Every finding on record at Resthaven Care Center

Based on interview and record review, the facility failed to prevent significant medication errors in 1 (Resident #14) of 7 residents reviewed for medication errors, resulting in Resident #14 receiving a mood stabilizing medication at a dose greater than the physician had ordered for 26 days. Findings include: Resident #14 Review of an admission Record revealed Resident #14 was originally admitted to the facility on [DATE] with pertinent diagnoses which include Alzheimer's disease with late onset (disease is a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior) and anxiety disorder. Review of Resident #14's Progress Note dated 3/6/26 and documented by Nurse Practitioner (NP) WW revealed, Chief Complaint: Medication Error . She (Resident #14) follows with (Local Mental Health Provider) for psychiatry. Her Depakote (anticonvulsant and mood-stabilizing medication) was increased last month to 375 mg (milligrams) three times daily due to worsening agitation and irritability. On medication review, it is discovered that patient has been receiving Depakote 375mg three times daily as well as an additional dose of 500 mg nightly since 02/10 During an interview on 7/30/2026 at 1:01 PM, Unit Manager (UM) TT reported she had been made aware of the medication error on 3/6/26 when it was discovered by NP WW during a medication review, and that she was the staff member that had investigated the medication error. UM TT reported that her investigation determined that the medication order change was recommended by Resident #14's Local Mental Health provider and then approved by NP WW. UM TT reported that Licensed Practical Nurse (LPN) RR entered the new medication orders but that she had missed discontinuing one of the previous Depakote orders which resulted in Resident #14 receiving the ordered 375 mg of Depakote three times a day and an additional 500 mg of Depakote every night that was not ordered. UM TT confirmed that Resident #14 received the incorrect dose of Depakote from 2/10/26 to 3/6/26. UM TT confirmed that NP WW had signed off and approved the medication orders, and therefore this error was missed by NP WW when she had approved the orders. UM TT reported that she had educated LPN RR on ensuring that all orders were reviewed when making medication changes. UM TT reported she had not provided any education to NP WW or any other nursing staff in the facility. UM TT reported that the facility did not audit all resident orders to ensure that there were not any other residents residing in the facility with inaccurate medication orders.

This citation pertains to intake # 2574196Based on interview and record review the facility failed to ensure the safety of 1 resident (Resident #1) of 3 residents reviewed for accidents/hazards resulting in Resident #1 having a fall in the facility parking lot while she was left unattended and as a result suffered frontal and temporal lobe hemorrhages, a 4th left rib fracture and a change in capacity.Findings include:Resident #1 (R1)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R1 admitted to the facility on [DATE] with pertinent diagnoses including cerebral infarction (stroke), chronic fatigue and cognitive communication deficit. R1 was in the hospital from [DATE] to 7/16/2025. Brief Interview for Mental Status (BIMS) on 5/5/2025 reflected a score of 10 out of 15 which indicated R1 was moderately cognitively impaired (8-12 is moderate cognitive impairment) prior to the fall and BIMS on 7/21/2025 reflected a score of 7 out of 15 which indicated R1 was severely cognitively impaired (0-7 is severe cognitive impairment) after the fall.An email correspondence received on 8/1/2025 at 1:08 PM from Family Member (FM) P stated that he was told during transport, the hairstylist stopped to retrieve something from her car, leaving (R1) unattended in the wheelchair. The wheelchair rolled unattended and tipped off a curb, causing (R1) to fall and hit her head on the pavement. It was not stated by the RN but for the wheelchair to move the wheel brakes must not have been engaged. The RN did also mention that there would be some additional training that would be done, referring to the person that was handling the transfer of my mom. She was left unattended during wheelchair transport across a parking lot.and ultimately lost the ability to make her own medical decisions.Review of R1's Fall Risk Assessments dated 11/1/2024, 2/3/2025 and 5/5/2025 revealed that R1 had a history of falls in the past 3 months. Review of R1's Care Plan revealed Focus: I have an ADL self-care performance deficit r/t (related to) activity intolerance, stroke affecting left side. Date initiated 11/1/2024. Interventions/Tasks: Transportation: I use a wheelchair with no footrest, self propel in room, to and from dining, with footrests to activities.Date initiated: 3/31/2025, revision 4/25/2025. Revision on 7/16/2025 revealed Transportation: I use a standard wheelchair for mobility. Please assist me as needed for propulsion.Review of R1's Fall Report dated 7/10/2025 revealed Nursing Description: Direct cares staff informed nurse that resident had fallen out of w/c (wheelchair) outdoors while being transported to the main building to get her hair done. Description: upon arrival resident was noted on ground lying in the fetal position on her left side. Resident was alert and responding appropriately ROM (range of motion) completed to bilateral upper/lower extremities with no verbal visual indicators of discomfort. Resident positioned to the sitting position. A gait belt was placed; resident was assisted to the standing position and placed into w/c (wheelchair) without complication and or indication of discomfort. Resident assisted into facility/room. Swelling/abrasion to left side of forehead evident. Ice pack applied for precautionary measures. Further assessment noted no other s/s (signs/symptoms) of injury. Neuro assessments initiated with no adverse indicators. NP (Nurse Practitioner) notified of occurrence. Voicemail left with POA (power of attorney) with request to contact (facility name omitted) for information associated with fall. Beautician to be educated not to leave residence unattended outdoors.Review of R1's Progress Note dated 7/11/2025 completed by Nurse Practitioner (NP) Q revealed She (R1) did begin complaining of pain in her left side/ribs in the early morning hours today and this was relieved with PRN (as needed) Tylenol. No changes noted to patient mentation as of 0338 today. Provider notified at 0935 today that patient was having some changes in multi-tasking abilities and orientation. In person assessment at 0950. Patient is alert and interactive, LEFT facial droop appears at baseline. Patient oriented to self and location per baseline, with seemingly normal conversational ability. No new focal deficits noted. Patient working on puzzle and several pieces are placed incorrectly which is unusual for her. Patient largely at baseline with some possible mild alteration in mentation. She does take aspirin and clopidogrel related to previous CVA (cerebrovascular accident). Nursing advised to send patient out to ED (emergency department) related to fall with head injury on clopidogrel with possible mentation changes.Review of R1's Progress Note dated 7/11/2025 revealed Transfer Details: Resident Sent To: (Hospital name deleted) Date: 7/11/2025. Reason(s) for Transfer: Trauma (fall-related or other) -- Fall and fluctuating orientation. Transfer is Unplanned. Other: Specify in Explanation area below CT scan of head secondary to fall occurrence dated 7/10/25. Resident also voicing left side discomfort.Review of the hospital notes from R1's hospital stay from 7/11/2025 to 7/16/2025 revealed . She (R1) lives in a facility and was going to get her hair done last night when the person driving the wheelchair forgot to put the brakes on.she fell out and struck her left forehead. Impression/ Plan: left frontal and temporal intraparenchymal hemorrhages (bleeding in brain tissue on the left side of the brain) .left 4th rib fracture.During a phone interview on 8/4/2025 at 11:40 AM, Beautician (B) N stated that on 7/10/2025 in the morning, she went to the cottage to get R1 and wheeled her in her wheelchair with her feet on the foot pedals to the main building for a permanent (perm) hair treatment because she had more supplies to do a perm there. B N said she put R1 on the sidewalk in front of her van by the passenger side, facing sideways with her left side parallel to the van. Then she left R1 to get into her van on the passenger side to get perm rods that she needed for the treatment and R1 said that the gardeners were there and she looked out the window from the van and saw R1's wheelchair was rolling forward and B N saw R1 went down the slope of the sidewalk and her left side hit the van and she ended up face down by the driver's side of the van in the parking lot. B N stated that she did not lock the brakes when she left R1 unattended which was a lapse in judgement. B N said that she didn't receive any formal training with wheelchair safety when she started at the facility until she received a write up and education from Recreation Therapy Manager (RTM) I after the incident. B N stated she had to learn what she could about wheelchair safety on her own and continued to take residents from 1 building to another at times as a favor to help staff.Review of the Employee Corrective Action Report for B N dated 7/10/2025 revealed Type of Violation: Violation of Company Policies and Procedures.Date of Violation: 7/10/25. Time: 9:10 AM. While helping transport resident from building to building resident was left briefly unattended which resulted in a fall. It was signed and dated by B N.During an interview on 8/4/2025 at 1:15 PM, RTM I stated that she gave B N the education piece surrounding safety protocol and awareness after the incident on 7/10/2025. RTM I During another interview on 8/4/2025 @3:10 PM, RTM I stated that B N transferred residents from building to building since she started at the facility 3 years ago but this was the first time she had to give a corrective action and educate B N on wheelchair safety and awareness because of the fall on 7/10/2025. RTM I wasn't sure if B N received any education when she started at the facility. During an interview on 8/4/2025 at 1:31 PM, Education and Infection Control Nurse (EIC) J stated that she does staff education and new employee education but doesn't do any education with contract staff which includes the therapy department and the beautician. EIC J said that Rehab Director (RD) O does education with her therapy staff while RTM I does any education with the beautician. During an interview on 8/4/2025 at 12:25 PM, RD O stated that R1 had poor safety awareness and needed reminders and cueing for safety prior to the fall due to her judgement being off. During an interview on 8/4/2025 at 1:03 PM, Certified Nursing Assistant (CNA) D stated that R1 had poor safety awareness since she first got to the facility and she needs constant reminders to not scoot herself in her wheelchair without supervision/assistance. During an interview on 8/4/2025 at 3:20 PM, Licensed Practical Nurse (LPN) F stated that he was working on 7/10/2025 and completed the fall report and contacted the family. LPN F said he worked at the facility for many years and B N had always taken residents back and forth from building to building depending on what supplies she needed and what hair treatment she was going to do but an incident like this didn't happen before that he knew of. During another phone correspondence on 8/4/2025 at 3:39 PM, B N stated that she had been taking residents from building to building maybe one person every 1-2 months on average since she started working at the facility and stated that she didn't receive any formal training on safety.During an interview on 8/4/2025 at 4:05 PM, Nursing Home Administrator (NHA) A stated that B N started at the facility in November/December 2018. NHA A also said that B N did not have any writeups or education since she started that he could locate. During an interview on 8/5/2025 at 10:41 AM, Social Worker (SW) K stated that R1 had the capacity to make her own decisions before the fall on 7/10/2025 but she couldn't make her own decisions now. SW K said that R1 couldn't look around and use context clues to be successful and her BIMS score declined from moderate impairment to severe cognitive impairment after the fall. SW K stated that the facility started the deeming process (where two physicians evaluate a resident's capacity to make healthcare decisions regarding their treatment options and about their care) and was waiting for 1 more physician signature and then her son FM P would be the activated POA.During an interview on 8/5/2025 at 12:50 PM, when discussing the incident on 7/10/2025, Director of Nursing (DON) B stated that the fall report didn't say whether the brakes on R1's wheelchair were locked or not. DON B verified after the fall that R1 had left frontal and temporal intraparenchymal hemorrhages, a left 4th rib fracture and had neurological changes and increased confusion and would be deemed due to her capacity changes. During an interview on 8/5/2025 at 1:05 PM, NHA A stated if the facility completes education, then they would include the contractors (therapy department and beautician) if needed and when it's in their scope. NHA A said he was aware that B N transported residents and stated that anyone can transport residents in a wheelchair as long as it's in the scope of what they are doing and had education. NHA A verified again that he couldn't locate any wheelchair safety education for B N.According to Wheelchair - Family & Caregiver OT Training Checklist (June, 2020) revealed, This contains a list of topics to cover when providing wheelchair education to family and caregivers. Education about wheelchair types (weight, width, material, etc.), Wheelchair Safety (hills, inclines, curb cuts), Precautions and Contraindications (if any), Brakes, Address psychosocial factors .

Based on observation, interviews and record review, the facility failed to maintain a comfortable ambient temperature between 71-81 degrees for 20 residents within a memory care unit (Rooms 401-415), resulting in resident's experiencing ambient room temperatures higher than 81 degrees and a potential for overheating and dehydration.Findings include: Review of Heat and Older Adults published by the Centers for Disease Control and Prevention, 6/25/24 revealed People aged 65 years or older are more prone to heat-related health problems .older adults .are more likely to have a chronic medical condition that changes normal body responses to heat .they are more likely to take prescription medicines that affect the body's ability to control its temperature or sweat .During an observation on 6/23/25 at 10:21am, a wall mounted oscillating fan was blowing in the common area of the memory care unit but could not be felt in the area where several residents sat.During an observation on 6/23/25 at 11:01am, Resident #112 in his bed with a comforter wrapped around his body and covering the back of his head. The ambient temperature in his room was 81.1 degrees. The resident's cheeks were mildly reddened. In an interview on 6/23/25 at 11:02am, Resident #112 reported he felt a little too warm in his room and that the air conditioning was not working well. In an interview on 6/23/25 at 1:42pm, Family Member (FM) TT reported she was concerned for Resident #112 when she visited him over the weekend of 6/21-6/22/25 because it was very hot on the memory care unit. FM TT reported Resident #112 was not able to recognize how hot or cold he was due to his type of dementia, and she was concerned he would overheat, especially since he usually kept himself wrapped up in a comforter in his room most of the time.In interview on 6/23/25 at 11:07am, Certified Nursing Assistant (CNA) BBBB reported she worked on the memory care unit over the weekend (6/21-6/22/25) and the air conditioning system stopped working. CNA BBBB reported some residents complained that they were too hot, and several family members voiced concern for their loved ones when they came to visit. CNA BBBB reported the nurse had asked for extra fans from the facility but when they weren't provided, staff moved some resident's personal fans into the common areas to try to keep residents cooler. CNA BBBB reported the facility's wall mounted falls were on but couldn't be felt where the resident's sat in the lounge. CNA BBBB reported the facility installed portable air conditioning units in the common areas at approximately 10:30am on 6/23/25, following entry by the State Agency. During an observation on 6/23/25 at 12:30pm, residents ate their lunch in the dining area. The ambient temperature registered at 81.3 degrees. A portable air conditioning unit was present in the dining area and running at that time. In an interview on 6/23/25 at 2:06pm, FM UU reported she visited Resident #104 on the afternoon of 6/22/25 and was concerned for the resident's well-being because it was extremely warm back there. FM UU reported she assisted Resident #104 with eating dinner and there was no portable air conditioning unit in the dining room at that time. FM UU reported the resident was sweating a lot and his arms felt warm and moist. FM UU reported she decided if it was as hot in the dining room when she arrived on 6/23/25, she was going to insist Resident #104 ate in his room, next to his fan. During an observation on 6/23/25 at 2:32pm in room [ROOM NUMBER]-1 the ambient temperature measured at 82 degrees. During an observation on 6/23/25 at 2:35pm, in room [ROOM NUMBER]-2 the ambient temperature measured at 81.3 degrees. During an observation on 6/23/25 at 2:37pm, the ambient temperature in Resident #112's room measured 82 degrees.In an interview on 6/24/25 at 9:40am, FM SS reported she assisted Resident #27 with his evening meal on 6/22/25 and when she arrived, his shirt was soaked with sweat. FM SS reported Resident #27 looked like he'd gone swimming because his shirt was so wet. FM SS reported she was concerned about Resident #27 becoming overheated and reported her concern to the nurse. In an interview on 6/24/25 at 10:10am, Licensed Practical Nurse (LPN) HH reported she called and reported the hot temperature on the unit to Building Services Specialist (BSS) PP on 6/21/25. LPN HH reported she was concerned for the residents and the staff because the unit was uncomfortably warm.In an interview on 6/24/25 at 10:23am, LPN C reported the air conditioning on the unit was not working on 6/21 or 6/22/25. LPN C reported she informed the on-call maintenance on 6/21/25 that the memory care unit was hot and was told they were working on the system. LPN C reported she was concerned for the resident's wellbeing due to the excessive level of heat and asked the on-call maintenance staff to bring extra fans to the unit. LPN C reported the facility did not provide any extra fans or portable air conditioning units over the weekend. LPN C reported the CNA's told her some residents felt sweaty and family members voiced concern about the temperature level/safety of the residents. LPN C reported she felt the facility should have at least provided extra fans right away. In an interview on 6/25/25 at 10:30am, FM YY reported she visited Resident #27 over the weekend and the memory care unit was very hot. FM YY reported the facility knew the cooling system was broken before and had mentioned they hoped to get it fixed before their annual certification survey. In an interview on 6/25/25 at 10:37am, BSS PP reported he was the on-call maintenance staff over the weekend of 6/21-6/22/25. BSS PP reported he got approximately 4 calls about the air conditioning over the weekend, 1 of which described extreme heat on the unit. BSS PP reported when he came to the facility on 6/22/25 in the morning to work on the air conditioning system, the temperature on the memory care unit was 78 degrees. BSS PP reported he did not know what time it was when the temperature was 78 degrees. BSS PP reported he did not provide extra fans, that he was very busy that day, and he did not speak to his manager to discuss the situation. BSS PP reported he knew it was hot on the unit and because of that, he and Building Services Manager (BSM) II purchased and installed portable air conditioning units on the unit on 6/23/25, the following day. In an interview on 6/25/25 at 12:13pm, BSM II reported BSS PP texted him at 10:47am on 6/22/25 and reported the temperature on the unit felt ok and it was 78 degrees inside at the time. BMS II reported at that time he and BSS PP opted to shut down the outside air intake on the cooling system because it was just blowing hot air. When further queried about monitoring the temperatures on the unit for the remainder of the day on 6/22/25, BSM II reported the system did not have remote temperature monitoring capabilities and he did not pursue monitoring of the ambient temperature on the unit in any other way. BSM II reported he did not pursue purchasing/installing portable air conditioning units on 6/22/25. Review of official outdoor temperatures recorded by the National Weather Service for the city in which the facility was located, revealed the outdoor temperature ranged from 80-92 degrees on 6/22/25. The facility did not have any portable air conditioning units installed in the memory care unit on 6/22/25. The outdoor temperatures on 6/23/25 ranged from 73-94 degrees. Temperatures higher than 81 degrees were measured on 6/23/25 on the memory care unit, after 6 portable air conditioning units were installed and had run for several hours on 6/23/25. Review of a Air Conditioning Response Timeline provided by Nursing Home Administrator A revealed .A/C (air conditioning) not operating at 100% due to partial chiller failure .capital request approved for replacement (January 2025) . unit operating at approximately 25-30% efficiency .6/22/25 on-call maintenance responded to the building shutting down make-up air system .unit remained off overnight .6/23/25 multiple portable A/C units installed throughout common areas .

Based on interview and record review, the facility failed to provide quarterly resident trust fund financial statements to 8 of 8 residents utilizing resident trust accounts resulting in the residents not being systematically informed about personal funds. Findings include: Review of electronic correspondence received from Nursing Home Administrator (NHA) A on 6/25/25 at 1:36 PM revealed, We currently have 8 residents utilizing resident trust. In an interview on 6/25/25 at 10:27 AM, Accounting Associate (AA) ZZ reported that resident trust fund financial statements were provided annually and upon request to the residents utilizing resident trust accounts. AA ZZ reported she did not provide quarterly trust fund financial statements but thought Resident Services Coordinator (RSC) V might send them. In an interview on 6/25/25 at 10:46 AM, RSC V reported she did not provide quarterly trust fund financial statements to the residents utilizing resident trust accounts but could let the resident know the balance of their account if they inquired about it. In an interview on 6/25/25 at 1:04 PM, NHA A reported the facility did not currently provide quarterly trust fund financial statements to the residents utilizing resident trust accounts but could provide a statement upon request at any time.

