chair at the table; -The resident's pants had brown stains on the back of them; -NA A gave the resident his/her meal; -Flies landed on the meal as soon as it was set on the table by NA A; -Multiple flies landed on the resident's food and the resident left the table and began opening drawers in the dining room; -The resident left the dining room and returned with a fly swatter; -Flies continued to land and crawl on the resident's food; -The resident laid the fly swatter on the table and started to eat the food after the flies had landed on it; -The resident's pants still had stains on them; -Staff failed to offer the resident a new plate of food after the flies had landed on the food; -Staff failed to offer to change the resident's stained pants. During an interview on 11/5/24 at 10:53 A.M., NA A said: -There should not be flies in the dining room landing on the residents' food; -Residents should not be eating food that flies have landed on and the staff should offer them a new plate; -Residents should be assisted closer to the table if they are dropping food on themselves or on the floor; -Residents should not eat off the the table and should be assisted by staff; -The staff should offer to change a resident's clothes if they look dirty or soiled; -Residents should be treated with respect. During an interview on 11/7/24 at 09:22 A.M., Registered Nurse (RN) A said: -Residents should be treated with dignity; -Residents who are having difficulty eating should be assisted by staff; -If staff see flies on a resident's food they should be given a new plate; -There should not be multiple flies in the dining room; -If a resident is wearing dirty clothes the staff should offer to change them. During an interview on 11/7/24 at 5:06 P.M., the Administrator said: -He/she expects staff to assistance residents who need assistance with eating; -Residents should not be eating off the table and staff should be assisting to accommodate them; -He/she expects staff give resident's a new plate of food if flies have landed on the food; -He/she expects staff to change residents to who are wearing dirty clothes. 31102 3. Review of Resident #33's care plan, reviewed 5/4/24 showed the resident did not wish to be called by his/her legal name. Review of the resident's quarterly MDS, dated [DATE] showed:- Cognitive skills intact; - Diagnoses included depression, dementia (inability to think), psychotic disorder (mental illness characterized by psychotic symptoms, which can generally be described as a loss of contact with reality), schizophrenia ( a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and post traumatic stress disorder (PTSD, a mental health condition that can develop after a person experiences or witnesses a traumatic event). During a group interview on 11/6/24 at 3:01 P.M., the resident said: - He/she did not like to be called honey, sweetie or dear; - He/she felt like it was very disrespectful for the staff to address him/her in such a manner; - He/she would prefer to be called by his/her given name or Ma'am/Sir. During an interview on 11/7/24 at 10:53 A.M., Licensed Practical Nurse (LPN) D said if a resident did not want to be called honey, sweetie or dear, the staff should not call them that. During an interview on 11/7/24 at 2:02 P.M., Certified Nurse Aide (CNA) A said: - He/she was not aware of any resident who did not want to be called honey, darling, sweetie or dear; - They are not supposed to call any of the residents by any nicknames; - We should not call the residents that if they did not want to be be called that. During an interview on 11/7/24 at 5:06 P.M., the Director of Nursing (DON) said she did not expect staff to call residents by nicknames.

Based on interviews and record reviews, the facility failed to assure staff transported one resident (Resident #1) in the facility van in a safe manner to prevent a serious injury. Resident #1 was transported in the facility van from a local hospital to the facility when the resident sustained [REDACTED]. This had the potential to affect all resident's who utilize the facility van for transportation. The facility census was 39. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 12/9/16 showed: -Alert and oriented and able to make decisions; -Supervision with transfer and walking; -Uses a wheelchair and a walker for ambulation; -[DIAGNOSES REDACTED]. Review of the nurses notes dated 2/24/17 signed by Licensed Practical Nurse (LPN)A at 8:10 P.M. showed; -The resident returned to the facility in a wheelchair via the facility van with assistance of two staff. This writer was called to the resident's room. Upon entering the room, the resident was sitting in the wheelchair. Certified Nurse Aide (CNA) A was holding a blue sock on the right foot and was applying pressure. The Maintenance Director was also present in the resident's room. This writer asked what happened and CNA A replied, His/her toe got caught on the van during transport. The Maintenance Director reported, It got caught on the lift in the van. Upon assessment after removal of the sock, the resident's right great toe was noted to have a severe deep laceration to the top aspect of the toe through the bone, The right great toe appears to be barely attached by the skin to the bottom aspect of the toe. Minimal bleeding noted. The resident denies pain. The resident received Versed (a sedative used in surgical procedures) at the hospital. Right great toe and foot wrapped with a pressure dressing. -At 8:17 P.M. attempted to notify primary care physician. -At 8:23 P.M. notified the medical director and orders received to send to the emergency room . - At 8:25 P.M. the resident was transported to the hospital via the facility van with the Maintenance Director and CNA A; -8:30 P.M. family notified of injury and the resident taken to the local emergency room ; -8:35 P.M. administrator notified; -9:40 P.M. notified by the emergency room , the resident is being taken to a hospital in the city for orthopedic consultation. During an interview on 3/2/17 at 10:00 A.M. LPN A said: -The resident had been at the hospital since 10:00 A.M. on 2/24/17 for outpatient surgery; -He/she received a call at 7:30 P.M. on 2/24/17 from the hospital that the resident was ready to return to the facility; -The Maintenance Director and CNA A took the facility van to the hospital to bring the resident back to the facility; -At 8:00 P.M. on 2/24/17 he/she was passing medications when a staff member told him/her that CNA A needed him/her to come to the resident's room immediately; -Upon entering the resident's room, CNA A was holding the resident's sock firmly on the resident's right foot; -When he/she told CNA A to remove the sock, the resident had a deep laceration on the right great toe; -The laceration was through the bone and the toe was being held onto the foot with only the skin on the underside of the toe; -CNA A said the resident got his/her toe caught on the lift of the van; -He/she applied a pressure dressing to the right foot; -The resident's primary care physician was unavailable so he/she called the medical director and got orders to send the resident to the hospital