Every finding on record at Ridgecrest Village

Based on observation, clinical record review and staff interviews, the facility failed to provide care that promotion each resident's dignity, demonstrated when staff failed to assist a dependent resident change out of a heavily soiled shirt that the resident continued to wear throughout the day, in front of other residents and facility visitors, for 1 of 7 residents in the open sample (Resident #7). The facility reported a census of 55 residents. Findings include:The Minimum Data Set (MDS) Assessment tool with reference date 9/19/25 revealed Resident #7 had diagnoses that included non-Alzheimer's dementia, depression and hypertension (high blood pressure), had severe cognitive impairment without symptoms of delirium present, rarely/never able to make himself understood and rarely/never able to understand others. The assessment described the resident able to feed himself, and substantial staff assistance was required for dressing, toileting, personal hygiene, bathing and transfers to and from bed and chair, the resident unable to stand or ambulate, utilized a wheelchair for motility and always incontinent of urine. A problem entitled Resident #7 has an ADL (activity of daily living) self-care performance deficit related to Dementia and limited mobility related to recent hospitalization, initiated 7/10/24 on the Nursing Care Plan identified a 12/18/25 goal that Resident #7 will maintain current level of function through the review date. Staff were directed with interventions that included:DRESSING: Resident #7 requires maximum assistance x1 staff with dressing upper and lower body, staff to put on sock and shoes, initiated 7/10/24.EATING: Resident #7 is able to feed himself most of the time, however he does require supervision and cueing/encouragement, initiated 7/10/24.PERSONAL HYGIENE/ORAL CARE: Resident #7 requires assistance with personal hygiene x1. Please shave daily or per family may shave every 2-3 days, initiated 7/10/24, revised 10/18/24.TOILET USE: Assist x 1 staff to complete toileting tasks. Resident #7 incontinent of bowel and bladder. He prefers to wear adult incontinent briefs for dignity concerns, initiated 7/10/24, revised on 7/5/25.TRANSFER: Resident #7 transfers using sit to stand non-mechanical lift x1 staff assist. He is non-ambulatory at this time and utilizes a wheelchair for mobility. He can propel self with feet. Staff assist as needed, initiated 7/10/24. Observations on 12/9/25 revealed:Continuous observations between 8:05 a.m. and 8:26 a.m. revealed Resident #7 seated in his wheelchair at a table in the Station 2 Dining Room, the resident fed himself sausage with his fingers and drank from a handled mug held in his right hand that he held to his mouth. The resident held the mug near the area of his right upper chest when he didn't hold the mug to his mouth.8:46 a.m. the resident remained in the Dining Room in his wheelchair, now positioned approximately 3 feet away from the table where he had been seated, wore a white T-shirt with a plaid material shirt over the top, unbuttoned that exposed an approximate 10 inch across area of the white undershirt, with at least 3 large, and several smaller brown colored stains and smears on the resident's right mid to upper chest area of the T-shirt. The larger stains measured approximately 3 to 4 inches across and 4 to 5 inches high, the smaller stains varied from approximately 1/2 inch to 2 inches in size, irregular shaped and spotted the shirt in between the larger stains. 9:29 a.m. the resident was seated in his wheelchair in his room, wore the same stained shirt.9:33 a.m. the resident self-propelled his wheelchair out to the hall headed to a different resident's room across the hall, with same soiled shirt on.9:35 a.m. Staff C, Registered Nurse (RN) directed Staff A, Certified Nursing Assistant (CNA) to assist the resident, and Staff A pushed the resident in his wheelchair into his room, then came out of his room. At 9:38 a.m. Staff A, CNA asked Staff D, CNA for help with the resident as she pushed a mechanical stand lift into his room. The resident remained seated in his wheelchair in his room in the same soiled clothes. 9:46 a.m. Staff A, CNA went into the resident's room with Staff B, CNA and closed the door. Both staff came out of the room at 9:47 a.m., Staff B pushed the mechanical lift from the room, the resident remained seated in his wheelchair dressed in the same clothes.9:58 a.m. Staff A, CNA went into the resident's room with Staff D, CNA who pushed a different mechanical stand lift into the resident's room and closed the door.10:06 a.m. resident seated in his room in his wheelchair, dressed in the same soiled clothes.12:03 p.m. resident dressed in the same soiled clothes, seated in his wheelchair at a table in the Station 2 Dining Room with 6 other residents for the noon meal.1:19 p.m. resident self-propelled wheelchair in the hallway dressed in the same soiled clothes, family visitors of other residents present in the hall. Staff interviews revealed:ON 12/9/25 at 1:16 p.m. Staff E, CNA, stated 1 of the mechanical stand lifts was out of service because the leg strap was missing from the lift, the lift was marked out of service and positioned in the resident's hall.On 12/9/25 at 1:31 p.m. Staff D, CNA, stated she assisted Staff A, CNA with the resident at 9:58 a.m. when incontinence care was provided as the resident stood with the mechanical stand lift. Staff D stated the resident was assigned to Staff A, Staff D was assigned to Station 1 and assisted with Station 2 residents as able, and the resident was always cooperative with care.On 12/10/25 at 11:55 a.m., the Director of Nursing (DON) stated staff were expected to assist dependent residents with care that included clothing changes when needed.

Based on clinical record review, resident and staff interviews, provider interview and facility policy review, the facility failed to provide a safe environment free from physical abuse for 1 resident (Resident #64). This resulted in harm to the resident in the form of a displaced fracture to the lower end of the right humerus and a non-displaced fracture to the head of the right radius. The facility reported a census of 55. Findings include: The Minimum Data Set (MDS) for Resident #64, dated 08/12/2025, documented the following diagnoses: Anemia, Atrial Fibrillation, Coronary Artery Disease, Hypertension, Cerebrovascular Accident (Stroke), and Non-Alzheimer's dementia. It further documented her hospice status. It failed to document osteopenia (mild bone loss) or osteoporosis (significant bone loss). It documented the resident's Brief Interview for Mental Status (BIMS) score as 06, indicating severely impaired cognition. The Care Plan for Resident #64, last revised 09/14/2025, documented both the radius and humerus fractures. It documented the residents need for one-person assistance for bed mobility and to get dressed. It documented Resident #64's cognitive impairment and identified behaviors such as calling out Mom/Dad, restlessness, and agitation. It instructed staff members to use caution when providing bed mobility or transferring the resident to avoid striking arms and hands on surfaces. It further instructed staff members that Resident #64 required moderate assistance when dressing her upper body. Review of the nursing progress notes revealed the following. On 09/04/2025: At 09:25 AM a late entry was made indicating a hospice nurse was presently evaluating Resident #64 due to a nursing report indicating the resident was shouting in pain. At 04:30 PM a pain assessment was completed stating the resident would scream whenever her right arm was even lightly touched. At 04:51 PM Staff N, Registered Nurse (RN), reported the resident's arm was swollen and distended and appeared painful. Resident was able to state she was in pain. Hospice was called to reevaluate the resident. At 06:06 PM the progress note indicated a Hospice nurse was again assessing the resident, it was noted the resident had a golf ball sized lump protruding from her right arm and became inconsolable if her arm was even lightly touched. The rest of the evening noted more of the same, with resident yelling out and screaming if her arm was even lightly touched. Hospice services refused X-Ray, and per family wishes the resident waited until the following morning for imaging.On 09/05/2025: At 04:30 AM Resident #64 became inconsolable and began yelling out, she was not able to be redirected or calmed down. At 05:32 AM Resident #64 had calmed down and was resting again. At 04:16 PM orders were obtained to get X-Ray images of the right arm. At 09:42 PM the facility medical director recommended sending Resident #64 to emergent discovery (ED) for further evaluation, and after speaking to the family they again requested the resident be allowed to rest for the evening under hospice care. On 09/06/2025: At 08:10 AM Resident #64 was sent to the emergency room for further imaging and assessment. At 01:45 PM progress note states the resident was confirmed to have a fractured radius and a displaced fractured humerus. Review of hospital documentation dated 09/06/2025 showed a significantly displaced fracture of the right humerus as well as a smaller secondary fracture to the right radius. In an interview on 10/01/2025 at 11:18 AM with Staff L, Certified Nurse Aide (CNA), she stated she was the second staff member to respond to Resident #64 on 09/04/2025. She stated she was getting another resident up for a shower when she heard Resident #64 crying out. She noted she was prone to crying out, but the screams made on the morning of 09/04/2025 were different. Shortly after the scream was heard, Staff Q, CNA, approached her and asked her for help. She was informed by Staff Q, Resident #64 was combative and was violently resisting cares. She requested aide. When Staff L entered Resident #64's room she found the resident half-dressed, and the resident began to scream and resist cares when Staff Q participated, attempting to get away from Staff Q. At one point in time during cares, the resident pointed at Staff Q and stated I don't want her in here, get her out!. Resident #64 did not resist cares with Staff L, though she cried out loudly when her right arm was touched. Staff L noted it was unlike Resident #64 to violently resist cares, and she had never seen the resident kick or lash out during cares. Throughout cares she noted Staff Q to be quiet, and felt she appeared cold and uncaring when Resident #64 was clearly in pain. After assisting the resident with cares, she told Staff Q to make a report to nursing. After she finished up another task Staff L reported to a nurse herself to find out Staff Q had only reported she was scratched by Resident #64 to the nurse. She also noted she had previously had issues with Staff Q's performance, and noted she always seemed to be in a rush. She also noted other residents had issues with her care, and provided the surveyor with the name of a resident who might remember Staff Q. In an interview on 10/01/2025 at 02:56 PM with Staff P, Licensed Practical Nurse (LPN), he confirmed he was the nurse who took report from Staff L and Staff Q on 09/04/2025. He stated he was aware of a situation, before either staff reported it to him, because he could hear Resident #64 scream that morning. He noted the resident often loudly cried out, but this scream was different. He noted he took report first from Staff Q, who only stated that she was scratched by Resident #64, which he felt was odd because he did not know the resident to violently resist cares. She stated she only cried out, often repeating Mommy daddy. After the report he told nurse management, who involved Hospice in her assessment. He further acknowledged he did not care for Staff Q, as he felt her cares were rough and quick and he had at least one resident complain. He stated he was preparing to make a report to nurse management about Staff Q when the incident occurred and she was removed from the facility. He stated in his professional nursing opinion, fractures of the severity seen in Resident #64 could not have occurred with a reasonable amount of force during cares. In an interview on 10/01/2025 at 03:11 PM with Resident #50, whose BIMS is noted as 15 indicating fully intact cognition, she stated she was familiar with Staff Q. She stated Staff Q doesn't listen to her and doesn't care, and moves too quickly and roughly which often causes her pain during cares. She stated she had tried to speak to Staff Q about the issues but she just does not listen to her. She stated she had recently talked to Staff P about the issues with Staff Q. In an interview on 10/01/2025 at 04:32 PM with Staff O, CNA, she stated she took report from Staff Q at shift change, and was only informed Resident #64 was resistive to cares. She stated she was familiar with the resident and had never known her to physically resist cares. She stated the resident was small and described her as frail, and posters in the resident's room instructed staff members to care for her gently as she did not have full use of her right arm following her strokes, but the resident never required force during cares as she did not resist. She stated after taking report she found a massive lump on the resident's arm and summoned nursing again because she felt it had been fractured, and was informed hospice had been called to assess the resident. In an interview on 10/02/2025 at 01:46 PM with Staff N, Registered Nurse (RN), she confirmed she was not in the facility when the incident initially occurred, but confirmed she did take report from Staff P about the situation and was very familiar with Resident #64. She stated she was told by Staff P something was wrong with the resident's arm, and that hospice had assessed but he felt the arm needed reassessment. She felt the resident's arm had been fractured. She stated the resident appeared frail, but never resisted cares. She would occasionally move away from things that caused her discomfort but never lashed out and kicked or hit at staff members. She stated in her professional nursing opinion, she does not believe that normal cares could have fractured the resident's arm so significantly. She stated she had cared for Resident #64 countless times and had always used what she considered normal amounts of force which had never even resulted in the resident expressing discomfort. In an interview on 10/02/2025 at 12:58 PM with Staff M, RN, she stated she was familiar with Resident #64 and did not believe standard care practices could have resulted in a fracture of such magnitude. In an interview on 10/01/2025 at 12:23 PM with the Facility Medical Director, she stated she was very familiar with Resident #64 and had cared for her for some time, she noted the resident had been diagnosed in 2017 with age related osteopenia and noted the loss of some bone mineralization in the hospital findings, which could contribute to a fracture. She confirmed the findings of the Hospital imaging was consisted with a significant fracture of the humerus and a less severe fracture of the radius and was not consistent with a typical osteopenia fracture presentation. She stated based on her medical opinion, she could not make a judgement as to whether or not the fracture was intentional, but further noted the kind of trauma required to fracture the resident's arm would need to be dramatic. She further noted the amount of times the resident underwent standard cares such as dressing without any issue gave her caution as to whether or not simple dressing practices would have been enough to fracture the residents arm. She stated she had directly performed some cares on Resident #64 and had never had an issue with the resident violently resisting cares, pushing her away, or ever becoming violent. In an interview on 10/02/2025 at 08:49 AM with the Director of Nursing, she stated her expectation is for staff members to perform cares as gently as possible to avoid injuries to frail and elderly residents. She acknowledged staff members should never rush cares as it increases the likelihood of injury. She further acknowledged that standard nursing cares should never result in a fracture of the magnitude Resident #64 suffered, even with osteopenia or osteoporosis. She finally stated that in her professional nursing opinion, the fracture Resident #64 suffered could only have resulted from excessive force, which is why Staff Q was terminated. Review of a facility provided document titled Abuse Prevention, Identification, investigation, And reporting, with a last revised date of 06/26/2024, it identifies under key definitions subsection #9 that Neglect is the failure of the facility, its employee or service providers to provide goods and services to a resident that are necessary to avoid physical harm. The policy further states All residents have the right to be free from abuse and neglect.

