Every finding on record at St Peters Post Acute

Based on observation, interview, and record review, the facility failed to follow physician orders for one resident (Resident #1), in a review of eight sampled residents. Staff failed to apply dressings and wraps to the resident's wound on both lower legs and a dressing to the left palm as ordered by the physician. The facility census was 117. Review of the facility policy, Medication and Treatment Orders, revised 07/2016, showed the following:-Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in this state;-Drugs and biological orders must be recorded on the physician's order sheet in the resident's chart. 1. Review of Resident #1's Physician Order Sheet (POS), dated 06/2026, showed the following:-Apply Ace wrap to right leg only in the morning and remove at night for edema (original order dated 05/10/26);-Wound to left palm: Cleanse with normal saline, apply betadine and dry dressing, and roll in left hand every day shift for wound (original order dated 04/21/26);-Wounds to both lower extremities (BLE): Cleanse with normal saline and pat dry. Apply calcium alginate (a highly absorbent, biodegradable wound dressing used for moderate to heavily draining wounds) to open areas, followed by abdominal dressing (ABD, a thick absorbent dressing) pad. Wrap with kerlix followed by ace wrap every shift every Monday, Wednesday, Friday and as needed for wound (original order dated 06/08/26). Observation on 06/09/26 at 9:45 A.M. showed the resident lay in bed with his/her lower legs uncovered. The resident had open sores on both lower legs. The resident did not have any dressings or ace wraps on his/her legs as ordered. Observation on 06/09/26 at 11:00 A.M. showed the resident lay in bed with his/her lower legs uncovered. The resident had open sores on both lower legs. The resident did not have any dressings or ace wraps on his/her legs as ordered. Observation on 06/09/26 at 1:10 P.M. showed the resident lay in bed with his/her lower legs uncovered. The resident had open sores on both lower legs. The resident did not have any dressings or ace wraps on his/her legs as ordered. Observation on 06/09/26 at 4:35 P.M. showed the resident sat on the side of the bed. The resident had several open wounds on his/her legs that had clear to red drainage. The resident did not have any dressings on his/her lower legs. The sheets on the resident's bed had spots of reddish, dried drainage. The resident did not have a dressing on his/her left palm. The nail of the resident's middle finger dug into the palm of his/her hand. During an interview on 06/09/26 at 4:35 P.M., the resident's family member, Family Member A, said staff were to wrap the resident's legs with a dressing due to the open sores. The resident's left hand was contracted. The resident used to have a splint in the palm of his/her hand, but he/she did not know what happened to the splint. Observation on 06/10/26 at 9:15 A.M. showed the resident sat in a wheelchair in the dining room. The resident did not have any dressings or ace wraps on his/her legs as ordered. The resident did not have a dressing on his/her left palm as ordered. During an interview on 06/10/26 12:02 P.M., Licensed Practical Nurse (LPN) A said the resident was to have a dressing to both lower legs due to open, draining sores. He/She was not aware the resident did not have dressings on his/her lower legs. The resident's left hand was very contracted, and the nail of the resident's middle finger left a sore in the resident's palm. The resident was supposed to have a dressing on his/her left palm. He/She was not aware there was no dressing on the resident's left palm. During an interview on 06/10/26 at 3:30 P.M., the Director of Nursing (DON) said she expected the nurses to follow physician orders. The resident should have dressings on both lower legs and to the palm of his/her hand as ordered. 30225773027618

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #1), in a review of eight sampled residents, received the appropriate treatment and services to increase range of motion and/or to prevent further decrease in range in motion in the resident's left hand. The resident had a contracture (fixed tightening of muscle, tendons, ligaments, or skin preventing normal movement) to his/her left hand which prevented him/her from opening his/her hand. The resident did not receive restorative nursing services for range of motion to the left hand. The facility census was 117. Review of the facility policy, Contracture Management, revised 11/2012, showed the following:-Residents will be assisted to maintain normal joint mobility, prevent complications associated with joint deformity and prevent worsening of existing contractures, unless the resident's cognitive, physical or medical condition is such that contracture formation or decline is unavoidable;-Joint mobility limitations/contractures will be identified on the nursing admission assessment upon admission, the scheduled Minimum Data Set (MDS) assessment and Physical Therapy or Occupational Therapy evaluation forms, as applicable;-Document interventions implemented to meet the resident's immediate needs which may include, but are not limited to pain relief, range of motion (ROM), repositioning for comfort and proper alignment, prevention of skin breakdown, padding or cushioning to prevent skin to skin contact, assistance with activities of daily living (ADLs);-Nurse and/or therapist will complete or revise the plan of care to include current or potential joint mobility limitations/contractures or complications;-Ongoing assessments and monitoring of new or existing joint mobility limitations or contractures will be conducted no less often than quarterly by a licensed nurse during the MDS assessment process with referral to rehab as appropriate. 1. Review of Resident #1's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 05/27/26, showed:-Received no physical therapy or occupational therapy, no restorative nursing and no assistance with splints or braces;-Diagnoses included stroke with hemiparesis on one side (a neurological symptom characterized by mild to severe muscle weakness or partial loss of movement on one side of the body). Review of the resident's Care Plan, dated 05/29/26, showed staff did not develop a care plan to address the resident's range of motion or the contractures in his/her hand. Observation on 06/09/26 at 4:35 P.M. showed the resident sat on the side of the bed. A family member assisted the resident to put on pants. The resident's fingers on the left hand were contracted, and he/she was unable to open his/her left hand. The resident's middle and third finger remained closed into the palm of his/her hand. During an interview on 06/09/26 at 4:35 P.M., Family Member A said he/she tried to open the fingers on the resident's left hand and wash the palm of the resident's hand when he/she visited. The resident's middle fingernail was long and caused a sore in his/her palm. The resident used to have a splint for his/her hand, but staff had not put it on the resident for a long time. During an interview on 06/29/26 at 4:35 P.M., the resident said he/she could not move the fingers on his/her left hand. It hurt when he/she or someone tried to moved his/her fingers. During an interview on 06/10/26 at 12:00 P.M. Certified Nurse Aide (CNA) B said he/she was the Restorative Nursing Aide. The resident was not receiving any range of motion (ROM) or restorative nursing services. He/She was unaware the resident's left hand was so contracted. During an interview on 06/10/26 at 12:02 P.M. Licensed Practical Nurse (LPN) A said the fingers on the resident's left hand were contracted and the middle finger caused a sore in the palm of his/her hand. He/She did not know if the resident had a splint to put in his/her hand or if the resident received restorative nursing services for ROM. During an interview on 06/10/26 at 1:30 P.M., the Director of Therapy said the resident did not receive any restorative nursing services, however, the resident would benefit from restorative nursing services. During an interview on 06/10/26 at 1:35 P.M., Certified Occupational Therapy Assistant (COTA) C said a therapist saw the resident in the past and the resident had a soft splint, but the resident was unable to use it because the resident could not open his/her hand. During an interview on 06/10/26 at 1:35 P.M., COTA D said he/she remembered therapy had ordered for the resident to wear a split to protect his/her palm due to the contractures. Observation on 06/10/26 at 1:40 P.M. showed CNA B found a hand splint in a drawer in the resident's nightstand. During an interview on 06/10/26 at 1:40 P.M., CNA B said he/she was unaware the resident had a splint for his/her left hand. During an interview on 06/10/26 at 1:45 P.M., LPN A said he/she was unaware the resident had a splint for his/her left hand. During an interview on 06/10/26 at 3:30 P.M., the Director of Nursing said she expected staff to refer residents to therapy when they noticed there may be a contracture for either therapy or restorative nursing services. She was unaware the resident had a splint or his/her fingers on the left hand had become so contracted. The resident would have benefited from restorative nursing services. The staff should have referred the resident to therapy for evaluation for the contracture.

Based on observation, interview, and record review, the facility failed to provide two residents (Residents #1 and #3), who required staff assistance for activities of daily living (ADLs), in a review of eight sampled residents, the necessary care to maintain good personal hygiene. The facility census was 117. Review of the facility policy, Activities of Daily Living (ADL) Support, revised 03/2018, showed the following:-Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs;-Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene;-Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, to include support with hygiene (bathing, dressing, grooming and oral care) and elimination (toileting). Review of the facility policy, Care of Fingernails/Toenails, revised 10/2010, showed the following:-The purpose of this procedure is to clean the nail bed, to keep nails trimmed and to prevent infections;-Nail care includes daily cleaning and regular trimming. 1. Review of Resident #1's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 05/27/26, showed the following:-Able to make self-understood and able to understand others;-Required staff assistance with dressing and personal hygiene. Review of the resident's Care Plan, dated 05/29/26, showed the following:-The resident required assistance related to anticipated declines in condition due to disease process, cognitive impairment, fluctuating ADLsand weakness-The resident required assistance from one staff for care during the morning and evening. Observation on 06/09/26 at 4:35 P.M. showed the resident's pants and shirt were dirty. The fingers on the resident's left hand were contracted. The fingernail on the resident's middle fingernail was long and pressed into the palm of the resident's hand causing a sore in the palm of his/her hand. There was a musty odor coming from the palm of the resident's hand. The fingernails on both of the resident's hands were long with a dark black substance under the nails. During an interview on 06/09/26 at 4:35 P.M., the resident's family member said the following:-The resident wore the same pants and shirt he/she put on the resident the day prior;-He/She cut the resident's fingernails to keep them from digging into the resident's palm. 2. Review of Resident #3's Care Plan, dated 10/24/24, showed the following:-The resident was incontinent of bowel and bladder;-Staff to anticipate and meet the resident's needs. Encourage the resident to use his/her call light for assistance;-The resident was incontinent of bowel and bladder;-The resident required assistance from one staff for toileting and hygiene;-Staff to provide peri-care with rounds and as needed. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Able to make self understood and able to understand others;-Alert and oriented with some difficulty making decisions;-Required assistance of staff with ADLs;-Incontinent of bowel and bladder. Observation on 06/09/26 at 9:39 A.M. showed the resident lay in bed. There was a foul smelling odor coming from the resident. Observation on 06/09/26 at 9:39 A.M. showed the resident activated his/her call light. Observation on 06/09/26 at 9:59 A.M., Certified Nurse Aide (CNA) E entered the resident's room and a few seconds later exited the resident's room. CNA E turned off the resident's call light. During an interview on 06/09/26 at 10:00 A.M., CNA E said the resident forgot what he/she wanted. Observation on 06/09/26 at 10:01 A.M. showed a foul-smelling odor coming from the resident and the resident's room. During an interview on 06/09/26 at 10:01 A.M., the resident said CNA E never asked him/her why his/her call light was on. CNA E just shut off the call light. Observation on 06/09/26 at 10:30 A.M. showed Licensed Practical Nurse (LPN) F entered the resident's room, took the resident's vital signs, exited the room and told CNA E the resident needed changed. Observation on 06/09/26 at 10:33 A.M. showed CNA E provided incontinence care for the resident. The resident's incontinence brief was saturated with urine and fecal matter. There was dried fecal matter on the resident's buttocks and thighs. During an interview on 06/09/26 at 10:50 A.M., CNA E said he/she was not aware the resident needed changed. The resident did not say he/she had a bowel movement. He/She did not smell any odors. During an interview on 06/09/26 at 12:00 P.M., LPN F said there were usually only two nurse aides on the Memory Care Unit and one nurse. It was difficult for staff to ensure all the residents received care when they needed the care. Staff should make sure to take residents to the toilet and change them as needed. 3. During an interview on 06/10/26 at 3:30 P.M., the Director of Nursing said the following:-Staff should recognize when a resident had a bowel movement and needed changed. She expected staff to assist residents with incontinence care immediately;-Staff should not turn off call lights without ensuring they met the resident's needs;-Staff should provide daily care to the residents, change their clothes, and ensure they cleaned and trimmed their nails. 30276183022577

Based on observation, interview, and record review, the facility failed to implement interventions as recommended by the registered dietician and ordered by the physician to prevent weight loss and failed to provide meal encouragement for two residents (Resident #1 and #2), who had a significant weight loss. The facility census was 120. Review of the facility policy for Weight Assessment and Intervention, revised March 2022, showed the following:-The threshold for significant unplanned and undesired weight loss will be based on the following criteria: one month - 5% weight loss is significant and greater than 5% is severe; three months - 7.5% weight loss is significant and greater than 7.5% is severe; six months - 10% % weight loss is significant and greater than 10% is severe;-Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met;-The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: cognitive or functional decline, chewing or swallowing abnormalities, pain, medication-related adverse consequences, environmental factors (such as noise or distractions related to dining), poor digestion or absorption, fluid and nutrient loss and inadequate availability of food or fluids;-Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietician, the consultant pharmacist and the resident or the resident's legal surrogate;-Individualized care plans shall address the identified causes of weight loss are based on careful consideration of the following: resident choice and preferences, nutrition and hydration needs of the resident, functional factors that may inhibit independent eating; the use of supplements.1. Review of Resident #1's care plan for weight, dated 06/13/25, showed the following:-The resident had a diet order of fortified food (products that have vitamins, minerals, or other micronutrients added to them that are not naturally present or are present in small amounts), regular diet, regular texture;-Interventions: Provide diet as ordered. Registered Dietician (RD) to evaluate and treat as needed. Review of the resident' quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/29/25, showed the following:-Severe cognitive impairment;-Required set-up assistance with meals;-Weight 123 pounds. Review of the resident's weights documented in the Electronic Medical Record (EMR), dated 01/06/26 at 5:06 P.M., showed the resident weighed 124 pounds. Review of the Physician Order Sheet (POS) dated February 2026 showed an order for fortified foods, regular texture, and thin liquids. Review of the resident's weights documented in the EMR, dated 02/05/26 at 6:26 P.M., showed the resident weighed 115.4 pounds (a 6.9% weight loss in one month). Review of the RD's progress note, dated 02/13/26 at 2:55 P.M., signed by RD, showed the resident was on a fortified diet. His/Her intake varied and were documented at 0-100%. Per Assistant Director of Nursing (ADON), the resident did not eat well. Current weight was 115.4 pounds, which reflected a 7% weight loss in 30 days, and an 8.4% weight loss in 90 days. Per the ADON, the resident did not like the food. Weekly weights for four weeks was added to monitor weight trends. Review of the resident's weights in the EMR showed the following:-No documentation of a weekly weight during the week of 2/15/26-2/21/26;-On 02/26/26 at 6:35 P.M., the resident weighed 113.6 pounds;-On 03/05/26 at 3:31 P.M., the resident weighed 106.2 pounds (a 6.5% weight loss in one week). Review of the resident's dietary progress note, dated 03/08/26 at 11:32 P.M., signed by the Dietary Manager (DM), showed the resident was alert and verbal and able to make his/her needs known. The resident was on a fortified diet. The resident had no noted difficulties with current diet. The resident's appetite was fair/poor. Current weight was noted as a significant weight loss. Interventions were in place for weight loss. (Review of the resident's care plan, dated 06/13/25, showed the only listed intervention for weight loss was a fortified diet.) Review of the resident's dietary progress note, dated 03/13/26 at 1:50 P.M., signed by the RD, showed the resident was on a fortified diet. The resident's intake varied and were documented at 0-100%. Per the ADON, the resident would not sit and eat. He/She liked to roam. Current weight was 106.2 pounds, which reflected a 7.9% weight loss in 30 days. Discussed adding finger foods since he/she roamed while he/she ate. Review of the resident's physician's orders, dated 03/13/26, showed a new order for finger foods. Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident weighed 106 pounds with an unplanned weight loss of 5% weight loss in two months or 10% weight loss in six months;-Set up assistance required with meals. Review of the resident's care plan for weight, revised 03/31/26, showed no updates to address the resident's weight loss or the RD's recommendation and new order for finger foods. Review of the resident's physician order sheet (POS), dated April 2026, showed an order for fortified foods, regular diet, regular texture, and finger foods. Review of the spreadsheet menu for the dinner meal on 04/01/26 showed the following:-The menu for regular diet included fish and chips with creamy coleslaw, Hawaiian roll and tropical fruit cup;-The menu for finger foods included options of chicken tenders, French fries, a sandwich cut into four, hotdogs, and onion rings;-The fortified foods were a nutritional shake or fortified honey bun. Observation on 04/01/26 at 4:40 P.M., showed the following:-The resident sat at the dining room table in the Memory Care Unit with a plate of [NAME] pie, a roll and a honey bun;-The resident took the honey bun, wheeled himself/herself out of the dining room and down the hall, then turned around, and came back into the dining room;-Three staff were in the dining room assisting other residents with their meals, and one nurse was at the medication cart passing medications;-The resident sat the half-eaten honey bun on the table then wheeled himself/herself between several tables to the counter where a bin of potato chips, cookies and crackers sat. He/She took out a bag of barbeque potato chips, opened the bag of chips, wheeled himself/herself out of the dining room, and ate from the bag of potato chips;-The resident returned to the dining room after several minutes, placed the partially eaten bag of potato chips on the table and wheeled himself/herself back out of the dining room and down the hall;-Staff removed the resident's uneaten plate of food from the table and placed it on the cart to return to the kitchen;-No staff attempted to encourage the resident to eat the food on the plate or offered the resident anything different to eat. Review of the resident's dietary card on 04/01/26 at 5:10 P.M., showed a diet order of fortified foods. There was no order for finger foods listed on the card and observation showed no finger foods were served per the RD's recommendation. During an interview on 04/01/26 at 5:10 P.M., the DM said the resident usually did not eat well and snacked as he/she propelled himself/herself in the wheelchair. Finger foods had not been served to see if the resident would eat them. Review of the spreadsheet menu for the breakfast meal on 04/02/26 showed the following:-The regular diet included cold cereal, bacon strips, scrambled egg, fresh grapes, and French toast stick;-The finger foods menu did not include any food items for breakfast.-The fortified food list did not include any fortified foods for breakfast. Observation on 04/02/26 at 8:40 A.M., showed the resident was in bed with a plate of food on an over-the-bed table in front of the resident. The plate contained one stick of French toast, two slices of bacon, and one scrambled egg. The silverware was still wrapped in a napkin and the resident was in bed with his/her eyes closed. Observation on 04/02/26 at 9:00 A.M., showed the resident lay in bed with his/her eyes closed. Staff removed the plate of food from the resident's room. The resident did not eat any of the food on his/her tray. Staff did not encourage the resident to eat prior to removing the plate of food from the resident's room. Review of the spreadsheet menu for the noon meal on 04/02/26 showed the following:-The regular diet menu included stuffed baked pork chop, glazed sweet potatoes, maple Dijon Brussel sprouts, wheat dinner roll, and apple crisp;-The finger foods menu consisted of either chicken tenders, French fries, sandwiches cut in four, hotdogs, or onion rings;-The fortified food was potato salad. Observation on 04/02/26 at 12:19 P.M. showed the resident was in bed. The resident's plate of food sat on an over-the-bed table in front of the resident. The plate contained a pork chop, broccoli, and mashed sweet potatoes. The resident had a cup of fruit and was drinking the liquid of the fruit. Staff had not assisted the resident with set up of the meal. Observation on 04/02/26 at 1:00 P.M., showed the resident was awake in bed. Staff removed the plate of uneaten food from the resident's room. The staff did not encourage the resident to eat or offer the resident anything different to eat prior to taking the food from the resident's room. During an interview on 04/02/26 at 2:00 P.M., the DM said the following:-Staff discussed the resident at the weight loss meeting on 03/13/26, but the RD did not issue any orders for finger foods;-He/She was not aware the resident had an order for finger foods on the POS;-It is the DM's responsibility to ensure new dietary orders are implemented;-The facility did not have any potato salad (on the fortified menu) for the noon meal;-He/She thought the mashed sweet potatoes may have been fortified. During an interview on 04/02/26 at 2:30 P.M., the ADON said the following:-Staff discussed the resident's weight loss at a meeting with the RD on 03/13/26;-Staff tried giving the resident finger food, but the resident wanted the main meal staff served to other residents, so staff stopped providing finger foods after a couple of days;-Staff did not notify the RD when they stopped providing the finger foods, and no other interventions were tried to address the resident's weight loss. During an interview on 04/02/26 at 2:36 P.M., the Director of Nursing DON) said the following:-Staff should monitor the resident and offer foods he/she would eat;-Staff should serve the finger foods diet as ordered. If the resident wanted the main meal, staff should serve it to the resident as well. During an interview on 04/02/26 at 3:32 P.M., the RD said the following:-The resident had a significant weight loss;-He/She, the DM, and the ADON discussed the resident's weight loss in a meeting (date unknown); -He/She recommended adding finger foods as the resident liked to wander at mealtimes;-He/She was not aware staff did not offer the resident finger foods;-He/She expected staff to offer finger foods and give the resident the main meal if the resident wanted it as well;-He/She expected staff to notify him/her if a resident refused the recommendations he/she made. 2. Review of Resident #2's face sheet showed the resident's diagnoses included dysphagia (difficulty swallowing, often caused by nerve/muscle issues, strokes, or esophageal obstructions.). Review of the resident's comprehensive MDS, dated [DATE], showed the following:-Able to make self-understood and understood others;-Severe cognitive impairment; -Required supervision with eating. Review of the resident's weights documented in the EMR for January 2026 showed the following:-On 01/13/26, the resident weighed 127 pounds;-On 01/14/26, the resident weighed 119 pounds;-On 01/15/26, the resident weighed 120 pounds;-On 01/16/26, the resident weighed 122 pounds;-On 01/22/26, the resident weighed 116 pounds;-On 01/29/26, the resident weighed 116.8 pounds;-On 01/31/26, the resident weighed 116.8 pound. Review of the resident's weights documented in the EMR, dated 2/5/26 at 2:05 P.M., showed the resident weighed 118.8 pounds. Review of the resident's RD progress note, dated 02/20/26 at 12:14 P.M., showed the resident is now on a fortified diet with a mechanical soft texture with chopped meats. He/She was on a regular diet with a mechanical soft/chopped meats texture before the review today. Intakes are documented at 51-100%. Able to feed self. Current weight is 118.8 pounds, which reflects a 6.4% weight loss in 30 days. RD recommended fortified diet due to weight loss, and the diet order was changed to fortified foods today. Review of the POS for February showed an order for soft/chopped meat and fortified foods with an order date of 02/20/26. Review of the resident's care plan for malnutrition, dated 02/22/26, showed the following:-Focus: Malnutrition: The resident is at risk for malnutrition due to dysphagia and unplanned significant weight loss;-Goal: Will maintain adequate nutritional status as evidenced by stable weight.-Interventions: Allow adequate time for meal consumption. Assist with meals/fluids as needed. Obtain weights as ordered and report significant changes to physician and responsible party. Provide diet, supplements, and vitamins/minerals per physician order. Provide nutritional/dietary supplements as ordered.-Refer to dietary and RD as needed. Review of the resident's weight in the EMR, dated 3/5/26 at 4:32 P.M., showed the resident weighed 112 pounds. Review of the RD progress note, dated 03/27/26 at 3:06 P.M., showed the resident received a fortified diet with a mechanical soft texture with chopped meats. Intakes were documented at 51-100%. Able to feed self after set up. Current weight was 112 pounds, which reflected a 5.7% weight loss in 30 days and a 10.8% weight loss in 90 days. The RD's recommendations included high-calorie, high-protein nutritional shakes twice a day for extra calories to help maintain current weight. Review of the resident's POS, dated March 2026, showed an order for nutritional shakes two times a day for weight loss with an order date of 03/30/26. Observation on 04/02/26 at 8:40 A.M., showed the following:-The resident was in bed;-The staff sat a meal tray, containing a French toast stick, chopped bacon and a small serving of scrambled eggs, in front of the resident;-Staff did not serve the resident a nutritional shake;-The resident's diet card on the tray did not indicate the resident was to receive a nutritional shake;-The resident ate only a few bites of the food;-Staff removed the meal tray from the room. Staff did not encourage the resident to eat more food or offer the resident different food when the resident did not eat his/her meal. Observation on 04/02/26 at 12:28 P.M. showed the following:-Staff served the resident a tray containing chopped pork chop, mashed sweet potatoes, and broccoli;-Staff did not serve the resident a nutritional shake;-There was no staff in the dining room to assist the resident, and the resident did not eat any of the food. During an interview on 04/02/26 at 2:00 P.M., the DM said the following:-Dietary staff served the nutritional shakes on the residents' meal trays;-The resident had an order for nutritional shakes, but the nutritional shakes were not listed on the resident's meal card;-The DM is responsible for reviewing the RD recommendations and following through with them;-The DM missed the RD recommendations for Resident #1 and #2. During an interview on 04/02/26 at 2:10 P.M., Dietary Aide C said the following:-The resident did not receive nutritional shakes;-He/She was not aware that Resident #1 was to receive the nutritional shake;-He/She did not give the resident a nutritional shake for breakfast or lunch today. During an interview on 04/02/26 at 2:36 P.M., the DON said she expected staff to follow physician orders and administer the diet and nutritional supplements as ordered. During an interview on 04/02/26 at 3:32 P.M., the RD said the following:-Dietary staff served the nutritional shakes and had the order for the shakes on the meal card;-She expected dietary staff to be aware of who received the nutritional shakes. During an interview on 04/02/26 at 4:00 P.M., the Administrator said he expected staff to follow physician orders and RD recommendations.