for evaluation; -The resident did not have shoes on and there were no foot pedals on the wheelchair. Review of the local hospital emergency room medical records dated 2/24/17 showed: -Partial amputation of the right great toe; -The resident was being transferred to the nursing home van when the toe got caught when using the lift; -Transfer to a hospital in the city for orthopedic consultation. Review of hospital medical records dated 2/25/17 showed: -Per Emergency Medical Services the resident is a nursing home resident that was sent out for an outpatient procedure. When he/she was being loaded up into the transport van by the care provider his/her great toe on the right became injured; -There is a near-complete amputation of the right great toe at the distal phalanx (a bone in the toe) at the area of the nailbed; -Orthopedic consultation notation: The right great toe was found to be more than three quarters amputated at the base of the distal phalanx. A complete amputation of the right great toe at the distal phalanx was performed. Observation on 3/2/17 at 10:30 A.M. showed: -The resident sitting in a wheelchair with a dressing on the right foot; -LPN A removed the dressing: -The portion of the toe above the joint was removed. During an interview on 3/2/17 at 10:30 A.M. Resident #1 said: -He/she got his/her toe caught on the tailgate of the van coming back to the facility from the hospital; -He/she does not feel much in the right foot; -The Maintenance Director took him/her back to the hospital. During a telephone interview on 3/2/17 at 11:10 A.M. CNA A said: -He/she and the Maintenance Director went to the hospital on [DATE] at 7:30 P.M. to bring the resident back to the facility; -When he/she brought the resident into the facility, he/she noticed blood on the resident's right sock; -He/she took the resident to his/her room and called for the nurse; -He/she does not know what happened to the resident's foot; -The resident only had socks on both feet; -There were no wheelchair pedals on the wheelchair when he/she transported the resident back to the facility; -The resident was wrapped in a blanket and he/she did not see the resident's feet until the resident raised his/her feet to be placed inside the van; -Once the resident was in the van, the resident put his/her feet down under the blankets; -Once the van was at the facility, he/she pushed the resident in the wheelchair back onto the lift to be lowered to the ground; -He/she did not see where the resident's feet was positioned on the lift. During a telephone interview on 3/2/17 at 11:25 A.M., the Maintenance Director said: -He/she and CNA A went to the hospital on [DATE] at 7:30 P.M. to bring the resident back to the nursing home; -The resident had a blanket around his/her shoulders and feet when he/she was placed on the lift to raise him/her into the facility van; -CNA A was inside the van; he/she was outside of the van working the controls to raise the lift to put the resident into the van; -There were no foot pedals on the wheelchair and he/she did not see the resident's feet; -At the facility, CNA A was inside the van and pushed the resident onto the lift to lower the resident to the ground; -He/she did not see the resident's feet while being lowered to the ground; -CNA A pushed the resident into the facility; -He/she does not know how the resident injured his/her right great toe; -The resident did not say anything during the transport. During a telephone interview on 3/2/17 at 1:15 P.M. LPN B said: -He/she was at the front door when the Maintenance Director and CNA A returned to the facility with the resident; -As CNA A was pushing the resident into the facility, CNA A said, The resident got his/her foot caught on the lift, I hope he/she is OK.; -He/she informed LPN A the resident was at the facility and his/her foot needed to be assessed; -The resident had on blue socks; -The wheelchair did not have foot pedals; -He/she did not see the foot injury. During an interview on 3/2/17 at 2:00 P.M. the Administrator said: -He/she was made aware of the injury on 2/24/17 at 9:00 P.M.; -He/she would expect the resident to have shoes on and pedals on the wheelchair during transport in the facility van. MO 5

Based on observation, interview, and record review, licensed staff failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for two of two residents (Residents #1 and #2) sampled for falls with injuries, when staff failed to follow the facility's fall protocol. Staff failed to notify the physician in a timely manner when Resident #1 fell and sustained facial bruising, which delayed the medical evaluation. Staff failed to perform a complete assessment prior to ambulating Resident #2 after a fall and prior to informing the physician that the resident had no injuries. The resident suffered a [MEDICAL CONDITION] which required surgery. The facility census was 38. 1. Review of the facility's undated fall protocol showed: - Do not move the resident until completing a physical assessment. - Perform a head-to-toe assessment noting any signs of injury. - Determine the source of any pain or discomfort on examination. - Determine if the resident is on any anticoagulants (medications used to prevent blood clots). - Notify the physician and report any visible injuries, physical limitation, head trauma, or other changes in the resident condition. Inform the physician if the resident is on anticoagulants. - Notify the resident's responsible party and inform them staff notified the physician. - Be hyper-vigilant when the resident is on anticoagulants. Consider internal bleeding even when there is no apparent injury. Never delay physician notification or do fax or next day notification of a fall when the resident is on anticoagulants. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/19/15, showed staff assessed the resident as: - Moderately impaired cognitive ability; - Required extensive assist of two or more staff for bed mobility and transfers; - [DIAGNOSES REDACTED]. Review of the resident's Medication Administration Record [REDACTED] - Staff documented they administered [MEDICATION NAME] (antiplatelet medication used to prevent blood clots) 75 milligrams (mg) daily for CAD; - Staff initialed aspirin (antiplatelet medication used to prevent blood clots) 81 mg daily for CAD. Review of www.healthline.com/anticoagulant-and-antiplatelet-drugs showed: - Anticoagulant and antiplatelet drugs are a type of medication used to eliminate or reduce the risk of blood clots. These medications help prevent or break up clots in your blood vessels or heart. During an interview on 2/26/15, at 9:30 A.M., Certified Nurse Aide (CNA) A said: - On 2/12/15 he/she and CNA B got the resident up, in the wheelchair, for supper and secured the wheelchair alarm. - CNA B took the resident to the dining room then both CNAs went to other residents' rooms. - Licensed Practical Nurse (LPN) A yelled for him/her to assist because the resident fell . During an interview on 3/25/15, at 3:20 P.M., LPN A said: - Staff usually got the resident up closer to supper because he/she did not like to sit up. - On 2/12/15 at 5:30 P.M., Resident #3 yelled to him/her when he/she found Resident #1 on the floor. - LPN A heard the resident's alarm, entered the room, and found the resident face down in a pool of blood, with his/her head turned to the side. - He/she asked the resident if he/she hurt. The resident "was flaccid in reaction, like maybe shock." - The aides helped transfer the resident, into the wheelchair, and washed the blood from his/her face. - LPN A started neuro checks (a brief neurological assessment of vital signs, level of consciousness, pupil response, and movement of extremities). - LPN A took the resident to the dining room because he/she needed to continue the neuro checks and monitor the dining room during supper. The resident "was shaking like a leaf" and LPN A gave him/her an ice pack to hold on his/her eye. - The resident had a bloody nose, a cut across the bridge of the nose, swelling and bruising of the nose, and swelling and bruising above the right eye. - LPN A thought the resident broke his/her nose during the fall. - In the dining room, each time the resident blew his/her nose it started to bleed again. - After supper, LPN A asked the resident to remain in the wheelchair for 30 more minutes because he/she thought the blood might continue to drain down the resident's throat. - LPN A raised the head of the resident's bed when staff put him/her to bed because blood might continue to drain down his/her throat. - LPN A notified Family Member (FM) A of the resident's fall. - Physician A and Physician B shared a medical practice and had offices in two cities. - LPN A could not find any phone numbers to contact the physicians after office hours. - LPN A did not know that hospital staff could page the physician. - He/she sent a fax to both of the physicians' offices. Review of LPN A's fax to Physician A and Physician B, dated 2/12/15, showed: - The resident fell at 5:30 P.M., had bruising above the right eye, a small abrasion below the right eye, and a small laceration across the bridge of the nose. Cleaned the laceration and applied antibiotic ointment and a band aid. The resident had a discolored, swollen, and possibly broken nose. Resident does not know what happened. Ice pack applied. Review of LPN A's nurse's note, dated 2/12/15 at 5:30 P.M., showed: - Resident's alarm sounded and resident found on floor on his/her right side. - Swelling and bruising above right eye and an abrasion below the right eye; - Swollen and discolored nose with a very small laceration across the bridge of the nose. - Alert but confused and does not know what happened; - Neuro checks within normal limits (WNL) and vital signs stable; - Notified FM A. - Attempted to send a fax the physician twice and no answer. Review of LPN A's fall investigation form, dated 2/12/15, showed: - The resident fell at 5:30 P.M.; - Fax to notify the physician did not go through; - Notified FM A at 8:45 P.M.; - LPN A left the notification of administrator (Adm) and director of nursing (DON) areas blank. - The DON noted that she called the physician's office at 11:15 A.M., and the staff would give the physician the message when he/she arrived at 1:00 P.M. During an interview on 2/26/15 at 8:05 A.M., LPN B said: - He/she worked as the night shift charge nurse on 2/12/15 from 11:00 P.M. to 7:00 A.M. - LPN A told him/her about the resident's fall. - He/she assessed the resident, did a neuro check, and asked if the resident hurt. LPN A said the resident's face looked like it hurt, so he/she thought it was strange when the resident denied pain. - He/she did not contact the physician about the fall and injuries. - LPN B said if a resident fell at 5:30 P.M. that nurse should notify the physician and not leave it for the night nurse to wake the physician and inform him/her about the fall. Review of the nurses' notes showed: - On 2/13/15 at 3:00 A.M., the resident was alert and answered questions appropriately. The resident had a swollen nose, a bruised right eye, and a bruised bridge of the nose. - On 2/13/15 at 7:30 A.M., neuro check WNL, purple, red, green bruising to both eyes and nose swollen. During an interview on 2/27/15 at 9:50 A.M., the Adm and DON said: - They expected staff to notify them when a resident fell , anytime of the day, even if the resident did not sustain an injury. - Staff did not notify them of the resident's fall until the next morning (2/13/15). - The DON said after office hours physicians' phones had a message with instructions for reaching them or obtaining care. If LPN A called her she would have told him/her to call the hospital to page the physician. - The Adm said had LPN A called her she would direct him/her to call Physician C, the facility's medical director, if he/she could not reach the physician. Review of the nurses' notes showed: - On 2/13/14 at 2:15 P.M., attempted to notify Physician A by phone, message left with office secretary with assessment and details. - On 2/13/15 at 8:00 P.M., the resident had bruises around the eyes and a swollen and bruised nose. The resident rated the facial pain at a five on a scale of one to ten. Neuro checks WNL at this time. Review of the nurses' notes, dated 2/21/15, showed the resident was sent to the emergency room (ER) for an unrelated medical event. Observation on 2/24/14, at 11:10 A.M., showed the resident had bluish, purple bruising below both eyes and a discolored nose. During an interview on 3/4/15 at 10:45 A.M., Physician A said: - The first he/she knew about the resident's bruised eyes and face was when he/she saw the resident on 2/21/15 in the ER. - He/she asked FM A if the staff called him about this and how it happened. - It looked like someone punched the resident in the face; the resident had really bruised eyes. - He/she ordered a computed tomography scan of the head (CT, test that used x-rays to create pictures of the skull, brain, eye sockets, and sinuses) to check for an orbital fracture (a broken bone around the eye usually caused by head or facial trauma) and the CT scan was negative. - If staff faxed or called him/her about the facial bruising he/she would have responded and ordered a CT scan. - Staff should notify the physician when a change in condition has occurred, including falling on the face with severe bruising. - His/her office did not have a fax machine but had a server so a fax may not go through. - Faxes may not arrive and messages can be misplaced. When staff sends an evening fax they do not see it until the next day. - He/she always initialed a fax and sent it back to the facility, so staff knew if he/she received it. - In February he/she was on call, so any info went to him/her. - He/she did not remember ever hearing or seeing anything about the resident's possible broken nose. - He/she expected staff to follow up if he/she had not responded to a message. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed staff assessed the resident as: - Moderately impaired cognitive ability; - Assist of one staff for transfers. - [DIAGNOSES REDACTED]. During an interview on 2/25/15 at 9:05 A.M., Resident #3 said: - About 10 days ago, he/she went to check on Resident #2 because he/she did not show up for his/her normal coffee break. - He/she found the resident on his/her hands and knees on the floor. - He/she yelled for LPN A and told him/her the resident was on the floor. During an interviews on 2/25/15 at 3:20 P.M. and 2/26/15 at 3:10 P.M., LPN A said: - On 2/12/15 at 4:30 P.M., the resident was in bed and at 5:15 P.M. Resident #3 told him/her the resident was on the floor. - He/she went to the room and found the resident on his/her hands and knees on the floor. - He/she asked the resident if he/she hurt anywhere and the resident said, no. - He/she did not lay the resident down to do a head-to-toe assessment to check for pain and fractures. - He/she asked the resident if he/she could stand and walk to the wheelchair. He/she helped the resident stand and walk backwards, about three steps, to the wheelchair. - He/she knew to do a head-to-toe assessment, so he/she had the resident move his/her legs, arms, shoulders, and neck while sitting in the wheelchair. LPN A demonstrated how the resident moved his/her lower legs forward, raised his/her arms/shoulders, and turned his/her head left to right. - The resident hit his/her head in the fall. - LPN A continued the resident's neuro checks in dining room. While in the dining room, the resident rubbed his/her leg and complained of pain. He/she checked and did not see any bruising or redness on the resident's knee and gave him/her Tylenol for the pain. - He/she left a phone message for the resident's responsible party. - He/she sent a text to Physician C saying they found the resident on the floor on his/her hands and knees assessment done, neuros WNL, and no apparent injuries at this time. - At 9:30 P.M. Physician C responded "okay." During an interview on 2/26/15 at 4:25 P.M., CNA B said: - He/she was in another resident's room when the resident fell . LPN A told him/her the resident fell . - He/she asked LPN A if the resident was okay. LPN A said yes, but he/she needed to do neuro checks. LPN A already had the resident in a wheelchair for supper. - After supper at approximately 7:00 P.M., the resident complained of a "shooting pain" in his/her left leg. CNA B demonstrated how the resident rubbed his/her hand from the left hip downward. CNA B said the resident made that motion to show where he/she had pain. Usually the resident never allowed staff to assist with transfers and was adamant about transferring independently. That evening the resident not only allowed him/her to assist with the transfers but also allowed assistance with transferring to the toilet and bed. The resident grasped CNA B's upper arms for support. The resident also allowed CNA B to change his/her clothes for the first time. - He/she told LPN A about the residents shooting pain and LPN A said he/she gave the resident Tylenol earlier. - He/she told LPN A and CNA A the resident must be hurt since the resident not only allowed him/her to do the transfers but held onto CNA B for support, and allowed CNA B to change his/her clothes. - CNA A agreed that the resident must hurt if he/she allowed assistance with transfers and changing clothes. During an interview on 2/27/15 at 2:00 P.M., LPN A said: - CNA B told him/her the resident complained of pain but did not remember if he/she said shooting pain. -CNA B told him/her the resident held onto him/her during the transfers and allowed the CNA to change his/her clothes. - LPN A said at times the resident let some staff change his/her clothes so he/she did not consider that a change. - LPN A said he/she did not assess the resident when the CNA reported the pain and him/her allowing staff to assist with transfers. Review of LPN A's nurse's notes, dated 2/12/15, showed: - At 5:15 P.M., called to resident's room and found the resident on hands and knees on the floor. No apparent injuries or complaints at this time. Neuro checks WNL, in wheelchair and to the dining room for evening meal. Resident said that he/she hit his/her head. He/she gave the resident Tylenol for comfort. - At 8:45 P.M. notified Physician C and the resident's responsible party. - At 9:00 P.M. neuro checks WNL and the resident had been asleep since 7:00 P.M. Review of LPN A's fall investigation form, dated 2/12/15, showed: - The resident fell at 5:15 P.M.; - Notified the physician at 8:45 P.M.; - Notified resident's responsible party at 8:45 P.M.; - LPN A left the notification of Adm and DON areas blank. During an interview on 2/26/15 at 8:05 A.M., LPN B said: - On 2/12/15 after LPN A gave shift report, he/she asked the resident if he/she hurt because he/she fell on the previous shift. - The resident said his/her hip hurt, so he/she checked the resident's leg. The resident's left leg was rotated and shortened (a clinical sign of a [MEDICAL CONDITION] is when the foot of the affected leg rotates outward and the leg is shorter than the unaffected leg) and the resident could not lift the leg off the bed. - He/she called Physician C who gave orders to send the resident to the hospital for x-rays. - A few hours later the hospital staff called and said the resident had a fractured left hip. Review of LPN B's nurse's notes, dated 2/13/15, showed: - At 11:45 P.M., assessed the resident for fall, vital signs, and neuro checks. The resident rubbed his/her left hip area and stated that the hip hurt a lot. Noted the resident's left foot had some external rotation and some shortening of the left leg. The resident grimaced when he/she, unsuccessfully, tried to raise the left leg off the bed. No hip bruising noted. - At 11:50 P.M. called Physician C and reported left hip pain and some external rotation with shortening. Physician C gave orders to send the resident to the hospital for evaluation and treatment by ambulance. - At 12:00 midnight, message left for the resident's responsible party and DON. Called Adm and informed her of the situation. - At 12:02 A.M. called for the ambulance with pertinent information. - At 12:22 A.M. ambulance staff arrived. The resident told the ambulance staff about the left hip pain. Staff used a lift sheet and transferred the resident to the gurney. - At 12:25 A.M. the resident left the facility by ambulance. - At 12:30 A.M. called ER with report. - At 1:45 A.M. received call from ER nurse stating the left hip was indeed fractured and required surgery. Review of the hospital's radiology report, dated 2/13/15, showed: - Reason for x-ray: fall and left hip pain; - A complete [MEDICAL CONDITION] with a displaced femur (thigh bone). During an interview on 2/27/15 at 9:50 A.M., the Adm and DON said: - They expected staff to notify them when a resident fell , anytime of the day, even if the resident did not sustain an injury. - LPN A did not notify them of the resident's fall. - Staff should do a head to toe assessment after any resident falls. - Staff should lay the resident down to assess for a [MEDICAL CONDITION]. - Staff should not move a resident until they completed the head to toe assessment. - Staff should assess any resident that complained of pain. - They expected staff to complete the assessment then notify the physician. MO 2

Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision to prevent two dependant residents (Residents #1 and #2), with a history of exit seeking, from leaving the facility unattended, falling, and sustaining injuries. The facility census was 36. 1. Review of Resident #1's care plan, updated on 3/20/14, showed: - The problem of Alzheimer's disease with an intervention to please check me frequently when I am wandering. During an interview on 7/16/14 at 1:20 P.M., Registered Nurse (RN) B, care plan coordinator, said: - One evening in June 2014 the resident attempted to go out the exit door but did not get out of the facility. - Staff had a care plan meeting right after that incident. - He/she did not put specific times on the care plan for staff to check on the resident because each staff may interpret frequent differently. Review of the resident's quarterly Minimum Data Set (MDS), a federally-mandated assessment instrument completed by facility staff, dated 6/13/14, showed: - Short- and long-term memory problems; - Moderately-impaired cognitive ability described as made poor decisions and required cues/supervision; - Ambulated with a wheeled walker and assist of one staff; - Wandered; - Two or more falls since the last assessment; - [DIAGNOSES REDACTED]. Review of the resident's elopement/wandering review, dated 6/16/14, showed: - Cognitively impaired; - Ambulated independently with or without an assistive device; - Had hearing, vision, or communication problems; - History of leaving the facility without informing staff; - Wandered aimlessly; - The family/responsible party voiced concerns that indicated the resident may wander or try to leave the facility. Review of the fall risk assessment, dated 6/16/14, showed staff scored the resident at an 18 (a score of seven or more indicated a higher risk for falls). During an interview on 7/15/14 at 10:20 A.M. the director of nursing (DON) said staff hung a residents' status sheets in each residents' closet to direct care. Review of the resident's undated, current status sheet, showed: - Moody, confused, and forgetful; - Ambulated with a wheeled walker and assist of one staff. - Did not show the resident wandered or attempted to go out the exit door alone. During an interview on 7/14/14 9:42 A.M. the DON said: - She started working at the facility on June 23, 2014. - The resident wandered and the facility wanted to move the resident to the South Hall (a locked behavioral hall). The family did not want the resident moved so the facility kept the resident on the North Hall. - The facility's staffing coordinator was on leave and not available. - The facility staffed two aides and one nurse on the night shift (11:00 P.M. to 7:00 A.M.) One aide for each hall and the nurse floated back and forth between the two halls. - She did not know if the resident attempted to exit the facility before the 7/9/14 incident. Review of the July 2014, staffing schedule showed: - For the 7/9/14 night shift (11:00 P.M. to 7:00 A.M.) the facility staffed Nurse Aide (NA) A on the North Hall, Certified Nurse Aide (CNA) B on the South Hall, and RN A. During an interview on 7/14/14 at 10:25 A.M. Family Member (FM) A and FM B said: - The resident fell repeatedly. - At times the resident had Alzheimer's episodes where he/she stayed up for 24 hours and wandered looking for doors to go out. - The resident was very determined and stubborn at times. During an interview on 7/14/14 at 11:25 A.M., Licensed Practical Nurse (LPN) A said: - The resident might sleep for three or four days straight and then wake up and wander up and down the North Hall. - In the past, the resident went through the closed doors into the employee-only hall (which had entrances into the kitchen, laundry, housekeeping, maintenance and staff break room). - It was not unusual for the resident to wander late at night. During an interview on 7/15/14 at 8:00 P.M., CNA A said: - He/she worked the day shift. - The resident either wandered or slept. - When he/she was in a "wandering mode" staff took attempted to get him/her to lay down but he/she got right back up and wandered. - About twice a week he/she wandered nonstop, worried about his/her family. - He/she then slept for 24 hours. During an interview on 7/15/14 at 8:44 P.M., LPN B said: - He/she worked as the charge nurse on the 7/9/14 evening shift. - In report LPN A told him/her the resident wandered the entire day shift. - The resident continued to wander the entire evening shift looking for his/her family. - He/she reported that to the night nurse. During an interview on 7/14/14 at 1:35 P.M., and 7/15/14 at 7:37 P.M., NA A said: - Staff knew the resident wandered on night shift but not every night. When the resident was in a "wandering state" staff could not get him/her to lie down or sit down for any amount of time. He/she wandered for days, a continual wandering and looked for family and wanted to leave. - On 7/9/14 when he/she arrived for work at 11:00 P.M. and saw the resident trying to get through the employee only hall double doors. - He/she redirected the resident to his/her hall. - NA B worked the evening shift (3:00 P.M. to 11:00 P.M.) on 7/9/14. - He/she and NA B put Resident #2 to bed and then NA B clock out to leave. - Resident #3 turned on the call light to go to the bathroom. While he/she assisted Resident #3 to the bathroom he/she heard Resident #2 screaming and crawling out of bed. - He/she heard the exit door alarm sound, left Resident #3 on the toilet, saw Resident #1 at the north exit door at the other end of the hall, and ran to stop the resident from going out the door. - The resident went out the door and fell before NA A reached him/her. - The resident left his/her walker in the facility when he/she opened the door. - He/she told RN A and he/she assessed the resident. - He/she believed that one aide could not monitor all the residents on the hall for safety. With only one aide assigned to the hall they could not stay with the resident or even watch him/her when he/she wandered. During an interview on 7/14/14 at 5:12 P.M., NA B said: - He/she worked the evening shift on 7/9/14. - He/she clocked out, passed the North Hall, and saw the resident at the exit door at the other end of the hall. - NA A exited a room and took off running but could not get to the resident before he/she stepped out the door and fell . During an interview on 7/14/14 at 6:22 P.M., RN A said: - He/she worked as the charge nurse every Wednesday and Thursday night (11:00 P.M. to 7:00 A.M.) - The resident did not wander every night, but when he/she did, he/she was on a hunt looking for his/her family. - The resident would stay up for three or four days without a night's sleep and during that time was on a tangent looking for his/her family. That would happen about one or twice a month but for days. - North Hall was busier so he/she tried to spend most of his/her time there but had to go to the South Hall for about two hours a night. Some nights on North Hall there were lots of call lights to answer. - On 7/9/14 the facility assigned NA A to the North Hall, CNA B to the South Hall, and he/she floated between the halls. He/she took report from the evening nurse and was on the South Hall counting the controlled