Based on interview and record review the facility failed to ensure accurate documentation of advance directives - code status (resident wishes for life sustaining interventions an emergency) for 1 (Resident #389) of 28 residents reviewed for advance directive - code status documentation resulting in the lack of an order or other documentation for the first 5 days of Resident #389's stay. Findings include:Review of an admission Record revealed Resident #389 was a female who admitted to the facility on [DATE] and had pertinent diagnoses which included: vascular dementia (dementia related to blood flow through narrowed blood vessels) and Alzheimer's disease. Review of a Minimum Data Set (MDS) assessment for Resident #389, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated Resident #389 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment).Review of Order Summary for Resident #389 on [DATE] revealed no noted order in place regarding the resident's code status. In an interview on [DATE] at 3:41 pm, Resident #389 reported that she wished to be a Do Not Resuscitate (DNR), (no cardiopulmonary resuscitation to be done in the facility if her heart stopped or she stopped breathing). Review of Resident #389 medical record revealed she had an appointed guardian and was not able to sign or speak for herself regarding her medical choices. In an interview on [DATE] at 12:12 pm, Social Worker (SW) QQ reported that the admitting nurse was who should complete advance directive forms. SW QQ reported that an order was required for every resident related to code status. SW QQ reported if a resident was to be a DNR then the resident or their representative and the doctor needed to sign the DNR form; once the DNR form was signed then the order could be placed for code status of DNR. SW QQ reported while waiting for the DNR form to be signed then nurse needed to ensure that here was an order for full code in place in the resident's record. SW QQ at this time reviewed Resident #389's record and confirmed that there was no order in place for a code status. In an interview on [DATE] at 12:21 pm, Clinical Manager (CM) O reviewed Resident #389's record and confirmed that there was no order for code status and CM O asked can I add it now? CM O then added an order for full code to Resident #389's record. In an interview on [DATE] at 12:23 pm, Licensed Practical Nurse (LPN) C reported that the admitting nurse was responsible for inputting code status orders into a resident's record. LPN C reported that a resident was a full code until the DNR form was signed by the resident and the doctor. LPN C reported that once the form was signed then the order could be changed to DNR. LPN C reported that a physician order was required for code status. In an interview on [DATE] at 12:34 pm, LPN X reported that a physician order was required code status and that every resident needed a code status in their record. LPN X reported that all resident who wanted to be a DNR had to have a DNR form signed by the physician before the order could be changed and that the resident was a full code until the form was signed. Review of Order Summary for Resident #389 revealed .Full code (Attempt CPR) with a start date of [DATE] and a discontinue date of [DATE] authored by CM O . Code status DNR (NO CPR) . with a start date of [DATE] authored by CM O .Review of Michigan Physician Orders For Scope of Treatment for Resident #389 revealed signatures from the resident representative and the physician and a date of [DATE]. Review of facility policy Code Status with a review date of [DATE] revealed . as part of the admission process, each resident/elder/responsible part will be asked to complete (Name Omitted) code status form . once the resident/elder/responsible party has completed the code status form, it will be reviewed and signed by the physician .The code status will be found in the resident's/elder's medical record .

Based on interview and record review, the facility failed to ensure a Preadmission Screening (PAS) / Annual Resident Review (ARR) Level I Screening Form DCH-3877 was completed annually for 1 (Resident #37) of 2 residents reviewed for preadmission screening / annual resident review screening, resulting in the potential for unmet mental health care needs. Findings include: Review of an admission Record revealed Resident #37 was a male, with pertinent diagnoses which included: anxiety disorder, unspecified; dementia in other diseases classified elsewhere, unspecified severity, with psychotic disturbance; and delusional disorders. Review of a Minimum Data Set (MDS) assessment for Resident #37, with a reference date of 3/14/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #37 was cognitively intact. Review of an OBRA (Omnibus Budget Reconciliation Act) PASARR Correspondence letter for Resident #37 dated 3/7/23 revealed, .The recipient may be admitted to or remain in the nursing facility and receive mental health services. Further PASARR Level II Evaluations (Annual Resident Reviews) are not required unless a significant change has been reported by the nursing facility. This does not alter the nursing facility's requirement for completing the annual Level I (DCH-3877) or reporting significant changes .A copy of this notice is required to remain in the recipient's medical record along with the current Level I (DCH 3877) . A review of Resident #37's electronic medical record on 6/24/25 at 9:07 AM revealed the most recent Level I (DCH-3877) Form had been completed for Resident #37 on 11/20/23. No subsequent Level I (DCH-3877) Forms for Resident #37 were found. In an interview on 6/24/25 at 12:30 PM, Social Services Technician (SST) HHH reported the last Level I (DCH-3877) Form that had been completed for Resident #37 was done in 2023 (referring to the form completed on 11/20/23). SST HHH reported Resident #37 should have had another Level I (DCH-3877) Form completed in 2024. SST HHH reported Social Worker (SW) Y was the social worker responsible for completing this form for Resident #37. In an interview on 6/24/25 at 1:37 PM, SW Y reported Resident #37 should have had a Level I (DCH-3877) Form completed in 2024 and they had it marked in their system as being completed but they couldn't find it. In a subsequent interview on 6/25/25 at 9:43 AM, SW Y reported she had contacted the OBRA coordinator who also could not locate a more recent Level I (DCH-3877) Form since the one completed in 2023.

Based on observation, interview and record review, the facility failed to ensure residents received food items within their preferences for 1 (Resident #27) of 2 residents reviewed for food, resulting in dissatisfaction and the potential for nutritional decline and gastrointestinal upset. Findings include: Review of Choice on the menu in residential aged care: An underrated tool for maintaining resident autonomy [NAME] PhD, APD, [NAME] L. [NAME] PhD, APD, [NAME] M. [NAME] PhD, Adv APD First published: 25 February 2025, revealed Food and mealtimes are areas where residents want to express their autonomy. In the community, individuals make decisions about food based on preferences, which have been shaped by a lifetime of experiences. Being able to choose foods that align with these preferences is a sign of normality and a continuation of self-identity. Resident #27 Review of an admission Record revealed Resident #27 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia (type of dementia caused by reduced blood flow to the brain, leading to damage and impaired cognitive function), barrett's esophagus with dysplasia (cells within the throat have undergone abnormal changes due to chronic acid reflux), diabetes mellitus (chronic condition in which the body doesn't produce enough insulin causing abnormal blood sugar levels), and dysphagia (difficulty swallowing). Review of a Minimum Data Set (MDS) assessment for Resident #27 with a reference date of 4/28//25, revealed a Brief Interview for Mental Status (BIMS) score of 00/15 which indicated Resident #27 was severely cognitively impaired. Review of a Care Plan for Resident #27 with a reference date of 5/20/24, revealed a focus/goal/interventions of: Focus: I am at risk for malnutrition as evidenced by Dx (diagnosis) of dementia, Barrett's esophagus, hx (history) of dysphagia DM (diabetes) receives insulin, hx diverticulitis with GI (gastrointestinal) bleed. Goal: Weight without consistent, ongoing significant change while tolerating diet and consistency without difficulty. Interventions: .Likes seafood, dislikes mac n cheese, likes tomato juice at meals .monitor and report to nurse s/sx (signs and symptoms) of GERD (gastroesophageal reflux disease) (condition in which stomach contents leak backward from stomach into esophagus that can be triggered by spicy foods). Review of a Kardex care guide for Resident #27 revealed Nutrition: Diet Per Physician Order .Likes seafood, dislikes mac n cheese, Likes tomato juice at meals. In an interview on 6/24/25, at 9:40am, Durable Power of Attorney (DPOA) SS reported she visited Resident #27 daily to assist him with his evening meal. DPOA SS reported she repeatedly told staff Resident #27 preferred foods that were prepared without spices, but he continued to receive spicy foods. DPOA SS reported she told staff who worked on Resident #27's unit and the staff who attended his most recent care conference, but the problem continued. DPOA SS reported Resident #27 had avoided spicy foods for many years because they caused him to have heartburn. DPOA SS stated some of the foods he's given would really bother his stomach if he ate them. DPOA SS reported one of the foods that he would not eat were the potatoes wedges the facility provided because they were spicy. DPOA SS reported Resident #27 put a bite of a potato wedge recently and promptly spit it back out. DPOA SS reported she was concerned because she was only present for 1 meal per day and Resident #27 would not voice why he wasn't eating if he was served certain foods and staff might assume he was not hungry. During an observation on 6/25/25 at 9:32am, Dietary Aide (DA) Q prepared breakfast plates for Resident #27's unit in the satellite kitchen. DA Q reviewed the meal ticket for each resident and then selected foods from a serving cart. In an interview on 6/25/25 at 9:37am, DA Q reported the meal tickets for each resident included their diet, likes, dislikes, and beverages of choice. DA Q reported she normally worked on Resident #27's unit and was responsible for setting up meals on each resident's plate. DA Q reported on Resident #27's unit, every resident received the meal listed on the facility menu because the residents did not have the cognitive ability to choose foods. DA Q reported she referred to the likes and dislikes on the meal ticket to ensure preferences for those residents were honored. When queried about Resident #27's preferences, DA Q reported I know his family does not want him to have tomato juice but other than that, I don't know of any food preferences for him. DA Q reported the facility's dietician was responsible for obtaining each resident's food preferences and the information was then placed on the meal tickets. In an interview on 6/25/25 at 11:57am, Dietary Services Director (DSD) RR reported food preferences were gathered by the dietician at the time of a resident's admission. In an interview on 6/25/25 at 1:11pm, Registered Dietician (RD) S reported she recorded a resident's preferences at the time of their admission and again as things come up. RD S reported Resident #27 had a diagnosis of barrett's esophagus, but she did not know if he had any issues with increased acid reflux related to the foods he consumed. RD S reported she relied on floor staff or members of the IDT (Interdisciplinary Team) to communicate additional food preferences to her and only reached out to family members for additional food preference information if the resident experienced weight loss, ongoing gastrointestinal upset or other food related issues. RD S reported Resident #27 was not able to tell her his food preferences. RD S reported she was not able to attend all care conference meetings because of her large caseload and was not aware Resident #27's DPOA had food concerns related to his preferences. RD S stated I don't know about any food preferences for him other than what's on his meal ticket. RD S appeared dismissive when told Resident #27's DPOA had a concern regarding the food he received, and stated You have to remember that when a family member tells you something, it might be something that was taken care of 20 years ago. We honor food preferences much better than most other places. Review of Resident #27's meal tickets for 6/25/25 revealed Lunch: dislikes: none, prefers: NO PREFERENCE meal: american chop suey .Dinner: dislikes: none, prefers: NO PREFERENCE meal: Salisbury steak .seasoned brussels sprouts. DO NOT GIVE TOMATO JUICE PER RESIDENT FAMILY REQUEST. Review of a Week at a Glance menu with a reference date of 6/22-6/28/25 revealed 6/25/25 Dinner: Salisbury Steak .potato wedges . Review of a Meal Preference-Prescreen assessment for Resident #27 with a reference date of 5/20/24 revealed A. Meal Preference .Resident able to make meal preferences known: yes .3. Any Food Allergies/Intolerances: No .7. Are there food items you like to have at meals: 7a. seafood .8. Are there food items you dislike and do not want to receive: 8a. Mac n cheese . Review of a Nutritional admission Assessment for Resident #27 with a reference date of 6/3/25 revealed .C. Nutrition Related Functional and Cognitive Issues: .5a. Dementia .6a. Aphasia (language disorder that affects a person's ability to communicate) .D. Estimated Nutritional Needs and Intake: .6. Food Allergies/Intolerance (Digestive problems that occur after a certain food is eaten) b) No .E. Details of Nutrition Summary .reviewed with IDT no concerns voiced . Review of a Nutrition Screening/preferences policy with a reference date of 1/23/25 revealed Policy: Dietary Supervisors, RDN (Registered Dietitian Nutritionist) or other designated associate with (sic) visit each resident within approximately 72 hours .following admission and complete .meal preference assessment. PROCEDURE .2. Obtain food preferences, allergies or intolerances .5. The frequency of subsequent visitations will depend on the nutritional status of the resident and as requested by the interdisciplinary team and/or family. 6. Selective menus are used with meal and beverage preferences obtained on a daily basis.

Based on observation, interview, and record review the facility failed to properly sanitized resident shared equipment, specifically a glucometer between uses during medication administration for 1 (Resident #129) of 5 residents observed for medication administration, resulting in the potential for the spread of infection, cross-contamination, and disease transmission. Findings include: Resident #129 Review of an admission Record revealed Resident #129 was a female who admitted to the facility on [DATE] and had pertinent diagnoses which included: Type 1 diabetes (a chronic condition where the pancreas produces little to no insulin for the body). Review of Order Summary for Resident #129 revealed .blood glucose scans QAC (before every meal) and HS (bedtime). Notify physician if blood glucose is less than 60 or over 400 unless individual parameters dictate otherwise four times a day for Type 1 Diabetes with a start date of 3/14/2025. On 6/24/25 at 11:45 am, Licensed Practical Nurse (LPN) C was observed completing a blood sugar check (obtaining a sample of blood from the tip of a finger that was then placed onto a test strip in a glucometer (a machine that measures sugar levels of the blood) and the machine resulted a value) on Resident #129. Once LPN C exited Resident #129's room, he returned to the medication cart and deposited the glucometer into a box for alcohol wipes in the bottom drawer of the medication cart. LPN C then opened the top drawer and proceeded to prep Resident #129's medications. LPN C did not clean or sanitized the glucometer after using it to check Resident #129's blood sugar and returning it to the cart. In an interview and observation on 6/24/25 at 11:55 pm, LPN C reported the glucometer should be cleaned after each use and LPN C confirmed he returned the glucometer to the medication cart after he checked Resident #129's blood sugar and he did not clean it. LPN C reported everything in the drawer that the glucometer touched was now contaminated. LPN C then retrieved the glucometer from the bottom drawer of the medication cart and immediately cleaned it. In an interview on 6/24/25 at 9:32 am LPN G reported the glucometer should be cleaned after every use and before being stored in the medication cart. In an interview on 6/24/25 at 9:40 am LPN T reported the glucometer should be cleaned after every use and before being stored in the medication cart. In an interview on 6/24/25 at 10:59 am, Education and Infection Control Nurse (EICN) OO reported her expectations were that the glucometer should be cleaned after every use. Review of facility policy titled Blood Glucose Monitoring with a revised date of 3/2024 revealed .the nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacture's instructions and in accordance with the facility's glucometer disinfection policy The nurse is responsible for cleaning and disinfection of the machine between residents following the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy .

Based on observation, interview, and record review, the facility failed to provide adequate supervision and ensure appropriate transfer techniques were implemented for 2 (Resident #96 and Resident #102) of 9 residents reviewed for accidents resulting in an increased risk for falls and injuries. Findings include: Resident #96Review of an admission Record revealed Resident #96 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia (general term for loss of memory, language, problem-solving and thinking abilities that are severe enough to interfere with daily life). Review of a Minimum Data Set (MDS) assessment for Resident #96 with a reference date of 4/21/25, revealed a Brief Interview for Mental Status (BIMS) score of 0/15 which indicated Resident #96 was severely cognitively impaired. Section GG revealed Resident #96 needed supervision or light touching to transfer from sitting to standing. Review of a Care Plan for Resident #96 with a reference date of 2/25/21, revealed a focus/goal/interventions of: Focus: (Resident #96) needs assistance with her ADL's (activities of daily living) because she has dementia. Goal: Resident will accept assistance with care he/she is not able to do for her/himself .Interventions: TRANSFER: .Assist as needed, may need assist getting up from low or soft furniture. During an observation on 6/24/25 at 12:22pm, Resident #96 sat in a small recliner in the common area of the facility's memory care unit. Certified Nursing Assistant's (CNA) J and BB stood facing Resident #96, on either side of the recliner, placed their flexed forearms under Resident #96's armpits and simultaneously lifted the resident from the low seated position to a standing position. The CNA's held on to the waistband of Resident #96's pants with their opposite hands as they lifted the resident. No gait belt was in place on Resident #96; however, CNA BB had a gait belt looped across her own body from shoulder to waist. CNA J then turned to the surveyor and stated Sorry, our little lady (Resident #96) needed help getting up from that low chair. In an interview on 6/24/25 at 12:24pm, CNA J confirmed that she and CNA BB completed a sit to stand transfer of Resident #96 without the use of a gait belt and instead, hooked their arms under the resident's and held on to the resident's waistband as they lifted her from the chair. In an interview on 6/24/25 at 1:02pm, Physical Therapist (PT) EEE reported a gait belt should always be used by staff when assisting residents with transferring from one position to another. PT 'EEE reported it was the expectation that any time a staff member is providing physical support of a resident, the safest way to do so was with the use of a gait belt. PT EEE reported staff that transfer residents by hooking their arms under the residents could easily result in injuring the resident's should joint. In an interview on 6/25/25 at 1:57pm, Nursing Home Administrator (NHA) A confirmed it was the expectation that staff members use a gait belt to assist resident's with transfers. Review of a facility Gait Belt policy with a reference date of 2025 revealed Purpose: To ensure the safe ambulation and transfer of residents through the standardized use of gait belts, thereby reducing the risk of injury to residents and staff. Policy Statement: Gait belts will be used by all direct care staff when assisting resident with transfers .Proper use of gait belts enhances resident stability, supports mobility, and minimizes the risk of falls and injury. Procedures .Residents refusing gait belt use will have that preference addressed and documented . Resident #102:Review of an admission Record revealed Resident #102 was a male with pertinent diagnoses which included dementia, Parkinson's disease with dyskinesia with fluctuations (dyskinesia symptoms are jerky movements they can't control such as swaying, wriggling around, [NAME] your head and can spread to the whole body), muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), dysphagia (damage to the brain responsible for production and comprehension of speech), anxiety, cerebellar ataxia (the cerebellum that coordinates voluntary movements is damaged) and osteoarthritis (the protective cartilage that cushions the ends of the bones wears down). Review of admission summary dated [DATE] at 6:52 PM, revealed, .Not processing well for new information, hx (history) of falls, will try to get out of bed .has confusion .unable to ambulate .has hx of frequency urinating .continent of bowels . Review of Nursing Progress Note dated 4/20/25 at 7:53 PM, revealed, .Daughter called to this nurse that guest was on the floor. Upon arrival, guest was on his hands and knees facing the bed, wheelchair behind him. Call light was on, alarm was not sounding. Guest stated I fell, as you can see .with x3 assist pt assisted to wheelchair. Guest reported he needed to use the restroom, guest toileted, Large BM result . Note: No incident or risk management report was provided to this writer when requested all reports for Resident #102. Review of Incident Report - Unwitnessed Fall dated 4/22/25 at 10:40 PM, revealed, .Nursing Description: This nurse was alerted by staff that the resident had fallen and was on the floor. This nurse went to the resident's room and noted him lying on his right side with his right arm underneath him in front of his recliner clutching an incontinence pad that staff stated was in the recliner under him originally. The resident's alarm pad was noted in the recliner seat and was on, but staff stated that it was not sounding when they noted the resident on the floor .Resident was toileted after the incident and staff believes that was his initial goal due to the resident having an incontinence episode of BM at the time .Injury: Right shoulder (rear) .This nurse noted a reddened area to his right should blade .Predisposing Environmental Factors: Alarm not Functioning .Predisposing Situation Factors: Attempting to toilet self .Ambulating without assist .Fall Investigation: Date of Last Fall: 4/20/25 .This is resident's 2nd fall r/t (related to) need for toileting .New intervention to implement toileting schedule and do bowel and bladder log to establish patterns . Review of Nursing Progress Note dated 4/23/25 at 06:33 AM, revealed, .Replaced guest alarm and it appears to be functioning properly without issue . Review of Nursing Progress Note dated 4/23/25 at 3:18 PM, revealed, .Guest's alarm started beeping and this nurse got up to check on guest. Guest was observed on floor crawling to bed from his recliner .Guest brought to common area . Review of Incident Report - Un-Witnessed Fall dated 4/23/25 at 3:00 PM, revealed, .Guest's alarm started beeping and this nurse got up to check on guest. Guest was observed on floor crawling to bed from his recliner .Guest brought to common area .Notes: 4/23/25: Guest last seen by Nurse an hour ago .Last fall was night prior .New intervention for q2h (every 2 hours) toileting .4/25/25: New intervention to encourage resident to sit in common area to increase supervision . Review of Secure Conversations dated 4/24/25 at 07:02 AM, revealed, .Guest had another unwitnessed fall. Walked in and guest was on hands and knees crawling to bed . Review of Incident Report - Unwitnessed Fall dated 4/24/25 at 8:45 PM, revealed, .The nurse was alert to resident being on hands and knees in common area by the tv. Resident observed on hands and knees by chair near tv .resident stated he was going to grab his iPad, unable to give more of a description .Predisposing Physiological Factors: Gait imbalance, impaired memory, poor standing balance, confused, antidepressants .Other info: is on alarms currently .Immediate Intervention: keep iPad close to the resident . Review of Order dated 5/1/25 for Resident #102 revealed, .Check chair alarm for function and placement q shift. every shift for fall .Start date: 5/1/25 . Review of Social Work admission assessment dated [DATE] at 11:11 AM, revealed, .Resident is deemed incapacitated. Current level of cognitive functioning: Resident had a diagnosis of dementia. He presents with disorientation and confusion. His cognition has the potential to fluctuate. His executive functioning is impaired .History of attempting to self-transfer and stand, rummaging, wandering, delusions, and agitation . Review of Nursing Progress Notes dated 5/15/25 at 2:48 PM, revealed, .Required 1 person assist with pivot transfer/sit to stand 2 assist as needed. Requires sensor alarm when in bed and chair alarm when in chair or wheelchair . Review of Concern Form - Cares dated 5/15/25 at 9:00 PM, revealed, .Nursing Description: (First Name), Daughter, expressed concern after returning to visit (Resident #102) at around 9pm just before the storm. Family expressed concern that no staff nearby. Resident was almost out of recliner. Back of knees were still in contact with foot area of recliner. Family assisted resident back in recliner and observed what appeared to be blood on nose (later discovered it was chocolate ice cream). Daughter then went to seek out CNA (Certified Nursing Assistant). Family expressed concern with CNA ' s responses once found .Resident Description: Resident Unable to give Description .Immediate Action Taken: CNA supervisor was notified of situation by on shift nurse. CNA supervisor assisted resident with cares and repositioning from recliner to bed. Nurse administered medications 9:30pm. Resident alarms in place and functioning properly .Statements: .(Licensed Practical Nurse (LPN) YYY): Family was upset with resident sliding down out of recliner, and they came to get me. The family was upset because they didn't like their interaction with the CNA. The family relayed to me that CNA seemed dismissive. I reached out to unit manager on phone and CNA supervisor .(Certified Nursing Assistant (CNA) ZZZ): I was getting towels and helping 110 to go to bed. I went to get her linen and, on my way, back to her room, A lady came up to me and approached me. She said, what happened to my dad ' s nose, do you know what happened? I didn't know who she was or who her dad was. Then she told me who her dad was. I said I'm not sure if you want to talk to the nurse she is probably in the office. I went in there 2-3 times, and I went in to take his tray and never saw anything. She thought he was injured. The new nurse came over and she has been giving me a hard time. I overheard her talking about me to the family. Saying I hadn't checked on him. They found that it was chocolate ice cream on his nose. After the nurse talked with family, she called someone else to come do his cares. The nurse came up to me and told me she wasn't in the office.(R102 Family Member (FM) AAAA: We were visiting my dad in the afternoon and then left to get dinner. When we came back around 9pm we saw my dad with his knees down to recliner. He had slid down, and he would normally be in bed at this time. He had what looked like blood on his nose. I walked out of room to find assistance and found a CNA. I asked the aide, who had my dad and why did it look like blood was on his nose? The aide was dismissive towards me and when I asked for some assistance, the aide said, I don't know, go ask the nurse. I asked her where the nurse was. The aide said, Probably in the office sitting down. I went to the office to find the nurse and she was not in the office. I found her coming out of a room and then she helped me. We went to room to see what happened to my dad ' s nose and discovered it was chocolate. The CNA supervisor came around to assist my dad into bed and get washed up. I do not want that aide taking care of my dad . Notes: Reviewed statements from nurse, family, and CNA. Reviewed times in (Medical Record System) that staff was documented in room. Resident was assisted with toileting at 1700 (5:00 PM) by CNA. Nurse administered medications at 1742 (5:42 PM). Resident had meal and dinner tray removed .At the time the resident was slipping out of recliner, CNA was giving cares to another resident. Implemented Dycem to recliner and wheelchair . This writer attempted to contact FM AAAA prior to exit and was unable to speak with them. Review of Order Note dated 5/21/25 at 11:23 PM, revealed, .Re-added Motion sensor alarm to alert staff of resident attempting to move out of bed. Resident was reported attempting to get up during the night 5/20 via 3rd shift staff Start Date: 5/22/2025 . Review of Nursing Progress Note dated 5/21/25 at 11:45 PM, revealed, .the resident was restless after supper. The staff transferred him into his chair to watch TV .He continued to press his call light five different times after 7pm but could not tell the staff what was needed. He appeared confused. He asked the CNA to help him call his wife. She did and the resident was left talking to his wife in hopes to calm the resident. Soon after the resident was found on the floor by another staff member. She notified this nurse and the CNA that was taking care of him. He was found on the floor on his hands and knees .When the resident was hoyered off the floor, he c/o (complained of) back pain but denied pain when in bed . Note: No incident or risk management report was provided to this writer when requested all reports for Resident #102. Review of Order dated 5/22/25 for Resident #102 revealed, .Ensure motion sensor is on and working when guest in room .Start date: 5/22/25 . Review of Nursing Progress Note dated 5/24/25 at 3:06 PM, revealed, .Staff responding to chair alarm. Upon entry to room resident was observed crawling on hands and knees. Resident stated he was looking for wife and needed his transportation(wheelchair) which was located in the bathroom . Note: No incident or risk management report was provided to this writer when requested all reports for Resident #102. Review of Nursing Progress Note dated 5/24/25 at 11:53 PM, revealed, .Resident was found on his knees in front of the chair at 1935 (7:35 PM). He had his medicine and an ice-cream previously. Note: No incident or risk management report was provided to this writer when requested all reports for Resident #102. Review of Nursing Progress Note dated 6/5/25 at 00:29 AM, revealed, .Resident was agitated after supper. He was given ice-cream but wondered where his wife was and waited for her to return. After 2000, he was trying to get out of his chair. The CNA was able to get him out of the chair into bed. HS meds were given. However, the resident was restless, trying to get out of his bed. The alarms went off and the staff had to put his legs in bed many times. Finally, it didn't seem he could relax from his high anxiety . Review of Incident/Accident/Unusual Occurrence Progress Note dated 6/6/25 at 11:08 AM, revealed, .Direct care staff reports responding to sounding alarm. Upon entering room resident was observed lying on his right side .Resident assisted back into recliner via two assist and gait belt. Assessment noted an abrasion to the right temple measuring 0.7cm x 0.1cm . During an observation on 06/24/25 at 3:01 PM, observed Resident #102 was seated at the edge of his recliner in his room, no alarm was sounding, call light was pressed. This writer observed no staff supervising residents during this time as there were no staff in the common area/dining area. This writer went to the front office and informed Recreation Therapy Aide (RTA) UUU of Resident #102's current situation. RTA UUU appeared bothered in body language and tone, she reported can't move him, maybe distract him until staff comes and headed to Resident #102's room. During an observation on 06/24/25 at 3:06 PM, CNA KKK exited a resident's room with soiled linen in her hands. She was informed of the current situation for Resident #102 and appeared agitated and reported she was responsible for 10 residents over here, and 3 of them had alarms. CNA KKK proceeded to dispose of soiled linen and returned to the area and obtained her call light/bed alarm tablet from the counter. (Note: CNA KKK did not have her tablet on her person while in a room with another resident). CNA KKK went into Resident #102's room and scooted him back in the recliner. Resident #102's chair alarm was not alerting as the resident was still providing pressure on half the pad as it had slid down when the resident scooted forward in the chair with Dycem on the top and alarm on the bottom. CNA KKK asked Resident #102 if he wanted to get into his bed, Resident #102 indicated her did want to get in bed. CNA KKK informed Resident #102 she had to obtain the sit to stand to transfer Resident #102 to his bed. CNA KKK proceeded to obtain the sit to stand and went into Resident #102's room and closed the door. Note: CNA KKK transferred resident #102 by herself into his bed. On 06/24/25 at 3:09 PM, This writer went to other attached cottage and observed three staff members in the front office and second CNA exited from a resident's room with soiled linen. Clinical Manager E and Licensed Practical Nurse (LPN) LLL were seated in the front office. LPN LLL was speaking with another staff member and indicated he was giving report to additional staff member. This writer asked if they were able to hear an alarm while in the office, they reported they did not hear an alarm alert. This writer requested if they would set off the alarm for the resident for the cottage they were currently located on, this writer walked to the other side to determine if able to hear the alarm on the other cottage. This writer was unable to hear the alarm in the common/tv/dining room area. This writer informed them Resident #102 had attempted to get up out of his recliner and was seated on the edge of the seat, leaning forward and was currently being assisted by CNA KKK. LPN LLL and this writer went to Resident #102's room, and he indicated the resident had a chair alarm which was a pressure alarm and was not connected to a motion sensor alarm which alerted to the sensors plugged in to the outlets at the counter as well as the tablet carried by the CNAs. There were two sensors plugged in, and they were numbered as 106 and 108 to indicate the room it was connected to. LPN LLL reported Resident #102 was restless and confused and previously had attempted to get up or slide out of his recliner to the floor. In an interview on 06/24/25 at 3:12 PM, CNA NNN reported the chair pressure pad alarm was not able to be heard when she was on the other attached cottage where she was assigned. CNA NNN was noted to not have her tablet on at the time. In an interview on 06/24/25 at 3:11 PM, Clinical Manager (CM) E reported the pressure pad alarm would not alert to anyone in the other cottage, where she was located at, only the alarms that were motion sensored. CM E reported the alarms were not a guarantee to keep a resident safe, the alarms were a tool to assist staff, not all falls can be prevented but the hope was staff would hear the alarm prior to the resident falling. CM E reported she did not believe there was a supervision requirement for residents. In an interview on 06/25/25 at 01:44 PM, Director of Nursing (DON) B reported supervision for the residents on the cottages the facility does not have a constant intervention for one to one supervision. DON B reported typically there would always be staff there and available to intervene for a resident. DON B reported the facility does use other interventions to help notify the staff such as chair and motion alarms. DON B reported for a resident who was impulsive and/or a fall risk the staff would conduct frequent rounds and investigate for the root cause of the fall(s). DON B reported there were interventions the facility could attempt such as if it was determined to be a toileting concern, then could schedule toileting for the resident. DON B reported she hoped that when the staff would hear a resident's alarm, they would be able to reach the resident in time. DON B reported it was proven that alarms do not prevent falls and could also be cause more agitation or distress for a resident especially for one with dementia. In an interview on 06/25/25 at 2:00 PM, Nursing Home Administrator A reported the facility had implemented multiple alarms for Resident #102 and he was unsure of what else could possibly be done for Resident #102's situation other than to provide a one to one for the resident and his situation did not warrant a one to one. NHA A reported the facility had the appropriate number of staff in the cottages based on the resident numbers. NHA A reported he did not think the facility was able to provide constant supervision of the residents as staff have to provide resident cares for all residents. Review of policy Fall Intervention Review Procedure implemented on 4/2025, revealed, .5. Supervision Enhancements: o Consider supplemental remote monitoring (sensor alarms and motion detectors) .o Consider increasing intermittent supervision (staff nearby or periodic check ins) .o Consider implementing more frequent observations at set intervals (hourly safety checks) .o Consider temporary direct supervision (1 :1 supervision) when unsafe to self or others while root cause of fall can be further evaluated and alternative interventions can be implemented .o Encourage participation in group activities to increase supervision .o A recreational therapy assessment may help identify appropriate engagement strategies .

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to prevent, treat, and promote healing of pressure ulcers in 1 of 2 residents (Resident #126) reviewed for pressure ulcers, resulting in the lack of repositioning and implementation of care planned interventions, delayed healing of pressure ulcers for the resident, and the potential for infection and the development of new ulcers.Findings include: Review of an admission Record revealed Resident #126 was a female with pertinent diagnoses which included pressure ulcer of right buttock, stage 3, dementia, diabetes and adult failure to thrive. Review of Care Plan for Resident #126 revised on 06/09/2025, revealed the focus, .The resident has open area to right buttocks. Healing complicated by poor intake, incontinence and diabetes . with the interventions .Administer treatments as ordered and monitor for effectiveness .Assess/record/monitor wound healing Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed, drainage and healing progress. Report improvements and declines to the MD (Medical Doctor) .Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning .Instruct/assist to shift weight in chairs/recliner chair regularly .Pressure Relief- cushion in her recliner and wheelchair . Review of Kardex dated 06/23/2025 for Resident #126, revealed, .Bed Mobility: I need minimal assistance to turn and reposition in bed .Encourage resident to stay in common areas when awake .Skin Health: Apply a sheer layer of barrier cream with each incontinence .INCONTINENT: Check regularly and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes .Instruct/assist to shift weight in chairs/recliner chair regularly .Pressure Relief- cushion in her recliner and wheelchair .Reposition after meals, with toileting, with cares in bed and in chair/recliner chair .Review of Order dated 04/28/2025 for Resident #126, revealed, .Wound Care to see patient for area on right buttocks . Review of Order dated 05/14/2025 for Resident #126, revealed, .Monitor open areas to right inner gluteal cleft (groove or crease located between the buttocks) w/ (with) ordered border gauze dressing in place every shift . Review of Order dated 06/04/2025 for Resident #126, revealed, .Right buttock wound - cleanse and flush with NS (normal saline)/wound cleanser. Lightly Pack with collagen. Cover with silicone bordered foam dressing. every day shift every other day for Wound care . Review of Order dated 06/04/2025 for Resident #126, revealed, .Right buttock wound - cleanse and flush with NS/wound cleanser. Lightly Pack with collagen. Cover with silicone bordered foam dressing. as needed for dressing disruption/soilage . Review of Minimum Data Set (MDS) Significant Change dated 03/31/2025, revealed, .(Resident #126) is at risk for pressure ulcers because she has incontinence, fluctuating intake of food and fluids (however this has improved within the last several months) her blood sugars fluctuate, and she has assistance with bed mobility at times. (Resident #126)'s overall mobility and time spent in bed has changed in the last months showing improvement in her ability to change positions and she makes position changes now in bed and chairs independently most often and she is spending much of her day out in the common area as well. (Resident #126) remains at risk for skin breakdown however therefore has a care plan for risk for impaired skin integrity with interventions to help prevent pressure ulcers. (Resident #126) does not have any pressure ulcers, see care plan .Review of Nursing Progress Note dated 4/26/2025 23:15 for Resident #126 revealed, .Resident noted to have superficial open area to intergluteal cleft, cleaned affected area with normal saline wipe and applied dermaseptin. Notified NP (Nurse Practitioner) (Name) .Wound UDA (assessment) completed, no new orders at this time. Resident resting in bed with even and unlabored respirations, pressure reducing interventions implemented .Review of Skin & Wound assessment dated [DATE] for Resident #126 , revealed, .Pressure ulcer, Stage 2, In house acquired .Discovered 4/25/25 .0.2 x 0.5 x 0.5 CM, treatment - Dermaseptin applied per orders, no dressing and no cleansing .interventions: turning / repositioning, and other .Review of Skin & Wound assessment dated [DATE] at 1:03 PM for Resident #126, revealed, .0.3 x 0.9 x 0.5 depth 0.9 and undermining 0.7 CM .Review of Skin & Wound assessment dated [DATE] at 11:56 AM for Resident #126, revealed, .0.3 CM x 0.7 CM x 0.6 CM depth 0.3 CM .undermining 0.2 CM . Review of Skin & Wound assessment dated [DATE] at 11:01 AM for Resident #126, revealed, .Pressure Stage 3 intergluteal cleft, medial, superior 1-3 months <0.1 CM Area x 0.5 CM Length x 0.3 CM Width x 0.3 CM Depth x 0.4 Undermining .Granulation 100% of wound filled .Moderate exudate . Serosanguineous Discoloration - black/blue .Extent: 1.5 CM .Review of Skin & Wound Evaluation dated 6/18/25 at 10:54 PM for Resident #126, revealed, .Exact date: 4/26/25 .in house acquired .1-3 months .Area: 0.2 CM x 0.7 CM length x 0.4 CM width .Depth: 0.2 CM .Undermining 0.3 CM .granulation 100% of wound filled .moderate exudate, serosanguineous, no odor. surrounding tissue: unbroken skin .Normal in color .Review of Skin Observation dated 6/24/25 at 2:42 PM for Resident #126, revealed, .Skin warm and dry, See wound UDAs for right outer lower leg, right Buttocks, Dressing done to right buttocks per order, tolerated dressing change, senile purpura to upper and lower extremities, Continent/incontinent of bowel and bladder .Interventions: Pressure reducing device for chair, Pressure reducing device for bed, Turning/Repositioning program, Nutrition or Hydration intervention to manage skin problems .Applications of ointments/medications other than to feet .Review of Hospice Comprehensive Assessment Details dated 06/18/2025, revealed, .the need for antibiotic therapy for chronic stage three to the right buttocks, several wound care adjustments, increased need of PRN (as needed) Morphine (effective), and a poor appetite. (Resident #126) is frail at her baseline and does not walk often; she sleeps 16+ hours daily .During an observation on 06/23/25 10:51 AM Resident #126 was observed seated in the atrium in a recliner, she had her feet up on the footrest, blanket over her legs, she laid in a supine position, head of recliner was approximately 60 degrees.During an observation on 06/24/25 at 2:36 PM, Resident #126 was observed in the recliner in the atrium, she had her feet up, was lying in a supine position. The head of the recliner was approximately 40 degrees. During an observation on 06/25/25 at 10:15 AM, Resident # 126 was observed in the recliner, she had her feet up, non-slip socks on her feet, and the recliner was placed at approximately 60-70 degrees. She was in a supine position. In an interview on 06/25/25 at 11:05 AM, Licensed Practical Nurse (LPN) HH reported Resident #126 had a special gel pad placed under her for when she was seated in the recliner in her room or common area. LPN HH reported the head of a bed should be under 45 degrees and definitely should not have her seated at 90 degrees. LPN HH reported the wound was debrided and then it opened up and she began to see the wound nurse and provider. LPN HH reported the providers would let the nurses know the orders for treatment. This writer observed LPN HH assist Resident #126 to a standing position and there was no gel pad in the seat of the reclinerDuring an observation on 06/25/25 10:36 AM LPN HH went to Resident #126's room and the pad was on a black chair in the corner off to the right side as you enter the room. LPN HH grabbed the gel pad and went back to the atrium and asked Resident #126 to stand up again to place the gel pad under her while in the recliner. When queried, LPN HH reported the gel pad should have been under Resident #126 while she was in the recliner. In an interview on 06/25/25 11:18 AM, Wound Nurse (WN) SSS reported Resident #126's pressure ulcer was debrided by the wound provider, developed an abscess and had to be debrided again by the wound provider. WN SSS reported it had initially started as a stage 2 pressure ulcer and developed into a stage 3 pressure ulcer. WN SSS showed this writer photos of Resident #126's wound progression as it worsened from a stage 2 to a stage 3. WN SSS reported it appeared to develop the abscess approximately on 5/7/25 when reviewing the photos. WN SSS reported when the wound opened, the wound team was called in to provide care and monitor the pressure ulcer. In an interview on 06/25/25 10:39 AM LPN HH reported if a resident refused cares, it would be documented in the record, the resident would be reapproached by staff, then different staff, and/or the nurse and the resident continued to say no, this was documented in the treatment administration record which would have a pop up for the nurse to enter a progress note. In an interview on 06/25/25 at 01:31 PM, Director of Nursing (DON) B reported if a resident refused cares the aides would use an alternative intervention, reapproach, walk away, try to reapproach at a later time, if the resident was still refusing the CNA would notify the nurse and the nurse would attempt to persuade the resident to allow the care to be performed.In an interview on 06/25/25 01:39 PM, DON B reported when the skin assessment was completed, nurses would complete a risk management report (incident report), and ongoing assessment and wound UDAs would be completed. DON B reported she reviewed the assessments weekly to determine if the wounds were improving or declining, change interventions/treatments needed to be changed and the facility had a wound committee would review as well to determine if the treatments were effective as well. DON B reported the skin assessments were completed at admission, weekly, and when a resident had a shower/bath. DON B reported skin assessments would be completed more than the standard if the resident had an actual wound. DON B reported if there were changes the provider would be notified to help get the wound going in another direction for healing.Review of policy, Prevention of Pressure Ulcers revised on 12/12/24, revealed, .To provide guidelines for skin care to assist in preventing the development of pressure ulcers in residents identified to be at risk .4. For a person in bed'. change position at least every two hours; if indicated, use a special mattress that contains foam, air, gel, or water; and raise the head of the bed as little and for as short a time as possible, and only as necessary for meals, treatments and as medically necessary. Use supportive devices per resident ' s Plan of Care. Repositions the top covers. Leave the bed covers loose so that air can circulate to all parts of the body and to prevent pressure on toes, feet and heels .5. For a person in a chair. Change position at least every two hours and use foam, gel or air cushion as indicated to relieve pressure .6. Reduce friction and shear by. lifting, using appropriate lifting technique and equipment, rather than dragging when repositioning .