Based on interview and record review, the facility failed to ensure three residents (Resident #1, #4 and #7) of 10 sampled residents received appropriate notice of discharge. The facility census was 126. Review of the undated facility policy for Transfer or Discharge showed the following:-Once admitted to the facility, residents have the right to remain in the facility. Transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record;-When the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider: the basis of the transfer or discharge; the appropriate notice was provided to the resident and /or legal representative; the date and time of the transfer or discharge, the new location of the resident, the mode of transportation, a summary of the resident's overall medical, physical and mental condition, disposition of personal effects, disposition of medications. The basis for the transfer or discharge;-Transfer or Discharge Appeals: residents have the right to appeal a transfer or discharge through the state agency that handles appeals;-Upon notice of transfer or discharge, the resident is provided with a statement of his or her right to appeal the transfer or discharge including the name, address, email and telephone number of the entity which receives such request, information about how to obtain, complete and submit an appeal form, how to get assistance completing the appeal process and the facility bed-hold policy. Review of Residents Rights provided from the Ombudsman program showed the following:-Rights during discharge/transfer: the resident has the right to appeal.-The resident has the right to receive a 30-day written notice of discharge that includes the reason, the effective date, the location of the accepting facility, the appeal rights and process for filing an appeal, and the name and contact information for the long-term care ombudsman. 1. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 01/27/26 showed the following:-Able to understand others and able to make self-understood;-Cognitively intact;-Dependent upon staff for Activities of Daily Living (ADL's). Review of the resident's progress notes dated 02/10/26 at 2:37 P.M. showed the following:-LATE ENTRY- Power of Attorney (POA) and resident offered placement in a semi-private room on long term care (LTC). Concerns r/t the size and set up of the semi-privaterooms on LTC were expressed due to residents' size and preferences;-Option to transfer to a facility with rooms to better accommodate resident's preferences offered;-POA and resident accepted. All questions answered at that time. Social Worker (S) notified of residents wish to transfer. Review of the resident's progress note dated 02/10/26 at 6:44 P.M. signed by SW A showed she obtained consent for Skilled Nursing Facility (SNF)-to-SNF transfer. Referral sent to facility per family request. Will wait for decision and update family. Review of the resident's progress notes dated 02/11/26 at 2:18 P.M. showed resident discharging to another facility, all belongings packed up and given to driver for new facility. During an interview on 02/26/26 at 10:20 A.M. the Family Member (FM) F said the following:-He/She received a telephone call from SW A on 02/09/26 telling him/her the resident needed to be out of the facility by 02/13/26 due to a reconstruction of the rehab unit and the need to have just rehab residents on the unit;-Neither he/she or the resident were offered a different room or a choice of facilities;-He/She was told that the facility where the resident was discharged had a bed available;-He/She did not know what to do, did not have a chance to see the new facility, and was not aware of any resident rights;-The resident moved to the new facility on 02/11/26.-Neither he/she or the resident received a written notice of discharge. 2. Review of Resident #4's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's quarterly MDS dated [DATE] showed the following:-The resident can make self-understood and able to understand others;-Cognition intact;-Dependent upon staff for ADL's. Review of the resident's progress notes dated 02/10/26 at 7:16 P.M. signed by SW A showed the following:-LATE ENTRY SW obtained consent for SNF-to-SNF transfer from resident;- Referral sent to a facility per family request. SW will wait for decision and update family. Review of the resident's progress notes dated 02/11/26 at 9:54 P.M. showed the resident discharged to a sister facility. During an interview on 02/26/26 at 11:00 A.M. the resident's FM G said the following:-He/She received a telephone call from the facility saying the resident had given his/her permission to be moved to a different facility and needed to be out in two days;-The facility told him/her they were reconfiguring the facility so the room that the resident was in was just for rehab residents;-They were not given the opportunity to pack up the resident's belongings, all his/her things were shoved in boxes.-The resident did not receive a written notice of discharge. During an interview on 02/26/26 at 12:15 P.M. FM H said the following:-He/She received a telephone call on 02/10/26 telling him/her the resident had consented to move to another facility because the facility was turning the resident's room back to a rehab room for potential rehab residents;-He/She talked with the resident who did give permission to be moved, but the resident felt like he/she did not have a choice;-No one informed them of their rights to appeal the move;-The resident was having a difficult time at the new facility due to the equipment that was required to take care of him/her;-There was no communication from the facility to the new facility regarding the resident's medication and his/her pain management;-The resident did not receive a written notice of discharge 3. Review of Resident #7's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's comprehensive MDS dated [DATE] showed the following:-Able to make self-understood and able to understand others;-Cognitively impaired;-Dependent upon staff for ADL's. Review of the resident's progress notes dated 02/12/26 at 2:32 P.M. showed the resident discharged to another facility. Review of the resident's progress notes dated 02/12/26 at 2:33 P.M. showed the resident's power of attorney (POA) called and informed of the resident's discharge. During an interview on 02/18/26 at 2:07 P.M. FM I (the resident 's POA) and J said the following:-They received a telephone call on 02/10/26 telling them that the resident had be discharged in two days to a facility they had never heard of;-They called another facility that they knew of, and asked them if they had a bed available for the resident;-The resident moved on 02/12/26, as they did not feel they had a choice;-They were told that they had to make room for an emergency admission;-They nor the resident received a written discharge notice. During an interview on 02/13/26 at 11:00 A.M. SW A and SW B said the following:-They were told around 02/9/26 by Employee A (who they understood was the administrator), they needed to move residents to free up rooms for actual rehab residents. They were to either find a bed on the long-term care side of the facility or discharge the residents;-All the LTC beds were taken, so they had to begin discharging residents to other facilities;-They thought since the facility was transferring resident to another skilled facility, they did not have to issue discharge letters;-They did not issue any 30 day or emergency discharge notices; -The local Ombudsman came to the facility on [DATE] and informed them they had to provide residents a discharge notice, and inform them of their rights;-The Ombudsman went room to room and provided residents a copy of their rights. During an interview on 02/17/26 at 3:00 P.M. Employee A (identified by SW A as the administrator) said the following:-He came to the facility as the administrator a couple of weeks ago, but his temporary license has not been approved;-He needed to move residents for better acuity for staffing purposes, to keep the rehab residents together and the long term care residents together;-They received permission for the residents to be discharged , so they did not need to issue a written discharge notice. 2741164

Based on observation, interview and record review, the facility failed to ensure residents had the right to receive written notice of a room change and ensure residents had the right to share a room with his/her roommate of choice for four residents (Resident #2, Resident #3, Resident #5 and Resident #8) in a sample of 10 residents. The facility initiated room changes for all four residents without providing the resident, family and/or resident representative an explanation in writing of why the move was required. The facility failed to ensure the residents were provided the opportunity to see the new location, meet the new roommate and ask questions about the move. The facility census was 126. Review of the undated facility policy for Room Change/Roommate Assignment showed the following:-Changes in room or roommate assignment are made when the facility deems it necessary or when the resident requests the change;-Resident room or roommate assignment may change if the facility deems it necessary. Resident preferences are considered when such changes are proposed;-Residents have the right to share a room with their roommate of choice, including a spouse, domestic partner, or friend;-Prior to changing a room or roommate assignment all parties involved in the change/assignment are given a verbal or written notice of such change;-Written notice of a roommate change includes why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate;-Residents have the right to refuse to move to another room in the facility unless necessary for health or safety reasons;-If a resident exercises his or her right to refuse a room change, this will not affect the resident's eligibility or entitlement to Medicare or Medicaid benefits. 1. Review of Resident #3's face sheet showed the resident admitted to the facility on [DATE] to a private room. Review of the resident's quarterly MDS dated [DATE] showed the following:-Able to make self-understood and able to understand others;-BIMS (Brief Interview for Mental Status, a standardized, tool with a 0-15 point scale used to screen for cognitive impairment) of 15 (cognitively intact);-Dependent upon staff for Activities of Daily Living (ADL's);-Diagnoses of traumatic spinal cord dysfunction, quadriplegia (paralysis of all four extremities), anxiety and depression. Review of the resident's progress note dated 02/05/26 at 2:14 P.M., signed by Assistant Director of Nursing (ADON) C showed the following:-Social Worker (SW) and this ADON called resident's Power of Attorney (POA) regarding room move. POA was agreeable and understood room move. Resident will be moved from a private room to a shared room. POA questions were all answered at this time and new room number provided. Resident was then made aware by this ADON and SW that he/she will be moving to a shared room tomorrow (semiprivate). Resident had no questions at this time. During an interview on 02/13/26 at 10:45 A.M. the resident said the following:-He/She was very upset over the room move from his/her private room that he/she had for many years to a room that was shared with someone;-He/She was not given an option, the SW and ADON came into his/her room and told him/her that he/she was moving the next day;-Staff came in the next morning and moved him/her to this room;-His/Her family had to take a lot of his/her decorations and belongings home due to no room to place items;-Staff just shoved his/her stuff into boxes and they had not offered to put them away. Observation on 02/13/26 at 10:45 A.M., showed the resident was visibly upset and angry as he/she was talking about the room move and the way staff moved his/her belongings. During an interview on 02/18/26 at 10:00 A.M. Family Member (FM) C said the following:-He/She was POA for Resident #3;-He/She received an email from SW A the day before staff moved the resident that Resident #3 was going to be moved to make room for potential isolation patients and staff knew the resident was going to be upset;-The resident has been in the private room for over two years;-There was no choice of rooms given and no one told him/her or the resident they could refuse the room move. Staff came in and shoved the resident's belongings into boxes and drawers;-The resident was afraid if he/she said anything then he/she would be discharged from the facility;-He/She was also afraid of saying anything in fear of the resident being discharged . 2. Review of Resident #2's face sheet showed the resident admitted to the facility on [DATE] to a private room. Review of the resident's progress note dated 2/9/26 at 11:03 A.M., signed by SW A showed the following:- SW A called and spoke with FM A and FM B about a room change. Consent obtained. (The note did not show what the consent was for) SW will continue to remain involved and assist as needed. Review of the resident's quarterly MDS dated [DATE] showed the following:-Able to make self-understood and able to understand others;-BIMs of 7 (cognitive impairment);-Required assistance of staff for ADL's;-Diagnoses of heart disease, high blood pressure, diabetes and stroke. During an interview on 02/17/26 at 12:40 P.M. FM A and FM B said the following:-They received a phone call on 02/09/26 from SW A telling then the resident would be moved to another room due to the need for a room to quarantine potential residents from the hospital. The room move had been approved by the Administrator;-SW A told them they had three days to move the resident to the other room;-They were not offered any other rooms and were not introduced to the new roommate until the resident moved into the semi-private room. 3. Review of Resident #5's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's quarterly MDS dated [DATE] showed the following:-Able make self-understood and able to understand others.-BIMS of 8 (cognitive impairment);-Requires assistance with ADL's;-Diagnoses of heart failure, hypertension, heart disease, fractured hip and dementia. Review of the resident's progress note dated 02/09/26 at 10:09 A.M., signed by SW A showed she called and spoke with resident's family member and obtained verbal consent; (the note did not show what the verbal consent was for); SW will continue to remain involved and assist as needed. Review of the resident's progress note dated 02/10/26 at 11:51 A.M., signed by SW A showed LATE ENTRY SW obtained consent for resident by spouse to move from rehab hall to long term care room that became available. During an interview on 2/19/25 at 2:20 P.M. FM D said the following:-He/She received a phone call from SW A they were moving the resident to a different room. The facility had a new administrator who was changing things and moving residents. He/She asked the SW if this could wait awhile and was told no;-He/She spoke staff who identified himself as the Administrator about moving the resident, and was told the room the resident was in, and had been in since admission, was meant for rehab. The resident was moving to the long term care section of the facility today and the resident was not the only resident who had to move;-The resident was not given the choice of a room or the roommate;-Staff moved the resident the next day. 4. Review of Resident #8's face sheet showed the resident admitted to the facility on [DATE] to a private room with the diagnoses of Hereditary motor and sensory neuropathy (genetic leading to muscle weakness, atrophy, and sensory loss in the feet, legs, and hands), high blood pressure, depression. Review of the resident's quarterly MDS dated [DATE] showed the following:-Able to make self-understood and able to understand others;-BIMS of 13 - able to make decisions;-Dependent upon staff for ADL's. During an interview on 02/20/25 at 12:30 P.M. FM E said the following:-He/She received a phone call from a person who identified himself as the Administrator. The Administrator said they were moving the resident to another room due to needing an isolation room for potential COVID patients (a highly contagious respiratory illness caused by the SARS-CoV-2 virus);-He/She spoke with SW A and said this was an infringement on the resident's rights. SW A said they had to move the resident, and the resident's new roommate did not want the camera in the room;-The resident was not offered a choice of rooms to be moved to, nor was the resident introduced to his/her new roommate. During an interview on 02/13/26 at 11:30 A.M. SW A said the following:-She was told by the staff member who identified himself as the Administrator, that residents needed to be moved off the rehab unit and free up those rooms for potential rehab residents. She was to find the residents a room on the long term care side of the facility or to discharge the residents;-She was not aware residents had a choice to move or not, or that they had a choice of roommates;-She was just doing what he/she was told to do;-The Ombudsman was in the facility on 02/12/26 and informed them of what residents' rights were regarding room moves. During an interview on 02/17/26 at 3:00 P.M. the Administrator (identified by SW A as administrator) said the following:-He came to the facility as the Administrator a couple of weeks ago, but his temporary license has not been approved;-He needed to move residents for better acuity for staffing purposes, to keep the rehab residents together and the long term care residents together;-They received permission for the residents to move. During an interview on 02/17/26 at 3:10 P.M. Administrator A said the following:-The facility was trying to streamline things making the acuity more equal among the staff;-He was not aware residents had to right to decline a room move;-He would expect staff to give the resident a choice when able if a room move needed to occur. 2741620

Based on observation, interview and record review, the facility failed to ensure staff transferred one dependent resident (Resident #10) of ten sampled residents, with a mechanical lift in a safe manner. Instead of lowering the resident slowly to the bed, staff chose to use the lift's emergency release button and dropped the resident quickly to the bed, startling the resident. The facility census was 126.Review of the undated facility policy for Using a Mechanical Lifting Machine showed the following:-The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instruction;-At least two nursing assistants are needed to safely move a resident with a mechanical lift;-Select a sling that is appropriate for the resident's size and the task;-Make sure the battery is charged;-Make sure the lift is stable and locked;-Place the sling under the resident and lower the sling bar closer to the resident;-Attach the sling straps to the sling bar;-Lift the resident two inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution;-Slowly lift the resident. Only lift as high as necessary to complete the transfer;-Gently support the resident as he or she is moved;-When the transfer destination is reached, slowly lower the resident to the receiving surface;-Once the resident's weight is released, stop the lowering and ensure that the sling bar does not hit the resident;-Detach the sling from the lift;-Carefully remove the sling from under the resident. Be mindful of the resident's position and balance, and skin. Review of Resident #10's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a chronic, progressive neurodegenerative disorder that impairs movement and motor control), Alzheimer's disease, dementia and anxiety. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 12/29/25 showed the following:-Usually able to understand others;-Severe cognitive impairment;-Dependent upon staff for transfers. Review of the ring video camera in the resident's room dated 02/12/26 at 1:07 P.M. showed the following:-Certified Nurse Aide (CNA) D and CNA E placed the resident is a mechanical lift sling to transfer him/her from the wheelchair to the bed;-CNA D worked the lift controls and moved the resident in the lift over the bed. CNA D had his/her hands on the resident in the sling during the process;-The resident was over the bed and suspended in the lift when CNA D said, Drop him/her? while he/she had his/her hand at the base of the lift on the red emergency release button;-He/She pushed the emergency release button, and the resident quickly dropped onto the bed. The resident said Oh! At the time the resident dropped to the mattress the bed moved;-The resident said, You said drop it, CNA D said, No you said drop it, the resident then said, why would I say drop it?. During an interview on 02/13/26 at 12:05 P.M. Family Member (FM) K said the following:-He/She showed the video to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) yesterday;-He/She told the DON the way staff lowered the resident to the bed was unacceptable and uncalled for. During an interview on 02/13/26 at 12:30 P.M. the DON said the following:-Resident #10's FM came in yesterday and showed she and the ADON the video of CNA D and CNA E transferring the resident from the wheelchair to the bed;-There was no reason for staff to have used the emergency release button. The mechanical lift battery was charged and there had been no report of the lift malfunctioning. During interview on 02/17/26 at 10:42 A.M. CNA E said the following:-He/She transferred the resident using the mechanical lift one day last week;-CNA D was manning the controls, he/she was guiding the resident;-He/She never head CNA D say, drop him/her. During an interview on 02/17/26 at 1:18 P.M. CNA D said the following:-He/She worked last week and took care of the resident;-He/She used the emergency release button to lower the resident because that lift lowered residents very slow, and the emergency release button lowered them quicker;-He/She had never been told not to use the emergency release button for a transfer;-He/She did not say drop him/her;-The resident said whoa when transferred to the bed. During an interview on 02/17/26 at 3:00 P.M. the ADON said the following:-CNA D admitted using the emergency release button on the lift to lower the resident on the bed;-CNA D has been trained that the emergency release button should only be used in an emergency. During an interview won 01/27/26 at 3:30 Administer A said the following:-The emergency release button should only be used in a real emergency when the resident needed to get out of the lift quickly;-He would expect staff be properly trained on how to use a mechanical lift. 272475

Based on interview and record review, the facility failed to ensure staff treated two sampled residents (Resident #1 and Resident #2) who had a diagnosis of Alzheimer's and dementia in a sample of 11 residents with dignity and respect. The facility census was 115.On 11/25/25 at 5:00 P.M. the Administrator was notified of the past non-compliance which occurred on 11/11/25 and 11/19/25. On 11/20/25 Family Member A provided the facility with a copy of the video from the ring camera in Resident #1's room, which showed Certified Nurse Aide (CNA A) providing care to the resident in a manner which violated the resident's rights to be treated with dignity and respect. CNA A was an agency aide, and the facility notified the agency on 11/20/25 the aide was not allowed to return to the facility. On 11/25/25 Family Member B provided the facility a video from the ring camera in Resident #2's room which showed CNA B providing care to the resident in a manner which violated the resident's rights to be treated with dignity and respect. CNA B was an agency aide, and the facility notified the agency CNA B was not allowed to return to the facility. The facility completed in-services of all staff on Resident Rights and Dementia on 11/20/25. The deficiency was corrected on 11/20/25. Review of the undated facility policy for Resident Rights showed employees shall treat all residents with kindness, respect, and dignity.Review of Resident 1's face sheet showed the was admitted to the facility on [DATE] resident with the diagnosis of dementia. Review of the resident's care plan for cognitive impairment with a revision date of 5/9/25 showed the following:- The resident exhibits cognitive loss related to dementia;-The resident will participate in facility activities and activities of daily living care as able;-Anticipate needs and meet them promptly, explain all care before providing to reduce resident tension and promote a comfortable experience. Review of the residents care plan for communication with a revision date of 5/9/25 showed the following:-The resident has impaired communication related to Alzheimer's disease;-Explain all cares before beginning, hearing impairment, increase volume of voice as needed; oriented to self only; use simple direct communication such as yes and not questions as needed. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 8/18/25 showed the following:-Usually able to make self-understood and usually understands others;-Unable to make decisions;-Has difficulty focusing attention and is easily distracted with no behaviors;-Dependent upon staff for Activities of Daily Living (ADL's) and transfers; -Incontinent of bowel and bladder. During an interview on 11/22/25 at 9:30 A.M. Family Member A said the following:-He/She has a camera in the resident's room;-He/She has supplied the facility with video footage of staff being rude, disrespectful and talking in a scolding voice toward the resident;-In September he/she sent video footage to the Administrator, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) of several staff members not talking with the resident while they were providing him/her care, just taking the resident's clothes off. The staff act like the resident knows and understands what they want the resident to do. The resident does not understand what staff want him/her to do, so he/she will show resistance when staff take his/her clothes off or push on him/her to roll over. Staff think the resident is defying them, but he/she does not understand. The resident deserves to be treated with dignity and respect. Review of the resident's ring camera video footage from 11/19/25 starting at 9:31 P.M. and ending at 9:45 P.M. provided by Family Member A showed the following:-Certified Nurse Aide (CNA) A and another CNA used a mechanical lift and transferred the resident to the bed; -Without greeting the resident or explaining to the resident what he/she was going to do, CNA A removed the resident's exposing the resident's legs and brief, then goes out of camera view with a towel and after several seconds returns to the bedside with a wet towel and tells the resident to roll towards the window. The resident looks at the staff member and does not roll. CNA A then pushes the resident by his/her leg to the left side. When the resident did not roll, the staff member released the resident's leg, and the resident relaxed. CNA A tells the resident, Do you understand what I am saying to you, do you understand what I am saying to you, I need for you to do what I am asking you to do. The resident looked at the staff member and did not reply; -CNA A leaves the resident laying on his/her back with his/her brief unfastened and the resident's perineal area exposed goes out of camera view and says, He/She doesn't do anything that I ask him/her to do; returns to the bedside and tells the resident I need you to do what I have asked you to do, I need to change your brief; -CNA A takes a wet towel and wipes the front of the resident's perineal area, then leaves the resident exposed for about 30 seconds. CNA A returns with a basin of water and a washcloth. CNA A removes the resident's brief, throws it on the floor and tells the resident, I will get you to do what I have asked you to do and proceeds to open the resident's knees and says, I need for you to work with me, not against me. CNA A goes to the resident's right side and begins to push the resident onto his/her left side by pushing on the residents hip, the resident reaches out with his/her hand and touches CNA A's arm. CNA A pulls the mechanical lift sling out from under the resident causing the resident to wince and then attempts to get the resident to roll once again to the right side. The resident reaches out for the aide with his/her hands. CNA A responds, Don't want to roll, then I will do what I need to do and proceeds to remove the resident's shirt. The resident pulls his/her arm back and CNA A says The more you fight, the longer this will take. I am trying to make you comfortable, so you can go to bed, do you understand me? Are you going to do what I am asking you to do, or do I need to get an extra set of hands in here? and grabs the resident's hands as the resident is trying to remove his/her hand from CNA A's hand. CNA A tells the resident You cannot fight me. Do I need to call the doctor and get you a sedative too, you have not fought me before, not tonight, I will not be struck on. Do you understand me? I am trying to clean you up; you are not going to swing on me. I can clean you up or I can ask them to send you out, which one do you want? A voice is then heard saying the resident's family member called and hospice gives the resident a bath. CNA A looked at the camera and said, Oh, I didn't know and proceeds to dress the resident, cover the resident up and then leaves the room. During an interview on 11/25/25 at 4:30 P.M. the Assistant Director of Nursing said the following:-Residents should be treated with dignity and respect, regardless of their cognition;-CNA A did not treat the resident with dignity, staff should take their time with the residents and explain what they are going to do before they provide care. During an interview on 11/25/25 at 5:00 P.M. the Director of Nursing said the following:-The video showed CNA A's interaction with Resident #1 was very inappropriate;-Staff need to treat residents with dignity and respect, tell residents what they plan to do, not to leave a resident exposed and not talk to them like a child. Review of Resident #2's face sheet showed diagnoses of Parkinson's disease (a progressive movement disorder of the nervous system. It causes nerve cells (neurons) in parts of the brain to weaken, become damaged, and die, leading to symptoms that include problems with movement, tremor, stiffness, and impaired balance), dementia, anxiety, depression and cognitive communication deficit (occurs when someone has trouble with one or more cognitive processes involved in communication). Review of the resident's comprehensive MDS dated [DATE] showed the following:-Usually able to make self-understood and usually able to understand others;-Unable to make decisions;-No behaviors;-Dependent upon staff for all ADL's;-Incontinent of bowel and bladder. Review of the resident's care plan for Trauma-Informed Care with a revision date of 10/13/25 showed the following:-The resident is at risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual well-being related to losing his/her significant other;-Allow time to make choices in care and encourage active decision making, approach in a calm, reassuring manner, encourage resident to verbalize feelings. Review of the resident's care plan for Cognitive Impairment with a revision date of 10/13/25 showed the following:-The resident exhibits cognitive loss related to Alzheimer's disease and other dementia, decreased ability to understand others, impaired decision-making skills, impulsivity, long term memory deficit, short term memory deficit;-Anticipate need; explain all care before providing to reduce resident tension and promote a comfortable experience. During an interview on 11/25/25 at 2:00 P.M. Family Member B said the following:-He/She was very concerned on how a staff member had treated Resident #2 on 11/11/25;-The staff member did not say anything to the resident, just walked in and started pushing on the resident providing care without explaining to the resident what the staff member was doing. The resident got very upset and began using foul language at the staff member, which was not like the resident. Review of the ring camera footage provided by Family Member B dated 11/11/25 from 6:04 A.M. to 6:13 A.M. showed the following:-CNA B entered the resident's room, the resident's was in the lowest position with a thick mat beside the bed; the resident was on the edge of the bed. CNA B turned on the light and without speaking to the resident, then starts to push the resident with his/her hands. The resident wakes up and says, What are you doing?. CNA B continues to push the resident's body towards the middle of the bed. I am and said, I am trying to stop you from rolling onto the floor then pushes the thick mat away from the bed and begins to raise the bed. As CNA B raised the bed, the resident says, I am going to throw a fit in a minute. CNA B replied, You can throw a fit if you want to and continued to raise the bed. The resident replied, How about me and you go outside CNA B replied, I am not going outside unless I feel like. The resident said, You will go outside if I tell you too. CNA B replied, No I am not and you ain't my daddy;-CNA B then walked around the resident's bed and without explaining what he/she was going to do, began to remove the blankets covering the resident. The resident asked CNA B not to take off the blankets and CNA B jerked the blankets off exposing the resident. The resident wore a shirt and a brief. The resident said, Damn it, give me back my covers. CNA B replied, Oh aren't you getting hostile. The resident replied, Damn right I am and tried to hit the aides' arm. CNA B grabbed the resident's wrist, balled up his/her fist and tapped his/her fist against the resident's fist and said, Keep your hands to yourself. CNA B then removed the resident's brief;-Resident #2 asked the aide why he/she was getting so hostile. CNA B replied he/she was not getting hostile, and the resident must have gotten up on the wrong side of the bed;-CNA B asked the resident to roll onto his/her right side, the resident said, No, and if you are going to push me, I am going to knock you down. CNA B replied,, Are you? and pushed the resident over onto his/her right side, laughing and said, I am not afraid of you. CNA B then began to pull on the pad under the resident. The resident balled up his/her fist, CNA B balled up his/her fists, taps the resident's fist and says, You know, someone is going to get hurt. The resident then loudly told CNA B to get out of his/her room. CNA B said No, I am going to change you and asks the resident to roll over again. The resident said No and began to swing at the aide. CNA B tapped the resident's fist with his/her fist again, then grabbed the pad under the resident. The resident yelled, Get out of my house! and grabbed at the aide's shirt. CNA B yelled, Why are you grabbing for me! and rolled the resident onto his/her side. The resident yelled out loudly Help! CNA B continued to provide peri-care;- At 6:11 A.M. the resident was on his/her back with CNA B on his/her right side of the bed, pulling the blankets back onto the resident. CNA B said, Don't you think this is pointless and who is going to help you? then laughed at the resident. The resident told CNA B to get out of his/her house. CNA B laughed at the resident again and with a gloved hand, tapped his/her fingers to the resident's lips and walked away. During an interview on 12/2/25 10:15 A.M. the Director of Nursing said the following:-After viewing the video's, CNA B acted very inappropriately towards the resident;-CNA B should have explained to the resident what he/she was doing before pushing on him/her and when the resident became upset, the aide should have removed him/herself and notified the nurse;-Staff need to treat residents with dignity and respect and not argue with the residents. During an interview on 12/2/25 at 10:15 A.M. the Administrator said the following:-It was obvious from the videos staff were not treating the residents with dignity and respect; -All staff are expected to treat all residents with dignity and respect, and to take their time with the residents. 2676560 26743972649705