medications with the evening nurse when the resident went out the exit door and fell . - NA A was correct, one aide cannot answer the call lights and monitor wandering residents when the nurse had to go to the other hall. - Staff cannot see or hear anything from one hall to the other hall. Review of RN A's nurse's note, dated 7/9/14 at 11:55 P.M., showed: - The resident went out the north exit door at 11:40 P.M. and fell off the sidewalk. - Resident complained of left hip and thigh pain. - Able to perform passive range of motion (PROM, when someone, other than the resident, moved the joints through range of motion) without increase in discomfort; - No abnormal positioning noted; - Able to stand without difficulty, assisted to wheelchair then to bed, but continued to complain of hip and thigh pain; - Ordered mobile x-ray (portable x-ray equipment brought to the facility); - Noted abrasion to left little toe and side of foot, cleaned and applied band-aid. Review of RN A's nurse's note, dated 7/10/14, showed: - At 1:30 A.M. mobile x-ray technician obtained x-rays and went to the van to view the films. - At 2:00 A.M. the technician said the x-rays did not show any fracture but the radiologist did the official reading. - At 6:00 A.M. received x-ray report at 4:45 A.M., that the resident had a hairline fracture of the left femoral (long thigh bone) neck (at the hip). Notified Physician A of x-ray results and received orders to send the resident to the emergency room (ER). Resident transported to hospital by ambulance at 5:15 A.M. Family notified. Review of the radiology report, dated 7/10/14, showed a fracture of the left femoral neck laterally. 2. Review of Resident #2's elopement/wandering review, dated 5/23/14, showed: - Cognitively impaired; - Did not ambulate independently with or without an assistive device; - No hearing, vision, or communication problems; - Did not wander aimlessly; - Staff determined the resident was not at risk for wandering/elopement at this time. Review of the resident's admission MDS, dated [DATE], showed: - admitted [DATE]; - Short- and long-term memory okay; - Moderately impaired cognitive ability, poor decisions, cues/supervision required; - Highly impaired vision; - Extensive assistance of two or more staff for transfers; - Did not ambulate; - Wheelchair; - Wandered; - Falls prior to admission; - Impaired range of motion of one arm and leg; - [DIAGNOSES REDACTED]. Review of the resident's care plan, dated 6/8/14, showed: - Problems - attempted to go out the front door, difficulty with memory and decision making, fall risk due to cognitive deficits and impaired mobility, impaired vision, and expressive aphasia due to stroke. - Interventions - remind the resident he/she cannot go out the front door alone, assist the resident to gather facts needed to base decisions, position the resident in the wheelchair so he/she can self propel the wheelchair from place to place. Review of the fall risk assessment, dated 6/20/14, showed staff scored the resident at a 28 (a score of seven or more indicated a higher risk for falls). Review of the resident's undated, current status sheet, showed: - Speech deficit; - Wheelchair; - Did not show the resident wandered or attempted to go out the front door alone. During an interview on 7/15/14 at 8:44 P.M., LPN B said: - Over the last three weeks the resident's mobility improved and he/she opened doors. - He/she caught the resident opening the door to the employee-only hall. - On the evening shift, the facility staffed one aide for each hall and a third aide floated to relieve staff for breaks and as needed for cares. The nurse and certified medication technician (CMT) floated to both halls. During an interview on 7/15/14 at 8:00 P.M., CNA A said: - The resident self propelled his/her wheelchair, opened doors, and numerous times attempted to enter the employee only hall. - On 7/3/14, he/she worked from 7:00 A.M. to 7:00 P.M. - About 5:00 P.M., he/she took residents' out for their scheduled smoke break. - The designated smoke area was outside the dining room and he/she could not see the front entrance from there. During an interview on 7/16/14 at 3:15 P.M., NA B said: - The resident wandered all over the facility for at least a month and tried, more than once, to open the doors to the employee only hall. - The evening staff started work at 3:00 P.M., one aide assigned to each hall and one aide to float. - They passed ice, answered call lights, fed the resident his/her snack, showered one resident before supper, took residents out for their smoke break, then stated to get residents up for supper. Eight residents required assist of both aides for transfers so 5:00 P.M. was a busy time. When the nurse and CMT had time they got the one-person assist residents up for supper and answered call lights. At times both the nurse and CMT went to the South Hall to deal with agitated residents. - On 7/3/14, staff assigned him/her to the North Hall. He/she fed the resident a snack around 5:00 P.M., and left him/her in the day room. He/she answered two residents' call lights, and when he/she exited the second resident's room LPN B asked him/her who fell . NA B replied that he/she did not know that anyone fell . - He/she went to the dining room and told CNA A to come in and monitor the hall. LPN B and he/she went out the front door and found the resident and his/her wheelchair on the ground in the parking lot. - LPN B, CNA A and he/she thought that when the Hospice nurse left the facility the resident stopped the door with his/her foot or arm before the delayed locked engaged and then wheeled out of the facility. During an interview on 7/15/14 at 8:44 P.M., LPN B said: - The evening of 7/3/14, he/she worked as the charge nurse and was on the South Hall with a resident who had increased anxiety. CMT A passed medications on the South Hall. The hospice nurse was on the South Hall with a resident, who was not doing well. CMT A came to the medication room and said he/she needed help because someone fell . He/she asked who fell and CMT A said a visitor came in and said a resident fell . LPN B and CMT A checked throughout the facility and did not find any resident who had fallen. They then went out the front door and found the resident and wheelchair on the ground in the parking lot. The resident and his/her wheelchair fell off the front porch. He/she assessed the resident and found an abrasion on the right shoulder, applied antibiotic ointment and a dressing, notified the physician, and DON. Observation on 7/14/14 at 5:00 P.M. showed: - The resident self-propelled his/her high-backed wheelchair down the North Hall toward the dining room. - His/her right leg was outstretched on an elevated wheelchair pedal. - The resident ran his/her wheelchair into the dining room door as he/she attempted to enter the dining room. During an observation and interview on 7/15/14 at 10:20 A.M., the DON said and did the following: - The front door did not unlock until a code was entered. - The door shut slowly and had a delayed lock. - She demonstrated how the door did not release without the code and the delayed click of the lock. - The staff showed her where they found the resident and determined the resident attempted to turn his/her wheelchair left around the porch post and the chair's wheel went off the edge of the porch and the resident fell into the parking lot with the wheelchair. - After the incident staff put a Wanderguard on the resident that alarmed whenever the resident approached the exit. - The step from the parking lot to the porch appeared six inches high. Review of the resident's care plan, updated on 7/7/14, showed: - Wanderguard on ankle to alert staff to exit seeking. MO

