Every finding on record at The Blossoms at Star City Rehab & Nursing Center

Based on observations, interviews, and record review, the facility failed to ensure medication regimen reviews were accurately completed with the rationale for the provider not agreeing with pharmacist recommendations for three (Residents #22, # 3, and #4) of three residents reviewed. The findings include: Review of facility policy titled, Drug Regimen Review, dated 01/2024, revealed the physician response would be documented on consultant pharmacist review record within one month of the report sent. Resident #22Review of Resident #22's admission Record, revealed the facility admitted Resident #22 on 01/28/2026 with diagnoses that included malignant neoplasm of bone and lymph nodes, bipolar disorder, diabetes mellitus, essential hypertension, major depressive disorder, low back pain, history of suicidal behaviors, and anxiety disorder. Review of Resident #22's Medication Administration Record (MAR), dated July 2026, indicated Resident #22 had active medication orders to treat diabetes, major depression, pain, and anxiety. The MAR also indicated active orders for over the counter (OTC) supplements. Review of Resident #22's Pharmacy Review dated, 02/26/2026, 03/28/2026, and 04/24/2026, indicated the provider did not agree with the pharmacy recommendations. There was no physician rationale for the disagreement indicated. During an interview on 07/28/2026 at 11:29 AM, the Advanced Practice Registered Nurse (APRN) stated, Resident #22 has bone cancer, and I didn't want to change the meds I just started. The former Director of Nursing and I would go through them, and I would just sign off on it. The APRN stated, Yes, I am supposed to write a rationale if I don't agree with the pharmacist. Resident #3 Review of Resident #3's admission Record, revealed the facility admitted Resident #3 on 06/10/2025 with diagnoses that included neurocognitive disorder with Lewy Bodies, Alzheimer's, bipolar, dementia, Parkinsons, atrial fibrillation, depression, essential hypertension, and anxiety. Review of Resident #3's Medication Administration Record (MAR), dated July 2026, indicated Resident #3 had active orders for medications that treat depression, anxiety, neurocognitive, anticoagulant, and psychosis. The MAR also indicated that Resident #3 had an active order for OTC supplements. Review of Resident #3's Pharmacy Review, dated 07/08/2025, 02/26/2026, 04/24/2026, and 06/16/2026, indicated the provider did not agree with the pharmacy recommendations. There was no physician rationale for the disagreement indicated. Resident #4 Review of Resident #4's admission Record, revealed the facility admitted Resident #4 on 10/12/2023 with diagnoses that included encephalopathy, acute pancreatitis, abnormal coagulation, chronic pulmonary edema, effusion, gastrointestinal hemorrhage, type-2 diabetes mellitus, pure hypercholesterolemia, insomnia, intracardiac thrombosis, gangrene, abnormal findings of blood chemistry, polyneuropathy, hypertension, acute posthemorrhagic anemia, hypothyroidism, hyperlipidemia, pressure ulcer, absence of left leg below knee, chronic atrial fibrillation, anxiety disorder, heart failure, chronic kidney disease, edema, chronic kidney disease, schizophrenia, gout, abdominal pain.Review of Resident #4's Medication Administration Record (MAR), dated July 2026, indicated Resident #4 had active orders for medications that treat diabetes, schizophrenia, gout, hyperlipidemia, anemia, hypothyroidism, cholesterol, pulmonary edema, atrial flutter, vitamin deficiency, COPD, depression, anxiety, rash, polyneuropathy, constipation, hypokalemia, diazepam, and pain.Review of Resident #4's Pharmacy Review dated 02/26/2026, indicated the provider did not agree with the pharmacy recommendations. There was no physician rationale for the disagreement indicated.During an interview on 07/29/2026 at 12:15 PM, the APRN stated the Medication Regimen Reviews (MRR) were important to make sure residents were not on medications they should not be on. The APRN stated, currently she and the Assistant Director of Nursing (ADON) completed the MRRs. The APRN stated , I review medications and labs monthly when I see the resident(s) to see if changes are needed. When the pharmacist puts in a recommendation, I have to agree or disagree and if I disagree, I must put in a recommendation, but I didn't on those. During an interview on 07/29/2026 at 12:37 PM the Director of Nursing (DON), stated, the ADON reviews the MRR with the provider and a rationale must be put in by the provider if they disagree with the pharmacist recommendation. The DON indicated it is important for resident safety and to know the reason why six months down the road [a medication was changed or not] and to be able to reference it again. During an interview on 07/29/2026 at 1:32 PM the Administrator stated the purpose of the MRR was for the residents to be on the least restrictive medications to benefit them. The Administrator stated, The provider should look at the recommendations and if they disagree, they must write a reason why they chose not to follow the recommendations. The Administrator stated it was the DON's responsible for the review and make sure the orders were carried out.