Based on observation, interview and record review, the facility failed to follow current infection control standards for two residents (Resident #1 and Resident #2), in a review of eleven sampled residents when staff failed to perform proper hand hygiene and change gloves to prevent infection during personal care for Resident #1 and Resident #2. The facility census was 115. Review of the undated facility policy for Handwashing/Hand Hygiene showed the following:-This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections:-All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections;-All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors;-Indications for Hand Hygiene: immediately before touching a resident, after contact with blood, body fluids or contaminated services, after touching a resident, after touching the resident's environment. Review of Resident 1's face sheet showed the resident was admitted on [DATE] with a diagnosis of dementia. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 8/18/25 showed the following:-Usually able to make self-understood and usually understands others;-Unable to make decisions;-Has difficulty focusing attention and is easily distracted with no behaviors;-Dependent upon staff for Activities of Daily Living (ADL's) and transfers; -Incontinent of bowel and bladder. There were no care plans for incontinent care or infection control. Observation on 11/25/25 at 1:19 P.M. showed the following:-Certified Nurse Aide (CNA) E and CNA F entered the resident's room and without performing hand hygiene, took gloves from their pockets and put on their hands, then using a mechanical lift transferred the resident from the wheelchair to the bed;-CNA E removed the resident's pants and CNA G removed the resident's urine soaked brief;-Wearing the same gloves, CNA G opened the nightstand drawer and removed a package of briefs, placed them on the nightstand then took a couple of premoistened wipes and performed peri care for the resident then tossed the soiled wipes into a trash can;-Without removing the soiled gloves and performing hand hygiene, CNA G took a clean brief out of a package of briefs on the nightstand and put it on the resident;-Wearing soiled gloves CNA E and CNA G pulled the sheet and blanket up and covered the resident;-Wearing the same soiled gloves, CNA G then picked up the controls for the bed, lowered the bed, placed the call light on the bed, took his/her gloves off, and with out washing his/her hands removed the mechanical lift from the resident's room. During an interview on 11/25/25 at 1:25 P.M. CNA G said hands should be washed before resident care, apply gloves and then wash your hands when finished with resident care. 2. Review of Resident #2's face sheet showed the resident was admitted to the facility on [DATE] with diagnosis of Parkinson's disease (a progressive movement disorder of the nervous system. It causes nerve cells (neurons) in parts of the brain to weaken, become damaged, and die, leading to symptoms that include problems with movement, tremor, stiffness, and impaired balance). Review of the resident's comprehensive MDS dated [DATE] showed the following:-Usually able to make self-understood and usually able to understand others;-Unable to make decisions;-No behaviors;-Dependent upon staff for all ADL's;-Incontinent of bowel and bladder. Review of the ring camera video footage supplied by a family member dated 11/20/25 at 3:36 P.M. showed:-CNA G entered the resident's room with a pair of gloves on, went to the resident's bed and began to raise the bed up from the low position. While raising the bed up, took a cell phone that was on the nightstand and began to, what appeared to be texting then sat the phone back down on the nightstand;-CNA G with the same gloves on, then took a package of disposable wipes and a clean brief to the residents bed, removed the resident covers and pants. He/she then removed the residents brief which appeared to be urine soaked. CNA F then enters the resident's room with a pair of gloves on and a mechanical lift. CNA F took the soiled brief off the bed and tossed into a trashcan, then took the controls of the mechanical lift and raised the lift up, while with the same gloves on, CNA G pulled up the resident's pants, picked up the cell phone again, looked a the phone then placed the phone down on the night stand, then pulled a wheelchair up to a chair in the room, sat down in the chair and held onto the handles of the wheelchair;-With the same gloves on CNA F transferred the resident from the bed to the wheelchair using the mechanical lift, lowered the resident into the chair, and removed the mechanical lift from the room;-Without removing his/her soiled gloves, CNA G took the resident out of the room. During an interview on 11/25/25 at 4:25 P.M. CNA G said gloves should be changed and hands washed when care was completed and before touching anything else. During an interview on 11/25/25 at 5:00 P.M. the Director of Nursing said the following:-Staff should wash their hands before providing care and change their gloves and wash hands between clean and dirty tasks;-Staff should not wear the same gloves after providing peri care and touch items in the resident's room;-Staff should remove their gloves, perform hand hygiene and apply a new pair of gloves after peri care. 26765602674397

Based on interview and record review, the facility failed to ensure the safety of two residents (Resident #1 and Resident #2), in a review of 11 sampled residents, who were dependent on staff for transfers and at risk for falls, when staff did not follow the facility policy and use two staff members when transferring the resident with a mechanical lift. The facility census was 115.Review of the facility policy for Mechanical Lift with a revision date of 7/2017 showed the following:-The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device;-At least two nursing assistants are needed to safely move a resident with a mechanical lift. 1.Review of Resident 1's face sheet showed the resident was admitted to the facility on [DATE] had diagnosis of dementia. Review of the resident's care plan for transfers with a revision date of 5/9/25 showed the following:-The resident required use of a mechanical lift with two person assist related to decreased mobility;-Explain all procedures prior to and utilize two persons to perform the transfers. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 8/18/25 showed the following:-Usually able to make self-understood and usually understands others;-Unable to make decisions;-Has difficulty focusing attention and is easily distracted with no behaviors;-Dependent upon staff for Activities of Daily Living (ADL's) and transfers. Review of the resident's ring camera footage, supplied by the resident's family from the resident's room, dated 11/19/25 at 12:27 P.M. showed the following:-Certified Nurse Aide (CNA) E and CNA F entered the resident's room to transfer the resident from the wheelchair to the bed via mechanical lift. Both staff members hooked the sling located under the resident to the mechanical lift;-CNA E then walked out of camera view as CNA F lifted the resident out of and above his/her chair with the lift, then moved the lift and the resident to the bed without the support of another staff;-As CNA F attempted to position the mechanical lift base under the bed, he/she moved the lift with the resident suspended, back and forth causing the resident to swing while up in the lift; the resident was not supported by any staff member;-When CNA F positions the legs of the lift under the bed, he/she began to lower the resident to the bed. At this point CNA E comes to the opposite side of the bed and grabs onto the sling as CNA F lowers the resident. Observation on 11/25/25 at 1:19 P.M. showed the following:-CNA E and CNA F take Resident #1 to his/her room to lay him/her down;-CNA F pushed the mechanical lift to the resident in the wheelchair and hooked the sling to the lift; he/she then began to lift the resident up off the wheelchair, then moved the resident in the lift over to the bed;-CNA E did not assist with the transfer and was getting supplies to provide incontinent care and looking in dresser drawers. When CNA F had the resident over the bed CNA E went to the opposite side of the bed and held onto the sling as CNA F lowered the resident onto the bed. During an interview on 11/25/25 at 1:25 P.M. CNA E and CNA F said the following-There should be two people when using a mechanical lift, one should hold onto the resident and the other should work the controls of the lift;-CNA E said he/she did not hold onto the resident, and he/she should have while CNA F was moving the resident in the lift. Review of Resident #2's face sheet showed the resident was admitted to the facility on [DATE] and diagnoses of Parkinson's disease (a progressive movement disorder of the nervous system. It causes nerve cells (neurons) in parts of the brain to weaken, become damaged, and die, leading to symptoms that include problems with movement, tremor, stiffness, and impaired balance), dementia and cognitive communication deficit (occurs when someone has trouble with one or more cognitive processes involved in communication). Review of the resident's comprehensive MDS dated [DATE] showed the following:-Usually able to make self-understood and usually able to understand others;-Unable to make decisions;-No behaviors;-Dependent upon staff for all ADL's. Review of the resident's care plan for ADL's/Mobility with a revision date of 10/13/25 showed the following:-At risk for ADL/mobility decline and requires assistance related to chronic disease progression, cognitive impairment;-Assist with transfers and bed mobility. Review of the resident's ring camera footage from the resident's room supplied by the resident's family member dated 11/20/25 at 3:36 P.M. showed the following:-CNA F and CNA G were in the resident's room and provided the resident with incontinent care while the resident was in bed;-CNA G positioned a mechanical lift sling under the resident;-CNA F got the mechanical lift and pushed it under the resident's bed; CNA F and CNA G secured the sling to the mechanical lift;-CNA G got a wheelchair and then sat in a chair with the wheelchair in front of him/her while CNA F attempted to pull the mechanical lift out from under the bed, the lift legs were caught under the bed. CNA F pulled back on the lift several times, causing the resident to swing while he/she was up off the bed. The resident was off the bed approximately one foot;-CNA F moved the mechanical lift away from the bed, while CNA G sat in the chair and did not participate in moving the lift and resident to the wheelchair. When CNA F was close to the wheelchair, CNA G got up and moved the wheelchair, so the resident was hovering over the wheelchair. As CNA F lowered the resident, CNA G pulled back on the sling and guided the resident down into the wheelchair. During an interview on 11/25/25 at 4:25 P.M. CNA G said the following-There should always be two people when transferring a resident using a mechanical lift, one person works the controls of the lift, and the other person guides the resident;-He/She did not remember the transfer of 11/20/25 with Resident #2. During an interview on 11/25/25 at 5:00 P.M. the Director of Nursing said the following:-Two staff are needed when using a mechanical lift, one person should be guiding the resident while the other staff is working the controls and pushing the machine;-She would expect that two staff members be used, one in guiding the resident while in the sling and the other working the controls of the mechanical lift for every resident who required a mechanical lift for transfers. 264977526743972676560

Based on observation, interview and record review, the facility failed to honor resident rights for one sampled resident (Resident #4), in a review of four sampled residents and for three additional residents (Residents #5, #6 and #7), by failing to allow them to choose their own wake up/get-up times. The facility census was 117. Review of the facility policy, Resident Rights, dated 2001, showed the following: -Employees shall treat all residents with kindness, respect and dignity; -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to a dignified existence, to be treated with respect, kindness and dignity, self determination, exercise his/her rights as a resident of the facility and be supported by the facility in exercising his/her rights. 1. Review of the facility Night Shift Early Rise document, dated 05/29/25, and provided by the Assistant Director Of Nursing (ADON), showed it included a list of residents and their rooms numbers. Included on the list was Resident #5, #6 and #7. Two additional residents were listed as get dressed only. A note at the bottom read: If resident declines to get up, have them dressed. Effective 05/29/25 -ADON. 2. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility and dated 12/23/24, showed the following: -Mildly impaired cognition; -Manual wheelchair; -Supervision to touch assist with transfers. Review of the resident's care plan, last revised 06/12/25, showed the following: -Encourage routine daily decision making as indicated; -Encourage out of bed for meals, activities and exercise. Offer to get up in the morning if awake, but allow to refuse (6/12/25); -Support choices for preferences regarding customary routine and activities. Observation, on 06/12/25 at 5:05 A.M., showed the resident sat awake in his/her wheelchair in his/her room, fully dressed and wearing shoes. During interview on 06/12/25 at 5:05 A.M., the resident said staff got him/her up too early. Staff were not supposed to get him/her up until 6:00 A.M. Breakfast was not until 7:00 A.M. It upset him/her to be up so early. During an interview, on 06/12/25 at 5:30 A.M., Certified Nurse Aide (CNA) E said the following: -He/She was the one who got Resident #4 out of bed this morning; -The resident was completely wet so he/she had to get the resident out of bed to change the bed. 2. Review of Resident #7's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Dependent on staff for transfers. Review of the resident's care plan, last revised 06/12/25, showed the following: -Dependent on staff for transfers; -Encourage out of bed for meals. Offer to get up in the morning if awake, but allow me to refuse (6/12/25); was this added at the time of our visit? -Preferences for customary routine will be honored to the fullest extent possible; -Support choices for preferences regarding customary routine. Observation on 06/12/25 at 5:45 A.M., showed the resident sat awake in the dining room in a broda chair (specialized wheelchair), fully dressed. During an interview, on 06/12/25 at 5:45 A.M., the resident said he/she did not want to get up early today and was tired. Staff woke him/her to get out of bed. During an interview, on 06/17/25 at 11:51 A.M., CNA C said the following: -He/She worked 7:00 P.M. to 7:00 A.M.; -They had a lot of residents to get up in the morning; -He/She got Resident #7 up on 6/12/25; -He/She asked the resident if he/she wanted to get up and the resident did not refuse; -If a resident refused, he/she asked if he/she could at least dress them. 3. Review of Resident #5's annual MDS, dated [DATE], showed the following: -Moderately impaired cognition; -No behaviors or rejection of care; -Substantial to moderate assist for dressing and transfers. Review of the resident's undated care plan directed staff to encourage the resident to get out of bed for meals. Offer to get the resident up in the morning but allow the resident to refuse. Observation, on 06/12/25 at 5:30 A.M., showed the resident sat in his/her wheelchair in the dining room. During an interview, on 06/12/25 at 5:30 A.M., the resident said the following: -They got me up too early; -He/She would rather get up around 7:30 A.M.; -They did not ask him/her if he/she wanted to get up. During interview on 06/12/25 at 5:42 A.M., CNA D said the following: -The aides have a list of around 12 people they are supposed to get up; -Resident #5 does not normally refuse; -Staff know which residents are adamant about not wanting to get up early. 4. Review of Resident #6's care plan last revised 3/5/25, showed staff should encourage out of bed for meals. Offer to get up in the morning if awake. (11/26/24). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Partial to moderate assist for dressing and transfers; -Manual wheelchair. Observation on 06/12/25 at 5:35 A.M., showed the resident sat awake in his/her wheelchair in the dining room. During interview on 06/12/25 at 5:35 A.M., the resident said staff got him/her up too early. He/She would rather get up around 7:00 A.M. During an interview, on 06/17/25 at 11:51 A.M., CNA C said the following: -He/She got Resident #6 up on 6/12/25; -He/She asked the resident is he/she wanted to get up after he/she had washed the resident up. The resident did not refuse. During interview on 06/12/25 at 5:18 A.M., CNA G said he/she worked from 7:00 P.M. to 7:00 A.M. and staff had a get-up list requiring them to get specific residents up in the morning. During interview on 06/12/25 at 5:20 A.M., CNA F said he/she worked from 7:00 P.M. to 7:00 A.M. and the facility had a get-up list for night shift to follow; staff should not start getting residents up until after 5:00 A.M. During interview on 06/12/25 at 8:35 A.M.,. the ADON said the following: -The facility did not have a get-up list; -They did have an early riser list, but the residents did not have to get up from bed. During an interview, on 06/12/25 at 3:00 P.M., the Director of Nursing (DON) said the following: -Residents should not have to get up out of bed if they did not want to get up; -The facility did not force residents to get out of bed. MO254899

Based on observation, interview and record review, the facility failed to ensure direct care staff utilized Enhanced Barrier Precaution (EBP) (an infection control strategy that uses gloves and gowns during high-contact resident care to reduce the spread of multi-drug-resistant organisms (MDROs) when providing care and failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional standards of practice during care for one sampled resident (Resident #2), who had a gastrostomy tube (G-tube) feeding tube placed surgically into the stomach through the abdominal wall) and for one additional resident (Resident #8), who had a urinary catheter (flexible tube inserted into the bladder to drain urine from the body) in a review of four sampled residents and three additional residents. The facility census was 38. Review of the facility policy, Enhanced Barrier Precautions, last revised 12/2024 showed EBP's are utilized to prevent the spread of MDROs to residents. EBP's refer to infection prevention and control interventions designed to reduce the transmission of MDROS during high contact resident care activities; Enhanced barrier precautions apply when: -A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; -Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status; -Indwelling medical devices, include urinary catheters and feeding tubes; -Examples of secretions or excretions include discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen; -EBP's employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply; -Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room); -Face protection may be used if there is also a risk of splash or spray; -Enhanced barrier precautions are in place for the duration of the resident's stay or until discontinuation of the indwelling medical device that place that at higher risk; -Staff are trained prior to caring for residents on EBP's; -Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required; -Personal protective equipment and alcohol-based hand-rub are readily accessible to staff. Review of the facility policy, Handwashing/ Hand Hygiene, last revised 10/2023 showed the following: The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections; -All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors; -Hand hygiene is indicated in the following instances: -Immediately before touching a resident; -Before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); -After contact with blood, body fluids, or contaminated surfaces; -After touching a resident; -After touching the resident's environment; -Before moving from work on a soiled body site to a clean body site on the same resident; -Immediately after glove removal; -Wash hands with soap and water when hands are visibly soiled; -Single-use disposable gloves should be used: -Before aseptic procedures; -When anticipating contact with blood or body fluids; -When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions; -The use of gloves does not replace hand washing/hand hygiene. Review of Infection Control Guidelines for Long Term Care Facilities (Section 3.0 Body Substance Precautions) showed dirty gloves are worse than dirty hands because micro-organisms adhere to the surface of a glove easier than to the skin of your hands. Hand washing remained the single most effective means of preventing disease transmission; wash hands whenever they are soiled with body substance and when each resident's care is completed. 1. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 03/05/25, showed the following: -Substantial to moderate assistance for bed mobility; -Dependent for toileting, lower body dressing and transfers; -Partial to moderate assist for personal hygiene and upper body dressing; -Presence of urinary catheter. Review of the resident's Physician Order Sheet (POS), dated 06/2025, showed the following: -Diagnoses included neuromuscular dysfunction of the bladder (a group of bladder problems caused by nerve damage that disrupts the normal communication between the brain, spinal cord and bladder muscles); -Suprapubic (urinary catheter inserted into the bladder through the abdomen) catheter: Check output amount every shift (12/30/24); -EBP: full PPE with high contact care or activities due to the urinary catheter. Ensure signage in place. (11/1/24). Review of the resident's care plan, last revised 06/02/25, showed the following: -EBP during high contact resident care activities due to the presence of a suprapubic catheter; not known to be infected or colonized with any MDRO (3/1/24); -Ensure items for the following EBP are in place (gloves, gown, alcohol-based hand rub, face-shield, signage , trash receptacle, etc.; -Hand hygiene utilizing alcohol-based hand rub; -Utilize PPE (gown and gloves: face shield as indicated) during high-contact resident care activities (e.g. dressing, bathing/showering, transferring, hygiene, linen changes, brief changes, toileting assistance, device care and wound care) 3/1/24. Observation on 06/12/25 at 7:05 A.M., showed EBP signage on the door frame of the resident's room instructing staff to don gloves and a gown for high contact resident care activities, including dressing, transferring providing hygiene, changing briefs and care of a urinary catheter. A bin of PPE was present in the hallway where the resident resided. Observation on 06/12/25 at 5:55 A.M., showed the following: -The resident lay on his/her back in a low bed and a urinary catheter bag hung from the bed frame; -Certified Nurse Assistant (CNA) B entered the room, donned gloves and prepared to assist the resident out of bed. He/She retrieved a urinal from the bathroom and without wearing a gown or eye shield, emptied the urine from the catheter bag into the urinal and hung the bag on the bed frame. He/She carried the urinal into the bathroom and dumped the urine from the urinal into the toilet. He/She degloved, and without washing hands with soap and water or using hand sanitizer, laid a clean incontinent brief on the bed, lowered the head and foot of the bed and raised the level of the bed height with the remote. With the same soiled hands he/she applied gloves and performed perineal care and catheter care; -CNA C entered the room, and without donning a gown or face shield, or washing his/her hands, donned gloves. He/She applied the resident's socks and pants threading the catheter bag through the leg of the pants; -CNA B rolled the resident to his/her right side and cleaned the resident's buttocks; -CNA C applied barrier cream to the resident's buttocks and CNA B (wearing the same soiled gloves) assisted the resident to his/her back and fastened the incontinent brief; -CNA B and CNA C placed a mechanical lift sling under the resident, and while CNA C held the catheter bag in his/her hand, CNA B positioned the chair and lowered the resident into the chair. CNA B and CNA C detached the sling and finished morning cares. They degloved and washed their hands. During an interview on 06/12/25 at 7:02 A.M., CNA C said he/she was not sure what why EBP was or why it was indicated. During an interview on 06/12/25 at 7:05 A.M., CNA B said the following: -The EBP bins on the halls were used when residents had something going on and he/she was not sure why they were still there; -Hands should be washed before and after cares, with glove changes and when moving from a dirty to a clean task; -Gloves should be changed when they become soiled. 2. Review of an EBP sign on Resident #2's room door instructed staff as follows: -Everyone must clean their hands, including before entering and when leaving the room; -Wear gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting and device care: central line, urinary catheter, feeding tube, tracheostomy and wound care (any skin opening requiring a dressing). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Presence of a feeding tube; -Always incontinent of bladder and bowel; -Dependent on two staff for bed mobility and personal hygiene. Review of the resident's POS, dated June 2025 showed the following: -Diagnoses included gastrostomy; -Enhanced barrier precautions during high contact resident care activities secondary to G-tube (3/20/25); -Enteral feed (a method of delivering nutritional support through a tube) two times daily (3/20/25); -Jevity 1.5 (liquid nutritional preparation) at 70 milliliters (ml) hour for 12 hours daily (8:00 P.M. to 8:00 A.M.) (3/20/25); -Flush g-tube with 30 ml's of water before and after medication administration as ordered (3/20/25); -Flush with 250 ml of water four times daily (3/20/25). Review of the resident's care plan, last revised on 06/12/25, showed the following: -Enhanced barrier precautions during high contact resident care activities secondary to G-tube, not known to be infected or colonized with any MDRO; -Incontinent; -Utilize PPE (gown, gloves, face-shield as indicated when dressing, bathing, transferring, hygiene, brief changes, toileting assistance); -Ensure items for following EBP are in place (gloves, gown, alcohol-based hand rub, face-shield, signage, trash receptacle (3/20/25); -Requires Enteral nutrition related to anorexia (weight loss), dysphagia (difficulty swallowing) and increased protein needs. Observation on 06/12/25 at 8:03 A.M., showed the following: -The resident lay in his/her bed with the head of the bed elevated and a feeding pump delivering Jevity via the resident's g-tube; -Licensed Practical Nurse (LPN) A entered the room, and without donning a gown or face shield, washed his/her hands and donned gloves. He/She stopped the feeding pump and detached the feeding tubing from the resident's g-tube; -He/She removed his/her gloves, washed hands and exited the room; -LPN A re-entered the room, and without donning a gown or face shield, washed his/her hands and donned gloves. He/She flushed the resident's g-tube with water. During an interview, on 06/12/25 at 2:25 P.M., LPN A said EBP should be worn when caring for residents who have a catheter, g-tube, or colostomy and he/she forgot to apply all of the PPE. Observation, on 06/12/25 at 10:17 A.M., showed the following: -The resident lay in bed with a urine soiled brief; -CNA B and CNA F entered the room, washed their hands and applied gloves; -Without donning gowns, CNA B unfastened the resident's soiled brief, pulled it down and wiped the resident's front perineal area with wipes; -CNA B and CNA F rolled the resident back and forth and cleaned the resident's buttock area; -CNA F applied barrier cream and assisted in applying a clean brief; -CNA B and F dressed the resident and transferred him/her to the broda chair via a mechanical lift. During an interview, on 06/12/25 at 2:35 P.M., CNA B said the following: -The EBP consisted of gowns, gloves, mask and goggles and should be worn when working with residents who had catheters, g-tubes and infections; -EBP should have been worn when providing cares for Resident #2 as he/she had a feeding tube. 3. During an interview, on 06/12/25 at 7:02 A.M., CNA C said he/she was not sure what the bins with gowns were for. During an interview, on 06/12/25 at 7:05 A.M.,. CNA D said to the best of his/her knowledge, he/she thought the bins with gowns and other PPE were used when residents had something going on (sick) and there were no residents sick at this time, so the bins should have been removed. During an interview on 06/12/25 at 3:00 P.M., the Director Of Nursing said the following: -She would expect staff to wear EBP when caring for residents who had EBP signage on their doors; -Staff should know what EBP was and when it should be used; -She would expect any staff providing direct care to a resident with a catheter or feeding tube to wear EBP.

Based on observation, interview, document review, and facility policy review, the facility failed to ensure the dish machine operated at the correct temperature and equipment and surfaces were kept clean for one of one kitchen. This had the potential to affect 113 of 113 residents who received meals prepared in the facility. Findings include: Review of the facility's policy titled, Sanitation, dated 11/22, revealed The food service area is maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects .2. All utensils, counters, shelves and equipment are kept clean .5. Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are . b. Low-Temperature Dishwasher (Chemical Sanitization): (1) Wash temperature (120 F [Fahrenheit]) . The policy did not address the temperature of the rinse cycle. Review of the kitchen cleaning schedule dated 12/15/24- 12/20/24, provided by the facility, revealed Walls In Dish Room .Deep Fryer 2x [two times] a week, and Stove & Oven were not initialed as completed. The floors and the ventilation hood exterior and filters were not listed on the cleaning schedule. 1. During an observation and interview on 12/16/24 at 9:41 AM, the dish machine was observed in progress and the temperature for the wash and rinse cycle reached 100 degrees F. Dietary Aide (DA) 2 was asked about the temperature of 100 degrees F. DA2 stated 100 was the average temperature. The dish machine started again, and the wash and rinse cycle reached 100 degrees F. Review of the December 2024 log for the dish machine located on the wall revealed no documentation for the wash and rinse temperatures. The Dietary Manager (DM) stated he documented the results of the sanitation test strips on the log but not the temperatures for the wash and rinse. During an observation and interview on 12/16/24 at 10:04 AM, the Administrator checked the dish machine's manufacturer's requirements posted on the machine. The posted plaque revealed 120 F for the wash and rinse cycles. The DM confirmed there were no temperatures documented on the log. The DM was asked why no temperatures were documented for the wash and rinse cycles. The DM stated he didn't know. The DM was asked if the temperatures had been documented, would the low temperatures have been identified sooner. DM stated probably. During an interview on 12/17/24 at 8:36 AM, the Administrator was asked how long the dish machine had been operating with the wash and rinse temperatures at 100 F, not according to manufacturer's requirement. The Administrator stated he wasn't sure. 2. On 12/16/24 at 9:39 AM and on 12/17/24 at 2:51 PM, kitchen observations were conducted with the DM present and again on 12/18/24 at 4:30 PM with the Dietary Manager Consultant (DMC) 1 which revealed the following: -The ventilation filters and exterior hood were noted to have a thick layer of grease present. The DM stated the dietary staff cleaned the exterior and filters every week. -The fryer was noted to be soiled with a collection of French fries and food particles inside the well. The side of the oven and grill touching the fryer contained a build-up of grease and food debris. The DM stated the dietary staff cleaned these areas every week. -The lower walls in and around the dish machine area contained an accumulation of dried splatters, a black substance, and a warped and gapping surface at the door. The booster heater box had an accumulation of debris. The floors in and around the dish machine contained dried spills, food and trash debris, and a dark build-up along the base boards and grout. The floor throughout the kitchen had white specks of food debris. During an interview on 12/18/24 at 4:30 PM, DMC1 was asked what kitchen items were cleaned at night. DMC1 stated the counter tops, any spills in ovens/range, floors, and the steam table. DMC1 was asked why the floors, walls, ventilation filters and exterior hood, and equipment were soiled 12/16/24, 12/17/24, and 12/18/24. DMC1 stated the kitchen had a cleaning schedule that should be followed. During a telephone interview on 12/19/24 at 11:06 AM, the Registered Dietitian (RD) was asked if she was aware of the dish machine not getting to the required temperatures for the wash and rinse cycles. The RD stated she had not been told about it but did hear the DM on the telephone discussing the repair. The RD was asked if she was aware the floors and various equipment had not been cleaned on the days of the survey. The RD stated, No she had not been told yet. The RD was asked if she conducted kitchen sanitation inspections. RD stated, Yes, monthly. The RD went on to say she just started working at the facility and conducted one inspection in November 2024.