Based on observation, record review and staff interviews the facility failed to store food properly, handle food correctly for 3 out of 3 meals observed and maintain clean refrigerator and microwave to prevent food borne illnesses. The facility identified a census of 55 residents. Findings include:1.) During the initial tour of the kitchen on 9/29/25 at 10:01 AM observed the following boxes open to air with plastic bags inside not sealed and not labeled or dated in the walk in freezer of the main kitchen:-Large bag of peas opened to air -Ice cream on cart 3 large containers lids not on tight, partially used and not dated- 5 gallon container of ice cream on shelf partially used and no lid on container - Peach Danish open - Croissants- Pizza dough- Gluten free pizza crust - Regular pizza crust - Tilapia- Catfish On 9/29/25 at 10:30 AM Staff F, Executive Chef stated all food in the walk-in freezer should be dated once opened and the bags should be sealed at all times. The ice cream should be covered. The facility provided a policy titled Food and Supply Storage with a revision date of 1/24 it directed all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. The policy directed staff to cover, label and date unused portions and open packages. 2.) On 09/29/25 at 2:00 PM the refrigerator in 200 hall dining room had brown dried substance on the inside door and a dried purple substance on the first and second wire shelf, and on the inside right side of the refrigerator. The front of the refrigerator had brown runs and liquid spills dried on it. The microwave had dried brownish orange substance on the glass plate inside of it. The handle and the door had smears on it and run marks across the bottom of the front door of the microwave. The second refrigerator on the 200 hall dining room had orange substance in the bottom below the bottom shelf and the seal across the bottom of the refrigerator had dirt on it. On 09/30/25 at 11:55 AM the refrigerators and microwave in the dining room on the 200 hall observed unchanged from 9/29/25. The observation of spills and dried food remained on both refrigerators and microwave. On 10/02/2025 at 9:13 AM Staff H, Dietary Aide stated they are supposed to clean the refrigerators in the dining rooms after every shift and make sure it is stocked for the next meal. There is a check off sheet of what to do and what to wipe down. All food that is opened that goes in the refrigerator or freezer should be labeled and dated and should be covered. On 10/02/25 at 10:27 AM the Dining Room Manager stated after every shift the microwaves and refrigerators in each dining room should be cleaned out and wiped down. There is a check list for the staff to complete. On 10/02/25 at 10:58 AM the Director of Nursing, Registered Nurse (RN) stated regarding the refrigerators on the units that are nursing related she is not sure who is responsible for cleaning them. She stated they have temperature logs and the nursing staff takes care of them. The microwaves should be cleaned by dietary. They do not have cleaning logs but she would expect it to be clean. The facility provided a Health Center End of Shift Checklist undated which indicated refrigerator to be organized and spills wiped out and to clean the microwave. The facility failed to produce any logs filled out by staff. 3.) During a continuous observation of meal service in the dining room on Unit one on 09/29/25 at 11:42 AM to 12:24 PM Staff G, Dietary Aide washed hands, donned gloves and proceeded to serve residents plates of food touching counters, cabinets and dietary slips. She then would pick up eggrolls with gloved hands and place on plate and cut in half. During the meal service she used the top of her shirt to wipe her face and wiped her face with shirt sleeve. Dietary staff failed to wash her hands or change her gloves during the meal service and continued to pick up eggrolls with gloved hands and place on plate. During the meal service she retrieved bread and touched with gloved hands. Staff G also served soup she touched the inside of the bowls before placed soup inside the bowls.On 09/30/25 8:30 AM Staff H, Dietary Aide served breakfast in dining room on unit one. The dietary aide served breakfast wearing gloves, touched diet slips, counters and utensils, she used gloved hands to touch the French toast to cut in half, removed gloves, did not wash hands and put on a new pair of gloves and touched trays, diet slips and utensils plated food and picked up toast with hands and cut in half on the plate. On 10/1/25 at 12:15 PM Staff I, dietary aide served lunch in the 300 hall dining room. She used gloved hands to touch the sweet potatoes served to residents and after placed on plate used gloved hands to cut in half. She failed to change gloves in between plates, she touched utensils, counters and diet slips. Staff I took cold turkey sandwich out of refrigerator and picked up with gloved hands to put on another plate. During the meal service Staff J, Dietary Aide used gloved hands to pick up cookies and place on individual plates after touching the counters and cabinets. Staff failed to change gloves during the meal service. On 10/02/25 at 9:09 AM Staff H, Dietary aide stated they had education on food handling, I think we had it once. She reported when wearing gloves we can touch the food if we have to. I have tongs, I also use those most of the time. She stated you can use gloved hands to touch the food but not if I have touched other things in between then would have to wash her hands and change gloves. On 10/02/25 at 10:18 AM Staff F, Executive Chef stated the expectation for every place is different with policy with handwashing and glove usage. The best practice is if you are handling food it needs to be handled with a fresh pair of gloves. If plating food, need to take gloves off wash hands and put on fresh pair of gloves. I would say even if plating cold food need to take gloves off and wash hands. On 10/02/25 at 10:44 AM the Director of Dietary stated the expectation is the staff should not be touching food after touching anything else with gloves on and should wash hands in between touching things and put on a new pair of gloves.The facility provided a policy titled Food Handling Guidelines with date revised 1/24 it directed single use disposable gloves are worn when preparing foods that will not be cooked again (ready-to-eat-foods) and while serving food. Gloves are to be placed over clean hands. Gloves are changed between tasks or if punctured or ripped. Hands are washed after gloves are removed.

Based on the previous Center for Medicare and Medicaid Services (CMS) Statement of Deficiencies forms, staff interview, current CMS Statement of Deficiencies form and facility policy review the facility failed to carryout Quality Assurance (QA) activities to prevent reoccurrence of deficiencies. The facility reported a census of 55 residents. Findings include: Review of the CMS 2567 report dated 9/26/24, included deficiencies related to F0865 (QAPI Program/Plan, Disclosure/Good Faith Attempt) at a D, F0812 Food Procurement, Store/Prepare/Serve-Sanitary, F0868 QAA Committee, and F0880 Infection Prevention & Control. The survey dated 10/2/25, included deficiencies related to F0865 (QAPI Program/Plan, Disclosure/Good Faith Attempt) at a D, F0812 Food Procurement, Store/Prepare/Serve-Sanitary, F0868 QAA Committee, and F0880 Infection Prevention & Control. On 10/02/2025 at 12:49 PM the Director of Nursing (DON) reported the facility worked on the previously cited deficiencies. The facility provided the QAPI Plan dated 8/25/17, that reflected oversight of the QAPI program is provided through a committee structure that is accountable to the facilities Executive Leadership. The leadership team and QAPI Steering Committee have the responsibility for planning, designing, implementing, and coordinating consumer care and service and selecting QAPI activities to meet the needs of residents and families.

Based on staff interviews, facility sign-in sheets and facility policy, the facility lacked the required Infection Preventionist (IP) at 3 of the 4 quarterly meetings. The facility reported a census of 55 residents. Finding include: Review of the Quality Assurance Process Improvement (QAPI) quarterly sign-in sheets dated 1/22/25, 4/23/25, and 7/23/25 lacked the IP in attendance. On 10/02/2025 at 12:49 PM the Director of Nursing (DON) reported Staff A, prior Assistant Director of Nursing (ADON) failed to attend the meetings. The DON reported she started here November 11th, 2024. The facility provided the QAPI Plan dated 8/25/17, that reflected oversight of the QAPI program is provided through a committee structure that is accountable to the facilities Executive Leadership. The leadership team and QAPI Steering Committee have the responsibility for planning, designing, implementing, and coordinating consumer care and service and selecting QAPI activities to meet the needs of residents and families. The facility provided a Key Personal list that included an IP.

Based on clinical record review, staff and resident interviews and facility policy review the facility failed to complete dialysis site assessments before and after dialysis for 1 of 1 residents reviewed (Resident#11). The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses of dependence of renal dialysis, end-stage renal disease, and diabetes mellitus (DM). The Brief Interview for Mental Status listed a score of 15, intact cognition. The Care Plan for Resident #11 dated 5/30/25, reflected she needed dialysis related to renal failure. The Care Plan directed staff to monitor/document/report as needed (PRN) any signs or symptoms (s/s) of infection to access site: redness, swelling, warmth or drainage. Monitor/document/report PRN for s/s of the following: bleeding, hemorrhage, bacteremia, and septic shock.The Medication Administration Record (MAR) dated 9/25, directed vital signs before and after dialysis appointment two times a day every Monday, Wednesday, and Friday. The MAR failed to direct nursing staff to assess her left arm for s/s of bleeding or the bruit and thrill. The Progress Notes for Resident #11 dated 9/1/25-9/30/25, lacked assessment of her left arm for s/s of bleeding or the bruit and thrill.The Assessment in the Electronic Health Record (EHR) dated 8/2/25 through 10/1/25 lacked dialysis assessments. On 09/29/2025 at 1:58 PM Resident #11 reported the staff check her vitals but they failed to check on the dialysis site for bleeding, failed to feel (thrill) or listen (bruit). On 10/02/2025 at 9:46 AM Staff D, Registered Nurse (RN) reported the dialysis assessments include listen to thrill, complete before and after vitals. She said the assessments are under the notes of dialysis under assessments in the EHR. On 10/02/2025 at 10:00 AM the Infection Preventionist (IP) reported dialysis assessment are for staff to check and make sure she's not bleeding.On 10/02/2025 at 10:45 AM the Director of Nursing (DON) reported the dialysis process needed work. The DON said at minimum nursing needed to check her when she gets back form dialysis. The facility provided a policy titled End-Stage Renal Disease, Care of Resident with dated 9/2010, failed to direct assessment of the access site.

Based on observations, staff and resident interviews and facility policy review the facility failed to implement Enhanced Barrier Precaution (EBP) for 2 out of 6 residents reviewed (Resident #2 and 11). The facility reported a census of 55 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses of dependence of renal dialysis, end-stage renal disease, and diabetes mellitus (DM). The Brief Interview for Mental Status listed a score of 15, intact cognition. The MDS identified Resident #11's pressure ulcer. The Care Plan for Resident #11 dated 7/5/25 revealed a pressure ulcer to right foot, pressure ulcer to left foot and followed by the wound center. The Care Plan dated 8/21/25 directed Enhanced Barrier Precautions will be in place for the duration of the residents stay or until a wound is resolved or the indwelling medical device is discontinued. The Progress Note dated 9/28/25 at 6:24 AM, revealed left heel pressure ulcer length 0.5 centimeter (cm) by 0.4 width and depth 0.1 cm. The Medication Administration Record dated 9/25, directed vital signs before and after dialysis appointment two times a day every Mon, Wed, and Fri. On 9/29/2025 at 1:50 PM Resident #11's room door failed to show an EBP sign. Resident#11 lay in bed while Staff B, Certified Nurse Aid (CNA) and Staff C, CNA provided incontinent care and transferred Resident #11 to her recliner. Both Staff B and Staff C failed to wear EBP. On 09/29/2025 at 1:58 PM Resident #11 reported the staff who come in and care for her failed to wear any EBP with any cares. On 10/02/2025 at 9:46 AM Staff D, Registered Nurse (RN) reported residents need EBP for cares if they have large open wound, foley catheter, colostomy, ostomy, tube or drains. She reported not for dialysis because she has no protocol in place that directed EBP. On 10/02/2025 at 10:00 AM the Infection Preventionist (IP) reported Resident #11 failed to need EBP. The IP said Resident #11 lacked a would or other requirement to need EBP. The IP reported a dialysis port not a reason for EBP. On 10/02/2025 at 10:10 AM Staff E, RN reported Resident #11's wound is from pressure and she went to the wound clinic for care. On 10/02/2025 at 10:24 AM the IP reported when a residents wound is open that required a dressing the resident needed EBP. The facility provided a policy titled EBP dated 7/12/2022, it is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO. Enhanced Barrier Precautions require gown and glove use for residents with a novel or targeted MDRO or any resident with a wound or indwelling medical device during specific high-contact resident care activities. Example: Transferring, Providing hygiene, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing. Gown and gloves are not necessary for resident care activities other than those listed above. 2. The Quarterly MDS for Resident #2, dated 06/25/2025, documented diagnoses of anxiety, malnutrition, and the presence of an abdominal feeding tube (G-tube). The Brief Interview for Mental Status listed a score of 15, indicating intact cognition. The Care Plan for Resident #2, last revised on 10/01/2025, identified the abdominal feeding tube and instructed staff members to utilize Enhanced Barrier Precautions (EBP) for the duration of the residents stay or until the remove of the abdominal feeding tube. It stated EBP required disposable gloves and a gown to be worn during use or care of the resident's feeding tube. In a direct observation on 09/30/2025 at 09:31 PM, Staff K, Registered Nurse (RN), was observed performing the tube feeding for Resident #2. During the feeding, Staff K was observed not to use enhanced barrier precautions despite the personal protective equipment kit being placed outside of Resident #2's door, and a sign on Resident #2's door instructing staff to wear EBP while caring for the resident. In an interview on 09/30/2025 at 09:57 AM, Resident #2 stated the staff members never wear gowns with him when performing cares, and he was unsure what enhanced barrier precautions were. In an interview on 10/02/2025 at 12:52 PM with Staff L, Certified Nurse Aide (CNA), she stated it was her understanding EBP should be worn when performing cares for residents with a catheter or a wound, but she was unsure if she was required to wear it if performing cares for a resident with an indwelling feeding tube. She stated she would always wear it out of precaution if the resident had a feeding tube. In an interview on 10/02/2025 at 12:58 PM with Staff M, RN, she stated that all indwelling medical devices, such as catheters or feeding tubes, as well as any resident with an open wound requires enhanced barrier precautions to be worn when providing care for the resident in their room. She stated it would not be required if they were helping a resident down the hallway. In an interview on 10/02/2025 at 08:49 AM with the Director of Nursing (DON), she stated her expectation was for Staff K to have worn EBP as directed by the care plan, and the posting outside of the resident's room. She further stated it had been an area of ongoing education for CNAs, but as a direct result of the survey more education would be provided to Nurses as well.

