Every finding on record at Regency At Bluffs Park

Based on observation, interview, and record review, the facility failed to ensure interventions to prevent falls were in place for one (R3) of three reviewed.Findings include:Review of the medical record revealed R3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included vascular dementia with behavioral disturbance, chronic pain, complete rotator cuff tear or rupture, and disorders of bone density. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/15/26 revealed R3 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had a history of falls. Review of the incident report dated 4/26/26 revealed R3 was observed lying on the floor on her back in between her bed and chair. Review of the Post Fall Evaluation revealed R3 was reaching for the phone on her table. The root cause was listed as environmental factors/items out of reach. Review of the incident report dated 5/15/26 revealed staff heard a loud noise followed by yelling and observed R3 lying face down on the floor with her head against the metal pole of the bedside table. The incident report revealed another resident reported R3 attempted to get up from her wheelchair to place something in the bin and fell forward. Review of the incident report dated 7/30/26 revealed R3 was observed falling forward in her room, face first onto the floor. Review of the Post Fall Evaluation revealed R3 was reaching from her chair to the light switch, trying to turn off the light. Review of the Nurses Note dated 7/30/26 revealed R3 was observed falling forward onto the floor, face first, trying to turn off her light. R3 was sent to the emergency room for evaluation. The Nurses Note dated 7/31/26 revealed Continue care plan interventions, resident continues to self transfer against care plan. Proper foot ware [sic], low bed, dycem, anti rollbacks, toileting program in place, items in reach. Goals to prevent falls with injury. Review of the incident report dated 8/1/26 revealed staff heard a loud noise, went into R3's room and found R3 face down on the floor. R3 reported she was trying to turn on the light. The Post Fall Evaluation revealed R3 was barefoot and did not have non-skid footwear. The root cause was listed as footwear. Initial interventions to prevent future falls included proper footwear, items in reach, bed in lowest position, and visual checks. Review of the Nurses Notes dated 8/1/26 revealed Call for help .Pt [patient] had a large knot on her [left] side of forehead and was complaining of head pain. R3 was sent to the emergency room for evaluation. Review of the Resident at Risk note dated 8/4/26 revealed Fall on 7/30 while ambulating without assistance to turn light off. Fall on 8/1 observed laying on floor face down while attempting to turn her light on without assistance. Review of the Nurses Note dated 8/4/26 revealed Continue care plan interventions, resident continues to self transfer against care plan. Proper foot ware [sic], low bed, dycem, anti rollbacks, toileting program in place, items within reach. Goals to prevent falls with injury. Review of R3's falls care plan revealed the following interventions that included: encourage and assist to wear gripper socks as resident allows due to history of removal, ensure table/items are within reach, keep wheelchair in reach, soft call light in reach, and keep wheelchair in reach. On 8/11/26 at 3:11 PM, R3 was observed asleep in bed on her left side, facing the wall. R3 had an enabler bar on the right side of the bed; the left side of the bed was against the wall. The bed was in a low position with a concave mattress in place. R3's wheelchair was not in reach as it was across the room, against the corner of the wall to the right of the bathroom, approximately five feet from R3's bed. R3's overbed table with numerous items was out of reach and against the wall opposite of R3's bed, approximately four to five feet from R3's bed. On 8/12/26 at 8:30 AM, R3 was observed asleep in bed. R3's wheelchair was at the end of the bed, on the other side of the footboard, and out of reach. On 8/12/26 at 12:40 PM, R3 was observed sitting in her wheelchair in her room, eating lunch. R3 had a large purple bruise surrounding her left eye with fading green/yellow bruising on the left side of her forehead. R3's left shoe was half off; her left heel was out of the shoe and resting on the back of the shoe. She did not have on socks. A Certified Nursing Assistant (CNA) was in her room gathering soiled linen. The CNA left the room with the soiled linen and returned 1 minute later with fresh linens to make R3's bed. The CNA made R3's bed and left the room at 12:43 PM. The CNA did not put R3's left shoe back on correctly. R3's touch pad call light was observed in the center of R3's bed, out of her reach. In an interview, R3 reported she recently fell in her room twice, both times on her face. When asked how she would ask for help if she needed it, R3 stated well it's right there, and pointed to her touch pad call light on her bed. When asked if she would be able to reach the call light, R3 stated, well I would just get up and get it. R3 reported staff had just made her bed and put the call light on her bed. In an interview on 8/12/26 at 1:48 PM, Assistant Director of Nursing (ADON) I reported Director of Nursing (DON) B was on vacation. ADON I reported R3's fall interventions that should be in place included gripper socks, wheelchair in reach, items in reach, and soft call light in reach.

Based on observation, interview and record review, the facility failed to effectively clean and maintain food service equipment resulting in the potential to spread food borne illness among all residents that consume food from the kitchen. Findings include: On 06/28/2026 at 10:00 A.M., An initial tour of the food service was conducted with Dietary [NAME] (DC) J and Registered Dietician (RD) K. The following items were noted:The juice machine (undersplash, backsplash, drip tray) was observed soiled with accumulated and encrusted food residue.The stainless-steel counter central drip tray was observed soiled with accumulated and encrusted food residue. The drip tray channel was also observed with bacterial growth (slurry) via flashlight illumination. The drip tray channel was not easily removable, due to the coffee machine and juice machine front support legs resting upon the channel grill assembly.The dry storage (flour, sugar, oats) bin exterior surfaces were observed with accumulated and encrusted food residue. The clear plastic lid tracks and handle assembly were also observed soiled with accumulated and encrusted food residue on each dry storage bin.The can opener assembly was observed soiled with accumulated and encrusted food residue. The handle, cutting blade, and mounting bracket insert were observed to be soiled with accumulated and encrusted food residue.The convection oven interior and exterior surfaces were observed to be soiled with accumulated and encrusted food residue.The two conventional oven interior and exterior surfaces were observed to be soiled with accumulated and encrusted food residue.The two conventional oven burner top surface backsplashes and the side panel of the convection oven were observed to be soiled with accumulated and encrusted food residue.One 5-pound container of commercially prepared chicken salad (1/2 full) was observed without an effective open or discard date, within the one-door reach-in cooler.A small portion of commercially prepared salami was observed with an effective open date (6-15-26) and an illegible discard date, within the one-door reach-in cooler.Several slices of commercially prepared turkey salami (sliced deli meat) were observed dated for 14 days instead of 7 days total, within the one-door reach-in cooler. The open and discard dates observed on the clear plastic sealable bag read 6-18-26 to 7-3-26.One bag of opened shredded iceberg lettuce was observed dated for 14 days instead of 7 days total, within the one-door reach-in cooler. The open and discard dates observed on the clear plastic sealable bag read 6-27-26 to 7-13-26.One gallon of whole milk (1/8 full) was observed with an open date that read 6-27-26 with no discard date documented, within the walk-in cooler.One gallon of 2% milk (1/2 full) was observed with an open date that read 6-27-26 with no discard date documented, within the walk-in cooler.The convection oven interior lights were observed non-functional.One container of hair nets (blue in color) and one case of canned ginger ale soda were observed stored directly beneath the plumbing waste lines, within a preparation dump sink cabinet.The ice machine condensate drain line was observed to be completely submerged into the sump pump well inlet chamber.On 06/28/2026 at 11:26 A.M., the Main Dining Room hand sink basin was observed draining slowly.On 06/28/2026 at 12:10 P.M., the three-compartment sink sanitizer basin test strips being utilized were observed to read PH Test Strips with a scale range of 1-12. Quaternary ammonia sanitizer was observed in use at this sink. Dietary [NAME] (DC) L was interviewed regarding the current test strips being utilized and stated: I usually look for the test to be in the 6-8 range.On 06/28/2026 at 3:28 P.M., a personal cell phone was observed resting directly upon a clean tray of inverted coffee cups. An interview was conducted with Dietary Manager (DM) I regarding the Policy/Procedure for cell phone usage and proper storage. (DM) I stated: Cell phones should be stored in their pockets or in their lockers.On 06/30/2026 at 08:00 A.M., record review of the Policy/Procedure entitled: Food Purchasing and Storage dated 12/10/2024 revealed under Procedure: (5) Perishable Food Storage: (7) All food items in refrigerators will be properly dated, labeled, and placed in containers with lids, will be wrapped, or stored in sealed food storage bags (See Cold Storage Chart).On 06/30/2026 at 08:30 A.M., Record review of the Policy/Procedure entitled: Nutritional Services Cleaning and Sanitation dated 3/11/2026 revealed under Policy: It is the policy of this facility to maintain the sanitation of the kitchen through proper cleaning and sanitizing stationary food service equipment and food contact surfaces to minimize the growth of microorganisms that may result in food contamination. Food contact surfaces are washed, rinsed, and sanitized: (a) After each use; (b) Before switching preparation to another food type; and (c) When the tool or items being used may have been contaminated.On 06/30/2026 at 09:00 A.M., Record review of the Policy/Procedure entitled: Use by Date Storage Chart dated 3/2018 revealed the following: All unopened prepackaged processed products should be used or discarded by the Manufacturer's Expiration Date. Milk, Yogurt, Unprocessed Soft Cheeses, Cottage Cheese opened 7 days or expiration date (soonest). Processed cheeses, sour cream opened 14 days or expiration date (soonest). All food items must be properly dated and labeled, and must be stored in either containers with lids, foil/film wrapped, sealed food storage bags, or their original container. Foods should not be refrozen.The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.The 2022 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.The 2022 FDA Model Food Code section 6-303.11 states: The light intensity shall be: . (B) At least 215 lux (20 foot candles): . (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators .The 2022 FDA Model Food Code section 3-305.12 states: FOOD may not be stored: (F) Under sewer lines that are not shielded to intercept potential drips; (G) Under leaking water lines, including leaking automatic fire sprinkler heads, or under lines on which water has condensed; (H) Under open stairwells; or (I) Under other sources of contamination.The 2022 FDA Model Food Code section 5-402.11 states: '(A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed.The 2022 FDA Model Food Code section 5-205.15 states: A plumbing system shall be: (A) Repaired according to LAW; and (B) Maintained in good repair.The 2022 FDA Model Food Code section 4-501.116 states: Concentration of the SANITIZING solution shall be accurately determined by using a test kit or other device.The 2022 FDA Model Food Code section 6-501.110 states: (A) Dressing rooms shall be used by EMPLOYEES if the EMPLOYEES regularly change their clothes in the establishment. (B) Lockers or other suitable facilities shall be used for the orderly storage of EMPLOYEE clothing and other possessions.

Based on observation, interview, and review, the facility failed to revise care plans for one (R65) of 15 reviewed. Findings include: Review of the medical record revealed R65 was admitted to the facility on [DATE] with diagnoses that included fracture of lower end of right femur, nondisplaced facture of head of right radius, and lymphedema. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/15/26 revealed R65 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). In an interview on 06/28/2026 at 11:16 AM, R65 was observed in her bed. R65 reported she completed her own bed baths and could do everything besides washing her feet. R65 reported she had an order for A&D ointment on her feet, but staff did not routinely apply the A&D ointment to her feet. R65's feet were observed to be dry with cracked skin. Review of the Physician's Order dated 6/12/26 revealed an order to assist patient with Activities of Daily Living (ADL) from knees down and apply A & D ointment on scheduled shower day. Review of R65's care plans revealed no mention of her shower days or the A&D ointment. Review of the Kardex (Nurse Aide Care Guide) revealed no mention of R65's shower days or A & D ointment. In an interview on 06/30/2026 at 9:51 AM, Certified Nursing Assistant (CNA) M reported R65 sometimes requested A&D ointment, and they would provide it but have never assisted R65 with applying A&D ointment to her feet. CNA M reported they thought R65 could do all their own care, including washing their feet. In an interview on 06/30/2026 at 9:56 AM, Unit Manager (UM) G reported staff worked together to update care plans. UM G reported if a care plan intervention was something the CNAs needed to know, the intervention would also be listed on the Kardex. UM G reviewed R65's medical record and agreed A&D ointment was not listed on the Treatment Administration Record (TAR), Kardex, or Care Plan and that it should be.

Based on interview and record review the facility failed to ensure for one out of 15 residents (Resident #79) the Minimum Data Set (MDS) assessment accurately reflected the resident's status. Findings Included: Per the facility's face sheet Resident #79 (R79) was admitted to the facility on [DATE] with a diagnosis of pressure ulcer of unspecified site, dated 6/8/2026. Review of a physician's progress note dated 6/12/2026 revealed that the physician documented under, Assessment & Medical Plan of Care: R79 had pressure injuries to her coccyx and right heel which the physician documented both to be a stage 2 pressure wounds. The physician documented treatments for the pressure wounds and the wound nurse to follow. Review of physician orders dated 6/12/2026 revealed an order for treatment to R79's stage 2 coccyx pressure ulcer. Review of physician orders dated 6/12/2026 revealed an order for treatment to R79's stage 2 right heel pressure ulcer. Review of progress notes dated 6/12/2026 revealed that the physician performed a physical assessment and diagnosed R79 with a stage 2 pressure ulcer on her coccyx and right heel. Review of a picture of R79's coccyx wound revealed a stage 2 wound to the coccyx area. Measurements were documented at 4.07 X 1.96 X 5.03. There were no measurements of the right heel wound. Review of R79's Treatment Administration Record (TAR) for the month of June 2026 revealed an order to educate R79's daughter on R79's wound treatments to prepare for discharge. Additionally, there were several different treatment orders for R79's stage 2 coccyx and right heel pressure ulcers. The treatment orders were dated from 6/12 through 6/26/2026 and identified to be for either the right heel stage 2 or the coccyx stage 2 pressure injury (pressure wound). Review of an admission MDS with an assessment reference date of 6/18/2026 revealed under section M R79 was not coded to have any pressure ulcers on the assessment. Review of R79's care plans revealed a care plan dated 6/12/2026 and revised on 6/26/2026, with a focus that R79 had an actual impairment to her skin integrity related to her right heel stage 2 pressure ulcer. In an interview on 6/30/2026 at 9:18 AM, Licensed Practical Nurse (LPN) P, who was the MDS nurse, stated that the Nurse Practitioner told her that R79's wounds were blisters and that was why she did not code the coccyx and right heel pressure ulcers on R79's MDS assessment.

Based on interview and record review, the facility failed to provide a bed hold prior to a transfer in one (Resident #2) out of one reviewed for bed holds. Findings include: Review of the medical record reflected R2 was admitted to the facility on [DATE], with diagnoses that included retention of urine. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6-4-26, reflected R2 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of a Progress Note dated 6/20/2026 at 9:17 AM stated new orders to send resident to the ER (emergency department). resident made aware. transfer paperwork completed . Review of the medical record revealed an absence of any indication that a bed hold was provided to R2 upon transfer to the Emergency Department. On 6/30/2026 at 9:07 AM Director of Nursing (DON) B stated that the expectation for residents transferring out was to provide the resident or resident representative with the bed hold and then document that the bed hold was provided in a Progress Note. Additionally, thr bed hold should be uploaded in thr medical record. DON B reviewed R2's medical record and confirmed an absence of both a Progress Note and the uploaded copy of the bed hold. In an interview on 6/30/2026 T 9:11 AM, Licensed Practical Nurse (LPN) O stated that she does not recall providing R2 a bed hold prior to transferring her to the hospital on 6/20/26.