Based on observation, interview, and facility policy review, the facility failed to ensure the facility's dumpster area was kept cleaned and the container lids were kept closed when not in use for 115 census residents. This had the potential to attract rodents and other pests that could enter the facility. Findings include: Review of the facility's policy titled, Food-Related Garbage and Rubbish Disposal, revised 04/06, revealed 1. All garbage and rubbish containing food waste shall be kept in containers. 2. All garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use .7. Outside dumpsters provided by garbage pick up services will be kept closed and free of surrounding litter. During an observation with the Dietary Manager (DM) on 12/17/24 at 3:18 PM, the dumpster container area, located adjacent to the kitchen's rear exit hall had two dumpsters for garbage and one dumpster for recycling. Two dumpster containers for garbage each had two separate top lids. Both lids on the dumpster containers were open, exposing the numerous plastic garbage bags that filled the dumpsters. Two plastic garbage bags were noted to be sitting on the concrete next to the dumpsters. The Maintenance Assistant (MA) was observed picking the bags up and placing them in the dumpster containers but didn't close the lids. The DM was asked if staff should close the dumpster lids after they deposited garbage in them. The DM stated, Yes, the staff who put trash in should. During an observation on 12/18/24 at 1:08 PM, the lids to the two garbage dumpsters were observed open and exposing trash bags. During an observation with the Administrator on 12/19/24 at 1:40 PM, the lids to the two garbage dumpsters were open and food debris spillage was noted to be on the outside of the recycling dumpster. The Administrator stated lids should be closed each time trash was placed inside but it was hard to get all the departments to do that.

Based on interview and record review, the facility failed to provide four residents (Resident #1, #4, #5 and #8) sampled residents, the necessary care and services to maintain his/her highest practicable well-being when staff failed to provide incontinent care for Resident #1 and Resident #8 in a timely manner. Resident #8 had been up in a wheelchair from 7:30 A.M. until 4:45 P.M. without being taken to the bathroom. Resident #1 had been observed incontinent at 11:30 P.M. and was not provided care until 4:00 P.M. Resident #4 and Resident #5 were observed in their beds at 11:30 A.M. and had not been given a noon meal tray or offered any food or fluids until staff got the residents to the dining room for the supper meal at 5:00 P.M. The facility census was 116. Review of the facility policy for Assistance with Meals dated 3/2022 showed the following: -Residents shall receive assistance with meals in a manner that meets the individual needs of each resident: -Dining Room Residents: all residents will be encouraged to eat in the dining room Facility staff will serve resident trays and will help residents who require assistance with eating; -Residents confined to bed: the food services department will deliver food carts to appropriate areas. The nursing staff will prepare residents for eating. The nursing staff and/or feeding assistants will take food trays into residents rooms. Nursing services and/or feeding assistants will pick up resident's food trays after each meal. 1. Review of Resident #1's face sheet showed the following: -admitted to the facility on [DATE] with diagnoses of Alzheimer's disease; -Resides on the locked memory care unit. Review of the resident's quarterly Minimum Data Set (MDS), a comprehensive assessment tool completed by staff dated 1/17/25 showed the following: -The resident was sometimes able to make self understood and sometimes able to under stand others; -Unable to make daily decisions; -Dependent upon staff for transfers, toileting and personal hygiene. -Incontinent of bowel and bladder. Review of the resident's care plan for Activities of Daily Living (ADL)/Mobility dated 10/16/24 showed the following: -At risk for ADL/Mobility decline and requires assistance; -The resident will have needs anticipated and met by staff; -Assist with toileting as needed. Incontinence care after each episode and as needed. Observation on 2/4/25 at 12:35 P.M. showed the following: -The resident sat at the dining room table in the main dining room; -A family member sat with the resident; -The resident's pants were wet between the resident's legs. During an interview on 2/4/25 at 1:00 P.M. the family member said the resident was incontinent and needed to be changed. Observation on 2/4/25 at 12:50 P.M. showed the following: -The resident's family member left the dining room and staff took the resident to the activity room; -The resident's pants were still wet; -Staff did not check or change the resident. Observation on 2/4/25 from 1:00 P.M. to 2:40 P.M. showed the following: -The resident sat in a wheelchair in the activity room with the front and back of his/her pants wet; -The resident removed an incontinence brief from within his/her pants and threw it on the floor; -Staff moved the resident from one spot in the activity room to another, the front and back of the resident's pants were wet as was the pad in the wheelchair, staff did not assist the resident; -Certified Nurse Aide (CNA) B picked up the brief off the floor, the brief was dry; -The resident was restless and moved back and forth in the chair. Observation at 2:40 P.M. showed CNA A moved the resident from one side of the activity room to another and pulled the resident's pant leg down; -The resident's pants were visibly wet with urine between the resident's legs; -CNA A did not check or change the resident. Observation from 2:40 P.M. to 3:32 P.M. showed the following: -The resident sat in the chair in the activity room with the Activity Director conducting an activity of hand massages; -CNA A and CNA B walked around the activity area conversing with the residents; -The resident's pants and the cushion in the chair were visibly wet with urine. Observation on 2/4/25 at 3:32 P.M. showed Hospice Registered Nurse (RN) came into the activity room to see the resident. The hospice nurse noted the resident's pants were wet with urine and said the resident was due for a shower from the hospice aide. Observation on 2/4/25 at 3:49 P.M. showed the following: -The hospice RN and a hospice CNA took the resident to his/her room; -Hospice staff removed the resident's urine saturated pants; -The seat cushion in the resident's wheelchair was saturated with urine; -The resident's peri area was red. During an interview on 2/4/25 at 4:40 P.M. the Hospice RN said the resident was soaked with urine, the urine was dark and the resident had been wet for some time. During an interview on 2/5/25 at 11:40 A.M. CNA B said the following: -He/She had gone on break after lunch and did not check on Resident #1 prior to this; -He/She was told that hospice was coming in and they would take care of the resident. During an interview on 2/7/25 at 9:30 A.M. LPN C said the following: -Staff should check the residents at least every two hours to see if they need to go to the bathroom or change the residents; -CNA B should have taken Resident #1 to the bathroom after lunch. 2. Review of Resident #8's face sheet showed the following: -admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, difficulty in walking, and kidney disease, Review of the resident's care plan for Activities of Daily Living /Mobility dated 11/7/24 showed the following: -The resident was at risk for ADL/Mobility decline and requires assistance; -Will have needs anticipated and met by staff; -Toileting assistance as needed. Review of the resident's care plan for skin dated 11/7/24 showed the following: -At risk for skin breakdown; -Keep skin clean and dry; minimize exposure of skin to moisture from incontinence. Review of the resident's care plan for incontinence dated 11/7/24 showed the following: -Resident is incontinent of bladder and bowel; -Provide check and change incontinence management, utilize pads/briefs for incontinence needs. Review of the resident's comprehensive MDS dated [DATE] showed the following: -Usually able to make self understood and usually able to understand others; -Unable to make decisions; -Required assistance with ADL's and toileting; -Incontinent of bowel and bladder. Observation on 2/4/25 from 12:35 P.M. to 1:50 P.M. showed the following: -The resident sat the dining room table with a family member who assisted the resident with the noon meal. -The resident's family member took the resident from the dining room to the activity room area in a wheelchair. During an interview on 2/4/25 at 2:00 P.M. the resident's Family Member (FM) C said he/she had a camera in the resident's room and the last time staff changed the resident was at 6:25 A.M. Review of the camera footage provided by the resident's family member dated 2/4/25 at 6:25 A.M. showed a staff member provided incontinent care for the resident. Footage at 7:18 A.M. showed CNA A entered the resident's room, felt the resident's brief, then dressed the resident and transferred the resident with a mechanical lift from the bed to the wheelchair. Observation on 2/4/25 from 1:50 P.M. to 4:46 P.M. showed the resident sat in the wheelchair in the activity room. Observation on 2/4/25 at 4:46 P.M. showed CNA B and Licensed Practical Nurse (LPN) C took the resident from the activity room to the resident's room; -LPN C pushed the mechanical lift into the room; -CNA A and LPN C lifted the resident up in the mechanical lift and urine ran out of the mechanical lift pad onto the floor as staff transferred the resident from the wheelchair to the bed; -Staff lowered the resident onto the bed with the left and CNA A removed the resident's pants and urine saturated brief; -The resident's buttocks and upper thighs were red with and indents from the mechanical lift pad and the wheelchair; -Assistant Director of Nursing (ADON) D entered the resident's room and assisted CNA A provide peri care and transfer the resident via mechanical lift back into the wheelchair. During an interview on 2/5/24 at 8:40 A.M. FM C said the following: -He/She watched the camera footage from 2/4/25; -A staff member provided the resident with peri care around 6:30 A.M. while the resident was in bed; -CNA A come into the room at 7:26 A.M. felt the resident's brief then transferred the resident from the bed to a wheelchair using the mechanical lift; -The resident did not go back into the room until 4:46 P.M. when LPN C took the resident into the room; -This was not the first time the resident has not been changed all day; -He/She had brought this to ADON D's attention before, but nothing had changed. During an interview on 2/7/25 at 9:15 A.M. CNA A said the following: -He/She had gotten the resident up the morning of 2/4/25; -He/She had not taken the resident to the bathroom on 2/4/25 prior to 4:45 P.M., he/she was busy; -He/She was not aware the resident was wet prior to changing him/her before supper. During an interview on 2/7/25 at 9:30 A.M. LPN C said the following: -He/She was not aware CNA A had not changed Resident #8 until supper on 2/4/25; -CNA A should have checked the resident at least every two hours. During an interview on 2/6/25 at 3:30 the Director of Nursing (DON) said the following: -Residents should be checked at least every two hours and changed or toileted; -She would expect staff to check residents before and after meals. During an interview on 2/6/25 at 3:30 P.M. the Administrator said the following: -He would expect staff to check residents at least every two hours; -He has talked with Family Member C and had seen the camera footage; During an interview on 2/7/25 at 11:30 A.M. the Medical Director said the following: -She would expect staff to check and change residents at least every two hours; -Residents should be offered to use the bathroom if they can, and if not staff should change the residents when soiled; -Staff should meet residents' needs. 3. Review of Resident #4's face sheet showed: -admitted to the facility on [DATE] with diagnoses of stroke with paralytics on one side; history of falling, hypertension, vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain). Review of the quarterly MDS dated [DATE] showed: -Unable to make self understood or understands others; -Unable to make decisions; -Dependent upon staff for ADL's and assistance with meals. Observation on 2/4/25 from 11:32 A.M. to 3:17 P.M. showed: -The resident in bed on his/her back with eyes closed; -An over the bed table next to to the bed with a container of a high protein/calorie open on the table. -The noon meal was served in the main dining room with service beginning at 11:45 A.M. The residents meal tray sat on the food cart. The food cart was removed from the dining area at 2:00 P.M. with the resident's meal tray on the cart untouched; -No staff member removed the meal tray from the cart to serve to the resident. Observation on 2/4/25 at 3:17 P.M. to 5:00 P.M. showed: -The resident in bed on his/her back with his/her eyes open; -Occasionally the resident would call out a name; -An over the bed table next to to the bed with a container of a high protein/calorie open on the table. -The container of the high protein/calorie drink was out of the reach of the resident. -No staff member served the resident any food. Observation on 2/4/25 at 5:30 P.M. showed: -The resident in the dining room and drank three glasses of orange juice. During an interview on 2/5/25 at 11:00 A.M. Registered Nurse (RN) E said: -Department Managers assist in the dining room at every meal on the Memory Care Unit; -He/She was not aware that Resident #4 was not served a meal try on 2/4/25 at the noon meal. During an interview on 2/7/25 at 9:15 A.M. CNA A said: -He/She was not aware that Resident #4 did not get a lunch tray on 2/4/25; -He/She does not know how it is monitored to ensure that everyone gets a meal tray. 4. Review of Resident #5's face sheet showed: -Resident was admitted to the facility on [DATE] with diagnoses of atrial fibrillation (irregular heartbeat), cognitive deficit, heart failure, hypertension, stroke, vascular dementia. Review of the care plan for ADL/Mobility dated 9/19/24 showed: -At risk for ADL/mobility decline and requires assistance related to anticipated declines due to disease process; -Goal: will have no significant declines in ADL's or mobility; -Interventions in part: assist with transfers; encourage me to get out of bed for meals; staff set up and assist with meals as needed. Review of the quarterly MDS dated [DATE] showed: -Usually able to make self understood and usually able to understand others; -Alert and oriented with some difficulty making decisions; -Independent with eating, supervision with transfer and ADL's. Observation on 2/4/25 at 11:32 A.M. showed the resident in bed with eyes closed. Observation on 2/4/25 at 12:35 P.M. showed staff deliver the noon meal tray to the residents room and place the tray uncovered on the over the bed table. The resident in bed with eyes closed. Observation on 2/4/25 from 12:58 P.M. to 3:00 P.M. showed the resident in bed with eyes closed with the noon meal tray on the over the bed table. Observation on 2/4/25 at 3:15 P.M. showed the resident got up out of bed and wheeled self to the activity room. The noon meal tray sat on the over the bed table. No staff offered to warm up the food or offer the resident any food or fluids. Observation on 2/4/25 at 3:15 P.M. to 5:30 P.M. showed; -The noon meal tray sat on the over the bed table; -No staff offered the resident any food or fluids; -At 5:30 P.M. the resident sat at the dining room table and was served a plate of beef and noodles and green beans; -The resident began to eat the food and said that he/she was hungry. During an interview 2/5/25 at 1:15 P.M. the Dietary Manager said: -She does not know if meal intakes get documented after every meal; -Each resident receives a tray card, then the resident's meal is served the tray card is removed from the tray; -Serving is monitored through the tray cards, if there are no tray cards left, then each resident has received a tray. During an interview on 2/6/25 at 3:30 P.M. the DON said: -Nursing staff should be checking after each meal if there are any resident's who did not receive a tray; -If a resident is sleeping or refuses a meal tray at the time of the meal, the meal can be put in the refrigerator and offered at a later time; -Staff should be monitoring the residents for when they wake up and offer them something to eat. During an interview on 2/6/25 at 3:30 P.M. the Administrator said: -He would expect staff to offer every resident a meal tray, if the resident refuses, then staff should offer food at a later time. During an interview on 2/7/25 at 9:30 A.M. LPN C said: -He/She does not know who passed Resident #5's noon meal tray on 2/4/25, staff should have checked on the resident and offered to warm up the food or provide him/her another tray when the resident got out of bed; -He/She was not aware that Resident #3 was not offered a noon meal tray on 2/4/25; -Meal intakes should be documented in the electronic medical record, this is the only way it can be checked to see if a resident does not eat; -He/She does not know how this can be monitored unless you look at each resident's record. During an interview on 2/7/25 at 11:30 A.M. the Medical Director said: -She would expect staff to monitor and offer every resident meals; -She would expect staff to monitor each resident to ensure that they are served every meal. MO249002 MO247043 MO248183 MO248650

Based on interview and record review, the facility failed to provide four residents (Resident #1, #4, #5 and #8) sampled residents, the necessary care and services to maintain his/her highest practicable well-being when staff failed to provide incontinent care for Resident #1 and Resident #8 in a timely manner. Resident #8 had been up in a wheelchair from 7:30 A.M. until 4:45 P.M. without being taken to the bathroom. Resident #1 had been observed incontinent at 11:30 P.M. and was not provided care until 4:00 P.M. Resident #4 and Resident #5 were observed in their beds at 11:30 A.M. and had not been given a noon meal tray or offered any food or fluids until staff got the residents to the dining room for the supper meal at 5:00 P.M. The facility census was 116. Review of the facility policy for Assistance with Meals dated 3/2022 showed the following: -Residents shall receive assistance with meals in a manner that meets the individual needs of each resident: -Dining Room Residents: all residents will be encouraged to eat in the dining room Facility staff will serve resident trays and will help residents who require assistance with eating; -Residents confined to bed: the food services department will deliver food carts to appropriate areas. The nursing staff will prepare residents for eating. The nursing staff and/or feeding assistants will take food trays into residents rooms. Nursing services and/or feeding assistants will pick up resident's food trays after each meal. 1. Review of Resident #1's face sheet showed the following: -admitted to the facility on [DATE] with diagnoses of Alzheimer's disease; -Resides on the locked memory care unit. Review of the resident's quarterly Minimum Data Set (MDS), a comprehensive assessment tool completed by staff dated 1/17/25 showed the following: -The resident was sometimes able to make self understood and sometimes able to under stand others; -Unable to make daily decisions; -Dependent upon staff for transfers, toileting and personal hygiene. -Incontinent of bowel and bladder. Review of the resident's care plan for Activities of Daily Living (ADL)/Mobility dated 10/16/24 showed the following: -At risk for ADL/Mobility decline and requires assistance; -The resident will have needs anticipated and met by staff; -Assist with toileting as needed. Incontinence care after each episode and as needed. Observation on 2/4/25 at 12:35 P.M. showed the following: -The resident sat at the dining room table in the main dining room; -A family member sat with the resident; -The resident's pants were wet between the resident's legs. During an interview on 2/4/25 at 1:00 P.M. the family member said the resident was incontinent and needed to be changed. Observation on 2/4/25 at 12:50 P.M. showed the following: -The resident's family member left the dining room and staff took the resident to the activity room; -The resident's pants were still wet; -Staff did not check or change the resident. Observation on 2/4/25 from 1:00 P.M. to 2:40 P.M. showed the following: -The resident sat in a wheelchair in the activity room with the front and back of his/her pants wet; -The resident removed an incontinence brief from within his/her pants and threw it on the floor; -Staff moved the resident from one spot in the activity room to another, the front and back of the resident's pants were wet as was the pad in the wheelchair, staff did not assist the resident; -Certified Nurse Aide (CNA) B picked up the brief off the floor, the brief was dry; -The resident was restless and moved back and forth in the chair. Observation at 2:40 P.M. showed CNA A moved the resident from one side of the activity room to another and pulled the resident's pant leg down; -The resident's pants were visibly wet with urine between the resident's legs; -CNA A did not check or change the resident. Observation from 2:40 P.M. to 3:32 P.M. showed the following: -The resident sat in the chair in the activity room with the Activity Director conducting an activity of hand massages; -CNA A and CNA B walked around the activity area conversing with the residents; -The resident's pants and the cushion in the chair were visibly wet with urine. Observation on 2/4/25 at 3:32 P.M. showed Hospice Registered Nurse (RN) came into the activity room to see the resident. The hospice nurse noted the resident's pants were wet with urine and said the resident was due for a shower from the hospice aide. Observation on 2/4/25 at 3:49 P.M. showed the following: -The hospice RN and a hospice CNA took the resident to his/her room; -Hospice staff removed the resident's urine saturated pants; -The seat cushion in the resident's wheelchair was saturated with urine; -The resident's peri area was red. During an interview on 2/4/25 at 4:40 P.M. the Hospice RN said the resident was soaked with urine, the urine was dark and the resident had been wet for some time. During an interview on 2/5/25 at 11:40 A.M. CNA B said the following: -He/She had gone on break after lunch and did not check on Resident #1 prior to this; -He/She was told that hospice was coming in and they would take care of the resident. During an interview on 2/7/25 at 9:30 A.M. LPN C said the following: -Staff should check the residents at least every two hours to see if they need to go to the bathroom or change the residents; -CNA B should have taken Resident #1 to the bathroom after lunch. 2. Review of Resident #8's face sheet showed the following: -admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, difficulty in walking, and kidney disease, Review of the resident's care plan for Activities of Daily Living /Mobility dated 11/7/24 showed the following: -The resident was at risk for ADL/Mobility decline and requires assistance; -Will have needs anticipated and met by staff; -Toileting assistance as needed. Review of the resident's care plan for skin dated 11/7/24 showed the following: -At risk for skin breakdown; -Keep skin clean and dry; minimize exposure of skin to moisture from incontinence. Review of the resident's care plan for incontinence dated 11/7/24 showed the following: -Resident is incontinent of bladder and bowel; -Provide check and change incontinence management, utilize pads/briefs for incontinence needs. Review of the resident's comprehensive MDS dated [DATE] showed the following: -Usually able to make self understood and usually able to understand others; -Unable to make decisions; -Required assistance with ADL's and toileting; -Incontinent of bowel and bladder. Observation on 2/4/25 from 12:35 P.M. to 1:50 P.M. showed the following: -The resident sat the dining room table with a family member who assisted the resident with the noon meal. -The resident's family member took the resident from the dining room to the activity room area in a wheelchair. During an interview on 2/4/25 at 2:00 P.M. the resident's Family Member (FM) C said he/she had a camera in the resident's room and the last time staff changed the resident was at 6:25 A.M. Review of the camera footage provided by the resident's family member dated 2/4/25 at 6:25 A.M. showed a staff member provided incontinent care for the resident. Footage at 7:18 A.M. showed CNA A entered the resident's room, felt the resident's brief, then dressed the resident and transferred the resident with a mechanical lift from the bed to the wheelchair. Observation on 2/4/25 from 1:50 P.M. to 4:46 P.M. showed the resident sat in the wheelchair in the activity room. Observation on 2/4/25 at 4:46 P.M. showed CNA B and Licensed Practical Nurse (LPN) C took the resident from the activity room to the resident's room; -LPN C pushed the mechanical lift into the room; -CNA A and LPN C lifted the resident up in the mechanical lift and urine ran out of the mechanical lift pad onto the floor as staff transferred the resident from the wheelchair to the bed; -Staff lowered the resident onto the bed with the left and CNA A removed the resident's pants and urine saturated brief; -The resident's buttocks and upper thighs were red with and indents from the mechanical lift pad and the wheelchair; -Assistant Director of Nursing (ADON) D entered the resident's room and assisted CNA A provide peri care and transfer the resident via mechanical lift back into the wheelchair. During an interview on 2/5/24 at 8:40 A.M. FM C said the following: -He/She watched the camera footage from 2/4/25; -A staff member provided the resident with peri care around 6:30 A.M. while the resident was in bed; -CNA A come into the room at 7:26 A.M. felt the resident's brief then transferred the resident from the bed to a wheelchair using the mechanical lift; -The resident did not go back into the room until 4:46 P.M. when LPN C took the resident into the room; -This was not the first time the resident has not been changed all day; -He/She had brought this to ADON D's attention before, but nothing had changed. During an interview on 2/7/25 at 9:15 A.M. CNA A said the following: -He/She had gotten the resident up the morning of 2/4/25; -He/She had not taken the resident to the bathroom on 2/4/25 prior to 4:45 P.M., he/she was busy; -He/She was not aware the resident was wet prior to changing him/her before supper. During an interview on 2/7/25 at 9:30 A.M. LPN C said the following: -He/She was not aware CNA A had not changed Resident #8 until supper on 2/4/25; -CNA A should have checked the resident at least every two hours. During an interview on 2/6/25 at 3:30 the Director of Nursing (DON) said the following: -Residents should be checked at least every two hours and changed or toileted; -She would expect staff to check residents before and after meals. During an interview on 2/6/25 at 3:30 P.M. the Administrator said the following: -He would expect staff to check residents at least every two hours; -He has talked with Family Member C and had seen the camera footage; During an interview on 2/7/25 at 11:30 A.M. the Medical Director said the following: -She would expect staff to check and change residents at least every two hours; -Residents should be offered to use the bathroom if they can, and if not staff should change the residents when soiled; -Staff should meet residents' needs. 3. Review of Resident #4's face sheet showed: -admitted to the facility on [DATE] with diagnoses of stroke with paralytics on one side; history of falling, hypertension, vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain). Review of the quarterly MDS dated [DATE] showed: -Unable to make self understood or understands others; -Unable to make decisions; -Dependent upon staff for ADL's and assistance with meals. Observation on 2/4/25 from 11:32 A.M. to 3:17 P.M. showed: -The resident in bed on his/her back with eyes closed; -An over the bed table next to to the bed with a container of a high protein/calorie open on the table. -The noon meal was served in the main dining room with service beginning at 11:45 A.M. The residents meal tray sat on the food cart. The food cart was removed from the dining area at 2:00 P.M. with the resident's meal tray on the cart untouched; -No staff member removed the meal tray from the cart to serve to the resident. Observation on 2/4/25 at 3:17 P.M. to 5:00 P.M. showed: -The resident in bed on his/her back with his/her eyes open; -Occasionally the resident would call out a name; -An over the bed table next to to the bed with a container of a high protein/calorie open on the table. -The container of the high protein/calorie drink was out of the reach of the resident. -No staff member served the resident any food. Observation on 2/4/25 at 5:30 P.M. showed: -The resident in the dining room and drank three glasses of orange juice. During an interview on 2/5/25 at 11:00 A.M. Registered Nurse (RN) E said: -Department Managers assist in the dining room at every meal on the Memory Care Unit; -He/She was not aware that Resident #4 was not served a meal try on 2/4/25 at the noon meal. During an interview on 2/7/25 at 9:15 A.M. CNA A said: -He/She was not aware that Resident #4 did not get a lunch tray on 2/4/25; -He/She does not know how it is monitored to ensure that everyone gets a meal tray. 4. Review of Resident #5's face sheet showed: -Resident was admitted to the facility on [DATE] with diagnoses of atrial fibrillation (irregular heartbeat), cognitive deficit, heart failure, hypertension, stroke, vascular dementia. Review of the care plan for ADL/Mobility dated 9/19/24 showed: -At risk for ADL/mobility decline and requires assistance related to anticipated declines due to disease process; -Goal: will have no significant declines in ADL's or mobility; -Interventions in part: assist with transfers; encourage me to get out of bed for meals; staff set up and assist with meals as needed. Review of the quarterly MDS dated [DATE] showed: -Usually able to make self understood and usually able to understand others; -Alert and oriented with some difficulty making decisions; -Independent with eating, supervision with transfer and ADL's. Observation on 2/4/25 at 11:32 A.M. showed the resident in bed with eyes closed. Observation on 2/4/25 at 12:35 P.M. showed staff deliver the noon meal tray to the residents room and place the tray uncovered on the over the bed table. The resident in bed with eyes closed. Observation on 2/4/25 from 12:58 P.M. to 3:00 P.M. showed the resident in bed with eyes closed with the noon meal tray on the over the bed table. Observation on 2/4/25 at 3:15 P.M. showed the resident got up out of bed and wheeled self to the activity room. The noon meal tray sat on the over the bed table. No staff offered to warm up the food or offer the resident any food or fluids. Observation on 2/4/25 at 3:15 P.M. to 5:30 P.M. showed; -The noon meal tray sat on the over the bed table; -No staff offered the resident any food or fluids; -At 5:30 P.M. the resident sat at the dining room table and was served a plate of beef and noodles and green beans; -The resident began to eat the food and said that he/she was hungry. During an interview 2/5/25 at 1:15 P.M. the Dietary Manager said: -She does not know if meal intakes get documented after every meal; -Each resident receives a tray card, then the resident's meal is served the tray card is removed from the tray; -Serving is monitored through the tray cards, if there are no tray cards left, then each resident has received a tray. During an interview on 2/6/25 at 3:30 P.M. the DON said: -Nursing staff should be checking after each meal if there are any resident's who did not receive a tray; -If a resident is sleeping or refuses a meal tray at the time of the meal, the meal can be put in the refrigerator and offered at a later time; -Staff should be monitoring the residents for when they wake up and offer them something to eat. During an interview on 2/6/25 at 3:30 P.M. the Administrator said: -He would expect staff to offer every resident a meal tray, if the resident refuses, then staff should offer food at a later time. During an interview on 2/7/25 at 9:30 A.M. LPN C said: -He/She does not know who passed Resident #5's noon meal tray on 2/4/25, staff should have checked on the resident and offered to warm up the food or provide him/her another tray when the resident got out of bed; -He/She was not aware that Resident #3 was not offered a noon meal tray on 2/4/25; -Meal intakes should be documented in the electronic medical record, this is the only way it can be checked to see if a resident does not eat; -He/She does not know how this can be monitored unless you look at each resident's record. During an interview on 2/7/25 at 11:30 A.M. the Medical Director said: -She would expect staff to monitor and offer every resident meals; -She would expect staff to monitor each resident to ensure that they are served every meal. MO249002 MO247043 MO248183 MO248650

