Every finding on record at Skyline Nursing & Rehabilitation

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure one (1) of 24 sampled residents were free of significant medication errors, Resident #6. This failure resulted in harm to Resident #6 requiring emergency care at the hospital. The findings included: Resident #6's clinical record listed diagnoses which included but not limited to other encephalopathy, Alzheimer's disease, vascular dementia, and malignant neoplasm of sigmoid colon.Resident #6's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 09/08/25 assigned the resident a Brief Interview for Mental Status (BIMS) score of 3 out of 15 in section C, cognitive patterns. This indicated that the resident was severely cognitively impaired.Resident #6's clinical record was reviewed and contained a Surgical Clinic History and Physical/Consultation Note which read in part, [Resident #6] presented to the ED [emergency department] on 6/29/2025 and Ed note is as follows: 'BIBA [brought in by ambulance] from . [facility name omitted] for evaluation of an episode of unresponsiveness. Per EMS [emergency medical services], patient was given another patient's medication, consisting of 150 mg Klonopin, 100 mg Sertraline, and 1 mg Benztropine. Patient is not on oxygen at baseline, but 02 [oxygen] was placed by EMS for 88% RA [room air] on scene. Pt [patient] is now 98% on 2L [liters] 02. EMS noted patient has a DNR (do not resuscitate) and adjusted 02 accordingly. Patient endorse abd [abdominal] pain but otherwise has no other medical complaints.Resident #6's clinical record contained an emergency department report dated 06/29/26 which read in part, Assessment and Plan: Patient . with history significant for dementia and CVA [cerebrovascular accident (stroke)] presents after an episode of unresponsiveness this morning after being accidentally given another patient's medication, including an unknown amount of Klonopin. We have observed [Resident #6] here for 4.5 hours. [Resident #6] is back to [their] baseline. [Their] vitals are stable . Problems Addressed: Accidental ingestion of substance, initial encounter: acute illness or injury . Condition: Stable and Improved.Resident #6's nurse's progress notes were reviewed and contained a note which read in part, 06/29/2025 11:12 Note Text: Nurse had administered medications to resident, a few moments later nurse identified she had administered another resident's medications to this resident. VS [vital signs] were immediately obtained, resident was alert and responding per base line. VS were 140/80, 98, 67, 17, 98% room air. A few moments after that staff observed that resident had eyes closed and leaning in stationary chair in common area. Blood pressure 70/54 and oxygen saturation 90%, pulse remained in the 60's. Resident with irregular respirations and not responding to verbal and touch stimulations. EMS services were immediately called. Staff placed resident in a chair that would elevate [Resident #6's] legs. Resident began to become responsive, however present with signs of agitation and hitting out. EMS services arrived and resident out of facility at 0945 [9:45 AM] to be transfer to ER for evaluation. MD notified and spouse notified.The facility administrator and staff educator were interviewed on 12/03/25 at 4:00 PM regarding Resident #6. The administrator stated they had completed a medication error report and provided a copy of the report. On 12/04/25 at 8:30 am, staff educator provided copies of a root cause analysis, immediate education provided to licensed practical nurse (LPN) #7, education provided to all staff, and medication administration observation forms for LPN #7. Staff educator stated that immediately upon discovery of the medication error, education was provided to LPN #7 and larger pictures of the residents were placed on the medication carts.Surveyor spoke with LPN #7 on 12/04/25 at 10:20 AM. LPN #7 stated they were working C-wing on the day of the error, and this was not her normal work assignment. LPN #7 stated they prepared and administered medications for who they thought was Resident #29 but instead was Resident #6. LPN #7 stated both residents were similar in appearance, both had beards and sat at the same place in the dining room. LPN #7 stated after administering the medications to who she thought was Resident #29, she heard staff telling Resident #29 to come to the dining room and realized she had administered the medications to Resident #6. LPN #7 stated she immediately reported the error to the director of nursing at the time. LPN #7 stated she was immediately provided with education, all staff were provided with education, and she was observed during subsequent medication passes.Surveyor observed Resident #6 and Resident #29 and noted that both residents were similar in appearance.A policy titled, Medication Administration revised 11/07/2025 specified Identify resident by photo in the MAR (medication administration record).The concern of not ensuring Resident #6 was free of significant medication errors was discussed with the administrator, director of nursing, staff educator, unit managers, social worker, and business office manager on 12/04/25 at 1:45 pm.The medication Klonopin is a benzodiazepine given to control seizures and panic attacks. Sertraline is a serotonin reuptake inhibitor (SSRI) given to treat depression, panic disorders, and obsessive-compulsive disorder. Benztropine is a medication given to treat the symptoms of Parkinson's disease. No further information was provided prior to exit.

Based on observations, staff interview, clinical record review, and facility document review, the facility staff failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The findings included: For the infection control program, the facility staff failed to follow the enhanced barrier precautions (EBP) process and maintain infection control interventions to help reduce the transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities for facility residents with wounds and indwelling medical devices. This surveyor requested and received a list of residents on EBP. One resident was listed on the report for a dialysis access port. A review of the complete matrix for the facility indicated three facility residents had indwelling catheters, one resident had a stage II pressure ulcer, and one resident had a feeding tube and a tracheostomy. One of the residents with a catheter was on Transition Based Precautions related to an infection. On 12/4/25 at 9:00 AM, this surveyor interviewed the infection preventionist, registered nurse #1 (RN#1) and she informed surveyor the facility staff are using EBP when there are residents at increased risk such as those residents that may have midlines, PIC lines, wound vacs, ports, catheters, etc. On 12/4/25 at 11:23 AM, RN#1 informed this surveyor she does not put long-term catheters, feeding tubes or tracheostomies on EBP if they have no adverse effects. She stated she does put new admissions on EBP if warranted and residents that have new catheters. This concern was discussed at the pre-exit meeting on 12/4/25 at 1:45 PM with the administrator, director of nursing, staff scheduler, registered nurse #1, licensed practical nurse #1, human resource director, unit manager #1, unit manager #2, unit manager #3, and the business office manager. Surveyor requested and received a facility policy titled, Enhanced Barrier Precautions with a revision date of 11/13/25, which read in part, .An order for enhanced barrier precautions will be obtained for residents with any of the following.Wounds.and/or indwelling medical devices (e.g.urinary catheters, feeding tubes, tracheostomy.midline catheters.High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use.urinary catheters, feeding tubes, tracheostomy.tubes.midline catheters. No further information regarding this concern was provided to the survey team prior to exit on 12/4/25.

Based on staff interview, clinical record review, and facility document review, facility staff failed to provide notification to the representative of the office of the local state long-term care ombudsman of a resident transfer to a higher level of care for (1) one of (24) twenty-four sampled residents. Resident #9. The findings included:For Resident #9, the facility staff failed to notify the office of the state long-term care ombudsman of a transfer/discharge to a higher level of care on 10/22/25. Resident #9's diagnosis list indicated diagnoses that included, but were not limited to, History of Falling, Age-Related Cognitive Decline, Osteoarthritis, Restlessness and Agitation, and Unspecified Fracture of Upper End of Left Humerus. The most recent significant change minimum data set (MDS) with an assessment reference date (ARD) of 11/14/25, assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A nursing progress note dated 10/22/25 read in part, .Placed call to EMS (emergency medical services) for transport out to ED (emergency department at hospital). This surveyor requested evidence that the office of the state long-term care ombudsman was notified of the transfer/discharge for Resident #9 on 10/22/25. On 12/3/2025 4:23 PM, the facility administrator informed this surveyor the facility does not notify the ombudsman if a resident is just transferred out to the hospital and the resident comes right back because the resident was not discharged . This concern was discussed at the end of day meeting on 12/3/25 at 5:41 PM with the administrator, director of nursing, staff scheduler, staff educator, MDS coordinator, human resource director, social services assistant, unit manager #1, unit manager #2, and unit manager #3. This surveyor requested and received a facility policy titled, Transfer and Discharge which read in part, .5. The facility will maintain evidence that the notice was sent to the Ombudsman.10. Emergency Transfers to Acute Care.h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman.No further information regarding this concern was presented to the survey team prior to the exit on 12/4/25.

Based on staff interview, clinical record review and facility document review, facility staff failed to process a medical provider order for (1) one of (20) twenty sampled residents, Resident #4 and the facility staff failed to follow physician orders for (1) one of (24) twenty-four sampled residents Resident #39. The findings included: 1. For Resident #4, the facility nursing staff failed to process a provider order for the medication Fluticasone Propionate inhaler. This provider ordered this medication on 11/26/25 and the order was not processed until 12/01/25. Resident #4's diagnoses included acute and chronic respiratory failure and chronic obstructive pulmonary disease (COPD). Section C (cognitive patterns) of Resident #4's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/14/25 included a brief interview for mental status (BIMS) score of 3 out of a possible 15 points. Per the MDS manual a score of 3=severe impairment in cognitive skills for daily decision making. Resident #4's comprehensive care plan included the focus area COPD. Interventions included administer medications as ordered. Resident #4's clinical record included the following progress notes that read in part, Provider progress note with date of service of 11/26/25. Assessment and Plan.COPD.Discontinue budesonide nebs due to nonformulary. Attempt fluticasone HFA 220 mcg 2 puffs inhaled twice daily with a spacer device. Nursing progress note transcribed on 12/01/25 by Licensed Practical Nurse (LPN) #1 Medication discrepancy noted.Nurse processed physician request to DC [discontinue] budesonide and start fluticasone but failed to do so. Physician notified of failure to follow recommendation and family notified of medication discrepancy. Orders have been corrected and processed. During an interview with LPN #1 on 12/04/25 at 11:45 a.m., this staff stated Resident #4 had a partial box of the medication budesonide and the nursing staff wanted to see if that medication could be exhausted prior to starting a new medication. The order was never processed, and they found the omission when completing a medication review audit. The facility staff were able to provide evidence that this order was transcribed on 12/01/25. On 12/04/25 at 1:45 p.m., during a meeting with the administrative staff that included the Administrator, Director of Nursing, LPN #1, and Nurse Educator the issue with the provider order not being processed on 11/26/25 was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #39 the facility staff failed to follow physician's orders for the administration of insulin. Resident #39's diagnoses list included but not limited to type 2 diabetes mellitus with hyperglycemia. Resident #39's most recent minimum data set with an assessment reference date of 10/11/25 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #39's comprehensive care plan was reviewed and contained a plan for . had Diabetes Mellitus. Interventions for this care plan include Diabetes medications as ordered by doctor. Monitor/document for side effects and effectiveness. Resident #39's clinical record was reviewed and contained a physician's order summary which read in part, Humalog KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro). Inject 2 unit subcutaneously before meals to aid in control of blood glucose related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9). hold for blood glucose at or below 90, Lantus SoloStar Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Glargine). Inject 2 unit subcutaneously at bedtime for glucose management related to DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65), and Metformin HCL ER Oral Tablet Extended Release 24 Hour 500 MG (Metformin HCl). Give 1 tablet by mouth one time a day for Glucose Management related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65). Resident #39's electronic medication record for the month of July 2025 was reviewed and contained entries which read in part, Humalog KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro). Inject 2 unit subcutaneously before meals to aid in control of blood glucose related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9). hold for blood glucose at or below 90, Lantus SoloStar Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Glargine). Inject 2 unit subcutaneously at bedtime for glucose management related to DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65), and Metformin HCL ER Oral Tablet Extended Release 24 Hour 500 MG (Metformin HCl). Give 1 tablet by mouth one time a day for Glucose Management related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65). The entry for Lantus was coded 9 on 07/06/25. Chart code 9 is equivalent to other/see nurses notes. Resident #39's nurses progress notes were reviewed and contained a note which read in part, 07/06/2025 22:25 Note Text: Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML. Inject 2 unit subcutaneously at bedtime for glucose management related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65). 56 did not administer. The entry for Metformin was coded 9 on 07/07/25. Resident #39's progress notes contained a note which read in part, 07/07/2025 09:00 Note Text: Metformin HCl ER Oral Tablet Extended Release 24 Hour 500 MG. Give 1 tablet by mouth one time a day for Glucose Management related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65). did not eat breakfast; has had recent low glucose reading. The entry for Humalog was coded 12 on 07/04/25 and 07/11/25 at 4:30 pm, with blood glucose readings of 127 and 92 respectively. Resident #39's electronic medication administration record (eMAR) for the month of September 2025 was reviewed and contained an entry which read in part, Humalog KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro). Inject 2 unit subcutaneously before meals to aid in control of blood glucose related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9). hold for blood glucose at or below 90. The eMAR was coded 12 on 09/08/25 and 09/27/25 at 6:30 am. Chart code 12 is equivalent to insulin not required. Resident #39's blood glucose was 95 on both occasions. The eMAR was coded 11 on 09/16/25 at 4:30 pm. Chart code 11 is equivalent to held per parameters. Resident #39's blood glucose was 100 on this occasion. Resident #39's progress notes were reviewed and there were no notes related to the incidents. Surveyor spoke with the director of nursing (DON) on 12/04/25 at 11:15 am regarding Resident #39. DON stated nursing staff should have administered Resident #39's insulin per the physician's order, and anytime the insulin is held, they should make a note. Surveyor requested and was provided with a facility policy entitled Medication Administration which read in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 17. Administer medication as ordered in accordance with the manufacturer specifications. The concern of not following the physician's order for the administration of insulin was discussed with the administrator, DON, staff educator, unit managers, and business office manager on 12/04/25 at 1:45 pm. No further information was provided prior to exit.