Based on observation, interview and record review, the facility failed to prevent a fall for one (R200) of three residents reviewed, resulting in major injury.Findings include:A review of the clinical record revealed R200 was admitted into the facility on [DATE] with diagnoses that included: hypotension, muscle wasting and atrophy, malaise and Liver cell carcinoma. According to the Minimum Data Set (MDS) assessment dated [DATE], R200 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). Review of Section GG: Functional Limitation in Range of Motion revealed the following:Lower extremity (hip, knee, ankle, foot)-impairment on one side. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed and with no back support-substantial/maximal assistance. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed-substantial/maximal assistanceToilet transfer: The ability to get on and off a toilet or commode-dependent. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space-dependentA review of the Incident report for R200, dated [DATE], revealed the following:Nursing Description: Resident was ambulating with CNA (certified nursing assistant) to the restroom when he fell flat on his back while transferring to the bathroom. CNA said (she) witnessed the fall, she said he fell backwards and went unconscious. Writer was immediately called, resident was lying on the floor on his back. He started responding, vitals were stable.Resident Description: Resident unable to give description. Level of Pain: PAINAD (Pain Assessment in Advanced Dementia-a pain scale used by caregivers to measure pain in residents with severe dementia or cognitive impairment): 7. Breathing: 1 (Score), (Detail)Occasional Labored Breathing. Short Period of Hyperventilation. Negative Vocalization: 1, Occasional Moan or Groan. Low Level of Speech with a Negative Quality. Facial Expression: 2, Facial Grimacing. Body Language: 2, Rigid, Fists, Clenched, Knees Pulled up or Pushing Away Striking OutConsolability: 1, Distracted or Reassured by Voice or Touch. Level of Consciousness: Lethargic (Drowsy). Injuries Report Post Incident: Injury Type-Fracture, Injury Location-Top of ScalpNotes: subdural hematoma, skull fracture, brain compression. Predisposing Physiological Factors: Weakness/Fainted. Predisposing Situation Factors: Ambulating with Assist, Other-ambulating with nursingA review of the facilities Summary for Failure to follow residents care plan, revealed In-depth analysis how the deficiency occurred: On [DATE] resident (initials redacted-R200) call light was on, CNA (initials redacted-CNA B) answered the light, and he requested to be taken to the restroom to have a bowel movement. CNA ( B) preceded to assist the resident out of bed and walked him to the restroom using the walker and standby assist, a gait belt wasn't used. The CNA (CNA B) turned away to open the door to the bathroom when the CNA (CNA B) heard what sounded like the door hitting a trash can. When the CNA (CNA B) turned back around, she observed the resident on the floor positioned on his back with loss of consciousness. Resident care plan stated resident requires substantial/maximal assistance with two helpers and the use of rolling walker with therapy only. The resident was sent to (hospital name redacted) Hospital where right parietal and temporal skull fracture, left occipital condyle fracture, and minor frontotemporal contusions were identified. Interview with therapy regarding residents abilities and rationale for nursing not being able to ambulate resident since he was able to walk. Was on OT (occupational therapy) & PT (physical therapy) services with focus on strengthening, balance, ADLs (activities of daily living), transfer and gait training. Had poor strength and balance. Required Max (maximum) assist for transfer along with increased time for processing and verbal cues for hand placement and proper tech (technique). Attempted gait training, using RW (rolling walker) and max assist. Required verbal and tactile cues for tech for safety and balance. Status was ambulation with therapy only d/t (due to) the assist level and needed cues for safety and tech. Transfer status for staff was sit to stand lift (device used to assist with transferring residents with balance/strength deficits) for safety as cont (continued) with poor strength and balance.A review of R200's Therapy to Nursing Communication, dated for [DATE] revealed Ambulatory Status: Substantial/Maximal (assistance), Rolling Walker, In Therapy Only.Transfers: 2 assist, sit to stand lift, substantial/maximal.Comments: Fall RiskA review of R200's Physical Therapy PT Evaluation and Plan of Treatment, dated [DATE], revealed the following:Reason for Referral: Patient exhibits exacerbation of decrease in strength, decease in transfers, reduced balance and decreased neuromotor control indicating the need for PT to promote safety. awareness, minimize falls, improve dynamic balance and enhance rehab potential. Strength/Manual Muscle Testing: Lower extremity, RLE (right lower extremity)=2+/5, LLE (left lower extremity)=2+/5. Functional Assessment: Transfers=Max/2 Sit to Stand=Max/2A review of R200's Physical Therapy Treatment Encounter Note, dated [DATE], documented in part patient co (complains of) dizziness BP (blood pressure) in standing 77/39 and in sitting 89/49, returned patient back to his bed and nursing has been notified.A review of R200's Physical Therapy Discharge summary, dated [DATE]-[DATE], revealed the following:Dynamic Standing: Baseline ([DATE]) Poor (stands with Mod A (moderate assistance) and minimally reaches ipsilaterally, unable to cross midline), Previous ([DATE]) Poor+ (stands with Min A and reached ipsilaterally, unable to weight shift). Distance Level Surfaces (ambulation): Baseline ([DATE]) 0 feet, Previous ([DATE]) 20 feet Max/2A review of R200's Occupational Therapy, Therapy Progress Report, dated [DATE]-[DATE], revealed the following: Toileting: Baseline ([DATE]) Max/2, Previous ([DATE]) Max/2, Current ([DATE]) Max/2.Review of R200's Occupational Therapy Treatment Encounter Note, dated [DATE], revealed the following: Functional Skills Assessment-Activities of Daily Living/Self Care-Toileting-Max/2. Functional Skills Assessment-Mobility During ADLs-Functional Mobility During ADLs=Max/2A review of R200's Kardex revealed the following: Safety.Provide assistive devices as needed: sit to stand lift for transfers with wc (wheelchair) for ambulationTransferring.Transfer: Resident requires substantial/maximal assistance with two helps, sit to stand lift Toileting.Toilet Transfer: Resident requires substantial/maximal assistance with (one, two) helper(s)A review of R200's Care Plan Report revealed the following:(Name redacted) has a functional ability deficit and requires assistance with self-care/mobility R/T (related to): Impaired Balance, Date initiated [DATE]. Interventions: AMBULATION/WALKING: Resident requires substantial/maximal assistance with rolling walker in therapy only with (one, two) helper(s), Date initiated [DATE]. Interventions: Transfer: Resident requires substantial/maximal assistance with two helps, sit to stand lift, Date initiated [DATE]. Interventions: TOILET TRANSFER: Resident requires substantial/maximal assistance with (one, two) helper(s), Date initiated [DATE].A review of Skilled Nursing Facility Progress Note-completed by the facilities Nurse Practitioner, dated [DATE], documented in part He (R200) says he feels weak, legs are weak and go out on him a lot.Assessment: 1. Physical deconditioning, 2. Dizziness, 3. Lightheadedness, 4. Generalized weakness.Medical Plan of Care: Generalized weakness with gait instability Physical Deconditioning-Continue PT/OT while at SAR (subacute rehab), He will need Home Care upon discharge from SAR; Dizziness, lightheadedness-Encourage increase po (oral) fluid intake, Counseled patient on need to reposition slowly.A review of Skilled Nursing Facility Progress Note-completed by the facilities Nurse Practitioner, dated [DATE], documented in part Assessment: 1. Dysuria, 2. Increased urinary frequency, 3. Dizziness, 4. Lightheadedness, 5. Generalized weakness, 6. Physical deconditioning .Medical Plan of Care: Generalized weakness with gait instability Physical Deconditioning-Continue PT/OT while at SAR, He will need Home Care upon discharge from SAR; Dizziness, lightheadedness-Encourage increase po fluid intake, Counseled patient on need to reposition slowly.A review of R200's progress notes revealed the following: On [DATE] at 07:54. Nurses Notes, Late Entry: Note Text: Resident was sent out to the hospital via ambulance accompanied by HVA (initials for ambulance company) due to a fall with injury. Vitals were stable, resident was lethargic and disorient(ed). Pupils were non reactive to light bilaterally, resident fall backwards on the floor, he hit his head and went unconscious for a moment. Responsible party and on call MD was notified. On [DATE] at 13:45. Change In Condition, Change In Condition Symptoms: AMS (altered mental status), more confusion. Current Vital Signs: BP 111/57 resp (respirations)18. Pulse 77.temp 97.4. O2 94.Nursing Action Taken: vital signs, contact Md, assessment. Practitioner Notification and Recommendations: order labs cbc (Complete blood count) with diff (differential), BMP (Basic metabolic panel) and UA C&S (urinalysis with culture and sensitivity).On [DATE] at 11:55 Behavior Note, Note Text: writer received call from patient's (family member redacted) that patient reported to have call light on for hours. Writer went up to patient's room, call light not on, CNA and Nurse right outside patient's room report patient's light has not been on for any extended time today. Call light in place, patient resting comfortable and not soiled. Visited with patient who reported to have had call light on for awhile. Call light monitoring has been initiated. Patient did not have any needs not met when visiting.On [DATE] at 09:35 Nurses Notes. Note Text: orthostatic blood pressures per MD one time only. 135/68 laying 80hr, 16resp, 97.9 temp, 94%. sitting 87/40, 96 hr, 19rsp 97.9 temp 94%standing 109/87, 91hr, 95%, 20resp.On [DATE] at 1:56 PM, during a telephone interview with CNA B, it was reported that on the morning of [DATE], she had gotten R200 up out of bed and attempted to get him to the bathroom with a walker and grippy socks only (no gait belt or other assistive devices were used), R200 was in a standing position, and CNA B reached to open the bathroom door, she heard a loud sound, turned back around and saw R200 on the floor, R200 was not responding initially. CNA B stepped out in the hallway to get a nurse and CNA G was on her way into the room at that time. Once CNA G had arrived R200 had started to regain consciousness. LPN C entered the room, took residents vital signs, an ambulance was called and the resident was sent out to the hospital. CNA B reported being aware that the Kardex should be used to determine the level of assistance a resident requires. When asked if she had checked the Kardex for R200 she reported that she had not because she had taken care of him before and didn't think to check. CNA B reported that after this incident she received education related to safe transfers, gait belt use and following care plans but did not receive any formal discipline. On [DATE] at 11:45 AM, during a telephone interview with LPN C, it was reported that she was the nurse assigned to R200 for the 11/14 to [DATE] shift. LPN C reported that she had seen R200 around 5:30 AM to give him his meds and he was alert and oriented at that time. LPN C was called to R200's room around 6 AM by the CNA, she grabbed the vital signs machine and when she arrived to his room he was observed on the floor, flat on his back, near the end of his bed and in front of his dresser. Upon her arrival R200 was speaking but was out of it, requesting to get back in bed and asking for his wife. LPN C reported that she told R200 that she couldn't get him back in bed at that time, his vital signs were stable, eyes were dilated, and he could squeeze her hands. LPN C reported that she stayed with the resident until paramedics arrived, which she estimated to be approximately 15-20 minutes from the time of his fall. LPN C denied being aware of R200 recently experiencing any dizziness or low blood pressure. LPN C believed that R200 was a one person assist at the time of his fall and used the urinal at night unless he needed to have a bowel movement.On [DATE] at 2:46 PM, during a telephone interview with LPN D (a floor nurse that had provided care for R200 in the past), it was reported that R200 walked with nursing staff (x2) with assistance and a walker. LPN D reported that R200 could get up to the walker fine with 2 people next to him but needed more assistance getting off the toilet due to his height. When asked what nursing staff should use to determine the level of assistance a resident requires, LPN D reported they use to use the ADL book but now look at the Kardex. When asked why she had completed a set of orthostatic vital signs on R200, she reported not being sure but thought the doctor could have ordered them because the resident felt dizzy after therapy. When asked what she had done with the results she was unsure but reported she probably followed up with the doctor. When asked if she knew what the criteria was for the results to be considered positive, she reported not remembering. On [DATE] at 12:55 PM, during an interview with Director of Nursing, it was reported that R200 fell while being ambulated to the bathroom with a gait belt and walker (after reviewed the PNC that she had completed the DON later corrected this statement to indicate that a gait belt was not used), he fell backwards as the CNA was opening the bathroom door, she yelled for the nurse, CNA told the nurse that resident had been unconscious but was awake when the nurse arrived, he was sent out to the hospital where they did imaging that revealed he had a skull fracture and a brain bleed. DON reported that nursing staff should refer to the Care plan or Kardex to determine what level of assistance a resident requires and that through the facilities investigation it was determined that the care plan was not followed and the resident should not have been ambulating with nursing staff due to weakness and immobility. DON reported that through their interviews it was determined that R200 had ambulated with nursing staff prior to this incident and that there was a walker at his bedside. When asked if she knew why a set of orthostatic vital signs were completed on [DATE], she reported that she did not and would let me know if she was able to determine that (no additional information was provided prior to survey exit). When asked if any new interventions were put in place for residents dizziness, lightheadedness and hypotension, DON reported that she would let me know if she found any documentation of new interventions (no additional information was provided prior to survey exit). When asked what the expectation was for gait belt use, DON reported that a gait belt should be used for all transfers for anyone that requires any level of assistance.Review of R200's Death Certificate revealed the following: date of death : [DATE]. Immediate cause of death: Complications of blunt force head trauma and FallDate of injury: [DATE], Time of Injury: 0645 on or about, Describe how injury occurred: The decedent fell from standing height, Place of Injury: Nursing Home.A review of the facilities policy titled Fall Management, documented in part Residents identified at risk for falls will have an initial plan of care developed to meet each resident's needs. Interventions should be related to the risk factors as well as incorporating resident choice to help minimize the risk of a fall.A review of the facilities policy titled Routine Resident Care, documented in part Staff members should observe the following safety precautions with all residents.Gait belts are used for transfers and ambulation, as indicated.R200's care plan, Kardex and Therapy to Nursing Communication sheet indicated resident should have been ambulated by therapy only. The resident was ambulated by a single (non-therapy) staff member without a gait belt or use of sit to stand, despite documentation that resident had experienced lightheadedness/dizziness, episodes of hypotension and required substantial/maximal assistance which resulted in major injury (multiple skull fractures and brain bleed).