Based on interview and record review, facility failed to make a prompt effort to resolve resident grievances (cause for complaint) and provide written documentation of responses related to the grievances for four sampled residents (Resident #1, #6, #8 and #9) when the family members of the residents requested a meeting with the administrator and department managers and filed grievances and the facility did not follow up or provide a plan for resolution to those grievances. The facility census was 116. Review of the facility policy for Filing Grievances/Complaints dated 4/2017 showed the following: -Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g. the State Ombudsman); -The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative; -Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished; -Residents, family, and resident representatives, have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal; -All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response; -Grievances and/or complaints may be submitted orally or in writing, and may be filed anonymously; -The administrator has delegated the responsibility of grievance and/or complaint investigation to the grievance officer; -Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint; -The administrator will review the finding with grievance officer to determine what corrective actions, if any, need to be taken; -The resident or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct the identified problems. The administrator or his or her designee will make such reports orally within ____ (area left blank) working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office; -This policy will be provided to the resident or the resident's representative upon request. Review of the facility policy for Recording and Investigating Grievances/Complaints dated 4/2017 showed the following: -All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s); -The administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer; -The department director(s) of any named employee(s) will be notified of the the nature of the complaint and that an investigation is underway; -Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations; -The investigation and report will include, as applicable: the date and time of the alleged incident; the circumstances surrounding the alleged incident; the location of the alleged incident; the names of any witnesses and their accounts of the alleged incident; the resident's account of the alleged incident; the employee's account of the alleged incident; accounts of any other individuals involved (i.e. employees supervisor, etc.) and recommendations for corrective action; -The grievance officer will record and maintain all grievances and complains of the Resident Grievance/Complaint Log. The following information will be recorded and maintained in the log: the date the grievance/complaint was received; the name and room number of the resident filing the grievance/complaint (if available); the name and relationship of the person filing the grievance/complaint on behalf of the resident (if available); the date the alleged incident took place; the name of the person investigating the incident; the date the resident, or interested party, was informed of the finding; and the disposition of the grievance (i.e. resolved, dispute, etc.); -The Resident Grievance/Complaint Investigation Report Form will be filed with the administrator within five (5) working days of the incident; -The resident, or person acting on behalf of the resident, will be informed of the finding of the investigation, as well as any corrective actions recommended, with _________ (area is blank on the policy) working days of the filing of the grievance or complaint; -A copy of the Resident Grievance/Complaint Investigation Report Form must be attached to the Resident Grievance/Complaint Form and filed in the business office; -Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident. 1. Review of the Resident Grievance/Complaint Log for November 2024, showed five Grievance/Complaints filed between 11/3/24 and 11/25/24 from five different residents and or family members concerning general concerns of missing clothing and personal items to care not being provided with the grievances/complaints being resolved. 2. Review of the Resident Grievance/Complaint Log for December 2024, showed eleven Grievance/Complaints filed between 12/3/24 and 12/17/24 from eleven different residents and or family members concerning general concerns of missing clothing and personal items to care not being provided with the grievances/complaints being resolved. 3. Review of the Resident Grievance/Complaint Log for January 2025, showed three Grievance/Complaints filed between 1/9/25 to 1/31/25 from three different residents and or family members concerning general concerns of missing clothing and personal items to care not being provided with the grievances/complaints being resolved. 4. Review of Anonymous Resident A's face sheet showed the following: -admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and malnutrition; -Resided on the locked memory care unit. During an interview on 2/4/25 at 10:30 A.M. Family Member A said the following: -He/She felt like he/she has to come in and feed the resident; -He/She has come in after a meal and found the resident's meal tray still sitting in front of him/her uneaten; -Staff need more training on how to work with Alzheimer's residents; -He/She has found the resident wet with urine; -He/She and other family members had a meeting with the prior Administrator, the Director of Nurses (DON) and several other managers in November 2024 and nothing had changed. The families have had no feed back from administration on their concerns. 5. Review of Anonymous Resident B's face sheet showed the following: -admitted to the facility June 2024 with diagnoses of Alzheimer's disease; -Resided on the locked memory care unit. During an interview on 2/4/25 at 2:05 P.M. Family Member B said the following: -He/She and several other family members had a meeting in November 2024 with the former Administrator and the DON and nurses about their residents not getting changed and fed and receiving the care they needed but nothing had changed; -The Administrator has been replaced and he/she has not heard anything from the new Administrator or from the DON about the concerns that families brought up in November; -He/She still feels like he/she has to come in at meal time or the resident does not get fed and he/she still has to ask staff to give the resident a bath; -He/She feels like the staff on the memory care unit were not trained to work with residents with Alzheimer's disease. 6. Review of Anonymous Resident C's face sheet showed the following: -admitted to the facility September 2024 with diagnoses of Alzheimer's disease and dementia, Dysphagia; -Resided on the locked memory care unit. During an interview on 2/4/25 at 2:00 P.M. Family Member (FM) C said the following: -His/Her resident needed help with meals and cares; -He/She felt like he/she has to come in and help the resident or the resident does not get fed; -He/She and several other family members had a meeting in November 2024 with the former Administrator and the DON about residents not getting fed and not receiving care, but nothing had changed since the meeting; -The families have not heard anything from the Administrator or the DON about any changes on the memory care unit; -Nothing has changed since the meeting. 4. Review of Anonymous Resident D's face sheet showed the following: -admitted to the facility September 2024 with diagnoses of Parkinson's disease ( a progressive neurodegenerative disorder that affects movement, balance, and coordination), Alzheimer's disease, cognitive communication deficit (a difficulty with communication caused by an impairment in cognitive processes. These deficits can affect a person's ability to speak, listen, read, write, and interact socially), dementia, and dehydration; -Resided on the locked memory care unit. During an interview on 2/5/25 at 11:30 A.M. Family Member D said the following: -He/She and several other family members had a meeting with the former Administrator and DON in November 2024 to discuss concerns they had about residents not receiving care and if the staff were trained on how to work with Alzheimer's residents; -He/She and other family members will come in and help the resident with meals as the staff do not always assist the resident; -He/She has not received any feedback from the meeting; -Nothing had changed, the same concerns are ongoing. During an interview on 2/5/25 at 3:00 P.M. the DON said the following: -Last November about 12 family members requested a meeting with the former Administrator, herself, and other department managers; -The family members had concerns about resident cares and assistance at meal times, they also had numerous complaints about the former Administrator; -She did not know if any one took any notes in the meeting; -She did not know if any grievance forms were completed; -The former administrator said he was taking care of it; -She would have thought that grievance forms should have been completed and follow up should have been done; -No family members had brought any further concerns to her. During an interview on 2/6/25 at 11:40 A.M. the Social Services Director for Long Term Care (SSD A) said the following: -She was the designated grievance officer; -When a grievance has been filed, she will log the grievance on the Grievance/Complaint log and review the concern with the Administrator. The Grievance will then be given to the appropriate department for resolution. That department has 72 hours to come to a resolution. Once this is done, it was reviewed with the administrator then reviewed with the person who filed the grievance; -She attended the meeting with the family members of the residents on the Memory Care Unit. She did not think to fill out any grievance forms and she did not know if she should; -She has not heard any further complaints from the families. During an interview on 2/6/25 at 3:30 P.M. the Administrator said the following: -He was not aware there was a family meeting in November, this was done before he started; -There is nothing documented about the meeting; -No family members had said anything to him about any concerns; -He would have expected grievance concern forms completed and follow up done; -When a grievance was received, it is reviewed by him and then given to the appropriate department to investigate and come to a resolution; -A resolution should be found within seven days of bringing the concern/grievance to the appropriate department. MO249002 MO248183

Based on interview and record review, facility failed to make a prompt effort to resolve resident grievances (cause for complaint) and provide written documentation of responses related to the grievances for four sampled residents (Resident #1, #6, #8 and #9) when the family members of the residents requested a meeting with the administrator and department managers and filed grievances and the facility did not follow up or provide a plan for resolution to those grievances. The facility census was 116. Review of the facility policy for Filing Grievances/Complaints dated 4/2017 showed the following: -Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g. the State Ombudsman); -The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative; -Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished; -Residents, family, and resident representatives, have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal; -All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response; -Grievances and/or complaints may be submitted orally or in writing, and may be filed anonymously; -The administrator has delegated the responsibility of grievance and/or complaint investigation to the grievance officer; -Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint; -The administrator will review the finding with grievance officer to determine what corrective actions, if any, need to be taken; -The resident or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct the identified problems. The administrator or his or her designee will make such reports orally within ____ (area left blank) working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office; -This policy will be provided to the resident or the resident's representative upon request. Review of the facility policy for Recording and Investigating Grievances/Complaints dated 4/2017 showed the following: -All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s); -The administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer; -The department director(s) of any named employee(s) will be notified of the the nature of the complaint and that an investigation is underway; -Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations; -The investigation and report will include, as applicable: the date and time of the alleged incident; the circumstances surrounding the alleged incident; the location of the alleged incident; the names of any witnesses and their accounts of the alleged incident; the resident's account of the alleged incident; the employee's account of the alleged incident; accounts of any other individuals involved (i.e. employees supervisor, etc.) and recommendations for corrective action; -The grievance officer will record and maintain all grievances and complains of the Resident Grievance/Complaint Log. The following information will be recorded and maintained in the log: the date the grievance/complaint was received; the name and room number of the resident filing the grievance/complaint (if available); the name and relationship of the person filing the grievance/complaint on behalf of the resident (if available); the date the alleged incident took place; the name of the person investigating the incident; the date the resident, or interested party, was informed of the finding; and the disposition of the grievance (i.e. resolved, dispute, etc.); -The Resident Grievance/Complaint Investigation Report Form will be filed with the administrator within five (5) working days of the incident; -The resident, or person acting on behalf of the resident, will be informed of the finding of the investigation, as well as any corrective actions recommended, with _________ (area is blank on the policy) working days of the filing of the grievance or complaint; -A copy of the Resident Grievance/Complaint Investigation Report Form must be attached to the Resident Grievance/Complaint Form and filed in the business office; -Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident. 1. Review of the Resident Grievance/Complaint Log for November 2024, showed five Grievance/Complaints filed between 11/3/24 and 11/25/24 from five different residents and or family members concerning general concerns of missing clothing and personal items to care not being provided with the grievances/complaints being resolved. 2. Review of the Resident Grievance/Complaint Log for December 2024, showed eleven Grievance/Complaints filed between 12/3/24 and 12/17/24 from eleven different residents and or family members concerning general concerns of missing clothing and personal items to care not being provided with the grievances/complaints being resolved. 3. Review of the Resident Grievance/Complaint Log for January 2025, showed three Grievance/Complaints filed between 1/9/25 to 1/31/25 from three different residents and or family members concerning general concerns of missing clothing and personal items to care not being provided with the grievances/complaints being resolved. 4. Review of Anonymous Resident A's face sheet showed the following: -admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and malnutrition; -Resided on the locked memory care unit. During an interview on 2/4/25 at 10:30 A.M. Family Member A said the following: -He/She felt like he/she has to come in and feed the resident; -He/She has come in after a meal and found the resident's meal tray still sitting in front of him/her uneaten; -Staff need more training on how to work with Alzheimer's residents; -He/She has found the resident wet with urine; -He/She and other family members had a meeting with the prior Administrator, the Director of Nurses (DON) and several other managers in November 2024 and nothing had changed. The families have had no feed back from administration on their concerns. 5. Review of Anonymous Resident B's face sheet showed the following: -admitted to the facility June 2024 with diagnoses of Alzheimer's disease; -Resided on the locked memory care unit. During an interview on 2/4/25 at 2:05 P.M. Family Member B said the following: -He/She and several other family members had a meeting in November 2024 with the former Administrator and the DON and nurses about their residents not getting changed and fed and receiving the care they needed but nothing had changed; -The Administrator has been replaced and he/she has not heard anything from the new Administrator or from the DON about the concerns that families brought up in November; -He/She still feels like he/she has to come in at meal time or the resident does not get fed and he/she still has to ask staff to give the resident a bath; -He/She feels like the staff on the memory care unit were not trained to work with residents with Alzheimer's disease. 6. Review of Anonymous Resident C's face sheet showed the following: -admitted to the facility September 2024 with diagnoses of Alzheimer's disease and dementia, Dysphagia; -Resided on the locked memory care unit. During an interview on 2/4/25 at 2:00 P.M. Family Member (FM) C said the following: -His/Her resident needed help with meals and cares; -He/She felt like he/she has to come in and help the resident or the resident does not get fed; -He/She and several other family members had a meeting in November 2024 with the former Administrator and the DON about residents not getting fed and not receiving care, but nothing had changed since the meeting; -The families have not heard anything from the Administrator or the DON about any changes on the memory care unit; -Nothing has changed since the meeting. 4. Review of Anonymous Resident D's face sheet showed the following: -admitted to the facility September 2024 with diagnoses of Parkinson's disease ( a progressive neurodegenerative disorder that affects movement, balance, and coordination), Alzheimer's disease, cognitive communication deficit (a difficulty with communication caused by an impairment in cognitive processes. These deficits can affect a person's ability to speak, listen, read, write, and interact socially), dementia, and dehydration; -Resided on the locked memory care unit. During an interview on 2/5/25 at 11:30 A.M. Family Member D said the following: -He/She and several other family members had a meeting with the former Administrator and DON in November 2024 to discuss concerns they had about residents not receiving care and if the staff were trained on how to work with Alzheimer's residents; -He/She and other family members will come in and help the resident with meals as the staff do not always assist the resident; -He/She has not received any feedback from the meeting; -Nothing had changed, the same concerns are ongoing. During an interview on 2/5/25 at 3:00 P.M. the DON said the following: -Last November about 12 family members requested a meeting with the former Administrator, herself, and other department managers; -The family members had concerns about resident cares and assistance at meal times, they also had numerous complaints about the former Administrator; -She did not know if any one took any notes in the meeting; -She did not know if any grievance forms were completed; -The former administrator said he was taking care of it; -She would have thought that grievance forms should have been completed and follow up should have been done; -No family members had brought any further concerns to her. During an interview on 2/6/25 at 11:40 A.M. the Social Services Director for Long Term Care (SSD A) said the following: -She was the designated grievance officer; -When a grievance has been filed, she will log the grievance on the Grievance/Complaint log and review the concern with the Administrator. The Grievance will then be given to the appropriate department for resolution. That department has 72 hours to come to a resolution. Once this is done, it was reviewed with the administrator then reviewed with the person who filed the grievance; -She attended the meeting with the family members of the residents on the Memory Care Unit. She did not think to fill out any grievance forms and she did not know if she should; -She has not heard any further complaints from the families. During an interview on 2/6/25 at 3:30 P.M. the Administrator said the following: -He was not aware there was a family meeting in November, this was done before he started; -There is nothing documented about the meeting; -No family members had said anything to him about any concerns; -He would have expected grievance concern forms completed and follow up done; -When a grievance was received, it is reviewed by him and then given to the appropriate department to investigate and come to a resolution; -A resolution should be found within seven days of bringing the concern/grievance to the appropriate department. MO249002 MO248183

Based on observations, record review, interviews, and facility policy review, the facility failed to provide a dignified dining experience for three of 20 residents (Resident (R) 68, R98, and R88) who resided on the memory care unit by standing to assist to feed R68 and R98; by failing to obtain an alternate meal in a timely manner for R88 when she refused what was served; and by failing to provide continuous dining service for one resident (R102) on the long term care unit of 30 sample residents. This failure had the potential to affect resident dignified dining experiences. Findings include: Review of the facility's policy titled Assistance with Meals, dated 03/22, revealed Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. not standing over residents while assisting them with meals; b. keeping interactions with other staff to a minimum while assisting residents with meals; c. avoiding the use of labels when referring to residents (e.g., 'feeders); and d. avoiding the use of bibs or clothing protectors instead of napkins, unless requested by the resident. 1. Review of R68's Admission Record located under the Profile tab in the electronic medical record (EMR) noted the resident was initially admitted on [DATE] with diagnoses that included dementia. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/24 revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated R68 was severely cognitively impaired. R68 was identified to require assistance with eating. During an observation on 12/16/24 at 12:53 PM, a Certified Nurse Aide (CNA) 5, was observed standing next to R68 while assisting to feed him lunch. During an interview on 12/16/24 at 1:00 PM, CNA5 stated, I know I should sit, I'm just ready to jump when someone needs something. During an observation on 12/18/24 at 12:23 PM, the MDS Coordinator (MDSC) was observed standing next to R68 while assisting to feed her lunch. When CNA6 told the MDSC to get a chair to sit next to R68, the MDSC stated, No, I'm good right here. During an observation on 12/18/24 at 12:30 PM when the MDSC left to pass a tray to another resident, a Certified Medication Technician (CMT) 1 stood next to R68 to continue feeding her lunch. CMT1 was asked why she was standing to assist R68 and stated, I don't know. 2. Review of R98's Admission Record located under the Profile tab in the EMR noted the resident was admitted on [DATE] with diagnoses that included Alzheimer's disease. Review of the admission MDS with an ARD of 10/18/24 revealed a BIMS score of zero out of 15 which indicated R98 was severely cognitively impaired. R98 was identified to require assistance with eating. During an observation on 12/18/24 at 7:59 AM, CMT2 was observed standing next to R98 at the dining table, twice offered a spoonful of breakfast to the resident, before moving to assist another resident at another table. When asked why she was standing, CMT2 said Oh, I need to sit, I just can't stay in one place. 3. Review of R88's Admission Record located under the Profile tab in the EMR noted the resident was admitted on [DATE] with diagnoses that included dementia. Review of the annual MDS with an ARD of 08/23/24 revealed a BIMS score of three out of 15 which indicated R88 was severely cognitively impaired. Continuous observation of R88 on 12/16/24 revealed at 12:38 PM, R88 was served lunch, a fish fillet, potatoes, and bread. The resident pushed her plate away stating, I don't want that. An alternative meal was not offered. At 12:54 PM, R88 was given a bowl of pears which she immediately started eating. R88 was observed to shrug her shoulders as she looked around the dining room at the other residents eating. The resident was then asked if she wanted something else to eat. At 1:21 PM, a Dietary Aide (DA) 1, who had been cleaning the tables, was identified as going to get it [grilled cheese]. R88 received a grilled cheese sandwich at 1:26 PM, 48 minutes after stating she did not want the lunch that was served. R88 was observed to eat once the grilled cheese sandwich was provided. During an interview on 12/16/24 at 1:35 PM, the Licensed Practical Nurse (LPN) 2 said she did not realize the length of time before the resident received the sandwich stating, We were just trying to get everyone served and help them eat before getting the sandwich. During an interview on 12/19/24 at 4:33 PM, the Director of Nurses (DON) confirmed that the staff should have been seated to assist the residents with their meals. The DON said, They could have called the kitchen to send a sandwich. 4. Observation of the main dining room on 12/16/24 at 11:45 AM revealed four residents seated at the second table closest to the lobby area, all had their drinks. One resident received a meal at 12:04 PM, a second resident received a meal at 12:06 PM. The third resident received their plate at 12:13 PM and the fourth resident received a meal at 12:20 PM. During an interview on 12/16/24 at 12:21 PM with the fourth resident (R102) regarding waiting while the others at the table were eating started, It made me feel unloved. Review of R102's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses that included spinal stenosis, type II diabetes, and chronic kidney disease. Review of R102's admission MDS with an ARD of 12/01/24 revealed a BIMS score of 13 out of 15 which indicated R102 had intact cognition. During an interview on 12/19/24 at 4:43 PM regarding one person watching others eat at the same dining table, the DON stated an expectation that all at a table should all be served so they could eat at the same time. In a follow up interview on 12/19/24 at 5:03 PM, the DON stated the facility did not have a policy that addressed residents at the same table eating at the same time. 28154

Based on record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a discharge return anticipated (DCRA) Minimum Data Set (MDS) assessment was submitted timely for processing for one of one resident (Resident (R) 6) reviewed out of 30 sample residents. This failure had the potential to adversely affect care planning and care provision or payment to other facilities for any resident that may not have had a discharge assessment transmitted. Findings include: Review of the facility's policy titled, MDS Completion and Submission Timeframes, reviewed July 2017, revealed Policy Statement. Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation. 1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. Review of the October 2023 Resident Assessment Instrument (RAI) Manual, located at https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf, page 2-19, chart showed the DCRA assessment should be transmitted by the MDS Completion Date + (plus) 14 calendar days. Review of R6's electronic medical record (EMR) MDS tab showed a DCRA MDS with an Assessment Reference Date (ARD) of 09/15/24 with a completed status not an accepted status. Review of the history tab for the assessment showed Assessment was never added to a batch. During an interview on 12/17/24 at 4:21 PM regarding the completed status and history of not added to a batch, the MDS Coordinator (MDSC) confirmed the unsubmitted status stating, I own that. It was not submitted.

Based on observation, record review and interview, the facility failed to ensure one resident (Resident #3) received an antibiotic and a probiotic to treat a urinary tract infection (UTI) as ordered by the physician. The assistant director of nursing (ADON) received a verbal order from the resident's physician on 8/2/24 for Florastor (probiotic) that was never entered on the resident's medication administration record to administer and on 8/7/24 she received another verbal order to discontinue Macrobid (antibiotic) and start Cipro (antibiotic). She discontinued one antibiotic but did not enter the order in the resident's electronic medication administration record for the new antibiotic. This resulted in the resident being hospitalized for his/her continued untreated symptoms from the UTI. The facility census was 117. Review of the facility policy Verbal Order, dated 2021, showed the following: -Verbal orders shall only be given in an emergency or when the attending physician is not immediately available to write or sign the order; -Verbal orders are those given by an authorized practitioner directly to a person authorized to receive and transcribe orders on his/her behalf; -The individual receiving the verbal order must write it on the physician's order sheet as a verbal order. 1. Review of Resident #3's care plan, dated 3/1/24, showed the following: -The resident was at risk for activities of daily living and mobility decline and required assistance related to anticipated declines in condition due to disease process; -Assist with toileting as needed. The resident was incontinent of bowel and bladder. Encourage and assist the resident with toileting frequently and provide peri care; -The resident had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), type two diabetes with diabetic nephropathy (deterioration of kidney function), hemiparesis (weakness of one entire side of the body) and hemiplegia (the loss of voluntary movement of one side of the body), and aphasia (difficulty speaking) following a stroke. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 5/16/24, showed the following: -The resident's cognition was severely impaired; -The resident did not have any behaviors and did not reject care; -The resident required substantial/maximum assist from staff for toileting; -The resident was occasionally incontinent of bladder; -The resident was always continent of bowel; -The resident was dependent on staff for transfers from sitting to standing and from chair to bed. Review of the resident's progress note, dated 7/17/24, showed the following: -Straight catheter (a tube inserted into the bladder to drain urine and then taken out right after it is used) for a urine analysis (UA); -Moderate amount of foul, dark, cloudy, amber urine. Review of the resident's progress note, dated 7/29/24 at 1:17 P.M., showed the following: -A new order to collect urine for a UA with a culture and sensitivity (test to determine which bacteria are in the urine and which antibiotic would best treat the infection) test tonight; -Urine will be picked up tomorrow morning. Review of the resident's progress note, dated 8/2/24, showed the following: -The ADON received a partial UA result and reported to resident's physician; -The physician gave a new order to start Macrobid (antibiotic) 100 milligrams (mg) two times a day for seven days; -The physician gave a new order to start Florastor (probiotic) 250 mg two times a day for 14 days. Review of the resident's final lab results report, dated 8/2/24, showed the following: -The urine was collected on 7/29/24; -The lab received the urine on 7/30/24; -The lab reported the culture and sensitivity to the facility on [DATE] at 12:23 P.M.; -The report contained abnormal results; -The results showed the culture and sensitivity test found Enterobacter aerogenes (bacteria generally found in the gastrointestinal tract) in the resident's urine that required a specific antibiotic, Cipro, that the bacteria would be most sensitive to; -The Director of Nursing (DON) reviewed the resident's results on 8/4/24 at 10:44 A.M. (two days after the results were sent to the facility). Review of the resident's progress note, dated 8/7/24, showed the following: -A culture and sensitivity report was received for the resident's UA; -The ADON reported the results to the resident's physician; -The physician gave a new order to discontinue Macrobid; -The physician gave a new order to start Cipro (antibiotic) 250 mg two times a day for seven days. Review of the resident's undated physician order sheet showed no documentation staff transcribed the orders for Florastor or Cipro to the resident's Medication Administration Record (MAR), as ordered by the physician. Review of the resident's MAR, dated August 2024, showed the following: -Macrobid was started on 8/3/24 and discontinued on 8/7/24; -Florastor was not on the resident's August MAR; -Cipro was not on the resident's August MAR. Review of the resident's hospital discharge records, dated 8/16/24, showed the following: -The resident was admitted with vomiting, an abnormal UA and possible pneumonia; -The resident was diagnosed with pyelonephritis (severe kidney infection). During an interview on 8/21/24 at 10 :49 A.M., the ADON said the following: -She gave a note to a nurse (unknown name) to enter the order for Cipro into the resident's electronic medical record; -The order just got missed and the resident did not get the newly ordered antibiotic; -She would think since the resident did not get the antibiotic it had a negative effect on the resident and caused the resident to go to the hospital; -Lab results should be reported to the physician the day they are reported to the facility. During an interview on 8/21/24 at 1:15 P.M., the Director of Nursing (DON) said the following: -She expected physicians to be notified of abnormal lab results immediately; -She expected the ADON to enter the antibiotic order and not pass it off to another nurse to enter. **need more interview as to why she did not report to the physician when she reviewed report on 8/4/24** During an interview on 8/26/24 at 4:18 P.M., the resident's physician said the following: -He learned from the resident's family member that the staff did not administer the Cipro to the resident as ordered; -Staff should have administered the Cipro. He did culture and sensitivity tests to make sure his residents received the correct antibiotic to best fight an infection; -He was not aware the resident did not receive Florastor as ordered; -Pyelonephritis is the most serious infection. When an infection got to this point it meant the infection has gone from the bladder to the ureters (tubes that carry urine to the bladder) and up to the kidneys; -The resident definitely may have avoided a trip to the hospital and an infection as serious as pyelonephritis if he/she had received Cipro as he had ordered. MO240413

Refer to 50SJ12. Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of four sampled residents, received care and treatment in accordance with professional standards of practice when staff failed to obtain an x-ray in a timely manner after the resident sustained a fall and was in pain. The resident fell at 2:15 A.M. and the responsible party (RP) chose not to send the resident to the hospital and requested a mobile x-ray. Staff obtained a physician order for a STAT mobile x-ray at 3:00 A.M. on 6/30/24. The x-ray provider did not arrive until 10:30 A.M. on 6/30/24 to complete the x-ray and sent the x-ray results to the facility at 10:50 A.M. by fax and directly to the facility's electronic medical record system and the facility failed to administer pain medication or alternate interventions for the resident's pain. Staff did not communicate the x-ray results to the physician until 1:30 P.M. Resident #1 was subsequently sent to the emergency room and diagnosed with a fractured right shoulder. The facility also failed to follow the emergency room discharge orders for pain medication until the resident was seen by his/her physician for 12 days after the initial injury. The facility census was 117.