Based on observation, interview, and record review the facility failed provide a dignified environment and assist residents with care needs in 1 (Resident #52) of 2 residents reviewed for dignity, resulting in feelings of frustration and the potential for depression, loss of self-worth, and an overall deterioration of psychological well-being.Findings include:Resident #52 Review of an admission Record revealed Resident #52 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dysphagia (difficulty swallowing) and depression. Review of a Minimum Data Set (MDS) assessment for Resident #52, with a reference date of 5/23/25 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #7 was severely cognitively impaired. Review of Resident #52's Orders revealed, Aspiration precautions: Sit upright for all PO(by mouth) intake and 30 minutes after, check for oral residue, excellent oral care including denture cleaning, encourage small bites, slow rate, drink to follow every 2-3 bites. every shift . Start date: 4/26/25. Review of Resident #52's Care Plan revealed, I have an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) activity intolerance, deconditioning. Date initiated: 4/22/25. Interventions: Eating: I require feed assist. Date initiated: 4/22/25 .In an interview on 6/23/25 at 11:29 AM Resident #52 was lying in her bed. Resident #52 reported that she felt like staff at the facility did not want to help her, and that they did not like to take care of her. Resident #52 reported that she needed help with eating, and that staff would tell her that she could feed herself, and refuse to help her. Resident #52 reported that she felt like some of the staff did not like her. It was noted that Resident #52 was tearful during the interview. In an observation on 6/24/25 at 8:32 AM, Resident #52's breakfast tray was sitting on her table next to her bed untouched. Resident #52 was noted to be lying in bed flat on her back. It was noted that Resident #52's breakfast tray had not been set up for Resident #52. In an observation on 6/24/25 at 9:13 AM, Certified Nursing Assistant (CNA) P entered Resident #52's room and asked Resident #52 if she was going to eat her breakfast. CNA P set up Resident #52's food tray and said All right (Resident #52) here you go, you can do it. As CNA P began to walk out of Resident #52's room, Licensed Practical Nurse (LPN) FF told CNA P that Resident #52 needed help with eating her breakfast. CNA P said loudly in front of Resident #52 (Resident #52) can do it herself, I know she can. She does not need help. CNA P then turned to Resident #52 and said to her again You can do it yourself. CNA P then exited Resident #52's room. Resident #52 was noted to be sitting up in bed staring at her breakfast tray. In an interview on 6/24/25 at 9:19 AM, LPN FF confirmed that Resident #52 required assistance with eating, and that staff were supposed to assist Resident #52 with eating. During an interview on 6/24/25 at 11:44 AM, CNA P reported that sometimes Resident #52 required assistance with feeding, and sometimes she did not. CNA P reported that staff followed the Resident care plan to determine if the resident required assistance with feeding. CNA P confirmed that Resident #52's care plan indicated that she needed assistance with feeding. CNA P then reported that even though Resident #52's care plan noted that she required assistance with feeding, that she felt that Resident #52 could feed herself. CNA P was unable to report on why she felt that Resident #52 could feed herself. In an interview and observation on 6/25/25 at 9:07 AM, Resident #52 was sitting up in her bed with her breakfast tray in front of her. When this writer entered her room, Resident #52 asked this writer to please help me with my breakfast. Resident #52 reported that she wanted to eat, but that she needed help. Resident #52 was trying to take a drink from her cup, and was struggling to bring the cup to her mouth. This writer found CNA P in the hallway and informed her that Resident #52 was asking for assistance with eating her breakfast. CNA P then entered the room and began to assist Resident #52 with her meal. After Resident #52 took a few bites of her food, she told CNA P that she was having a hard time swallowing. CNA P began asking her over and over, Well do you want to be done then, do you want to be done then? Resident #52 told CNA P that she wanted to eat, but that she was struggling to swallow. CNA P replied to Resident #52 and said Well, I would have a hard time eating too if I was swallowing the way you are. You need to put your head in the right alignment. Do you want to be done then? Resident #52 again said that she wanted to eat, and CNA P assisted Resident #52 to a better position to swallow more easily. CNA P continued to assist Resident #52 with her meal and frequently asked her if she wanted to be done every few bites. In an interview on 6/25/25 at 9:21 AM, CNA P reported that she was assisting Resident #52 with her meal prior to when this writer entered her room, but she had to leave to pick up trays and keep up with the tasks on the floor. CNA P confirmed that Resident #52 was having trouble swallowing because of the way her head was tilted and that she needed to help Resident #52 adjust it. CNA P confirmed that Resident #52 was not able to adjust her head on her own. When this writer asked if she felt like she had enough time to assist Resident #52 to eat at her own pace, CNA P' was not able to answer.Review of the facility's Resident Rights policy revealed, Policy: The facility will provide written guidelines that will aid our facility in protecting and promoting each resident's right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility that enhances the resident's quality of life. Policy Explanation and Compliance Guidelines: The objectives of Resident Rights are: 1. To provide each resident with a clear statement of how he or she will be treated by the facility, its personnel, volunteers, and others involved in providing care/services. 2. To protect and promote the rights of each resident as guaranteed to them under federal and state law to include: A. Privacy and respect .Review of the facility's Dignity policy last revised 6/2/23 revealed, It is the practice of this facility to treat each resident with respect and dignity and care, recognizing each resident's individuality and protecting the rights of each resident. Guidelines. Cares: Follow the care plan/Kardex for daily cares, transfers, and person centered care outlined in the care plan .

Based on observation, interview and record review, the facility failed to ensure professional standards of nursing were followed for treatment of a skin tear for 1 (Resident #43) of 1 resident reviewed for professional standards of nursing practice. Findings include: Review of an admission Record revealed Resident #43 was a female with pertinent diagnoses which included Alzheimer's disease, dementia with behavioral disturbance, and pressure inducted deep tissue damage of right heel. Review of Care Plan for Resident #43 revised on 6/8/25 revealed the focus, .The resident has potential impairment to skin integrity due to limited mobility and incontinence. She can be resistant and refuse care and toileting at times with combativeness - hitting, kicking - that could cause skin injury and delay in care . with the intervention .Derma Sleeves- to bilateral arms when up . Review of Treatment Administration Record (TAR) for June 2025 revealed, documentation of Resident #43 with bilateral derma sleeves noted as on for day, evening, and night shifts. Review of Order for Resident #43 revealed, .Monitor skin tear to left outer forearm, steri-strips in place, clean and reapply if needed, every shift .Start Date: 05/23/2025 . Review of TAR for June 2025 for Resident #43 revealed, .Complete wound UDA-skin tear to outer left forearm every evening shift every Fri .Start Date: 05/30/2025 . During an observation on 06/23/25 at 11:01 AM, Resident #43 was seated in the atrium, and she had a bandage on her left forearm with no date or initials. No derma sleeves were observed on resident's arms. During an observation on 06/23/25 at 12:27 PM, Resident #43 was seated in her wheelchair in the dining room, and she had a bandage on her left forearm with no date or initials noted on it. No derma sleeves were observed on resident's arms. During an observation on 06/23/25 at 12:41 PM, Resident #43 was seated in her wheelchair in the dining room and was observed to have a bandage on her left forearm with no date or initials noted on it. Review of Skin Assessment dated 6/17/2025 at 5:12 PM for Resident #43, revealed, .Reason for Assessment: Weekly/Biweekly skin Observation .Notes: Skin assessment, Skin warm and dry, See wound UDA for Right forearm, left dorsal palm/hand, Left forearm, right heel, Treatments done per order .Uses a high back wheelchair for mobility, does not self-propel in wheelchair .Unit Director was previously notified of the skin impairment .Interventions: Pressure reducing device for chair in place .Pressure reducing device for bed in place .Nutritional supplements in place. Ointment applied to the area of skin impairment . Review of orders revealed no order for a dressing for Resident #43's left forearm skin tear. In an interview on 06/25/25 at 11:12 AM, Licensed Practical Nurse (LPN) HH reported when a resident had a skin tear, the floor nurses were the ones who completed the wound assessment and took the photos, type of treatments discussed with the provider on what they would like for the floor nurses to do. LPN HH reported if the resident had a pressure ulcer then the wound nurse would be consulted to review. LPN HH reported the nurse would contact the provider to obtain an order for any changes in treatment. LPN HH reported the bandage should have had initials and a date written on it. In an interview on 06/25/25 at 11:18 AM, Wound Nurse (WN) SSS reported she would not be involved in the care of the skin tears unless there was a flap of skin missing or it was a significant skin tear. WN SSS reported for residents with fragile skin an intervention used was application of extra cream to help prevent skin tears. In an interview on 06/25/25 at 01:31 PM Director of Nursing (DON) B reported Resident #43 had fragile skin with lots of risk reports. DON B reported she had multiple interventions such as protective sleeves, or at least long sleeves to protect her skin.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: 1. During the initial tour of the main kitchen, at 11:09 AM on 6/4/24, observation of the Blueair Refrigeration unit found the digital thermometer on the outside stated it was 34F. Upon opening the door it was noticed that the ambient temperature of the unit felt warm and there was no ambient air thermometer in the unit. A temperature of an open half gallon of fat free milk was taken with a digital rapid read thermometer and found to be 55F. When asked how long it had been since the last temperature of the unit was taken, Kitchen Supervisor BB stated that a temperature of 39F was logged at 8:00 AM this morning, when asked if they would have used the outside digital thermometer to record that that temp, KS BB stated yes. When asked what was going to happen to the drinks and the food product in the unit, KS BB stated they would be discarded. According to the 2017 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: .(2) At 5C (41F) or less. 2. During the initial tour of the kitchen, at 11:23 AM on 6/4/24, it was observed that eight packages of beef roasts were thawing in the wash compartment of the three compartment sink. The drain line from the wash compartment was found to be directly connected to the waste water line. When asked about thawing in the wash compartment, KS BB stated it should be done in a different location. According to the 2017 FDA Food Code guidelines section 4-501.16 Warewashing Sinks, Use Limitation. If the wash sink is used for functions other than warewashing, such as washing wiping cloths or washing and thawing foods, contamination of equipment and utensils could occur. According to the 2017 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed . 3. During the intial tour of the kitchen, at 11:35 AM on 6/4/24, it was observed that a green mechanical scoop with stuck on food debris was found stored with clean utensils. During a tour of Rachels' and Davids' Kitchens, starting at 12:48 PM on 6/4/24, it was observed that the underside of the juice dispensers were found with an accumulation of dried on sticky orange debris in the corners and underside of the spouts. During a tour of the Borsma Cottage kitchen, at 1:25 PM on 6/4/24, it was observed that the resident silverware drawer was found with an accumulation of food crumbs and debris inside the drawers plastic insert. Further observation found that some of the utensil drawers in this area are pitting and chipping on the inside, no longer making it a smooth and easily cleanable surface. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 4. During the initial tour of the kitchen, at 11:44 AM on 6/4/24, it was observed that the mop sink on the kitchen was found left on, putting undue back pressure on the faucet's internal vacuum breaker. Although a wasting tee was installed, it had failed and was not working properly. During a tour of the Cottages, at 1:15 PM on 6/4/24, it was observed that the janitors sink, used by kitchen staff for getting sanitizer, was found to be left on, putting undue back pressure on the faucets internal vacuum breaker. The device has a wasting tee that is clogged and not working. According to the 2017 FDA Food Code section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: .(B) Maintained in good repair. 5. During a tour of Rachels' Kitchen, at 12:48 PM on 6/4/24, it was observed that a container of a dozen shake supplements was found in the refrigeration unit. Most shakes had a smeared writing and could not be identified with a legible discard date. A couple that were legible had discard dates of 6/3. The product information states it has to be used within 14 days of thaw. When asked what she was going to do to the product, KS BB stated discard it. Further review of the refrigeration unit found a couple containers of thickened water and juice. These items were found dated with receive by dates, but not dated for discard once opened. A review of the thickened water product found it was to be used within seven days of opening. During a tour of the [NAME] kitchen area, at 1:05 PM on 6/4/24, it was observed that front fridge had a package of sliced ham with a smeared date. It was also found that two ready care shakes were found with no date to indicate discard (item is good 14 days from thaw). Observation of the back pantry fridge found an open package of red skin potatoes dated 5/11 to 8/11, staff and KS BB was unsure why it was dated this way and was discarded. According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2017 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . 6. During an observation of the [NAME] pantry refrigeration unit, at 1:10 PM on 6/4/24, it was observed that a container of shell eggs was found stored on the middle shelf of the unit, over ready to eat product (including shredded cheese and cooked potatoes). According to the 2017 FDA Food Code section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below, separating raw animal FOODS during storage, preparation, holding, and display from: (a) Raw READY-TO-EAT FOOD including other raw animal FOOD such as FISH for sushi or MOLLUSCAN SHELLFISH, or other raw READY-TO-EAT FOOD such as fruits and vegetables,(b) Cooked READY-TO-EAT FOOD .