Based on observation, interviews, record review, and facility document review, it was determined the facility failed to ensure multi-dosed insulin vials was labeled in accordance with currently accepted professional principles. Specifically, three insulin vials were not labeled with the date the vial was first accessed/opened for two (Residents #95,and Resident #66,) of three residents reviewed for multi-dosed insulin vial labeling. The findings include: During a concurrent observation and interview on 07/28/2026 at 4:04 PM, Licensed Practical Nurse (LPN) #4 stated, All the insulin vials should have the opened date on the vials and these three do not have a date written on the vial. LPN #4 stated she would not know when it was opened [without a date]. LPN #4 stated, I am unsure why the vials for [Resident #95, #66, and #32] did not have resident identifier labels on them. During a concurrent observation and interview on 07/28/2026 at 4:22 PM, the Assistant Director of Nursing (ADON) reviewed the vials and stated, Insulin vials should have the opened date written on them to know when they were opened. Review of Lantus Package Insert revised 05/2025, revealed an opened Lantus multi-dose vial should be used within 28 days if refrigerated or at room temperature. Review of Residents #95's Medication Administration Record (MAR) dated July 2026, indicated the [long-acting insulin] multi-dosed vial was opened, and unlabeled with pharmacy date of delivery as 07/14/2026. The MAR indicated the long-acting insulin charted as given 15 times for insulin administration from the printed date from the facility pharmacy. The multi-dosed vial observed did not have the opened date written on the vial nor was the resident identifier label present on the vial. For Resident #66 there was two multi-dose vials of long-acting insulins observed: Review of Resident #66's MAR dated July 2026, indicated the [long-acting insulin] multi-dosed vial was opened, and unlabeled with a pharmacy date of delivery as 06/24/2026. The MAR indicated that the insulin was charted as given 29 times for insulin administration from the printed date of delivery from the facility pharmacy. The multi-dosed vial observed did not have the opened date written on the vial nor was the resident identifier label present on the vial.Review of Resident #66's MAR dated July 2026 indicated a second [long-acting insulin] multi-dosed vial observed was opened, and unlabeled with a pharmacy date of deliver as 06/24/2026. The MAR indicated that the insulin was charted as given 29 times for insulin administration from the printed date of delivery from the facility pharmacy. The resident identifier label was on the vial, but no opened date was written. During an interview on 07/29/2026 at 10:30 AM, the Pharmacy Consultant stated [long-acting insulin] once opened should be used within 28 days from first access or after removing from the refrigerator. She stated it was the nurse's responsibility to write the opened date on the insulin vial. The Pharmacy Consultant stated, The insulin could be less effective according to how long [it had been opened] and is not as stable after the 28 days. The Pharmacy Consultant stated it was important to have the opened date on the vials of insulin. During an interview on 07/29/2026 at 12:15 PM, the Advanced Practice Registered Nurse (APRN) stated insulin should be used within 28 days and the nurse that opened it should write the date on the insulin vial. The APRN stated The nurse should not use the insulin if there was not a resident identifier on the vial, or if the date was not on the vial due to being less effective after the 28-day date. During an interview on 07/29/2026 at 12:37 PM, the Director of Nursing (DON) stated The [long-acting insulin] should be used within 28 days, and the date should be written on the vial once opened. She stated the insulin would not have the same effect if used past the 28 days. The DON stated, it was important to put the opened date on the insulin vial to know when to dispose of it. During an interview on 07/29/2026 at 1:32 PM, the Administrator stated, Most insulins should be disposed of in 28 days from opening and the nurse that opened it should write the opened date on it. She stated, It is important to write the opened date due to insulin is not as strong as it should be past the date.Review of an article dated 08/16/2025 over the subject of using insulin after 28 days, revealed for healthcare professionals the 28-day rule for insulin is a safety and efficacy guideline, and is based on the degradation of insulin's protein structure after that timeframe.