Based on interview and record review, the facility failed to follow the care plan for one (R200) of three residents reviewed. Findings include:A review of the clinical record revealed R200 was admitted into the facility on [DATE] with diagnoses that included: hypotension, muscle wasting and atrophy, malaise and Liver cell carcinoma. According to the Minimum Data Set (MDS) assessment dated [DATE], R200 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). Review of Section GG: Functional Limitation in Range of Motion revealed the following:Lower extremity (hip, knee, ankle, foot)-impairment on one side. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed and with no back support-substantial/maximal assistance. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed-substantial/maximal assistanceToilet transfer: The ability to get on and off a toilet or commode-dependent. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space-dependentA review of the Incident report for R200, dated 11/15/2025, revealed the following:Nursing Description: Resident was ambulating with CNA (certified nursing assistant) to the restroom when he fell flat on his back while transferring to the bathroom. CNA said (she) witnessed the fall, she said he fell backwards and went unconscious. Writer was immediately called, resident was lying on the floor on his back. He started responding, vitals were stable.Resident Description: Resident unable to give description. Level of Pain: PAINAD (Pain Assessment in Advanced Dementia-a pain scale used by caregivers to measure pain in residents with severe dementia or cognitive impairment): 7.Breathing: 1 (Score), (Detail)Occasional Labored Breathing. Short Period of Hyperventilation.Negative Vocalization: 1, Occasional Moan or Groan. Low Level of Speech with a Negative Quality.Facial Expression: 2, Facial Grimacing. Body Language: 2, Rigid, Fists, Clenched, Knees Pulled up or Pushing Away Striking Out.Consolability: 1, Distracted or Reassured by Voice or Touch.Level of Consciousness: Lethargic (Drowsy).Injuries Report Post Incident: Injury Type-Fracture, Injury Location-Top of Scalp.Notes: subdural hematoma, skull fracture, brain compression.Predisposing Physiological Factors: Weakness/Fainted.Predisposing Situation Factors: Ambulating with Assist, Other-ambulating with nursing.A review of the Summary for Failure to follow residents care plan, revealed In-depth analysis how the deficiency occurred: On 11/15/2025 resident (initials redacted-R200) call light was on, CNA (initials redacted-CNA B) answered the light, and he requested to be taken to the restroom to have a bowel movement. CNA ( B) preceded to assist the resident out of bed and walked him to the restroom using the walker and standby assist, a gait belt wasn't used. The CNA (CNA B) turned away to open the door to the bathroom when the CNA (CNA B) heard what sounded like the door hitting a trash can. When the CNA (CNA B) turned back around, she observed the resident on the floor positioned on his back with loss of consciousness. Resident care plan stated resident requires substantial/maximal assistance with two helpers and the use of rolling walker with therapy only. The resident was sent to (hospital name redacted) Hospital where right parietal and temporal skull fracture, left occipital condyle fracture, and minor frontotemporal contusions were identified. Interview with therapy regarding residents abilities and rationale for nursing not being able to ambulate resident since he was able to walk. Was on OT (occupational therapy) & PT (physical therapy) services with focus on strengthening, balance, ADLs (activities of daily living), transfer and gait training. Had poor strength and balance. Required Max (maximum) assist for transfer along with increased time for processing and verbal cues for hand placement and proper tech (technique). Attempted gait training, using RW (rolling walker) and max assist. Required verbal and tactile cues for tech for safety and balance. Status was ambulation with therapy only d/t (due to) the assist level and needed cues for safety and tech. Transfer status for staff was sit to stand lift (device used to assist with transferring residents with balance/strength deficits) for safety as cont (continued) with poor strength and balance.A review of R200's Therapy to Nursing Communication, dated for 10/28/25 revealed Ambulatory Status: Substantial/Maximal (assistance), Rolling Walker, In Therapy Only.Transfers: 2 assist, sit to stand lift, substantial/maximal.Comments: Fall RiskA review of R200's Kardex revealed the following: Safety.Provide assistive devices as needed: sit to stand lift for transfers with wc (wheelchair) for ambulation.Transferring.Transfer: Resident requires substantial/maximal assistance with two helps, sit to stand lift.Toileting.Toilet Transfer: Resident requires substantial/maximal assistance with (one, two) helper(s).A review of R200's Care Plan Report revealed the following:(Name redacted) has a functional ability deficit and requires assistance with self-care/mobility R/T (related to): Impaired Balance, Date initiated 10/27/2025.Interventions: AMBULATION/WALKING: Resident requires substantial/maximal assistance with rolling walker in therapy only with (one, two) helper(s), Date initiated 10/30/2025.Interventions: Transfer: Resident requires substantial/maximal assistance with two helps, sit to stand lift, Date initiated 10/30/2025.Interventions: TOILET TRANSFER: Resident requires substantial/maximal assistance with (one, two) helper(s), Date initiated 10/30/2025.On 2/20/2026 at 1:56 PM, during a telephone interview with CNA B, it was reported that on the morning of 11/15/25, she had gotten R200 up out of bed and attempted to get him to the bathroom with a walker and grippy socks only (no gait belt or other assistive devices were used), R200 was in a standing position, and CNA B reached to open the bathroom door, she heard a loud sound, turned back around and saw R200 on the floor, R200 was not responding initially. CNA B stepped out in the hallway to get a nurse and CNA G was on her way into the room at that time. Once CNA G had arrived R200 had started to regain consciousness. LPN C entered the room, took residents vital signs, an ambulance was called and the resident was sent out to the hospital. CNA B reported being aware that the Kardex should be used to determine the level of assistance a resident requires. When asked if she had checked the Kardex for R200 she reported that she had not because she had taken care of him before and didn't think to check. CNA B reported that after this incident she received education related to safe transfers, gait belt use and following care plans but did not receive any formal discipline.On 2/20/2026 2:46 PM, during a telephone interview with LPN D (a floor nurse that had provided care for R200 in the past), it was reported that R200 walked with nursing staff (x2) with assistance and a walker. LPN D reported that R200 could get up to the walker fine with 2 people next to him but needed more assistance getting off the toilet due to his height. When asked what nursing staff should use to determine the level of assistance a resident requires, LPN D reported they use to use the ADL book but now look at the Kardex. On 2/20/2026 at 12:55 PM, during an interview with Director of Nursing, it was reported that R200 fell while being ambulated to the bathroom with a gait belt and walker (the DON later corrected this statement to indicate that a gait belt was not used), he fell backwards as the CNA was opening the bathroom door, she yelled for the nurse, CNA told the nurse that resident had been unconscious but was awake when the nurse arrived, he was sent out to the hospital where they did imaging that revealed he had a skull fracture and a brain bleed. DON reported that nursing staff should refer to the Care plan or Kardex to determine what level of assistance a resident requires and that through the facilities investigation it was determined that the care plan was not followed and the resident should not have been ambulating with nursing staff due to weakness and immobility. DON reported that through their interviews it was determined that R200 had ambulated with nursing staff prior to this incident and that there was a walker at his bedside.Review of R200's Death Certificate revealed the following:date of death : November 30, 2025. Immediate cause of death: Complications of blunt force head trauma and Fall. Date of injury: 11/15/2025. Time of Injury: 0645 on or aboutDescribe how injury occurred: The decedent fell from standing height. Place of Injury: Nursing HomeA review of the facilities policy titled Fall Management, documented in part Residents identified at risk for falls will have an initial plan of care developed to meet each resident's needs. Interventions should be related to the risk factors as well as incorporating resident choice to help minimize the risk of a fall.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 58 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 04/15/25 at 09:24 A.M., An initial tour of the food service was conducted with Dietary Manager G. The following items were noted: The Juice Machine interior surfaces (backsplash, undersplash, drip tray assembly) were observed soiled with accumulated and encrusted food residue. Dietary Manager G indicated she would have staff thoroughly clean and sanitize the Juice Machine as soon as possible. The Vulcan stove/oven backsplash and stove top burners were observed soiled (black) with accumulated and encrusted carbonized/caramelized food residue. The Vulcan interior and exterior surfaces were also observed soiled with accumulated and encrusted food residue. The Vulcan convection oven side exterior surface was further observed soiled (black) with accumulated and encrusted food residue. Dietary Manager G indicated she would have staff thoroughly clean and sanitize the Vulcan stove/oven as soon as possible. The can opener assembly was observed soiled with accumulated and encrusted food residue. Dietary Manager G indicated she would have staff thoroughly clean and sanitize the can opener assembly as soon as possible. The [NAME] stand mixer support table surface was observed heavily soiled with accumulated and encrusted food residue. Dietary Manager G indicated she would have staff thoroughly clean and sanitize the [NAME] stand mixer support table as soon as possible. The M3 Turbo Air refrigerator exterior surfaces were observed soiled with accumulated and encrusted food residue. Dietary Manager G indicated she would have staff thoroughly clean and sanitize the M3 Turbo Air' refrigerator exterior surfaces as soon as possible. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The Vulcan stove/oven door handles were observed loose-to-mount. Dietary Manager G indicated she would contact maintenance for necessary repairs as soon as possible. The 2022 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. The food preparation sink faucet assembly was observed leaking water from the spout. The hot water and cold-water supplies could not be shut completely off, allowing a continuous water stream. Dietary Manager G indicated she would contact maintenance for necessary repairs as soon as possible. The 2022 FDA Model Food Code section 5-205.15 states: A plumbing system shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. The mechanical dish machine wash temperature digital display screen was observed to read 130.1 degrees Fahrenheit during the cleaning cycle. The 2022 FDA Model Food Code section 4-501.110 states: (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than: (1) For a stationary rack, single temperature machine, 74oC (165oF); (2) For a stationary rack, dual temperature machine, 66oC (150oF); (3) For a single tank, conveyor, dual temperature machine, 71oC (160oF); or (4) For a multitank, conveyor, multitemperature machine, 66oC (150oF). (B) The temperature of the wash solution in spray-type warewashers that use chemicals to SANITIZE may not be less than 49oC (120oF). On 04/15/25 at 10:30 A.M., An interview was conducted with Registered Dietician H regarding the mechanical dish machine warewashing temperature. Registered Dietician H indicated the facility had a contractual service for maintaining the mechanical dish machine. On 04/17/25 at 10:00 A.M., Record review of the Policy/Procedure entitled: Maintenance and Repairs of Equipment in Nutritional Services Department dated 12/19/2024 revealed under Policy: It is the policy of this facility that all malfunctions and need for repairs are reported to the Maintenance Department and the Administrator in a timely manner. Record review of the Policy/Procedure entitled: Maintenance and Repairs of Equipment in Nutritional Services Department dated 12/19/2024 further revealed under Procedure: (1) The Nutritional Professional will be notified when a piece of equipment malfunctions. (2) The Nutritional Professional will notify the Maintenance Department in writing of the equipment issue (or via TELS program). The Nutritional Professional will also notify the Administrator. (3) If the repair requires outside servicing, the Nutritional Professional will schedule this in conjunction with the Maintenance Director and Administrator. (4) Preventative maintenance will be completed for major equipment at regular intervals. The Nutritional Professional and Maintenance Department will be responsible to coordinate these projects. On 04/17/25 at 10:15 A.M., Record review of the Policy/Procedure entitled: Dietary Cleaning and Sanitation dated 11/12/2021 revealed under Policy: It is the policy of this facility to maintain the sanitation of the kitchen through proper cleaning and sanitizing stationary food service equipment and food contact surfaces to minimize the growth of microorganisms that may result in food contamination. Food-contact surfaces are washed, rinsed, and sanitized: (a) After each use., (b) Before switching preparation to another food type., (c) When the tool or items being used may have been contaminated.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 60 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, reduced air quality, and potential cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 04/16/25 at 08:30 A.M., A common area environmental tour was conducted with Maintenance Director I. The following items were noted: Jefferson Shower Room: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. Maintenance Director I indicated he would have housekeeping thoroughly clean and sanitize the soiled grill assembly as soon as possible. [NAME] Staff Break Room: The Men's and Women's Restroom return-air-exhaust ventilation grills were observed soiled with accumulated and encrusted dust/dirt deposits. Maintenance Director I indicated he would have housekeeping thoroughly clean and sanitize the soiled grill assemblies as soon as possible. [NAME] Resident/Visitor Restroom: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. Maintenance Director I indicated he would have housekeeping thoroughly clean and sanitize the soiled grill assembly as soon as possible. Occupational Therapy/Physical Therapy: 1 of 3 oval mobile chairs were observed (etched, scored, particulate), exposing the inner Styrofoam padding. The damaged surface measured approximately 1-inch-wide by 3-inches-long twice. Maintenance Director I indicated he would remove and replace the damaged chair as soon as possible. Nursing Station: 1 of 2 chairs were observed (etched, scored, particulate), exposing the inner Styrofoam padding. The damaged chair surface measured approximately 4-inches-wide by 30-inches-long. Maintenance Director I indicated he would remove and replace the damaged chair as soon as possible. [NAME] Resident/Visitor Restroom: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. Maintenance Director I indicated he would have housekeeping thoroughly clean and sanitize the soiled grill assembly as soon as possible. Service Corridor Staff/Shower Room: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. Maintenance Director I indicated he would have housekeeping thoroughly clean and sanitize the soiled grill assembly as soon as possible. Kitchen Storage Room: The atmospheric vacuum breaker was observed broken (missing bonnet) on the mop sink faucet assembly. Maintenance Director I indicated he would have staff replace the faulty atmospheric vacuum breaker as soon as possible. On 04/16/25 at 01:30 P.M., An environmental tour of sampled resident rooms was conducted with Maintenance Director I. The following items were noted: 122: The restroom return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. The maroon vinyl covered recliner was also observed (etched, scored, particulate), adjacent to Bed 1. The damaged headrest surface area measured approximately 12-inches-wide by 30-inches-long. The damaged armrest surface area measured approximately 3-inches-wide by 6-inches-long, along each armrest section. Maintenance Director I indicated he would have staff remove and replace the damaged recliner chair as soon as possible. Maintenance Director I also indicated he would have housekeeping thoroughly clean and sanitize the soiled grill assembly as soon as possible. 135: The shower wand assembly was observed missing an atmospheric vacuum breaker. Maintenance Director I indicated he would have staff install an atmospheric vacuum breaker on the shower wand assembly as soon as possible. 142: The shower wand assembly was observed missing an atmospheric vacuum breaker. Maintenance Director I indicated he would have staff install an atmospheric vacuum breaker on the shower wand assembly as soon as possible. 218: The shower wand assembly was observed missing an atmospheric vacuum breaker. Maintenance Director I indicated he would have staff install an atmospheric vacuum breaker on the shower wand assembly as soon as possible. 224: The maroon-colored vinyl recliner chair was observed (etched, scored, particulate), exposing the inner Styrofoam padding. The damaged headrest surface measured approximately 12-inches-wide by 30-inches-long. Maintenance Director I indicated he would have staff remove and replace the damaged recliner chair as soon as possible. 232: The restroom return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. Maintenance Director I indicated he would have housekeeping thoroughly clean and sanitize the soiled grill assembly as soon as possible. 246: The maroon-colored vinyl recliner chair was observed (etched, scored, particulate), exposing the inner Styrofoam padding. The damaged headrest surface measured approximately 12-inches-wide by 30-inches-long. Maintenance Director I indicated he would have staff remove and replace the damaged recliner chair as soon as possible. On 04/16/25 at 03:15 P.M., An interview was conducted with Maintenance Director I regarding the facility maintenance work order system. Maintenance Director I stated: We have the TELS system. On 04/17/25 at 09:30 A.M., Record review of the Policy/Procedure entitled: Maintenance Department dated 09/19/2024 revealed under Policy: To assure proper maintenance of the physical plant. Record review of the Policy/Procedure entitled: Maintenance Department dated 09/19/2024 further revealed under (IV) General Facility Maintenance: The department will do on-going monitoring of the facility for areas needing repair and, if needed, will report to the supervisor for approval of the repairs needed. On 04/17/25 at 09:30 A.M., Record review of the Policy/Procedure entitled: Housekeeping Services dated 02/28/25 revealed under Policy: To promote a sanitary environment. Record review of the Policy/Procedure entitled: Housekeeping Services dated 02/28/25 further revealed under (I) Frictional Cleaning: (A) Thorough scrubbing will be used for all environmental surfaces that are being cleaned in resident care areas. On 04/17/25 at 09:45 A.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff to respond to resident needs timely for five of 15 reviewed (R1, R14, R22, R48 and R62). Findings include: In an interview on 4/15/25 at 10:23 AM, Certified Nurse Aide (CNA) C reported they were caring for 16 residents that shift (day shift), and their ability to keep up with resident care needs was dependent upon acuity levels. Resident #22 (R22): Review of the medical record reflected R22 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included fusion of the spine and dependence on renal dialysis. On 4/15/25 at 10:45 AM, R22 was observed in bed and reported slow response time when they used their call light. R22 reported they had waited 45 minutes or longer for staff assistance, three to four times, primarily on day shift. R22 reported they were typically calling to request pain medication. On 4/15/25 at 1:02 PM, R22 was observed seated in a wheelchair, in their room. R22 reported their call light had just been on for 50 minutes, and the nurse had not yet been back with their medication. Resident #1 (R1) Review of the medical record reflected R1 admitted to the facility on [DATE]. On 4/15/25 at 3:05 PM, R1 was observed in bed. They reported between the hours of 8:00 PM and 8:00 AM, it took 30 minutes for staff to respond to their call light. 27306 On 04/16/25 at 02:20 PM during an interview with Licensed Practical Nurse U and V they reported the facility was understaffed and there was not enough Certified Nursing Assistants (CNA's) to meet the needs of the residents. During this interview CNA T interrupted the interview reporting to LPN U and LPN V that she could not locate the other CNA that was assigned to the same hall. CNA T elaborated that she was fed up with the other CNA because they always hide and do not take care of their assigned residents leaving CNA T with her residents (approximately 15 residents) and the other CNA's assignment (another 15 residents) CNA T stated she cant take care of 30 residents. 46954 On 4/15/25 at 10:22 AM, Resident 14 (R14) was observed in their room. R14 stated that staffing is not good and it creates a delay in receiving her pain medication timely which impacts her physical therapy progress. On 4/15/25 at 10:00 AM, Resident #48 (R48) stated that there are significant call light response delays in the afternoon and midnights. Staff will tell R48 to shut his call light off and state they will be back, however, they do not return. R48 states it is an ongoing concern that is repeatedly brought up in Resident Council, however, nothing has been resolved. R48 states he hears other residents yelling out for help nearly every night. On 4/15/25 at 12:48 PM, Resident #62 stated that it takes staff up to an hour to answer his call light. R62 states he fears for the time that he experiences an actual emergency because he doubts staff will answer is call for help promptly. In an interview on 4/18/25 at 9:29 AM, Certified Nursing Assistant (CNA) L stated that it is difficult to find an additional CNA to assist with two person transfers and that he is unable to take his breaks due to insufficient staffing. In an interview on 4/18/25 at 10:19 AM, CNA P stated that current staffing levels make their job, really, really hard. CNA P states sometimes she has up to 18 residents and they often get really mad at you because of call light response times. CNA P states that she is constantly apologizing for the wait. CNA P stated that they are unable to take any breaks. In an interview on 4/17/25 at 10:02 AM, CNA O stated that staffing is poor and with the amount of resident needs required and the absence of sufficent staffing numbers, the job can be overwhelming and there is a likelihood in an increase of accidents. In an interview on 4/23/25 at 10:34 AM, CNA M stated that CNA's would instruct residents to use the bathroom in their brief as a time saving measure.