Based on observations, staff interview, clinical record review, and facility document review, the facility staff failed to provide services and/or treatment to prevent further decrease in range of motion, including the provision of equipment for limited range of motion for (1) one of (24) twenty-four sampled residents. Resident #10. The findings included:For Resident #10, the facility staff failed to provide a right knee brace as ordered by a medical provider to prevent abduction and external rotation of the right hip for contracture management. Resident #10's diagnosis list indicated diagnoses that included, but were not limited to, Diffuse Traumatic Brain Injury, Muscle Weakness, Abnormalities of Gait and Mobility, Quadriplegia, Contracture Right Hand, Contracture Left Hand, Paraplegia, Contracture Right Knee, Contracture Left Knee, Contracture Right Ankle, Contracture Left Ankle, and Abnormal Posture. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 9/5/25, was coded in Section C (Cognitive Patterns) to indicate Resident #10 was rarely/never understood, exhibited short and long-term memory problems, and was severely impaired in decision making. On 12/2/25 at 1:54 PM, this surveyor observed Resident #10 lying in bed. This surveyor asked certified nursing assistant #1 (CNA#1) to assist in removing the sheet covering to the resident's lower extremities. Surveyor observed resident to have bilateral knee contractures and a wedge beneath the resident's hips. CNA#1 informed this surveyor Resident #10 has contractures and they use the wedge for the resident's hip areas. A right knee brace was not observed to be on Resident #10's right knee. A review of a medical provider orders included an order with a start date of 11/1/25 which read in part, .Place knee brace on right knee with wedge at hip to prevent abduction and external rotation of hip. One time a day for contracture management related to CONTRACTURE, RIGHT KNEE.aides may apply and remove and remove per schedule. A review of the December 2025 TAR (treatment administration record) was coded to reflect the right knee brace had been applied to Resident #10's right knee at 10:00 AM on 12/2/25 and removed at 15:59 (3:59 PM) on 12/2/25. On 12/3/25 at 10:40 AM, registered nurse #1 (RN#1) accompanied this surveyor to Resident #10's room. RN#1 removed the sheet covering the resident's lower extremities. This surveyor observed a wedge beneath the resident's hips. A right knee brace was not observed. RN#1 informed surveyor that the restorative aides apply the right knee brace to the resident and they were probably busy and had not made it into Resident #10's room to apply the brace yet. This surveyor spoke with RN#1 and the director of nursing (DON) and asked to speak to the restorative aides and was informed by the DON that one of the aides was on FMLA (family medical leave) and the other restorative aide was not working today. A review of the December 2025 TAR (treatment administration record) was coded to reflect the right knee brace had been applied to Resident #10's right knee at 10:00 AM on 12/3/25. A review of the person-centered comprehensive care plan disclosed a focus which read in part, .impaired physical mobility r/t (related to) traumatic brain injury with paraplegia/quadriplegia.requires staff to provide her care needs. A goal and intervention related to the focus read in part, .will receive appropriate staff support with ADLs (activities of daily living).Place knee brace on right knee with wedge at hip to prevent abduction and external rotation as ordered. This concern was discussed at the end of day meeting on 12/3/25 at 5:41 PM with the administrator, director of nursing, staff scheduler, staff educator, MDS coordinator, human resource director, social services assistant, unit manager #1, unit manager #2, and unit manager #3. On 12/4/25 this surveyor was provided with a copy of an Orthotic Maintenance and Wearing Schedule signed by a PTA (physical therapy assistant) and dated 7/30/25 which read in part, .Hip-knee Orthotic.Wearing Schedule.Daily while in chair 4 hours recommended-do not exceed 8 hrs (hours).On 12/4/25 at 10:37AM, this surveyor interviewed other staff #9 (OS#9) and she informed surveyor she wrote the orthotic maintenance and wearing schedule for Resident #10. She stated she does not write orders and this was a recommendation about the brace to the medical provider. OS#9 agreed the medical provider gave the current order to wear the brace daily and agreed she would recommend getting the brace wearing time increased daily for Resident #10. On 12/4/25 at 1:45 PM during the pre-exit meeting, licensed practical nurse #3 (LPN#3) provided this surveyor with two new orders for Resident #10. A review of the new orders disclosed the following: A medical provider orders with a start date of 12/4/25 read in part, .Place knee brace on right knee with wedge at hip to prevent abduction and external rotation of hip. One time daily while in bed only 4 hours recommended, aids may apply.remove per schedule. A medical provider orders with a start date of 12/4/25 read in part, place hip - knee orthotic on daily while in chair to right knee with wedge at hip to prevent abduction and external rotation of hip. 4 hours are recommended not to exceed 8 hours. Surveyor requested and received a facility policy with a revision date of 11/10/25 titled, Prevention in Decline of Range of Motion which read in part, .1. The facility.shall establish and utilize a systemic approach for prevention of decline in range of motion, including.preventative care.a. Based on the comprehensive assessment the facility will provide interventions.to maintain.range of motion.b. the facility will provide treatment and care in accordance with professional standards of practice. This includes but is not limited to.ii. Appropriate equipment (braces or splints). No further information regarding this concern was presented to the survey team prior to the exit on 12/4/25.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure medications were available for administration for (1) one of (24) twenty-four sampled residents, Resident #4. The findings included:The facility staff failed to ensure the provider ordered medication Fluticasone Propionate inhaler was available for administration on 12/01/25 and 12/02/25.Resident #4's diagnoses included acute and chronic respiratory failure and chronic obstructive pulmonary disease (COPD).Section C (cognitive patterns) of Resident #4's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/14/25 included a brief interview for mental status (BIMS) score of 3 out of a possible 15 points. Per the MDS manual a score of 3=severe impairment in cognitive skills for daily decision making.Resident #4's comprehensive care plan included the focus area COPD. Interventions included administer medications as ordered.Resident #4's clinical record included a provider order for the medication Fluticasone Propionate inhaler 2 puffs every 12 hours for acute and chronic respiratory failure. Date of order 12/01/25 start date 12/01/25 at 9:00 p.m.A review of Resident #4's medication administration records (MARs) for 12/2025 revealed that for 12/01/25 at 9:00 p.m. and 09/02/25 at 9:00 a.m. the facility nursing staff documented a 5 for this medication. Per the preprinted code on the MAR a 5=Hold/See Nurse Notes.On 12/01/25 at 10:34 p.m., the nursing staff documented they were .awaiting arrival from pharmacy. for this medication.On 12/02/25 at 10:31 a.m., the nursing staff documented they had contacted the pharmacy regarding the unavailability of this medication.On 12/03/25 at 5:40 p.m. and again on 12/03/25 at 1:45 p.m., during meetings with the administrative staff of the facility to include the Administrator, Director of Nursing, and Nurse Educator. The staff were notified that Resident #4 did not have their provider ordered medication available for administration on 12/01 and 12/02/25. The Nurse Educator identified the facility as using a local pharmacy for a backup pharmacy.A policy regarding unavailable medications was requested from the facility but was never provided to the surveyor prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to follow-up on pharmacy recommendations for (3) three of (24) twenty-four sampled residents, Resident #11, Resident #12, and Resident #23. The findings included:1. For Resident #11, the facility staff failed to follow up on a pharmacy recommendation for 07/15/25. The facility staff were unable to locate this recommendation. Resident #11's diagnoses included chronic obstructive pulmonary disease, protein calorie malnutrition, adult failure to thrive, and vascular dementia. Section C (cognitive patterns) of Resident #11's significant change in status minimum data set (MDS) assessment with an assessment reference date (ARD) of 09/17/25 was coded 1/1/3 to indicate this resident had problems with long- and short-term memory and was severely impaired in cognitive skills for daily decision making. Resident #11's clinical record included a progress note dated 07/15/25. The pharmacist had transcribed that a medication regimen review had been completed and to see their .report for any noted irregularities and/or recommendations. During the record review the surveyor was unable to locate this report. On 12/03/25 at 5:40 p.m. during an end of the day meeting with the administrative staff of the facility to include the Administrator, Director of Nursing, and Nurse Educator. These staff were asked for the missing pharmacy recommendation. On 12/04/25 at 1:20 p.m., the Administrator and Staff Educator stated to the survey team that there was an issue with their software system in 07/25, the pharmacist was unable to access the system, and they now had a different pharmacist. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #12 the facility staff failed to follow up on a pharmacy recommendation on 7/15/25. Resident #12's diagnosis list indicated diagnoses that included, but were not limited to, Anxiety Disorder, Malignant Neoplasm of Prostate, Muscle Wasting and Atrophy, Cognitive Communication Deficit, and Chronic Pain. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 9/13/25, assigned the resident a BIMS (brief interview for mental status) summary score of 3 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A medication regimen review (MRR) dated 7/15/25 read in part, .[x] See report for any noted irregularities and/or recommendations. Evidence of the MRR recommendations for 7/15/25 could not be located on the clinical record and this surveyor requested evidence of the pharmacy recommendations report. A review of Resident #12's comprehensive person-centered care plan disclosed a focus which read in part, .uses psychotropic medications to manage his depression and anxiety related to dementia. A review of the interventions associated with this focus included an intervention which read in part, .Consult with pharmacy, MD (medical doctor) to consider dosage reduction when clinically appropriate at least quarterly . On 12/4/25 at 1:20 PM, the administrator and registered nurse #1 (RN#1) informed this surveyor they do not have a copy of the 7/15/25 pharmacy recommendations for Resident #12, as the electronic clinical record was not accessible by the pharmacy on that date. This concern was discussed at the pre-exit meeting on 12/4/25 at 1:45 PM with the administrator, director of nursing, staff scheduler, registered nurse #1, licensed practical nurse #1, human resource director, unit manager #1, unit manager #2, unit manager #3, and the business office manager No further information regarding this concern was provided to the survey team prior to exit on 12/4/25. 3. For Resident #23 the facility staff failed to follow up on a pharmacy recommendation. Resident #23's clinical record listed diagnoses which included but not limited to vascular dementia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and asthma. Resident #23's most recent minimum data set with an assessment reference date of 10/30/25 assigned the resident brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Section N, subsection N0415, High-Risk Drug Classes, indicates that the resident receives antipsychotic, antidepressant, opioid, hypoglycemic and anticonvulsant medications. Resident #23's comprehensive care plan was reviewed and contained a plan for . uses psychotropic medications. Interventions for this plan include Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly. Resident #23's clinical record was reviewed and contained a medication regimen review dated 07/15/2025 which read in part, See report for any noted irregularities and/or recommendations. Surveyor could not locate a pharmacist recommendation in the clinical record. Surveyor spoke with the administrator and staff educator on 12/04/25 at 1:20 pm regarding Resident #23's pharmacy recommendations. Administrator stated they do not have a copy of the pharmacy recommendations, due to electronic clinical records not being accessible by the pharmacist at that time. The concern of not following up on a pharmacist recommendation was discussed with the administrator, director of nursing, staff educator, unit managers, and business office manager on 12/05/25 at 1:45 pm. No further information provided prior to exit.