Based on observations, clinical record review, and staff interviews, the facility failed to ensure staff assisted 3 of 6 residents (Resident #5, #6, and #8) to eat in a dignified manner, and promoted their individuality while during a meal service. The facility reported a census of 61 residents. Findings include: 1. The 2/12/25 Minimum Data Set (MDS) assessment tool revealed Resident #5 diagnoses included: cerebrovascular accident (a stroke), non-Alzheimer's dementia, anxiety and malnutrition. Resident #5 Brief Interview for Mental Status (BIMS) exam result of 5 out of 15 indicated a severe cognize impairment. The MDS indicated the resident dependent on staff for most activities of daily living (ADL's) and required staff supervision or touch assistance for eating. Review of the Care Plan revealed a Focus area to address [Name redacted} has an ADL self-care performance deficit r/t Dementia, Fatigue, Impaired balance. Date Initiated: 10/6/23; Date Revised: 11/15/24. Interventions included, in part: a. [Name redacted] needs x1 assist for dining. Needs cueing as well as physical assist .Date Initiated: 10/6/23; Date Revised: 11/15/24. During an observation on 3/12/25 at 12:31 p.m., during the lunch meal, Resident #5 sat in a Broda Chair (name brand of a type of wheelchair that reclines). Staff B, Certified Nursing Assistant (CNA) stood next to the resident and fed her 4 bites, and assisted the resident take a drink. Staff B then walked away from the table. During an observation on 3/18/25 at 9:10 a.m., during breakfast Staff D, CNA, stood next to Resident #5, who sat at the table in a Broda Chair in the Station 2 Dining Room. Staff D fed the resident her breakfast. Staff D walked away at 9:13 a.m., leaving Resident #5 and one other resident alone at the table. During the same meal, at 9:17 a.m., Staff C, CNA stood next to Resident #5 and fed her with a spoon until Staff D, CNA returned at 9:23 a.m. Staff D then proceeded to stand next to Resident #5 and assisted her to eat. During an interview on 3/18/25 at 12:50 p.m., the Director of Nursing (DON) stated she expected nursing staff to sit next to a resident while proving assistance to eat rather than stand over the resident. She stated she expected staff to interact with the resident while providing eating assistance. 2. The 2/19/25 MDS assessment Tool revealed Resident #6 had diagnoses that included Alzheimer's disease, anxiety and glaucoma, had severe cognitive impairment. The MDS indicated Resident #6 dependent on staff for to eat. Review of the Care Plan revealed a Focus area to address [Name redacted} has an ADL self-care performance deficit r/t Dementia. Date Initiated: 7/31/23; Date Revised: 11/20/24. Interventions included, in part: a. EATING: Set up Assist x1 for direct eating assistance. Date Initiated: 3/1/25; Date Revised: 3/1/25. During an observation on 3/17/25 at 11:35 a.m., Resident #6 sat in a Broda Chair, asleep in the Station 3 Dining Room. The resident remained reclined as meals were served to other seated residents. At 12:07 p.m., 2 staff repositioned the resident in the chair, the resident remained reclined as staff C, CNA stood next to the resident, held the resident's beverage and offered a drink at 12:08 p.m., and the resident coughed. Staff C then lifted the back of the Broda Chair to position the resident more upright. Staff C continued to stand as she fed the resident with a spoon. At 12:11 p.m., Staff C called the resident's name and stated you need to wake up (resident's name redacted). Staff C repeated the statement two more times, then walked away from the resident at 12:12 p.m. During a continuous observation, at 12:23 p.m., the resident had not had any additional feeding assistance, and remained asleep in the Broda chair as other residents ate their meal. During an observation on 3/18/25 at 11:48 a.m., Resident #6 at a Station 3 Dining Room table for the noon meal. The resident sat in a reclined position in a Broda chair, asleep. At 12:09 p.m. the resident remained at the table, asleep in the Broda Chair. At 12:29 p.m., the resident remained asleep and reclined and had ate very little of her meal. 3. The 12/10/24 MDS Assessment Tool revealed Resident #8 had diagnoses that included Alzheimer's disease, anxiety, severe cognitive impairment. The MDS indicated Resident #8 dependent on staff for all ADL care that included feeding assistance. Review of the Care Plan revealed a Focus area to address [Name redacted} has an ADL self-care performance deficit r/t dementia Fatigue, Limited Mobility, Musculoskeletal impairment. Date Initiated: 6/25/23; Date Revised: 9/19/24. Interventions included, in part: a. EATING: The resident is totally dependent on x1 staff for eating. Date Initiated: 6/25/23; Date Revised: 7/11/23. During an observation on 3/12/25 at 11:33 a.m., Resident #8 positioned reclined in a Broda Chair, asleep in the Station 3 Dining Room for the lunch meal with 15 other seated residents. The resident remained asleep in the Broda Chair as the lunch meal was delivered to her table and left uncovered at 12:19 p.m. At 12:26 p.m. Staff C, CNA came to the resident's table, lifted the back of the Broda Chair to position the resident more upright, and stood by the resident as she fed her with a spoon. The facility's Certified Nursing Assistant Job Description dated August, 2022 stated the CNA was to provide personal care to residents in a manner conducive to their safety and comfort, consistent with the facility policy. and demonstrate competency in skills mandated by required education and training. The facility's Assistance with Meals policy, dated revised March, 2022, directed: 1. Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. 2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals; b. keeping interactions with other staff to a minimum while assisting residents with meals.

Based on observation, interview, and record review the facility failed to hold warfarin, an anticoagulant medication (Coumadin, brand name for warfarin) following a documented International Normalized Ratio (INR) documented as 7.8 on 4/8/24 for one of one resident reviewed for warfarin administration (Resident #19). The resident received doses of warfarin on 4/8/24 and 4/9/24 when the medication was to be held. The resident's INR was documented as 9.3 on 4/10/24. The resident was found with blood on their arms and legs on 4/13/24. Resident sent to the hospital and admitted for INR of 8.2, Hemoglobin (Hgb) of 8.6, and treated with Vitamin K (antidote). This deficient practice resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident. The facility reported a census of 51 residents. Findings include: The State Agency informed the facility of the Immediate Jeopardy (IJ) on 9/25/24 at 4:20 PM. The IJ began on 4/8/24, when warfare administered to the resident following an INR of 7.8. Facility staff removed the IJ on 9/25/24 at 11:36 AM through the following actions: 1. The identified resident's Coumadin/warfarin was discontinued on 5/9/24 2. All other residents with Coumadin/warfarin orders were reviewed for accuracy on 9/25/24. 3. Implemented new procedure regarding Coumadin/warfarin administration 9/25/24. 4. Coumadin/warfarin Procedure New orders or New Admit with orders for Coumadin/warfarin the Nurse will: 4a. Enter Coumadin/warfarin order into Electronic Health Record. 4b. Nurse will document order on Coumadin/warfarin log located at each station. 4c. DON (Director of Nursing)/Designee will check all new Coumadin/warfarin orders and the log within 24 hours to ensure dosing and follow-up labs are entered as ordered on the log and in Electronic Health Record. 5. The Nurse who took the order to hold Coumadin/warfarin on 4/8/24 is no longer employed at the facility. 6. All nurses will be educated on the new procedure on 9/26/24. Additionally, all nurses will be educated on how to properly enter orders in Electronic Health Records. 7. New employees and agency staff will be trained on how to complete this procedure including entering orders in Electronic Health Records during their orientation. 8. Audit tool implemented to ensure nurses are administering Coumadin/warfarin according to physician orders. 9. Audits will be completed weekly for one month and then monthly ongoing as needed. 10. The audit results will be brought to the Quarterly QA (Quality Assurance) meeting. The scope and severity lowered from a J to a D during the survey. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #19 revealed the resident scored 14 out of 15 on a Brief Interview for Mental Status exam, which indicated intact cognition. Per this assessment, the resident took anticoagulant medication. On 9/24/24, review of the resident's Care Plan revised 7/18/23 revealed, The resident is on anticoagulant therapy; Coumadin. Review of the Intervention dated 7/18/24 revealed, Administer ANTICOAGULANT medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT (every shift). Review of Medical Diagnoses for Resident #19 revealed, in part, cardiac arrythmia. Review of the Health Status Note dated 4/1/24 at 4:16 PM revealed, Dr. [Name Redacted] aware of residents INR of 3.7 new orders given for Coumadin 3mg (milligram) on Thursday and Sundays and Coumadin 1.5mg on all other days, recheck INR on 4/8/24. The Physician Order present on Resident #19's MAR (Medication Administration Record) dated April 2024 revealed the following: a. (Start Date 4/1/24, with hold and discontinuation date 4/10/24): Coumadin Oral Tablet (warfarin sodium) Give 1.5 mg by mouth in the evening every Mon, Tue, Wed, Fri, Sat related to LONG TERM (CURRENT) USE OF ANTICOAGULANTS . 3mg on Thursday and Sundays recheck INR 4/8/24. The Orders-General Note from eRecord dated 4/8/24 at 3:03 PM authored by Staff L, Licensed Practical Nurse (LPN) revealed, [Lab Name Redacted] called with STAT lab results; Verbal report received from [Lab Name Redacted] staff [Name Redacted], PT (prothrombin, test for blood clotting): 73.4, INR: 7.8. Coumadin Clinic notified by this nurse. <sic>Comedian <sic> Clinc staff verbal response received from [Name Redacted]; Hold Coumadin for today and tomorrow. Check INR EARLY Wednesday. Watch out for bleeding. Any continuous bleeding, send resident out to the ER for further evaluation. Review of the fax sheet to Provider for Resident #19 dated 4/8/24 revealed, Please review labs. Coumadin clinic notified and gave orders to hold meds today & tomorrow. Draw labs early Wednesday send resident to ER if any continuous bleeding noticed. Review of the Lab Report for Resident #19 dated 4/8/24 revealed INR result 7.8 and Hgb 9.9. The Lab Report noted standard anticoagulant INR range 2.0-3.0 INR, and aggressive anticoagulant range 2.5-3.5 INR. Review of the Coumadin Dosage Schedule chart dated 4/8/24 from the clinic managing the resident's Coumadin revealed the resident not to receive Coumadin on 4/8/24 or 4/9/24. The Medication Administration Record (MAR) dated April 2024 revealed Resident #19 was administered Coumadin 1.5 mg on 4/8/24 and 4/9/24. The Health Status Note dated 4/8/24 at 4:05 PM revealed, Response received from [Anticoagulation clinic name redacted] goes as follows: Continue same meds and follow up 4/30/24 as planned. Staff will continue to monitor. The Communication-with Physician note dated 4/10/24 at 10:59 AM revealed, Call received from [Name Redacted] at [Facility Redacted]/Coumadin clinic. Has concerns about Coumadin dosing/staff. Relayed to supervisor ([Name Redacted], ADON). The Lab Note dated 4/10/24 at 3:00 PM revealed, Call placed to Coumadin clinic RE: INR 9.3, PT 86.3. Spoke with [Name Redacted]. Has to speak to Dr. [Name Redacted] and will call back. The Order Note dated 4/10/24 at 3:30 PM revealed, ANY S/S (signs/symptoms) OF BLEEDING or FALLS - TO ER IMMEDIATELY. INR 9.3 PT 86.3 HOLD COUMADIN THROUGH SUNDAY RETEST INR 04/15/22. DO NOT GIVE COUMADIN UNTIL SPEAKING WITH CLINIC 04/15!!!!! every shift until 04/15/2024 18:00 (6:00 PM) Start Date: 4/10/2024 End Date: 4/15/2024 .Lab updated, wanted to d/c (discontinue) INR 04/11 and place the INR for 04/15. Pharmacy aware. The Health Status Note dated 4/13/24 at 5:25 AM revealed, Resident has a standing order to be sent to ED (emergency department) for eval (evaluation) if any bleeding. Resident found in bed with blood on her arms and legs. BP (blood pressure) 80/40. 02 (oxygen) sat 88% on room air. Placed on oxygen . Have standing order to be sent to ED for eval and treat for any bleeding. Left message with POA (Power of Attorney) daughter. Called medic for transport they are on their way. Paperwork prepared. Review of ED Admission Paperwork from Resident #19's Hospital Records dated 4/13/24 at 6:43 AM revealed the following per Chief Complaint: pt (patient) arrived from [Facility Name Redacted] d/t (due to) staff finding dry blood, skin tear on left forearm, and INR 9.3. has gallbladder infection. Review of the resident's vital signs revealed blood pressure documented as 102/50 mm hg. Review of the Physician Progress Note dated 4/14/24 revealed the following documented Hemoglobin levels of 8.6 on 4/13 and 4/14, with INR documented as 8.2 on 4/13 and 2.6 on 4/14. The Progress Note dated 4/13/24 at 11:40 AM revealed, Spoke to nurse [Name Redacted] at [Name Redacted] ER. admitted for an INR 8.2. Positive for blood in stool. Hemoglobin 8.6. Administered Vitamin K in ER. Bp (blood pressure) low, and not moving very well due to weakness. Coumadin clinic faxed, [Facility Name] on-call made aware. On 9/24/24 at 8:31 AM, Resident #19 observed in their room. The resident was wearing a nasal cannula, with oxygen concentrator set to 4 Liters. On 9/25/24 at 12:54 during an interview with Staff K, Medical Assistant from anticoagulation clinic, Staff K explained the following about Resident #19: Per Staff K, the resident's INR on 4/8 was 7.8, and at that point guidance was to hold the resident's warfarin on 4/8 and 4/9, and test on 4/10. Per Staff K, test on 4/10 revealed INR 9.3, and the resident ended up taking the warfarin on those nights when was supposed to be held. Per Staff K, Dr.[Name Redacted] said to hold Wednesday through Sunday (4/10-4/14), and test on Monday (4/15). Staff K explained the clinic did not get test on 4/15 because the resident was in the hospital. Staff K further explained the clinic would call (facility) after every INR, every single one. When queried as to a set number for a critical value, Staff K responded it would depend on the person's range. Staff K explained for Resident #19, anything over 4.6 INR would hold the resident's warfarin. Staff K further explained she believed a lab would come in and draw the INR, and the clinic did not get it until the next day. Per Staff K, a schedule faxed with every INR which told whatever orders given. On 9/25/24 at 1:48 PM, interview conducted with Staff M, Licensed Practical Nurse (LPN). Staff M explained if INR was followed by the Coumadin clinic, the clinic would give the orders unless had an on-call for the weekend, but still should be the Coumadin clinic. Staff M explained the nurse would input the orders, usually would come with a print out and would have a calendar week with dosing and when to recheck. Per Staff M, the order would continue until the day of the INR, and would not give Coumadin that day until got orders. Staff M further explained needed to get the result (INR) to have orders, and not supposed to give Coumadin until go INR drawn. On 9/25/24 at 2:01 PM, the facility's Assistant Director of Nursing (ADON) queried about Resident #19's Progress Note which said the Coumadin clinic called with concerns, and phone call directed to the ADON. The ADON explained, in part, it was regarding the resident's high INR and she believed it was just an informative call. When queried if she was made aware of any Coumadin medication errors for Resident #19, the ADON responded no. When queried who would draw INRs at the facility, the ADON explained there was a lab, and that they would come in and draw. When queried how the Coumadin clinic communicated with the facility, the ADON responded sometimes sent a fax, and sometimes gave (facility) a call too. The ADON explained the following about critical lab values: The tab would call (facility), and a fax would come in from the lab after lab called. The ADON acknowledged staff should be on the phone and call any critical lab either to Coumadin clinic or PCP (Primary Care Physician). When queried how quickly INR results turned around to the facility, the ADON explained they had it now if the lab was not going to get back in a timely manner, the facility would take to a local lab. The ADON explained had not been doing too bad with INRs, and had not had to implement local lab process yet. The ADON explained INR supposed to be turned around and present before 3 PM because medication had to be given at 4 PM. The ADON explained unless result was critical, as would call immediately for those labs, and if not needed to be on the phone Dr, calling lab, and needed to be checking in on that. The ADON explained INRs were usually drawn about 5:00 AM/6:00 AM. When queried who would input the orders for Coumadin dosing, the ADON responded the nurses. Per the ADON, they would either get a fax back or if called, get a telephone order. The Coumadin clinic would give a telephone order and they would send a fax too. When queried about coordination between the Coumadin clinic and the provider, the ADON explained usually the nurses were the drivers, and they were going to make sure communication with the Coumadin clinic, info needed, and right dose. Per the ADON, they needed to make sure everything was in, everything on hold, and needed to be calling back, putting everything on hold, whatever the orders were. When queried if staff would wait until had the INR result to give the drug that day, the ADON acknowledged they would. Per the ADON, on INR days would not give until get those results, and waited until got the results which is why wanted by 3 (PM) or would call the doctor. Per the ADON, she had never had a doctor say to give without results. The ADON was asked to pull up Resident #19's MAR for 4/8/24 and 4/9/24. When queried if she had been made aware of any errors, the ADON responded no. On 9/25/24 at 2:45 PM during an interview with Staff L, former Licensed Practical Nurse (LPN) at the facility (who had charted the note to hold the medication on 4/8/24 and 4/9/24), Staff L explained she hardly worked down the hall where resident resided. Staff L explained she could not enter labs because she did not have access to labs. Per Staff L, the she was never given access to labs, and the facility kept turning over directors. Staff L explained she went by word of mouth to get lab results. When queried if she was able to put in orders, Staff L expressed the following: Like meds and stuff like that, [Staff L] didn't ever do any of those things there (facility), [Staff L] couldn't do anything. Staff L explained they emailed human resources with concerns. Staff L expressed being able to do the bare minimum with the electronic health record system. Per Staff L, the former Director of Nursing (DON) was supposed to work on her computer access, and Staff L further explained she would show (facility) things she (Staff L) could not do, and (facility) said they would do it. Staff L explained she currently knew how to get into the computer system and put (order) on hold due to other employment, and then (prior) didn't know how to do those things and would pass information on to the ADON. Per Staff L, the ADON was aware Staff L could not access things. On 9/25/24 at 3:21 PM, interview conducted with the facility's DON. The DON explained she started in the position on 4/8/24. When queried if there were any concerns with Coumadin (warfarin) in April, the DON responded no. When queried if notified about blood on resident's arms/legs, the DON responded no. When queried if she was made aware of any concerns with Resident #19's Coumadin, the DON responded no. When queried about the situation, the DON acknowledged the following expectation: write the order to stop the Coumadin, stop the Coumadin, signs/symptoms of bleeding go the the ER (emergency department), watch for INR in 2 days, and make sure to discontinue on the MAR (Medication Administration Record), absolutely. When queried if she was aware of computer access concerns, the DON responded no, and the DON knew agency staff did not have access to lab. During the interview, the DON was made aware of the resident's INR of 7.8 followed by Coumadin administration, INR of 9, then hospitalization . The DON acknowledged the situation could have ended very poorly. When queried if the orders would be handled by the anticoagulation clinic if resident saw them, the DON acknowledged they would be, and further explained would usually do a verbal asked to fax them, they would do either. The DON further explained she would really think with 7.8 (INR) would send the resident out because facility was not a hospital. The DON further explained they would have sent the resident out that day with the INR of 9. On 9/26/24 at 10:47 AM the ADON queried about any computer issues, and responded the [electronic health record] system was kind of new for the facility, and the facility had only been using it for a year at present time. When queried if Staff L, LPN had computer issues, the ADON responded she did. The ADON explained she remembered Staff L received education on a few things. The ADON further explained Coumadin levels were kind of hard to put in too, and wanted to make sure right dose each day. Per the ADON, everyone got education on the first day they came and as needed. Review of the Facility Policy dated Administering Medications, dated 2001 and revised 4/19, revealed the following: Medications are administered in a safe and timely manner, and as prescribed.