Based on interview and record review, the facility failed to provide the necessary care and services for one resident (Resident #1) when the resident developed swelling and pain in the left knee and leg. The resident had swelling and pain in the left knee and leg for nine days before staff notified the physician. The physician ordered an xray which showed the resident had a distal femoral (lower thigh bone) [MEDICAL CONDITION] leg. The facility census was 43. 1. Review of Resident #1's care plan dated February 2011, showed the care plan did not address pain or direct staff how to transfer the resident. Review of the resident's physician order [REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated resident assessment, completed by facility staff dated 10/27/11, included the following: - Brief interview for mental status (BIMS) showed a score of one. A score of zero to seven indicates severe cognitive impairment. - Did not ambulate. - Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. - Used a wheelchair for mobility. - Frequently incontinent of bladder and bowel. - [DIAGNOSES REDACTED]. - No falls documented. Review of the resident's undated care card (A tool used by staff to identify resident care needs) showed the resident had recent falls. He/she required assistance of two staff for transfers. The card did not show the transfer method the resident required. Review of the resident's undated resident status sheet (A tool used by staff to identify resident care needs) showed the resident used a wheelchair for mobility and required the assistance of two staff. The sheet did not show the transfer method the resident required. During an interview on 12/14/11 at 11:10 A.M., Certified Nurse Aide (CNA) C said he/she worked on 12/5/11, as a certified medication technician (CMT.) Resident #1 did not complain of leg or knee pain during that time. During an interview on 12/14/11 at 11:30 P.M., Nurse Aide (NA) A said he/she and another aide got Resident #1 up the morning of 12/5/11. The resident usually wore a dress, but that morning, night shift staff laid out pants for the resident to wear. As the aides put the resident's pants on, the resident started screaming, which was not normal for the resident. The resident's left knee was bigger than the right one and felt warm to touch. The aides used the mechanical lift and transferred the resident to his/her wheelchair. The aides told the charge nurse about the resident's knee pain and swelling as they took the resident to the dining room for breakfast. The resident continued to complain of left leg pain throughout the day. The NA said he/she told the charge nurse again about the leg pain and also told the evening shift aides the resident had complained of left leg pain and had swelling in the left knee. NA A said the resident complained of left leg pain the rest of the week. NA A said he/she really worried about the resident's leg, but the nurses kept saying it was arthritis. He/she even mentioned the resident's complaints of left leg pain to the hospice aide when he/she came and gave the resident a bath. The hospice aide said he/she would tell his/her nurse. During an interview on 12/14/11, at 11:55 A.M., CNA D said he/she thought he/she worked the day shift on 12/5/11. He/she and NA A got Resident #1 up and dressed that morning. The resident was agitated and hollered that morning. He/she normally wore a gown, but night staff laid out pants for the resident to wear that day. As the aides put the resident's pants on, he/she hollered in pain, a different kind of pain. CNA D said they did not finish putting the pants on the resident. CNA D looked at the resident's left leg and it was swollen. He/she went and told LPN B. LPN B told the aides he/she thought it was arthritis. The resident complained about leg pain all day. The next day, 12/6/11, CNA D said the resident continued to complain of pain so he/she told another nurse about the knee. The nurse said he/she thought it was arthritis and did not go look at the resident's knee. CNA D said he/she even told the director of nursing (DON) about the resident's leg. The DON said she would check on the leg. CNA D did not see the DON check the resident's knee during her shift. CNA D said he/she knew something was wrong with Resident #1's leg, because it would not bend without the resident "screaming in excruciating pain." Review of the resident's nurses notes dated 12/6/11, showed Licensed Practical Nurse (LPN) B documented hospice would be notified of the resident crying out in pain and the left knee bigger in size than the right knee. Pressure to the knee cap made the resident cry out. The knee was not warm to touch. Staff applied ice to the resident's knee. The resident displayed a positive effect. During an interview on 12/14/11 at 10:50 A.M., LPN B said he/she worked as the day shift charge nurse on 12/5 and 12/6/11. On 12/6/11, CNA A and CNA B told him/her Resident #1 hollered and cried with pain in his/her left knee. When he/she went to look at the resident, the resident was in bed, with his/her left knee bent. The resident cried out when LPN B put pressure on his/her left knee. The left knee was a little bigger, but not red or bruised. The aides told LPN B the resident cried out when they rolled him/her. The hospice nurse also saw the resident that day and they both looked at the resident's left knee. The hospice nurse said he/she would contact the physician. LPN B did not notify the physician because hospice said they would. During an interview on 12/19/11 at 11:00 A.M., CNA B said he/she worked one day the week of 12/12/11, but could not remember the specific day. He/she helped NA A provide care for Resident #1. The resident complained of his/her left leg hurting. NA A said he/she told the charge nurse and DON about the resident's left leg, so CNA B did not report it. The resident's left knee was bigger that it should have been, but CNA B did not see any redness. Review of the nursing shift report sheet (a report completed by nurses and aides to show what happened during their shift for review by the oncoming shifts) dated 12/8/11, showed a CNA documented for the 7:00 A.M. to 3:00 P.M. shift the resident said his/her knee hurt really bad. During an interview on 12/14/11, at 11:10 A.M., CNA C said on 12/8/11, he/she worked as a CMT. Resident #1 complained of his/her leg hurting and he/she gave the resident pain medication and an antianxiety medication to try and calm the resident down. The resident occasionally complained of back pain but it was unusual for the resident to complain of leg pain. CNA