Based on staff interviews, clinical record reviews, and facility document review, the facility staff failed to ensure a complete and/or accurate clinical record for (2) two of (24) twenty-four sampled residents. Resident #6 and Resident #10. The findings included:1 For Resident #6 the facility staff filed another resident's Durable Do Not Resuscitate form in Resident #6's clinical record. Resident #6's clinical record contained diagnoses not limited to Alzheimer's disease, unspecified. Resident #6's most recent minimum data set with an assessment reference date of 09/08/25 assigned the resident a brief interview for mental status score of 3 out 15 in section C, cognitive patterns. Resident #6's clinical record was reviewed and contained a Durable Do Not Resuscitate form belonging to another resident. The concern of another resident's information being in Resident #6's clinical record was discussed with the administrator, director of nursing, staff educator, unit managers, and business office manager on 12/04/25 at 1:45 pm. No further information was provided prior to exit. 2. For Resident #10, the facility staff failed to accurately document a right knee brace placement as ordered by a medical provider. Resident #10's diagnosis list indicated diagnoses that included, but were not limited to, Diffuse Traumatic Brain Injury, Muscle Weakness, Abnormalities of Gait and Mobility, Quadriplegia, Contracture Right Hand, Contracture Left Hand, Paraplegia, Contracture Right Knee, Contracture Left Knee, Contracture Right Ankle, Contracture Left Ankle, and Abnormal Posture. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 9/5/25, was coded in Section C (Cognitive Patterns) to indicate Resident #10 was rarely/never understood, exhibited short and long-term memory problems, and was severely impaired in decision making. This surveyor made observations of Resident #10 on 12/2/25 and 12/3/25. A right knee brace was not visible on the resident's right knee during these observations. A review of a medical provider orders included an order with a start date of 11/1/25 which read in part, .Place knee brace on right knee with wedge at hip to prevent abduction and external rotation of hip. One time a day for contracture management related to CONTRACTURE, RIGHT KNEE.aides may apply.and remove per schedule. A review of the December 2025 TAR (treatment administration record) was coded to reflect the right knee brace had been applied to Resident #10's right knee at 10:00 AM on 12/2/25 and removed at 15:59 (3:59 PM) on 12/2/25. On 12/3/25 the TAR was coded to reflect the right knee brace had been applied to Resident #10's right knee at 10:00 AM. On 12/3/25 at 10:40 AM, registered nurse #1 (RN#1) informed this surveyor that the restorative aides apply the right knee brace to the resident and they were probably busy and had not made it into Resident #10's room to apply the brace yet. This surveyor spoke with RN#1 and the director of nursing (DON) and asked to speak to the restorative aides and was informed by the DON that one of the aides was on FMLA (family medical leave) and the other restorative aide was not working today. A review of the person-centered comprehensive care plan disclosed a focus which read in part, .impaired physical mobility r/t (related to) traumatic brain injury with paraplegia/quadriplegia.requires staff to provide her care needs. A goal and intervention related to the focus read in part, .will receive appropriate staff support with ADLs (activities of daily living).Place knee brace on right knee with wedge at hip to prevent abduction and external rotation as ordered. This concern was discussed at the end of day meeting on 12/3/25 at 5:41 PM with the administrator, director of nursing, staff scheduler, staff educator, MDS coordinator, human resource director, social services assistant, unit manager #1, unit manager #2, and unit manager #3. Surveyor requested and received a facility policy with a revision date of 11/10/25 titled, Documentation in the Medical Record which read in part, .Each resident's medical record shall contain an accurate representation of the actual experiences of the resident.Documentation shall be completed at the time of service.Documentation shall be factual.False information shall not be documented.Record.information based on.service provided. No further information regarding this concern was presented to the survey team prior to the exit on 12/4/25.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify a medical provider of a change in condition for (3) three of (24) twenty-four sampled residents. Resident #5, Resident #39, and Resident #51. The findings included:1.For Resident #5 the facility staff failed to notify a medical provider of the resident's transfer to a higher level of care on 4/22/25. Resident #5's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease-Stage 4, Hypertension, Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease, Chronic Respiratory Failure with Hypoxia, and Diabetes Mellitus Type 2. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 9/19/25 assigned the resident a BIMS (brief interview for mental status) summary score of 3 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A review of Resident #5's census list disclosed that the resident had been transferred out of the facility on 4/22/25. A nursing progress note dated 4/22/25 read in part, .Received notification.during (Resident #5's) cardiology appoint. (appointment) that [cardiologist name omitted] noted an arrythmia and wanted resident seen at the ER (emergency room at hospital).RP.called and notified of ER transfer. This surveyor requested evidence that the medical provider was notified on 4/22/25 of Resident #5's transfer to the hospital. On 12/3/2025 at 4:24 PM, the facility administrator informed this surveyor that no evidence could be located that the medical provider was notified of Resident #5's transfer to the ER from cardiology on 4/22/25. This concern was discussed at the end of day meeting on 12/3/25 at 5:41 PM with the administrator, director of nursing, staff scheduler, staff educator, MDS coordinator, human resource director, social services assistant, unit manager #1, unit manager #2, and unit manager #3. Surveyor requested and received a facility policy titled, Notification of Changes which read in part, .The facility must.consult with the resident's physician.when there is a change requiring such notification. Circumstances requiring notification include.4. A transfer or discharge of the resident. No further information regarding this concern was presented to the survey team prior to the exit conference on 12/4/25. 2. For Resident #39 the facility staff failed to notify the medical provider of a blood glucose level of 56 and failed to notify the medical provider when insulin was held. Resident #39's diagnoses list included but not limited to type 2 diabetes mellitus with hyperglycemia. Resident #39's most recent minimum data set with an assessment reference date of 10/11/25 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #39's comprehensive care plan was reviewed and contained a plan for . had Diabetes Mellitus. Interventions for this care plan include Diabetes medications as ordered by doctor. Monitor/document for side effects and effectiveness. Resident #39's clinical record was reviewed and contained a physician's order summary which read in part, Lantus SoloStar Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Glargine). Inject 2 unit subcutaneously at bedtime for glucose management related to DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65), and Metformin HCL ER Oral Tablet Extended Release 24 Hour 500 MG (Metformin HCl). Give 1 tablet by mouth one time a day for Glucose Management related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65). Resident #39's electronic medication record for the month of July 2025 was reviewed and contained entries which read in part, Lantus SoloStar Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Glargine). Inject 2 unit subcutaneously at bedtime for glucose management related to DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65), and Metformin HCL ER Oral Tablet Extended Release 24 Hour 500 MG (Metformin HCl). Give 1 tablet by mouth one time a day for Glucose Management related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65). The entry for Lantus was coded 9 on 07/06/25. Chart code 9 is equivalent to other/see nurses notes. Resident #39's nurses progress notes were reviewed and contained a note which read in part, 07/06/2025 22:25 Note Text: Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML. Inject 2 unit subcutaneously at bedtime for glucose management related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65). 56 did not administer. There is no note stating the medical provider had been notified of low blood glucose or that the medication had been held. The entry for Metformin was coded 9 on 07/07/25. Resident #39's progress notes contained a note which read in part, 07/07/2025 09:00 Note Text: Metformin HCl ER Oral Tablet Extended Release 24 Hour 500 MG. Give 1 tablet by mouth one time a day for Glucose Management related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65). did not eat breakfast; has had recent low glucose reading. There is no note stating that the medical provider had been notified of low blood glucose or that the medication had been held. Surveyor spoke with the director of nursing (DON) on 12/04/25 at 11:15 am regarding Resident #39. DON stated nursing staff should have notified the medical provider of a blood glucose reading of 56. DON also stated that nursing staff should not hold a medication without a provider order to do so. Surveyor requested and was provided with a facility policy entitled Notification of Changes which read in part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Circumstances requiring notification include: 3. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. 3. Circumstances that require a need to alter treatment. The concern of not notifying the resident's medical provider of a change in condition and holding of medication was discussed with the administrator, DON, staff educator, unit managers, and business office manager on 12/04/25 at 1:45 pm. No further information was provided prior to exit. 3. For Resident #51, the facility nursing staff failed to notify the provider of a 2-pound weight gain. Resident #51 had an order for daily weights and to notify the MD of a weight change of 2 or more pounds in 1 day or a 5 or more-pound change in 1 week. Resident #51 diagnoses included congestive heart failure (CHF), chronic kidney disease, and hypertension. Section C (cognitive patterns) of Resident #51's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/30/25 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Indicating Resident #51 was cognitively intact. Resident #51's comprehensive care plan included the focus area has CHF. Interventions included monitor/document/report as needed any signs or symptoms of CHF, weight gain unrelated to intake. Resident #51's clinical record included a provider order for daily weights, notify MD of weight change of 2 or more pounds in one day or 5 or more-pound change in one week. A review of Resident #51's 11/2025 medication administration records revealed that on 11/06/25 the resident's weight was recorded as 118.4 pounds. On 11/07/25 the weight was documented as 121.6 pounds and on 11/08/25 Resident #51's weight was documented as 124 pounds. This indicated there was a 3.2-pound increase from 11/07/25 to 11/08/25 and a 2.4-pound increase from 11/07/25-11/08/25. The nursing staff documented Resident #51's weight as 123.4 on 11/26/25 and 125.6 on 11/27/25 indicating the resident had a 2.2-pound weight increase. The surveyor was unable to find any evidence that the MD had been notified of the weight gains. On 12/03/25 at 5:40 p.m., during an end of the day meeting with the administrative staff that included the Administrator, Director of Nursing, and Nurse Educator the issue with Resident #51's notifications of weight gain to the provider were reviewed. On 12/04/25 at 1:00 p.m., the Administrator stated they did not have evidence of the weight gain notifications to the provider. During the course of the survey the facility staff provided the survey team with a copy of their policy titled, Notification of Changes. This policy read in part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician.when there is a change requiring notification. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and facility document review, the facility staff failed to provide evidence of education regarding the risks, benefits and potential side effects of the COVID-19 vaccine for facility employees and failed to provide evidence of informed consent of the COVID-19 vaccine for facility employees. The findings included:This surveyor requested evidence of a facility staff member's screening and eligibility, provision of education, risks versus benefits, offering and administration of the COVID-19 vaccine during the infection prevention review. On 12/3/25 at 9:12 AM, the facility administrator informed this surveyor if an employee wants a COVID-19 vaccine, the facility orders the vaccine from the pharmacy and administers it. If an employee does not want a COVID-19 vaccine, then the facility does not do anything. This surveyor asked the administrator for any evidence of staff education and any evidence of employee declinations of the COVID-19 vaccine. On 12/3/25 at 10:05 AM, the facility administrator provided this surveyor with a facility document titled, Staying Up to Date with COVID-19 Vaccines which contained education criteria about the COVID-19 vaccine. He informed this surveyor the facility offers the facility employees the COVID-19 vaccine, but he could not provide any evidence the employees of the facility had been educated or if they refused or accepted the COVID-19 vaccine. On 12/3/25 at 11:53 AM, the facility administrator provided this surveyor with a facility document titled, COVID-19 Vaccine Consent Form and a facility document titled, Informed Consent for COVID-19 Vaccine. The facility administrator informed this surveyor that starting today, the facility will have facility employees sign these consents and education will be provided about the vaccine and if the vaccine is declined by an employee. This concern was discussed at the pre-exit meeting on 12/4/25 at 1:45 PM with the administrator, director of nursing, staff scheduler, registered nurse #1, licensed practical nurse #1, human resource director, unit manager #1, unit manager #2, unit manager #3, and the business office manager. On 12/4/25 at 2:25 PM, a surveyor interviewed licensed practical nurse #8, certified nursing assistant #3, certified nursing assistant # 4, and certified nursing assistant #5 and they all agreed they are offered the COVID-19 vaccine and offered education about the vaccine. Surveyor requested and received the facility policy titled COVID-19 Prevention, Response and Reporting with a revision date of 10/14/25, which read in part, .The facility should offer resources and counseling to healthcare personnel.on the importance of receiving the COVID-19 vaccine and staying up to date with all recommended COVID-19 vaccine doses.14. Communication and Education 1. Educate staff.regularly. No further information regarding this concern was provided to the survey team prior to exit on 12/4/25.