Based on observation, facility policy review, and staff interviews, the facility failed to serve food that maintained a safe and appetizing temperature. The facility reported a census of 51 residents. Findings include: During the observation on 9/24/24 of the noon meal results of temperatures, in part, taken by Staff B, [NAME] were as follows: a. At 11:12 AM, pureed lasagna temperature at 148.4 degrees F (Fahrenheit.) At 1:09 PM after the last meal served, pureed lasagna temperature at 127 degrees F. b. At 11:14 AM, ground meat temperature at 153.6 degrees F. At 1:08 PM after the last meal served, ground meat temperature at 130 degrees F. Temperatures from a test tray for the noon meal on 9/24/24 at 1:17 PM were as follows: a. [NAME] beans temperature at 120.1 degrees F. B. Potato wedges temperature at 114.4 degrees F. The State Agency tested the tray, and the above food tasted lukewarm. During an interview on 9/25/24 at 9:20 AM, Staff B, Cook, stated when taking the temperature of the food after the meal is served, warm foods should have a temperature of at least 165 degrees Fahrenheit. The [NAME] stated there have been problems in the past with keeping foods at the required temperatures. She believed one of the problems is that the steam table did not have a heat lamp. She added residents have complained about low food temperatures and they are usually the ones who have room trays. Yesterday, there were 25 room trays served. During an interview on 9/25/24 at 9:44 AM, the Director of Dining Services stated when taking the temperature of the food after the meal is served, warm foods should have a temperature of above 145 to 165 degrees Fahrenheit. The Director stated on occasion, there have been problems with foods being above the required temps in the past. He stated there are as many as 40 to 50% room trays. Both the steam table and warmers are very old and getting replaced [DATE] with induction heat. The Director stated there have been resident complaints about the temperature of the food at resident council meetings, however, the last one was months ago. A review of the facility policy titled: Food Handling Guidelines, revision date January 2024, documented food should be held hot for service at a temperature of 135 degrees Fahrenheit or higher.

Based on observation, facility policy review and staff interviews, the facility failed to use standard food handling practices of washing hands and glove changes between tasks to prevent the potential for cross contamination during meal service. The facility reported a census of 51 residents. Findings include: Observations of the 9/24/24 noon meal revealed: At 11:44 AM Staff B, [NAME] while wearing gloves, picked up a bun. The staff, with the same gloved hand touched the edge of the tray that she placed a plate upon. Without a glove change, Staff B picked up the bun again. At 11:47 AM after hand hygiene and a change of gloves, Staff B touched the edge of tray, picked up the phone, and then picked up another plate and bun with the same gloves on. At 12:07 PM with gloved hands Staff B touched multiple surfaces, then picked up a piece of bread with same gloved hands and placed the bread on a plate. Staff B then opened a can of soup, poured it into a bowl, touching the handle and buttons on the microwave placed the soup in the microwave. With the same gloved hands, Staff B picked up another piece of bread. During an interview on 9/25/24 at 9:20 AM, Staff B, Cook, reported when using gloves, she would change them when she touches her face, hair or other surfaces. During an interview on 9/25/24 at 9:44 AM, the Director of Dining Services reported when using gloves, he would expect staff wash hands and change gloves any time they switch items, any time they touch their face, and any time they touch any surface. A review of the facility policy titled: Food Handling Guidelines, revised January 2024, documented: Single use disposable gloves are worn when preparing foods that will not be not be cooked again (ready to eat foods) and while serving food. Gloves are changed between tasks.

Based on observation, interview, and record review the facility failed to ensure residents treated in a dignified manner for one of three residents reviewed for dignity (Resident #5). The facility reported a census of 51 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #5 revealed the resident was rarely to never understood and used a wheelchair and/or scooter. Review of Resident #5's Care Plan dated 9/20/23, revised 5/9/24, revealed, [Resident #5] has an ADL (activities of daily living) self-care performance deficit r/t (related to) dementia and impaired balance. An Intervention dated 9/26/23, revised 5/9/23, revealed Resident #5 utilizes a rolling Broda Chair (brand name of a type of chair that allows a resident to tilt or recline) for mobility. She is able to propel herself with her feet. During an observation on 9/24/24 at 12:11 PM Resident #5 pulled backwards down the hallway in a Broda chair with a staff member, Staff A, Certified Nursing Assistant (CNA) holding the resident's feet while the resident being transported backwards. The resident was being assisted rapidly backwards down the hallway. On 9/26/24 at 8:22 AM during an interview with Staff O, CNA, queried which way resident should be facing, backward or forward, when assisted in Broda chair and acknowledged forward. When queried about foot pedals. Staff O responded foot pedals should always be on when assisting/pushing a resident. On 9/26/24 at 10:49 AM, when queried what direction the resident should face when moving, the Assistant Director of Nursing (ADON) responded forward, and no back pulling of anyone. When queried about if it would be appropriate to hold the resident's feet, the DON acknowledged would not be. On 9/26/24 at 11:02 AM when queried about the above observation, the DON responded need foot pedals on, and to move forwards not backwards. The DON responded no pedal, no push. Review of the Facility Policy titled Dignity, dated 2001 and revised 2/21, revealed the following: Residents are treated with dignity and respect at all times.

Based on interview, clinical record review, and facility policy review the facility failed to ensure timely completion of an Admission Minimum Data Set (MDS) assessments for one of two residents reviewed for Resident Assessment Task (Resident #38). The facility reported a census of 51 residents. Findings include: Review of Resident #38's Electronic Health Record (EHR) revealed the resident admitted to the facility 1/16/24. Review of the resident's Admission Minimum Data Set (MDS) assessment with Assessment Reference Date 1/23/24 revealed the assessment completed on 2/16/24. On 9/26/24 at 10:30 AM, the MDS Coordinator confirmed the assessment was late. On 9/25/24 at 3:02 PM, a Facility Policy to address MDS completion requested. On 9/25/24 at 4:07 PM, the Administrator explained the facility did not have a policy.

Based on clinical record review and staff interview the facility failed to ensure timely completion of quarterly Minimum Data Set (MDS) assessments for two of two residents reviewed for Resident Assessment Task (Resident #13, Resident #38). The facility reported a census of 51 residents. Findings include: 1. Review of Resident #13's Quarterly MDS assessment with Assessment Reference Date (ARD) 6/25/24 completed on 7/11/24. 2. Review of Resident #38's Quarterly MDS assessment with ARD 4/23/24 completed on 5/9/24. On 9/26/24 at approximately 10:30 AM, the MDS Coordinator queried if there were issues completing quarterly assessments timely. Per the MDS Coordinator, it was pipped (part of Performance Improvement Project) for QAPI (Quality Assurance Performance Improvement). When queried about the specific MDS above, the MDS Coordinator explained for MDS 4/23/24 was waiting on other people to do their section, and for the MDS dated [DATE] MDS Coordinator had other matters she was attending to and there was not a back-up. On 9/25/24 at 3:02 PM, a Facility Policy to address MDS completion requested. On 9/25/24 at 4:07 PM, the Administrator explained the facility did not have a policy.

Based on clinical record review and staff interview the facility failed to ensure Minimum Data Set assessments submitted timely for one of two residents reviewed for Resident Assessment Task (Resident #13). The facility reported a census of 51 residents. Findings include: Review of Resident #13's Quarterly MDS assessment with Assessment Reference Date (ARD) 4/2/24 was completed 4/16/24. The assessment was submitted 5/16/24. On 9/26/24 at approximately 10:30 AM the MDS Coordinator explained they submitted every other week on Friday. When queried about Resident #13's MDS, the MDS Coordinator acknowledged it was late. A Facility Policy to address submitting MDS requested via email to the facility's Administrator. On 4/26/24 at 1:25 PM, the Administrator explained via email the facility did not have a policy.

Based on clinical record review and staff interview the facility failed to ensure accurate coding of medications on the Minimum Data Set (MDS) assessment for one of five residents reviewed for unnecessary medications (Resident #23). The facility reported a census of 51 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #23 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, the resident took antianxiety, anticoagulant, opioid, and antiplatelet medication. Review of the resident's Medication Administration Record (MAR) dated August 2024 revealed the resident only took anticoagulant medication from the medication classes listed above. On 9/26/24 at 10:59 AM, the MDS Coordinator explained she looked at the wrong person, and acknowledged that was why the mistake occurred. On 9/25/24 at 3:02 PM, a Facility Policy to address MDS accuracy requested. On 9/25/24 at 4:07 PM, the Administrator explained the facility did not have a policy.