Based on observation, interview, and record review the facility failed to: 1.) ensure resident shared equipment was properly cleaned and sanitized between each use, 2.) ensure personal protective equipment (PPE) was worn by staff and visitors in care units where required and by staff when caring for 1 (Resident #119) of 29 sampled residents, 3.) ensure clean laundry bins used for transport were free from dirt and debris; and 4.) ensure 1 (Resident #91) of 2 residents sampled for dialysis had a dressing applied to their dialysis access site (an indwelling device). These deficient practices resulted in the increased potential for the spread of infection, bacterial harborage, cross contamination, and disease transmission for residents residing in the facility. Findings include: Resident Shared Equipment During an observation on 6/5/24 at 1:21 PM, noted Licensed Practical Nurse (LPN) LL in the activity room near the front entrance of the facility taking vitals on a resident. After LPN LL had finished taking vitals on the first resident, a second resident in the activity room requested LPN LL take her vitals as well. LPN LL did not clean and sanitize the vitals machine after taking vitals on the first resident before taking vitals on the second resident. LPN LL finished taking vitals on the second resident, exited the activity room with the vitals machine, and took the vitals machine into a third resident's room to take their vitals. LPN LL did not clean and sanitize the vitals machine after taking vitals on the second resident before taking vitals on the third resident. In an interview on 6/5/24 at 1:29 PM, LPN LL reported the vitals machine was supposed to be cleaned and sanitized between each use to prevent the spread of infection. LPN LL reported she had not cleaned nor sanitized the vitals machine between use on the three residents but should have. In an interview on 6/6/24 at 1:03 PM, Infection Control Nurse (ICN) YY reported resident shared equipment (including vitals machines) should be cleaned and sanitized between every resident every time. ICN YY reported that practice was important to prevent the spread of infection. Personal Protective Equipment Review of signage posted on the wall outside the entry to the Good [NAME] Home (GSH) locked memory care units (Rachel's House and David's House) revealed, NOTICE WE ARE EXPERIENCING A RESPIRATORY INFECTION ON GSH. OUR MASKS MUST BE WORN BY ALL FAMILY, VISITORS AND EMPLOYEES WHEN VISITING. IF YOU HAVE RESPIRATORY SYMPTOMS, WE ASK THAT YOU CONSIDER NOT VISITING AT THIS TIME. THANK YOU, FOR SUPPORTING OUR EFFORTS TO KEEP OUR RESIDENTS, EMPLOYEES AND VISITORS SAFE. Review of signage posted at eye level directly on the double door entry to the GSH revealed, Notice: MASKS ARE REQUIRE (sic) FOR VISITORS AND EMPLOYEES UPON ENTERING GSH, [NAME] AND [NAME] Visitation is not restricted however our masks are required when visiting. Thank you, for your support We appreciate your support and understanding as we all work together to protect our residents and one another. We will keep you informed, and again Thank you. During an observation on 6/5/24 at 2:28 PM, noted two visitors standing at the signage posted on the wall outside the entry to the Good [NAME] Home (GSH). They appeared to be reading the signage. There was hand sanitizer and a box of surgical masks on a tray table underneath the signage on the wall. The visitors did not don (put on) surgical masks prior to entering the GSH. During an observation/interview on 6/5/24 beginning at 2:33 PM in GSH David's House, noted the two visitors, still not wearing surgical masks, seated at a table in the common area with two residents. Licensed Practical Nurse (LPN) N was conversing with the visitors. LPN N did not direct the visitors to don surgical masks. During this observation, Clinical Manager (CM) EE walked past the visitors, into the nursing office. CM EE then walked back out of the nursing office and again past the visitors. CM EE did not direct the visitors to don surgical masks. CM EE and LPN N then walked over to this surveyor. CM EE was queried as to whom should be wearing surgical masks and why. CM EE reported all visitors and staff were required to wear surgical masks when in GSH, regardless of whether they were in Rachel's House or David's House, because residents in Rachel's House had parainfluenza (a respiratory virus) and the facility was trying to prevent the spread of the virus to all resident's of GSH. This surveyor queried CM EE and LPN N if the two visitors should be wearing surgical masks and LPN N reported she had caught other visitors earlier that were not wearing masks and directed them to put masks on but had not noticed the current visitors were not wearing masks. LPN N reported she should have educated the visitors and directed them to don surgical masks. In an interview on 6/6/24 at 1:03 PM, Infection Control Nurse (ICN) YY reported all staff and visitors were expected to wear surgical masks when in GSH. ICN YY reported if anyone, including visitors, entered through the double doors and into one of the houses (David's or Rachel's), any staff who saw them should educate them on the importance of wearing the surgical masks and then provide them with a surgical mask at that time. 46999 During an observation on 6/4/24 at 11:01am signage was posted on the wall, at eye level outside the memory care unit that stated, We are experiencing a respiratory infection on (name of locked unit) our masks must be worn by all family, visitors, and employees. Hand sanitizer and masks were provided on a raised table under the sign. The same sign hung at eye level on the double doors leading into the unit. During an observation on 6/4/24 at 11:03am, Kitchen Supervisor (KS) XX and Dining Room Supervisor (DRS)WW, walked past the signage, table, and PPE, and entered the locked memory care unit without donning a surgical mask or completing hand hygiene. During an observation on 6/4/24 at 11:05am, KS XX and DRS WW were observed completing rounds in the kitchen area of the locked memory care unit. Neither staff member wore any personal protective equipment (PPE). During an observation on 6/4/24 at 11:07am, KS XX and DRS WW worked in the kitchen area that was open and easily seen by those passing by. Several other staff members passed by but did not alert KS XX or DRS WW about the need to wear PPE. In an interview at 6/4/24 at 11:07am, KS XX and DRS WW reported they were not aware that the use of a surgical mask was required on the locked memory care unit at this time. Both staff members denied awareness of a suspected infectious illness outbreak on the unit. In an interview on 6/4/24 at 11:46am, Infection Preventionist (IP) YY reported all staff were required to use a surgical mask while on the locked memory care unit because the unit had 1 confirmed case of parainfluenza 3 and 2 more suspected cases of the illness. When further queried about how staff were educated on the need to wear masks, IP YY reported staff were educated by the signage present, a message sent on the electronic medical record and by their supervisors. IP YY reported masking throughout the unit was important to reduce the risk of spreading the illness, especially since some of the residents who were suspected of being ill could not comply with staying in their rooms. In an interview on 6/6/24 at 11:17am, KS XX reported on 6/4/24 she was told by her supervisor to come to the locked memory care unit to do her weekly rounding of the kitchen. KS XX reported her supervisor did not tell her about the infection prevention precautions underway on the unit. KS XX reported she quickly went to the unit to complete her assigned task. KS XX stated To be honest, I was in a hurry and didn't notice the signage. When further queried about the areas in which she worked, KS XX reported she was primarily in the administrative office at this time but could go to any of the company's facilities/kitchens as needed. 41424 Review of Centers for Disease Control and Prevention (CDC) dated March 20,2024, revealed, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .EBP are indicated for residents with any of the following: *Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or *Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .Effective Date: April 1, 2024 . Resident #119: Review of an Admission Record revealed Resident #119 was a male with pertinent diagnoses which included cancer of the temporal lobe and brain. Review of current Care Plan for Resident #119, revised on 7/10/2018, revealed the focus, .The resident has wound on his head (right lateral) related to cancer. At times his wife removes the dressing on her own. This was something she did for him at home . with the intervention .Change wound dressings as ordered .EBP (Enhanced Barrier Precautions) .Keep skin clean and dry .Monitor/document locations, size, and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration (excessive moisture, leading to the softening and breaking down of the surrounding skin) . During an observation on 06/04/24 at 02:15 PM, Resident #119 was observed lying in his bed on the phone with the head of the bed at approximately 45 degrees with pillows behind him. There was another male in the room with him. room [ROOM NUMBER]: Sverre [NAME]: was on the phone when attempted to speak to him, had a male visitor in the room. During an interview and observation, Hospice Volunteer BBB exited Resident #119's room and informed me the resident was on the phone with his daughter and he was a volunteer with hospice who went to visit residents in the facility. Review of Order dated 4/19/24, revealed, .Dressing Change: change dressing to right skull wound daily. Remove old bandage, lay patient flat on right side in bed with pad underneath head and allow wound to drain for 10 minutes, cleanse surrounding areas with NS (normal saline), apply 1/3 ABD pad over wound and wrap head with coban (a bandage wrap that adheres to itself with no sticky adhesives) to secure, then secure coban with tape .every day shift . During an observation on 06/04/24 at 02:31 PM, Licensed Practical Nurse (LPN) OO had entered Resident #119's room as he was lying in the bed with the head of the bed at approximately 60 degrees. LPN OO was observed to not have a gown or face mask on. LPN OO began to remove the bandages wrapped around Resident #119's head. LPN OO reported she was cleaning the inside of the wound with normal saline and gauze. LPN OO reported it was a chronic surgical wound. Resident #119 reported he had a craniotomy performed due to a lesion on his brain and the wound was from the surgery. LPN OO used a tablet to take a photo of the wound and reported it would upload to the medical record. LPN OO placed a non stick pad to the dressing and wrapped his head with gauze. Note: LPN OO did not allow the wound to drain for 10 minutes prior to changing the dressing and did not wrap the head with coban. In an interview on 06/04/24 at 02:51 PM, LPN OO reported she did not don a gown when she performed a dressing change on Resident #119. In an interview on 06/05/24 at 02:37 PM, Registered Nurse (RN) Y reported prior to the dressing change for Resident #119, the bandage had to be removed and allowed to drain, lying on the right side to help it drain, before she could replace the bandage. RN Y reported the wound was opened more due to the tumor started growing again, it opened the wound back open and it has to drain. In an interview on 06/06/24 at 01:04 PM, LPN V reported Resident #119's wife was in today and she completed the wound dressing change for his chronic surgical wound on his head. In an interview on 06/06/24 at 02:15 PM, Director of Nursing (DON) B reported for the wound dressing change for Resident #119, the gown and gloves were appropriate for the dressing change as there was no risk of splashing from the wound care. DON B reported the wound had to be allowed to drain for 10 minutes prior to applying the new dressing. DON B reported the spouse of Resident #119 was permitted to change the dressing on Resident #119 using the supplies per the hospice order. DON B reported this order was entered when Resident #119 was at the facility earlier in the year for respite but was unable to locate it when asked to review the order. DON B reported the facility did not rediscuss the order for allowing the wife to do the dressing change as the wound was draining more and upon his return for long term care. This writer requested the order to allow the spouse to change the dressing and it was not received prior to exit from the facility. Review of policy, Enhanced Barrier Precautions reviewed/revised on 4/15/24, revealed, .b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) .even if the resident is not known to be infected or colonized with a MDRO.3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident ' s room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care) . 38384 R91 According to the Minimum Data Set (MDS) dated [DATE], R91 scored 14/15 (cognitively intact) on his BIMS (Brief Interview Mental Status), required a fistula/port for dialysis for a medical diagnosis of chronic kidney disease stage V. Review of R91's Summary Order, dated 2/23/23, revealed, Change dressing to hemodialysis site daily. Review of R91's Medication Administration Record/Treatment Administration Record (MAR/TAR) dated February 2023 did not contain the order for Change dressing to hemodialysis site daily on it. Subsequently, the order was not added to the resident's MARs/TARs from February 23, 2023, through June 5, 2024. Review of R91's Care Plan, revised on 5/16/24, revealed, The resident needs dialysis related to renal failure three times a week. The goal, revised on 3/2/24, was for the resident to have no signs or symptoms of complications from dialysis with interventions that included check and change dressing daily at access site. Document. (date initiated 1/16/2023). During an observation and interview on 6/5/24 at 9:28 AM, R91 stated, I go to dialysis Monday, Wednesday, and Friday. I have a port in my right arm. It gets a lot of use. Observed a dialysis port in resident's right arm with no dressing. The skin covering the port had three small openings that were scabbed over. During an interview and record review on 6/5/24 at 2:57 PM, Licensed Practical Nurse (LPN) JJ stated while reviewing R91's medical chart, When (R91) comes back from dialysis the night shift changes his dressing that night. That is what I assume because I've never done a dressing change over his dialysis port. I do not see an order on the MAR to do a dressing change on my shift, 7a-7p. For the night shift, 7p-7a, the order it is not there either. There is no order for R91 to have a dressing change over his port. During an interview and record review on 6/5/24 at 3:02 PM, Clinical Manager (CM) D, reviewed R91's Order Summary, MAR/TAR, and Care Plan stating, I see the order dated 2/23/23 to do a dressing change daily for the dialysis port and it is on the care plan. It is not on his MAR/TAR to be done daily. It should have been a routine schedule to be done and it was not. The port is direct access to the resident's blood and should have a dressing after dialysis if there are open wounds from access for infection control. 38905 During a tour of the laundry room, at 2:37 PM on 6/4/2024, it was observed that both clean laundry bins (used to transport clean laundry from the washer to the dryers and from the dryers to folding area) were found with an increased amount of debris underneath their false bottom support. Observation underneath the carts bottoms found three socks, rolled up paper trash, some rubber bands, and an accumulation of dirt and crumbs.

Based on interview, and record review the facility failed ensure physician orders were in place for dialysis treatment (the process of removing excess fluid and toxins in people with insufficient kidney function) and monitoring, and post dialysis assessments were documented for 2 residents (Resident #65 and #91) of 2 residents reviewed for dialysis care, resulting in the potential for the resident to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #65 Review of an Admission Record revealed Resident #65 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: stage 4 chronic kidney disease. Review of a Minimum Data Set (MDS) assessment for Resident #65, with a reference date of 5/15/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #65 was cognitively intact. In an interview and observation on 06/04/24 at 04:40 PM, Resident #65 reported that he had returned from dialysis about 90 minutes prior. Resident #65 reported that normally he did not go to dialysis on Tuesdays, but that it was a make up day because he wasn't able to finish his treatment the day before. Resident #65 reported that he had not seen any facility staff yet, but was waiting to be laid down. Observed a dressing on Resident #65's right chest, and he reported that it was his port, where they hook up the dialysis. Review of Resident #65's Care Plan revealed, I need dialysis r/t (related to) renal failure. Date initiated 7/3/2023, Interventions: Check and change dressing daily at access site. Document, Do not draw blood or take B/P (blood pressure) in arm with graft . The care plan did not indicate the type of dialysis, when or where the dialysis took place, and/or monitoring of the dialysis port located on the right chest. Review of Resident #65's Physician Orders revealed no current or discontinued orders for Dialysis. Review of Resident #65's Treatment Administration Record revealed no treatments and/or monitoring for a dialysis port. In an interview on 06/06/24 at 08:21 AM, Resident #65 reported that he did not know who was supposed to be changing the dressing that covered his dialysis port and stated, .they have never change it here .when I go to dialysis they change it . In an interview on 06/06/24 at 08:24 AM, Licensed Practical Nurse (LPN) F, who was assigned to Resident #65, reported not normally working on that unit and stated, .I know he (Resident #65) does dialysis, but I don't see orders .not sure where his port is . In an interview on 06/06/24 at 08:28 AM, Clinical Manager (CM) D reported that based on review of the medical record, she was not able to confirm where or when Resident #65 received dialysis, when he started dialysis, and/or where specifically his dialysis port was located. CM D reported that there were no orders in Resident #65's record related to dialysis and/or monitoring of his dialysis port. CM D reported that the facility nurse should be visually monitoring Resident #65's dialysis port site at least daily, but there was no documentation to support that it was being done. Review of Resident #65's Vital Signs Record indicated that vital signs were not obtained regularly, nor were they consistently recorded on Dialysis days (Monday, Wednesday and Friday). For the month of May blood pressure findings were recorded on 8 days. For the month of May 2024, 4 of the 8 days that blood pressures were recorded, coincided with Dialysis days. Review of the facility policy Dialysis date last reviewed/revised 1/2/2024 revealed, Policy: the facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis (dialysis). Purpose: .The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices .7. The nurse will monitor and document the status of the resident's access site upon return from the dialysis treatment to observe for bleeding or other complications .10. The facility will ensure that the physician's orders for dialysis include: a. The type of access for dialysis and location. b. The dialysis schedule .d. The dialysis facility name and phone number .11. The nurse will ensure that the dialysis access site is checked before and after dialysis treatments and every shift . 38384 R91 According to the Minimum Data Set (MDS) dated [DATE], R91 scored 14/15 (cognitively intact) on his BIMS (Brief Interview Mental Status), required a fistula/port for dialysis for a medical diagnosis of chronic kidney disease stage V. Review of R91's Order Summary did not have orders for dialysis including the days of the week or designated dialysis facility. Review of R91's Care Plan, revised on 5/16/24, revealed, The resident needs dialysis related to renal failure three times a week. Further review of R91's Care Plan, did not include the days of the week or which dialysis facility the resident received treatment from. During an observation and interview on 6/5/24 at 9:28 AM, R91 stated, I go to dialysis Monday, Wednesday, and Friday. During an interview and record review on 6/5/24 at 3:02 PM, Clinical Manager (CM) D, reviewed R91's Order Summary, stated, I do not see an order for (R91's) dialysis. Staff double-check orders when new orders come in. The nurse double-checks with the Provider when they put the order in, and a second nurse double checks the MAR/TAR to make sure the orders are in. (R91's) order was missed. Review of R91's Patient Transfer admitted [DATE] revealed, .Mon/Wed/Fri (name of Nephrologist) (name of dialysis facility) (address) . Review of facility policy Dialysis dated 1/2/24, revealed, .10. The facility will ensure that the physician's orders for dialysis include: a. They type of access for dialysis .and location. b. The dialysis schedule. c. The nephrologist's name and phone number. d. The dialysis facility name and phone number. e. Transportation arrangements to and from the dialysis facility. f. Any medication administration or withholding of specific medications prior to dialysis treatments. g. Any fluid restriction if ordered by the physician.

Based on interview and record review, the facility failed to provide written notification of the bed hold policy upon transfer to the hospital for 1 of 2 residents (Resident #98) reviewed for transfer and discharge requirements, resulting in the potential for residents and/or their representatives to be unaware of their rights in regard to facility bed holds. Findings include: Resident #98: Review of an Admission Record revealed Resident #98 was a male with pertinent diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms (BPH has frequent urination, weak stream, leaking or dribbling of urine), obstructive and reflux uropathy (urine flow is blocked causing urine to back up into the kidneys) and bladder neck obstruction, and cystostomy status (suprapubic catheter). Review of current Care Plan for Resident #98, revised on 10/25/22, revealed the focus, .The resident has a suprapubic catheter: due to BPH, urinary retention related to CVA (stroke), and obstructive and reflux uropathy. He has a history of urinary tract infections .Suprapubic was placed on 1/13/22. New surgical placement on 6/28/22 . with the intervention .Enhanced barrier precautions .Monitor for s/sx of discomfort on urination and frequency .Monitor/document for pain/discomfort due to catheter . Review of Secure Conversations dated 2/9/2024 at 7:06 PM, revealed, .(Licensed Practical Nurse (LPN) OO: Resident sent out to (Local Hospital) for an eval via AMR for severe distention of abdomen, severe pain, and fever. UA sent out to (Local Hospital) today at 2pm. Family has been notified and will meet resident at the hospital . Review of Nursing Progress Note dated 2/10/2024 at 2:58 PM, revealed, .Update from (Local Hospital): Resident was admitted late last night for obstructed kidney stone, currently in surgery and will likely stay another 1-2 days . Review of Admission Summary dated 2/13/2024 at 5:08 PM, revealed, .Resident admitted to facility on 7/20/2020 from [NAME] Community Hospital r/t Ureterolithiasis .INFECTION STATUS: Resident is being treated for an infection. Bactrim DS as preventative for kidney stone removal Resident is not receiving IV antibiotics . Resident does not have an active MDRO infection. Resident does not require TBP, continue with standard precautions .GUASSESSMENT: Relevant History/Current GU Problems: SP CATH d/t obstructive and reflux uropathy, BPH. Resident has a catheter Catheter Type: suprapubic catheter. Resident is continent of bladder. Urinary symptoms/complaints noted upon admission include: None . Review of Antibiotic Charting dated 2/16/2024 at 11:36 PM, revealed, .Resident is on Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 MG for Urinary Tract Infection,,. Resident has a suprapubic catheter. No adverse reactions noted to antibiotic. No improvement noted to symptoms. Describe symptoms: Emptied foley bag, 700 output at 2248. Noted left flank has large amount of swelling, resident rated pain 5/10. Flushed foley catheter with 60cc. Resident appears relaxed. Afebrile . In an interview on 06/06/24 at 01:29 PM, LPN JJ reported when a resident was sent to the hospital, there was a packet which was sent and it included the bed hold and resident information. The paperwork was handed to the ambulance service. In an interview on 06/06/24 at 01:32 PM, Clinical Manager (CM) E reported the facility would call the resident or the representative about the bed hold. In an interview on 06/06/24 at 01:38 PM, CM D reported the bed hold was in a prepacked envelope. The next day, admissions would call and follow up with the resident/representative. CM D reported there was a checklist the nurse completed when the resident was sent to the hospital. In an interview on 06/06/24 at 01:42 PM Director of Nursing (DON) B reported the unit clerks gathered the paperwork for a transfer out to the hospital. The admissions coordinator would contact the resident or representative to determine if they would like to go with the bed hold. DON B reported there was no documentation in the medical record the communication had happened. Review of policy, Bed Hold reviewed/revised 1/24/2024, revealed, .(Facility) has established the following policy to provide notification of options of holding a bed when a resident is discharged from the facility for hospitalization or leave of absence .C. The responsible party must sign a facility form stating he or she wishes to hold the bed .3. Notice of Bed Hold Policy Before/Upon Transfer .a. At the time the admission contract is reviewed, the resident representative will be provided with written notice of this bed hold policy and Bed Hold Authorization Form (See Admissions Form Bed Hold Authorization) .i. Upon transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice of this bed hold policy. In the case of emergency transfers, the facility will attempt to contact the resident ' s representative to provide notice of the bed hold policy .ii. All attempts to reach the resident ' s representative must be documented .