Based on interviews, clinical record review, and facility document review, the facility staff failed to ensure a resident's medical provider and/or responsible party (RP) was notified of a significant weight loss for one (1) of 20 sampled residents, Resident #9. For Resident #9, the facility staff failed to notify the resident's medical provider and/or responsible party (RP) of the resident's following weight changes: on 7/1/22 Resident #9's weight was documented as 121.4 pounds; on 7/5/22 Resident #9's weight was documented as 121.4 pounds; and on 8/2/22 Resident #9's weight was documented as 114.6 pounds. The findings include: Resident #9's clinical documentation failed to provide evidence of medical provider and/or responsible party (RP) notification of the resident's aforementioned weight loss. Resident #9's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 7/1/22, was dated as completed on 7/7/22. Resident #9 was assessed as sometimes able to make self understood and sometimes able to understand others. Resident #9 was assessed as having short-term memory problems and long-term memory problems. Resident #9 was documented as requiring assistance with bed mobility, dressing, and toilet use. Resident #9 was documented as being dependent on others for personal hygiene and bathing. Resident #9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following information was found in a facility policy titled Notification of Change in Condition (with a revision date of 12/16/20): - POLICY: The Center to promptly notify the Patient / Resident, the attending physician, and the Resident Representative when there is a change in the status or condition. - The nurse to notify the attending physician and Resident Representative when there is a(n): . Significant change in the patient / resident's physical, mental, or psychosocial status . - Notify the patient / resident and the resident representative of the change in condition. Document notification in the medical chart. On 9/22/22 at 1:57 p.m., the facility's Director of Nursing (DON) was interviewed about Resident #9's aforementioned weight loss. The DON acknowledge the weight loss was a significant change in the resident's weight. The DON reported neither the resident's medical provider nor the resident's responsible party had been notified of the weight loss. On 9/22/22 at 4:06 p.m., the failure of the facility staff to notify Resident #9's medical provider and/or responsible party of the resident's significant weight loss was discussed during a survey team meeting with the facility's Administrator, DON, Nurse Consultant, and Infection Preventionist. No additional information related to this issue was provided prior to the conclusion of the survey.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide notice in writing to the resident and resident representative prior to a facility transfer or discharge for 1 of 20 residents in the survey sample, Resident #32. For Resident #32, the facility failed to provide the resident written notice to include the reason for the move prior to transfer to an acute care hospital. The findings included: Resident #32's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission minimum data set (MDS) with an assessment reference date (ARD) of 8/08/22 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. A review of Resident #32's clinical record revealed the resident was transferred to an acute care hospital on 8/18/22. On 9/21/22 at 2:56 pm, surveyor spoke with the Director of Nursing (DON) who stated they did not have documentation of a written notice of transfer provided to the resident, staff did a Change of Condition assessment instead of a Notice of Discharge. Surveyor requested and received the facility policy entitled Transfer/Discharge Notification & Right to Appeal which read in part .Notice Before Transfer: Before a center transfers or discharges a resident the center must: Notify the resident and resident representative(s) of the transfer or discharge and the reasons for the move in writing (in a language and manner they understand) . On 9/21/22 at 3:32 pm, survey team met with the administrator, DON, Infection Preventionist, and Regional Nurse Consultant and discussed the concern of the facility staff failing to provide written notice of transfer to Resident #32 prior to transfer to an acute care hospital. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/22/22.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide written bed hold policy information to the resident or resident representative prior to transfer for 1 of 20 residents in the survey sample, Resident #32. For Resident #32, the facility failed to provide the resident written bed hold policy information prior to transfer to an acute care hospital. The findings included: Resident #32's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission minimum data set (MDS) with an assessment reference date (ARD) of 8/08/22 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. A review of Resident #32's clinical record revealed the resident was transferred to an acute care hospital on 8/18/22. On 9/21/22 at 2:56 pm, surveyor spoke with the Director of Nursing (DON) who stated they did not have documentation of bed hold information being provided to Resident #32. Surveyor requested and received the facility policy entitled Bed Hold which read in part .At the time of transfer to the hospital or therapeutic leave, the center will provide a copy of notification of bed hold . On 9/21/22 at 3:32 pm, survey team met with the administrator, DON, Infection Preventionist, and Regional Nurse Consultant and discussed the concern of the facility staff failing to provide bed hold information to Resident #32 when transferred to an acute care hospital. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/22/22.

Based on interviews, clinical record review, and facility document review, the facility staff failed to address a significant weight loss for one (1) of 20 sampled residents, Resident #9. For Resident #9, the facility staff failed to address the resident's following weight changes: on 7/1/22 Resident #9's weight was documented as 121.4 pounds; on 7/5/22 Resident #9's weight was documented as 121.4 pounds; and on 8/2/22 Resident #9's weight was documented as 114.6 pounds. The findings include: The facility staff failed to notify a medical provider of Resident #9's aforementioned weight loss. The facility staff failed to address Resident #9's aforementioned weight loss. No evidence was found to indicate Resident #9's weight loss was evaluated by a medical provider and/or a registered dietitian. Resident #9's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 7/1/22, was dated as completed on 7/7/22. Resident #9 was assessed as sometimes able to make self understood and sometimes able to understand others. Resident #9 was assessed as having short-term memory problems and long-term memory problems. Resident #9 was documented as requiring assistance with bed mobility, dressing, and toilet use. Resident #9 was documented as being dependent on others for personal hygiene and bathing. Resident #9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following information was found in a facility policy titled Weighing the Resident (with a revision date of 10/4/21): Record weight and alert nurse to any significant change. Nurse to notify the physician of any significant weight change . Consult with the Director of Dietary Services and/or dietitian . Notify the Interdisciplinary Team in order to update the plan of care. On 9/22/22 at 11:23 a.m., the Director of Nursing (DON) reported the facility did not have a policy detailing the definition of a significant change in weight for a resident. On 9/22/22 at 1:57 p.m., the facility's Director of Nursing (DON) was interviewed about Resident #9's aforementioned weight loss. The DON acknowledge the weight loss was a significant change in the resident's weight. The DON reported neither the resident's medical provider nor the resident's responsible party had been notified of the weight loss. The DON reported a dietary supplement was implemented prior to the resident's weight loss; the DON acknowledged no evidence was found to indicate Resident #9's aforementioned weight loss was addressed by facility staff members. On 9/22/22 at 4:06 p.m., the failure to ensure Resident #9's significant weight loss was addressed by facility staff was discussed during a survey team meeting with the facility's Administrator, DON, Nurse Consultant, and Infection Preventionist. No additional information related to this issue was provided prior to the conclusion of the survey.

Based on observation, staff interview, and facility document review, the facility failed to provide food and drink that is palatable, attractive, and served at a safe and appetizing temperature. The findings included: The facility failed to hold and serve food at a safe temperature of 135 degrees F or higher on the steam table. On 9/30/19 at approximately 11:20 am, the surveyor observed dietary staff member #1 obtain food temperatures from the steam table. Food temperatures obtained were as follows: Roasted Potatoes 153.5 F Green Beans 193.1 F Green Beans (Puree) 134.4 F Pasta Noodles - 154.6 F Pasta Sauce 168.4 F Breaded Chicken Patty 129.6 F Breaded Chicken Patty (Ground) 127.7 F Chicken Parmesan (Puree) 141.9 F Mashed Potatoes approximately 54.0 F Dietary staff member #1 reheated the mashed potatoes to a temperature of 150.1 F and returned to the steam table and began plating lunch meals. No additional food items were reheated. The surveyor asked Dietary staff member #1 what the food temperatures on the steam table should be, dietary staff member #1 stated 145 degrees. The concern of not holding and serving food at a safe temperature was discussed with the administrative team (administrator and director of nursing) during a meeting on 10/02/19 at approximately 5:15 pm. On 10/03/19 at approximately 8:30 am, the dietary service manager was notified of the above documented findings. The dietary services manager stated that the employee will be given more education on the process when food temperatures do not meet the expected temperatures while on the steam table. No further information was provided prior to exit conference on 10/03/19.