Based on clinical record review, resident and staff interview, the facility failed to complete a Baseline Care Plan within 48 hours of admission for 2 of 2 newly admitted residents reviewed (Resident #32 and Resident #53). The facility reported a census of 51 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. The MDS listed diagnoses included: acute chronic systolic heart failure (commonly called congestive heart failure), type 2 diabetes mellitus with unspecified complications. The MDS documented Resident #32 was admitted on [DATE]. A review of the Clinical Admission Assessment, dated 8/19/24, revealed the Care Planning section did not identify Focus Areas, Goals or Interventions for the risk factors, diagnoses or care needs for Resident # 32. During an interview on 9/25/24 10:22 AM, the MDS Coordinator reported she does not complete the Baseline Care Plans and these should be completed by the admitting nurse. During an interview on 9/25/24 at 3:38 PM, Staff J, RN disclosed she did not complete the Care Planning section of the Clinical Admission Assessment as this is completed by the MDS Coordinator. 25855 2. The MDS assessment, dated 9/1/24, identified Resident #53 with a moderate cognitive impairment as a result of a BIMS score of 9 out of 15. The MDS listed diagnoses included: atrial fibrillation (an abnormal heart rhythm), coronary artery disease and respiratory failure. The MDS documented Resident #53 admitted to the facility on [DATE]. A review of the N Adv- Skilled Evaluation, dated 8/26/24, revealed the Care Planning section did not identify revealed the Care Planning section did not identify Focus Areas, Goals or Interventions for the risk factors, diagnoses or care needs for Resident # 53. During an interview on 9/26/24 at 11:59 AM, the Director of Nursing (DON) reported she would expect the Nurses who took care of the Resident in the first 48 hours to develop the Baseline Care Plan within 48 hours. During an interview on 9/25/24 at 4:07 PM, the Administrator reported the facility did not have a policy on Baseline Care Plans.

Based on interview and record review the facility failed to update the resident's Care Plan following discontinuation of anticoagulant medication for one of seventeen residents reviewed for care plans (Resident #19). The facility reported a census of 51 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #19 revealed the resident scored 13 out of 15 on a Brief Interview for Mental Status exam, which indicated intact cognition. Per this assessment, the resident did not take anticoagulant medication. On 9/24/24, review of the resident's Care Plan, revised date 7/18/23, revealed the resident is on anticoagulant therapy; Coumadin (brand name of blood thinner medication, commonly known as warfarin.) Review of Resident #19's Physician Orders for revealed Coumadin discontinued on 5/9/24. On 9/26/24 at 10:43 AM, the MDS Coordinator explained she had recently figured out how to use the review history in [electronic health record system brand name redacted]. The MDS Coordinator acknowledged when she looked at the resident's current Care Plan saw Coumadin still on there, realized yesterday, and explained would take it off. On 9/26/24 at 11:06 AM when queried if the MDS Coordinator did all the care plans, the Director of Nursing (DON) responded yes. When queried about Care Plan revision, the DON responded they should be revised any time a change, and definitely should be looked at quarterly. On 9/25/24 at 3:02 PM, a Facility Policy to address care plan revision requested. On 9/25/24 at 4:07 PM, the Administrator explained did not have a policy. 25855 2. The MDS assessment, dated 8/20/24, revealed a BIMS score of 15 out of 15 for Resident #23, indicating the resident cognitively intact. The MDS listed diagnoses included: spinal stenosis, paroxysmal atrial fibrillation (an abnormal heart rhythm) and left foot drop. The MDS assessed Resident #23 dependent on staff for assistance with oral hygiene, toileting hygiene, showering, lower body dressing and transfers. The MDS also identified Resident #23 as having an impairment to one side of his body. A review of the Physician Orders revealed an order dated 12/27/23 OT (Occupational Therapy) to evaluate for a left hand brace. A review of the Care Plan, dated 11/29/23, included a Focus Area to address ADL (activities of daily living) self-care performance deficit r/t (related to) Impaired balance and limited mobility r/t spinal stenosis. Interventions included [resident name redacted] has left sided weakness of the upper and lower extremity. [Resident name redacted} is dominant on the right side. The Interventions did not address a brace for the left hand, including when to apply and remove. An observation on 9/25/24 at 12:48 PM revealed Resident #23 sat up in a wheelchair in his room eating lunch, and wore a brace on his left hand. Therapy evaluation and recommendation notes requested. The facility did not not produce the requested documentation. During an interview on 9/26/24 at 8:57 AM, Staff O, Certified Nursing Assistant (CNA) stated Resident #23 is to have his left hand brace put on when he gets up in the morning. Staff stated she did not recall when the brace should be removed. She also stated she did not know where to find information as to when the brace should be applied or removed. During an interview on 9/26/24 at 10:01 AM, Staff F, Registered Nurse stated Resident #23 is to have his left hand brace applied in the first part of the morning. Staff F stated the CNA's will usually remove the left hand brace at bedtime. She stated she could not explain why the left hand brace was not addressed on the Care Plan. Staff F explained the MDS Coordinator is primarily the one who makes changes to Care Plans, and she may not have been notified of the order for the brace. During an interview on 9/26/24 at 11:59 AM, the Director of Nursing (DON) stated Resident #23 is to have his left hand splint applied in the morning and removed at night. The DON stated she could not recall where the aides documented this as they are the ones who put it on and take it off. She stated she would expect the left hand brace to be addressed on the Care Plan. The DON stated any Nurse can update a Care Plan.

Based on observation, staff interviews, and clinical record review the facility failed to ensure ongoing coordination of care between facility staff and hospice staff for one of one resident reviewed for hospice (Resident #19). The facility reported a census of 51 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 8/6/24, revealed Resident #19 scored 13 out of 15 on a Brief Interview for Mental Status exam, which indicated intact cognition. Per the assessment the resident received hospice care while a resident. On 9/25/24, review of Resident #19's Physician Orders present in the electronic health record (EHR) lacked an order for when the resident admitted to hospice services. Review a Transfer to Hospital Summary Note, dated 6/9/24 at 11:00 PM, revealed Resident was found by this nurse calling out help. Resident was checked on previously five minutes prior, was stable, comfortable, expressed no needs. Resident was found on floor on right side with bump to head and bleeding from top right forehead. Oxygen saturation at 87% on 3L (3 Liters), medic came to evaluate resident, resident wanted to be evaluated at the hospital. Said I do not feel right. I . The Progress Note lacked documentation hospice staff were notified. Review of the resident's Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report with SOC (Start of Care) date 5/2/24 revealed, At 2300 (11:00 PM) on 06/09/2024 pt (patient) had unwitnessed fall. The facility had difficulty getting the bleeding to stop, patient recently on Coumadin (anticoagulant medication), and she was severely dyspneic (short of breath) and hypoxic (having too little oxygen) saturating at 86% on 3L/min (liters per minute) continuous O2 (oxygen). The facility sent patient to [Hospital Name Redacted] at 2300 and did not inform hospice. Call from triage at 0249 (2:49 AM) from patient's daughter, [Name Redacted] to inform. Contacted [Hospital Name] ER (emergency room ) PA (Physician Assistant), [Name Redacted] with update. Provided DNR (Do Not Resuscitate), med, and allergy list. Per [PA Name Redacted] the patient's head is fine, bleeding stopped, negative for fractures are the concern and she has agreed to IV (intravenous) Lasix (medication to treat fluid retention), DuoNebs (brand name for combination of two medications to open up the airways), labs and a chest X-ray. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report for IDG Meeting Date 6/21/24 revealed, Order date 6/17/24 Patient to discharge from hospice due to moved out of service territory. Patient admitted to non contracted facility for treatment. On 9/24/24 at 8:31 AM, Resident #19 observed in their room. The resident was wearing a nasal cannula with oxygen concentrator set to 4 Liters. On 9/25/24 at 10:55 AM during an interview with Staff N, Hospice Case Manager, explained the following when queried about sending the resident out of the facility and not calling hospice: Per Staff N, she thought it happened maybe one time, she knew the resident had gone to the hospital a couple of times, and it might have happened maybe once, she didn't specifically recall. Per Staff N, she was pretty sure the resident requested to go to the ER, the resident had fallen or rolled out of bed something maybe, the resident was sent to the hospital, hospice was unaware, and resident was admitted . Per Staff N, the resident came off services and had to admit to services. When queried what should happen when resident sent out, Staff N responded supposed to notify hospice, and if the patient competent and could make decisions and requested ER was their right. Staff N explained most of the time hospice tried to send a nurse out immediately to assess, and if could not manage, then would send the resident out. Staff N explained hospice asked facility notified them, hospice would give report to the hospital, so everyone was on the same page and hospice would have people follow up. On 9/26/24 at 11:09 AM when queried about a resident on hospice going to the hospital, the Director of Nursing (DON) explained staff should first call hospice, see what they say. Per the DON, the family would be called and let them know, and generally if the patient, family, wanted resident to go out and nursing would go out. Per the DON, if not, someone would come from hospice to see the resident. When queried if hospice should be notified if all parties in agreement to send the resident out, the DON responded yes, and if didn't, then missed it. When queried about hospice saying they were not notified, the DON responded that did happen, and there was serious re-education done about calling hospice with any condition change, concern, any falls, and any of those. A Facility Policy to address hospice requested via email to the facility's Administrator. On 4/26/24 at 1:25 PM, the Administrator explained via email the facility did not have a policy.

Based on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies forms, the facility Quality Assessment and Performance improvement (QAPI) Plan, and staff interview the facility failed to carry out Quality Assurance (QA) activities to ensure effective measures had been taken to prevent reoccurrence of deficiencies. The facility reported a census of 51 residents. Findings include: The CMS 2567, dated 1/03/24 listed, in part, the following deficiencies cited during Recertification Survey and Complaint Survey: F550, F641, F657, F812, and F880. The current Recertificaton survey, conducted 9/23/24-9/26/24, also identified the above citations. During an interview on 9/26/24 at 10:18 AM, the Administrator reported the staff had been educated on all of the above tags and could not explain why the problems have re-occurred. The facility policy titled Quality Assurance Process Improvement Plan for the Facility, revised 8/29/24 instructed the following: a. The Facility monitors provider and facility adherence to quality standards through ongoing review of complaints, adverse events, and sanctions and limitations on licensure. The purpose of the peer review program is to monitor accessibility, quality, adequacy, and outcomes of services delivered. b. The Facility performs audits to review clinical and administrative policies and procedures, clinical records against standards, adherence to timely access to care requirements, and administrative practices for the purpose of monitoring compliance with the Facility contract, including state and federal requirements. If the practitioner or facility treatment record review fails to meet an established goal, corrective action and/or re-audit is required. Follow-up reviews measure progress on corrective actions until the goal is met.