C said on one of the days he/she worked, he/she gave the aides an ice pack to put on the resident's knee, but he/she could not remember which day. During an interview on 12/14/11 at 10:15 A.M., LPN A said he/she worked as the day charge nurse on 12/7, 8, and 9/11. The resident was confused most of the time. LPN A did not know how the resident injured his/her leg. He/she did not know about the resident's leg pain when working those days. Review of the nursing shift report sheet dated 12/9/11, showed the following: - 7:00 A.M. to 3:00 P.M. shift; An unknown nurse documented the resident complained of left knee pain. Staff iced the knee and there was no swelling or warmth but it was bigger. The CNA documented the resident yelled all day. - 3:00 P.M. to 11:00 P.M. shift; A CNA documented the resident yelled all night. - 11:00 P.M. to 7:00 A.M. shift; A nurse documented the resident as loud and gave [MEDICATION NAME] (anti-anxiety medication) at midnight and [MEDICATION NAME] (narcotic pain medication) at 2:00 A.M., which was very little help. During an interview on 12/14/11 at 12:10 P.M., the DON said she first knew about the resident's left leg pain on 12/8 or 12/9/11. Two aides reported the resident's leg as red, hot and swollen. The DON said he/she went and looked at the the resident's left leg. It was slightly swollen and hot, but not red. He/she moved the resident's left leg and when she put the left leg down, the resident yelled. The DON told LPN B to notify the physician. She thought she told him/her this toward the end of the shift. She did not follow up to make sure staff notified the physician. The DON found out the nurse did not notify the physician because they thought hospice would notify him/her. The facility nurse is responsible for notifying the resident's physician of a change in condition. Even though the nurses thought the problem was arthritis, they still needed to notify the physician because it was a change in the resident's condition. Review of the nursing shift report sheet dated 12/12/11, showed the following: - 7:00 A.M. to 3:00 P.M. shift; A nurse documented the resident's left knee was swollen and hospice in to see the resident. Hospice and staff to monitor for changes. A CNA documented the resident yelled and complained of leg pain. - 3:00 P.M. to 11:00 P.M. shift; A nurse documented left knee pain and very [MEDICAL CONDITION]. The pain was better after [MEDICATION NAME] and [MEDICATION NAME], hospice aware. The CNA documented the resident yelled most of the night. Review of nurses notes dated 12/12/11, at 1:30 P.M. showed LPN A documented hospice nurse (HN) A was in the facility to see the resident's wound. The resident complained of left knee pain. The resident's left knee was swollen. The hospice nurse was going to monitor the resident's left knee, along with facility staff, for any changes. During an interview on 12/14/11, at 10:15 A.M., LPN A said the first he/she knew anything was wrong with Resident #1's left leg was Monday, 2/12/11. when the aides reported the resident's leg was swollen. LPN A and HN A went and looked at the resident's left knee The resident said "ouch" when they touched his/her leg but it was not bruised, red or warm to touch. HN A and LPN A decided to monitor the leg until the next day. LPN A did not notify the resident's physician. During an interview on 12/14/11, at 3:15 P.M., HN A said he/she saw the resident most of the time but he/she did not see the resident 12/5/11, through 12/9/11. He/she saw Resident #1 on 12/12/11. The resident's left knee was a little swollen and slightly red on the inside. HN A said he/she could touch the resident above the left knee without problems, but when he/she touched the knee, it hurt the resident. After he/she checked the knee, HN A decided to watch the knee for another day. The facility staff did not tell HN A the resident had pain and swelling of the knee the previous week. Even though he/she did not see the resident the previous week, he/she worked Thursday and Friday and the facility did not contact him/her about the resident. Review of nurses notes dated 12/13/11 at 9:20 A.M., showed LPN A documented HN A in the facility to see Resident #1. Order written for an x-ray of the left knee at the hospital. During an interview on 12/14/11 at 10:15 A.M., LPN A said when he/she came to work on 12/13/11, the resident's left leg was still swollen and she still complained of pain so he/she called to get an order for [REDACTED]. Review of the resident's physician order [REDACTED]. Review of the hospital outpatient nurse assessment dated [DATE], showed Resident #1 arrived as an outpatient on 12/13/11 at 12:55 P.M. The chief complaint was left leg pain with an onset of about four days ago. The notes showed the physician ordered an x-ray through outpatient. The x-ray showed the resident had a left distal femur fracture and the resident went through the emergency room . Review of facility nurses' notes dated 12/13/11 at 1:00 P.M., showed LPN A spoke with the resident's family member about the resident getting an x-ray of the left knee. The nurse told the family member he/she would inform him/her of any changes. Review of the resident's x-ray report dated 12/13/11, showed the reason for the procedure was left knee pain and swelling. The findings showed a distal femoral (lower thigh bone) fracture. Review of the hospital emergency room record dated 12/13/11at 1:26 P.M., showed the resident was admitted via wheelchair, from x-ray to the emergency room and then admitted to the hospital due to a left distal femoral fracture. The note showed the resident "hollers" in pain when moved. During an interview on 12/14/11 at 2:20 P.M., Physician A said he/she did not recall receiving a telephone call from the facility regarding Resident #1's left leg, until 12/13/11. If the facility did not have records of them notifying him/her, then they probably did not notify him/her the previous week. The facility staff contact him/her for everything else about residents, he/she was surprised they did not contact him/her. They should call him/her anytime there was a problem with one of the residents. Review of the facility's undated policy titled Physician Notification re: Resident Change of Condition included the following: - There are two definitions for physician notification. Immediate notification is when the physician should be informed at the time the event occurs either directly or by beeper. Non-immediate notification is when the physician should be informed of the problem or event during office hours and generally no later than the next regular office day. If a non-immediate event occurs on a weekend or holiday, good nursing judgement shall determine if the notification could wait until the next office day or should be made during the weekend or holiday. - Nursing personnel identify those residents with a change of condition which requires an immediate notification of the physician and those which require non-immediate notification. - The nurse should not hesitate to contact the physician at any time for a problem which in their judgement requires immediate medical attention. MO