Based on resident interview, staff interview, and facility document review, facility staff failed to make prompt efforts to resolve resident grievances. The findings included: The facility failed to act upon grievances voiced at resident council for the months of September 2018, November 2018, December 2018, February 2019, and May 2019. The surveyor reviewed the resident council minutes and the following was noted in the July 2019 minutes There are outstanding concerns from previous meetings (2 from May 2019, 2 from Feb. 2019, 2 from Dec. 2018, 5 from Nov. 2018 and 4 from Sept. 2018). I will continue to try and get responses/resolutions from those departments. The August 2019 minutes stated in part, Residents stated that most of the outstanding concerns from previous meetings has been resolved. On 10/01/19 at approximately 10:30 am, surveyor spoke with the activities director concerning the unresolved resident concerns documented in the Resident Council Minutes. He stated that he started in this position approximately one month ago and stated during his first resident council meeting in August, the residents stated there were no unresolved issues at that time. The activities director stated that he notifies the administrator of any resident concerns and she takes care of them. The concern of the facility not following up on grievances voiced at resident council was discussed with the administrator during a meeting on 10/01/19 at approximately 10:40 am. The administrator stated the activities director in the position at the time of the reported grievances is no longer employed at the facility. No further information was provided prior to exit conference on 10/03/19.

Based on observation, staff interview and clinical record review, and facility document review, facility staff failed to ensure an environment free of accident hazards for 6 of 21 residents in the survey sample (Residents #32, 68, 26, 62, 67 and 72) The findings included: 1. The facility staff failed to perform post fall documentation every shift for 72 hours when Resident #32 had a fall that had occurred on 7/6/19. Resident #32 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to [CONDITION(S)], high blood pressure, dementia, anxiety disorder and depression. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/19/19 coded the resident as having short term and long-term memory loss and being severely impaired in daily decision-making. Resident #32 was also coded as requiring extensive assistance of 2 staff members for dressing and personal hygiene and being totally dependent on 2 staff members for bathing. During the clinical record review on 10/3/19, the surveyor noted that Resident #32 had been documented as having a fall on 7/6/19 at 10 pm. There was post fall documentation noted on 7/7/19 at 11pm, 7/9/19 at 7:30 pm and 7/9/19 at 10:30 pm. The surveyor notified the DON (director of nursing) of the above post fall documentation as documented above at 2:30 pm on 10/3/19. The DON (director of nursing) stated, There is to be a post fall documentation in the nursing notes every shift for 72 hours. The surveyor asked the DON if this documentation had occurred every shift for 72 hours for the fall that had occurred on 7/6/19. The DON stated, According to the documentation in the nursing notes, no it was not. The surveyor asked the DON for a copy of the facility's policy on post fall documentation. The DON provided a copy of the facility's policy titled Fall Management on 10/3/19 at 5 pm to the surveyor. The policy read in part, .Initiate post fall documentation every shift for 72 hours . No further information was provided to the surveyor prior to the exit conference on 10/3/19. 2. The facility staff failed to complete post fall documentation every shift for 72 hours for a fall in which Resident #68 had on 7/10/19. Resident #68 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to [CONDITION(S)], heart failure, anxiety, depression and orthostatic high blood pressure. On the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/7/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 2 out of a possible score of 15. Resident #68 was also coded a requiring total dependence of 1 staff member for bathing and requires extensive assistance of 1 staff member for dressing and personal hygiene. During the clinical record review on 10/3/19, it was noted by the surveyor that Resident #68 had a fall documented on 7/10/19. The following dates and times reflected the staff's post fall documentation for the fall that occurred on 7/10/19: 7/10/19 at 1930 (7:30 pm), 7/11/19 at 0910 (9:10 am) and 2120 (9:20 pm), 7/12/19 at 1100 (11:00 am) and 2300 (11:00 pm). The surveyor notified the DON (director of nursing) of the above documented findings on 10/3/19 at 1 pm in the conference room. The surveyor requested and received copies of the facility's policy titled Fall Management on 10/3/19 at 5 pm. The policy read in part, .Initiate post fall documentation every shift for 72 hours . No further information was provided to the surveyor prior to the exit conference on 10/3/19. 3. The facility staff failed to complete post fall documentation every shift for 72 hours when Resident #26 had (3) falls which occurred on 6/26/19, 8/3/19 and 8/11/19. Resident #26 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, diabetes, dementia, depression and psychotic disorder. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/11/19, the resident was coded as having short term and long term memory problems. Resident #26 was also coded as requiring extensive assistance of 2 staff members for dressing, personal hygiene and is totally dependent on 2 staff members for bathing. During the clinical record review on 10/3/19, the surveyor noted documentation on 6/26/19, 8/3/19 and 8/11/19 that Resident #26 have had a fall. After this documentation noted by the surveyor, there was no further documentation following these dates to have follow up of these falls. At 1 pm, the surveyor notified the DON (director of nursing) of the above documented findings. The DON stated, It's our policy to document every shift for 72 hours after a resident has a fall. The surveyor requested and received the facility's policy titled Fall Management on 10/3/19 at 5 pm. The policy read in part, .Initiate post fall documentation every shift for 72 hours . No further information was provided to the surveyor prior to the exit conference on 10/3/19. 4. For Resident #62, the facility failed to place side rails on the bed per physician order dated 6/08/19. Resident #62's face sheet listed an admitted [DATE] and a readmitted [DATE]. The Resident's diagnosis list indicated diagnoses, which included, but not limited to fracture of unspecified part of the neck of the right femur with routine healing, fracture of unspecified part of right clavicle with routine healing, pressure ulcer of left heel, generalized muscle weakness, dysphagia, cognitive communication deficit, [CONDITION(S)] of the skin, pulmonary fibrosis, chronic obstructive pulmonary disease, vascular dementia, major depressive disorder and essential hypertension. The most recent 90 day MDS (minimum data set) with an ARD (assessment reference date) of 9/04/19 assessed the resident with impaired short and long term memory with signs of [CONDITION(S)]. Resident #62 was also coded as requiring extensive assistance of two or more staff members for bed mobility and dressing. The Side Rail Evaluation dated 6/30/19 states the resident uses side rails for turning and positioning in bed. The 9/04/19 signed physician order summary includes an order for 2 ¼ Side Rails for Bed Mobility and Positioning. This order is present on the September Treatment Administration Record and signed each shift. On 10/02/19 at approximately 2:35 pm, the surveyor observed Resident #62 sitting in a wheelchair and the resident's bed to be without side rails. The concern of Resident #62 not having 2 ¼ side rails on the bed as ordered was discussed with the administrative staff (administrator and director of nursing) during a meeting on 10/02/19 at approximately 5:15 pm. On 10/03/19 at approximately 8:20 am, the director of nursing stated a side rail assessment was completed on 10/02/19 for Resident #62 which indicated the resident no longer required side rails and the physician's order was discontinued. No further information was provided prior to exit conference on 10/03/19. 5. For Resident #67, the facility failed to assess for the use of a wanderguard. Resident #67's face sheet listed an admitted [DATE]. The Resident's diagnosis list indicated diagnoses, which included, but not limited to [CONDITION(S)] of the left hip, [CONDITION(S)], muscle weakness, cognitive communication deficit, unspecified [CONDITION(S)], dementia, major depressive disorder, and delusional disorder. The most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 9/06/19 assessed the resident with impaired short and long term memory with signs of [CONDITION(S)]. Resident #67 was also coded as requiring extensive assistance of two or more staff members for dressing, personal hygiene and requiring physical help of two or more staff members for bathing. Resident #67 was coded as using a wander/elopement alarm daily. The 9/04/19 signed physician order summary includes an order for Wanderguard to (R) ankle due to decreased safety awareness - check placement every shift. On 10/02/19 at approximately 11:28 am, surveyor observed a wanderguard to Resident #67's right ankle. The most recent Elopement Risk Evaluation completed on 9/10/17 determined resident to be at risk for elopement. The surveyor requested and was provided with a copy of a facility policy entitled Elopement Risk which read in part, It is the policy of the company that on admission and quarterly, all residents will be assessed for elopement risk. The concern of Resident #67 not being assessed for elopement risk quarterly was discussed with administrative staff (administrator and director of nursing) during a meeting on 10/02/19 at approximately 5:15 pm. On 10/03/19 at approximately 8:50 am, surveyor met with the director of nursing who stated Resident #67's Elopement Risk Evaluation was completed last night. The director of nursing stated that the Elopement Risk Evaluation should have been completed quarterly but staff had failed to do so. An Elopement Risk Evaluation was completed on 10/02/19 after the surveyor notified the administrative team of this in the conference on 10/02/19. No further information was provided prior to exit conference on 10/03/18. 6. For Resident # 72, facility staff failed to assess and document the resident's condition after a fall. 10/01/19 09:08 AM Resident had a fall 8/2/19. SBAR (Situation/Backbround/AssessmentRecommendation) assessment in record. Fall 7/28 (self transfer for toileting) SBAR assessment present in record. MDS (Minimum Data Set) ARD (Assessment Reference Date) 6/11: locomotion on and off the unit 1/2 (1 person assist); ambulate with walker or wheelchair; unable to transfer to and from toilet or bed without assistance. 7/28 fall-- no documentation of follow-up. Next nursing note was 8/1. 8/2 fall-- no documentation of followup. Time and situation of fall is not documented on SBAR or in nurse's notes. The documentation is not clear regarding who completed the SBAR. 10/02/19 11:oo AM spoke with director of nursing about the 8/2 fall. She stated that the nurses told her they had been instructed to put all fall documentation on the SBAR form and not in the nurse's notes. She said she would check the incident reports for time and situation details about the fall. 11:32 DON reported that the incident reports directed the reader to the nurse's notes for details about the incident.

Based on staff interview and clinical record review, facility staff failed to review and revise the comprehensive care plan to reflect the resident's status for 1 of 21 residents in the survey sample (Resident #72). Resident #72 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the quarterly Minimum Data Set assessment with assessment reference date 9/11/19, the resident scored 6/15 on the brief interview for mental status and was assessed as without signs of [CONDITION(S)], [CONDITION(S)], or behaviors affecting care. The resident was assessed as requiring extensive assistance for transfer to or from bed or toilet, cueing or supervision of one person for locomotion on or off the unit, and was unsteady moving from seated to standing, turning around, moving on and off the toilet, and surface to surface transfers. During clinical record review, the surveyor noted the resident had falls on 7/28/19 and 8/2/19. For the fall on 7/28/19, there was no post fall documentation. The next nursing progress note was dated 8/1/19. On 10/02/19 11:00 AM, the surveyor spoke with director of nursing (DON) about the 8/2 fall. The DON stated that the nurses told her they had been instructed to put all fall documentation on the SBAR form and not in the nurse's notes. The DON said she would check the incident reports for time and situation details about the fall. At 11:32 AM, the DON reported that the incident reports directed the reader to the nurse's notes for details about the incident. The DON provided SBAR ( Situation/Background/Assessment/Recomendation) forms for the 2 falls. For the fall on 7/28, the SBAR form described the circumstance of the fall. There was no post-fall documentation. For the fall on 8/2/19, a SBAR assessment form was in the record. The time and situation of the fall was not documented in the SBAR form. The SBAR form referred the reader to the nurse's notes for assessment. The DON provided Post fall questionnaires for the 2 falls. Those questionnaires were not part of the clinical record. The questionnaires documented the resident's general assessment and vital signs at the time of the fall, but no follow-up of the resident's status during the days after the fall. The resident's care plan did address the resident had fallen while in the facility. The care plan was not updated after the resident's fall on either date. The administrator and director of nursing were notified of the concerns during a summary meeting on 10/4/19.