Based on observations, clinical record review, and resident and staff interviews the facility failed to identify and respond to an elopement in a timely manner for 1 of 1 residents reviewed for elopement (Resident #1). Resident #1 eloped from the facility on 7/20/24 at approximately 3:00 a.m., was found at 7:20 a.m. by facility staff on a neighboring business property approximately 100 yards from the facility. Facility staff initially identified the resident was missing at 6:50 a.m., notified management staff at 7:08 a.m., and staff went outside and looked for the resident at 7:15 a.m. The facility failed to follow appropriate precautions when a door alarm sounded on 7/20/24, they did not assess the area around the door for residents and did not take action to ensure that all residents were accounted for that resulted in a resident's elopement and fall with injuries. Residents that were cognitively impaired but independently mobile could potentially have been impacted by the facility's failure. The facility reported a census of 51 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/6/24 at 2:00 p.m. The IJ began on 7/20/24. The facility staff removed the IJ on 8/6/24 by implementing the following actions: 1. Staff educated to account for all residents when a door alarm is sounded, effective 2:00 p.m. on 7/20/24. All door alarms were checked for correct operation; concerns were identified on the Station 2 door and beauty shop door, and a staff member was positioned by the doors and designated as a door watch until the security alarm company arrived on 7/22/24 and assessed alarm functions on all exit doors. Adjustments to the alarm sensitivity were made at that time, replacement parts ordered, the company returned on 7/24/24 and completed repairs on the effected exit doors. The door watch was discontinued after alarm functions were verified on all WanderGuard alarmed doors. 2. Staff educated on 7/22/24, 7/23/24, 7/24/24, 7/25/24, 7/26/24 and 7/30/24 regarding proper head counts of residents when the door alarm sounds, including visual confirmation that they are present in the facility. Additionally, staff were educated to respond to every door alarm. If there is an unwitnessed alarm activation staff have been educated to check the area around the door on both sides of the door and surrounding areas within proximity of the door that alarmed, and initiate an immediate headcount if the resident is not found near the door and completed prior to deactivating the alarm. 3. Nursing staff were educated that all residents should be accounted for, including visual verification, on the change of shift rounds at every shift change 4. Responsible staff have been educated to complete door alarm checks every shift. 5. Nursing staff educated they are required to verify placement of the WanderGuard bracelet on each of the resident's that have them, on every shift, and document on the resident's Treatment Administration Record (TAR). The WanderGuard alarm bracelets are also checked to ensure proper working order daily on the night shift using the remote checking device, also documented on the TAR. The IJ was removed on 8/6/24 at 5:30 p.m., the scope was lowered from a J to a G verified by onsite survey. Findings include: The Minimum Data Set (MDS) Assessment tool dated 6/4/24 revealed Resident #1 had short and long term memory deficits and severe cognitive impairment, had a diagnosis of non-Alzheimer's dementia, was able to make himself understood and understood others, able to ambulate independently and required staff supervision to maintain his safety. A Wandering Risk Scale assessment form completed 6/6/24 revealed the resident scored between 0 and 8 points, in the low risk category for wandering. A score of 9-10 indicated the resident was at risk for wandering, and a score of 11 or greater indicated the resident was at high risk for wandering. A Risk for Wandering/Elopement problem initiated 6/15/23 on the resident's Nursing Care Plan directed staff: 1. Engage resident in purposeful activity, initiated 7/15/23. 2. Identify if there is a certain time of day when wandering/elopement attempts occur, initiated 6/15/23. 3. Resident wears a WanderGuard bracelet (a device that activates an audible alarm when it is near an exit door). Staff to check placement every shift and 3rd shift to check if working properly, initiated 6/11/24. 4. Clearly identify resident's room and bathroom, initiated 6/15/23. The resident's July, 2024 Treatment Administration Record (TAR) revealed staff were directed to check for placement/confirmation that the WanderGuard bracelet was on the resident every shift (3 times a day, on the day shift, evening shift and night shift). Staff were also directed to check the functioning of the resident's WanderGuard bracelet daily on the night shift. The July, 2024 TAR revealed staff did not check for placement of the WanderGuard bracelet on the evening shift on 7/19/24, and the night shift on 7/20/24, and staff did not check the functioning of the WanderGuard bracelet on the night shift on 7/20/24. The posted daily schedule for 7/19/24 revealed scheduled employees on the night shift that started at 10 p.m., and ended at 6 p.m. on 7/20/24 included Staff D, CNA, Staff E, CNA, Staff F, LPN (Licensed Practical Nurse) through a staffing agency, and Staff G, LPN, also through a staffing agency. The posted daily schedule for the 6 a.m. to 2 p.m. day shift on 7/20/24 revealed Staff J, CNA, assigned to the resident, Staff A, CNA, also assigned to the resident's station, Station 3, and Staff C, RN assigned to Station 2. A Nursing Progress Note transcribed by Staff C, Registered Nurse (RN) on 7/20/24 at 1:33 p.m. stated: Alerted by staff that the resident was not in his room and staff unable to find the resident. All the CNA's (Certified Nursing Assistants) went around the facility to look for the resident, this nurse went around the health center looking for the resident door to door, at 7:08 a.m. notified the manager on call that the resident was missing and was advised to call the police if the resident could not be located. This nurse took their car and drove around the facility campus looking for the resident, while driving staff called and notified this nurse the resident was located by staff (Staff A, CNA and Staff B, CNA) at 7:20 a.m. at an adjacent property. This employee notified the manager on call the resident was located and drove to the resident's location. The 2 CNA'a were with the resident, reported they found him face down on the pavement facing the direction of the facility. Staff A said the resident was bleeding; this employee knelt down and assessed the resident, his eyes were open, he was breathing, his pulse was racing, blood was on the pavement approximately 12 inches away from where he was laying. The resident was able to move, turned him over to his back for comfort and let him rest his head on the employee's leg. The resident did not did not cry or yell out in pain, appeared anxious and his hands were shaking. His forehead had a laceration, nose had dried blood and had debris covering his face. This nurse asked the resident if he was okay, the resident kept looking at this employee and did not respond (the resident's normal status due to his dementia) and called EMS right away (Emergency Medical Services). The 3 staff remained with the resident until EMS arrived at 7:37 a.m. and transported the resident to hospital. A hospital Discharge Summary report dated 7/22/24 revealed the resident presented to the Emergency Department on 7/20/24 after a fall that resulted in: 1. A right sided triquetral fracture (bone in the wrist) that required application of a splint to be worn at all times, and follow-up with an orthopedic physician. 2. Forehead and facial abrasions from fall. The facility's Wandering and Elopement policy, dated as last revised March, 2019 directed staff: 1. The facility will identify residents who are at risk of unsafe wandering. 2. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety plan. 3. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner, b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. 4. If a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and c. If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies. 5. When the resident returns to the facility, the director of nursing services or charge nurse shall: a. examine the resident for injuries; b. contact the attending physician and report findings and conditions of the resident; c. notify the resident's legal representative; d. notify search teams that the resident has been located; e. complete and file an incident report; and f. document relevant information in the resident's medical record. Observations revealed: 8/1/24 at 3:15 p.m. revealed Staff H, Support Services Coordinator had a WanderGuard testing device by the Station 2 exit doors, the first set of exit doors alarmed when the device was near the door, and allowed the doors to open, as intended. The alarm continued to sound until a passcode was entered by staff. The second set of doors were equipped with magnetic locks, when the WanderGuard device activated the door alarm, the door became locked and required continuous pressure applied to the bar for 15 seconds in order for the door to open, also as intended. The alarm continued to sound until a passcode was entered by staff. The second set of doors opened to a hall that led directly to an unalarmed exit door. Staff H stated at that time she checked all door alarms daily from Monday through Friday, the doors alarmed with the device she used to check the alarms, but they found the alarms didn't always work with a resident that wore a WanderGuard bracelet. 8/1/24 at 3:24 p.m. the first set of exit doors by Station 1 alarmed when a WanderGuard device was near it, and continued to sound until a passcode was entered by staff. The second set of exit doors had a magnetic lock activated when a WanderGuard device was near, and required 15 seconds of continuous pressure on the bar for the door to open, as intended. The alarm continued to sound until reset by staff. The 2nd set of exit doors led to an area between administrative offices and an attached independent living facility, both areas led to unalarmed exit doors to the outside. 8/2/24 at 11:41 a.m., Resident #1 ambulated independently in the hall with regular gait, had shoes on and wore a splint on the right lower arm. Staff interviews revealed: 8/1/24 at 2:56 p.m., Staff D, CNA, stated he worked the night shift that started at 10 p.m. on 7/19/24 and ended at 6 a.m. on 7/20/24, there was usually 3 CNA's on the night shift but that night 1 of them had called in, and the other one (Staff E) arrived late, around 10:45 p.m. Staff D stated he was the only aide there for the night shift until Staff E arrived, he took report on all residents and saw Resident #1 laying down in his bed around 10:30 p.m. Once Staff E arrived, she had the Station 3 residents (the resident's area), Staff D had Station 2 residents, and the 2 aides split the Station 1 residents. The resident was still in his bed between 10:50 p.m. and 11 p.m. when he gave report to Staff E, CNA and rounded with her. He went past his room around 12 a.m. and the resident was still in bed. Between 2 a.m. and 2:30 a.m., he heard water running in the sink in the resident's bathroom and the resident was in there. Around 3 a.m. he went to Station 3 to assist Staff E, saw Staff G, LPN (Licensed Practical Nurse) as she came back from break and the door alarm at Station 1 was going off. Prior to that time that night, Resident #3 was up in her wheelchair, self-propelled and wandered throughout the facility, a usual activity for her, and activated the WanderGuard alarms at both Station 1 and Station 2 as she wandered. He followed Staff G, LPN to Station 1, Resident #3 self-propelled her wheelchair away from the exit door area and towards Station 2, Staff G told him to turn the door alarm off because she didn't know how to. Staff D stated he went out the first set of exit doors to turn the alarm off, the alarm on the 2nd set of doors was not activated, he didn't know the code to reset the alarm and silenced the alarm by inserting an ink pen into a whole located on the bottom of the alarm box, that was the only way he knew to silence the alarm. Staff D stated he thought Resident #3 had activated the door alarm because she was moving away from the door as they came down the hall from the Station 3 area. Staff D stated he had not seen Resident #1 out of his room that night. 8/1/24 at 3:44 p.m., Staff E, CNA, stated when she worked the night shift on 7/19/24 to 7/20/24, she saw the resident in bed in his room around 2 a.m. The resident will get up by himself and use the bathroom, she thought she saw the bathroom light on with the bathroom door shut around 4:30 a.m. and thought the resident was in the bathroom. Resident #3 was up in her wheelchair that night, she goes around in her wheelchair and sets the door alarms off and had been doing that on that night. When she made rounds with the day shift that morning, she thought the resident was in the bathroom because the bathroom door was shut, the bathroom light was on, and did not see the resident at that time. She did not see the resident out of his room that night, and did not know the resident got out of the facility until she got a call that day about it. 8/2/24 at 9:36 a.m., Staff F, LPN from a staffing agency, stated when she worked on the 7/19/24-7/20/24 night shift the resident was assigned to her, she saw him around 2 a.m., he was lying in his bed. She didn't see him in the halls that night. 8/1/24 at 5:06 p.m., Staff G, LPN from a staffing agency, stated the door alarm at Station 1 was going off that night (7/20/24), as she returned from break at approximately 3:00 a.m. There was a resident that self-propels in her wheelchair throughout the night and had set door alarms off earlier that shift, she was going towards Station 2 from Station 1 at the time (Resident #3). The agency staff received little instruction on specifics to the facility, she did not know the passcode or how to reset the door alarm, Staff D knew how to reset the alarm and did. Staff G stated she wasn't assigned to the resident that night, had no observations of him and had not seen him in the hall that night. 8/2/24 at 5:42 a.m., Staff I, CNA, stated she had worked on the night shift for several years, knew Resident #1 well, he didn't sleep very good and was up and down at night. He usually came out of his room, sat in a recliner across from the Nurse's Station, he ate a snack and has something to drink, then goes back to bed. He always puts his shoes on or had his shoes on when he came out of his room, she has seen him wander towards Station 2 and will get to the door if staff don't intervene and redirect him back to Station 3. She had not seen him go towards Station 1. 8/2/24 at 3:40 p.m., Staff J, CNA, stated he worked the day shift on 7/20/24. When he got report from the night shift, the resident wasn't in his bed, the bathroom door was shut, the light was on in the bathroom, and the staff that gave report to him said he was in the bathroom. As he assisted his residents that morning he could not find the resident in his room, he wasn't in the bathroom and he couldn't find him in the area, so he asked his coworker if she had seen him, she had not, and everyone started looking for him. 8/6/24 at 11:32 a.m., Staff A, CNA, stated she worked the day shift on 7/20/24, around 6:50 a.m. Staff J came to her and asked if she had seen the resident, she had not, she told him they needed to alert all staff and she notified staff at Station 2, then went to Station 1 and alerted them. Staff looked from room to room and she even went to the attached Assisted Living facility and did not see the resident. She went outside, saw 1 of the other aides outside looking for the resident (Staff B, CNA) who said she hadn't found him in the area, they went to the road that went around the facility, the gate on the fence line by the road was open so they went through it, she thought she saw someone in the distance on the ground, moved toward them and as she got closer she knew it was the resident. He was on the pavement, face down, he had dried blood on his face and on the ground by him, he was awake, his eyes were open, and she called the facility to tell them where he was. They stayed with the resident, the nurse, Staff C, RN, came in her car, she assessed him and called 911. Staff A stated she knew the resident well, he had walked towards Station 1 a couple of times but was easy to redirect. 8/5/24 at 11:34 a.m., Staff C, RN, stated she worked the day shift on 7/20/24, around 7 a.m. that day staff said they couldn't find the resident and they all started looking for him. They didn't find him in the facility, she called the manager on call to notify her, and got in her car to drive around the property to see if she could find him. She got a call that he was found in a business parking lot and drove there. The aides that found him were with him, he was laying on the ground face down, there was dried blood on his face and on the ground near him. He was awake, his eyes were open, she tried to talk to him, he didn't respond but that was normal for him. He could move everything and didn't act like he was in pain so they turned him to his back so he would be more comfortable, she didn't see injuries other than cuts/abrasions on his face. She called 911 and the manager on call. Prior to that day, she had seen the resident walk to Station 2 a couple of times in the last year, and when he was first in the facility he had gone to the Station 1 door. He was always easy to redirect. 8/2/24 at 2:20 p.m., the Director of Nursing (DON) stated staff called her on the morning of 7/20/24, notified her the resident had eloped, she went to the facility immediately, spoke with staff and implemented education that day on the expectations of what staff were supposed to do when a door alarm went off. They also assigned a staff member to each of the exit doors to monitor the doors in case there was an alarm malfunction until their service provider could inspect the alarm system. The facility was equipped with several surveillance security cameras and she thought she could review how the resident exited and the time, however, it was right after the computer software crash on 7/19/24, and their security cameras did not function because of that. One of the employee's there had connections to a neighboring business and how the facility had access to their security surveillance videos, that showed the resident walked across the parking lot at 3:13 a.m., headed south, to the corner of a business, then he turned, walked towards the facility, walked along a fence line that separated the parking lot from a business, the resident fell where staff found him that morning. The DON didn't know if the time on the video was correct, but she didn't think the resident was in the bathroom or in the building when staff said he was at 4:30 a.m., she thought the resident left through the Station 1 door when it alarmed at 3 a.m. and staff didn't check to see if anyone had gone out the door, or check for missing residents when the door alarmed and staff should have done that. All staff were educated to look on both sides of the door and around the area when a door alarm sounded, to make sure a resident hadn't left, do a headcount and make sure all residents were accounted for before the door alarm was reset. Staff were also educated to account for all residents, visually see each one when they gave the shift to shift report, and staff had not done this on that day. 8/2/24 at 10:33 a.m., a representative from the facilities contracted WanderGuard service provider was interviewed and stated they were at the facility on 7/23/24 to assess the system. They found all door alarms functioned but had to adjust the sensitivity of the signal on 1 of the doors due to electrical interference in the area. He stated the doors/alarms were normally set to alarm when a WanderGuard was within 6 feet of the door, but due to the interference at that door, it was sensitive and alerted when the WanderGuard was within 2 feet of the door. They returned on 7/25/24 and made additional adjustments to the sensitivity settings for the alarms, all alarms worked.