Based on observation, interview, and record review, the facility failed to ensure professional standards of practice for physician orders were obtained/followed for two residents (R91 and R291) of two residents reviewed for professional standards of care, resulting in the lack of documentation, and the potential for the worsening of a condition and a delay in treatment. Findings include: R91 According to the Minimum Data Set (MDS) dated [DATE], R91 scored 14/15 (cognitively intact) on his BIMS (Brief Interview Mental Status), required a fistula/port for dialysis for a medical diagnosis of chronic kidney disease stage V. Review of R91's Summary Order, dated 2/23/23, revealed, Change dressing to hemodialysis site daily. Review of R91's Medication Administration Record/Treatment Administration Record (MAR/TAR) dated February 2023 did not contain the order for Change dressing to hemodialysis site daily on it. Subsequently, the order was not added to the resident's MARs/TARs from February 23, 2023, through June 5, 2024. Review of R91's Care Plan, revised on 5/16/24, revealed, The resident needs dialysis related to renal failure three times a week. The goal, revised on 3/2/24, was for the resident to have no signs or symptoms of complications from dialysis with interventions that included check and change dressing daily at access site. Document. (date initiated 1/16/2023). During an observation and interview on 6/5/24 at 9:28 AM, R91 stated, I go to dialysis Monday, Wednesday, and Friday. I have a port in my right arm. It gets a lot of use. Observed a dialysis port in resident's right arm with no dressing. The skin covering the port had three small openings that were scabbed over. During an interview and record review on 6/5/24 at 2:57 PM, Licensed Practical Nurse (LPN) JJ stated while reviewing R91's medical chart, When (R91) comes back from dialysis the night shift changes his dressing that night. That is what I assume because I've never done a dressing change over his dialysis port. I do not see an order on the MAR to do a dressing change on my shift, 7a-7p. For the night shift, 7p-7a, the order it is not there either. There is no order for R91 to have a dressing change over his port. During an interview and record review on 6/5/24 at 3:02 PM, Clinical Manager (CM) D, reviewed R91's Order Summary, MAR/TAR, and Care Plan stating, I see the order dated 2/23/23 to do a dressing change daily for the dialysis port and it is on the care plan. It is not on his MAR/TAR to be done daily. It should have been a routine schedule to be done and it was not. When the facility does a resident's MDS we look through Care Plans for each department, we look at orders with new orders double-checked. The nurse double-checks with the Provider when they put the order in, and a second nurse double checks the MAR/TAR to make sure the orders are in. (R91's) order was missed. 41424 Resident #291: Review of an Admission Record revealed Resident #291 was a male with pertinent diagnoses which included lung cancer, heart failure, pneumonia, asthma, sepsis, MRSA, diabetes, muscle wasting, and low back pain. Review of current Care Plan for Resident #291, revised on 5/30/24, revealed the focus, .The resident has MRSA in his sputum . with the interventions .CONTACT ISOLATION: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry (follow protocol (policy) .Educate the resident/family/caregivers regarding the importance of hand washing. Use antibacterial soap and disposable towels. Wash hands immediately after ADLs, care tasks, and activities .Give antibiotic therapy as ordered . During an observation on 06/04/24 at 12:05 PM, Resident #291's door was shut to the room. On the door was hanging a personal protective equipment (PPE) pocketed door caddy, a sign which indicated Droplet Precautions and how to don and doff PPE. In an interview on 06/04/24 at 12:57 PM, Licensed Practical Nurse (LPN) Charge Nurse HH reported the resident was on droplet precautions and full PPE would be used when entering the room. LPN HH reported Resident #291 was admitted on [DATE] with pneumonia, sepsis, congestive heart failure, and MRSA. In an interview on 06/06/24 at 11:46 AM, Infection Control Nurse (ICN) YY reported there was no order in the medical record for droplet precautions or contact precautions. ICN YY reviewed the order checks for the admission orders and observed LPN T had completed both the first check and the second check for the admission orders on the same day and at the same time and that should not have happened. ICN YY reported the order checks should have been completed by different nurses, not on the same day, at the same time to ensure the accuracy of the orders. In an interview on 06/06/24 at 12:00 PM, ICN YY reported the resident did not come to the facility with precautions as he didn't need it as he was not productive coughing and he had been on multiple antibiotics for extended lengths of time. ICN YY reported he was on an antibiotic as a prophylactic measure, the resident was not symptomatic, and infectious disease had treated him extensively with multiple antibiotics and basically released him. ICN YY reported she ran an antibiotic report every day and that was how she was aware of Resident #291 being admitted . ICN YY reported the resident would have been on enhanced barrier precautions (EBP). ICN YY reported since EBP had started the nurses see certain diagnoses and get confused and had a hard time with implementing EBP. In an interview on 06/06/24 at 12:37 PM, IFC YY reported she went through the chart and was not sure how the staff decided to implement the droplet precautions. IFC YY reported no one asked her for clarification and she assumed the nurse saw MRSA in sputum and placed the resident on droplet precautions. IFC YY reported the care plan should have been updated for enhanced barrier precautions for Resident #291. IFC YY reported the unit managers have been the ones to update the care plans when they review the admission, as they were responsible for the MDS as well. In an interview on 06/06/24 at 01:57 PM, Director of Nursing (DON) B reported the admission paperwork came to the nurse and the nurse would take it to the unit clerks who would enter the orders, then the nurses make the updated first check of the orders, the Unit Manager does the other checks. DON B reported the unit managers created the baseline care plans. Once the care plan was created, it was a collaborative effort between members of the interdisciplinary team to update the care plans as it was treated as a working document for the resident and accessed on a frequent basis. DON B reported when there was a new admission the referral was reviewed and complete a work up to see the diagnoses, if any specialty equipment was needed, what the potential residents functional status was, diets needed, etc. DON B reported contact precautions was the option available to the nurses when the care plan was created and she needed to have the other precautions added but there was in there the option to select enhanced barrier precautions (EBP). DON B reported the resident should have been placed on EBP. DON B reported because of the MRSA diagnosis and the antibiotic use, the nurses felt Resident #291 was supposed to be on droplet precautions and the order did not get entered for droplet precautions as it was not on his discharge orders from the hospital. The medical record is a legal document and is used to protect the patient as well as the professional practice of those in healthcare. Documentation of the care you give is proof of the care you provide .Charting is objective, not subjective. This means chart only what you see, hear, feel, measure, and count, not what you infer or assume. All nurses know that if it wasn't charted, it wasn't done the patient's complete and accurate medical record the most reliable source of information on the care of that patient. Proper nursing documentation prevents errors and facilitates continuity of care. (https: //www. asrn.org/journal-chronicle-nursing/341-charting-and- documentation.html) The quality of patient care depends on your ability to communicate with other members of the healthcare team. Regardless of whether documentation is entered electronically or on paper, each member of the health care team needs to document patient information in an accurate, timely, concise, and effective manner to develop and maintain an effective, organized, and comprehensive plan of care. When a plan is not communicated to all members of the health care team. Care becomes fragmented tasks are repeated and delays or omissions in care often occur. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 23982-23986). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review the facility failed to provide a written notice of transfer for 1 of 2 residents (Resident #98) reviewed for hospitalization , resulting in the potential of residents and/or resident representatives being uninformed of the reason for transfer and their rights, and failed to provide timely notification to a representative of the Office of the State Long-Term Care Ombudsman for emergency transfer of residents being discharged , residents left without an advocate to inform them of their rights, and for the Office of the State Long-T erm Care Ombudsman to be unaware of the facilities practices related to transfers and discharges. | Findings include: Resident #98: Review of an Admission Record revealed Resident #98 was a male with pertinent diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms (BPH has frequent urination, weak stream, leaking or dribbling of urine), obstructive and reflux uropathy (urine flow is blocked causing urine to back up into the kidneys) and bladder neck obstruction, and cystostomy status (suprapubic catheter). Review of current Care Plan for Resident #98, revised on 10/25/22, revealed the focus, .The resident has a suprapubic catheter: due to BPH, urinary retention related to CVA (stroke), and obstructive and reflux uropathy. He has a history of urinary tract infections .Suprapubic was placed on 1/13/22. New surgical placement on 6/28/22 . with the intervention .Enhanced barrier precautions .Monitor for s/sx of discomfort on urination and frequency .Monitor/document for pain/discomfort due to catheter . Review of Secure Conversations dated 2/9/2024 at 7:06 PM, revealed, .(Licensed Practical Nurse (LPN) OO: Resident sent out to (Local Hospital) for an eval via AMR for severe distention of abdomen, severe pain, and fever. UA sent out to (Local Hospital) today at 2pm. Family has been notified and will meet resident at the hospital . Review of Nursing Progress Note dated 2/10/2024 at 2:58 PM, revealed, .Update from (Local Hospital): Resident was admitted late last night for obstructed kidney stone, currently in surgery and will likely stay another 1-2 days . Review of Admission Summary dated 2/13/2024 at 5:08 PM, revealed, .Resident admitted to facility on 7/20/2020 from [NAME] Community Hospital r/t Ureterolithiasis .INFECTION STATUS: Resident is being treated for an infection. Bactrim DS as preventative for kidney stone removal Resident is not receiving IV antibiotics . Resident does not have an active MDRO infection. Resident does not require TBP, continue with standard precautions .GUASSESSMENT: Relevant History/Current GU Problems: SP CATH d/t obstructive and reflux uropathy, BPH. Resident has a catheter Catheter Type: suprapubic catheter. Resident is continent of bladder. Urinary symptoms/complaints noted upon admission include: None . Review of Antibiotic Charting dated 2/16/2024 at 11:36 PM, revealed, .Resident is on Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 MG for Urinary Tract Infection,,. Resident has a suprapubic catheter. No adverse reactions noted to antibiotic. No improvement noted to symptoms. Describe symptoms: Emptied foley bag, 700 output at 2248. Noted left flank has large amount of swelling, resident rated pain 5/10. Flushed foley catheter with 60cc. Resident appears relaxed. Afebrile . In an interview on 06/06/24 at 01:29 PM, LPN JJ reported when a resident was sent to the hospital, there was a packet which was sent and it included the bed hold and resident information. The paperwork was handed to the ambulance service. LPN JJ reported the interact form used for transfer was sent with the paperwork. In electronic correspondence received on 06/06/24 from the local Ombudsman, she reported she had not received the transfer notices since 2022. In an interview on 06/06/24 at 01:32 PM, Clinical Manager (CM) E reported the facility would call the resident or the representative about the bed hold. CM E was not sure the resident initiated or facility initiated transfer form was sent with the resident. The interact form was sent with the paperwork. In an interview on 06/06/24 at 01:35 PM, Social Worker (SW) MM reported she does not send the resident emergent transfer information to the Ombudsman. In an interview on 06/06/24 at 01:42 PM, Director of Nursing (DON) B reported the unit clerks gathered the paperwork for a transfer out to the hospital. The admissions coordinator would contact the resident or representative to determine if they would like to go with the bed hold. DON B reported there was no documentation in the medical record the communication had happened. DON B reported she was not familiar with the resident initiated or facility initiated transfer form which would have been sent with a resident at a discharge and that the Ombudsman would need to receive documentation of the transfers.

Based on observation, interviews, and record review, the facility failed to ensure services to maintain and prevent further decrease in ROM (range of motion) for 1 of 2 residents (Resident #7) reviewed for limited ROM, resulting in the potential for decreased ROM, contractures (hardening of the muscles, tendons, and other tissues) and pain. Findings include: Resident #7 Review of an Admission Record revealed Resident #7 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: cerebral palsy (a disorder of movement, muscle tone, or posture). Review of a Minimum Data Set (MDS) assessment for Resident #7, with a reference date of 4/18/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #7 was cognitively intact. Review of Resident #7's Care Plan revealed, .Restorative: Active Range of Motion Date Initiated: 08/29/2022. Goal: Maintain ROM to Extremities. Revision on: 11/07/2023. Interventions: Notify nurse if decline or significant change in performance. Revision on: 05/01/2024. Notify nurse if pain is present/increased or presents with performance of plan. Revision on: 05/01/2024. PROM (passive ROM: staff moves the joint) to upper and lower extremity Joints 5 reps each daily with cares. Revision on: 05/01/2024. Review of Resident #7's Kardex (CNA care guide) revealed, .PROM to upper and lower extremity Joints 5 reps each daily with cares. In an interview on 06/04/24 at 01:03 PM, Resident #7 reported concerns with increasing pain and cramps in her legs. Resident #7 reported that she was not getting any type of therapy for her arms and legs and stated, .they are supposed to do it every day, but don't .I wish the therapist would show them how to do it . In an interview on 06/05/24 at 01:59 PM, Resident #7 reported that the CNA's had not done any ROM with her yet that day. During an observation on 06/05/24 at 02:17 PM, CNA Z and CNA III transferred Resident #7 into bed, performed incontinence care and then transferred her back into her wheelchair. There was no observation on ROM activities performed. In an interview on 06/05/24 at 02:32 PM, CNA Z reported that she does ROM with Resident #7 when she gets the resident dressed in the morning, and she had done it that morning. CNA Z reported that when she was educated by the facility, she was told that getting the resident dressed in the morning is considered ROM and stated, .no, I do not bend her arms or legs .I try not to . In an interview on 06/05/24 at 02:33 PM, CNA III reported that the only time ROM involves repetitions of bending legs and arms is when therapy does it. In an interview on 06/06/24 at 11:09 AM, Clinical Manager (CM) C reported that Resident #7 was very aware of her ROM needs and would prefer to be in therapy all of the time. CM C reported that Resident #7 becomes anxious when she does not have Biofreeze (pain relieving cream) and also if she has a decrease in her ROM abilities. In an interview on 06/06/24 at 11:10 AM, CM D reported that the CNA's should be performing PROM per Resident #7's care plan, which consists of repetitious movement of her arms and legs. CM D reported that she had not heard that Resident #7 had any concerns with her ROM being performed, but that she had not specifically asked the resident about it. In an interview on 06/06/24 at 11:11 AM, CNA Manager (CNA-MA) S reported that the staff that get Resident #7 dressed in the morning are typically who would be expected to perform the PROM, and that she expected that CNA's perform repetitions of moving the residents arms and legs per the care plan, and not just once when they put her arms through her shirt and/or legs through her pants. Review of the CNA Tasks revealed that CNA's were documenting Resident #7's tolerance of PROM exercises to the upper and lower extremity joints 5 reps daily with cares. The documentation over the past 30 days indicated at the resident tolerated well 12 of 30 days, tolerated poorly 10/30 days, resident refused due to pain 1/30 days, and not applicable 5/30 days. Review of Resident #7's Occupational Therapy Evaluation dated 12/28/23 revealed, .Diagnoses: .cerebral palsy, muscle wasting and atrophy .Contracture Functional Limitations Present d/t (due to) Contracture = Yes; Functional Limitations as Result of Contracture(s): ADL tasks; Is skilled therapy needed to address impairment? = No (Staff educated on PROM restorative care) . Review of the facility policy ROM (Range of Motion) dated 12/4/2023 revealed, Policy: To exercise the resident ' s joints and muscles and to maintain function and prevent decline for as long as possible. Guidelines: 1. Review resident ' s Plan of Care for special needs. 2. Support the extremity at the joint as it is being exercised. 3. Move each joint through its range of motion three (3) times unless otherwise instructed. 4. Move each joint gently, smoothly and slowly through its range of motion. 5. Remember to stop an exercise before the point of pain. 6. Include range of motion in dressing and undressing the resident as much as possible. 7. Encourage resident to actively stretch and move joints .

Based on observation, interview and record review, the facility failed to follow orders for monitoring of blood sugars for 1 resident, (R292), and to follow orders for dressing changes for 1 resident, (R119) resulting in the lack of monitoring and the resident not receiving appropriate interventions with the potential of worsening health status. Findings include: Resident #292: The quality of patient care depends on your ability to communicate with other members of the healthcare team. Regardless of whether documentation is entered electronically or on paper, each member of the health care team needs to document patient information in an accurate, timely, concise, and effective manner to develop and maintain an effective, organized, and comprehensive plan of care. When a plan is not communicated to all members of the health care team. Care becomes fragmented tasks are repeated and delays or omissions in care often occur. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 23982-23986). Elsevier Health Sciences. Kindle Edition. Review of an Admission Record revealed Resident #292 was a female with pertinent diagnoses which included gastrostomy status (artifical entrance to the stomach, tube feeding), parkinson's disease, irritable bowel syndrome (IBS), acquired absence of parts of digestive tract, cancer of small intestine, muscle wasting, GERD, disease of the esophagus, kidney disease, and dysphagia (a condition that affects your ability to produce and understand spoken language). Review of current Care Plan for Resident #292, revised on 5/16/2024, revealed the focus, .I am at risk for malnutrition as evidenced by Dx (diagnosis) Parkinson's, depression, GERD, metastatic neuroendodrine tumor of ileum/jejunum (NET) (small bowel tumor that can spread to the liver and regional lymph nodes with symptoms which include weight loss, diarrhea, nausea/vomitting, tired, bloated) s/p (status post) small bowel resection, dysphagia requiring enteral feeding/NPO status . with the intervention .Administer medications per physician orders .Diet per physician order: NPO (nothing by mouth) Jevity 1.5 enteral feeding and flushes per physician order .Obtain labs as ordered and notify physician of abnormal results . Review of Orders for Resident #292 revealed, .Please check BS (blood sugar) Q AM before breakfast and before dinner x5 days dtr says pts BS was low at times .dated 5/13/24 . Review of Resident #292's record revealed there were no blood sugar results taken prior breakfast and prior to dinner. In an interview on 06/06/24 at 11:23 AM, Licensed Practical Nurse (LPN) O the orders for Resident #292 and reported the order was written on 5/13/24, was only to be done for 5 days, before breakfast and dinner. LPN O reviewed the vitals section for Resident #292 and there were no blood sugar results, reviewed the results section for lab work and reported on 6/4/24 the blood sugar results were 78. In an interview on 06/06/24 at 11:31 AM, Clinical Manager (CM) C reviewed the vitals section on the profile and reported there were no blood sugar results. CM C reviewed the treatment administration record (TAR) and reported there were no results there as well. CM C reviewed the order and reported it was entered by the provider and checked by RN EEE. CM C when an order was entered by a provider, the double check of the order was the nurse who reviewed it. CM C opened the order and discovered the order did not have a routine or schedule attached to it and without that it would not transfer over to the medication administration record (MAR) so the nurse would be prompted to check the blood sugar on their screens. CM C since the provider entered the order, there would only be the two checks and if it was a verbal order then there would be three checks. CM C reported RN EEE should have caught there was no routine/schedule attached to the order when she completed her check. CM C reviewed the Skilled Dcoumentation assessment which would pull over to a progress note to verify if a blood sugar had been documented in the assessment and there were no progress notes with blood sugars noted in them. In an interview on 06/06/24 at 02:11 PM, Director of Nursing (DON) B reported the provider's template did contain a schedule and in review of the medical record for Resident #292 the provider entered the order manually and did not include a schedule which did not prompt the nurses to complete blood sugar checks for Resident #292 as she was a resident who received nutrition through a tube feeding with the potential for variations with her blood sugar levels. Resident #119: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 72648-72650). Elsevier Health Sciences. Kindle Edition.A health care provider's order for changing a dressing indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound . According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 20790-20791). Elsevier Health Sciences. Kindle Edition.Nurses are responsible for performing all procedures correctly and exercising professional judgment as they carry out health care providers' orders . Review of an Admission Record revealed Resident #119 was a male with pertinent diagnoses which included cancer of the temporal lobe and brain. Review of current Care Plan for Resident #119, revised on 7/10/2018, revealed the focus, .The resident has wound on his head (right lateral) related to cancer. At times his wife removes the dressing on her own. This was something she did for him at home . with the intervention .Change wound dressings as ordered .EBP (Enhanced Barrier Precautions) .Keep skin clean and dry .Monitor/document locations, size, and treatment of skin injury. Report abnormalities, failur eot heal, s/sx (signs and symptoms) of infection, maceration (excessive moisture, leading to the softening and breaking down of the surrounding skin) . During an observation on 06/04/24 at 02:15 PM, Resident #119 was observed lying in his bed on the phone with the head of the bed at approximately 45 degrees with pillows behind him. There was another male in the room with him. room [ROOM NUMBER]: Sverre [NAME]: was on the phone when attempted to speak to him, had a male visitor in the room. During an interview and observation, Hospice Volunteer BBB exited Resident #119's room and informed me the resident was on the phone with his daughter and he was a volunteer with hospice who went to visit residents in the facility. Review of Order dated 4/19/24, revealed, .Dressing Change: change dressing to right skull wound daily. Remove old bandage, lay patient flat on right side in bed with pad underneath head and allow woudn to drain for 10 minutes, cleanse surrounding ares with NS (normal saline), apply 1/3 ABD pad over wound and wrap head with coban (a bandage wrap that adheres to itself with no sticky adhesives) to secure, then secure coban wiht tape .every day shift . During an observation on 06/04/24 at 02:31 PM, Licensed Practical Nurse (LPN) OO had entered Resident #119's room as he was lying in the bed with the head of the bed at approximately 60 degrees. LPN OO was observed to not have a gown or face mask on. LPN OO began to remove the bandages wrapped around Resident #119's head. LPN OO reported she was cleaning the inside of the wound with normal saline and gauze. LPN OO reported it was a chronic surgical wound. Resident #119 reported he had a craniontomy performed due to a lesion on his brain and the wound was from the surgery. LPN OO used a tablet to take a photo of the wound and reported it would upload to the medical record. LPN OO placed a non stick pad to the dressing and wrapped his head with gauze. Note: LPN OO did not allow the wound to drain for 10 minutes prior to changing the dressing and did not wrap the head with coban. In an interview on 06/04/24 at 02:51 PM, LPN OO reported she did not don a gown when she performed a dressing change on Resident #119 and she did not allow the wound to drain for 10 minutes prior to cleaning and applying a new bandage. In an interview on 06/05/24 at 02:37 PM, Registered Nurse (RN) Y reported prior to the dressing change for Resident #119, the bandage had to be removed and allowed to drain, lying on the right side to help it drain, before she could replace the bandage. RN Y reported the wound was opened more due to the tumor started growing again, it opened the wound back open and it has to drain. In an interview on 06/06/24 at 02:15 PM, Director of Nursing (DON) B reported for the wound dressing change for Resident #119, the gown and gloves were appropriate for the dressing change as there was no risk of splashing from the wound care. DON B reported the wound had to be allowed to drain for 10 minutes prior to applying the new dressing. DON B reported the spouse of Resident #119 was permitted to change the dressing on Resident #119 using the supplies per the hospice order. DON B reported this order was entered when Resident #119 was at the facility earlier in the year for respite but was unable to locate it when asked to review the order. DON B reported the facility did not rediscuss the order for allowing the wife to do the dressing change as the wound was draining more and upon his return for long term care. This writer requested the order to allow the sposue to change the dressing and it was not received prior to exit from the facility.