Based on observations, record review, and interviews, the facility failed to review and revise the Comprehensive Care Plan for one (Resident #7) of one resident. Specifically, Resident #7's Care Plan goals were not revised or resolved from the care plan under the focus as at risk for elopement related to history of attempts to leave facility with an intervention of a tracking bracelet. The findings include: During an observation on 07/28/2026 at 12:59 PM, this surveyor observed Resident #7 walking down the street and asked if they lived at the nursing home. Resident #7 stated, Yes and they did it all the time[referring to walking down the street]. This surveyor then observed Resident #7 continue walking and crossed a four-lane highway to sit at a laundry facility. A review of Resident #7's Comprehensive Care Plan, revision dated 06/29/2026, indicated Resident #7 was an elopement risk related to a history of attempts to leave the facility unattended with a tracking bracelet as an intervention. The Care Plan listed the goal as; Resident #7 would not leave the facility unattended through the review date with a target date of 07/08/2026. A review of Resident #7's admission Record, dated 06/19/2026, indicated resident was admitted by the facility with diagnoses that included diabetes mellitus, schizoaffective disorder, depression, nicotine dependency, anxiety disorder, and cerebral infarction. A review of Resident #7's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 06/25/2026, indicated a BIMS score of 13, which indicated Resident #7 was cognitively intact. The MDS also indicated that Resident #7 functioned independently, and that wandering behaviors were not exhibited. The MDS continued that Resident #7's medications consisted of an antipsychotic, anticoagulant, opioid, hypoglycemic, and anticonvulsant. A review of Resident #7's Elopement Risk, dated 07/31/2025, indicated Resident #7 had a score of 9. No elopement risk had been completed again since 07/31/2025 admission. During an interview and concurrent document review on 07/28/2026 at 1:10 PM, the Administrator stated, Resident #7 had a Brief Interview Mental Status (BIMS) score of 14 and could leave the facility when they chose to; Resident #7 could sign out and back in when they left. The Administrator reviewed the Comprehensive Care Plan of Resident #7 and stated, Resident #7 was care planned to be at risk for elopement with a tracking bracelet. She stated it should not be on there and would be removed. The Administrator stated, Resident #7 should be care planned to leave the facility at leisure. The Administrator stated, Resident #7 had been in the facility multiple times and the person that initiated this care plan had mistakenly copied the previous admission's care plan without reading the care plan thoroughly.Review of a facility form titled Release of Responsibility for Leave of Absence for Resident #7 indicated sign in and out times that the resident had signed themselves out of the facility and then back again multiple times a day from 07/3/2026-07/28/2026. During an interview on 07/28/2026 at 2:18 PM, Licensed Practical Nurse (LPN) #1 stated Resident #7 frequently signs in and out. She stated it varies on the length of time the resident stayed gone. LPN #1 stated she was not aware of the resident being a wanderer. LPN #1 stated they follow the care plan to know what to do for the residents. During a concurrent observation and interview on 07/28/2026 at 2:55 PM, Resident #7 returned to the facility and stated, I leave all the time and have friends that will meet me at the laundry mat to visit. Resident #7 stated they used the code to enter and exit the facility but had to sign out and in at the nurse's station. Resident #7 stated they used to do drugs but not since their admission into the facility. Resident #7 stated I told the staff that I had taken a hit of meth while out on a stroll one time, they did a drug test, but I really had not done it. Resident #7 stated, if anyone offers a cigarette while I am out, I will take it. Resident #7 was observed with leaves on the back of shirt and in their hair, the resident's eyes were pink/red tinged, and the resident smelled like smoke. On 07/28/2026 at 2:55 PM, the Administrator brought in a No Policy Note, indicating the facility did not have a policy that addressed wander guards, care plans, residents using codes to exit the facility, or cognitive residents leaving the facility. The note was signed and dated by the Administrator. During an interview on 07/29/2026 at 8:15 AM, Certified Nurse's Assistant (CNA #2), revealed the staff follows the care plan to know what to do for the residents. She stated, I knew Resident #7 before working here. The CNA stated Resident #7 had a history of homelessness, and drug abuse but seemed okay now. CNA #2 stated, Resident #7 wanted to leave all the time; coming and going as the resident wanted. CNA #2 stated, Resident #7 revealed to staff they had taken a hit of meth while out of facility at the end of June but did not know if Resident #7 really did. During an interview on 07/29/2026 at 8:50 AM, LPN #3 stated, Staff followed the care plan to know what to do for a resident and if it wasn't updated, we wouldn't know. LPN #3 stated, Resident #7 would come to the desk to sign out to go get air and would sign back in when they returned. LPN #3 indicated that she did not know where Resident #7 went but was aware of Resident #7's past with drugs and stated there was no telling what Resident #7 did when they left the facility.