Refer to 50SJ12. Based on observation, interview, and record review, the facility failed to identify weight loss, notify the physician and dietician of further weight loss, implement interventions, or evaluate effectiveness of the interventions for three residents (Resident #2, #3, and #4) out of four sampled residents who had significant weight loss. Resident #2 had a 5.9% weight loss in five months; Resident #3 had a 9.3 % weight loss in 3 months and Resident #4 had a 17% weight loss in seven months. The facility failed to notify the physician or the registered dietician of the weight loss. The facility failed to implement and communicate the interventions that the Registered Dietician had put in place for Resident #4 to help prevent further weight loss. The facility census was 117.

Based on observation, interview, and record review, the facility failed to identify weight loss, notify the physician and dietician of further weight loss, implement interventions, or evaluate effectiveness of the interventions for three residents (Resident #2, #3, and #4) out of four sampled residents who had significant weight loss. Resident #2 had a 5.9% weight loss in five months; Resident #3 had a 9.3 % weight loss in 3 months and Resident #4 had a 17% weight loss in seven months. The facility failed to notify the physician or the registered dietician of the weight loss. The facility failed to implement and communicate the interventions that the Registered Dietician had put in place for Resident #4 to help prevent further weight loss. The facility census was 117. Review of the facility policy for Weight Assessment and Intervention dated 3/2023 showed the following: -Resident weights are monitored for undesirable or unintended weight loss or gain; -Residents are weighed upon admission and at intervals established by the interdisciplinary team; -Weights are recorded in each unit's weight record chart and in the individual's medical record; -Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing; -Unless notified of significant weight change, the dietician will review the unit weight record monthly to follow individual weight trends over time; -The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. one (1) month - 5% weight loss is significant; greater than 5% is severe; b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe; 6 months - 10% weight loss is significant; greater than 10% is severe; -If the weight is desirable, this is documented; -Evaluation: Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes: the resident target weight range (including rationale if different from ideal body weight); the residents calorie, protein, and other nutrient needs compared with the resident's current intake; the relationship between current medical condition or clinical situation and recent fluctuations in weight and; whether and to what extent weight stabilization or improvement can be anticipated; -The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss; -The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time; -The staff and physician will define the individual's current nutritional stats (weight, food/fluid intake and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutritional; -The physician will consider whether any assessment including diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition; -The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. 1. Review of Resident #2's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff dated 4/12/24 showed the following: -Usually able to make self understood and usually able to understand others; -Brief Interview for Mental Status (BIMS, an assessment used in nursing homes and other long-term care facilities to monitor cognition. The assessment involves three sections with the ultimate purpose of testing short-term word recall and orientation in time) of 5 - indicating severe cognitive impairment; -Independent with eating, oral hygiene, bathing, dressing, personal hygiene, transfer and ambulation. Assistance with toilet hygiene and putting on shoes; -Diagnoses of arthritis, dementia, and malnutrition; -Weight of 118 pounds. Review of the resident's care plan for malnutrition dated 4/15/24 showed the following: -Resident has a diagnosis of protein calorie malnutrition as evidenced by dementia and selective eater; -Goal: Will maintain adequate nutritional status as evidenced by stable weight; -Allow adequate time for meal consumption; Cater to food preferences: family brings in Honey Nut Cheerios and resident often requests only this for breakfast meal; Encourage adequate nutrition and hydration; Provide diet as ordered: regular. -The care plan did not address interventions when the resident did not come out for a meal or that it was his/her preference to sleep through a meal. Review of the resident's weights from 4/12/24 through 7/17/24 showed the following: -3/12/24 117 pounds; -4/19/24 112.6 pounds; -5/1/24 113.8 pounds; -6/21/24 113.0 pounds; -7/17/24 100.2 pounds. --5.98 % weight loss in five months. Review of the resident's progress notes from 4/12/24 through 7/17/24 showed no documentation from the Registered Dietician or the physician regarding the resident's weight loss. Review of the resident's physician order sheet (POS) for July 2024 showed an order for a regular diet and monthly weights. Observation on 7/23/24 at 11:48 A.M., showed Resident #2 in bed with his/her eyes closed. Observation on 7/23/24 from 11:50 A.M. through 1:15 P.M. showed the following: -At 11:50 A.M., staff assisted residents into the dining room on the memory care unit and began to serve the noon meal; -Staff assisted some residents with the meal, serving drinks and dessert; -One staff member exited the dining room at 12:26 P.M., and walked down the hall looking into each room. This staff entered room [ROOM NUMBER] and brought a resident to the dining room and served him/her a meal; -No staff entered Resident #2's room; -At 12:45 P.M., a dietary staff member removed the food from the kitchenette on the memory care and took it back to the kitchen leaving two covered plates in the kitchenette. Neither of the plates were labeled with Resident #2's name; -At 1:15 P.M., Resident #2 was in his/her room coming out of the bathroom. When asked if he/she was hungry, he/she replied, Yes; -No observation of staff following up with the resident and asking if the resident wanted to have lunch or providing the resident cereal or other food rather than the lunch service. During an interview on 7/23/24 at 1:00 P.M. Certified Nurse Aide (CNA) A said the following: -Resident #2 doesn't always come out for lunch; -We let him/her sleep and he/she will let us know if he/she wants to eat; -The family has brought in cereal for him/her, that is what he/she usually eats. 2. Review of Resident #3's quarterly MDS dated [DATE] showed the following: -Usually able to make self understood and usually able to understand others; -BIMS of a 6 - indicating severe cognitive impairment; -Required supervision with eating and assistance of staff with Activities of Daily Living (ADLs); -Diagnoses of Alzheimer's disease, dementia, anxiety, and depression; -Weight of 174 pounds. Review of the resident's monthly weights showed the following: -4/25/2024 176.0 pounds; -5/9/2024 174.4 pounds. Review of the care plan for nutrition dated 5/9/24 showed the following: -Resident is receiving mechanically altered diet; -Goal: Resident will maintain nutrition and hydration status as evidenced by good consumption; -Intervention: Feeds self in Memory Care Dining Room with set up assistance and cues. Review of the resident's malnutrition assessment form dated 5/9/24 showed the following: -No nutritional concerns identified; -Not at risk for malnutrition. Review of the resident's monthly weight dated 6/21/24 showed a weight of 168.6 pounds. Review of the resident's progress noted dated 6/21/24 signed by the Registered Dietician showed a weight loss nutrition note: weight: 168.6# on 6/21/24, -3.3% in 1 month. Feeds self in Memory Care dining Room. Recommend add NIP (nutritional interventions protocol) foods with meals to help increase nutritional intake. Recommend weekly weights x 4 weeks to follow trend. Will continue to follow and intervene further as needed. Review of the resident's progress notes dated 6/22/24 through 7/24/23 showed no documentation of weekly weights, no documentation of resident's intake, and no documentation of physician of weight loss. Review of the resident's medical record monthly weight showed the following: -7/17/24 157.8 pounds. -No weekly weights were documented; -A 9.3% weight loss in 3 months. Observation on 7/23/24 at 11:50 A.M. of the dining room on the memory care unit showed the following: -Staff assisted Resident #3 to a dining room table and served a meal of white rice, pureed meat and chopped broccoli; -Staff unwrapped the silverware and placed it in front of the resident then served the other residents. Observation on 7/23/24 from 11:50 A.M. to 12:45 P.M. showed no staff assisted Resident #3 with the meal, no staff asked the resident if he/she wanted anything different to eat. Observation on 7/23/24 at 12:45 P.M. showed Resident #3 sat in the same spot with a plate of food in front of him/her, he/she had not eaten any of the food. Staff took the resident away from the table back to his/her room and offered no substitutes to the meal. 3. Review of Resident #4's face sheet showed the resident admitted to the facility on [DATE]. Review of the monthly weights showed the following: -1/27/2024 - 131.0 pounds; -2/6/2024 - 126.8 pounds; -2/20/2024 - 126.8 pounds; -3/19/2024 - 138.4 pounds; -3/27/2024 - 124.6 pounds; -4/23/2024 -112.4 pounds; -4/30/2024 - 119.8 pounds. Review of the quarterly MDS dated [DATE] showed the following: -Usually able to make self understood and usually understands others; -BIMS of 4, indicating severe cognitive impairment; -Supervision with eating; -Diagnoses of anemia, Alzheimer's disease, dementia, seizure disorder, anxiety, and respiratory failure; -Weight of 120 pounds. Review of the resident's malnutrition assessment dated [DATE] showed the resident was at risk for malnutrition and the dietician should follow. Review of the resident's care plan for malnutrition dated 4/30/24 showed the following: -Resident at risk for malnutrition based on significant weight loss and inconsistent consumption; -Goal: Resident will maintain nutrition and hydration status as evidenced by adequate consumption through next review; -Interventions: Encourage food and fluids with and between meals and high calorie snacks between meals. Feeds self in Memory Care dining room with setup assistance and cues/prompts/encouragement; Regular diet with fortified foods. Review of the resident's progress notes dated 5/8/24 at 3:34 P.M. titled Care Conference Meeting showed the following: -Dietary: Appetite fluctuates. The family wants to make sure he/she is not sleeping through dinner time. If he/she doesn't like meals offer grilled cheese sandwiches or mac and cheese or potatoes. Enjoys breakfast related food. Enjoys sweets; -Reviewed weights and has had significant weight loss since admission. Offering fortified foods. Review of the POS for July 2024 showed an order for a regular diet with fortified foods with a start date of 4/17/24. Review of the resident's progress notes dated 5/8/24 through 7/17/24 showed no documentation from the Registered Dietician or a review of the weights. Review of the resident's monthly weight dated 7/17/24 showed a weight of 108.6 lbs. for a 17% weight loss in seven months. Review of the resident's progress notes dated 7/17/24 through 7/23/24 showed no documentation staff notified the physician of the resident's significant weight loss. Observation on 7/23/24 at 11:40 A.M. through 1:15 P.M. showed CNA A take Resident #4 into the dining room in a wheelchair and position the resident at a table with three other residents; -At 11:50 A.M., the Dietary Aide began serving the noon meal of white rice, broccoli and diced roast beef. CNA A served Resident #4 a plate of white rice, broccoli and diced beef that was served out of the same steam table pans as all of the other plates of food. There was no other food, protein or high calorie food added to the regular service to make it fortified; -CNA A sat the plate in front of the resident and then served the other residents; -Resident #4 wheeled him/herself out of the dining room several times and staff wheeled the resident back in to the dining room to the same spot, but did not offer to assist the resident with the meal; -At 12:18 P.M., CNA B served the residents in the dining room an ice cream sandwich; -Resident #4 ate the ice cream sandwich but did not eat any of the rice, broccoli or diced beef; -Staff removed the resident's uneaten plate of food at 12:40 P.M. and pushed Resident #4 into the sitting area. During an interview on 7/23/24 at 2:00 P.M. the dietary manager said the following: -Fortified foods should have been rice with butter and perhaps a roll with butter; -She was not sure if Resident #4 was on a fortified diet; -She does not attend any meetings about weight loss; -The weights are reviewed by the Registered Dietician and nursing. 4. During an interview on 7/24/24 at 10:00 A.M. the Registered Dietician said the following: -She will review the weights that are provided by nursing each time she comes into the facility; -She will review any resident who has had a weight loss to see if the weight loss continues; -She will document her assessment and plan in the progress note section of the electronic medical record and generate a report with her recommendations that goes to the Administrator, the Director of Nursing (DON), Unit Managers, MDS coordinator and the Dietary Manager. Once she makes her recommendations, she will follow up on her next visit to see if the recommendations have been followed; -If she makes a recommendation for weekly weights for four weeks, she will review after four weeks. She is assuming that nursing is following through with the recommendations; -She will re-evaluate a resident's weight if it shows back up on the weight report. Resident #2, #3, and #4 have not shown back up on the weight report. During an interview on 7/24/24 at 10:30 A.M. Unit Manager, Licensed Practical Nurse C said the following: -He/She has not completed any of the weights for a while, he/she does not think that the weights are accurate; -He/She spoke with the former DON about this concern and was waiting on guidance from him. He resigned several weeks ago, and he/she has not discussed this with the new DON yet; -He/She should go through the reports from the registered dietician and call the physician for orders and update the family. He/She had not done this. During an interview on 7/24/24 at 10:30 A.M. the DON said she was use to discussing the weights at risk management meetings but she has only been at the facility for a week and has not had the opportunity to review the weights or attend a risk management meeting. During an interview on 7/24/24 at 12:00 P.M. the MDS coordinator said the following: -The dietary manager should be taking the orders received and updating the care plan and the diet orders; -He/She was not sure if this had been done. During an interview on 7/30/24 at 9:10 A.M. the Administrator said he would expect nursing to review and discuss the registered dietician's recommendations and notify the physician of these recommendations. During an interview on 7/25/24 at 9:25 A.M. the Medical Director said she would expect the facility to monitor residents weights, notify the physician of any weight loss and registered dietician recommendations; -She would expect the facility to provide the diet as ordered. MO238155

Based on observation, interview, and record review, the facility failed to identify weight loss, notify the physician and dietician of further weight loss, implement interventions, or evaluate effectiveness of the interventions for three residents (Resident #2, #3, and #4) out of four sampled residents who had significant weight loss. Resident #2 had a 5.9% weight loss in five months; Resident #3 had a 9.3 % weight loss in 3 months and Resident #4 had a 17% weight loss in seven months. The facility failed to notify the physician or the registered dietician of the weight loss. The facility failed to implement and communicate the interventions that the Registered Dietician had put in place for Resident #4 to help prevent further weight loss. The facility census was 117. Review of the facility policy for Weight Assessment and Intervention dated 3/2023 showed the following: -Resident weights are monitored for undesirable or unintended weight loss or gain; -Residents are weighed upon admission and at intervals established by the interdisciplinary team; -Weights are recorded in each unit's weight record chart and in the individual's medical record; -Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing; -Unless notified of significant weight change, the dietician will review the unit weight record monthly to follow individual weight trends over time; -The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. one (1) month - 5% weight loss is significant; greater than 5% is severe; b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe; 6 months - 10% weight loss is significant; greater than 10% is severe; -If the weight is desirable, this is documented; -Evaluation: Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes: the resident target weight range (including rationale if different from ideal body weight); the residents calorie, protein, and other nutrient needs compared with the resident's current intake; the relationship between current medical condition or clinical situation and recent fluctuations in weight and; whether and to what extent weight stabilization or improvement can be anticipated; -The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss; -The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time; -The staff and physician will define the individual's current nutritional stats (weight, food/fluid intake and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutritional; -The physician will consider whether any assessment including diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition; -The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. 1. Review of Resident #2's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff dated 4/12/24 showed the following: -Usually able to make self understood and usually able to understand others; -Brief Interview for Mental Status (BIMS, an assessment used in nursing homes and other long-term care facilities to monitor cognition. The assessment involves three sections with the ultimate purpose of testing short-term word recall and orientation in time) of 5 - indicating severe cognitive impairment; -Independent with eating, oral hygiene, bathing, dressing, personal hygiene, transfer and ambulation. Assistance with toilet hygiene and putting on shoes; -Diagnoses of arthritis, dementia, and malnutrition; -Weight of 118 pounds. Review of the resident's care plan for malnutrition dated 4/15/24 showed the following: -Resident has a diagnosis of protein calorie malnutrition as evidenced by dementia and selective eater; -Goal: Will maintain adequate nutritional status as evidenced by stable weight; -Allow adequate time for meal consumption; Cater to food preferences: family brings in Honey Nut Cheerios and resident often requests only this for breakfast meal; Encourage adequate nutrition and hydration; Provide diet as ordered: regular. -The care plan did not address interventions when the resident did not come out for a meal or that it was his/her preference to sleep through a meal. Review of the resident's weights from 4/12/24 through 7/17/24 showed the following: -3/12/24 117 pounds; -4/19/24 112.6 pounds; -5/1/24 113.8 pounds; -6/21/24 113.0 pounds; -7/17/24 100.2 pounds. --5.98 % weight loss in five months. Review of the resident's progress notes from 4/12/24 through 7/17/24 showed no documentation from the Registered Dietician or the physician regarding the resident's weight loss. Review of the resident's physician order sheet (POS) for July 2024 showed an order for a regular diet and monthly weights. Observation on 7/23/24 at 11:48 A.M., showed Resident #2 in bed with his/her eyes closed. Observation on 7/23/24 from 11:50 A.M. through 1:15 P.M. showed the following: -At 11:50 A.M., staff assisted residents into the dining room on the memory care unit and began to serve the noon meal; -Staff assisted some residents with the meal, serving drinks and dessert; -One staff member exited the dining room at 12:26 P.M., and walked down the hall looking into each room. This staff entered room [ROOM NUMBER] and brought a resident to the dining room and served him/her a meal; -No staff entered Resident #2's room; -At 12:45 P.M., a dietary staff member removed the food from the kitchenette on the memory care and took it back to the kitchen leaving two covered plates in the kitchenette. Neither of the plates were labeled with Resident #2's name; -At 1:15 P.M., Resident #2 was in his/her room coming out of the bathroom. When asked if he/she was hungry, he/she replied, Yes; -No observation of staff following up with the resident and asking if the resident wanted to have lunch or providing the resident cereal or other food rather than the lunch service. During an interview on 7/23/24 at 1:00 P.M. Certified Nurse Aide (CNA) A said the following: -Resident #2 doesn't always come out for lunch; -We let him/her sleep and he/she will let us know if he/she wants to eat; -The family has brought in cereal for him/her, that is what he/she usually eats. 2. Review of Resident #3's quarterly MDS dated [DATE] showed the following: -Usually able to make self understood and usually able to understand others; -BIMS of a 6 - indicating severe cognitive impairment; -Required supervision with eating and assistance of staff with Activities of Daily Living (ADLs); -Diagnoses of Alzheimer's disease, dementia, anxiety, and depression; -Weight of 174 pounds. Review of the resident's monthly weights showed the following: -4/25/2024 176.0 pounds; -5/9/2024 174.4 pounds. Review of the care plan for nutrition dated 5/9/24 showed the following: -Resident is receiving mechanically altered diet; -Goal: Resident will maintain nutrition and hydration status as evidenced by good consumption; -Intervention: Feeds self in Memory Care Dining Room with set up assistance and cues. Review of the resident's malnutrition assessment form dated 5/9/24 showed the following: -No nutritional concerns identified; -Not at risk for malnutrition. Review of the resident's monthly weight dated 6/21/24 showed a weight of 168.6 pounds. Review of the resident's progress noted dated 6/21/24 signed by the Registered Dietician showed a weight loss nutrition note: weight: 168.6# on 6/21/24, -3.3% in 1 month. Feeds self in Memory Care dining Room. Recommend add NIP (nutritional interventions protocol) foods with meals to help increase nutritional intake. Recommend weekly weights x 4 weeks to follow trend. Will continue to follow and intervene further as needed. Review of the resident's progress notes dated 6/22/24 through 7/24/23 showed no documentation of weekly weights, no documentation of resident's intake, and no documentation of physician of weight loss. Review of the resident's medical record monthly weight showed the following: -7/17/24 157.8 pounds. -No weekly weights were documented; -A 9.3% weight loss in 3 months. Observation on 7/23/24 at 11:50 A.M. of the dining room on the memory care unit showed the following: -Staff assisted Resident #3 to a dining room table and served a meal of white rice, pureed meat and chopped broccoli; -Staff unwrapped the silverware and placed it in front of the resident then served the other residents. Observation on 7/23/24 from 11:50 A.M. to 12:45 P.M. showed no staff assisted Resident #3 with the meal, no staff asked the resident if he/she wanted anything different to eat. Observation on 7/23/24 at 12:45 P.M. showed Resident #3 sat in the same spot with a plate of food in front of him/her, he/she had not eaten any of the food. Staff took the resident away from the table back to his/her room and offered no substitutes to the meal. 3. Review of Resident #4's face sheet showed the resident admitted to the facility on [DATE]. Review of the monthly weights showed the following: -1/27/2024 - 131.0 pounds; -2/6/2024 - 126.8 pounds; -2/20/2024 - 126.8 pounds; -3/19/2024 - 138.4 pounds; -3/27/2024 - 124.6 pounds; -4/23/2024 -112.4 pounds; -4/30/2024 - 119.8 pounds. Review of the quarterly MDS dated [DATE] showed the following: -Usually able to make self understood and usually understands others; -BIMS of 4, indicating severe cognitive impairment; -Supervision with eating; -Diagnoses of anemia, Alzheimer's disease, dementia, seizure disorder, anxiety, and respiratory failure; -Weight of 120 pounds. Review of the resident's malnutrition assessment dated [DATE] showed the resident was at risk for malnutrition and the dietician should follow. Review of the resident's care plan for malnutrition dated 4/30/24 showed the following: -Resident at risk for malnutrition based on significant weight loss and inconsistent consumption; -Goal: Resident will maintain nutrition and hydration status as evidenced by adequate consumption through next review; -Interventions: Encourage food and fluids with and between meals and high calorie snacks between meals. Feeds self in Memory Care dining room with setup assistance and cues/prompts/encouragement; Regular diet with fortified foods. Review of the resident's progress notes dated 5/8/24 at 3:34 P.M. titled Care Conference Meeting showed the following: -Dietary: Appetite fluctuates. The family wants to make sure he/she is not sleeping through dinner time. If he/she doesn't like meals offer grilled cheese sandwiches or mac and cheese or potatoes. Enjoys breakfast related food. Enjoys sweets; -Reviewed weights and has had significant weight loss since admission. Offering fortified foods. Review of the POS for July 2024 showed an order for a regular diet with fortified foods with a start date of 4/17/24. Review of the resident's progress notes dated 5/8/24 through 7/17/24 showed no documentation from the Registered Dietician or a review of the weights. Review of the resident's monthly weight dated 7/17/24 showed a weight of 108.6 lbs. for a 17% weight loss in seven months. Review of the resident's progress notes dated 7/17/24 through 7/23/24 showed no documentation staff notified the physician of the resident's significant weight loss. Observation on 7/23/24 at 11:40 A.M. through 1:15 P.M. showed CNA A take Resident #4 into the dining room in a wheelchair and position the resident at a table with three other residents; -At 11:50 A.M., the Dietary Aide began serving the noon meal of white rice, broccoli and diced roast beef. CNA A served Resident #4 a plate of white rice, broccoli and diced beef that was served out of the same steam table pans as all of the other plates of food. There was no other food, protein or high calorie food added to the regular service to make it fortified; -CNA A sat the plate in front of the resident and then served the other residents; -Resident #4 wheeled him/herself out of the dining room several times and staff wheeled the resident back in to the dining room to the same spot, but did not offer to assist the resident with the meal; -At 12:18 P.M., CNA B served the residents in the dining room an ice cream sandwich; -Resident #4 ate the ice cream sandwich but did not eat any of the rice, broccoli or diced beef; -Staff removed the resident's uneaten plate of food at 12:40 P.M. and pushed Resident #4 into the sitting area. During an interview on 7/23/24 at 2:00 P.M. the dietary manager said the following: -Fortified foods should have been rice with butter and perhaps a roll with butter; -She was not sure if Resident #4 was on a fortified diet; -She does not attend any meetings about weight loss; -The weights are reviewed by the Registered Dietician and nursing. 4. During an interview on 7/24/24 at 10:00 A.M. the Registered Dietician said the following: -She will review the weights that are provided by nursing each time she comes into the facility; -She will review any resident who has had a weight loss to see if the weight loss continues; -She will document her assessment and plan in the progress note section of the electronic medical record and generate a report with her recommendations that goes to the Administrator, the Director of Nursing (DON), Unit Managers, MDS coordinator and the Dietary Manager. Once she makes her recommendations, she will follow up on her next visit to see if the recommendations have been followed; -If she makes a recommendation for weekly weights for four weeks, she will review after four weeks. She is assuming that nursing is following through with the recommendations; -She will re-evaluate a resident's weight if it shows back up on the weight report. Resident #2, #3, and #4 have not shown back up on the weight report. During an interview on 7/24/24 at 10:30 A.M. Unit Manager, Licensed Practical Nurse C said the following: -He/She has not completed any of the weights for a while, he/she does not think that the weights are accurate; -He/She spoke with the former DON about this concern and was waiting on guidance from him. He resigned several weeks ago, and he/she has not discussed this with the new DON yet; -He/She should go through the reports from the registered dietician and call the physician for orders and update the family. He/She had not done this. During an interview on 7/24/24 at 10:30 A.M. the DON said she was use to discussing the weights at risk management meetings but she has only been at the facility for a week and has not had the opportunity to review the weights or attend a risk management meeting. During an interview on 7/24/24 at 12:00 P.M. the MDS coordinator said the following: -The dietary manager should be taking the orders received and updating the care plan and the diet orders; -He/She was not sure if this had been done. During an interview on 7/30/24 at 9:10 A.M. the Administrator said he would expect nursing to review and discuss the registered dietician's recommendations and notify the physician of these recommendations. During an interview on 7/25/24 at 9:25 A.M. the Medical Director said she would expect the facility to monitor residents weights, notify the physician of any weight loss and registered dietician recommendations; -She would expect the facility to provide the diet as ordered. MO238155

Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of four sampled residents, received care and treatment in accordance with professional standards of practice when staff failed to obtain an x-ray in a timely manner after the resident sustained a fall and was in pain. The resident fell at 2:15 A.M. and the responsible party (RP) chose not to send the resident to the hospital and requested a mobile x-ray. Staff obtained a physician order for a STAT mobile x-ray at 3:00 A.M. on 6/30/24. The x-ray provider did not arrive until 10:30 A.M. on 6/30/24 to complete the x-ray and sent the x-ray results to the facility at 10:50 A.M. by fax and directly to the facility's electronic medical record system and the facility failed to administer pain medication or alternate interventions for the resident's pain. Staff did not communicate the x-ray results to the physician until 1:30 P.M. Resident #1 was subsequently sent to the emergency room and diagnosed with a fractured right shoulder. The facility also failed to follow the emergency room discharge orders for pain medication until the resident was seen by his/her physician for 12 days after the initial injury. The facility census was 117. The facility shared no policy upon request for reporting x-ray results or expectation for following discharge instructions. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 5/16/24 showed the following: -Brief Interview for Mental Status (BIMS, a test used to assess cognitive function. A BIMS score can range from 0 to 15, with lower scores indicating a decline in cognitive performance) of 3, which indicated severe cognitive impairment; -Required maximum assistance of staff for transfers, standing and unable to walk; -Diagnoses of Alzheimer's disease, stroke with paralysis one one side, and dementia. Review of the resident's care plan for falls dated 5/21/24 showed the the resident was at risk for falls with or without injury related to altered balance while standing and/or walking, and altered mental status. Review of the resident's progress note dated 6/30/24 at 10:26 A.M., signed by Licensed Practical Nurse (LPN) D showed the following: -Summoned to the resident's room approximately at 2:15 A.M. Upon starting rounds at 2:15 A.M. staff found the resident on the floor on his/her right side. The resident complained of right shoulder and arm pain. The resident's pain was assessed and observed to be in the right shoulder and arm. The resident was unable to complete full range of motion (ROM). Resident transferred by two staff members to bed. At 2:23 A.M., the resident's physician was notified for possible ER visit and evaluation. The physician said to follow up with the RP to see if he/she wanted resident to go to hospital or have an in house mobile x-ray. Contacted the RP at 2:30 A.M. and RP declined hospital transfer, but agreed to in house mobile x-ray. Mobile x-ray notified at 3:00 A.M. and an order for a x-ray was placed. As needed pain medication administered with good results. At 10:03 A.M. the facility mobile x-ray provider was in the facility to complete the x-ray. Currently awaiting the results. No other alternate interventions for pain were documented. During an interview on 8/2/24 at 1:40 P.M. LPN D said the following: -An aide came notified him/her on 6/30/24 around 2:15 A.M. that Resident #1 was on the floor; -He/She found the resident on his/her right side of the bed on a fall mat. The resident complained of pain in the right shoulder and could not move his/her right arm; -He/She called the physician and the physician gave an order for a STAT x-ray by the mobile x-ray provider or to send to the ER depending upon what the RP wanted; -The RP was notified and requested that the mobile x-ray provider take the x-ray; -He/She called the mobile x-ray provider numerous times and finally got someone on the phone around 3:00 A.M.; -The resident was in pain; -The mobile x-ray provider arrived at 10:00 A.M. and obtained the x-ray; -The RP was in the facility. Review of the Medication Administration Record (MAR) dated June 2024 showed no documentation staff administered Tylenol. Review of the resident's electronic medical record (EMR) showed the x-ray results were available to be viewed from the x-ray provider on 6/30/24 at 10:37 A.M. Review of the faxed x-ray report sent by the facility mobile x-ray provider dated 6/30/24 at 10:46 A.M. showed a complete fracture involving proximal right humerus (the largest bone of the upper arm) with displacement. Review of the resident's nurses notes dated 6/30/24 at 1:21 P.M. signed by LPN E showed the resident's shoulder x-ray results reported to the physician. New order received to send the resident to the ER for further evaluation. During an interview on 7/25/24 at 2:50 P.M. LPN E said the following: -LPN D reported the resident had fallen and an order was received for an x-ray; -The mobile x-ray provider was in the facility around 10:00 A.M. on 6/30/24 and took an x-ray of the resident's right shoulder; -The resident had been complaining of pain in the shoulder and the resident's RP was in the facility; -The RP asked several times throughout the morning if the results were available and he/she had not received any; -After lunch he/she received a phone call from the resident's physician inquiring about the results, he/she called the mobile x-ray provider and was told the results had been faxed to the facility around 10:30 A.M.; -He/She checked the fax machine on the hall he/she was working and the machine was broken; -Around 1:00 P.M., he/she checked the fax machine on the other halls and the x-ray results was there; -He/She notified the physician and received orders to send to the resident to the hospital ER for evaluation; -He/She worked for an agency and the facility had not informed him/her x-ray results would be uploaded in the EMR. Review of the resident's nurses note dated 6/30/24 at 1:31 P.M. showed the resident left the facility for treatment and evaluation at a local hospital. Review of the resident's progress note dated 6/30/24 at 7:05 P.M., showed the resident returned from the local hospital via EMS (emergency medical services). Instructions from the hospital included to keep the sling on at all times for comfort and support. The resident was non weight bearing of the right upper extremity. Follow up with physician in two to three weeks. Continue to take Tylenol as needed for pain. Use Lidoderm patch (brand name for lidocaine medication used to help reduce pain) as directed. Resident is at baseline and all vitals with in normal limits. Call placed to primary physician to notify of return. Awaiting return call. Review of the resident's hospital discharge orders showed an order for lidocaine 5% (pain medication in the Lidoderm patch), one patch daily for pain. Review of the resident's Medication Administration Record (MAR) for June 2024 showed no order for the Lidocaine (Lidoderm) patch. Review of the nurses notes dated 6/30/24 at 7:14 P.M. showed staff notified the resident's primary physician of the resident's return and no new orders. Review of the resident's MAR for July 2024 showed no order for the lidocaine patch 7/1/24 through 7/12/24. Review of the follow up orders from a local hospital orthopedic clinic dated 7/12/24 showed please apply lidocaine patch at least once a day to the right shoulder. Review of the MAR for July 2024 showed an order for lidocaine external patch 4 % patch. Apply to right shoulder topically one time a day for right shoulder pain with a start date of 7/16/24. The MAR showed the patch was applied daily starting 7/16/24 through 7/24/24. During an interview on 7/24/24 at 2:45 P.M. Registered Nurse F said the following: -He/She was the house supervisor on 6/30/24 but worked the 300 hall as the nurse; -LPN E reported Resident #1 had fallen in the night, had an x-ray done by the mobile x-ray company around 10:00 A.M. and had been sent to the hospital for evaluation after lunch; -He/She did not know the time the x-ray was available to be reviewed; -The x-ray should be uploaded by the x-ray provider in the EMR. He/She verified the x-ray had been uploaded in the EMR on 6/30/24 at 10:37 A.M.; -The x-ray provider also sends a fax report of the x-ray to the facility; -He/She did not know if the x-ray was faxed or if the nurse on the resident's hall was aware the report was also uploaded in the EMR. During an interview on 7/24/24 at 3:04 P.M., Representative A from the mobile x-ray provider said the following: -X-ray reports are faxed to the facility and verified the resident's x-ray report was faxed on 6/30/24 at 10:50 A.M.; -The report was also uploaded into the resident's EMR on 6/30/24 at 10:37 A.M.; -Some facilities will also set up a for a phone call notification of results that are positive for a fracture, he/she was not sure if this facility had this set up. During an interview on 7/31/24 at 9:57 A.M. Representative B from the mobile x-ray provider said the following: -The facility did not set in their contract to receive a phone call with results from x-rays; -The facility set up for results to be faxed to the facility, uploaded in the EMR and have text messages sent out to management personnel who were no longer employed at the facility; -Verification of the emails that were set up to receive text messages were for the former Director of Nursing (DON), Assistant Director of Nursing (ADON) and managers; -No one currently employed at the facility received any text messages to alert them of the results. -The facility called the order for the x-ray as a STAT order; -It is their policy that a STAT order can take from 4-6 hours to complete. Since the order was placed on a weekend, it would have taken longer to be completed; -Since the STAT order was obtained on a Sunday morning at 3:00 A.M., the completion time of 10:30 A.M. would have been considered acceptable; -He/she does not know if this timeframe was communicated to the facility. During an interview on 7/30/24 at 2:00 P.M. RP A said: -He/She came to the facility in the early hours the morning of 6/30/24; -He/She told the facility not to send the resident to the hospital but to have the facility mobile x-ray provider take the x-ray to save the resident the trauma of having to go to the hospital; -The nurse did not report the results until after lunch; -He/She would have had the resident sent to the hospital if he/she would have known it would have taken so long to get the x-ray and the results; -The resident has been in pain from the fractured shoulder and he/she has asked the nursing staff to call the physician for pain medication; -The resident came from the hospital with an order for lidocaine patches and the facility did not put the patch on for 12 days. During an interview on 7/24/24 at 3:30 P.M. the DON said: -He/she is not aware of the timeframes that the x-ray provider set for STAT orders; -He/she would not accept a turn around time of 4-6 hours or 7 and half hours for a STAT order to be completed; -He/she would expect staff to call the x-ray provider if they were not in the facility sooner than 4-6 hours and for sure before 7 hours; -He/she would expect staff to call the mobile x-ray provider if a report was not available within an hour. During an interview on 7/30/24 at 9:10 A.M. the Administrator said: -He does not know the time frame for the x-ray provider to come to the facility once called on a weekend; -He would not consider 1-3 hours as a long time to wait for results; -He would consider up to 3 hours an acceptable time frame for the physician to be notified of the results of the x-ray. During an interview on 7/25/24 at 9:27 A.M. the Medical Director said the following: -She would expect a STAT order to be completed sooner that 7 hours; -She would expect the facility to notify a physicians within an hour of the facility receiving results from x-rays or labs; -The facility should ensure all staff are aware of where to find these results, report timely and notify the physician of any pain a resident is having, and obtain orders for a stronger pain medication if needed; -The facility should have administered the lidocaine patch when ordered by the ER physician. MO238488

Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of four sampled residents, received care and treatment in accordance with professional standards of practice when staff failed to obtain an x-ray in a timely manner after the resident sustained a fall and was in pain. The resident fell at 2:15 A.M. and the responsible party (RP) chose not to send the resident to the hospital and requested a mobile x-ray. Staff obtained a physician order for a STAT mobile x-ray at 3:00 A.M. on 6/30/24. The x-ray provider did not arrive until 10:30 A.M. on 6/30/24 to complete the x-ray and sent the x-ray results to the facility at 10:50 A.M. by fax and directly to the facility's electronic medical record system and the facility failed to administer pain medication or alternate interventions for the resident's pain. Staff did not communicate the x-ray results to the physician until 1:30 P.M. Resident #1 was subsequently sent to the emergency room and diagnosed with a fractured right shoulder. The facility also failed to follow the emergency room discharge orders for pain medication until the resident was seen by his/her physician for 12 days after the initial injury. The facility census was 117. The facility shared no policy upon request for reporting x-ray results or expectation for following discharge instructions. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 5/16/24 showed the following: -Brief Interview for Mental Status (BIMS, a test used to assess cognitive function. A BIMS score can range from 0 to 15, with lower scores indicating a decline in cognitive performance) of 3, which indicated severe cognitive impairment; -Required maximum assistance of staff for transfers, standing and unable to walk; -Diagnoses of Alzheimer's disease, stroke with paralysis one one side, and dementia. Review of the resident's care plan for falls dated 5/21/24 showed the the resident was at risk for falls with or without injury related to altered balance while standing and/or walking, and altered mental status. Review of the resident's progress note dated 6/30/24 at 10:26 A.M., signed by Licensed Practical Nurse (LPN) D showed the following: -Summoned to the resident's room approximately at 2:15 A.M. Upon starting rounds at 2:15 A.M. staff found the resident on the floor on his/her right side. The resident complained of right shoulder and arm pain. The resident's pain was assessed and observed to be in the right shoulder and arm. The resident was unable to complete full range of motion (ROM). Resident transferred by two staff members to bed. At 2:23 A.M., the resident's physician was notified for possible ER visit and evaluation. The physician said to follow up with the RP to see if he/she wanted resident to go to hospital or have an in house mobile x-ray. Contacted the RP at 2:30 A.M. and RP declined hospital transfer, but agreed to in house mobile x-ray. Mobile x-ray notified at 3:00 A.M. and an order for a x-ray was placed. As needed pain medication administered with good results. At 10:03 A.M. the facility mobile x-ray provider was in the facility to complete the x-ray. Currently awaiting the results. No other alternate interventions for pain were documented. During an interview on 8/2/24 at 1:40 P.M. LPN D said the following: -An aide came notified him/her on 6/30/24 around 2:15 A.M. that Resident #1 was on the floor; -He/She found the resident on his/her right side of the bed on a fall mat. The resident complained of pain in the right shoulder and could not move his/her right arm; -He/She called the physician and the physician gave an order for a STAT x-ray by the mobile x-ray provider or to send to the ER depending upon what the RP wanted; -The RP was notified and requested that the mobile x-ray provider take the x-ray; -He/She called the mobile x-ray provider numerous times and finally got someone on the phone around 3:00 A.M.; -The resident was in pain; -The mobile x-ray provider arrived at 10:00 A.M. and obtained the x-ray; -The RP was in the facility. Review of the Medication Administration Record (MAR) dated June 2024 showed no documentation staff administered Tylenol. Review of the resident's electronic medical record (EMR) showed the x-ray results were available to be viewed from the x-ray provider on 6/30/24 at 10:37 A.M. Review of the faxed x-ray report sent by the facility mobile x-ray provider dated 6/30/24 at 10:46 A.M. showed a complete fracture involving proximal right humerus (the largest bone of the upper arm) with displacement. Review of the resident's nurses notes dated 6/30/24 at 1:21 P.M. signed by LPN E showed the resident's shoulder x-ray results reported to the physician. New order received to send the resident to the ER for further evaluation. During an interview on 7/25/24 at 2:50 P.M. LPN E said the following: -LPN D reported the resident had fallen and an order was received for an x-ray; -The mobile x-ray provider was in the facility around 10:00 A.M. on 6/30/24 and took an x-ray of the resident's right shoulder; -The resident had been complaining of pain in the shoulder and the resident's RP was in the facility; -The RP asked several times throughout the morning if the results were available and he/she had not received any; -After lunch he/she received a phone call from the resident's physician inquiring about the results, he/she called the mobile x-ray provider and was told the results had been faxed to the facility around 10:30 A.M.; -He/She checked the fax machine on the hall he/she was working and the machine was broken; -Around 1:00 P.M., he/she checked the fax machine on the other halls and the x-ray results was there; -He/She notified the physician and received orders to send to the resident to the hospital ER for evaluation; -He/She worked for an agency and the facility had not informed him/her x-ray results would be uploaded in the EMR. Review of the resident's nurses note dated 6/30/24 at 1:31 P.M. showed the resident left the facility for treatment and evaluation at a local hospital. Review of the resident's progress note dated 6/30/24 at 7:05 P.M., showed the resident returned from the local hospital via EMS (emergency medical services). Instructions from the hospital included to keep the sling on at all times for comfort and support. The resident was non weight bearing of the right upper extremity. Follow up with physician in two to three weeks. Continue to take Tylenol as needed for pain. Use Lidoderm patch (brand name for lidocaine medication used to help reduce pain) as directed. Resident is at baseline and all vitals with in normal limits. Call placed to primary physician to notify of return. Awaiting return call. Review of the resident's hospital discharge orders showed an order for lidocaine 5% (pain medication in the Lidoderm patch), one patch daily for pain. Review of the resident's Medication Administration Record (MAR) for June 2024 showed no order for the Lidocaine (Lidoderm) patch. Review of the nurses notes dated 6/30/24 at 7:14 P.M. showed staff notified the resident's primary physician of the resident's return and no new orders. Review of the resident's MAR for July 2024 showed no order for the lidocaine patch 7/1/24 through 7/12/24. Review of the follow up orders from a local hospital orthopedic clinic dated 7/12/24 showed please apply lidocaine patch at least once a day to the right shoulder. Review of the MAR for July 2024 showed an order for lidocaine external patch 4 % patch. Apply to right shoulder topically one time a day for right shoulder pain with a start date of 7/16/24. The MAR showed the patch was applied daily starting 7/16/24 through 7/24/24. During an interview on 7/24/24 at 2:45 P.M. Registered Nurse F said the following: -He/She was the house supervisor on 6/30/24 but worked the 300 hall as the nurse; -LPN E reported Resident #1 had fallen in the night, had an x-ray done by the mobile x-ray company around 10:00 A.M. and had been sent to the hospital for evaluation after lunch; -He/She did not know the time the x-ray was available to be reviewed; -The x-ray should be uploaded by the x-ray provider in the EMR. He/She verified the x-ray had been uploaded in the EMR on 6/30/24 at 10:37 A.M.; -The x-ray provider also sends a fax report of the x-ray to the facility; -He/She did not know if the x-ray was faxed or if the nurse on the resident's hall was aware the report was also uploaded in the EMR. During an interview on 7/24/24 at 3:04 P.M., Representative A from the mobile x-ray provider said the following: -X-ray reports are faxed to the facility and verified the resident's x-ray report was faxed on 6/30/24 at 10:50 A.M.; -The report was also uploaded into the resident's EMR on 6/30/24 at 10:37 A.M.; -Some facilities will also set up a for a phone call notification of results that are positive for a fracture, he/she was not sure if this facility had this set up. During an interview on 7/31/24 at 9:57 A.M. Representative B from the mobile x-ray provider said the following: -The facility did not set in their contract to receive a phone call with results from x-rays; -The facility set up for results to be faxed to the facility, uploaded in the EMR and have text messages sent out to management personnel who were no longer employed at the facility; -Verification of the emails that were set up to receive text messages were for the former Director of Nursing (DON), Assistant Director of Nursing (ADON) and managers; -No one currently employed at the facility received any text messages to alert them of the results. -The facility called the order for the x-ray as a STAT order; -It is their policy that a STAT order can take from 4-6 hours to complete. Since the order was placed on a weekend, it would have taken longer to be completed; -Since the STAT order was obtained on a Sunday morning at 3:00 A.M., the completion time of 10:30 A.M. would have been considered acceptable; -He/she does not know if this timeframe was communicated to the facility. During an interview on 7/30/24 at 2:00 P.M. RP A said: -He/She came to the facility in the early hours the morning of 6/30/24; -He/She told the facility not to send the resident to the hospital but to have the facility mobile x-ray provider take the x-ray to save the resident the trauma of having to go to the hospital; -The nurse did not report the results until after lunch; -He/She would have had the resident sent to the hospital if he/she would have known it would have taken so long to get the x-ray and the results; -The resident has been in pain from the fractured shoulder and he/she has asked the nursing staff to call the physician for pain medication; -The resident came from the hospital with an order for lidocaine patches and the facility did not put the patch on for 12 days. During an interview on 7/24/24 at 3:30 P.M. the DON said: -He/she is not aware of the timeframes that the x-ray provider set for STAT orders; -He/she would not accept a turn around time of 4-6 hours or 7 and half hours for a STAT order to be completed; -He/she would expect staff to call the x-ray provider if they were not in the facility sooner than 4-6 hours and for sure before 7 hours; -He/she would expect staff to call the mobile x-ray provider if a report was not available within an hour. During an interview on 7/30/24 at 9:10 A.M. the Administrator said: -He does not know the time frame for the x-ray provider to come to the facility on ce called on a weekend; -He would not consider 1-3 hours as a long time to wait for results; -He would consider up to 3 hours an acceptable time frame for the physician to be notified of the results of the x-ray. During an interview on 7/25/24 at 9:27 A.M. the Medical Director said the following: -She would expect a STAT order to be completed sooner that 7 hours; -She would expect the facility to notify a physicians within an hour of the facility receiving results from x-rays or labs; -The facility should ensure all staff are aware of where to find these results, report timely and notify the physician of any pain a resident is having, and obtain orders for a stronger pain medication if needed; -The facility should have administered the lidocaine patch when ordered by the ER physician. MO238488

Based on interview and record review, the facility failed to follow professional standards of practice for one resident (Resident #1) when the resident sustained an injury that was not reported timely. On 5/31/23, staff found the resident in his/her wheelchair, unresponsive, with a dime sized hematoma (an injury caused blood to collect an pool under the skin) to the left eyebrow and bruising and protrusion (a bulge or bump) to the left shoulder. The resident required extensive assistance of one staff for transfers and had a diagnosis of stroke with hemiplegia (paralysis of one side of the body). Certified Nurse Aide (CNA) C reported he/she changed the resident's incontinence brief, dressed the resident for the day, and covered the resident back up and left him/her in bed at approximately 5:30 A.M. At 6:50 A.M. Licensed Practical Nurse (LPN) B found the resident in his/her wheelchair unresponsive (unconscious) with a facial injury. Facility staff members said the resident would be unable to get himself/herself off the floor without assistance and were unable to explain how the resident got from the bed to the wheelchair or how the resident's injuries were obtained. Staff failed to report the resident's injuries or how they were obtained in accordance with acceptable standards of practice, causing a delay in assessment and treatment of the resident. The facility census was 116. Review of the facility policy, Change in Condition, revised 3/16/23, showed the following: -The purpose of the policy is to provide guidelines to ensure timely identification and physician notification of a change in a resident's baseline; -A physician should be notified promptly of any change in a resident's condition including but not limited to the following: -The occurrence of a fall or accidental injury (skin tear, bruise, etc.); -Change in mental status; -Signs of an impending stroke such as facial drooping, numbness in extremity, or sudden loss of use; -The nurse should document notification of the physician and any orders obtained into medical record and implement as ordered. 1. Review of Resident #1's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 5/9/23, showed the following: -Diagnoses included cerebral vascular accident (stroke or CVA), hemiplegia (paralysis of one side of the body); -Clear speech; -Makes self-understood and understands others; -Severe cognitive impairment; -No behaviors exhibited; -Limited assistance of one staff member with bed mobility and locomotion on and off the unit; -Extensive assistance of one staff member with transfers, dressing, toilet use and personal hygiene; -Not steady and only able to stabilize with human assistance with moving from seated to standing position, moving on and off the toilet, and surface to surface transfer (transfer between bed and chair or wheelchair); -Functional limitation of range of motion on one side of both the upper and lower body; -Utilized a wheelchair; -Two or more falls without injury since admission or prior assessment. Review of the resident's care plan, last revised on 5/31/23, showed the following: -Cognitive deficit: the resident had progressive short and long term memory loss due to cognitive impairment, anticipate needs, encourage independence and respect, observe for signs of frustration, anxiety, or agitation. Gently attempt to calm the resident and refocus to other activities; -The resident had a CVA with left side hemiplegia and neglect, the resident had emotional incontinence (a disorder of emotional control following brain damage) and would cry often. This can happen when he/she was happy, sad and mad; -The resident was at risk for falls related to weakness and health decline. The resident was a high risk for falls due to decreased safety awareness and impulsiveness. Review of the resident's progress note, completed by Unit Manager/Licensed Practical Nurse (LPN) I, dated 5/31/23 at 7:00 A.M., showed at or around 6:53 A.M., staff notified the nurse of a change in condition in the resident. Upon entering the room the resident was found sitting in his/her wheelchair at an angle at the foot of his/her bed facing the bed towards the headboard. The resident was unresponsive with saliva coming from the right side of his/her mouth, a large hematoma to his/her left eye, pupils dilated to eight or nine with no response to light, unable to return grips. Bruising and protrusion to his/her left shoulder with some redness noted to his/her inner left arm fold. The nurse called out the resident's name and there was no response, attempted to complete a neurological and stroke assessment. The resident was unable to follow request or commands. At this time the nurse initiated a call to physician's emergency after hours on call. When there was no answer a 911 call was made for hospital escort and began to print out hospital transfer paperwork while other staff remained with the resident. Notified the supervisor and left a message for a family member with a return call shortly after. This nurse gave an update on the findings along with the time and the place. The resident was taken to the hospital. Review of the facility's investigation summary and conclusion, undated, showed the following: -Date of incident: May 31, 2023, injury of unknown origin; -Summary: the resident was found in his/her wheelchair unresponsive (unconscious) with a facial injury at 6:50 A.M. by the floor nurse. The nurse sent for assistance from the nurse supervisor, assessed the resident, and sent the resident to the emergency room via 911 ambulance; -Hospital records showed initial hemorrhagic stroke (a ruptured blood vessel causes bleeding inside the brain) which caused her to fall and hit his/her head leading to another traumatic intracerebral brain hemorrhage (ICH, a collection of blood within the skull. Usually caused by a blood vessel that bursts in the brain, it may also be caused by trauma such as a car accident or a fall); -Conclusion: after observation of the resident's room and furniture and room placement, the resident most likely fell during the stroke and hit the corner of his/her night stand and the floor. The resident had a history of attempting to self-transfer as well as falls. Review of the resident's hospital consult note, dated 5/31/23 at 3:26 P.M., showed the following: -Complaint: unresponsive bilateral (BIL, both sides of the body) intracerebral brain hemorrhage. The resident had a history of right frontal IPH (intraparenchymal hemorrhage, a bleed that occurs within the brain) on 7/1/22 with residual left hemiparesis (partial paralysis one side of the body) right caudate nucleus (a structure that lies deep inside the brain and plays a critical role in various higher neurological functions) infarct (dead tissue resulting from failure of blood supply), presented today unresponsive. The resident was found this morning sitting in chair with left sided facial injury and unresponsive. The resident was worked up and found to have bilateral IPH; -It was possible that the patient had an initial hemorrhagic stroke which caused him/her to fall and hit his/her head leading to another traumatic ICH. During an interview on 6/6/23 at 3:45 P.M. Certified Nurse Aide (CNA) C said the following: -He/She was assigned the resident's hall on the night shift (7:00 P.M. to 7:00 A.M.) on 5/31/23. The resident did not have a fall on his/her shift; -At 5:30 A.M., CNA C changed the resident's incontinence brief, dressed the resident for the day, and covered the resident back up and left him/her in bed; -CNA C left the facility around 6:00 A.M.; -CNA C was not aware the resident had attempted to get up without assistance in the past. Sometimes the resident sat on the side of the bed and yelled for help to get up. During an interview on 6/14/23 at 7:00 A.M. Licensed Practical Nurse (LPN) A said the following: -He/She worked the evening and night shift of 5/30/23; -He/She administered medication to the resident around 5:00 A.M. on 5/31/23. The resident was in bed asleep and he/she had to wake the resident to administer the medication; -The resident spoke to him/her and was responsive, no injury was noted at that time. LPN A did not recall if the resident was dressed, as the resident was under the covers; -After LPN A finished his/her medication pass he/she went to give report to the oncoming nurse LPN B. LPN A charted around 30 minutes and then left the facility at 6:31 A.M.; -LPN A did no go back down the resident's hall, did not hear anything unusual and was not aware of the resident had any type of fall or injury; -LPN A was unaware of the resident's injuries until the Director of Nursing (DON) called him/her later that morning and questioned him/her about the injuries. During an interview on 6/22/23 at 12:40 P.M. LPN B said the following: -The morning of 5/31/23 LPN B went to pass medications on the resident's hall; -LPN B looked into the resident's room (from the doorway) and saw the resident seated in his/her wheelchair, positioned at the foot of the bed at an angle and faced the head board. The resident was typically still in bed at that time; -LPN B observed two knots (raised areas on the resident's face) on the left side of the resident's face (visible from the hall). LPN B entered the room and the resident was unresponsive. LPN B immediately went to get the Unit Manager/LPN I to assist him/her; -The resident must have had a fall and someone put the resident in his/her wheelchair without reporting the incident. The resident required assist of one staff member with transfers. The resident could not get up off the floor after a fall without assistance; -The resident had attempted to self-transfer in the past. During an interview on 6/6/23 at 4:40 P.M. Unit Manager/LPN I said the following: -He/She was the unit manager on Resident #1's hall. On the morning of 5/31/23 at approximately 6:53 A.M., LPN I was working in his/her office when LPN B came running and yelling that something was going on with the resident; -LPN I got the vital sign equipment and went to the resident's room. The resident was not responsive; -The resident was seated in his/her wheelchair, the wheelchair brakes were locked, and the wheelchair was positioned at the foot of the bed and the resident faced toward the headboard of the bed; -The resident had a hematoma to the left eye brow, approximately dime sized. It appeared new and had not started to bruise much yet; -The resident could not follow commands. LPN I tried to reach the resident's physician and was unsuccessful, so he/she called 911. During an interview on 6/6/23 at 10:38 A.M. and 4:35 P.M., the Director of Nursing (DON) said the following: -She feels the resident had a fall the morning of 5/31/23 and a staff member put the resident into his/her wheelchair without notifying anyone. It would be an impossibility for the resident to get up off of the floor on his/her own after a fall; -She would expect staff to report a fall immediately to the charge nurse who would notify the physician; -The charge nurse, LPN A, administered medications to the resident on 5/31/23 at approximately 5:00 A.M. and LPN A said there was nothing out of the ordinary with the resident at that time; -On 5/31/23, CNA C was assigned to the resident and left at 6:00 A.M. CNA C said he/she had changed the resident and left him/her in bed prior to leaving that morning; -All staff were interviewed that worked on 5/31/23 during the timeframe the resident was found in his/her wheelchair. All of the staff denied knowledge of the resident falling that morning or putting the resident in his/her wheelchair. During an interview on 6/12/23 at 10:45 A.M., the administrator said the following: -The facility was unaware of how the resident sustained the injury. The facility reported the incident to the state agency because the injury was of unknown origin; -If the resident had a fall, it was unlikely that the resident could get himself/herself back up into the wheelchair; -The facility completed an investigation and were unable to determine how the injuries occurred. If the resident had a fall she would expect staff to report it, and for the fall to be investigated and documented. During an interview on 6/12/23 at 11:00 A.M., the resident's primary physician said the following: -The resident had a past history of CVA; -She felt the resident had a fall on 5/31/23. The resident would not be able to get back up in the wheelchair without assistance from the nursing staff. MO00219508 MO00219225