Based on observation, interview, and record review the facility failed to ensure for 14 out of 14 residents (Resident # 5, 7, 13, 15, 18, 25, 37, 48, 51, 69, 333, 335, 340, 341) allegations of abuse were identified and investigated. Findings Included: Resident #5 (R5): Review of the grievance log revealed that on 3/7/2025, R5 had put in a grievance that it tool one and a half hours to get assistance to use the bathroom, and she had missed her shower two times. The grievance further revealed, I (R5) was told to get a private aid. NO! Hire more help. The resolution was to continue to hire more staff. Abuse was not identified, R5 refused to sign the facility's resolution. No investigation for an allegation of abuse was conducted. Resident #7 (R7): Review of the grievance log revealed that on 2/10/2025, R7's daughter put in a grievance that if R7 did not take a shower then she would have a refusal. No resolution was noted regarding showers. No investigation for an allegation of abuse was conducted. Resident #13 (R13): Review of the grievance log revealed that on 12/09/2024, R13 put in a grievance that she had gone to the kitchen and upon speaking with a staff member (did not reveal who the dietary staff member was) she was told that when she spoke with the staff member on the phone she had raised her voice, and she was not allowed to call the kitchen, and to stop calling everyday. The statement revealed that when R13 went to the kitchen to speak with the staff member the staff member would not come out of the kitchen to speak with her, but then told her that she was not going to do this, and then tried to slam the kitchen door. The resolution for the allegation of abuse was, discharged No investigation for an allegation of abuse was conducted. Resident #15 (R15): Review of a grievance log revealed that on 3/30/2025, R15 put in a grievance that she was told by a Certified Nurse Aid (CNA) that she was not dealing with this today and to suck it up. The statement also revealed that R15 was told to wait to go to the bathroom while others were being rounded on. Resolution was education to CNA, and remove CNA from case load (will not provide care to R15, but will for other residents). No investigation for an allegation of abuse was conducted. Resident #18 (R18): Review of a grievance log revealed that on 2/5/2025, R18 put in a grievance that a CNA transferred her with a lift by herself, but the lift required two people, and reported that the CNA yelled at her. The resolution did not address the allegation of abuse with the CNA yelling at the resident. No investigation for an allegation of abuse was conducted. Resident #25 (R25): Per the facility face sheet R25 was originally admitted to the facility on [DATE]. On 4/16/2025 at 3:29 PM, an attempt was made to visit R25 in her room. Upon knocking on R25's room door, R25 stated she was in the bathroom and would be available after she finished. In an interview on 4/17/2025 at 9:23 AM, R25 was visited in her room. R25 stated that she did make the statement in resident council in [DATE] that a CNA, could not recall who, told her that she did not have time to provide her with care, and told her to go to the bathroom in her brief. Review of grievances revealed that on 2/6/2025 R25 put in a grievance that revealed, CNA told resident They do not have time, use the bathroom in their brief, Between 4pm-8pm . No investigation for an allegation of abuse was conducted. Resident #37 (R37): Review of a grievance log revealed that on 10/20/2024, R37 put in a grievance that a CNA told her that .she wasn't going to change her. The resolution was a discussion with the resident, and to continue with receiving assistance as needed. No identifying of abuse was noted. No investigation for an allegation of abuse was conducted. Resident #51 (R51): Per the facility face sheet R51 had resided at the facility since 7/23/2024. On 4/16/2025 at 2:58 PM, R51 was visited in his room. R51 stated that he wore a brief, but stated he knew when he had to urinate, and have a bowel movement. R51 said staff who put briefs on him have not ever offered to allow him to wear his own underwear, and said he was not sure if he even had underwear in his room with his own belongings. With permission R52's top dresser drawer was opened, and several pairs of underwear were observed to be in the drawer that were R51's underwear. R51 stated he had no idea those pairs of underwear were there in the drawer, and again stated no one had ever offered him to wear his own underwear instead of a brief. An urinal was observed to be at R51's bedside with urine in it. R51 said he can either go in the urinal or the toilet in the bathroom, and stated he was able to walk with his walker. R51 stated that he did not need to wear a brief it made him feel like an invalid, stated that he was a grown man, said he was embarrassed to wear the brief. R51 stated that one time, could not recall who the Certified Nurse Aid (CNA) was or the exact date, he asked for assistance to use the toilet and stated the CNA told him, (as quoted by R51), they did not have time to provide any care to me, and to have my bowel movement in my brief. R51 said he reply to the CNA, did you just tell me to poop in my pants?, and said the CNA said yes because no one had time to provide him with care, R51 said that made him saw wow. R51 said he was not able to comprehend what he was just told. R51 stated he was embarrassed, felt like no one cared about him, he did not matter, and again said he could not comprehend what he was just told. R51 stated that he wants the brief off, did not want to wear the briefs anymore, and no one had offered him to wear his own underwear. R51 further stated that he did not wear briefs prior to coming to the facility, he used the toilet, and did not want to wear them now. Resident #69 (R69): Review of a grievance form dated 11/26/2024, revealed R69's daughter filled out the grievance which stated that staff told her if they did not have time then they would tell the R69 to go to the bathroom in her diaper. The resolution was staff education. No investigation for an allegation of abuse was conducted. Resident #333 (R333): Review of a grievance form dated 1/6/2025, revealed R333 filled out a grievance that he had asked a CNA to help him to the bathroom, but the CNA gave him a urinal instead, and then left his room. The statement revealed that R333 could not use a urinal, and wanted to use the bathroom. The resolution was education. No investigation for an allegation of abuse was conducted. Resident #335 (R335): Review of the grievance log revealed the on 10/18/2024, R335 put in a grievance that she had vomited while in an activity at around 2:30 PM, and stated that her wound bandages were saturated. R335 wrote on the grievance that a CNA told her that her wound dressings would not be changed until 6:00 or 7:00 PM. There was no documented resolution. No investigation for an allegation of abuse was conducted. Resident #340 (R340): Review of a grievance form dated 6/14 and 6/15/2024 revealed, R340's CNA would not assist her to the bathroom, but just stood there and watched her walk unassisted, would not straighten her bed, and threw the bed covers over her. Resolution was the CNA was terminated. No investigation for an allegation of abuse was conducted. Resident #341(R341): Review of a grievance form dated 6/8 & 6/9/2024, revealed R341 filled out a grievance which stated she had asked her CNA if she could help her with her colostomy bag, and the CNA just rolled her eyes at her and walked out. The form also revealed that the CNA had entered R341's room and rolled her eyes again when she saw R341 was not done eating her dinner. The resolution was the CNA was disciplined. No investigation for an allegation of abuse was conducted. In an interview on 4/21/2025 at 11:07 AM, Administrator A stated that she was the abuse coordinator, and all abuse including allegations of abuse were to be reported to her immediately. Administrator A stated that psychosocial/mental harm is the way the resident was feeling and included dismissal of their feelings by staff. Administrator A stated that resident grievances would be placed into her mailbox but stated if nursing received the grievance it would go to Director of Nursing B (DON), who would then give it to the appropriate staff member to follow up on. Administrator A stated that she did read the grievances. Furthermore, Administrator A stated that she had read the resident grievances that they were told by CNAs that they did not have time to provide them care, and to go to the bathroom in their briefs. Administrator A stated she took the statements as an issue with customer care and not allegations of abuse. In an interview on 4/21/2025 at 12:06 PM, DON B stated that there were concerns about residents being told to go to the bathroom in their briefs. DON B stated that education was provided to CNAs, and said the grievances regarding the briefs were considered customer service concerns, and not allegations of abuse. None of the allegations of abuse were identified as allegations of abuse, and no investigations were conducted. 46954 Resident #48 (R48) Review of the medical record reflected R48 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/15/25, reflected R48 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 4/17/25 at 8:27 AM, R48 was observed in his room. R48 reported that call light response is incredibly long, and once he was denied assistance to use the bathroom for a bowel movement and was told to have a bowel movement in his brief while he was in bed. R48 described the situation as humiliating and degrading. R48 confirmed that he is occasionally incontinent of urine, however, continent of bowel and can report when he needs assistance to the bathroom. R48 stated that after that incident, he has forced himself to learn how to transfer himself to his wheelchair and assist himself to the bathroom, despite the need for staff assistance by one person. R48 stated that this became necessary so that he would never be made to have a bowel movement in his brief. R48 stated that he filled out a Grievance form related to this incident, however, never had any appropriate follow up or resolution for the concern and now just ensures that he self transfers to the bathroom for bowel movement. R48 stated that he feels like a second class citizen. Review of a Grievance form revealed R48's handwritten name at the top of the form with a concern which stated cna (certified nursing assistant) told resident they do not have time, use the bathroom in your brief.

Based on observation, interview, and record review the facility failed to ensure for 14 out of 14 residents (Resident # 5, 7, 13, 15, 18, 25, 37, 48, 51, 69, 333, 335, 340, 341) allegations of abuse were reported to the state agency. Findings Included: Resident #5 (R5): Review of the grievance log revealed that on 3/7/2025, R5 had put in a grievance that it tool one and a half hours to get assistance to use the bathroom, and she had missed her shower two times. The grievance further revealed, I (R5) was told to get a private aid. NO! Hire more help. The resolution was to continue to hire more staff. Abuse was not identified, R5 refused to sign the facility's resolution. Resident #7 (R7): Review of the grievance log revealed that on 2/10/2025, R7's daughter put in a grievance that if R7 did not take a shower then she would have a refusal. No resolution was noted regarding showers. Resident #13 (R13): Review of the grievance log revealed that on 12/09/2024, R13 put in a grievance that she had gone to the kitchen and upon speaking with a staff member (did not reveal who the dietary staff member was) she was told that when she spoke with the staff member on the phone she had raised her voice, and she was not allowed to call the kitchen, and to stop calling everyday. The statement revealed that when R13 went to the kitchen to speak with the staff member the staff member would not come out of the kitchen to speak with her, but then told her that she was not going to do this, and then tried to slam the kitchen door. The resolution for the allegation of abuse was, discharged Resident #15 (R15): Review of a grievance log revealed that on 3/30/2025, R15 put in a grievance that she was told by a Certified Nurse Aid (CNA) that she was not dealing with this today and to suck it up. The statement also revealed that R15 was told to wait to go to the bathroom while others were being rounded on. Resolution was education to CNA, and remove CNA from case load (will not provide care to R15, but will for other residents). Resident #18 (R18): Review of a grievance log revealed that on 2/5/2025, R18 put in a grievance that a CNA transferred her with a lift by herself, but the lift required two people, and reported that the CNA yelled at her. The resolution did not address the allegation of abuse with the CNA yelling at the resident. Resident #25 (R25): Per the facility face sheet R25 was originally admitted to the facility on [DATE]. On 4/16/2025 at 3:29 PM, an attempt was made to visit R25 in her room. Upon knocking on R25's room door, R25 stated she was in the bathroom and would be available after she finished. In an interview on 4/17/2025 at 9:23 AM, R25 was visited in her room. R25 stated that she did make the statement in resident council in [DATE] that a CNA, could not recall who, told her that she did not have time to provide her with care, and told her to go to the bathroom in her brief. Review of grievances revealed that on 2/6/2025 R25 put in a grievance that revealed, CNA told resident They do not have time, use the bathroom in their brief, Between 4pm-8pm . Resident #37 (R37): Review of a grievance log revealed that on 10/20/2024, R37 put in a grievance that a CNA told her that .she wasn't going to change her. The resolution was a discussion with the resident, and to continue with receiving assistance as needed. No identifying of abuse was noted. Resident #51 (R51): Per the facility face sheet R51 had resided at the facility since 7/23/2024. On 4/16/2025 at 2:58 PM, R51 was visited in his room. R51 stated that he wore a brief, but stated he knew when he had to urinate, and have a bowel movement. R51 said staff who put briefs on him have not ever offered to allow him to wear his own underwear, and said he was not sure if he even had underwear in his room with his own belongings. With permission R52's top dresser drawer was opened, and several pairs of underwear were observed to be in the drawer that were R51's underwear. R51 stated he had no idea those pairs of underwear were there in the drawer, and again stated no one had ever offered him to wear his own underwear instead of a brief. An urinal was observed to be at R51's bedside with urine in it. R51 said he can either go in the urinal or the toilet in the bathroom, and stated he was able to walk with his walker. R51 stated that he did not need to wear a brief it made him feel like an invalid, stated that he was a grown man, said he was embarrassed to wear the brief. R51 stated that one time, could not recall who the Certified Nurse Aid (CNA) was or the exact date, he asked for assistance to use the toilet and stated the CNA told him, (as quoted by R51), they did not have time to provide any care to me, and to have my bowel movement in my brief. R51 said he reply to the CNA, did you just tell me to poop in my pants?, and said the CNA said yes because no one had time to provide him with care, R51 said that made him saw wow. R51 said he was not able to comprehend what he was just told. R51 stated he was embarrassed, felt like no one cared about him, he did not matter, and again said he could not comprehend what he was just told. R51 stated that he wants the brief off, did not want to wear the briefs anymore, and no one had offered him to wear his own underwear. R51 further stated that he did not wear briefs prior to coming to the facility, he used the toilet, and did not want to wear them now. Resident #69 (R69): Review of a grievance form dated 11/26/2024, revealed R69's daughter filled out the grievance which stated that staff told her if they did not have time then they would tell the R69 to go to the bathroom in her diaper. The resolution was staff education. Resident #333 (R333): Review of a grievance form dated 1/6/2025, revealed R333 filled out a grievance that he had asked a CNA to help him to the bathroom, but the CNA gave him a urinal instead, and then left his room. The statement revealed that R333 could not use a urinal, and wanted to use the bathroom. The resolution was education. Resident #335 (R335): Review of the grievance log revealed the on 10/18/2024, R335 put in a grievance that she had vomited while in an activity at around 2:30 PM, and stated that her wound bandages were saturated. R335 wrote on the grievance that a CNA told her that her wound dressings would not be changed until 6:00 or 7:00 PM. There was no documented resolution. Resident #340 (R340): Review of a grievance form dated 6/14 and 6/15/2024 revealed, R340's CNA would not assist her to the bathroom, but just stood there and watched her walk unassisted, would not straighten her bed, and threw the bed covers over her. Resolution was the CNA was terminated. Resident #341(R341): Review of a grievance form dated 6/8 & 6/9/2024, revealed R341 filled out a grievance which stated she had asked her CNA if she could help her with her colostomy bag, and the CNA just rolled her eyes at her and walked out. The form also revealed that the CNA had entered R341's room and rolled her eyes again when she saw R341 was not done eating her dinner. The resolution was the CNA was disciplined. In an interview on 4/21/2025 at 11:07 AM, Administrator A stated that she was the abuse coordinator, and all abuse including allegations of abuse were to be reported to her immediately. Administrator A stated that psychosocial/mental harm is the way the resident was feeling and included dismissal of their feelings by staff. Administrator A stated that resident grievances would be placed into her mailbox but stated if nursing received the grievance it would go to Director of Nursing B (DON), who would then give it to the appropriate staff member to follow up on. Administrator A stated that she did read the grievances. Furthermore, Administrator A stated that she had read the resident grievances that they were told by CNAs that they did not have time to provide them care, and to go to the bathroom in their briefs. Administrator A stated she took the statements as an issue with customer care and not allegations of abuse. In an interview on 4/21/2025 at 12:06 PM, DON B stated that there were concerns about residents being told to go to the bathroom in their briefs. DON B stated that education was provided to CNAs, and said the grievances regarding the briefs were considered customer service concerns, and not allegations of abuse. None of the allegations of abuse were reported to the state agency. Furthermore, review of the facility's policy and procedure titled, Care Program (grievances) dated 6/11/2024, revealed under Actions, If the concern is related to alleged abuse, neglect, and/or mistreatment the concerns should be forwarded immediately to the supervisor, administrator, and director of nursing. 46954 Resident #48 (R48) Review of the medical record reflected R48 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/15/25, reflected R48 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 4/17/25 at 8:27 AM, R48 was observed in his room. R48 reported that call light response is incredibly long, and once he was denied assistance to use the bathroom for a bowel movement and was told to have a bowel movement in his brief while he was in bed. R48 described the situation as humiliating and degrading. R48 confirmed that he is occasionally incontinent of urine, however, continent of bowel and can report when he needs assistance to the bathroom. R48 stated that after that incident, he has forced himself to learn how to transfer himself to his wheelchair and assist himself to the bathroom, despite the need for staff assistance by one person. R48 stated that this became necessary so that he would never be made to have a bowel movement in his brief. R48 stated that he filled out a Grievance form related to this incident, however, never had any appropriate follow up or resolution for the concern and now just ensures that he self transfers to the bathroom for bowel movement. R48 stated that he feels like a second class citizen. Review of a Grievance form revealed R48's handwritten name at the top of the form with a concern which stated cna (certified nursing assistant) told resident they do not have time, use the bathroom in your brief.

Based on observation, interview, and record review the facility failed to maintain resident dignity for three of three residents (Resident 25, 48, & 51) resulting in feelings of anger, embarrassment, degrading, feeling not important. Findings Included: Resident 51 (R51): Per the facility face sheet R51 had resided at the facility since 7/23/2024. On 4/16/2025 at 2:58 PM, R51 was visited in his room. R51 stated that he wore a brief, but stated he knew when he had to urinate, and have a bowel movement. R51 said staff who put briefs on him have not ever offered to allow him to wear his own underwear, and said he was not sure if he even had underwear in his room with his own belongings. With permission R52's top dresser drawer was opened, and several pairs of underwear were observed to be in the drawer that were R51's underwear. R51 stated he had no idea those pairs of underwear were there in the drawer, and again stated no one had ever offered him to wear his own underwear instead of a brief. An urinal was observed to be at R51's bedside with urine in it. R51 said he can either go in the urinal or the toilet in the bathroom, and stated he was able to walk with his walker. R51 stated that he did not need to wear a brief it made him feel like an invalid, stated that he was a grown man, said he was embarrassed to wear the brief. R51 stated that one time, could not recall who the Certified Nurse Aid (CNA) was or the exact date, he asked for assistance to use the toilet and stated the CNA told him, (as quoted by R51), they did not have time to provide any care to me, and to have my bowel movement in my brief. R51 said he reply to the CNA, did you just tell me to poop in my pants?, and said the CNA said yes because no one had time to provide him with care, R51 said that made him saw wow. R51 said he was not able to comprehend what he was just told. R51 stated he was embarrassed, felt like no one cared about him, he did not matter, and again said he could not comprehend what he was just told. R51 stated that he wants the brief off, did not want to wear the briefs anymore, and no one had offered him to wear his own underwear. R51 further stated that he did not wear briefs prior to coming to the facility, he used the toilet, and did not want to wear them now. Resident #25 (R25): Per the facility face sheet R25 was originally admitted to the facility on [DATE]. On 4/16/2025 at 3:29 PM, an attempt was made to visit R25 in her room. Upon knocking on R25's room door, R25 stated she was in the bathroom and would be available after she finished. In an interview on 4/17/2025 at 9:23 AM, R25 was visited in her room. R25 stated that she did make the statement in resident council in [DATE] that a CNA, could not recall who, told her that she did not have time to provide her with care, and told her to go to the bathroom in her brief. Review of grievances revealed that on 2/6/2025 R25 put in a grievance that revealed, CNA told resident They do not have time, use the bathroom in their brief, Between 4pm-8pm . In an interview on 4/21/2025 at 11:07 AM, Administrator A stated that she was the abuse coordinator, and all abuse including allegations of abuse were to be reported to her immediately. Administrator A stated that psychosocial/mental harm is the way the resident was feeling and included dismissal of their feelings by staff. Administrator A stated that resident grievances would be placed into her mailbox but stated if nursing received the grievance it would go to Director of Nursing B (DON), who would then give it to the appropriate staff member to follow up on. Administrator A stated that she did read the grievances. Furthermore, Administrator A stated that she had read the resident grievances that they were told by CNAs that they did not have time to provide them care, and to go to the bathroom in their briefs. Administrator A stated she took the statements as an issue with customer care and not allegations of abuse. In an interview on 4/21/2025 at 12:06 PM, DON B stated that there were concerns about residents being told to go to the bathroom in their briefs. DON B stated that education was provided to CNAs, and said the grievances regarding the briefs were considered customer service concerns, and not allegations of abuse. Resident #48 (R48) Review of the medical record reflected R48 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/15/25, reflected R48 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 4/17/25 at 8:27 AM, R48 was observed in his room. R48 reported that call light response is incredibly long, and once he was denied assistance to use the bathroom for a bowel movement and was told to have a bowel movement in his brief while he was in bed. R48 described the situation as humiliating and degrading. R48 confirmed that he is occasionally incontinent of urine, however, continent of bowel and can report when he needs assistance to the bathroom. R48 stated that after that incident, he has forced himself to learn how to transfer himself to his wheelchair and assist himself to the bathroom, despite the need for staff assistance by one person. R48 stated that this became necessary so that he would never be made to have a bowel movement in his brief. R48 stated that he filled out a Grievance form related to this incident, however, never had any appropriate follow up or resolution for the concern and now just ensures that he self transfers to the bathroom for bowel movement. R48 stated that he feels like a second class citizen. Review of a Grievance form revealed R48's handwritten name at the top of the form with a concern which stated cna (certified nursing assistant) told resident they do not have time, use the bathroom in your brief.