Based on observation and interviews, the facility failed to ensure expired, over the counter medications were removed from active medication storage and disposed of to prevent administration to all residents who received medication from the facility. The findings include: During an interview and concurrent observation on 07/28/2026 at 3:30 PM, this surveyor observed two boxes of iron supplements in the over the counter (OTC) medication storage room that were past their expiration date of June 2026. The iron supplement wase removed from the cabinet by Licensed Practical Nurse (LPN #5). LPN #5 stated, These expired medications should not be on the shelf and should be placed in the destruction barrel. LPN #5 stated when they find expired OTC medications, the medications were to be logged in the destruction book, and the Director of Nursing (DON) was notified. During an interview on 07/29/2026 at 8:50 AM, LPN #3 stated that when expired medications were found, they would put them in the sharps container in the medication room and write them in the book. During an interview on 07/29/2026 at 12:37 PM, the DON stated, expired OTC medications were supposed to be written in the expired medication binder and then disposed of in the disposal barrel once logged. The DON stated, When expired medications are found, the staff inform me. Like what you found today unfortunately. The DON stated we do not want to administer expired medications to residents. During an interview on 07/29/2026 at 1:32 PM, the Administrator stated when an expired OTC medication was found, the nurse would put the medication in the destruction barrel, and the medication would be reordered by central supply.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure privacy and dignity was provided for 1 ( Resident #28) of 2 sampled residents reviewed for privacy and dignity. The findings are: A review of a facility policy titled, Resident Rights, dated 01/01/2024, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents ' right to: a. a dignified existence. b. be treated with respect, kindness, and dignity . A review of the Admission Record indicated the facility admitted Resident #28 with diagnoses that included chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, Asperger's syndrome, and bipolar disorder, current episode mixed, severe, with psychotic features. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/18/2024, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. A review of Resident #28's care plan revised on 12/10/2024, revealed the resident had an ADL self-care performance deficit related to muscle weakness, Asperger's syndrome, muscle wasting and atrophy, and unsteady gate. Interventions included personal hygiene: the resident required assistance by staff with personal care, and toilet use: the resident required assistance by staff for toileting. During an observation on 01/27/2025 at 3:33 PM, Certified Nursing Assistant (CNA) #9 changed Resident #28's brief while the resident was standing, exposing the resident's buttock to the roommate. CNA #9 wiped Resident #28's bottom with a wipe while Resident #28's roommate was sitting up in bed watching the care be provided. CNA #9 did not pull the privacy curtain between the residents' beds. During an observation on 01/28/2025 at 11:57 AM, Resident #28 was in their room, standing up with no pants or brief on while CNA #9 removed a dirty brief from the resident in the room. Resident #28 was standing exposing the resident's buttock to the roommate. CNA #9 wiped Resident #28's bottom with a wipe while the resident's roommate was lying in bed watching the care be provided. CNA #9 did not pull the privacy curtain between the residents' beds. During an interview on 01/30/2025 at 10:26 AM, CNA #11 confirmed Resident #28 stood to have a brief change, and the privacy curtain should be pulled between the resident beds. During an interview on 01/30/2025 at 10:48 AM, Licensed Practical Nurse (LPN) #3 confirmed Resident #28 stood to have a brief change while holding onto the walker and the privacy curtain should be pulled between the resident beds. During an interview on 01/30/2025 at 12:41 PM, the Director of Nursing (DON) confirmed Resident #28 stood to have a brief change while holding onto the walker and the privacy curtain should be pulled between the resident beds. 43409

Based on observations, interviews, and record reviews, the facility failed to accurately complete the care plan to address bipolar disorder and post-traumatic stress disorder (PTSD) (Resident #13) and contractures (Resident #44) for two (Resident #13 and Resident #44) of 23 sampled resident who were reviewed for care plan accuracy. The findings are: 1. Resident #13's Order Summary Report was reviewed and indicated diagnoses of a mental health condition caused by a traumatic event affecting one's ability to function daily (post-traumatic stress disorder) and a mental disorder characterized by periods of depression and periods of abnormal moods (bipolar disorder). [Antipsychotic medication name] 25 milligrams (mg) give 1 table by mouth at bedtime for post-traumatic stress disorder (PTSD) and [antipsychotic medication name] 2.5 mg give 1 tablet by mouth two times a day for bipolar disorder was ordered. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/2024 was reviewed and revealed Resident #13 had a Brief Interview for Mental Status (BIMS) of 7, which indicated severely cognitively impaired, and had active diagnoses of bipolar disorder and PTSD. A care plan, dated 12/16/2024, was reviewed and did not address Resident #13's PTSD or bipolar disorder. 2. Review of Resident #44's diagnosis sheet indicated the resident had diagnoses of cerebral infarction (stroke), pneumonia, dysphagia (swallowing difficulties), heart failure and muscle weakness. Resident #44's quarterly MDS with an ARD of 01/13/2025 revealed a Staff Assessment of for Mental Status (SAMS) that indicated severe cognitive impairment. The MDS indicated the resident had impairments to bilateral upper and lower extremities, was dependent on staff for activities of daily living, transfer, wheelchair ambulation and incontinence care. The restorative section of the MDS indicated Resident #44 received no range of motion, splints or braces for assistance. Review of Resident #44's care plan did not mention or address contractures of upper or lower extremities. Review of progress notes dated 12/30/2024 to 01/30/2025 did not indicate identification of contractures to musculoskeletal system. On 01/27/2025 at 10:28 AM, Resident #44 was observed lying in bed. The resident ' s left upper extremity was contracted into a forward bend at the wrist and hand into a semi fist, both legs were contracted to a near fetal position. No brace or hand roll was observed on the upper extremity, no pillows or positioning devices were observed to the lower extremities. Resident #44 was observed again on 01/28/2025 at 09:15 AM, 01/29/2025 at 8:47 AM and 3:36PM, and 01/30/2025 at 10:00 AM and 1:30 PM without any devices to the left upper extremity or bilateral lower extremities. On 01/30/2025 at 1:33 PM, Licensed Practical Nurse (LPN) #4/ MDS Coordinator was asked how she determines what was included in the resident's care plans. She related she uses the MDS, new orders, diagnoses and nurses notes to help guide her as to what is included in the resident's care plans. She said the care plan should be updated daily as needed related to the resident's condition as well as at least quarterly. The MDS Coordinator was asked if Bipolar, PTSD, and contractures were concerns that should be addressed on the care plan, to ensure proper interventions are used. She confirmed they should be. 46724

Based on observation, interview, record review, and facility policy review, the facility failed to ensure smoking paraphernalia was not stored in the resident rooms and failed to ensure residents with vape devices were assessed for safe usage for 2 (Residents #24 and #176) of 2 sampled residents reviewed for smoking. The findings are: On 01/27/2025 at 2:34 PM, Resident #24 was sitting up on the side of the bed awake and there was a small device on the overbed table. The resident was interviewed and when asked about the device, the resident picked up the device, placed it in the resident's mouth, inhaled and blew white smoke from the resident's mouth. The resident stated once the vape device was empty, it was refilled. The resident opened the top drawer on the nightstand and removed a glass bottle. The label on the bottle indicated the contents were a flavored liquid for vaping and contained nicotine. Resident #24's care plan, dated 01/16/2025, was reviewed and indicated the resident was a smoker and tobacco user and vaped and to instruct the resident about the facility policy on smoking/electronic smoking devices/smokeless tobacco. The care plan did not indicate if the resident required supervision or if the resident was safe to keep or use the vape device/refill bottle in the resident's room. The resident's IHCMA Quarterly/Annual/Significant Change Nursing Evaluation dated 01/17/2025 did not indicate if the resident was safe to use/store the vape device or refill bottle in the resident's room, or if the vaping paraphernalia was to remain with staff. Resident #24's Order Summary Report was reviewed and there was no indication the resident smoked. On 01/30/2025 at 12:20 PM, Licensed Practical Nurse (LPN) #2 was interviewed and stated the nurses assessed the residents on admission and quarterly for capabilities to hold/light a cigarette, and if he/she required supervision. She stated residents were not allowed to have smoking paraphernalia in their room. LPN #2 stated smoking paraphernalia, and vaping devices were locked in the medication room. At 12:28 PM, LPN #2 stated residents were not allowed to keep the refills for the vape devices in their rooms and those items were kept in the nursing station with other cigarette items. A Smoking Policy, dated as reviewed 02/2024, was reviewed and indicated the facility will establish and maintain safe resident smoking practices. The smoking policy indicated smoking was only permitted outside in designated smoking areas, was not allowed inside the facility under any circumstances and included tobacco and electronic