Based on staff interview and clinical record review, facility staff failed to ensure that a resident who displays or is diagnosed with dementia, receives the appropriate treatment and services by monitoring targeted behaviors associated with the use of an antipsychotic medication for 1 of 21 residents in the survey sample (Resident #67). The findings included: For Resident #67 the facility failed to monitor targeted behaviors associated with the use of [MEDICATION(S)], an antipsychotic medication. Resident #67's face sheet listed an admitted [DATE]. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 9/06/19 assessed the resident with impaired short and long term memory with signs of [CONDITION(S)]. Resident #67 was also coded as requiring extensive assistance of two or more staff members for dressing, personal hygiene and requiring physical help of two or more staff members for bathing. The 9/04/19 signed physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The September 2019 Behavior/Intervention Monthly Flow Record indicates the target behaviors for the use of [MEDICATION(S)] are refusal of meds and refusal of care. The concern of Resident #67 not being monitored for the symptoms of paranoia and violent behavior associated with the use of [MEDICATION(S)] was discussed with the administrative staff (administrator and director of nursing) during a meeting on 10/02/19 at approximately 5:15 pm. On 10/03/19 at approximately 8:55 am, the director of nursing stated the Resident's Behavior Monitoring log for [MEDICATION(S)] has been revised to reflect monitoring for violent outburst. No further information was provided prior to exit conference on 10/03/19.

Based on staff interview and clinical record review, facility staff failed to have a stop date for an as needed [CONDITION(S)] medication for 2 of 21 residents in the survey sample (Residents #7 and 69). The findings included: 1. The facility staff failed to ensure that PRN (as needed) orders for [CONDITION(S)] drugs are limited to 14 days except by having a stop date for an as needed [CONDITION(S)] medication for Resident #7. The [CONDITION(S)] medication was [MEDICATION(S)]. Resident #7 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, stroke, [CONDITION(S)], heart failure, high blood pressure, Alzheimer's disease, anxiety disorder and depression. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/27/19, the resident was coded as having memory problems in her short term and long-term memory problems. Resident #26 was also coded as requiring extensive assistance of 2 staff members for bathing and personal hygiene and totally dependent on 2 staff members for bathing. During the clinical record review on 10/3/19, the surveyor noted a physician's order dated and timed for 6/20/19 at 2330 (11:30 pm) for Resident #7 which read [MEDICATION(S)] 1 mg (milligram). Give one tablet by mouth three times a day as needed for agitation or anxiety. There was no stop date or time for this medication to be discontinued. The surveyor notified the DON (director of nursing) of the above documented findings on 10/3/19 at 2 pm. The DON stated, We will have to get that fixed. I haven't been here long and wasn't aware that this was going on. The surveyor notified the DON and administrator of the above documented findings on 10/3/19 at approximately 3 pm. No further information was provided to the surveyor prior to the exit conference on 10/3/19. 2. The facility staff failed to have a stop date for an as needed [CONDITION(S)] medication for Resident #69. The [CONDITION(S)] medication was [MEDICATION(S)]. Resident #69 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, dementia, [CONDITION(S)] disorder, depression and psychotic disorder. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/7/19, the resident was coded as having short term and long-term memory problems and was severely impaired in making daily decisions. Resident #69 was also coded as requiring extensive assistance of 2 staff members for dressing and personal hygiene and was totally dependent on 2 staff members for bathing. During the clinical record review on 10/3/19, the surveyor noted the following order: [MEDICATION(S)] ([MEDICATION(S)]) 0.5 mg (milligram) .Take 1 tab every 4 hours (May crush) as needed .for signs of anxiety, increased agitation or [CONDITION(S)] activity . This order had originally been given to staff on 4/12/19 and was present on the Physician Order Sheets (POS) for the months of August, September and October 2019. There was no stop date or time for this medication to be discontinued. The surveyor notified the DON (director of nursing) of the above documented findings on 10/3/19 at 2 pm. The DON stated, We will have to get that fixed. I haven't been here long and wasn't aware that this was going on. The surveyor notified the DON and administrator of the above documented findings on 10/3/19 at approximately 3 pm. No further information was provided to the surveyor prior to the exit conference on 10/3/19.