Based on observation, interview and record review the facility failed to ensure dignity was maintained for one resident (resident #52) of four residents reviewed for dignity. Review of the clinical record Resident # 52 (R52) was admitted to the facility on [DATE] with diagnosis that include compression fracture and cognitive deficit. Review of the Minimum Data Set (MDS) dated [DATE] revealed R52 scored 9 out of 15 (moderate cognitive) on Brief Interview Status Score for Mental Status (BIMS) . On 04/15/25 at 10:37 AM R52 was observed resting in bed, next to the bed was a recliner chair, a pillow was on the chair and on top of the pillow was a pile of un-bagged pile of linen smeared with feces. The pile of un-bagged soiled linen sat approximately 2 to 3 feet away from R52's face. R52 was observed again 31 minutes later with the soiled linen still on the reclining chair. On 04/23/25 at 12:40 PM, during an interview with Certified Nursing Assistant (CNA) R reported the process for providing care for an incontinent resident who also had soiled linen, first step was to meet the resident needs, by providing peri care, changing the brief , clothing linen etc CNA R reported all soiled linen would immediately be put in a bag then brought to then taken to soiled utility room. When queried if there would ever be a reason for soiled linen not to be bagged and placed on resident furniture. CNA R stated no, that shouldn't happen. On 04/23/25 01:02 PM during an interview with Director of Nursing (DON) B reported it was not protocol to leave soiled linen un-bagged and nest to a resident. DON B stated perhaps whoever assisted R52 that day forgot to get a bag.

Based on observation, interview and record review, the facility failed to 1) ensure appropriate use of Personal Protective Equipment (PPE) for one (R7) of three reviewed for Transmission-Based Precautions (TBP); and 2) ensure appropriate hand hygiene. Findings include: Resident #7 (R7): Review of the medical record reflected R7 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included pain in thoracic spine and chronic obstructive pulmonary disease. The admission/Medicare 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/2/25, reflected R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 04/15/25 at 12:20 PM, R7's room door was observed to be open, with a droplet precaution sign and PPE hanging on the exterior of the door. Two staff members were observed in the room, each wearing a gown, gloves and an N95 mask. Neither of the staff members were observed wearing eye protection. At 12:23 PM, one staff member exited R7's room, wearing an N95 mask with a surgical mask beneath it. The staff member proceeded to walk through the hallway with both masks in place. At 12:27 PM, the staff member returned to R7's room with face shields and was observed wearing a surgical mask. In an interview on 04/15/25 at 2:43 PM, Director of Nursing (DON) B reported R7 was in Transmission-Based Precautions due to being tested for COVID-19. DON B reported a gown, gloves, N95 mask and face shield were to be worn in R7's room. According to DON B, the gown and gloves were to be removed prior to exiting the room. The face shield was to be disinfected, and the N95 was to be removed in the hallway, immediately upon exiting the room. On 04/16/25 at 9:41 AM, a droplet precaution sign and PPE were observed hanging on the exterior of R7's room door. R7 was observed in bed, wearing oxygen via nasal cannula. R7 reported they did not know why they were placed in TBP but expressed they wish they had been notified. A Progress Note for 4/16/25 at 10:14 AM reflected R7's respiratory panel was negative. The medical record reflected isolation (TBP) was discontinued on 4/16/25 due to a negative COVID-19 test. According to the Centers for Disease Control and Prevention, .HCP [Healthcare Personnel] who enter the room of a patient with suspected or confirmed SARS-CoV-2 [COVID-19] infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) . (https://www.cdc.gov/covid/hcp/infection-control/index.html) 45135 During an interview and observation on 04/23/25 at 9:00AM, Licensed Practical Nurse (LPN) S was preparing medications to administer to R14. LPN S completed his preparation and picked up the medication cup and a glass of water and walked into R14's room. LPN S observed R14 take her oral pill form medications. LPN S did not was perform hand hygiene before or after entering R14s room and went back to the medication cart and started preparing the next residents medications. During an interview and observation on 04/23/25 at 9:25AM, LPN S preparing medications to administer to R10. LPN S completed his preparation, stated this resident was on contact precautions due to having Covid. LPN S begun donning up by putting on a disposable blue gown, he already had a blue surgical mask on, and did not change it, then put on gloves before going into the room. LPN S did not perform hand hygiene before putting on his gloves as the recommendation on R10's door. LPN S administered the medications and started to exit the room after removing the disposable gown, and gloves. LPN S did not remove and replace his blue surgical mask that he had been wearing prior to going into R10's room, and now after being in R10's room. LPN S did not follow the recommendation for the use of PPE for R10 or follow the policy and procedure for providing care to a resident on contact precautions, increasing the risk of cross contamination to other residents.

Based on observation, interview and record review, the facility failed to provide Occupational Therapy (OT) services as ordered for one (R22) of two reviewed. Findings include: Review of the medical record reflected R22 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included fusion of the spine and dependence on renal dialysis. At the time of review, R22's Admission/Medicare 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/10/25 was In Progress. On 4/15/25 at 10:50 AM, R22 was observed in bed, wearing a Miami J cervical collar (type of neck brace). R22 reported they were supposed to receive Physical Therapy (PT) and OT five times per week, for one hour per day, but were receiving less. R22 reported the facility was discussing discharge due to lack of progress and stated, how can I progress if they don't work with me more? In an interview on 4/17/25 at 9:48 AM, Physical Therapist (PT) E reported there were times therapy was unable to work with R22 during the week due to dialysis. It was reported the facility tried to adjust R22's therapy schedule around outside appointments, as well as provide therapy on the weekends. PT E reported R22 had an OT evaluation on 4/4/25 and received OT treatment/services on 4/5/25, 4/7/25, 4/8/25, 4/9/25, 4/10/25 and 4/11/25. R22's Physician Orders reflected they were to receive OT services six times per week for 12 weeks. R22's OT evaluation, dated 4/4/25, reflected they were to receive OT services five times per week for 12 weeks. In an interview on 4/17/25 at 10:27 AM, Therapy Director (TD) F reported OT was working on standing balance, bathing, toileting and commode transfers, upper extremity strengthening and activities of daily living (ADLs). TD F reported R22's orders were to receive OT five times per week, as noted on their therapy evaluations. According to TD F, they had to shift R22's therapy days and minutes due to not having OT staff in the facility. R22 was still on OT caseload at the time of the interview. On 4/17/25, review of R22's OT Service Log reflected they had not received any OT services since 4/11/25.

Based on observation, interview and record review, the facility failed to ensure prevention of a fall for one (Resident #10) of two reviewed for falls. Findings include: Resident #10 (R10) R10 admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included muscle wasting and atrophy and anoxic brain damage. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/2/25, reflected R10 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R10's Care Plan revealed R10 was dependent on two staff members with the use of a mechanical Hoyer lift for transfers. On 4/15/25 12:35 PM, R10 was observed in his room, sitting on a motorized wheelchair. R10 had a seatbelt across his lap. R10 reported that he fell out of chair recently. R10 explained that staff had transferred him to his wheelchair and after being placed in his wheelchair, staff had forgotten to put the armrest on his chair down. R10 stated that he has no trunk control, weakness on his left side of his body, and very limited use of his right side of the body. R10 stated that the staff member had moved on with his care duties and due to the armrest being up, he fell sideways out of his chair and suffered a hematoma to his head. R10 stated that he was transferred to the hospital. Review of an Incident report dated 3/1/25 revealed R10 had a fall out of his wheelchair and sustained an injury to the left side of his head. The resident description of the fall indicated that the left arm rest of the wheelchair was up when he was placed in his chair, causing him to fall out of the left side of his wheelchair. The intervention included to have the left arm rest of his wheelchair down during transfers. Review of a Seating and Mobility Evaluation dated 7/12/24 revealed R10 could not independently maintain a neutral upright posture and had poor posture when sitting. In an interview on 4/17/25 at 10:02 AM, Certified Nursing Assistant (CNA) O stated she was assisting with R10's transfer the day that he fell . CNA O reported that after assisting CNA M with the transfer, she removed the Hoyer lift from R10's room and heard the sound of R10 falling. CNA O stated that typically she stays and assists with transfers, however, she was assigned to a different hall that shift and had several call lights activated and had to report back to her assigned area. CNA O reentered the room and observed R10 on the floor on the left side of the chair. CNA O stated that R10 is very weak, with very little trunk control so it is important to ensure that the arm rests are down on the chair before you leave R10's side. CNA O indicated that she did not feel that the CNA's had sufficient training on how to transfer him into the motorized wheelchair. CNA O stated that after the fall, the facility trained the staff on how to safely transfer R10 to the motorized wheelchair In an interview on 4/23/25 at 10:34 AM, CNA M stated that he was present when R10 experienced the fall. CNA M stated that he used the Hoyer lift to transfer R10 to his motorized wheelchair and reported that it was his first time transferring R10 to this particular chair. CNA M confirmed that R10 had no trunk control and due to the left arm rest being left up after the transfer, R10 fell sideways out of the chair and hit his head. CNA M stated he had no training prior to this and had no idea that the arm rest needed to be down to prevent R10 from falling out. In an interview on 04/23/25 at 12:50 PM, Director of Nursing (DON) B stated that R10 was placed into his motorized wheelchair, however, the arm rest was not down and due to the lack of core strength, R10 fell sideways out of his wheelchair. DON B stated that staff education to ensure arm rests were down when R10 was in the motorized chair was provided after the fall.

Based on observation, interview, and record review, the facility failed to ensure showers were offered and completed per resident preference for one out of four residents (Resident #30). Findings include: Resident #30 (R30) Review of the medical record reflected R30 was admitted to the facility on [DATE], with diagnoses that included difficulty in walking. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/19/25, reflected R30 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 4/15/25 at 10:30 AM, R30 was observed in her room resting in bed. R30 expressed frustration with the lack of communication at the facility. R30 stated that she has had several room changes and typically, staff would not give her any notice and would state that they were moving her that day. R30 also stated that due to the constant room changes, she believes her shower days were mixed up, therefore, R30 had missed some of her scheduled shower days. R30 added that staff were offering her showers at unreasonable times in the evening, resulting in a refusal for a shower and on once instance, a shower was offered after her dressing changes were completed. R30 denied refusing other showers. R30 was unsure of what her scheduled shower days were. Review of R30's shower task documentation reflected the following: 3/22/25 refused, per shower sheet, R30 did not know about her shower in advanced, too late now. 3/26/25 refused, no refusal shower sheet 3/29/25 refused, legs wrapped per shower sheet 4/9/25 refused per shower sheet she said she had one yesterday 4/12/25 marked no shower 4/22/25 refusal, no shower sheet for refusal In an interview on 04/23/25 at 12:47 PM, Director of Nursing (DON) B stated that the expectation for showers was to document the refusal in the medical record, and/or document the refusal on a shower sheet. DON B stated that staff should not be marking no in the shower task ands should be offering showers per the shower schedule.

Based on observation, interview and record review, the facility failed to assess a seatbelt as potential restraint for one (Resident #10) of one reviewed. Resident #10 (R10) R10 admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included muscle wasting and atrophy and anoxic brain damage. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/2/25, reflected R10 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R10's Care Plan revealed R10 was dependent on two staff members with the use of a mechanical Hoyer lift for transfers. On 4/15/25 12:35 PM, R10 was observed in his room, sitting on a motorized wheelchair. R10 had a seatbelt across his lap. R10 was unable to self release his seatbelt. R10 stated due to limited use of only one hand, he knew he would not be able to release the seatbelt independently. R10 reported he had never been asked if he could release the seatbelt independently. In an interview on 04/18/25 at 10:19 AM, Certified Nursing Assistant (CNA) P stated that R10 was unable to unlatch his seatbelt. In an interview on 4/23/25 at 10:34 AM, CNA M stated that R10 was unable to unlatch his seatbelt. In an 4/18/25 at 10:36 AM, Therapy Director F reported that R10 had a physical restraint evaluation for the use of the seatbelt on his motorized power chair. Therapy Director F was unable to locate the physical restraint evaluation. One was then created after the interview due to surveyor intervention. A Physician order which stated Electric wheelchair for mobility with seat belt for proper positioning was created on 4/18/2025.

Based on observation, interview, and record review, the facility failed to provide advanced written notice prior to a room change for one Residents (#30), of one residents reviewed for room changes. Findings include: Resident #30 (R30) Review of the medical record reflected R30 was admitted to the facility on [DATE], with diagnoses that included difficulty in walking. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/19/25, reflected R30 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 4/15/25 at 10:30 AM, R30 was observed in her room resting in bed. R30 expressed frustration with the lack of communication at the facility. R30 stated that she has had several room changes and typically, staff would not give her any notice and would state that they were moving her that day. R30 stated she had a variety of roommates and questioned the compatibility of a few of her previous roommates. Review of R30's room change history revealed R30 had four room changes since admission on 2/28/25, 3/14,24, 3/20/25, and 4/2/25. Review of R30's room change notice evaluations reflected two room change notifications, one dated 3/14/25 and one dated 3/20/25. In an interview on 04/23/25 at 10:58 AM, Social Worker (SW) D stated that prior to a room change, staff should inform the resident of the room change and document the conversation in the room change evaluation. SW D was unable to locate the missing room change notifications for R30.