cigarettes. A review of the Admission Record, indicated the facility admitted Resident #176 with diagnoses that included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side, cerebral infarction, other seizures, nicotine dependence, unspecified and psychoactive substance abuse with other psychoactive substance induced disorder. A review of the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/27/2025, was incomplete. A review of Resident #176's care plan initiated on 01/15/2025, revealed the resident had chosen to smoke and needed to be observed for safety. Interventions included the resident may need to wear a smoker's apron when smoking due to safety concerns, store all my smoking material, including lighters, matches, etc., in a safe place; remind the resident's family not to give smoking materials directly to the resident, show the resident the designated smoking areas and assist the resident to and from smoking area during smoking times. A review of the physician orders revealed Resident #176 was admitted to the male secure unit due to diagnosis of psychoactive substance abuse with other psychoactive substance induced disorder. A review of the Admission/Readmission Nursing Evaluation Packet, revealed Resident #176 had medications that affected awareness, judgement, and safety including medications with adverse reactions, a smoking related burn in the past 6 months and required supervision while smoking with additional comments which included needs assist/supervision. During an observation on 01/27/2025 at 1:38 PM, Resident #176 had a vape device lying on the nightstand and a vape device on the charger lying on the bed. During an observation on 01/28/2025 at 9:07 AM, Resident #176 was sitting in a wheelchair with vape device in the resident's hand. During an observation on 01/28/2025 at 12:03 PM, Resident #176 was lying in bed with a vape device in the resident's left hand and another vape device lying on the nightstand charging. During a concurrent observation and interview on 01/28/2025 at 2:48 PM, Resident #176 verbalized going outside to smoke and while in room using a vaping device. Resident #176 took two puffs from the vaping device during the interview.

43409 Based on observation, interview, record review, and facility policy review, the facility failed to ensure a glucometer was disinfected per disinfectant wipe directions for one of one glucometer disinfecting observed; failed to ensure infection prevention and control practices were implemented to prevent the development of communicable diseases and infections as evidenced by leaving a clean linen cart uncovered and placing used hangers with clean clothes on linen cart; failed to ensure infection prevention and control practices were implemented to prevent the development of communicable diseases and infections as evidenced by failure to keep dirty briefs and linen off of the floor in Resident #28 ' s room and failure to contain items during transport through the hallway. The findings are: 1. On 01/29/25 11:28 AM, Licensed Practical Nurse (LPN) #1 was observed walking up the North Hall with a glucometer in her hand, she unlocked her medication cart, removed a disinfectant wipe from the bottom drawer of the medication cart and wiped the glucometer once. She then laid the wiped glucometer on a tissue on the top of the medication cart. The glucometer was not visibly wet. At 11:29 AM, LPN #1 gathered supplies of gloves, alcohol swabs, one piece lancet and a bottle of glucose testing strips, then picked up the glucometer in the tissue and proceeded to room [ROOM NUMBER]-S-B. After performing a blood glucose test, LPN #1 wrapped the glucometer back in the tissue and placed it in a disposable plastic cup and took it back to the medication cart. At 11:30 AM, back at the medication cart, she removed a disinfectant wipe from the bottom drawer of her medication cart and wiped the glucometer once, then laid it on a clean tissue on top of the cart. The glucometer was not visibly wet. On 01/29/25 at 11:31 AM, LPN #1 was asked to describe her procedure for disinfecting the glucometer. She stated, after using it she wiped it with a disinfectant wipe and laid it on a tissue to air dry for 3-5 minutes for the disinfectant to be effective. After being asked to read the directions printed on disinfectant wipe container, she read the label and stated, It says two minutes. LPN #1 was then asked to read the directions for use on the label which indicated for disinfected areas to remain visibly wet for 2 minutes and allowed to air dry. LPN #1 was then asked if the surface of the glucometer had remained wet for 2 minutes, she replied, probably not. When asked what the outcome of improper disinfecting could be, she confirmed it could lead to cross contamination. The glucometer cleaning and disinfecting instructions indicated disinfecting was needed to prevent the transmission of bloodborne pathogens. The label for the disinfecting wipes indicated that the surface of the item to be disinfected should remain wet for 2 minutes for disinfection to be effective. 