Based on observation, record review, policy review and staff interviews, the facility failed to ensure one of five residents had been free from possible abuse. Record review identified Resident #1 required staff assistance for nearly all of his/her cares. Resident #1 sustained an injury to his/her head on 1/5/17, and staff interviews identified relevant staff had not been interviewed, including the staff that initially discovered the injury. The facility reported a census of 75 residents. Findings Include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident#1 scored 11 out of 15 on the cognitive test, Brief Interview for Mental Status. A score of 11 identified moderate cognitive impairments and MDS identified the resident displayed disorganized thinking. The MDS documented the resident required total assistance of two staff members for transfers, extensive assistance of one staff member for dressing, eating, toilet use, personal hygiene, and bed mobility; and total assistance of one staff member for bathing. The MDS documented the resident did not ambulate and required total assistance for locomotion on and off the unit. The resident was unable to complete the walking or turning around section of assessment. The MDS documented the resident had the [DIAGNOSES REDACTED]. The Care Plan with a goal date of 3/26/17 documented Resident #1 required staff assistance for the following: propelling the wheelchair, bed mobility, eating and bathing. The care plan identified all transfers required staff use the Hoyer lift and the resident used a Broda chair. The Incident/Accident Report dated 1/5/17 written by Staff C, without a specific time (only p.m. documented) revealed a Certified Nurse Aide (C.N.A) observed a slightly raised purple hematoma (bruise) on the right parietal (side) of the head. The Incident reported documented the bruised area measured 5 centimeters by 3 centimeters, and the resident denied pain or headache. The resident had been lethargic and stated she/he hit her/his head on the chair, and had been unable to report anything else. The Nurse's Note written by Staff C, dated 1/5/17 documented at 4:30 p.m. on 1/5/17 the aide observed a slightly raised purple hematoma (bruise) on the right parietal of the head. The bruised area measured 5 centimeters by 3 centimeters, and the resident denied pain or headache. The physician and family were notified. A Skin Sheet identified Staff A only wrote the date of 1/5/17 and Resident#1's name/room number. The nurse/Staff C completed the following assessment: Certified Nurse Aide (C.N.A) observed a slightly raised purple hematoma on parietal lobe. The resident denied pain or headache. The resident reported he/she hit her/his head on the chair. The facility self-reported the following: Resident #1 used a Hoyer for transfers and when up sits in a Broda chair and requires total (staff) assistance with activities of daily living (ADL) and feeding. The resident had pain in his/her hands which are contracted and received arthritis and pain medication. At times the resident can be very coherent in conversation. Staff A, CNA was giving resident #1 a shower and Staff A noticed a dark raised area on the right upper parietal region of the resident's scalp. The area was slightly raised and dark purple in color. When the resident was asked if he/she remember how it (the injury) happened, he/she reported when they were repositioning him/her in the chair he/she bumped his/her head. Nothing was reported from the day or night shift. The resident does have (use) quarter (side) rails to assist with cares. The bump on his/her head is looks too high to have hit the rail and too low to have hit the head of the bed. The resident had a bolsters on the Broda chair at the height of his/her head and the bump is not in the appropriately placed if they (staff) repositioned him/her to hit the side where the frame is (at). The resident is a Hoyer transfer and the pay special attention when transferring to and from the bed, and there is two (2) staff present when using the lifts. Staff B stated she had been fixing Resident #1's hair the night prior (1/4/17) and there was no bruise present then. When talking with 6-2 p.m., CNAs they did not notice the bump or discoloration on his/her scalp. The following day, the bruise was turning yellow around the edges and still slightly raised. Upon review of the facility incident file, only contained Staff B's interview. Staff B statement only identified the following: Staff B had been playing with Resident #1's hair around 5:20 p.m., on Wednesday January 4, 2017 and did not see any bruises or bump on his/her head. During an interview on 2/21/17 at 1:47 p.m. Staff B, CNA reported she did not find the hematoma on Resident#1 on 1/5/17. Staff B reported she worked the evening shift of 1/4/17 and did not notice a hematoma and provided hair care that shift. Staff B reported she had been asked to document about the bruise since she was with Staff A, CNA when she found the bruise (hematoma). Staff B reported the resident can be alert to self, but confused and provided examples. Staff B stated Resident #1 cannot walk. Staff B stated Resident #1 requires two staff assist for transfers & Hoyer, one staff assistance with bathing. During an interview on 2/21/17 at 3:23 p.m. Staff C, Licensed Practical Nurse (LPN) reported Resident#1 had been confused and a poor historian. Staff C reported being on duty when Staff B, CNA notified her of the bump on the side of Resident#1's head. Staff C reported the bump had been purple about the size of an egg. Staff C reported the resident said he/she hit it on the back of the chair, and did not provide any other details. Staff C reported she notified Staff P (Supervisor) for the evening shift on 1/5/17 and Staff P measured the hematoma. Staff C completed an incident report. Staff C reported that she had not been interviewed about the incident or completed a written statement. During an interview on 2/22/17 at 12:54 p.m. Staff A (CNA), stated on 1/5/17 she gave Resident#1 a shower on evening shift, and while blowing drying the resident's hair she found a dark purple egg sized bump on the resident's head. Staff A reported it had not been there the previous evening shift when she worked. Staff A stated she told the nurse about the bump. Staff A reported the resident used a Hoyer lift for transfers, no side-rails on the resident's bed, and a Broad chair. Staff A reported the shower chair is a short back chair. Staff A reported there was no formal investigation or questioning done. Staff A reported she had not been questioned by any Administrative staff about the incident (and no longer employed at the facility). During an interview on 2/22/17 at 2:30 p.m. the Director of Nursing (DON) reported she had been in the building on 1/5/17 (shortly after second shift started) and staff told her that staff found a hematoma on the side of Resident#1's head after the resident's shower. The DON stated an assessment had been completed, along with an incident report, then she notified the Department of Inspections and Appeals (DIA) of the event on the computer. She sent DIA the MDS cognitive portion, incident report, and any interviews she had completed. She reported she could not figure out how the hematoma happened. During an interview on 2/22/17 at 8:55 a.m. Staff K (CNA), reported that she worked day shift 1/4/17, and 1/5/17 both times on station 2 where Resident#1 had been. Staff K reported Staff P, Care Coordinator called her at home the afternoon of 1/5/17, and questioned about the hematoma on Resident#1. Staff K stated did not have knowledge of a hematoma on Resident#1 at that time. Staff K stated she had not been questioned about the incident by any other staff from the facility, and had not been asked to write a statement about the incident related to Resident#1. During an interview on 2/21/17 at 2:44 p.m. Staff P, R.N., (hospice Case Manager) had not been questioned about the hematoma on Resident#1's head. She stated she had been informed of it by facility staff. Staff P reported no visits were completed for the date 1/5/17. During an interview on 2/23/17 at 8:38 a.m. the Director of Nursing (DON) reported she had no other documented interviews to submit other than the interview with Staff B, CNA. Observation on 2/22/17 at 9:20 a.m., revealed Resident #1 seated in a Broda chair and staff attached a sling to the Hoyer lift. The resident's head was not close to the metal part of the Hoyer lift. An observation of the shower chair/s on the station revealed they are low back chair/s. The Facility Abuse Prevention, Identification, Investigation, and Reporting Policy with revised date of 11/28/16 identified the following: all residents have the right to be free from abuse, residents must not be subject to abuse by anyone including but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies or other individuals. The policy identified Resident Abuse under the Federal Certification Guidelines is defined as: abuse means the willful infliction of injury or punishment with resulting physical harm or pain. Instances of abuse of all residents, irrespective of any mental, physical condition, cause physical harm or pain. The policy defined mistreatment as inappropriate treatment of [REDACTED]. The Policy identified should an incident or suspected incident of resident abuse (as defined above) be reported or observed, the Administrator will designated a member of management to investigate the alleged incident. The Administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documentation relative to the alleged incident. The policy identified an attempt to obtain witness statements from all known witness.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazard from self, others, or elements in the environment. Resident #11 was left unattended in the dining room, fell and sustained a head injury. The facility also failed to ensure direct nursing care provided required services and procedures to ensure resident ' s needs were met. Residents #11, #2, and #1 failed to have services to meet their needs. The sample included 9 residents and concerns were identified for three residents. The facility reported a census of 83 residents. 1. According to the 11/26/12 MDS, Resident #11 had [DIAGNOSES REDACTED]. Care Area Assessments (CAA's) on the last full MDS dated [DATE] revealed Resident #11 identified at risk for falls. A Fall Risk assessment completed on 11/29/12 revealed a score of 14 points. A score of 10 or greater points indicated high risk for falls. Resident #11's nursing care plan included a problem described as risk for falls related to increased weakness with 3/14/12 onset date, the care plan reviewed and updated by staff on 6/13/12, 7/11/12, 10/10/12 and 12/5/12 with goal that the resident would be safe and free from injury if fall occurred and interventions that included: 1. Monitor for increased confusion, consult physician as needed. 2. Ensure safe footing. 3. Ensure room is clutter free. 4. Assist of 1 staff member and gait belt applied to resident's waist in room and hall. 5. Walk to meals as tolerated. 6. Restorative care as tolerated, walking. 7. Motion sensor alarm at night. 8. Night light in room. 9. Bed moved away from window. 10 Non-skid strips next to bed (the intervention discontinued without date of discontinuation not recorded). On 1/1/13, chair alarm when in recliner or dining room chair was added to the care plan. The daily assignment sheet for the 12/21/12 2:00 p.m. to 10:00 p.m. shift revealed Staff O, CNA, Staff T, CNA, Staff N, CNA and Staff W, CNA scheduled, and various activities assigned to the staff that included "monitor dining room" assigned to Staff N. Nursing staff scheduled for the evening shift on 12/21/12 included Staff M, licensed practical nurse (LPN). Staff X, LPN was scheduled from 6 p.m. to 10 p.m. Record review revealed dietary staff found Resident #11 on the dining room floor with blood loss from the head after a fall on 12/21/12 at 6:45 p.m. A 12/21/12 physician Visit Summary note revealed Resident #11 sustained a subarachnoid hemorrhage (bleeding on the brain) and subdural hematoma (bruising on the brain/within the skull) from a fall on that date at the nursing home. The resident was hospitalized from [DATE] through 12/31/12, and readmitted to the facility on [DATE] with physician order [REDACTED]. Resident #11's 2/25/13 MDS revealed short and long-term memory deficits, moderate cognitive impairment with signs and symptoms of delirium and unable to complete the cognitive assessment, the resident required extensive assistance by 2 or more staff members for transfers to and from bed and chair, dressing, toileting and personal hygiene, unable to ambulate and wheel chair used for mobility, and occasional incontinence of bladder. A Major Injury Determination Form signed by the physician on 12/26/12 revealed that Resident #11 sustained a major injury from the 12/21/12 fall at the facility. Staff interviews revealed: Five of 5 CNA's interviewed that included Staffs N, O, R, S, and T, all regularly assigned to the evening shift, described that as residents complete their meals, CNA staff assisted residents to leave the dining room and 1 CNA always assigned to remain in the dining room until all residents completed the meal. Three of 3 nurses interviewed that included Staffs M, X, and Staff Q, registered nurse (RN) and assigned as the clinical coordinator on the evening shift on 12/21/12 all reported that staff remained in the dining room during resident meals and a CNA assigned to remain in the dining room until all residents completed their meal. When interviewed on 3/27/13 at 9:45 a.m., Staff O, CNA, stated he/she worked on the evening shift on 12/21/12, assisted Resident #13 to ambulate to his/her room after the evening meal. Staff N assigned to remain in the dining room that evening and in the dining room with 2 or 3 residents left to assist with Resident #13. Staff O stated he/she called for assistance after Resident #13 was toileted, Staff N responded and told him/her that Staff M, LPN, agreed to watch the dining room. Staff O stated that Staff N and him/herself left Resident #13's room a few minutes later and learned that Resident #11 had fallen in the dining room when Staff M left the dining room unattended. On 3/27/13 at 10:01 a.m., Staff N stated he/she worked on the evening shift on 12/21/12, assigned to the dining room and required to remain in the dining room until the last resident had finished their meal. Staff N stated 3 residents that included Resident #11 remained in the dining room when Staff O called for assistance with Resident #13, Staff M was located at the nurse ' s station at that time and agreed to watch the dining room when Staff N left to assist Staff O. The other nurse, Staff X, was in Resident #10's room at that time, and the other CNA's were assisting residents in their rooms. Staff N stated that he/she left Resident #13's room with Staff O and Staff M was in the dining room with Resident #11 and Staff M stated that Resident #11 fell when he/she had left the dining room to assist Staff X in Resident #10's room. When interviewed on 3/27/13 at 10:46 a.m., Staff M stated he/she worked on the evening shift on 12/21/12. Staff M indicated staff was to remain in the dining room when residents ate. Staff M thought the residents had finished their meals when he/she went to assist Staff X in Resident #10's room. Staff M stated that a dietary employee came to Resident #10's room and alerted the staff that Resident #11 had fallen in the dining room, he/she responded and found the resident on the floor with blood under his/her head. Staff M stated that a CNA called Staff Q and requested assistance, and, "it was just a fluke thing that happened Resident #11 had not tried to self-transfer before and was a 1:1 transfer and ambulation." On 3/27/13 at 1:05 p.m., Staff X stated he/she worked on 12/21/12 from 6 p.m. to 10 p.m., went to Resident #10's room soon after his/her arrival that day, the resident was having medical problems that required attention, and Staff M came to assist him/her shortly after he/she had assessed the resident. Staff X stated that residents would have been in the dining room at the time; a dietary employee came to Resident #10's room and told them that a resident had fallen in the dining room, and Staff M left the room. On 3/27/13 at 1:37 p.m., Staff Q, clinical coordinator, stated he/she was at another nursing station when someone called for assistance at Resident #11's nursing station, his/her role was to assist nurses and CNA's at all stations as needed, and would have been available to assist the staff earlier if notified that they needed assistance. Staff Q stated he/she assisted the staff as they prepared to transport Resident #10 and Resident #11 to the hospital. On 3/27/13 at 3:05 p.m., Staff L, dietary aide, worked on 12/21/12 and assigned to "bus" tables at Resident #11's dining room after supper, estimated that at approximately 6:30 p.m. or 6:35 p.m. several residents were seated by Resident #11's nurse ' s station and 1 of the residents said that someone fell . Staff L found Resident #11 on the dining room floor, near the table that he/she usually sat at, thought he/she must have hit their head on the wall heater unit and bleeding from his/her head. Staff L stated that no staff was available in the halls or at the nurse ' s station and he/she went from room to room until she found the nurse and told him/her that Resident #11 had fallen. Staff L could not recall how many residents were in the dining room or if residents were eating at that time, not unusual to start to bus tables when a few residents continued to eat, and staff would clear tables that were already empty. On 3/28/13 at 8:31 a.m., Staff T stated that he/she worked on the evening shift on 12/21/12, he/she was in a resident's room after the supper meal when one of the dietary employees said that Resident #11 fell in the dining room, found Resident #11 on the floor, Staff M arrived at about the same time, and quite certain that Staff M stated that he/she was supposed to watch the dining room, called to assist Staff X with Resident #10 and that was when Resident #11 fell . During an interview on 3/28/13 at 11:50 a.m., the Director of Nursing (DON) stated that staff should have notified Staff Q that they needed assistance sooner than when they did. During an interview on 3/28/13 at 12:55 p.m., the DON stated there was no policy for CNA dining room duties. 2. According to the Minimum Data Set (MDS) assessment tool dated 12/31/12 Resident #1 required staff assistance with most activities of daily living. The physician orders [REDACTED]. The care plan dated as last reviewed 1/9/13 identified the resident at risk for falls and directed staff to use a wheelchair for mobility but did not direct staff to apply foot rests on the wheelchair for transports. In an observation on 3/26/13 at 7:43 a.m., Staff E, Certified Nursing Assistant (CNA), pushed the resident from the bathroom to the side of the bed by the window in the wheelchair without footrests and with both feet and toes dragging on the floor. In an interview on 3/27/13 at 10:02 a.m., Staff D, Registered Nurse (RN), reported when staff pushed residents in wheelchairs the foot rests should be on the wheelchair. In an interview on 3/27/13 at 10:03 a.m., Staff E, CNA, reported the foot pedals were placed on Resident #1's wheelchair only when out of his/her room as the resident did not like having the foot rests on the wheelchair while in the room as he/she was able to self-propel in the room. 3. The MDS dated [DATE] identified the resident required staff assistance with most activities of daily living. The March 2013 physician order [REDACTED]. The care plan with the last revision date of 3/6/13 identified the resident at risk for falls with a 1/10/13 intervention of placing a Dycem (non-slip mat) in the wheelchair was added to the care plan. An observation of the resident being toileted on 3/26/13 at 10:38 a.m. revealed no dycem in the wheelchair, neither under or on top of the waffle cushion in the seat. In an observation of the resident's wheelchair on 3/27/13 at 10:02 a.m., Staff D, RN, verified there was no Dycem in the wheelchair and Dycem should have been in the wheelchair. In an interview on 3/27/13 at 10:03 a.m., Staff E, CNA, reported the only fall precaution for the resident was to keep him/her out of the resident's room when not in bed, that CNAs did not have worksheets and information about the residents were provided by the nurses. In an interview on 3/27/13 at 10:57 a.m., Staff E, CNA, reported the CNA worksheet only had the resident as on Hospice and she did not know about the need for the Dycem until that day and was told the Dycem was supposed to be on top of the cushion in the wheelchair. A review of the incident reports reviewed the resident fell : 1/10/13 at 5:30 p.m. when the resident backed into the restroom and slid out of the wheelchair 3/23/13 at 5:20 p.m. when a CNA found the resident sitting on the floor in the bathroom. A review of the fall risk assessments completed on the following dates: 11/20/12 score of 10 11/29/12 score of 12 12/5/12 score of 12 The last assessment did not have documentation of the date completed and with a score of 12 A score of greater than 10 identified the resident at high risk for falls. A review of the CNA worksheet revealed Resident #2 should have a Dycem in the wheelchair. In an interview on 3/27/13 at 2:30 p.m., the Director of Nursing (DON) reported the Assistant Director of Nursing and MDS coordinator were responsible for updating the care plans after falls with new interventions and that the DON and nursing staff were responsible for ensuring the interventions were implemented. The DON also reported she expected staff pushing residents in wheelchairs to have foot pedals on the wheelchairs and there would be no good reason why Resident #2 did not have the Dycem in the wheelchair as that was stocked in the facility and available at all times. A review of the undated facility policy titled: accidents and supervision directed staff to: a. Following a fall, take the following action: aa. ascertain if there were injuries and treat if necessary bb. determine what caused or contributed to the fall cc. address the contributing factors dd. revise the resident's care plan, as appropriate, to prevent another fall b. Base interventions on the results of evaluation and analysis of information about what the hazards and risks and consistent with relevant standards, including evidence-based practice when available. If interventions cannot be fully implemented right away, the facility should develop interim safety measures. A review of the 5/28/09 policy titled: Falls, directed the staff to assess for the cause: a. Statements by the resident b. Environmental issues - furniture placement, out of reach object, urine on the floor, etc. change in physical/mental status due to: new medication, psychotropic or other drugs that affect blood pressure or pulse, blood sugar level; signs and symptoms of infection, etc. c. Personal care issues: last toilet, shoes on, shoes need repair, don't fit, wheelchair unlocked, etc. d. Adaptive equipment - was equipment on and in place, was the resident using it, using it appropriately Upon request of the facility policy on transporting residents in wheelchairs, the facility provided a form titled, "wheelchair foot pedals", which directed staff to use wheelchair pedals when transporting all residents in a wheelchair, carefully replace leg rest to the wheelchair after a transfer if it is not in place, making sure to lower the foot rest and place the resident's feet on the foot rests before transporting. Failure to follow this procedure will result in progressive discipline. "Put in orientation packet" was handwritten on the form.