This citation pertains to intakes MI00140976, MI00140959 & MI00141121. Based on observation, interview, and record review, the facility failed to perform a through assessment after a change of condition, in 2 of 7 reviewed for assessment (Resident #1 and #5), resulting in a delay in treatment and services. Findings include: Resident #1 (R1) R1's electronic medical record (EMR) revealed he admitted to the nursing home on 8/15/23; had the diagnoses of Chronic Obstructive Pulmonary Disease (COPD, lung disease) and heart failure. R1's EMR indicated he had transferred to the hospital 4 times since he admitted to the facility. R1's most recent re-admission was 10/23/23. R1's Care Plan dated 8/18/23, revealed he planned to return to the community after rehabilitation, to live with his daughter and grandchildren. R1's goal was to demonstrate correct administration of medications, treatments, and activities of daily living (ADL) to the level needed for a safe return to the community. R1's Oxygen Saturation Summary report indicated R1's pulse oximetry (oxygen in bloodstream) on 11/07/23 at 4:18 PM was 93 percent (%, normal 95 to 100%) with oxygen and his pulse (normal pulse 60-100 beats per minute at rest) was 100 beats per minute (bpm). Medication Error Report dated 11/07/23, and written statement signed by Licensed Practical Nurse (LPN) C; revealed LPN C set-up medications in medication cups for two residents at the same time. LPN C marked each cup with the resident's room numbers, room [ROOM NUMBER] and room [ROOM NUMBER]. On 11/07/23 at around 9:20 PM, R1 received medications intended for the resident that was in room [ROOM NUMBER]. LPN C explained in her statement, that when she attempted to administer medications to the resident in room [ROOM NUMBER], the resident dumped the medications on the bed and reported they were not his medications. In LPN C's statement, she wrote she saw the medication cup that she had labeled room [ROOM NUMBER], and realized she had administered medications to R1 that were not prescribed to him and had resulted in a serious medication error. Medication Error Report dated 11/07/23 at 9:20 PM, revealed the wrong medication was administered to the wrong resident that included: Oxycontin (opioid pain medication) Extended Release 80 milligrams (mg), Tizanidine (muscle relaxant) 2 mg, and Acetaminophen 1,000 mg. The same report indicated the reason for the error was failure to identify resident. LPN C indicated in her statement that she was scared and checked on R1 every 20 to 30 minutes. The same statement indicated on 11/08/23 at 1:00 AM, R1's oxygen saturation level was 80 % with 2 liters of oxygen provided via a nasal canula. R1 was not responding to stimuli. LPN C's statement went on to indicate she called another nurse to assist her. A call to 911 was placed and R1's physician was notified. R1's physician ordered Narcan (medication used to treat narcotic overdose) to be administered. Per Medication Error Report dated 11/07/23, R1 was transferred to the emergency department (ED) for evaluation and treatment. Nurses note created on 11/08/23 at 11:47 AM indicated effective date was 11/08/23 at 2:00 AM revealed at approximately 9:43 PM medication was provided to R1; at approximately 9:50 PM, LPN C realized that a medication error had occurred. LPN's statement indicated she started assessing R1 every 30 minutes; at about 10:30 PM R1's blood pressure was low, 98/65 (normal 120/80 millimeters of mercury, mm Hg), LPN C stated in the same nurses note that at approximately 1:00 AM R1's blood pressure was 108/65, his pulse was 112 bpm, and his pulse ox was 82 %. LPN C wrote she tried to sit R1 up, called out his name, but was not responding to verbal stimuli, R1 opened his eyes following a sternal rub. The same note indicated she called another nurse from the building for help. Medication error reports dated 11/07/23 at 9:43 PM indicated R1's medications were documented as administered, but were not administered: Midodrine (treatment for low blood pressure), Melatonin (sleep aid), Mucinex (expectorant) and Lotemax (steroid) eye drops. LPN C was contacted on 11/27/23 at 1:29 PM for an interview, but declined to be interviewed by this writer without her attorney present, as her employment was terminated by the facility. LPN D was interviewed on 11/28/23 at 11:10 AM, and stated on 11/07/23 at 1:20 AM, she was made aware of R1's change in condition; LPN C asked LPN D if she had ever cared for him and after LPN D assessed R1, she advised LPN C to call 911; then LPN C reported to her that she may have given R1 the wrong medication. LPN D stated that following the incident, the facility provided in- servicing education on medication error prevention. During an interview with Director of Nursing (DON) B on 11/28/23 at 10:00 AM, she stated nurses don't have assigned units and may work in any unit in the building. DON B stated on the night of 11/07/23, LPN C had worked on that unit before. As of 11/28/23, R1 had not readmitted to the facility. Change in status, identifying and communication, long-term care policy dated revised 8/21/23, indicated a change in a resident's baseline status must be identified and addressed. A resident was more likely to return to baseline status and avoid complications when a condition was recognized early and treated. Resident #5 (R5) On 11/27/23 at 3:20 PM, R5 was observed sitting up in bed in her room. R5 stated due to a medication error, she had to go to the ED on Thanksgiving Day. R5 stated she really didn't want to go to the ED, but it was probably best because at least she was monitored. R5 stated the nurse didn't know her medications, she had medications prescribed for a-fib, and it took the nurse 32 minutes for her nurse to arrive to help her after her request. Prior to Thanksgiving Day, R5 stated she was not provided her nebulizer treatment medication for 3 treatments, and had mucus build up. Situation, Background, Appearance, Review/Notify (SBAR) dated 11/23/23 at 9:00 AM and progress note summary dated 11/23/23 at 6:40 PM indicated R5's vital signs (VS) were generated from 11/22/23 at 8:29 PM (Blood Pressure 155/77, Pulse 80, Apical pulse 125, Respirations 18 per minute [normal respiration rate for an adult was 12 to 20 breaths per minute, and her Temperature was 97.9 degrees Fahrenheit). R5's VS were not documented at the time when R5 reported she was in a-fib. The same progress note indicated R5 was not taking an anticoagulant; in which was not correct. The same progress note summary indicated patient said that she was in a-fib because her med [medication] didn't come in until 4 am. which would have prevented it. The same summary indicated Primary Care Provider feedback recommendations was she said if she wanted to go to the hospital let her. There was no mention of chest pain. In review of R5's November 2023's MAR, Propafenone 425 mg, extended release, was to be administered at 9:00 AM and 9:00 PM. On 11/22/23 at 9:00 PM Propafenone was documented as 5, hold/see nurses notes; and was not administered on 11/23/23 at 4:30 AM when pharmacy delivered the medication. R5's nurse progress note dated 11/22/23 at 9:10 PM indicated medication was re-ordered several days ago and Pharmacy was notified. Pharmacy stated that the medication was coming from another State. The same note did not indicate R5's physician was notified. R5's November 2023 MAR revealed an as needed order for Propranolol 10 mg every day for treatment of a-fib; and was not documented as administered on 11/22/23. The same order did not include any pulse or blood pressure parameters when administering the medication. In review of R5's care plans, there was no care plan regarding atrial fibrillation or decreased cardiac output (amount of blood pumped by the heart per minute). Adult Emergency Services Evaluation Note revealed R5 arrived in the emergency roiagnom on [DATE] at 9:48 AM. The same note revealed R5 reported she was receiving nursing home care due to a recent lower leg fracture. The same emergency room note indicated R5 was taking the anticoagulant Eliquis for atrial flutter (upper chambers of the heart beat too quickly). R5 reported she was informed by the nurse they had run out of her Proprafenone and was not able to get her medication until the morning. In the morning on 11/23/23 she reported to the nurse she was in a-fib and needed her Proprafenone. The same note indicated there was a delay in getting the medication and she continued with a-fib. R5 called her husband at home and he called for an ambulance. Emergency Medical Services arrived at the facility and R5 converted to normal sinus rhythm (healthy rhythm). R5 continued to complain of chest pain that did not radiate. The same note indicated R5 stated prior to not receiving her medication, she felt at her baseline state of health. The same note indicated R5 had a cardiac workup and determined her chest pain was likely from her brief episode of A-fib with rapid ventricular response (RVR, ventricles beat too fast, if ventricles beat too fast, not enough blood is received and meet body's need for oxygenated blood). R5 returned to the nursing home. In review of R5's Vital Signs Summary, vital signs were only documented once on 11/23/23 at 8:00 PM, after R5 returned from the emergency department. During an interview with Licensed Practical Nurse (LPN) E on 11/28/23 at 11:31 AM, stated on 11/23/23 at 9:00 AM, the nurse assistant reported R5 needed medication, and R5 reported she was in a-fib. LPN E stated she was in the middle of caring for another resident on a different unit when the nurse assistant reported R5's request for medication. LPN E stated she did not recall how long it was before she was able to get to R5's room. LPN E stated she had not administered R5 morning medications that day, that she asked what medication R5 needed, administered Propafenone (antiarrhythmic, treat or prevent a-fib) that had been delivered from the pharmacy at 4:30 AM. LPN E stated the nurse assistant took R5's VS, her pulse was 145 and went down to 85. LPN E stated she did not listen to R5's heart or take an apical pulse (auscultated with a stethoscope over the heart that has the most accurate reading of the heart rate). LPN E stated R5 was assessed by the ambulance staff. In review of R5's physician order dated 11/25/23, Propranolol 10 mg was increased to every 12 hours; and under notes indicated to give if systolic (top number) blood pressure was 100 or greater. The parameters were not transferred to R5's MAR. In review of R5's November 2023 MAR, Perforomist Inhalation Nebulization Solution was ordered to be administered via nebulizer two times a day for COPD, and was not administered on 11/21/23 at 9:00 AM and on 11/21 at 5:00 PM. Nurse progress notes dated 11/21/23 at 9:06 AM and 5:07 PM indicated Perforomist was re-ordered, and awaiting from pharmacy. The same notes did not indicate the physician was notified or a respiratory assessment was completed at 9:00 AM and 5:00 PM. DON B was interviewed on 11/28/23 at 2:00 PM and stated an assessment for a-fib would include listening to the heart and lungs. DON B stated she would have to look into why instructions (give when systolic blood pressure was 100 or greater) for Propranlol were not transferred to the MAR. DON B stated Medication Error reports were not generated for omission errors related to pharmacy not delivering medications timely.

This citation pertains to intakes MI00140976, MI00140959 & MI00141121. Based on interview and record review, the facility failed to prevent significant medication errors in 6 of 7 residents reviewed for medication errors (Resident #1, #3, #4, #5, #6, and #7), resulting in a transfer to the hospital for assessment and treatment (Resident #1 & #5), and the potential for a change in condition (Resident #3, #4, #6, and #7). Findings include: Resident #1 (R1) R1's electronic medical record (EMR) revealed he admitted to the nursing home on 8/15/23; had the diagnoses of Chronic Obstructive Pulmonary Disease (COPD, lung disease) and heart failure. R1's EMR indicated he had transferred to the hospital 4 times since he admitted to the facility. R1's most recent re-admission was 10/23/23. R1's Care Plan dated 8/18/23, revealed he planned to return to the community after rehabilitation, to live with his daughter and grandchildren. R1's goal was to demonstrate correct administration of medications, treatments, and activities of daily living (ADL) to the level needed for a safe return to the community. R1's Oxygen Saturation Summary report indicated R1's pulse oximetry (oxygen in bloodstream) on 11/07/23 at 4:18 PM was 93 percent (%, normal 95 to 100%) with oxygen and his pulse (normal pulse 60-100 beats per minute at rest) was 100 beats per minute (bpm). Medication Error Report dated 11/07/23, and written statement signed by Licensed Practical Nurse (LPN) C; revealed LPN C set-up medications in medication cups for two residents at the same time. LPN C marked each cup with the resident's room numbers, room [ROOM NUMBER] and room [ROOM NUMBER]. On 11/07/23 at around 9:20 PM, R1 received medications intended for the resident that was in room [ROOM NUMBER]. LPN C explained in her statement, that when she attempted to administer medications to the resident in room [ROOM NUMBER], the resident dumped the medications on the bed and reported they were not his medications. In LPN C's statement, she wrote she saw the medication cup that she had labeled room [ROOM NUMBER], and realized she had administered medications to R1 that were not prescribed to him and had resulted in a serious medication error. Medication Error Report dated 11/07/23 at 9:20 PM, revealed the wrong medication was administered to the wrong resident that included: Oxycontin (opioid pain medication) Extended Release 80 milligrams (mg), Tizanidine (muscle relaxant) 2 mg, and Acetaminophen 1,000 mg. The same report indicated the reason for the error was failure to identify resident. LPN C indicated in her statement that she was scared and checked on R1 every 20 to 30 minutes. The same statement indicated on 11/08/23 at 1:00 AM, R1's oxygen saturation level was 80 % with 2 liters of oxygen provided via a nasal canula. R1 was not responding to stimuli. LPN C's statement went on to indicate she called another nurse to assist her. A call to 911 was placed and R1's physician was notified. R1's physician ordered Narcan (medication used to treat narcotic overdose) to be administered. Per Medication Error Report dated 11/07/23, R1 was transferred to the emergency department (ED) for evaluation and treatment. Nurses note created on 11/08/23 at 11:47 AM indicated effective date was 11/08/23 at 2:00 AM revealed at approximately 9:43 PM medication was provided to R1; at approximately 9:50 PM, LPN C realized that a medication error had occurred. LPN's statement indicated she started assessing R1 every 30 minutes; at about 10:30 PM R1's blood pressure was low, 98/65 (normal 120/80 millimeters of mercury, mm Hg), LPN C stated in the same nurses note that at approximately 1:00 AM R1's blood pressure was 108/65, his pulse was 112 bpm, and his pulse ox was 82 %. LPN C wrote she tried to sit R1 up, called out his name, but was not responding to verbal stimuli, R1 opened his eyes following a sternal rub. The same note indicated she called another nurse from the building for help. LPN C was contacted on 11/27/23 at 1:29 PM for an interview, but declined to be interviewed by this writer without her attorney present, as her employment was terminated by the facility. LPN D was interviewed on 11/28/23 at 11:10 AM, and stated on 11/07/23 at 1:20 AM, she was made aware of R1's change in condition; LPN C asked LPN D if she had ever cared for him and after LPN D assessed R1, she advised LPN C to call 911; then LPN C reported to her that she may have given R1 the wrong medication. LPN D stated that following the incident, the facility provided in- servicing education on medication error prevention. During an interview with Director of Nursing (DON) B on 11/28/23 at 10:00 AM, she stated nurses don't have assigned units and may work in any unit in the building. DON B stated on the night of 11/07/23, LPN C had worked on that unit before. DON B stated LPN C had not given a reason why she set-up medications for 2 residents. DON B stated after the medication error incident, all nurses received education and a past non-compliance process was implemented with a compliance date of 11/10/23. DON B stated no nurses worked after 11/10/23 without receiving education. As of 11/28/23, R1 had not readmitted to the facility. Resident #3 (R3) R3's Minimum Data Set (MDS) assessment dated [DATE] revealed she was admitted to the facility on [DATE] and had a BIMS score of 13 (13-15 Cognitively Intact). Discharge Summary with hospital stay dated 10/31/23 to 11/12/23, revealed R3 was hospitalized for heart failure. The same record indicated she had the diagnoses of diabetes, atrial fibrillation (a-fib; irregular, often rapid heart rate that could cause poor blood flow, increased risk of a stroke, and risk of blood clots in the heart). Medication Error Report dated 11/13/23 revealed a medication error occurred on 11/12/23 at 5:00 PM. Amiodarone (used to treat heart rhythm disorders) 200 mg, was scheduled to be started on 11/15/23; the order was transcribed incorrectly and should have been started on 11/13/23. Medication Error Report dated 11/13/23 revealed a medication error on 11/12/23 at 5:51 PM: Lispro Insulin 200 units/ml (short acting insulin used to treat diabetes), 2 units was administered and should have been of 2 units of Lispro Insulin 100 units/ml that was administered. Resident #4 (R4) Physician Progress Note dated 11/24/23 at 9:00 AM revealed R4 was a [AGE] year-old woman that had past medical history of back surgery, lung cancer, depression, anxiety, heart failure, lung disease, and high blood pressure. Prior to admission at the nursing home, she was seen in the ED for right ankle and knee following a fall. She was found to have a fracture of her right ankle and underwent surgery. R4 was non-weight bearing on her right leg, and had a splint and knee brace. The same note indicated R4 had the capacity for individual decision making. R4's goals of care included more complete pain management and improved level of function. Medication Error Report dated 11/27/23, revealed a medication error occurred on 11/24/23 at 9:00 PM. R4 received Oxycodone (immediate-release opioid) 10 milligrams (mg) instead of Oxycodone Extended Release (ER, prescribed for opioid-tolerant residents). R4's Medication Administration Record (MAR) dated 11/24/23 at 9:00 PM, revealed R4's pain level, on a 0 to 10 scale, with 0 being no pain, and 10 being the worse pain imaginable; was documented as 5. Mayo Clinic website at https://mayoclinic.org indicated oxycodone extended-release tablets work differently from the regular oxycodone tablets, even at the same dose. Resident #5 (R5) On 11/27/23 at 3:20 PM, R5 was observed sitting up in bed in her room. R5 stated due to a medication error, she had to go to the ED on Thanksgiving Day. R5 stated she really didn't want to go to the ED, but it was probably best because at least she was monitored. R5 stated the nurse didn't know her medications, she had medications prescribed for a-fib, and it took the nurse 32 minutes for her nurse to arrive to help her after her request. Prior to Thanksgiving Day, R5 stated she was not provided her nebulizer treatment medication for 3 treatments, and had mucus build up. Situation, Background, Appearance, Review/Notify (SBAR) dated 11/23/23 at 9:00 AM and progress note summary dated 11/23/23 at 6:40 PM indicated R5's vital signs (VS) were generated from 11/22/23 at 8:29 PM (Blood Pressure 155/77, Pulse 80, Apical pulse 125, Respirations 18 per minute [normal respiration rate for an adult was 12 to 20 breaths per minute, and her Temperature was 97.9 degrees Fahrenheit). R5's VS were not documented at the time when R5 reported she was in a-fib. The same progress note indicated R5 was not taking an anticoagulant; in which was not correct. The same progress note summary indicated patient said that she was in a-fib because her med [medication] didn't come in until 4 am. which would have prevented it. The same summary indicated Primary Care Provider feedback recommendations was she said if she wanted to go to the hospital let her. There was no mention of chest pain. In review of R5's November 2023's MAR, Propafenone 425 mg, extended release, was to be administered at 9:00 AM and 9:00 PM. On 11/22/23 at 9:00 PM Propafenone was documented as 5, hold/see nurses notes; and was not administered on 11/23/23 at 4:30 AM when pharmacy delivered the medication. R5's nurse progress note dated 11/22/23 at 9:10 PM indicated medication was re-ordered several days ago and Pharmacy was notified. Pharmacy stated that the medication was coming from another State. The same note did not indicate R5's physician was notified. R5's November 2023 MAR revealed an as needed order for Propranolol 10 mg every day for treatment of a-fib; and was not documented as administered on 11/22/23. The same order did not include any pulse or blood pressure parameters when administering the medication. In review of R5's care plans, there was no care plan regarding atrial fibrillation or decreased cardiac output (amount of blood pumped by the heart per minute). Adult Emergency Services Evaluation Note revealed R5 arrived in the emergency roiagnom on [DATE] at 9:48 AM. The same note revealed R5 reported she was receiving nursing home care due to a recent lower leg fracture. The same emergency room note indicated R5 was taking the anticoagulant Eliquis for atrial flutter (upper chambers of the heart beat too quickly). R5 reported she was informed by the nurse they had run out of her Proprafenone and was not able to get her medication until the morning. In the morning on 11/23/23 she reported to the nurse she was in a-fib and needed her Proprafenone. The same note indicated there was a delay in getting the medication and she continued with a-fib. R5 called her husband at home and he called for an ambulance. Emergency Medical Services arrived at the facility and R5 converted to normal sinus rhythm (healthy rhythm). R5 continued to complain of chest pain that did not radiate. The same note indicated R5 stated prior to not receiving her medication, she felt at her baseline state of health. The same note indicated R5 had a cardiac workup and determined her chest pain was likely from her brief episode of A-fib with rapid ventricular response (RVR, ventricles beat too fast, if ventricles beat too fast, not enough blood is received and meet body's need for oxygenated blood). R5 returned to the nursing home. In review of R5's Vital Signs Summary, vital signs were only documented once on 11/23/23 at 8:00 PM, after R5 returned from the emergency department. During an interview with Licensed Practical Nurse (LPN) E on 11/28/23 at 11:31 AM, stated on 11/23/23 at 9:00 AM, the nurse assistant reported R5 needed medication, and R5 reported she was in a-fib. LPN E stated she was in the middle of caring for another resident on a different unit when the nurse assistant reported R5's request for medication. LPN E stated she did not recall how long it was before she was able to get to R5's room. LPN E stated she had not administered R5 morning medications that day, that she asked what medication R5 needed, administered Propafenone (antiarrhythmic, treat or prevent a-fib) that had been delivered from the pharmacy at 4:30 AM. LPN E stated the nurse assistant took R5's VS, her pulse was 145 and went down to 85. LPN E stated she did not listen to R5's heart or take an apical pulse (auscultated with a stethoscope over the heart that has the most accurate reading of the heart rate). LPN E stated R5 was assessed by the ambulance staff. In review of R5's physician order dated 11/25/23, Propranolol 10 mg was increased to every 12 hours; and under notes indicated to give if systolic (top number) blood pressure was 100 or greater. The parameters were not transferred to R5's MAR. In review of R5's November 2023 MAR, Perforomist Inhalation Nebulization Solution was ordered to be administered via nebulizer two times a day for COPD, and was not administered on 11/21/23 at 9:00 AM and on 11/21 at 5:00 PM. Nurse progress notes dated 11/21/23 at 9:06 AM and 5:07 PM indicated Perforomist was re-ordered, and awaiting from pharmacy. The same notes did not indicate the physician was notified or a respiratory assessment was completed at 9:00 AM and 5:00 PM. DON B was interviewed on 11/28/23 at 2:00 PM and stated an assessment for a-fib would include listening to the heart and lungs. DON B stated she would have to look into why instructions (give when systolic blood pressure was 100 or greater) for Propranlol were not transferred to the MAR. DON B stated Medication Error reports were not generated for omission errors related to pharmacy not delivering medications timely. Resident #6 (R6) R6's Discharge Summary with discharge date of [DATE], revealed she was hospitalized due to a neck fracture and had a diagnosis of diabetes. Metformin (diabetes medication) 500 mg extended release (XR), 1000 mg was to be administered twice daily. In review of R6's November 2023 MAR, Metformin was transcribed as Metformin 500 mg immediate release (IR), give 2 tabs (1000 mg) twice a day. Nurse Practitioner progress note dated 11/16/23 at 12:37 PM revealed R6 reported she was taking Metformin 500 mg twice a day; and hospital records confirmed that she was transitioned over to 500 mg XR twice a day and would update the order on the same day. No medication error report was generated. In review of R6's November 2023 MAR, Metformin was changed on 11/16/23 to Metformin XR 500 mg, one tab, twice a day. During an interview with DON B on 11/28/23 at 2:25 PM, she stated she would clarify R6's Metformin dosage and release type with the nurse practitioner. Following the above interview, DON B presented a Medication Error Report for R6, dated 11/28/23, that indicated a transcription medication error occurred beginning on 11/14/23. Metformin 500 mg XR, 2 tablets were to be administered twice a day; and was transcribed as Metformin 500 mg IR, 2 tablets twice a day. The same report indicated measures taken to prevent the re-occurrence of similar errors included re-read orders. Resident #7 (R7) Hospital Discharge Summary dated 11/22/23 revealed R7 had been hospitalized for 12 days following oral cavity surgery due to cancer. R7's had other diagnoses including diabetes. Discharge instructions indicated Trulicity 0.75 mg/0.5 milliliters (ml) insulin pen and 0.75 mg were to be administered every Monday, per her usual schedule. In review of R7's November 2023 MAR on 11/28/23 at 2:00 PM, Trulicity was to be administered on Monday 11/27/23 at 9:00 AM, 5 days after admission to the nursing home. The nurse documented Trulicity was held/see nurses notes. DON B was interviewed on 11/28/23 at 3:50 PM and stated R7's Trulicity medication came in from pharmacy Monday night, but still had not been administered. DON B stated the nurse was re-educated. Medication Administration Policy, date of last revision was 10/17/23 indicated to begin a new medication order timely. Begin routine orders on the same day ordered, unless the next dose would normally be given the next day. Verify the medication label against the Medication Administration Record (MAR) for resident name, time, drug, dose and route. Prepare medications immediately prior to administration. The same policy indicated if applicable and/or prescribed, take vital signs prior to administration of the dose; for example, pulse with digitalis, blood pressure with anti-hypertensive medication, etcetera (etc.). Administer medications within 60 minutes of the scheduled time to be considered timely.