Based on staff interview, clinical record review, and clinical record review, facility staff failed to store and prepare food in accordance with professional standards for food service safety. The surveyor entered the facility on 7/31/17 at 9 PM. The surveyor toured the facility with emphasis on evidence of residents with symptoms of gastric illness such as vomiting and diarrhea. No residents exhibited signs of gastric distress. Residents were asked if the food was acceptable and if they had been ill while in the facility. Staff reported no resident had recently exhibited symptoms. On 7/31/17 at 9:45 PM, the surveyor toured the kitchen with the director of nursing (DON). The prep counter near the walk-in refrigerator and freezer were splattered with a yellow substance and some food residue. There were approximately 2 cups of peas in the prep sink, there were pans and food debris in 1 compartment of the 3 compartment sink. There was food residue on the stovetop. One counter had a head of lettuce and a tomato on it. The steam table had approximately 2 inches of water in each compartment with food visible in each of the 4 compartments that appeared to be macaroni, peas, lima beans, and ground meat. There was a pan of sweet potato halves in the proof oven. The three garbage cans in the kitchen contained garbage. The dry storage room had unshelved food in cases stacked on the floor. There were 3 collapsed boxes scattered .on the floor. A 50 pound flour bag sat open on a bottom shelf. The walk-in freezer temperature was 22 F (degrees Fahrenheit). The Aide Refrigerator was 34 F; walk-in refrigerator, 36 F; and the cook's fridge, 35 F. The surveyor and DON were unable to locate an interior thermometer in the freezer. The external freezer temperature reading matched the daily freezer temperature log. There was a frozen red substance on the floor. There was ice on two boxes of food on the shelf under the fan. A case of canned foods propped the freezer door closed. There was a small pool of water under the freezer door. The surveyor stated the freezer temperature and the cleanliness of the kitchen were a concern. On 8/1/17 at 9:07 AM, the counters, sinks, steam table, and dry storage room were clean. The walk-in freezer temperature was 0 and the door was propped closed by a case of canned goods on a crate. The puddle of water under the door was present. Inside the freezer, there was red frozen matter on the floor. Some food items showed evidence of thawing and refreezing. Plastic tubs of ice cream showed layers. The vanilla had approximately two inches of opaque matter on top of a yellowish translucent substance. The chocolate showed three different layers, each approximately 2 inches thick. A box of wieners was frozen in a solid mass with a bright pink substance filling the space between the plastic weiner packages. A bag of sausage patties on the shelf under the wieners was open to the air. A package of chicken breasts appeared to have ice crystals both on the outside and the inside of the plastic package. A box labeled pork patties had ice on the top, which appeared to be from water dripping from the fan. The box was partially open and the bag was open with a small amount of ice on it. The surveyor made the administrator and dietary manager aware of the evidence of thawing and refreezing. Some of the items were removed or wrapped in plastic. The administrator stated that they had been working on the freezer for a couple of months. He stated they had put a new clasp on the door and had a service visit the prior week on 7/28/17. The freezer temperature logs for July documented that there was no day in July that one or both of the recorded temperatures was above the recommended 0 F. The recorded AM and PM temperatures for July were: 7/1/17 10 32 7/2/17 10 32 7/3/17 38 20 7/4/17 10 20 7/5/17 10 34 7/6/17 20 20 7/7/17 -3 26 7/8/17 -2 26 7/9/17 -4 36 7/10/17 30 20 7/11/17 20 10 7/12/17 10 10 7/13/17 25 40 7/14/17 10 30 7/15/17 30 30 7/16/17 20 30 7/17/17 26 30 7/18/17 15 26 7/19/17 28 26 7/20/17 40 30 7/21/17 35 38 7/22/17 blank 30 7/23/17 31 30 7/24/17 30 40 7/25/17 40 40 7/26/17 30 30 7/27/17 40 40 7/28/17 40 blank 7/29/17 10 5 7/30/17 2 6 7/31/17 -5 20 The recorded AM and PM recorded temperatures were: 6/1/17 20 10 6/2/17 10 18 6/3/17 10 -20 6/4/17 20 0 6/5/17 22 30 6/6/17 28 15 6/7/17 -9 32 6/8/17 -10 40 6/9/17 25 34 6/10/17 2 34 6/11/17 5 20 6/12/17 21 34 6/13/17 18 20 6/14/17 20 22 6/15/17 19 20 6/16/17 28 30 6/17/17 24 0 6/18/17 0 -20 6/19/17 15 18 6/20/17 0 6 6/21/17 -9 10 6/22/17 8 -22 6/23/17 32 30 6/24/17 10 -20 6/25/17 15 0 6/26/17 2 0 6/27/17 -9 0 6/28/17 0 0 6/29/17 10 0 6/30/17 0 0 The surveyor consulted the central office concerning the information of thawing and refreezing and the documented freezer temperatures at 11 AM. At 11:30 AM on 8/1/17, the surveyor informed the facility administrator, director of clinical services, dietary manager, corporate district clinical representative, the district dietary consultant that there was a situation of immediate jeopardy as of 7/31/17 at 9:45 PM due to the fact that the freezer was not maintaining a consistent appropriate temperature. Food displayed evidence of melting and refreezing and temperature logs confirmed that the freezer not been maintaining the recommended storage temperature of 0 F. Facility staff were instructed not to serve meats that had been stored in the freezer. At 2:30 PM on 8/1/17, facility staff offered a plan for immediate abatement of the condition of jeopardy: Allegation of Compliance F371-Sanitary Conditions To remove immediacy, Skyline has implemented and completed the following: On 8/1/17 11:15am, a staff member cleaned out the freezer and disposed of all food or food items in dumpster. 8/1/17 11:20am, all Facility Menu ' s have been adjusted for the week and approved by dietician. 8/1/17 11:30am portable on site freezer has been ordered, scheduled to arrive no later then 8-2-17. Freezer temps to monitored for correct temperatures by Dietary staff as well as ED upon arrival 8/1/17 11:30am education has been started for facility dietary staff on freezer temperatures and who and when to report inadequate temperatures too. 8/1/17 11:45am DCS ensured no Residents received chicken as an alternate. 8/1/17 11:45am clinical review of Residents and Infection Control Line listings since May of 2017 reflect there has been no resident affected by freezer food temperatures. On 8/1/17, current residents were reviewed for presence of gastrointestinal symptoms. On 8/2/17 at 2 PM, the temporary replacement refrigerator was delivered and the condition of jeopardy was abated. After abatement of the immediate jeopardy, several issues were of continuing concern. On 8/1/17 during the 9 AM tour of the kitchen, the surveyor asked about the procedure for closing the kitchen at night. The dietary manager offered the Dining Services Closing Checklist for the week of 7/30- 8/5. For Monday 7/31/17, all items were checked. The checked items included the following which the surveyor and director of nursing observed had not been completed on 7/31/17 at 9:45 PM: storage areas locked, prep sinks clean and sanitized, pot sink drained and cleaned, counters clean and dry, all garbage taken out and cans clean, and lights out and lock up. The surveyor also observed that staff had failed to recognize that the high freezer temperatures should be addressed and staff failed to recognize signs of thawing and refreezing in food. In addition, at the time the survey ended, the facility still relied on leased, temporary freezers. The kitchen freezer continued to require a heavy external door stop to keep the door closed (the case of canned goods resting on the milk crate). Dietary staff member #1 working on 8/1/17 at 3 PM in the kitchen reported that they would inform the dietary manager if the freezer temperatures were greater than 0 degrees in the future. The two staff members who worked the evening shift on 7/31/17 were not present during the remainder of the survey. The facility policy concerning freezer maintenance documented that the freezer should be maintained at 10 degrees. The surveyor asked what the facility's freezer manual recommended. Facility staff were unable to locate a user's manual for the approximately [AGE] year old freezer. Visual examination did not offer clues to the model or manufacturer of the freezer, so the surveyor was unable to search for an online version of the manual. The surveyor found that the USDA linked to https://www.foodsafety.gov/keep/charts/storagetimes.html for recommendations for food storage for older adults. The chart states that frozen food is safe indefinitely if kept at 0 degrees F. The above concerns were discussed with the administrator and district dietary consultant on 8/2/17 at approximately 10 AM. At 2 PM on 8/2/17 the Immediate Jeopardy level 4 widespread was assigned a scope and severity of Level 2 widespread- not substandard. This is a complaint deficiency.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide service in a safe maner (resident not wearing gripper socks, only locking one side of the wheelchair, and attempting to help the resident with the activity just before reporting off from duty) resulting in a fall with injury for 1 of 21 residents (Resident #7) and failed to ensure a hazard free environment for 1 of 21 residents (Resident #1). The findings include: 1. For Resident #7, the facility staff failed to transfer the resident in a safe manner resulting in a fall with injuries. As a result of the fall, Resident #7 received a hematoma to the left side of her head and a fracture of the left humeral head, closed, large ecchymosis (bruising) on medial side of left shoulder, and scalp contusion near crown of head on left. The surveyor reviewed the clinical record of Resident #7 on 9/5/13 and 9/6/13. Resident #7 was admitted to the facility 3/24/1980 with [DIAGNOSES REDACTED]. IQ (intelligent quotient) score of 42. This information from the Virginia Annual Resident Review Instrument Mental Retardation and/or Related Conditions completed 5/24/1996), [DIAGNOSES REDACTED], seizures and depression. The most recent minimum data set (MDS) assessment completed was an annual assessment with an assessment reference date (ARD) of 7/16/13. Section C Cognitive Summary had "dash marks." Section E Behaviors revealed no evidence of behaviors in behavioral symptoms (E0200), Overall presence of behaviors (E0300), Impact on Resident (E0500), Impact on Others (E0600), Rejection of Care (E0800), Wandering (E0900), Wandering Impact (E1000), and Change in Behavior or other symptoms (E1100). All were coded either 0 (no/behavior not exhibited) or left blank. Section G Functional Status revealed Resident #7 required extensive assistance (3) of one person (2) for transfers. Section G0300 Balance During Transitions and Walking was reviewed. Resident was assessed to be a "2" for moving from seated to standing position. 2 indicated resident was not steady, only able to stabilize with staff assistance and was assessed as a "2" for transferring from surface to surface (transfer between bed and chair or wheelchair). Mobility was checked for wheelchair only in Section G0600. Section G0400 Functional Limitations in Range of Motion assessed the resident as having impairment in both lower extremities (hip, knee, ankle, foot). Functional rehabilitation (G0900) was left blank. Section H Bladder and Bowel revealed Resident #7 was assessed as a "3" for both urinary and bowel. A "3" indicated resident was always incontinent (no continent episodes). Section J1800 revealed the resident had experienced no falls. Resident #7's Care Area Assessment Summary revealed triggers for communication, falls, nutritional status, and pressure ulcers with each decided to be care planned. The surveyor reviewed the clinical record on 9/5/13 and 9/6/13. The nurse's notes dated 9/2/13 at 1405 (2:05 p.m.) read "@ (at) 1320 (1:20 p.m.) when staff changing rsd (resident) clothes rsd (resident) began resisting care towards staff rsd (resident) then lost balance and fell to L (L in a circle meant left) side rsd (resident) hit head causing hematoma meas. (measuring) 3 cm (centimeters) x 3 cm (centimeters) rsd (resident) c/o (complained of) h/a (headache). @ (at) 1345 (1:45 p.m.) prn (whenever necessary) APAP (acetaminophen) given, ROM (range of motion) WNL (within normal limits), neuro ? (neurological checks) WNL (within normal limits), rsd (resident) added to FSP (falling star program) MD, RP (responsible party), ADON (assistant director of nursing) and admin (administrator) aware and DON (director of nursing). VS (vital signs) 140/70 (blood pressure), 97.7 (temperature), 98 (pulse), 20 (respirations), 91% (oxygen saturation level). Will monitor." Signed by licensed practical nurse #5. The nurse's note dated 9/2/13 at 1530 (3:30 p.m.) read "prn (whenever necessary) APAP (Tylenol) eff (effective) for c/o (complaints of H/A (headache). rsd (resident) sitting in room in w/c (wheelchair). No s/s (signs or symptoms) of distress." The nurse's note written 9/2/13 at 1530 (3:30 p.m.) read "V/S (vital signs) stable. Resident propelling self in w/c (wheelchair) in the halls. Denial of any pain or discomfort. Neuro ? (neurological checks) WNL (within normal limit). Hand grips strong. ROM (range of motion) passive and active." Signed by licensed practical nurse #4. Nurse's note of 9/2/13 1630 (4:30 p.m.) read "Denial of any pain or discomfort. V/S (vital signs) stable. Neuro ? (neurological checks) WNL (within normal limit). Hand grips strong. Will cont (continue) to monitor." Signed by licensed practical nurse #4. 9/2/13 1730 (5:30 p.m.) nurse's note read "V/S (vital signs) stable. Noted during evening meal resident left upper arm @ (at) bicep area dark purplish bruise noted 10 cm (centimeters) x 10 cm (centimeters) w/a (with a ) dime size knot present @ (at) arm pit. ROM (range of motion) active and passive no facial grimaces noted. Denial of any pain when asked. Will monitor." Signed by licensed practical nurse #4. 9/2/13 1830 (6:30 p.m.) nurse's note read "Resident noted to be leaning in w/c (wheelchair) toward her left side. Denial of any pain Lt (left) shoulder seems slightly swollen remains bruised. V/S (vital signs) 126/76 (blood pressure), 98 (temperature) 76 (pulse) 20 (respirations) 93% room air (oxygen saturation level). Hand grips strong, assist to w/c (wheelchair) is needed." Signed by licensed practical nurse #4. 9/2/13 2045 (8:45 p.m.) nurse's notes read "Resident's lt (left) shoulder. Seemed swollen when access. Purplish bruise present and has spread more on her bicep. 15 cm (centimeters) x 15 cm (centimeters). ROM (range of motion) limited. Call other #4 on call. OK to get x-ray of lt (left) shoulder. Also clavicle. Call mobile x claim # 939 per ____ (name omitted). Will be here within 1-2 hours." Signed by licensed practical nurse #4. 9/2/13 2050 (8:50 p.m.) nurse's note read "Resident #7 aware and guardian made aware". Signed by licensed practical nurse #4. 9/2/13 2100 (9:00 p.m.) nurse's note read "Resident received a shower. Assist by (2) cna's (certified nursing assistants) w/transfer (with transfer). Resident states her arm is sore." Signed by licensed practical nurse #4. 9/2/13 2220 (10:20 p.m.) nurse's note read "Mobile x-ray here to perform x-rays. Results pending. 9/2/13 2330 (11:30 p.m.) nurse's note read "Received x-ray results. Clavicle normal. Lt (left) shoulder impacted humeral fx (fracture) noted. Call other #4. Uncertain when she will be seen by an ortho (orthopedic) MD (doctor). OK to send to ____ (name of hospital) emergency room for eval. Call to guardian. Message left on voice mail for a return call." 9/2/13 2330 (11:30 p.m.) nurse's note "Call 9-1-1. Called for transport." Signed by licensed practical nurse #4. 