The following deficiency relates to facility reported Incident # -I. Based on record review, resident and staff interview, the facility failed to provide the necessary provisions to ensure Resident #3 and Resident #4 received adequate supervision from hazards in the environment. Four residents and three facility staff were traveling in the facility vehicle for a community outing when the vehicle stopped abruptly forcing two residents seated in wheelchairs without any safety devices in-place to fall out from their wheelchairs. Resident #3 received injuries and subsequently died after the incident and Resident #4 sustained a fractured pelvis. The findings constitute an Immediate Jeopardy situation. Concerns were identified for two out of five residents with reported census of 88 residents. Findings Include: The facility used the Q'Straint system to secure residents and their wheelchairs in the facility vehicle for transportation. The Q'Straint manufacture's handbook identified the lap/shoulder belt should always be used on your passenger's to keep them safely in their wheelchairs, should you need to stop quickly or make a sudden diving maneuver or experience an impact. The Q'Straint manufacture's handbook explained to begin by threading the lap belt around the passenger and through the opening in the chair; and the lap belt should take a direct path from the passenger to the rear tie-down anchorage. A document signed by the Administrator summarized an incident that occurred on [DATE]. The summary identified four residents and three staff were traveling in the facility vehicle/van on a community outing when the van driver suddenly stopped to prevent hitting the car in front of them. The report documented two residents seated in wheelchairs were not secured with the lap belts and sustained fractures. 1.According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #3's required the assistance of one staff member for bed mobility, transfer, dressing and assist of two staff members for toileting. A physician's orders [REDACTED]. The Care Plan dated [DATE] for Resident #3 indicated the resident required assist of two staff members for transfers to and from the wheelchair and assistance of one staff member for wheelchair mobility. A hospital consultation reports dated [DATE] identified Resident #3 admitted to the hospital following the motor vehicle incident and sustained trauma to both knees when s(he) slid out of the wheelchair. The resident had been hypotensive and resuscitated in the emergency room with fluid and blood. The X-ray findings showed Resident #3 sustained both a right and left femur fracture, fracture of the right wrist, fracture of the right long finger, a possible neck fracture and acute blood loss (anemia) and hypotension. The resident had been admitted to the intensive care unit with the orthopedic physician discouraging surgery due to his/her clinical condition. According to the hospice care interdisciplinary team notes, on [DATE] Resident #3 returned to the nursing home. The resident responded with nonverbal communication and shook his/her head "yes" when asked if in pain. Nurse's notes dated [DATE] at 2:20 a.m., revealed the resident moaning in pain; and at 11:30 a.m. the hospice nurse visited Resident #3 and increased the resident's pain medication. The notes documented the resident yelling with movements. A facsimile (FAX) transmission dated [DATE] identified the resident's cause of death (on [DATE]) as coronary arterial disease causing congestive heart failure as a result of bilateral femur fracture and anemia. 2. According to the Minimum Data Set ((MDS) dated [DATE] indicated Resident #4 had [DIAGNOSES REDACTED]. Review of the Radiology Report dated [DATE] revealed Resident #4 admitted following a motor vehicle accident. The results of the pelvis examination identified the resident sustained [REDACTED]. Interview on [DATE] at 3:22 a.m., Resident #4 revealed s(he) did recall the van outing and stated s(he) had fallen out of the wheelchair while in the van. Resident #4 stated staff had not used the lap belt to secure him/her when in the van. Staff interviews: Interview with Staff F on [DATE] at 12:34 a.m. revealed Resident #3 wanted to participate on the activity on [DATE]. Staff F stated Staff E and Staff D were also on the van when they left the facility around 9:30 a.m. Staff F indicated the staff assisted the residents out of van and into the activity for approximately one hour until Staff D returned to pick them up around 11:00 a.m.. Staff F stated Resident #3's wheelchair had been positioned behind Resident #4's wheelchair. Staff F indicated he/she had been seated in the passenger front seat. Staff F stated two additional residents occupied the seats behind her/him and they had their seats belts applied. Staff F stated the wheelchairs were secured in the van, but he/she never checked to see if the two residents seated in wheelchairs had their lap belts applied. Staff F reported after they were on the van Staff D started driving north when he/she slammed on the van brakes causing Resident #4 to come out of wheelchair landing in the front floor of the van; and Resident #3 had come out of wheelchair and landed on the floor behind Resident #4's wheelchair. Staff F indicated that ' s when he/she realized Resident #3 and #4 did not have their lap belts applied. Staff F informed Staff D to call 911 and the facility. Staff F reported the ambulance arrived and transported Residents #3 and #4 from the van to the hospital. Staff F further reported it was the van driver's responsibility to ensure all residents had their lap belts on/applied before transporting them. During an interview with Staff E (nurse) on [DATE] at 1:30 p.m., he/she identified going on the activity outing on [DATE]. Staff E indicated they left the facility around 9:30 a.m. and around 11:00 a.m. Staff D returned to transport the residents back to the facility. Staff E indicated he/she was sitting behind Resident #3 in an empty wheelchair and Resident #3 had been positioned behind the wheelchair of Resident #4. Staff E stated while driving that Staff D slammed on the van breaks to avoid hitting a car in front of the van. Resident #4 fell out of his/her wheelchair and Resident #3 flew forward out of his/her wheelchair into Resident #4's wheelchair then fell to the floor underneath Resident #4's wheelchair. Staff E reported that Resident #3's legs were bent in an awkward position and appeared fractured. Staff E stated Resident #3 complained that he/she could not breath and of leg pain. Staff E stated that Resident #3's knee instantly swelled up. Staff E further stated she/he move Resident #3 just slightly to elevate his/her head so the resident could breathe easier. Staff E indicated she/he noted Resident#3's right index finger in a awkward position to the side. Staff E stated apparently Staff D did not put the lap belts onto Resident #3 and Resident #4. Staff E reported the ambulance crew arrived on the sight and they had to remove Resident #4's wheelchair up off of Resident #3 to get the resident out of the van. Staff E reported the other two residents seated in the van were not injured and returned to the facility. Staff E indicated that it was the van driver's responsibility to ensure the residents were secured in and had their lap belts on/applied. Staff E stated Staff D stated after the accident he/she forgot to put the lap belts on. During an interview with Staff D on [DATE] at 1:55 p.m., he/she identified driving the van for the morning activity on [DATE]. Staff D indicated Resident #3 and Resident #4 were secured in the wheelchairs and he/she applied the safety belt(lap belt) to the residents around ,[DATE]:30 a.m. Staff D stated he/she drove the van from the facility to the community activity and returned to transport residents back to the facility around 11:00 a.m.. Staff D stated he/she secured Resident #3 and Resident #4 wheelchairs in the van but failed to apply the lap belts. Staff D stated he/she was driving when the car in front of the van came to a stop and he/she abruptly applied the van breaks causing Resident #3 and Resident #4 to come out of their wheelchairs and landed on the floor of the van. Staff D stated the van came into contact with the car's back bumper but no damage had been done to either the van or the car. Staff D reported he/she called 911 and the ambulance arrived and took Resident #3 and Resident #4 to the hospital. Staff D stated the other two residents had their seat belts on returned to the facility after the incident. Staff D admitted he/she did not apply or ensure Resident #3's and Resident #4's lap belts were on/applied. Staff D further reported that he/she received training from the facility when he/she started driving the van to secure the wheelchairs in and apply the lap belts. Staff D explained the training focused on spending one week with a trained van driver prior to driving and the facility provided him/her with training of transporting residents in the van, which included applying lap belts. Staff D indicated he/she did receive a traffic ticket from the accident for failure to assure safe driving distance. Staff D stated he/she had worked at the facility for three years. The interview acknowledged Staff D failed to place the lap belts to secure residents in their wheelchairs. The facility submitted a written affidavit for Staff D which indicated he/she did not have the lap belts on the residents on (November) 19, (2010) because it was hectic, crowded and he/she had forgot. Record Review of Staff D's personnel file revealed no indication of any training completed after date of hire regarding the van transportation of residents. Interview on [DATE] at 12:00 noon and [DATE] at 2:25 p.m., the Administrator revealed when hired, the van drivers receive one week training with another trained van driver, however the facility did not have documentation of training provided when van drivers are hired. Interview with the Administrator on [DATE] at 2:25 p.m., revealed prior to the incident (on [DATE]) the facility did not have a policy/procedure in place for van driver's training or their procedures. The Administrator stated it was the responsibility of the van driver to ensure residents are secured in the van and the seat belts are applied. The Administrator indicated that after the accident on [DATE] the facility has provided training for the van drivers that included demonstration, testing and a completed checklist of areas covered in training. The facility Administrator stated there was no policy/procedure in place and he would begin creating one. The facility abated the immediate jeopardy on [DATE] when they developed a written policy for van drivers to follow and a checklist for drivers to complete prior to departing on any outing. The facility's Driver Policy dated ,[DATE] indicated training would be provided to drivers prior to driving or transport residents. The drivers would watch the manufacture's training videos, complete the test, and demonstrate understanding of the training materials. The facility's procedure identified that all drivers will follow the manufacture's instructions for securing wheelchairs and passengers. The facility "Trip Checklist" included the following questions for drivers: Are the wheelchair secured. Are all residents secured with lap belts. Are floor anchorages secured? The checklist identified that if a driver answered "no" to any of the questions, then he/she should not depart from their location and must contact the supervisor for further direction. The facility re-educated all five drivers from [DATE] to [DATE] on the manufacture's handbook. These actions lowered the deficiency from a scope and severity level J to a D level. At the time of the exit conference, the facility had not determined a routine monitoring of the Trip Checklist.