Based on interview and record review, the facility failed to ensure cardiopulmonary resuscitation (CPR) was performed timely by competent staff and according to standards of practice for one (Resident #60) of one reviewed for death, resulting in delayed CPR and the potential for ineffective CPR efforts and death. Findings include: Review of the medical record reflected Resident #60 (R60) was admitted to the facility on [DATE], with diagnoses that included unspecified severe protein-calorie malnutrition, atherosclerosis of coronary artery bypass graft(s) without angina pectoris, hypertension (high blood pressure), kidney transplant status, malignant neoplasm of kidney (except renal pelvis) and acute kidney failure. The Minimum Data Set (MDS) history reflected R60 died in the facility on [DATE]. Review of the medical record reflected R60 was a full code (full resuscitation and life sustaining treatment). The Miscellaneous tab of the Electronic Medical Record (EMR) reflected the code status document was effective [DATE] and was uploaded to the medical record on [DATE]. A Progress Note for [DATE] at 11:16 AM reflected, .CNA [Certified Nurse Aide] Trainee was changing resident, resident told trainee that she had difficulty breathing and as resident was on her side she rolled out of bed on to [sic] the floor. trainee [sic] aid came and notified nurse that resident fell to the floor and was non responsive, code blue was called at 10:56a [AM], paramedics was [sic] called at was called [sic] at 10:56a, compressions started at 11:00a, paramedics arrived @ [at] 11:05a took over cpr . A Progress Note for [DATE] at 11:55 AM reflected, .Paramedics called time of death at 11:40 . A Post Fall Evaluation for a fall date of [DATE] at 10:56 AM reflected R60 had a witnessed fall to the floor, while Certified Nurse Aide (CNA) Z was present, providing incontinence care.What did the guest/resident say they were trying to do just before they fell ? reflected, Breathe. According to the Evaluation, R60 lost consciousness and became non-responsive. She was lying parallel to the bed, on her right side, with her face towards the wall. The section for re-enactment of the fall reflected that during incontinence care, the CNA rolled R60 onto her side to tuck her brief. R60 stated, I can't breathe, lost consciousness and rolled out of the bed, onto the floor. Code blue (cardiac/respiratory arrest) was called, and Emergency Medical Services (EMS) were called. An Incident Report for a fall on [DATE] at 11:16 AM reflected R60 was lying on her right side, on the floor, next to the bed. Bloody saliva was noted, and R60 was having difficulty breathing. The immediate action taken reflected, Attempted to clear airway, 911 called, CPR started. During a phone interview on [DATE] at 08:55 AM, CNA Z reported she only cared for R60 that day ([DATE]). CNA Z described that as she was changing R60 and doing a complete bed change, it seemed to her like R60 went into cardiac arrest. CNA Z then reported she did not know for sure, as she was not a nurse. CNA Z described that R60 launched onto the floor. CNA Z stated she wanted to say R60 landed on her side or maybe even on her face. She looked at R60, then ran to get the nurse immediately. CNA Z reported the incident to Licensed Practical Nurse (LPN) O. According to CNA Z, all the nurses in the facility responded, and 911 was called. After that, R60's vital signs were being checked, she was being assessed, and CNA Z went to call 911. The crash cart and suction were brought to the room, and maybe even the defibrillator, according to CNA Z. During an interview on [DATE] at 10:50 AM, LPN O reported nurses had to have their CPR up to date. Regarding R60, LPN O stated it was reported to her that between 10:00 AM and 11:00 AM, the CNA was providing pericare, cleaning R60, turned R60 on her side and was putting on her brief. R60 told the CNA she could not breathe, then went limp and went out of the bed. When LPN O responded to the room, R60 was non-responsive, lying on her side and still had a pulse and was still breathing. LPN O could see that it was difficult for R60, as she was using accessory muscles when breathing. LPN O called for another nurse and called a code. LPN O reported that she turned R60 over, and there was bloody saliva in her mouth, which she had tried to clear. 911 was called, and they were doing compressions when EMS arrived. LPN O reported it was difficult to bag R60 (provide breaths via an ambu bag), and stated, it was fighting. When LPN O responded to R60's room, she had to change R60's position, check her head and check for a pulse. R60 did not have any muscle tone. Except for bloody saliva, LPN O did not see any visible injuries to R60. She then stated it could have been bloody mucus that she saw. R60 was kind of rolled back on her side in attempt to clear her until they rolled R60 to her back to begin chest compressions. When asked how much time had passed until they had to perform chest compressions, LPN O stated maybe two minutes. (According to the Progress Note for [DATE] at 11:16 AM, code blue (cardiac/respiratory arrest) was called at 10:56 AM, and chest compressions began at 11:00 AM) LPN O reported R60 was still breathing and still had a pulse for that time (two minutes). She stated it looked like R60 wasn't getting anything. LPN O described that R60 was placed on her back, and after about 30 to 40 chest compressions, they tried to use the ambu bag (to deliver breaths). LPN O reported they kind of kept that pattern until they were tired and switched (with another nurse). She stated Registered Nurse (RN) DD took over, then LPN H was performing CPR when EMS arrived. LPN O reported the automated external defibrillator (AED) was also placed on R60, which had a beeping mechanism to keep pace (for CPR). LPN O reported a shock was not advised by the AED. LPN O was unable to report a ratio for chest compressions and breaths, reporting the number was escaping her. When asked if they were doing CPR according to a ratio (of compressions to breaths), LPN O reported they were doing it with an AED. During a phone interview on [DATE] at 11:55 AM, LPN O reported that in the moment (of R60's code), she relied on the AED for timing and count (for CPR). She stated she would not say there were exactly 30 compressions. According to American Heart Association CPR & First Aid Emergency Cardiovascular Care, .How is CPR Performed? There are two commonly known versions of CPR: 1. For healthcare providers and those trained: conventional CPR using chest compressions and mouth-to-mouth breathing at a ratio of 30:2 compressions-to-breaths . (https://cpr.heart.org/en/resources/what-is-cpr) During a phone interview on [DATE] at 02:03 PM, RN DD stated a new CNA reported they were needed in a patient room. When she responded to the room, R60 was on the floor. The crash cart was already there. RN DD reported R60 was taking her last breaths when she walked in the room, and she had pinkish stuff coming out of her mouth. RN DD reported there were a bunch of people in the room. RN DD denied that she assisted in the code (CPR) for R60. She was going to but was hit in the head, so she ran to the phone to call 911. RN DD reported she placed the backboard beneath R60, and LPN H and LPN O started CPR. She denied being present for CPR but reported CPR was to be administered with 30 chest compressions and two breaths. She reported the AED had been applied, and chest compressions were being delivered. There was no shock advised by the AED. RN DD reported they were required to have CPR certification. During an interview on [DATE] at 02:49 PM, LPN H reported there was an in-service on CPR a month or two prior, as well as the crash cart and everything in it. She reported CPR certification was required for her job and was to be renewed every two years. LPN H described the process for CPR was to tilt the chin and give three breaths. She then stated first, the AED pads were to be applied. She stated they were to listen for when to do breaths, and when it (AED) said to do chest compressions, they used the beat for 30 seconds, then they repeat. LPN H reported each round of CPR was to be delivered by 30 chest compressions and three breaths. LPN H reported she recently assisted in a code for a resident. The resident (R60) was on the floor, and the crash cart was in the room. She reported she just got down and started doing compressions. She stated LPN O gave three breaths with the ambu bag, and she started doing compressions until they got the AED on. Once the AED was on, they followed the prompts. She reported alternating CPR with LPN O until EMS arrived. LPN H reported R60 was not breathing and did not have a pulse when she arrived to the room. LPN H reported they could tell the breaths were not going in, like the air was splattering out when trying to get air in (give breaths). LPN H stated they did not see R60's chest expand (when breaths were delivered). She stated you could tell R60's airway was closed. LPN H reported the mask for the ambu bag was on properly and had a good fit. When asked if R60 was on oxygen, LPN H could not recall. On [DATE] at 5:23 PM, an email was sent to Nursing Home Administrator (NHA) A, requesting the most recent CPR certifications for all licensed nurses that were on duty on [DATE]. An email was received from NHA A on [DATE] at 6:12 PM, with CPR cards for licensed nurses, in response to the survey request. LPN H's Basic Life Support (BLS) Provider (CPR and AED) certificate was issued [DATE] and was to be renewed by ,d+[DATE] (certificate was expired). An email was received from NHA A on [DATE] at 8:47 AM with an updated BLS card for LPN H, with an issue date of [DATE]. During a phone interview on [DATE] at 12:10 PM, LPN H reported having CPR training the prior Thursday ([DATE]). She stated her CPR certification had been expired. LPN H described CPR administration and reported they would watch for the chest to rise to see if the patient was receiving the breaths. If it appeared the breaths were not being delivered, LPN H reported she did not know what she would do and stated she would just continue with CPR until EMS arrived. According to the American Red Cross CPR Steps, .Giving CPR .Give 30 chest compressions .Give 2 breaths .Open the airway to a past-neutral position using the head-tilt/chin-lift technique .Ensure each breath lasts about 1 second and makes the chest rise; allow air to exit before giving the next breath Note: If the 1st breath does not cause the chest to rise, retilt the head and ensure a proper seal before giving the 2nd breath If the 2nd breath does not make the chest rise, an object may be blocking the airway .Continue giving sets of 30 chest compressions and 2 breaths. Use an AED as soon as one is available! . (https://www.redcross.org/take-a-class/cpr/performing-cpr/cpr-steps) During an interview on [DATE] at 01:32 PM, Director of Nursing (DON) B reported that other than speaking to LPN O on the phone the day of R60's code, there had been no discussion with the CPR process (for R60). When they met the prior Thursday ([DATE]), it was identified that some of their practices were incorrect (nurses involved in R60's code). DON B conveyed that the answers the nurses provided to the State Agency were incorrect, but they could not necessarily say they were wrong for the code. When queried on what had been identified as incorrect, DON B stated that when speaking to LPN O, she mentioned being asked about the compression ratio, and she was unaware. LPN H said breaths came before compressions. DON B acknowledged that LPN H had not been current on her CPR certification.