9/2/13 2350 (11:50 p.m.) nurse's note "9-1-1 here to transport." Signed by licensed practical nurse #4. 9/3/13 0002 Nurse's note report giving to ___ (name documented from receiving emergency room hospital) @ (at) this time." Signed by licensed practical nurse #4. 9/3/13 0600 nurse's note read "Rsd (resident) will be returning to facility c (c with a line over it meant with) orders to see orthopedic (name omitted) as outpatient." The surveyor reviewed the emergency room 's visit notes. Resident #7 arrived in the emergency roiagnom on [DATE] at 12:46 a.m. HPI (history of present illness ) read in part "Female who presents with EMS with left shoulder pain after sustaining a fall in which she hit her left shoulder and head today (09/02/13). Pt (patient) has large ecchymosis on medial side of left shoulder. She denies chest pain, neck pain, head pain. Unable to verify LOC (level of consciousness). Xray of shoulder was conducted today (09/02/13) at nursing home and impacted humeral fx (fracture) on left arm was noted. Medical hx (history) includes MR (mental retardation), [DIAGNOSES REDACTED], constipation, osteoporosis, seizures. Fall The accident occurred 3 to 5 hours ago ( exact time frame uncertain). The fall occurred while standing (While transferring from sitting to standing with assist). She fell from a height of 3 to 5 ft. (feet). There was no blood loss. The point of impact was the left shoulder. The pain is severe. She was not ambulatory at the scene. Pertinent negatives include no fever, no abdominal pain, no nausea, no vomiting and no loss of consciousness. Physical exam: Scalp contusion near crown of head on left. Good capillary refill in left hand, pulse palpable. Musculoskeletal: She exhibits tenderness. Left shoulder: She exhibits tenderness and deformity. Moving her left hand, Severe ecchymosis on left shoulder medial side, Small contusion on left scalp under hair Pertinent Lab Findings and Radiologic Report: Results for orders placed during the hospital encounter of 09/03/13 CT Head/Brain WO (without) contrast Impression: 1. The exam is limited by motion artifact. 2. No acute intracranial abnormality is seen. 3. Mild paranasal sinus disease. 4. No significant change from preliminary report. CT Cervical Spine WO Cont (without contrast) 1. No acute fracture, subluxation, or abnormal soft tissue swelling is seen. 2. Multilevel degenerative changes infusions as noted below. XR Humerus LT (left) 2 + VW Impression: Impression: Fracture of the proximal humerus. XR Shoulder Complete LT 2+ VW Findings/Impression: 1. There is a displaced fracture of the proximal humerus. 2. No glenohumeral dislocation is seen. 3. The AC joint appears intact. Final Impression: 1. Fracture of humeral head, left, closed 2. [DIAGNOSES REDACTED] 3. Mental retardation Medical Decision Making included sling and swath, follow up by orthopedist in outpatient setting, and pain medication (Vicodin). The surveyor interviewed L.P.N. #5 on 9/5/13 at 1:40 p.m. She stated certified nursing assistant #5 came and got her. She stated that Resident #7 had fallen and was laying on the floor on her left side. She stated she was throwing a fit, yelling, screaming. L.P.N. #5 asked Resident #7 if she was alright and she kept saying Yes! Her arms and legs were flailing-like someone who has a temper tantrum. She then stated no, no, no-answering the questions but screaming the answers out. L.P.N. #5 did an assessment on her. Her range of motion was ok. L.P.N. #5 checked her head. She had a roughly 3 cm x 3 cm area on the left side of her head. She had no skin tears or bruises. L.P.N. #5 and C.N.A. #4 got her up. C.N.A. #4 was changing her. C.N.A. #4 stated to L.P.N. #5 that Resident #7 started swaying, throwing her arms in the air, lost her balance and fell . L.P.N. #5 stated she gave Resident #7 Tylenol about 15 minutes later for a headache. "She told me her head was hurting. Neurological checks were done and everything was fine. We didn't have a treatment nurse that day so I went back to reassess her. She was wheeling herself up front. She doesn't complain about anything." During the interview with L.P.N. #5 she stated the certified nursing assistant #4 had made arrangements to leave the facility that day at 1:30 p.m. The incident occurred at 1:20 p.m. "C.N.A. #4 was probably rushing Resident #7 and you can't tell her what to do. She will have behaviors if rushed. She's like a baby. You have to take your time with her." L.P.N. #5 stated she informed the physician and the responsible party of the incident. L.P.N. #5 was asked if C.N.A. #4 had used a gait belt to transfer Resident #7 from sitting to a standing position. She stated "No. C.N.A. #4 did not use a gait belt. Resident #7 didn't have her gripper socks on either and the wheelchair was only locked on one side." The surveyor interviewed the assistant director of nursing on 9/5/13 at 2:45 p.m. The ADON stated she was not present on the day of the incident 9/2/13. She stated she received a call from L.P.N. #5. "L.P.N. #5 told me that Resident #7 had fallen in her room with C.N.A. #4. Resident #7 is a 1 person assist. She told me when the C.N.A. was changing her, the resident lost her balance and fell to the floor on her left side. L.P.N. #5 did ROM (range of motion). She had no complaints of arm pain. All certified nursing assistants use gait belts. Everybody who is not independent or a total lift requires a gait belt. Resident #7 requires a gait belt. I was told she was resisting care, wiggling around, lost her balance, and fell . C.N.A. #4 was written up for not locking the wheelchair brakes, not using gripper socks. I didn't think to add about the gait belt but that should have been included. She was placed on suspension until the investigation is over. Currently DHP (department of health professions) is investigating this incident and another one that occurred on the same day with an unsampled resident." The surveyor and the ADON reviewed C.N.A. #4's personnel file on 9/5/13 at 3:00 p.m. C.N.A. #4 was given oral counseling on 9/2/13 for the fall of Resident #7 on 9/2/13. The areas of not locking brakes on the wheelchair and resident not wearing non skid foot wear were addressed. Failure to use the gait belt during the transfer was not addressed in the write-ups. The 9/2/13 oral counseling also revealed a second resident involvement with C.N.A. #4 regarding transfers from the toilet to the wheelchair. Other write-ups included 7/10/13 cell phone use, 5/18/13 not answering call lights x2 and stating to the resident "she had no time help her-wait until the next shift." ADON stated she was counseled for "talking rude to the resident." Her hire date was 8/29/12. The ADON stated "DHP has been contacted and started their investigation. She's probably terminated." The ADON and the surveyor reviewed the "Employee Education Checklist" for C.N.A. #4. On 8/31/12, there is documentation that she was trained about the "Low Lift Program" and included methods for identifying resident's transfer and mobility requirements and review of disciplinary action for not complying with Low Lift Program and on 8/29/12 the falling star program, accident prevention, proper lifting techniques, gait belt transfer, lifting and moving residents. The surveyor interviewed L.P.N. #4 on 9/5/13 at 3:30 p.m. L.P.N. #4 stated "I got in report that Resident #7 had fallen, lost her balance when being changed. She got aggressive with a staff member. She was observed that evening self-propelling self to the dining room. I was doing neuro checks on her and kept asking her if she was in pain. She stated no. I noticed a bruise but she had no pain. She had a 10 cm x 10 cm bruise on her left shoulder to her elbow with a dime size knot. Her range of motion both arms was ok. I noticed about 7:00 p.m. when she came out of the dining room, she was self propelling herself. She was leaning more to the left in her wheelchair. She kept saying "me fine!" Active range of motion ok on the upper extremities. Around 8:30 p.m., she was getting ready for bed. I noticed that her shirt looked tight. The bruise had spread on her left shoulder and inner aspect of her left arm. She had a knot in her armpit. I checked her clavicle and didn't feel anything broken. Her left shoulder looked out of alignment to me. I called the on call person and they ordered an x-ray (mobile). It was done here that night. Looks like a fracture. The technician gave her the report. I called and got an order to send her to the emergency room . I called the guardian. The guardian told me "to do what I think is best." I called the emergency room and gave them a report. I called 911 and the local EMS transported her. I wasn't in her room when she was placed on the stretcher but it looked like she was comfortable when she left the building." She was asked if the on call person gave orders for any first aid measures, she stated "No. Just the x-ray and then to send to the emergency room ." The surveyor called C.N.A. #4 on 9/5/13 at 4:15 p.m. She stated she was standing Resident #7 up and changing her pants. She was mad. "When I pulled her pants down, she put her arms behind my head. I lost my grip and she fell and landed on her left side. She was in the wheelchair." During the interview, she was asked if she had used a gait belt to transfer resident #7. She stated "No. Yeah, most of the time I do." She also was asked if she had locked the wheelchair brakes. She stated "I know one was locked." She was also asked what type of foot wear resident #7 had on her feet. "She had those slipper socks on." She stated C.N.A. #5 was in the room assisting another resident. The surveyor was unable to reach the second C.N.A. #5 in the room on 9/2/13 when she was called 9/5/13 at 4:20 p.m. The surveyor reviewed the weekly nursing progress notes 7/18/13 through 8/29/13. No behaviors documented. The September 2013 medication administration records were reviewed. Resident #7 received stool softeners and pain medications as needed. The surveyor reviewed the current comprehensive care plan dated 10/13/12 for inability to participate in ADLs (activities of daily living) with target date of 6/4/13. Approaches/Interventions: Allow resident to choose appropriate clothes-assist as needed, Monitor needs for assistance and provide appropriate level prn (whenever necessary), Change gown or clothing daily as needed Will resist-Encourage her to pick out clothes to keep with compliance, talk to resident during care and allow opportunities to express self, assistive devices as needed for transfers and mobility-w/c (wheelchair). The care plan for behaviors dated 7/26/13 read "Potential for impaired inappropriate behaviors-related to M.R. (mental retardation). Becomes upset when room is cleaned. Approaches/interventions included Introduce self when providing care, explain procedure to resident before providing care, assess behaviors for underlying medical issues, redirect inappropriate behavior as needed, wait and attempt when refusing care or treatment." The care plan for falls dated 7/17/13 read "Approaches/Interventions: Encourage proper fitting shoes/gripper socks, complete falls risk on admission and quarterly rehab screen." The last "risk for falls" screen was dated 5/29/13 and Resident #7 scored 10. A 10 means the resident was deemed at risk for falls. The last rehab screen was completed 5/13/13 and read "Pt (patient) with no fxl (functional) changes, w/c (wheelchair) or splinting." The surveyor informed the administrator, the director of nursing and the administrative staff other #4 of the above finding on 9/5/13 at 6:00 p.m. On 9/6/13 at 8:05 a.m. the director of nursing and the administrative staff other #4 met with the survey team. She stated "We recognize the harm. We have had monthly fall inservices the last one being done 8/21/13. We have assessed all of our other residents, started in-services for compliance to be completed today, discussed in QI, discussed adaptive equipment, have educated our staff. We feel this should be looked at as a past non-compliance and not a current deficient practice." The surveyor reviewed the facility policy on gait belts titled "Gait Belt Transfer." A gait belt may be utilized to promote stability/safety in the transfer or ambulation of a resident who requires assistance." No further information was provided prior to the exit conference on 9/6/13. 2. For resident #1, the facility staff failed to ensure a hazard free environment. Resident #1 was observed by the facility staff "attempting to eat lotion." Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment completed on this resident was a quarterly review MDS assessment with an ARD (assessment reference date) of 07/08/13. Section C (cognitive patterns) of this assessment was coded 1/1/2 indicating the resident had problems with long and short term memory and was moderately impaired in cognitive skills for daily decision making. The resident's admission MDS assessment with an ARD of 10/30/12 was coded 1/1/3 to indicate the resident had problems with long and short term memory and was severely impaired in cognitive skills for daily decision making. Section E (behavior) was coded to indicate the resident did not have hallucinations or delusions, did have physical behavior symptoms directed and not directed toward others (hitting, scratching, pacing, rummaging...). Section E0500 (impact on resident) indicated that these behavioral symptoms put the resident at significant risk for physical illness or injury. Section E0900 (wandering) was coded (1) to indicate the resident wandered but that the wandering did not place the resident at significant risk of getting to a potentially dangerous place (stairs, outside of the facility). The clinical record included a nurse's entry that had been documented on 03/18/13 at 1112 (11:12 a.m.) "Rsd (resident) (c with a line over it to indicate (with)) small tube of hand lotion in hand, lotion noted around mouth, + on hands, was attempting to eat lotion, lotion removed from rsd. No s/s (signs/symptoms) distress. No N/V/D (nausea/vomiting/diarrhea) noted at this time. MD aware. Will monitor." The surveyor was unable to locate any further documentation in the residents clinical record that referenced this incident or any continued monitoring of the resident. A review of the residents CCP (comprehensive care plan) identified the following problem areas-self care deficit related to cognitive loss, impaired vision, impaired cognitive status, and potential for impaired or inappropriate behaviors related to dementia, psychosis. On 09/04/13 at approximately 4:40 p.m., an end of the day meeting was held with the administrator and DON (director of nursing). During this meeting the administrative staff were interviewed regarding the resident's hygiene supplies on the dementia unit. The DON verbalized to the survey team that the hygiene supplies were "usually locked up" but that sometimes the resident's families would bring things in. On 09/05/13 at approximately 3:05 p.m., the surveyor completed an observation of the residents personal room and bathroom. During this observation the surveyor did not observe any lotions/creams, etc... that would have been available to the resident. On 09/06/13 at approximately 7:55 a.m., during an interview with CNA (certified nursing assistant) # 8. CNA #8 verbalized to the surveyor that the resident's lotions, shampoos, etc... were locked up in the resident's bathroom. On 09/06/13 at approximately 8:10 a.m., an observation was made of the residents communal shower room. The cabinets were observed to be locked and there were no hygiene supplies visible. No further information regarding this issue was provided to the survey team prior to the exit conference.