Based on observation, interview, and record review, the facility failed to prevent a facility acquired pressure ulcer and provide pressure ulcer preventative care and monitoring consistent with professional standards of practice for 1 out of 4 residents (Resident #79) reviewed for pressure injuries, resulting in the development and worsening of a Stage III pressure ulcer on the sacrum (coccyx), the development of a pressure injury on left lateral ankle, and the potential for skin breakdown and overall deterioration in health status. Findings include: Review of an Admission Record revealed Resident #79 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #79, with a reference date of 11/24/21 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #79 was moderately cognitively impaired. Review of the Functional Status revealed that Resident #79 required extensive assistance of 2 people for mobility in bed. Review of Resident #79's Skin Integrity Care Plan revealed, The resident has potential impairment to skin integrity of the r/t (related to) fragile skin, Immobility. High risk due to poor intake, etc with a significant decline .Date Initiated: 11/04/2021. GOALS: The resident will maintain intact skin by the review date. Date Initiated: 11/04/2021 Revision on: 12/14/2021. INTERVENTIONS: Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 11/04/2021. Identify/document potential causative factors and eliminate/resolve where possible. Date Initiated: 11/04/2021. Keep skin clean and dry. Use lotion on dry skin. Date Initiated: 11/04/2021. Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no interventions related to repositioning or heel protection. Review of Resident #79's Pressure Ulcer Care Plan revealed, The resident has developed a stage 3 pressure ulcer on her coccyx due to immobility and confusion r/t Dementia. Developed another wound on her wound to her left posterior lower leg. Date Initiated: 12/07/2021 Revision on: 12/28/2021. INTERVENTIONS: .Air- flow pressure reduction mattress .Date Initiated: 12/07/2021. Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed, drainage and healing progress . Date Initiated: 12/07/2021. Avoid positioning the resident on coccyx. Date Initiated: 12/07/2021 .Follow Pressure Alert Protocol. Date Initiated: 12/07/2021 .Monitor dressing to ensure it is intact and adhering. Date Initiated: 12/07/2021. Review of Resident #79's Kardex (direct caregiver care guide) revealed, .Resident Care: Air- flow pressure reduction mattress .12/1/2021. Avoid positioning the resident on coccyx . There were no interventions related to turning/repositioning, HOB (head of bed) level or heel protection, and no indication that the resident had a pressure ulcer. Review of Resident #79's Braden Scale for Predicting Pressure Ulcers dated 12/8/21 revealed, 15, which indicated that Resident #79 was at high risk for pressure ulcer development. During an observation on 01/12/22 at 09:53 A.M., Resident #79 was lying in bed on her back with the HOB at approximately 30 degrees. During an observation on 01/12/22 at 12:35 P.M., Resident #79 was lying in bed on her back with her eyes closed, the HOB was between 45-90 degrees, and her head and upper body were slumped over to the right. Resident #79 was positioned directly on her coccyx. During an interview on 01/13/22 at 12:48 P.M., Certified Nursing Assistant (CNA) F reported that she had just repositioned Resident #79 and stated, .the nurse asked me to . During an observation and interview on 01/13/22 at 12:51 P.M. Resident #79 was lying in bed, positioned slightly on her left side. Resident #79 stated my bottom is really really bad .so much pain . During an observation and interview on 01/13/22 at 02:58 P.M. Resident #79 was lying in bed, positioned slightly on her right side. Licensed Practical Nurse (LPN) CC and Registered Nurse (RN) HH were in the room to perform a dressing change to Resident #79's wound on her coccyx. LPN CC reported that she does all treatments, as long as there is adequate staffing. A gaping (a hole) wound was observed on Resident #79's coccyx and the dressing had dislodged from covering the wound. The wound was approximately the size of a quarter and was draining whitish fluid. LPN CC cleaned the wound with saline and applied Venelex ointment (topical barrier and moisturizer, that covers and protects pressure wounds) and large bandage. Resident #79 stated, .I want to be turned over to my left side .yes, that's comfortable . During an observation on 01/14/22 at 08:48 A.M. Resident #79 was in bed, positioned slightly on her left side with the HOB between 45-60 degrees, and both of her feet were touching the foot board at the end of the bed and her heels were laying directly on the mattress. CNA MMM was observed assisting Resident #79 with a meal. Resident #79's feet were not off the bed. During an observation on 01/14/22 at 09:59 A.M. Resident #79 was in bed, positioned slightly on her left side with the HOB at approximately 45 degrees. Resident #79's feet were observed touching the foot board at the end of the bed, with her heels directly on the mattress. There was a pillow observed between Resident #79's legs that was not providing any support. This was the same position as the previous observation. During an observation and interview on 01/14/22 at 11:13 A.M. Resident #79 was lying in bed, positioned slightly on her right side, with the HOB between 30-45 degrees, and both feet/heels laying directly on the mattress. There was a flat pillow observed under Resident #79's lower legs, that was not providing support to float her heels. Resident #79 stated, my butt is very tender . During an observation on 01/14/22 at 11:55 A.M. Resident #79 was lying in bed, positioned slightly on her right side, with the HOB between 30-45 degrees, and both feet/heels laying directly on the mattress. During an observation on 01/14/22 at 12:42 P.M. Resident #79 was lying in bed, positioned slightly on her right side, with the HOB between 30-45 degrees, and both feet/heels laying directly on the mattress. Resident #79's head and upper body were now slumped to the right side of the bed. During an observation and interview on 01/14/22 at 12:54 P.M. Resident #79 was lying in bed, positioned slightly on her right side, with the HOB now at approximately 15 degrees, and both feet/heels laying directly on the mattress. Family Member (FM) NNN was in the room and reported that he had lowered the head of the bed and stated, .she (Resident #79) didn't look comfortable .she has a bed sore and says that it's painful . During an observation on 01/14/22 at 01:24 P.M. Resident #79 was lying in bed, positioned slightly on her right side, with the HOB at approximately 15 degrees, and both feet/heels laying directly on the mattress. During an observation on 01/14/22 at 01:52 P.M. Resident #79 was lying in bed, positioned slightly on her right side, with the HOB at approximately 15 degrees, and both feet/heels laying directly on the mattress. Review of Resident #79's Skin & Wound Observation dated 12/3/21 revealed, Pressure, Stage 3: full thickness, Location: (not documented), In-House acquired, How long has the wound been present: New, Exact Date: 12/4/21, 2.6 cm x 1.7 cm x 0.0 cm depth, 0.0 cm tunneling .Evidence of Infection: None, Exudate (liquid drainage): light, Odor: none .Goal of Care: Healable .Progress: New . There were no Skin & Wound Observation records from 12/4/21-12/17/21. Review of Resident #79's Skin & Wound Observation dated 12/18/21 revealed, Pressure, Stage 3 .Location: (not documented), In-House acquired, New, 3.0 cm x 2.0 cm x 0.0 cm depth, 0.0 cm tunneling .Evidence of Infection: None, Exudate: None, Odor: None .Healable .Dressing Appearance: Missing. Progress: (not documented) . Review of Resident #79's Skin & Wound Observation dated 12/26/21 revealed, Pressure, Stage 3: full thickness, Location: sacrum (coccyx), In-House acquired, How long has the wound been present: New, 3.1 cm x 2.7 cm x 1.0 cm depth, tunneling 0.0 cm .Exudate: light .Odor: none .Surrounding tissue: [CONDITION(S)] (red) .Healable .Dressing Appearance: none. Primary Dressing: No dressing applied. Progress: Deteriorating .Notes: wound appears larger and deeper. Review of Resident #79's Skin & Wound Observation dated 12/28/21 revealed, Type: (not documented), Location: (not documented) .How long has the wound been present: (not documented), 5.1 cm x 1.6 cm, 0.5 cm depth .Surrounding Tissue: [CONDITION(S)] .Progress: (not documented) . Review of Resident #79's Skin & Wound Observation dated 1/9/22 revealed, Pressure, Stage 3: full thickness, Location: sacrum (coccyx), In-House acquired, How long has the wound been present: New, 2.1 cm x 1.6 cm x 2.2 cm depth, tunneling 2.2 cm .Evidence of Infection: Increased drainage, Exudate: Heavy .Odor: faint .Goal of Care: Healable .Progress: Deteriorating .Current treatment is cleanse with normal saline, apply Venelex to wound bed, apply magic butt cream peri (surrounding) wound, and cover with sacral [MEDICATION(S)] (bandage dressing). Review of Resident #79's Skin & Wound Observation dated 1/9/22 revealed, Type: (not documented), Location: (not documented) .How long has the wound been present: (not documented), 6.5 cm x 1.6 cm, depth (not applicable), .Evidence of Infection: Redness/inflammation, Exudate: light .Surrounding Tissue: [CONDITION(S)] (redness) .Progress: Deteriorating . During an interview on 01/14/22 at 01:54 P.M. to clarify Resident #79's Skin & Wound Observation records, Assistant Director of Nursing (ADON) C reported that several of the records were missing wound location, wound type and the dates that the wound originated were not accurate and stated, .new would mean it was just found that day . ADON C reported that Unit Manager (UM) DDD would be better able to provide clarification. During an interview and observation on 01/14/22 at 02:04 P.M., UM DDD reported that wound assessments were completed by the floor nurses and Resident #79's documentation was not completed as expected and stated, .there are 2 separate pressure ulcers .coccyx .left lateral ankle .yes, she is at high risk for wounds . UM DDD observed Resident #79 at this surveyor's request for concerns with preventative measures not being in place. Resident #79 was observed in the same position as previous observations. Resident #79's left lower leg was turned towards the outside of the bed and positioned directly on a left lateral ankle wound that was observed with a bandage covering it. Resident #79's heels were observed red and non-blanchable (when pressed does not turn white). UM DDD stated, .she should have the pressure ulcer alerts in place .floating heels .repositioning . During an interview on 01/14/22 at 02:20 P.M., CNA OOO reported that Resident #79 was repositioned on her right side prior to lunch and stated, .she (Resident #79) does not like to be turned on her left side .no, she does not wear boots .she has an air mattress, that's the same . The facility policy Pressure Alert Protocol indicated that a specialty mattress did not replace positioning the heels off the bed. During an observation on 01/14/22 at 02:23 P.M. Resident #79 was still in the same position, lying in bed, slightly on her right side, with the HOB at approximately 15 degrees, and both feet/heels laying directly on the mattress. Resident #79 had been observed in this position for greater than 3 hours, with the exception of the HOB change. During an interview on 01/14/22 at 02:43 P.M., UM DDD reported that Resident #79's care plan did have pressure ulcer alert listed, but it did not pull over any interventions to the Kardex and stated, .so it didn't trigger specific tasks for the staff .like the repositioning . Review of Resident #79's Physician Orders revealed, Pressure Alert Protocol- Follow Pressure Alert Protocol. every shift -Start Date- 12/07/2021 .Wound UDA (skin related assessment) to be completed Weekly on coccyx .for Pressure Ulcer -Start Date- 12/06/2021. Wound UDA to be completed Weekly on coccyx and area to left leg. every day shift .for Pressure Ulcer -Start Date- 01/03/2022. Review of Resident #79's Physician Orders revealed, Monitor blister to left lateral lower leg/shin. every day and night shift -Start Date- 12/19/2021 1900 -D/C Date- 12/28/2021 1117. Place Meplix or Allyvn (foam bandage) dressing to Left Ankle QD (every day) every night shift for Left Ankle -Start Date- 12/21/2021 1900. There was no end date indicated. Review of Resident #79's Physician Orders revealed, Clean coccyx with NS (normal saline) apply [MEDICATION(S)] paste and cover with sacrum dressing every 72 hours or as needed for saturation every day shift every 3 day(s) for Pressure area -Start Date- 12/06/2021 0700 DC date 12/28/2021. Dressing Change - apply Venelex to wound bed on coccyx and cover with Mepliex dressing . every day and night shift .-Start Date- 12/29/2021 0700. Venelex Ointment ([NAME]- [NAME] Oil) Apply to wound bed on coccyx topically every day and night shift related to PRESSURE ULCER OF SACRAL REGION, STAGE 3 .-Start Date- 12/29/2021 0700 There was no end date indicated. Review of the facility policy Prevention of Pressure Ulcer dated 2/22/21 revealed, Purpose: To provide guidelines for skin care to assist in preventing the development of pressure ulcers in residents identified to be at risk. General Guideline: .2. Assess the resident's skin condition per facility skin and wound care program .4. For a person in bed: change position at least every two hours; if indicated, use a special mattress that contains foam, air, gel, or water; and raise the head of the bed as little and for as short a time as possible, and only as necessary for meals, treatments and as medically necessary. Use supportive devices per resident's Plan of Care .Leave the bed covers loose so that air can circulate to all parts of the body and to prevent pressure on toes, feet and heels .Preventative Actions: .When in bed, every attempt should be made to bridge (keeping heels off of the bed) by placing a pillow under ankles or use of other devices as recommended by therapist and prescribed by the physician . Review of the facility policy Pressure Alert Protocol dated 2/17/21 revealed, Purpose: To provide assessment standards for the prevention of pressure ulcers Pressure Alert Protocol will be initiated by Unit Director or designee if resident is assessed to be at risk for pressure ulcer/injury. Factors to be considered in assessing pressure ulcer risk: .4. The Pressure Alert Protocol consists of: a. Bedfast residents/elders will be turned and repositioned a minimum of every 2 hours .d. Immobile residents/elders should have heels off the bed including specialty beds. (i.e. a 20-30-degree angle is sufficient to allow blood flow to surfaces). e. Use pillows or prescribed devices under lower legs .h. Keep head of bed at lowest level and limit time of elevation whenever possible. On high risk residents/elders do not elevate head above 30 degrees to prevent shearing effect on hips and coccyx .

Based on interview and record review the facility failed to transcribe admission orders [REDACTED]. Findings include: Review of the Face Sheet revealed Resident #102 was a [AGE] year old male admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 had a brief interview for mental status (BIMS) score of 3 which indicated he had severely impaired cognition. Review of the Policy Medication Physician order [REDACTED]. Review of the Hospital Discharge Orders dated 5/21/18 revealed Resident #102 was ordered to be given levetiracetam ([MEDICATION NAME], a [MEDICAL CONDITION] medication) . 1500 milligram (mg) oral 2 times a day. Patient takes liquid form . Review of the Medication and Treatment Incident Report dated 5/25/18 revealed [MEDICATION NAME] was ordered upon admission and not noted in (computerized chart) to administer. The Medication and Treatment Incident Report further revealed the Failure to Follow Procedure .to administer an ordered medication. Review of the Incident/Accident Report dated 5/24/18 revealed Resident #102 was reported .guest is having rhythmic repetitive movements, blood dribbling out of mouth. Guest is sitting in recliner, appears to behaving a [MEDICAL CONDITION]. Unable to obtain blood pressure due to condition .(ambulance) arrives to facility .leaves with patient on stretcher. The incident report further revealed the cause/possible cause of incident was History of [MEDICAL CONDITION] and medication error. Review of the Nurses Notes dated 6/4/18 at 4:39 pm revealed Resident #102 admitted from hospital (indicated resident admitted for more than a week due to medication error) for [MEDICAL CONDITION], unspecified. In an interview on 6/27/18 at 1:38 pm, Unit Clerk (UC) J stated, I got orders by fax from the hospital and entered them (orders) into the que (computerized medication order entry, medication entered into the que for not active until a nurse verifies the ordered medication). UC J stated, the nurse checks them over and activates the orders for Resident #102 in the computerized medication order entry. UC J stated, that medication ([MEDICATION NAME]) was tablet but patient (Resident #102) takes liquid form was inconsistent so I made a star next to the [MEDICATION NAME] medication order and let the nurse know that the medication was not placed into the computerized medication order entry. In an interview on 6/27/28 at 1:45 pm, Licensed Practical Nurse (LPN) K stated I .failed to enter the prescription in liquid form for the medication [MEDICATION NAME] for Resident #102. LPN K stated, I took the transfer order packet; the transfer orders (hospital discharge orders) did not coincide with the computerized medication order entry) for Resident #102. LPN K stated Resident #102 did not receive his [MEDICATION NAME] medication as ordered by the discharge hospital. LPN K stated, he (Resident #102) had a [MEDICAL CONDITION] thats why he was on the medication ([MEDICATION NAME]). In an interview on 6/27/18 at 3:35 pm, Unit Manager (UM) O stated, there was an order that was missed, an order for [REDACTED].#102 had a [MEDICAL CONDITION] and was hospitalized . The facility was able to identify and correct the deficient practice prior to the survey being conducted as evidenced by: -On 5/25/18 the facility identified a deficient practice by nursing staff when reviewing the resident's admission medication orders after the resident (Resident #102) was hospitalized . -On 5/25/18, the facility identified that all residents who had been admitted , and will admit, to the facility with discharge medication lists have the potential to be affected by the deficient practice. -On 5/29/18, the facility reviewed the admission orders [REDACTED]. -On 5/25/18 the facility notified all facility nurses and unit clerks of the change in the medication ordering process in all licensed nurses would double-check recording on the admission checklist. -By 5/29/18 the facility had completed education of facility nurses and unit clerks to the policy Medication Orders. -Assistant Nursing Home Administrator and Unit Director of the Rehab Cottage began auditing the admission orders [REDACTED]. Audit findings will be presented to the facility QAPI Committee by the Director of Nursing or designee.