2. A review of a facility policy titled, Infection Prevention and Control Program, revised on 01/01/2024 indicated, 1. The infection prevention and control programs are a facility-wide effort involving all disciplines and individuals. 2. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety .policies and procedures a. policies and procedures are utilized as the standards of the infection prevention and control program .prevention of infection .educating staff and ensuring that they adhere to proper techniques and procedures. During an observation on 01/29/2025 at 12:48 PM, a clean linen cart with clean clothes hanging on the rod and linen setting inside the basket was uncovered on the 500 hallway. During an observation on 01/29/2025 at 12:49 PM, Laundry #12 walked out of a resident's room and placed hangers onto the rod with clean clothing. During a concurrent observation and interview on 01/29/2025 at 12:50 PM, Laundry #12 placed hangers laying in the basket on the rod with clean clothes and verbally confirmed the hangers in the basket were the hangers removed from the resident rooms while placing the resident's clean clothes into the closet. Laundry #12 confirmed the clean clothes, and linen should be covered while in the hallway to prevent contamination. Laundry #12 confirmed putting hangers from resident rooms on the rod with clean clothes and that it can cause cross contamination. During an interview on 01/30/2025 at 12:05 PM, LPN #10 confirmed clean clothing should be covered while on the clean linen cart in the hallways. LPN #10 confirmed hangers removed from resident rooms should not be placed on a rod with clean clothes due to contaminating the clean clothes. During an interview on 01/30/2025 at 12:25 PM, the Director of Nursing (DON) confirmed clean clothing on a linen cart should be covered while in the hallways and DON confirmed hangers removed from resident rooms should not be placed on a rod with the clean clothes due to cross contamination. 3. A review of the Admission Record, indicated the facility admitted Resident #28 with diagnoses that included chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, Asperger's syndrome, bipolar disorder, current episode mixed, severe, with psychotic features. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/2024 revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. A review of Resident #28's care plan revised on 12/10/2024, revealed the resident had an ADL (activities of daily living) self-care performance deficit related to muscle weakness, Asperger's syndrome, muscle wasting and atrophy and unsteady gate. Interventions included personal hygiene: the resident requires assistance by staff with personal care, toilet use: the resident requires assistance by staff for toileting. During an observation on 01/27/2025 at 3:33PM, Certified Nursing Assistant (CNA) #9 removed Resident #28 pants and dirty brief and threw the pants and dirty brief onto the floor. CNA #9 used wet wipes to clean Resident #28 and threw the wet wipes onto the floor. CNA #9 removed the wet linen off the bed and placed it on the floor. After Resident #28 was dressed, CNA #9 picked up all the items off the floor, opened the door, walked down the hallway and placed the items into a trash can and the soiled linen receptacle. During an observation on 01/28/2025 at 11:57 AM, CNA #9 placed Resident #28's brief and pants on. Lying on the floor was a dirty brief, used wipes, wet clothes, and wet bed linen. After Resident #28 was dressed, CNA #9 picked up the dirty brief and dirty wipes and placed them in the trash can with a trash liner. CNA #9 removed the trash liner and tied it in a knot. CNA #9 opened the door with dirty gloved hands, walked down the hallway and placed the trash liner with dirty items into the trash receptacle. CNA #9 returned to the room, picked up the dirty clothes and linens, walked down the hall with the wet items and placed them into the soiled linen receptacle. During an interview on 01/30/2025 at 10:26 AM, CNA #11 confirmed dirty briefs, used wipes, dirty clothes and wet linens should be placed into a trash bag and not on the floor. CNA #11 verbalized items should be in a bag to transport down the hallway due to possible contamination. During an interview on 01/30/2025 at 10:48 AM, the LPN #3 confirmed dirty briefs, used wipes, dirty clothes and wet linens should be placed into a trash bag and not on the floor due to possible spread of bacteria. LPN #3 verbalized items should be in a bag to transport down the hallway due to possible spread of bacteria. During an interview on 01/30/2025 at 12:10 PM, the LPN #10 confirmed dirty briefs, used wipes, dirty clothes and wet linens should be placed into a trash bag and not on the floor due to possible cross contamination. LPN #10 verbalized items should be in a bag to transport down the hallway due to possible cross contamination. During an interview on 01/31/2025 at 12:41 PM, the DON confirmed dirty briefs, used wipes, dirty clothes and wet linens should be placed into a container like a trash bag and not on the floor due to possible cross contamination. The DON verbalized items should be in a bag to transport down the hallway due to possible cross contamination.