This citation pertains to intake M100134151 Based on observation, interview, and record review, the facility failed to monitor for ongoing/worsening bruising, inflammation, and monitor/treat pain timely; complete physician notification and additional testing for 1 (Resident # 8) of 17 sampled residents reviewed for quality of care resulting in delayed identification and treatment of a fractured femur, and increased pain. Findings include: Resident # 8 (R8) initially admitted to facility 8/4/2021 with most recent facility readmission 1/11/23 with diagnoses including COVID-19, unspecified fracture of left femur, muscle weakness, unspecified atrial fibrillation, embolism and thrombosis of arteries of the upper extremities, and cognitive communication deficit. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/17/23 revealed that R8 had unclear speech, was usually understood and understands, and that a Brief Interview for Mental Status was not conducted. Staff assessment for mental status revealed short and long-term memory impairment and severely impaired cognitive skills for daily decision making. Section G of MDS revealed that R8 required two-person extensive assistance with bed mobility, personal hygiene, and toilet use; two-person total dependence with transfers; one-person extensive assistance with dressing; and set up assistance with eating. Review of the Discharge MDS dated [DATE], revealed that R8 had an unplanned discharge to an acute care hospital and that her return to the facility was anticipated. On 1/31/23 at 1:21 PM, R8 was observed sitting in wheelchair with meal tray positioned in front of her on over the bed table. R8 was dressed in personal clothing, well-groomed, and was noted to have consumed lunch meal with exception of rice. R8 denied pain right now but stated I have pain in my legs at which time resident was noted to point at left leg and began to rub left thigh with left hand. Irregular shaped fading purple bruise noted to dorsal left hand with R8 acknowledging stating they took my blood there. R8 recalled recent hospitalization for my left leg pain but denied injury or surgery to extremity. Review of R8's medical record complete with the following findings noted: Nurses Note dated 12/27/2022 at 1:47 PM, stated Writer informed Dr. (Doctor) of bruising and warmth to left upper thigh area. Patient denies pain/discomfort at this time. Dr. ordered venous ultrasound to LLE (left lower extremity) STAT (immediately) . No further assessment information noted within chart regarding size and color of bruise or range of motion of left lower extremity at time of identification with no additional entries on 12/27/2022 reflecting resident status or presentation of left lower extremity. Nurses Note dated 12/28/2022 at 8:33 AM, stated Pt (patient) tested positive for covid 12/28/22. MD (Medical Doctor) notified and family member notified. Upon assessing pt and obtaining vital signs pt had a non productive cough and temp (temperature) . No documentation contained within note regarding assessment of left lower extremity. Venous Doppler with 12/28/22 1:05 PM examination date and 12/28/22 5:27 PM reported date, indicated CONCLUSION: No evidence of deep venous thrombosis in the left lower extremity. No Nurses Note entry noted to be placed on 12/29/22. Nurses Note dated 12/30/2022 4:33 PM, stated Message left for (name of family) to call facility. Call was placed to inform of patient's refusal to get out of bed today. Patient stated she would get out of bed tomorrow. No documentation contained within note regarding assessment of left lower extremity. Nurses Note dated 12/30/2022 at 11:03 PM, stated writer spoke to Dr. about hematoma/bruise left posterior leg and pain 1st reported on 12/27 continues to bother patient. He ordered to discontinue Eliquis. No additional documentation contained within note regarding characteristics (size and color) of the hematoma/bruise to left leg, range of motion assessment to extremity, or pain assessment. Skin/Wound Progress Note dated 1/2/2023 at 4:17 PM, stated Cena (Certified Nurse Aide) (name of staff) raised concern over swelling and diffuse stages of bruising noted to lle (left lower extremity), vascular studies done and results negative for DVT (Deep Vein Thrombosis). Reassurance given to res. (resident) test results are negative. No additional documentation contained within note regarding characteristics (size and color) of the hematoma/bruise to left leg, range of motion assessment to extremity, or pain assessment. Physician Note dated 1/4/2023 at 8:55 AM, stated .History of present illness: Currently lying in bed and complains of left leg/thigh pain. Left thigh is swollen and also painful to move .ASSESSMENT AND PLAN Left thigh pain and swelling. No reported trauma. Could be spontaneous hematoma. Eliquis is on hold. Considering worsening pain, will send her to hospital for further evaluation . Nurses Note dated 1/4/2023 at 9:45 AM, stated MD (Medical Doctor) notified of increased discoloration to LLE. Pt (patient) not currently on Eliquis. MD examined pt. Per MD: send pt to hospital for evaluation and tx (treatment) of spontaneous hematoma without trauma. Review of notes titled Skilled Care Note - COVID - 19 dated 12/29/22, 12/30/22, 12/31/22, 1/2/23, 1/3/23, and 1/4/23 reflected no documentation which pertained to the assessment or monitoring of left lower extremity, range of motion, pain, or size and shape of the bruising. Hospital History and Physical dated 1/4/2023 indicated Pt (patient) has bruising (yellowish-purple) to left lateral calf with knee swelling .Pt complaining of pain to area, unknown if injury occurred as pt cannot give detailed description. CT (computerized tomography) scan results contained within same document reflected MUSCULOSKELETAL FINDINGS: There is a spiral fracture of the mid left femoral diaphysis. There is approximately three cm (centimeters) of medial displacement of the distal fracture fragment . Review of Medication Administration Record (MAR) dated 12/1/2022-12/31/2022 and 1/2/2023-1/31/2023 complete with an as needed dose of oxycodone (a strong opioid used medically for treatment of moderate to severe pain) noted to be administered x 1 on 12/1, 12/2, 12/5, 12/6, 12/7, 12/9, 12/11, 12/12, 12/16, 12/19, 12/21, 12/22, 12/24, 12/25, 12/27 with an increase frequency of administration noted to start on 12/30/22 as an as needed dose of oxycodone noted to be administered x 3 on 12/30, x 1 on 12/31, x 2 on 1/1/23, x 2 on 1/2/23, x 3 on 1/3/23 and x 1 on 1/4/23 prior to R8's hospital transfer. Comprehensive review of R8's medical record reflected that left thigh alteration identified on 12/27/2022 with physician notification on same date with no follow up assessment, documentation, or physician notification of left lower extremity status until 12/30/22, despite completion of negative left lower extremity venous doppler on 1/28/22, at which time physician order received for discontinuation of Eliquis. Further review reflected no documented assessment of left lower extremity status on 12/31/22, 1/1/23, and 1/3/23 with documentation contained within 1/2/23 Skin/Wound Progress Note indicating swelling and diffuse stages of bruising noted to lle (left lower extremity) with no follow-up physician notification despite reported ongoing pain with increased frequency of as needed oxycodone usage. Furthermore, no physician assessment complete from the time the alteration was initially identified on 12/27/22 until 1/4/23 at which time R8 was transferred to the emergency room with CT indicative of spiral fracture of the mid left femoral diaphysis. In a telephone interview on 2/06/23 at 9:33 AM, Licensed Practical Nurse (LPN) T stated that from what she could recall, R8 was transferred to the second floor on 12/27/22 as prior roommate had tested positive for COVID. LPN T stated that upon R8's arrival to unit, was notified by assigned CNA that R8's left thigh was swollen. Per LPN T, upon completion of assessment, noted swelling to left thigh and a bruise to middle aspect of left inner thigh which presented yellowish/blue to purple in color, irregular shaped and that area was inflamed and warm to touch. LPN T stated that R8 denied pain, known injury or fall and upon physician notification of leg presentation received orders for doppler of left lower extremity and labs. LPN T stated that her assessment led her to believe alteration was vascular in nature, denied that assessment included movement or range of motion of the left lower extremity, and did not even consider the need for an x ray. LPN T stated that she had not received report regarding any concerns to R8's left lower extremity and that to her knowledge, was the first to identify this change in status. In a telephone interview on 2/6/23 at 9:35 AM, nurses note dated 12/28/22 8:33 AM reviewed with LPN W with LPN acknowledging completion. LPN W stated that she worked part time at the facility and floated throughout the building but from what she could recall, did not receive anything in shift report regarding acute changes in R8's status involving her left lower extremity. LPN W further stated that, from what she could recall, a respiratory assessment was complete based on R8's symptoms and that she tested positive for COVID. Per LPN W, a skin assessment or a head-to-toe assessment was not completed and she did not recall the CNA reporting that R8 had any pain or skin alterations. LPN W stated, whatever assessment I did, was what was documented. In an interview on 2/02/23 at 2:30 PM, LPN G stated that she was a Unit Manager and therefore assisted in the oversight of all residents in the building. LPN G confirmed that on 12/30/22 she had worked as a nurse on the floor and was the nurse assigned to R8 from 7:00 AM to 7:30 PM. LPN G reviewed the 12/30/22 4:33 PM nurses note entry that she had completed regarding R8's refusal to get out of bed but stated that she did not complete a resident assessment or assess left lower extremity on the 12/30/22 shift. LPN G stated that she was unaware that R8 had concerns with her left leg or that a doppler had been completed previously as did not receive this information in shift report. LPN G stated that assigned CNA did not report any concerns regarding pain or alterations in skin status on 12/30/22 but noted that at 1:17 PM she had administered an as needed dose of oxycodone for indication of leg pain but did not recall specific location of reported pain. LPN G further stated that R8 may have had tearful episodes during the shift and that these were indications of pain for her. In a telephone interview on 2/02/23 at 12:09 PM, LPN I confirmed familiarity with R8 and that she was the assigned nurse on 1/2/23 and 1/3/23 from 7:00 AM to 7:30 PM. LPN I stated that she was informed in shift report from prior nurse on both dates that R8 was experiencing ongoing pain despite negative doppler results. LPN I also stated that assigned CNA, on both dates, had informed her of R8's ongoing pain, most notably with movement of left leg. LPN I stated that she witnessed R8 to be crying out in pain and that as needed oxycodone had been administered on both dates for a pain level as high as 9. LPN U stated that as R8 was in an even numbered room (132), routine COVID assessment/documentation was assigned to night shift and therefore she did not complete. Although LPN U acknowledged resident to be in distress, denied completion of any resident assessment including that of the left lower extremity. LPN U stated that she tried to contact physician via phone once on 1/3/23 without success and that no follow up attempt was complete. In an interview on 2/02/23 at 3:12 PM, Certified Nurse Aide (CNA) Q confirmed familiarity with R8 and stated that had frequently been assigned to her for the approximate 4-5 months that had been employed at facility. CNA Q stated that sometime after Christmas (was unable to provide a more specific time frame), R8 was noted to require more assist with incontinency care and bed mobility as would cry out in pain with movement of the left leg. CNA Q also stated that he noted a small purple bruise (which he estimated to be about the size of a quarter) at the middle of the inner thigh region and that he reported both the increase in pain and the bruise to Licensed Practical Nurse (LPN) U. CNA Q further stated that upon the start of shift on 1/2/23, as R8 was still painful and crying out when care was provided, was concerned and informed Registered Nurse (RN) S. CNA Q stated that RN S assisted with incontinency care and repositioning of R8 and that he noted ongoing bruising to left thigh region now, from what he could recall, presented as a small area of yellow/purple fading discoloration about the same quarter size. In a telephone interview on 2/06/23 at 8:45 AM, LPN U confirmed familiarity with R8 and that she was the assigned nurse on 12/29/22, 12/30/23, 1/2/23, and 1/3/23 from 7:00 PM to 7:30 AM. LPN U stated that on 12/29/22 she did not receive information in shift report regarding concerns with R8's left lower extremity or that a doppler had recently been complete. Per LPN U, a focused COVID assessment was complete that included a respiratory assessment but that an assessment of R8's left lower extremity was not completed as stated that she did not assist the assigned CNA with resident care that night and received no concerns from the CNA regarding pain or skin presentation. During same interview, LPN U stated that 12/30/22 shift report did not include any concerns with R8's left lower extremity, but that CNA Q notified her of discoloration and pain to left upper leg. Nurses Note dated 12/30/22 at 11:03 PM reviewed with LPN U which included writer spoke to Dr. about hematoma/bruise left posterior leg and pain 1st reported on 12/27 continues to bother patient . with LPN confirming to have completed. Per LPN U, upon notification of alteration by CNA, assessment complete with approximate half dollar size red and purple hematoma noted at posterior left upper thigh region. LPN U denied inflammation at site and to surrounding area stating that surrounding skin was within normal limits. Per LPN U, range of motion was not attempted as was using caution as R8 was not able to move extremity without being in pain. Per LPN U, R8 was noted to have moderate to severe pain in left lower extremity and as R8 had an existing order for as needed oxycodone, administered a dose, which LPN U stated was unusual as R8 had not been previously noted to require oxycodone for pain management on the night shifts that she had worked. LPN U stated that she proceeded to review R8's medical record, noted that the alteration was first identified 12/27/22 and that the dopplers were negative. LPN U stated that upon physician notification of the hematoma presentation and ongoing pain, order received to discontinue Eliquis. Per LPN U, physician was questioned if additional order changes were desired or if emergency room evaluation was warranted but that physician declined need as did not believe anything additional would be done. LPN U stated that she did not request additional testing, including a X Ray, from physician as had seen the negative doppler and did not make the connection that a fracture may be present. During the same interview, LPN U confirmed that she was the nurse assigned to R8 on 1/2/23 and 1/3/23 from 7:00 PM to 7:30 AM. LPN U confirmed that she completed and documented COVID assessments for these dates. Per LPN U, on both 1/2/23 and 1/3/23, R8's left thigh presented much the same as on 12/30/22 as was noted to have same hematoma with no additional discoloration or inflammation. LPN U stated that R8 was noted to have severe pain on both days and that movement of R8's left leg was minimized as movement of lower extremity was so painful for her. LPN U stated that assessment of left lower extremity was not documented on 1/2/23 or 1/3/23 and that physician was not contacted as stated that it would have been her preference to send R8 to the emergency roiagnom on [DATE] but as physician declined, did not follow up again. LPN U stated that although assessment was not documented, left lower extremity assessment information was passed onto day shift nurse through report in the morning of 1/4/23. In an interview on 2/02/23 at 3:07 PM, LPN O confirmed that on the morning of 1/4/23 she had received in shift report that the bruising at R8's left posterior thigh was extending anteriorly and that severe pain in the same extremity was ongoing. LPN O stated that she did not complete resident assessment on 1/4/23 and had never seen left lower extremity alteration as floated to various units and was not the assigned nurse when a skin assessment was due. LPN O stated that as the physician was at the facility in the morning of 1/4/23, she provided him with the assessment information that she had been provided in shift report and that the physician proceeded to assess resident and provided orders for R8's emergency room transfer. In an interview on 2/06/23 at 11:42 AM, Director of Nursing (DON) B stated that she would have expected that a comprehensive assessment be completed with any change in resident condition and that follow up assessment and documentation of resident status be completed thereafter. Per DON B, would have expected to see descriptive documentation of any skin alteration including color, size, and shape of alteration as well as a corresponding assessment of surrounding tissue, extremity range of motion, and signs and symptoms of pain as well as physician follow-up for any ongoing symptoms. Review of Lippincott Procedures - Change in status, identifying and communicating, long-term care with an August 19, 2022 revision date that was provided by DON B and confirmed to be utilized by facility for a resident change in status, included .Introduction: In a long-term care setting, any change from baseline in a resident's status must be identified and addressed .When a nurse recognizes a potentially life-threatening condition or significant change in a resident's status, the nurse must communicate with other health care providers to meet the resident's needs .Implementation: Identify a suspected acute change in the resident, review the resident's medical record .Perform a complete physical assessment, focusing on the identified change in status .Communicate the change in the resident's condition to the appropriate practitioner .Document the procedure .

Based on interview and record review, the facility failed to prevent a fall from bed during resident care for one (Resident #60) of three reviewed for accidents, resulting in R60 being rolled away from staff and falling out of bed during care. Findings include: Review of the medical record reflected Resident #60 (R60) was admitted to the facility on [DATE], with diagnoses that included unspecified severe protein-calorie malnutrition, atherosclerosis of coronary artery bypass graft(s) without angina pectoris, hypertension (high blood pressure), kidney transplant status, malignant neoplasm of kidney (except renal pelvis) and acute kidney failure. The Minimum Data Set (MDS) history reflected R60 died in the facility on [DATE]. Review of the medical record reflected R60 was a full code (full resuscitation and life sustaining treatment). The Miscellaneous tab of the Electronic Medical Record (EMR) reflected the code status document was effective [DATE] and was uploaded to the medical record on [DATE]. A Progress Note for [DATE] at 11:16 AM reflected, .CNA [Certified Nurse Aide] Trainee was changing resident, resident told trainee that she had difficulty breathing and as resident was on her side she rolled out of bed on to [sic] the floor. trainee [sic] aid came and notified nurse that resident fell to the floor and was non responsive, code blue was called at 10:56a [AM], paramedics was [sic] called at was called [sic] at 10:56a, compressions started at 11:00a, paramedics arrived @ [at] 11:05a took over cpr . A Progress Note for [DATE] at 11:55 AM reflected, .Paramedics called time of death at 11:40 . A Post Fall Evaluation for a fall date of [DATE] at 10:56 AM reflected R60 had a witnessed fall to the floor, while Certified Nurse Aide (CNA) Z was present, providing incontinence care.What did the guest/resident say they were trying to do just before they fell ? reflected, Breathe. According to the Evaluation, R60 lost consciousness and became non-responsive. She was lying parallel to the bed, on her right side, with her face towards the wall. The section for re-enactment of the fall reflected that during incontinence care, the CNA rolled R60 onto her side to tuck her brief. R60 stated, I can't breathe, lost consciousness and rolled out of the bed, onto the floor. Code blue (cardiac/respiratory arrest) was called, and Emergency Medical Services (EMS) were called. An Incident Report for a fall on [DATE] at 11:16 AM reflected R60 was lying on her right side, on the floor, next to the bed. Bloody saliva was noted, and R60 was having difficulty breathing. The immediate action taken reflected, Attempted to clear airway, 911 called, CPR started. During a phone interview on [DATE] at 08:55 AM, CNA Z reported she had been a CNA for [AGE] years and employed by the facility for about two weeks. Her training at the facility had been two weeks. When queried about the training process on the floor, CNA Z reported that being an older CNA, if she saw a call light on, she could answer it. Regarding R60, CNA Z stated she only cared for her that day ([DATE]). CNA Z described that as she was changing R60 and doing a complete bed change, it seemed to her like R60 went into cardiac arrest. CNA Z then reported she did not know for sure, as she was not a nurse. CNA Z described that R60 launched onto the floor. CNA Z stated she wanted to say R60 landed on her side or maybe even on her face. She looked at R60, then ran to get the nurse immediately. CNA Z reported the incident to Licensed Practical Nurse (LPN) O, and all the nurses in the facility responded, and 911 was called. After that, R60's vital signs were being checked, she was being assessed, and CNA Z went to call 911. The crash cart and suction were brought to the room, and maybe even the defibrillator, according to CNA Z. Just prior to R60 falling from the bed, CNA Z was putting the brief under R60. CNA Z reported R60 was facing towards the wall where the thermostat was and was turned away from her at that time. CNA Z reported she had never seen anything like that, and R60 launched out of the bed. According to CNA Z, it was sudden, and she would not watch her patient roll out of bed. CNA Z reported she was training with someone that day, who was in the bathroom at the time, so she began doing rounds. During an interview on [DATE] at 10:50 AM, LPN O stated it was reported to her that between 10:00 AM and 11:00 AM, the CNA was providing pericare, cleaning R60, turned R60 on her side and was putting on her brief. R60 told the CNA she could not breathe, then went limp and went out of the bed. When LPN O responded to the room, R60 was non-responsive, lying on her side and still had a pulse and was still breathing. LPN O could see that it was difficult for R60, as she was using accessory muscles when breathing. LPN O called for another nurse and called a code. LPN O reported that she turned R60 over, and there was bloody saliva in her mouth, which she had tried to clear. 911 was called, and they were doing compressions when EMS arrived. LPN O reported it was difficult to bag R60 (provide breaths via an ambu bag), and stated, it was fighting. When LPN O responded to R60's room, she had to change her position, check her head and check for a pulse. R60 did not have any muscle tone. Except for bloody saliva, LPN O did not see any visible injuries to R60. She then stated it could have been bloody mucus that she saw. R60 was kind of rolled back on her side in attempt to clear her until they rolled R60 to her back to begin chest compressions. When asked how much time had passed until they had to perform chest compressions, LPN O stated maybe two minutes. LPN O reported R60 was still breathing and still had a pulse for that time. (According to the Progress Note for [DATE] at 11:16 AM, code blue (cardiac/respiratory arrest) was called at 10:56 AM, and chest compressions began at 11:00 AM) During a phone interview on [DATE] at 02:03 PM, RN DD stated a new CNA reported they were needed in a patient room. When she responded to the room, R60 was on the floor. The crash cart was already there. RN DD reported R60 was taking her last breaths when she walked in the room, and she had pinkish stuff coming out of her mouth. RN DD reported there were a bunch of people in the room. She asked the CNA what happened, and it did not make a lot of sense to her (RN DD). She described that R60 was sitting up, talking to her (CNA) while doing care, and she just rolled out of the bed. The CNA told RN DD she had never seen anything like that and thought R60 had a heart attack or something. RN DD believed the CNA was supposed to be training with another CNA. RN DD stated if a patient was being rolled, they should be coming towards you, not away from you. RN DD conveyed that when rolling a patient towards you, your body would be protecting the patient, and they would not roll out of bed. During an interview on [DATE] at 02:49 PM, LPN H reported that as far as she heard when asking the CNA, the CNA was changing R60, and R60 told the CNA she was feeling weird, not feeling good, was on her side and rolled out of bed. LPN H reported the CNA was new. During an interview on [DATE] at 01:32 PM, Director of Nursing (DON) B reported believing CNA Z was on orientation at that time. When asked if the facility permitted an orientee/trainee to provide care alone, DON B reported they wanted them with work with CNAs for the first couple days. Positioning for care in bed would depend on what was going on with the patient, according to DON B. She reported each patient would be different based on what they were at the facility for. DON B denied knowledge of how care and rolling was done for R60. She reported CNAs were usually in training for a week before getting their own assignment, but it depended on the CNA and if they were new and needed more time. On [DATE] at 02:14 PM, DON B provided information that CNA Z's date of hire to the facility was [DATE]. Day two of her CNA orientation was [DATE], and her training dates on the floor were [DATE], [DATE], [DATE], [DATE] and [DATE].