This citation pertains to intake number MI 518 and MI 743. Based on observation, interview, and record review, the facility failed to prevent staff to resident neglect for 1 of 3 sampled resident (Resident #100), reviewed for neglect, from a total sample of 3 residents, resulting in Resident #100 sustaining a fractured left shoulder. Findings include: Review of the facility Incident and Investigative Reports dated 7/27/16, reflected that An Incident/Accident report shall be completed for .All accidents or incidents where there is injury or the potential to result in an injury .Procedure: 1. Nurse is to assess the resident for injury. 10. Nurse is to document in the clinical record the following: Accurate description of the incident/accident, Results of nursing assessment, notification of physician, Identification of etiology/causative factors, 13. Continue to observe the resident closely for any changes. Notify the physician immediately with any changes, such as development of pain, decrease in mobility Review of the facility Abuse Prohibition Program dated 5/2016 reflected, Patients/residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff Definitions .Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or illness . Review of the facility Patient/resident Protection during Abuse Investigation dated 7/27/16, reflected Policy Any employee or any other individual who is accused of PATIENT ABUSE, whether PHYSICAL or VERBAL, will not be allowed in the facility and employees will be suspended without pay pending further investigation Procedure 1. All alleged or suspected neglect or abuse, whether physical, verbal, sexual, involuntary or mental, will be cause for a thorough investigation conducted immediately by facility patrons, inc management. 3. The accused individual will not be permitted to enter the facility unless otherwise directed by the Administrator, until the investigation has been completed and final disposition has been given. Review of the Record of Admission and Minimum Data Set ((MDS) dated [DATE], reflected Resident #100 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS reflected that Resident #100's ability to make daily decisions was cognitively intact and she currently required the assistance of one staff members for toileting, hygiene, and bathing. Review of the Care Area Assessment (CAA) dated 10/21/16. reflected Resident #100 Triggering conditions 2.Surface to surface transfers (transfer between bed and chair or wheelchair) Not steady, only able to stabilize with staff assistance (2). Physical performance limitation: .Difficulty maintaining sitting balance, Impaired balance during transitions. Review of the facility Incident/Accident Report dated (date of event) 1/11/17 early on 3-11 shift, reflected Resident #100 was in her room and had an injury to her left shoulder during a transfer. Aide stated that she had placed gait belt to help resident stand, then saw Hoyer sling (mechanical lift) and removed belt, resident leaned back in recliner. Resident #100 statement of what happened: She tried to have me stand but I told her that I can't stand. Cause/Possible cause of the incident: Certified Nursing Aid (CNA) F not familiar with resident. Comments: Resident complained that aide tried to stand her up, and she nearly fell : stated that she told aide that she could not stand. Aide stated that she put gait belt around resident then noticed Hoyer sling and took belt off. Starting that evening, resident reported pain in left shoulder. Increased severity the next day so that she is not able to move her left arm without pain. Physician M stated no x-ray if pain not severe. Review of the Radiology Report dated 1/13/17, reflected that Resident #100's left shoulder .[MEDICAL CONDITION] head (shoulder fracture). During an interview on 1/25/17 at 3:14 p.m., Human Resource Director (HRD) R reported that she was part of the interview process and her documentation of the interview included CNA F .picked up a shift on Anna's Cottage. Because she was unfamiliar with this unit, CNA F should have taken time to receive report from the nurse and review the patient profile. Instead, she refused report and began providing care. She proceeded to transfer a very frail resident (Resident #100) via gait belt, when this resident is documented to be a Hoyer transfer. In the process of the transfer violation, the resident informed CNA F that she was not to be lifted. CNA F had placed her hands in the armpit area. She lowered the resident back down to her chair after also noticing the Hoyer pad under her. This violation of transfer resulted in a broken shoulder for the resident. While this was under investigation, CNA F worked her next shift on her home unit .She was witnessed by a charge nurse to be performing a transfer violation by using an easy stand lift by herself, when the resident is documented to be a two person transfer . During an interview and observation on 1/24/17 at 8:55 a.m., Resident #100 was in her room sitting in her bed, a sling was on her left arm and she stated I do not want to move my arm because it hurts to move it. Resident #100 reported that she told the lady (CNA) I can't stand my legs are like noodles, she got me half way up. I said I told you I can't do this, I never hit the floor. I hung on for dear life. During an interview on 1/24/17 at 11:40 a.m., CNA F reported that this was not her unit and it was the beginning of the 3-11 shift on 1/11/17, and she had not looked at the Care Guide for the residents on the unit. CNA F reported that she turned on her pager and Resident #100's room had a repeat which meant the call light had been on for a while. CNA F went in Resident #100's room and the resident was very agitated and stated she had been calling for 20 minutes and no one answered, so CNA F placed the wheelchair in front of Resident #100's recliner chair, put a gait belt on her and tried to stand her up. CNA F reported that as she was standing her she saw the Hoyer pad under her and put Resident #100 back on the recliner. CNA F reported she went to get help and the Hoyer lift to assist Resident #100 to bed so she could be placed on the bedpan. CNA F reported that when Resident #100 was rolled to place the bedpan under her, she complained about pain in her left shoulder. CNA F reported that she informed Registered Nurse (RN) C who said it was not normal for Resident #100 to complain about pain. During an interview on 1/24/17 at 12:07 p.m., CNA D reported that CNA F came to ask for assistance with a Hoyer transfer. CNA D reported that Resident #100 was complaining about CNA F who had attempted to stand her, and that when she was put in bed Resident #100 complained about pain to her left shoulder. CNA D reported that he asked CNA F if she reported Resident #100's complaint about pain to the nurse since the resident was not their assignment, but that later checked to see if CNA F had talked to RN C who said she would assess Resident #100. CNA D reported that a family member was in with Resident #100 and she was complaining about the pain in her left shoulder and CNA F trying to stand her. During an interview 1/24/17 at 2:15 p.m., CNA J reported that on 1/11/7 CNA F had picked up an extra shift. CNA J reported that Resident #100's family member came to get her and CNA D to do care for Resident #100 who complained that she had left shoulder pain and she was upset and did not want CNA F around her anymore because she had made her fall. CNA J reported that she informed RN C that Resident #100 was complaining of pain. CNA J reported that RN C was in there when Resident #100 told CNA F to get away from her. CNA J reported that Resident #100 could move her left arm without pain prior to the afternoon shift on 1/11/17. During an interview on 1/24/17 at 1:39 p.m., RN C reported that at 4:30 p.m. on 1/11/17 she took Resident #100's medication in and Resident #100 told her about a CNA who tried to have her stand up. RN C reported that she could not recall anyone telling her Resident #100 was painful. RN C reported that she did not think about doing an Incident/Accident Report on 1/11/17, because there did not appear to be an injury until she came in on 1/12/17 and the pain had increased. During an interview on 1/24/17 at 12:55 p.m., LPN H reported that she received report from CNA N that Resident #100 could not move her left arm without hurting her. LPN H reported that she came in on 1/12/17 at 3:00 a.m. and no one had informed her of any problems with Resident #100. LPN H reported that it was not normal for Resident #100 to have pain with movement. LPN H reported that she informed her supervisor RN K about the pain in Resident #100's arm and that she had given her Tylenol. LPN H reported that she had emailed the Unit Director RN L about an unknown CNA trying to stand Resident #100 and Resident #100 reporting that she had informed the CNA that she could not stand. During an interview on 1/24/17 at 2:30 p.m., RN K reported that on 1/11/17 she came on shift at 9:00 p.m. and that no one informed her about any incident with Resident #100 until 1/12/17 at about 6:00 a.m RN K reported that she called the Unit Director RN L to tell her Resident #100 had complained about arm pain and that a CNA had grabbed arm and that's what caused the pain. RN K reported that Resident #100's arm hurt if she moved it a little, that it did not feel displace, her pain medications were increased, she was concerned due to fragile bones, and that she felt it could have been a fracture. RN K reported that the CNA who had hurt Resident #100 had not followed the care plan or the CNA Care Guide. During an interview on 1/24/17 at 12:00 p.m., LPN G reported that on 1/12/17 Resident #100 had pain and she had been medicated with as needed Tylenol. LPN G reported that she did not call the physician, but did talk to him at noon when he called in. LPN G ask Physician M about an x-ray due to pain, but did not inform Physician M that Resident #100's pain was with movement of her left shoulder and that she had decreased movement. LPN G reported that Physician M did not want an x-ray at this time and to monitor the pain. During an interview on 1/24/17 at 1:35 p.m., Unit Director RN L reported that LPN H called to report pain in Resident #100's left shoulder and that Tylenol was effective, and that Physician M said to continue to monitor the pain. Unit Director RN L reported that she spoke to CNA F about the transfer of Resident #100 on 1/11/17 and another nurse had just given CNA F a write up for not following the transfer care plan of a different resident. During an interview on 1/24/17 at 3:00 p.m., RN E reported that some time between 12/23/16 and 12/28/16 (she was not able to recall the exact day) she counseled CNA F for not following the care plan and CNA Care Guide when transferring a different resident. RN E reported that she monitored CNA F the rest of her shift, but that she did not work with her that often. RN E reported that at the beginning of each shift the nurse goes through how to transfer each resident in report to the CNA's. Review of the facility Correction Action Report dated between 12/23/16 and 12/28/16, documented by RN E, Corrective Action Being Taken: counseling .CNA F was assisting guest in room [ROOM NUMBER] (not Resident #100) Transfer status as determined by PT/OT was a 2 person assist using gait belt and slide board to prevent weight bearing to right leg. Right leg was casted. CNA F was alone in room with guest, guest was sitting on bedside commode. CNA F stated she had transferred her there herself using gait belt .Describe Behavior/Action Necessary for Improvement: CNA F will always be mindful of safety. Follow care plans. State how, when, and by whom behavior/action will be monitored/reviewed: Charge nurse will monitor CNA F during all shifts to maintain safety .Supervisor Addition Comments: Discussed with CNA F the potential for injury to guest and herself when not following recommended transfer status. CNA F is aware of this and verbalized that she was understanding of the expectation. During an interview on 1/25/17 ay 2:37 p.m., RN P reported that she was a full time day shift nurse on the 500 hall, was not aware that CNA F was counseled for transferring and had not been monitoring her during times they were working together. During an interview on 1/25/17 at 2:30 p.m., RN Q Unit Director reported that that she had been on vacation when RN E counseled CNA F and RN E was doing her duties. RN Q reported that the Corrective Action Report dated some time between 12/23/16 and 12/28/16 would have come to her desk and she would have informed the other nursing staff on the unit about the counseling. RN Q reported that RN E should have been aware of this. RN Q reported that the counseling would not have been reported to any other units in the facility. Review of the Activities of Daily Living (ADL) Care Plan dated 7/21/15 reflected Resident #100 has an ADL self-care performance deficit related to Musculoskeletal impairment with limited mobility. Resident #100 has had a pathological fracture in her back from [MEDICAL CONDITION]. She also has [MEDICAL CONDITION] arthritis . Interventions/Tasks - Transfers: Hoyer with 2 staff assistance for transfers (10/28/15). Review of the Fall Care Plan dated 1/28/16, reflected Resident #100 is alert and oriented x 3 and does not try to self-transfer. Interventions/Tasks Hoyer lift for transfers. Review the CNA Care Guide dated 1/16/17, reflected SAFETY Hoyer lift for transfers. Transferring TRANSFERS: Hoyer with 2 staff assistance for transfers. In an interview on 1/24/16 at Director of Nursing reported that the CNA Care Guide had not been updated after the incident on 1/11/17. Review of the Progress Notes dated 1/11/17, reflected that there was no documentation of Resident #100 pain in left shoulder or her receiving any pain medications. Review of the Progress Notes dated 1/12/17 at 6:36 a.m., reflected Resident #100 complained left upper extremity (LUE) pain to staff who reported to signee. Resident unable to lift arm at this time due to pain. Signee assessed resident's LUE and administered PRN (as needed) Tylenol for the pain. No injuries noted at this time. Review of the Progress Notes dated 1/12/17 at 9:07 a.m., reflected Resident continues to report pain in left shoulder, at the top of the shoulder. Occurs with any movement of the left arm. Some relief from Tylenol and Biofreeze, but only while arm is still. #

This citation pertains to MI 272. Based on observation, interview and record review, the facility failed to prevent the elopement and ensure safety in 1 of 5 sampled residents (Resident #101), from a total sample of 5 residents reviewed for wandering/elopement, resulting in an immediate jeopardy (IJ) when Resident#101 left the faciity on [DATE] at approximately 10:30 a.m., unbeknownst to facility staff. Resident #101 was found on the sidewalk, across the street from the facility at approximately 10:45 a.m., meaning the resident crossed a 3 lane, 35mph street. This deficient practice placed 3 additional residents at risk for serious harm, injury and /or death. Findings include: Review of the Face Sheet, [DIAGNOSES REDACTED].#101 was an [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #101 had a history of [REDACTED]. The MDS indicated Resident #101 was to be supervised for transfers and locomotion on the unit. Review of the Elopement Assessment, dated 4/24/14 at 11:15 a.m., revealed Resident #101 was "at risk " for elopement from the facility. Review of the Care Plan "Elopement", dated 4/14/14, revealed a "goal" for Resident #101 was to "not leave the building unattended". Interventions included: residing "in a locked unit" and "wanderguard" (alarm device used to notify facility if residents exit out a facility door). In an observation and interview on 6/9/14 at 2:35 p.m., Resident #101 was noted to be in her bed with Certified Nurse Aide (CNA) #7 at her side. Resident #101 stood from the bed with steady gate with her alarm sounding. CNA #7 asked Resident #101 to be seated and she complied. Resident #101 stated she had been outside this morning. Resident #101 stated, "I came over from my house." Resident #101 was not able to answer any questions about the elopement. Review of the Facility Incident/Accident Report dated 5/23/14 at 10:45 a.m. revealed an incident of "elopement", on 5/23/14, by Resident #101 was not witnessed and Resident #101 was "observed...outside the facility on the sidewalk." The Incident/Accident Report revealed "cause/possible cause of incident" was a "dining room window (was) unlocked." The Incident/Accident Report revealed Resident #101 was "ambulatory...confused, agitated" and had "poor safety awareness." Review of the Incident/Accident Report witness statement revealed (CNA #4) "did open the dining room window to air out..." the locked dementia unit during third shift on 5/22/14. Review of the Corrective Action Report dated 5/23/14 (un-timed) revealed "on 5/23/14 a window in the dining room was found to be unlocked and open after a resident was noted to have left the facility unattended." The Corrective Action Report revealed "during the investigation of this incident (CNA #4) stated she had unlocked and opened the dining room window while mopping on her 11-7 shift from 5/22/14- 5/23/14...(CNA #4) stated she shut the window and thought she had locked it." The Corrective Action Report revealed "GHS (Good Shepherd Home) is a locked unit, it is the expectation of the staff that they maintain the locked security of the unit" and "the resident...was brought back in the building...however the potential for harm was present." In an interview on 6/9/14 at 8:02 p.m., CNA #4 stated that on 5/22/14 at approximately 1:00 a.m., she unlocked the dining room window in the locked dementia unit. CNA #4 stated "I dropped it from the top (opened the window in the locked dementia unit)" for fresh air. CNA #4 stated, "I thought it (the window) was locked but it turned out not to be locked." CNA #4 stated, "It 's supposed to be a locked unit so I shouldn't have unlocked and opened the window." In an interview on 6/9/14 at 3:55 p.m., CNA #12 stated that on 5/23/14 at approximately 10:15 a.m., Resident #101 was in the dining room on the locked dementia unit "at her table." CNA #12 stated Resident #101 was "an exit seeker." CNA #12 stated she then assisted residents to an activity in the living room of the locked dementia unit. CNA #12 stated the next time she observed Resident #101 was when she noticed Resident #101 "on the other side of the road on the sidewalk" from the facility. In an interview on 6/9/14 at 4:16 p.m., Activity Director (AD) #9 stated that on 5/23/14 at approximately 10:00 a.m., she observed Resident #101 "sitting at a table in the dining room." AD #9 stated, at approximately 10:30 a.m., "I looked out the window and saw somebody" outside the facility on the sidewalk. AD #9 reported that she went to CNA #13 and told CNA #13 "I think one of our ladies is outside." AD #9 reported that CNA #13 stated, " Yes" and went to alert the nurse. AD #9 stated, "I walked down the hallway and saw the window open all the way open (in the dining room)." AD #9 stated the windows of the locked dementia unit "are locked for a reason, people (residents) can open them and get out." In an interview on 6/9/14 at 9:12 p.m., CNA #13 stated that on 5/23/14 at approximately 10:45 a.m., she was alerted by AD #9 a resident had been observed outside the facility. CNA #13 stated she went to the window and observed Resident #101 "across from the parking lot" outside the facility locked dementia unit. CNA #13 stated Resident #101 "was across the street already". CNA #13 reported she then alerted LPN #10 that Resident #101 was outside the facility. In an interview on 6/9/14 at 3:17 p.m., Licensed Practical Nurse (LPN) #10 stated that on 5/23/14, at approximately 10:45 a.m., CNA #13 "told me she (Resident #101) was out front" of the facility. LPN #10 stated, "I went to the window and saw her (Resident #101)." LPN #10 stated Resident #101 "was on the other side of the street" from the facility. In an interview on 6/9/14 at 2:25 p.m., CNA #7 reported that LPN #10 told her Resident #101 was outside the facility on 5/23/14. CNA #7 stated, "I went through the gate, crossed the road" and Resident #101 "was on the corner, across the street, on the sidewalk." CNA #7 stated she brought Resident #101 back to the facility. In an interview on 6/9/14 at 3:50 p.m., Housekeeper #11 stated that on 5/23/14 at approximately 11:00 a.m., "I closed the window in the dining room" of the locked dementia unit. Housekeeper #11 stated the window "was all the way up" and had "no screen." Housekeeper #11 stated the windows are "supposed to be locked at all times." On 6/10/14 at 3:45 p.m., Administrator #1, Director of Nursing (DON) #2 and Assistant Director of Nursing (ADON) #14 was notified of the Immediate Jeopardy that was identified on 6/9/14 and began on 5/23/14 at approximately 10:45 a.m. for Resident #101 who was identified at risk for elopement, and left the faciity on [DATE] at a time determined to be between 10:30-10:45 a.m., unbeknownst to facility staff. On 6/11/14 the surveyor confirmed the facility implemented the following to remove the Immediate Jeopardy. 1. On 5/23/14, upon noticing Resident #101 was outside the facility, Resident #101 was brought back into the locked unit by staff. The nurse assessed Resident #101 for injuries and found none. A staff member was assigned as a 1 to 1 for Resident #101 and was continued until 5/27/14. All windows were assessed and confirmed locked in the dementia unit where Resident #101 resides. 2. On 5/23/14, Maintenance was contacted to evaluate the windows in the locked dementia unit. No issues were noted with any windows in the locked unit. 3. On 5/23/14, All 18 of 18 residents were accounted for in the locked unit where the elopement occurred. 4. On 5/23/14, 4 of 47 Licensed Nurses and 13 of 98 CNA's working on the 7 a.m. - 3 p.m. and 3 p.m. - 11 p.m. shift were instructed that at no time are any windows to be opened in the locked unit. No staff will work the locked unit until the education is completed. 5. On 5/23/14, 4 of 47 Licensed Nurses were educated by ADON #14 to verify and documented all windows were closed and locked on the locked unit. 6/ On 5/23/14, Wanderguards for Residents residing in the Good Shepherd Home (GSH, locked unit) were checked and verified as functioning properly. 7. On 5/23/14, CNA #4 stated to ADON #14 she had a key and did open the window to air out the room after mopping the floor. CNA #14 was counseled over the phone and then in writing on 5/29/14 which was her next scheduled work day. 8. On 5/23/14, ADON #14 reviewed the Elopement policy and determined that no changes needed to be made. 9. On 5/26/14, Maintenance placed a bolt on the Atrium windows in the locked unit. The Atrium exits to another locked area in the building and a locked courtyard. 10. On 5/26/14, Administrative staff began collecting keys from staff members. By 5/28/14, all keys were collected and Maintenance Director (MD) #3 had possession of keys to windows in the locked unit. 11. On 5/26/14, the Locked unit was instructed by DON #2 to review care plans on all residents with Wanderguard's. Those with continued need were reduced from 16 to 13 residents. 12. On 6/10/14, Reassessment of all residents for elopement was started. No new residents were identified as elopement risk. 13. On 6/11/14, hourly checks were initiated on those residents who have been identified as a wandering risk. The hourly checks will continue until an evaluation determines the resident is no longer a wandering risk. 14. Functionality of the wandergard doors were checked on 6/11/14 and all doors were found to be functioning properly. 15. Functionality of the wandergard bands are checked every evening shift, which was policy, and will continue. Although the Immediate Jeopardy was removed on 5/26/14, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance had not been verified by the State Agency. ( )