Based on observation, interview and record review, the facility failed to implement interventions to prevent accidents for one resident (Resident #12) in a review of 26 sampled residents and for one discharged resident (Resident #405). The facility census was 117. 1. Review of the facility policy Fall Program undated, showed : Identification of a fall risk is the first step in prevention of a fall. Upon getting a referral to our center, the Admission coordinator will be gathering any prior fall information available. This information will be considered during the bed management/placement process. The admissions coordinator will alert the receiving nurse if there is a known fall risk. The admissions coordinator will identify the chart with a yellow sticker. The name label on the door will be printed with yellow label tape. Prior to admission, the admitting nurse will gather clinical information from report from the sending hospital or referral source. If it is determined that there is a risk for falls, the nurse will identify the chart with a yellow sticker if not done previously. Upon admission, the nurse will complete a fall risk assessment. If the patient is identified as a fall risk, one or more appropriate interventions will be put into place, coded on the interim care plan and on the CNA flow sheet. Yellow name for new admissions and high risk resident. Upon admission, the therapy department will complete a fall risk assessment and communicate with the nursing department if interventions are to be put in place, care planned and identified. Yellow flat zip ties will be placed on any ambulation device, wheelchair, walker, etc. to alert all staff to the potential fall risk and to consult the care plan for interventions. At the time of a fall, any partner who witnessed or is in the area Huddle. Safety intervention will immediately be assessed. Intervention will be added. Falls will be reviewed weekly at five star meetings and monthly QA for Administrator and Medical Director Review. 2. Review of the facility policy Accidents and Incidents-Investigating and Reporting, dated 7/17 showed: Policy Statement: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. 1.) The nurse supervisor/charge nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2.) The following data, as applicable, shall be included on the Report of Incident/Accident form: The date and time the accident/incident took place; the nature of the injury/illness (e.g. bruise, fall, nausea, etc.); the circumstances surrounding the accident/incident; where the accident took place; the names of witnesses and their accounts of the accident; the injured person's attending physician was notified as well as the time the physician responded and his/her instructions; the date/time the injured person's family was notified and by whom; the condition of the injured person, including vital signs; the disposition of the injured (i.e , transferred to hospital, put to bed, etc ., any corrective action taken; follow-up information; other pertinent data as necessary or required and the signature and title of the person competing the report. 3.) This facility is in compliance with current rules and regulation governing accidents and /or incidents involving a medical device; 5.) The nurse supervisor/charge nurse and/or department director or supervisor shall complete a Report of Incident/ Accident form and submit the original to the Director of Nursing (DON) Services within 24 hours of the incident or accident. 3. Review of Resident #405's care plan dated 5/1/19, showed the following: -admitted [DATE]; -[DIAGNOSES REDACTED]. -The resident was a fall risk related to decreased mobility. Goal was remain free from injury. Staff should encourage the resident to assume a standing position slowly and use environmental devices such as hand grips and hand rails. Staff should give the resident verbal reminders not to ambulate/transfer without assistance, keep the bed in lowest position with brakes locked, keep personal items and frequently used items within reach and provide proper, well-maintained footwear. Review of the resident's Skilled Nurse's Note dated 5/1/19, showed the following: -Alert with short and long term memory problem; -Staff documented provided fall prevention education; -Resident up with assistance only to a wheelchair. Review of the resident's Fall Risk assessment dated [DATE], showed the following: -One fall within the previous six months, scored 5 points; -Age greater than or equal to 80, scored 3 points; -Required assistance or supervision for mobility, transfer, or ambulation, scored 2 points; -Unsteady gait, scored 2 points; -Altered awareness of immediate physical environment, scored 1 point; -Total fall risk score of 13 indicated moderate fall risk. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/6/19, showed the following: -Moderately impaired cognition; -No behaviors or rejection of care; -Supervision of one staff for bed mobility; -Limited assist of one staff for transfer dressing, toilet use and personal hygiene; -Balance unsteady, only able to stabilize with human assistance; -No range of motion impairment; -Wheelchair for mobility; -Occasionally incontinent of bladder/bowel; -Fall in last month prior to admission. No falls since admission; -Occupational and Physical Therapy last five days (5/1/19). Review of the resident's Skilled Nurse's Note dated 5/11/19, showed the following: -Oriented to person and situation; -Unsteady, shuffling gait and weakness; -Resident up with assistance only to a wheelchair; -At 3:15 P.M., summoned to the resident's room. CNA heard a banging noise from the room. Resident observed on the bathroom floor. The resident stated honestly honey I don't know whether I tripped or what, I just know I fell and hit my elbow, my head, and my leg. Resident denied pain. Red discoloration noted to the right and left elbows with abrasion. A bump was noted to the crown of the resident's head. The resident was able to move all extremities without pain. Assisted the resident from the floor with two staff members assistance. The resident's wheelchair was noted at bedside, he/she ambulated without staff assistance to the bathroom. Feces was noted in the toilet. Review of the resident's Fall Event Report dated 5/11/19 showed the following: -Fall with head injury; -Resident fell while ambulating in the bathroom without assistance or a device; -Unwitnessed fall; -Bruising, bump were noted to the head, extremities or trunk; -Initiated neurological checks, fall prevention program and monitor status for 72 hours for bruising, change in mental status or condition, pain or other injuries related to the fall; -Resident counseled on importance of using call light for assistance, wander-guard in place to right ankle and resident was placed at nurses' station for closer monitoring; -Resident was educated on calling for assistance and room kept free of clutter. Care plan updated. Review of the resident's care plan updated 5/11/19, showed the resident fell while self-ambulating in the bathroom and hit head. Staff should check resident frequently, verbally prompt to toilet, and encourage staff assistance and use of wheelchair for mobility. Review of the resident's Therapy Assessment Fall Screen dated 5/14/19 ,showed the following: -Resident fell [DATE]; -Resident had unwitnessed fall while toileting alone. Fall precautions were in place, resident had wander guard and had begun using the wheelchair for functional mobility rather that a wheeled walker. Recommended frequent room checks and reminders to use call light for obtaining assistance for transfers. Review of the resident's care plan updated 5/14/19, showed the resident would attempt to stand and not use a device. Staff should encourage assistance and verbal prompting to assist with memory recall of safety awareness. The resident had poor fall and safety awareness due to moderately impaired cognition. Review of the resident's Nurses' Notes showed the following: -On 5/26/19 at 4:45 A.M., staff documented heard a loud bump; -Resident found on the floor next to bed with trash can between his/her legs and no pants or underwear on; -The resident said he/she had to use the bathroom and tripped over the trash can; -No new injuries noted. Review of the resident's Fall Event Report dated 5/26/19 and completed on 5/31/19, showed the following: -On 5/26/19 found resident on floor in his/her room; -Unwitnessed fall; -No injuries reported; -The resident was kept in the common area and started day programming on memory care, bed in low position. Review of the resident's care plan updated 5/26/19, showed the resident fell in his/her room while attempting to self-toilet. Staff noted decreased fall and safety awareness with poor memory recall, no injuries. Staff should check frequently in the night and offer to toilet and rise when awake. Review of the care plan showed no evidence staff evaluated current interventions or implemented new interventions to prevent further falls after the 5/26/19 fall. Review of the resident's Nurses' Notes showed the following: -On 5/27/19 at 3:24 A.M., staff documented the resident continued to transfer self without staff assistance; -The resident was up throughout the night in the wheelchair; -At approximately 2:30 A.M., the resident was found with pants down sitting on the air/heat unit; -The resident said he/she needed to use the bathroom and urinated on the air/heat unit. Review of the resident's Therapy Assessment Fall Screen dated 5/27/19 showed the following: -Resident fell [DATE]; -Resident fell attempting self-transfer following need to use restroom. Continue per plan of care with frequent checks and education on use of call light for Activities of Daily Living (ADLs) needs. Review of the resident's Nurses' Notes dated 5/31/19, showed staff documented the resident fell near the door to his/her room. Resident's right hip displayed external rotation, resident was crying out in pain holding his/her right hip. Emergency Medical Services (EMS) was notified. The resident was transferred to the hospital emergency department. Review of the resident's Fall Event Report dated 5/31/19, showed the following: -Found on the floor; -Unwitnessed fall; -Exhibited excruciating pain in the right hip with bone fracture. Review of the resident's care plan updated 5/31/19 showed the resident fell in room self-ambulating without a wheelchair. Staff noted the resident was injured and sent to the hospital emergency room . During interview on 8/16/19 at 4:40 P.M., the Director of Rehab services said the following: -Resident #405 had poor cognition and he/she doubted the resident would remember to use the call light from one time to the next. The resident would not have remembered to use his/her walker and he/she was not sure the resident was added to the Restorative Program before he/she was sent out; -They try to look at event (falls) and come up with interventions; -During the five star meeting (held on Thursday) they go through each person and try to find root cause, looking at cognition, timing and toileting schedule; -The nurse who attended the five star meeting would be responsible for updating the care plans; -He/she expected staff to implement new interventions and implement them if the current ones had not worked. 4. Review of Resident #12's Fall Risk Assessment, dated 4/3/19, showed the resident was not at risk for falls. (No assessment completed since). Review of the resident's annual MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Extensive assist of one staff for bed mobility, toileting and personal hygiene; -Total dependence of two staff for transfers; -Ambulation in room and corridor did not occur; -Surface to surface transfer (between bed and chair or wheelchair) unsteady, only able to stabilize with human assistance; -Upper Range of Motion (ROM) impairment on one side; -Lower ROM impairment on both sides; -Wheelchair for mobility; -No falls since admission or prior assessment; -No therapy. Review of the resident's care plan, last revised 8/5/19, showed the following: -Limited mobility and [MEDICAL CONDITION]; -Approaches: Assist with toileting, bathing and ambulation as needed; -Assist with transfers, mobility and bathing; -Ensure resident safety during [MEDICAL CONDITION] (observe for signs and symptoms); -Fall risk or interventions were not addressed on the care plan. Review of the resident's Physician Order Sheet (POS), dated 7/22/19 to 8/22/19, showed the following: -[DIAGNOSES REDACTED]. -Mechanical lift (Hoyer) with assist of two for transfers. (11/12/18). Review of the resident's nurse's notes dated 8/8/19 at 10:27 A.M., showed the following: -Notified by CNA that resident was on the floor in resident's room; -Resident stated, I just slipped; -Resident denies pain or injury; -Denies hitting head on floor or wheelchair. Review of the resident's care plan showed no evidence staff evaluated current interventions or implemented new interventions to prevent further falls after the 8/8/19 fall. Review of the resident's event report dated 8/13/19 at 10:42 P.M., showed the following: -Notified by CNA that the resident started sliding down from her wheelchair during transfer from chair to the bed; -CNA tried to ease the resident to the floor; -CNA stated that he/she witnessed this fall; -Resident did not hit his/her head on the floor; -No apparent injuries noted; -Will continue to monitor for any changes. Review of the resident's care plan showed no evidence staff evaluated current interventions or implemented new interventions to prevent further falls after the 8/13/19 fall. Review of therapy screening dated 8/14/19, showed the resident had a recent fall sliding out of wheelchair with witness from staff. Nursing reported no new injuries. Therapy is still waiting for authorization from insurance for wheelchair positioning. Nurse reported increased confusion from patient and possible urinary tract infection. Recommended Occupational Therapy (OT) referral. Observation on 8/15/19 at 5:00 P.M., showed the following: -The resident was slouched in his/her wheelchair and appeared to be nearing the edge to fall out of it; -The resident's Broda (reclining, padded chair) chair did not have a cushion to keep the resident from sliding down in the chair. During interview on 8/16/19 at 5:45 P.M., the Care Plan Coordinator said the following: -He/she did resident care plan updates as often as he/she got around to it; -Staff assessed residents following a fall and attempted to determine the root cause, looked at trends and adjusted the care plan interventions to prevent additional falls; -He/she was supposed to update the resident's care plan after each fall which was currently hard to complete. His/Her department was short staffed; -Care plan interventions should be resident centered. During interview on 8/16/19 at 6:00 P.M., the DON said the following: -Staff should start the event documentation after a resident incident occurred, address the interventions to prevent additional incidents or accidents and inform the CNA staff of any new interventions; -The charge nurses could update care plan interventions, but the care plan coordinator put the new interventions into the electronic medical record; -Resident care plans should be individualized and specific to the residents' needs. MO 462

Based on observation, interview and record review, staff failed to provide supervision and monitoring to prevent one resident (Resident #1) with a history of falls from falling. The resident tripped and fell over an electrical cord placed in the hallway by houskeeping staff. The resident sustained [REDACTED]. The facility also failed to maintain the memory care hallway free of obstruction. The census was 102. 1. Review of the resident's care plan, dated 5/2/10, and last updated 11/15/10, showed the following: -The resident at risk for falls, history of falls, poor safety awareness and medications used. -Problem: 5/20/10, last update 11/15/10; I have short and long term memory problems secondary to dementia, as well as poor safety awareness and decision making. I live on Memory Lane. I will have all needs met and function in Memory Lane without difficulty through next 90 days. Interventions: I will live on Memory Lane for the safest, most therapeutic environment and to participate in programming. - Problem; 6/21/10, had a fall. Goal: prevent further falls for 90 days. Intervention: anticipate needs, and monitor for decline in status. -8/6/10, had a fall. Goal: prevent further falls for 90 days. Intervention: Monitor environment for clutter, monitor gait stability, encourage walker use. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/17/10, showed: -Short and long term memory problem; -Moderately impaired cognitive skills; -Resists care; -Unsteady gait; -fell in past 30 days. Review of the resident's nurses notes, showed the following: 10/16/10 at 10:45 A.M., resident fell when a family member shut the door to keep him/her out. 11/10/10, daily skilled nurse's note, showed unsteady gait on evening shift. Review of the resident's fall risk evaluation, dated 11/15/10, showed the following: -No falls within the last 90 days; -Steady balance; -Total score of 9 (score of 10 or higher is at risk for falls. Consider environmental risk factors in assessing resident's risk of falls: Slippery floors, uneven surfaces, foreign objects in hallway, new arrangement of objects, time of day, time of activity, glare, poor illumination, patterned carpet, walking in crowded area. If a resident scored a 10 or above, interventions should be initiated. Document interventions below and on the resident's care plan. Resident should be informed of the risks/benefits associated with each intervention). Further review of the resident's daily skilled nurses notes, dated 11/15/10, 11/16/10, 11/17/10, and 11/18/10, showed unsteady gait, balance problem, on day, evening, and night shifts. On 11/22/10 at 9:00 P.M., the resident wandered in and out of rooms. At 8:40 P.M., resident stood over a television on the floor. Further review of the resident's care plan, showed the following; -11/23/10, and 11/24/10; had falls. Goal: prevent further falls for 90 days. Intervention: Monitor environment for safety. Toilet regularly. Assist with activities of daily living (ADLs). Monitor gait and mental status for any possible medical causes. Further review of the resident's nurses notes dated 11/23/10, 6:00 A.M., showed resident found sitting on floor on roommate's mat, undressed from the waist down. Stated he/she fell on mat coming back from bathroom. Review of the resident's care plan summary, dated 11/23/10, showed risks/consequences: monitor for falls, loose stools, any behaviors. Will continue to monitor falls. Review of the resident's physical therapy screening form, dated 11/30/10, showed comments: Fall 11/22/10 and 11/23/10. Resident found sitting on floor on mattress. Further review of the resident's care plan, showed the following; -11/24/10 and 12/7/10-had falls. Interventions included: Make sure surroundings are free of clutter. Monitor environment for clutter. Monitor environment for safety. Monitor gait stability. Monitor gait/balance. Anticipate needs. Review of the resident's nurses notes, showed the following: -12/7/10 at 9:10 P.M., resident fell . Other nurse heard a bang against the double doors. Resident had a right side head lump, legs weak,right shoulder blade red, right shoulder looks out of place. Pain 10/10. Confused and disoriented; -12/7/10 at 9:25 P.M., received orders to send resident to hospital. Review of the resident's emergency room hospital records, dated 12/7/10, showed the resident presented with a complaint of a fall. He/she had pain, swelling, and a contusion (bruise) on the scalp, and pain and a contusion on the right scapula (shoulder blade). According to the Emergency Medical Services (EMS) report, he/she fell at the nursing home, hit his/her head on a railing, and landed on his/her right side. He/she complained of pain to the shoulder. Further review of the resident's nurses notes, showed the following: -12/7/10 at 11:45 P.M., resident returned to facility. Right arm in sling, resident frequently attempts to remove sling. [DIAGNOSES REDACTED]. -12/8/10 at 3:00 A.M., Sling no longer on resident. Complains of pain in right shoulder. -12/8/10 at 2:00 P.M., Gait unsteady at times. Required frequent verbal cues and redirection. New orders noted, therapy informed. Further review of the resident's nurses notes, showed the following: -12/17/10 at 10:00 A.M., resident found on floor in dining room, scooting on butt; -12/22/10 at 1:40 P.M., resident ambulatory towards nurses station, tripped and fell to floor. Resident complained of discomfort all over. Resident said "I can't use my leg", and points to left leg. Three by three blue discoloration to left cheek and 4 by 3 blue discoloration left knee. Tear to chin. -12/22/10 (no time listed), received order to send resident to hospital. -12/22/10, 8:00 P.M., ambulance at facility to transport the resident to the hospital. During an interview on 1/4/11 at 12:30 P.M., Housekeeper B said he/she cleaned the carpet on the memory care hall, using a machine rented by the facility. He/she had to carry the cord on the rental carpet cleaning machine. The area was long. He/she had to "stretch the cord". He/she had to plug the cord in the electrical outlet in the living room. He/she placed the cord along the wall. He/she cleaned the carpet, and staff told him/her the resident fell . During an interview on 1/7/11 at 9:00 A.M., Dietary Server A said he/she saw the resident fall on 12/22/10. The resident tripped over a cord, and the resident fell . The resident walked in the side hall, past the memory care nurses station, in the direction of the bathrooms on the side hall. Housekeeping staff placed a cord from the living room, down the long hall, to the carpet sweeper near the exit door. Housekeeping staff plugged the carpet sweeper in the living room. Housekeeping staff were by the exit door at the end of the long hallway. He/she wrote a lengthy statement about what happened, and gave the statement to the DON. Observation on 1/4/11 showed the living room located at the end of the corridor by the short hallway and the nurses station. The short hallway and the long hallway met near the living room and the nurses station. During an interview on 1/4/11 at 2:30 P.M., Housekeeping Supervisor C said he/she told Housekeeper B to ensure the carpet sweeper cord was "short". He/she expected housekeeping staff to keep the cord length as short as possible, and to keep the cord close to the wall. He/she conducted four day training in resident safety for all new housekeeping employees. During a interview on 1/4/11 at 11:00 A.M., Licensed Practical Nurse (LPN) D said on 12/22/10, he/she did not see the resident fall, but he/she heard the fall. The resident walked in the memory care hall, close to the nurses station. He/she did not know if any staff saw the resident fall. The resident tripped on a cord from a carpet cleaner. An unknown housekeeper was on the end of the memory care hall by the exit doors. The cord was on the carpet. The resident said he/she fell . The resident had a skin tear to his/her chin, and he/she complained of knee pain. Review of the nurses note, dated 12/22/10 at 11:50 P.M., showed the resident returned to the facility via ambulance. Had splint on left leg. Fracture left patella and fracture mandible noted from hospital. Review of the resident's care plan, showed the following; -12/23/10, problem: Fall. Goal: Resident will be free of complications related to fall. Approaches included: Notify physician and family/responsible person. Monitor for 72 hours for possible injury related to fall. Neurochecks for 72 hours if appropriate. Document assessments. Encourage resident to use call light, assist as needed. Report changes in endurance, ambulation, transfers, etc. Monitor at frequent intervals, reposition for comfort and safety. 12/23/10, fell in hallway, sent to ER. Apply knee immobilizer and keep in place due to knee fracture. Change diet to soft foods as tolerated due to fractured mandible. Interventions: I will live on Memory Lane for the safest, most therapeutic environment and to participate in programming. During an interview on 1/4/11 at 3:00 P.M.,the Assistant Director of Nurses (ADON) said: -LPN D reported Housekeeper B cleaned the carpet on the memory care unit with an electric carpet cleaner. Housekeeper B plugged in the electrical cord in the living room, and stretched the cord down the hallway. -Housekeeping Supervisor C said he/she told Housekeeper B to keep the "cord short". -The ADON expected staff to have the cord extremely close. She expected staff not to stretch the cord with tension; -LPN D notified her the resident fell , and she came to the memory care hall. Housekeeper B was in the hall. Observation on 1/4/11, at 12:10 P.M., showed an electric carpet sweeper was plugged into an electrical outlet in the main hallway. The carpet sweeper cord lay on the floor, in the middle area of the main hallway. No staff were observed in the vicinity. Review of the facility's undated, "Fall Prevention and Management Program Policy", showed the following: -Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Interventions should include: Immediate assessment after fall. Implement a communication system whereby all caregivers are alerted to the fact that certain residents are at high risk for falls. Assess the environment and make appropriate changes; -When a fall occurs, staff must immediately assess the injury, if any, treat the injury, and identify the cause of the fall. Initiate the comprehensive assessment following a fall form. Initiate interdisciplinary assessment/intervention checklist. Document on the checklist the interventions and date implemented. -Negative Outcome Review: Falls should be reviewed daily; documentation should be reviewed. Assure that immediate interventions are in place. Assure the care plan has been updated; -Extrinsic or External Risk Factors for falls. Definition: related to the environment, implicated in 33% to 50% of falls, may include: electrical cords in pathways, clutter, uneven surfaces; -Fall prevention and management program interventions for the environment. Floors: Decrease cluttered pathways. Clutter: Keep a 2 foot wide clear path around bed, and to bathroom and lounge chair. Remove cords from walking area. Remove unused equipment and items from room and bathroom. Miscellaneous: Instruct staff to perform frequent safety checks of rooms, hallways and common areas to decrease physical hazards and obstacles. During an interview on 1/12/11 at 10:15 A.M., the Director of Nurses (DON) said: -If a resident is found on the floor, it is considered a fall; -Resident #1 had a history of [REDACTED]. -Staff should provide basic oversight and redirect as needed after a fall; -The ADON conducted an investigation regarding the resident's last fall. There is no conclusion how the resident fell ; -The resident said he/she tripped. The DON said she did not know what caused the resident to trip. The resident received a fracture of the mandible and a fracture of the patella as a result of the fall. The DON did not know if the resident's last fall was unavoidable; -The resident received a fracture of the patella and a fracture of the mandible after the last fall; -She expected the memory care charge nurse to know how a fall occurred if staff reported it to the charge nurse. She expected the charge nurse to report how the fall occurred to her. During an interview on 1/12/11 at 10:30 A.M., the DON said: - She was now made aware of the conclusion to the resident's last fall. The conclusion was the resident tripped over a cord on the floor on the memory care hall. She was now made aware of a statement from a staff person on the memory care hall. She had no prior knowledge of the statement. Housekeeping Supervisor C was notified after the resident fell ; -She expected staff to keep the cord short, and close to the wall; -She did not know where housekeeping staff placed the cord in the hall, and did not know the location where staff plugged in the electrical cord; -Staff incorrectly scored the resident's fall assessment, dated 11/15/10. The fall assessment's total score should be 10. A resident who scores at 10 or higher is at risk for falls. During an interview on 1/12/11 at 2:00 P.M., the resident's physician said the resident had significant advanced dementia, an ongoing problem. The resident was a fall risk, and he/she fell several times in the past. His/her balance was "not great", and he/she had a "very unsteady gait". Anything on the floor would have been a tripping hazard. He/she probably could not recognize a cord on the floor as a tripping hazard. It was definitely not a good thing to have a cord in his/her path. The physician would not expect staff to have a cord in the resident's path. The number one risk for falls is previous falls in the past. 2. Observation on 1/4/11 at 10:30 A.M., 11:30 A.M., and 1:20 P.M., showed five twin sized mattresses in the hallway of the memory care unit. Four mattresses were propped against the handrails on the right hand side of the hallway, and one mattress was propped against the handrails on the left hand side. These mattresses blocked access to the handrails. Residents walked up and down the hall. During an interview on 1/4/11 at 11:05 A.M., LPN F said he/she saw staff pull out the mattresses from resident rooms early that morning. During an interview on 1/12/11 at 10:15 A.M., the DON said: -She would not expect staff to store mattresses in the memory care hall. -She would not expect the access to handrails to be blocked on the memory care hall; MO 639