Based on interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure wound measurements were completed and wound care was documented for 1 (Resident #6) of 3 residents reviewed for skin issues. Findings include: A review of a facility policy titled, Wound and Pressure Ulcer Management Policy, revised on 01/01/2024, indicated, .Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. The goal is one of promoting healing and minimizing infection unless a resident's preferences and medical condition necessitate palliative care as primary focus .1. A system for pressure injury assessment and documentation with each dressing change or at least weekly is established 2. Comprehensive wound assessment includes the following parameters (at a minimum): . b. length, width, depth measurements recorded in centimeters. C. direction and length of tunneling and undermining. D. appearance of the wound base. E. Type and percentage of tissue in wound. F. Drainage amount and characteristics including color, consistency, and odor .g. appearance of wound edges. H. description of the peri-wound condition on evaluation of the skin adjacent to the wound . i. pain associated with wound . A review of the care plan indicated the facility admitted Resident #6 with diagnoses that included bipolar disorder, unspecified [not named] soft tissue disorder related to use, overuse, and pressure left ankle and foot, complete traumatic amputation of one left lesser toe, and first-time active treatment for a condition or injury. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/11/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. Section M indicated the presence of an infection of foot, other open lesions on foot, and surgical wound. A review of Resident #6's Care Plan, revised on 09/27/2024, revealed the resident had pain medication therapy related to pain from amputation to 2nd left toe and resident has actual skin impairment related to fragile skin and limited mobility, soft tissue disorder related to use, overuse and pressure, left ankle and foot. Amputation to one left lesser toe. Interventions included administering analgesic [a drug that reduces pain] medications as ordered by physician, monitor respiratory rate, depth and effort after administration of pain medications and perform treatment per MD [medical doctor] orders. A review of physician orders revealed Resident #6 had Adaptic non-adhering dressing external pad (wound dressing) apply to left foot surgical site topically every day shift related to complete traumatic amputation of one left lesser toe until 7/25/24 starting on 7/12/24. A review of physician orders revealed Resident #6 had Adaptic (non-adhering) dressing external pad (wound dressing) apply to left foot surgical site topically every day shift related to complete traumatic amputation of one left lesser toe until 7/26/24 starting on 7/13/24. A review of resident's EMR (electronic medical record) indicated the last documented wound observation was completed on 1/31/23. There had not been any further wound observation documented. A review of the weekly body audit on 6/10/24 indicated discoloration to right second toe. A review of x-ray completed on 6/11/24 indicated no bony erosion to suggest osteomyelitis. A review of admission/re-admit form completed on 6/12/24 indicated discoloration to right second toe. A review of the weekly body audit completed on 6/17/24 indicated SDTI [suspected deep tissue injury]to toe, antibiotics ongoing. A review of the weekly body audit completed on 6/24/24 indicated SDTI to toe, antibiotics completed. No measurements documented. A review of the APRN [Advanced practice registered nurse] wound care note dated 6/28/24 indicated the podiatrist [foot doctor] seen resident and treated toe with mupirocin and cipro. The wound has worsened and now necrotic. [tissue death]. APRN was unable to palpate pulse and ordered further imaging to determine baseline for circulation and blood perfusion. A review of weekly body audit completed on 7/1/24 indicated SDTI to toe, antibiotics completed. A review of weekly body audit completed on 7/8/24 indicated osteomyelitis [bone infection]to left 2nd toe with surgery scheduled for 7/11/24. No measurements documented. A review of the weekly body audit completed on 7/15/24 indicated resident had toe amputation on 7/11/24 sutures intact with some edema [swelling] and bruising noted. No drainage noted. No measurements documented. A review of the weekly body audit completed on 7/22/24 indicated treatment continues to left 2nd toe surgical area. Observed slight bleeding to area. Sutures remain intact. No odor or sign of infection noted. A review of the weekly body audit completed on 7/29/24 indicated treatment continues to left 2nd toe surgical area. observed slight bleeding to area. no odor and sign of infection noted. surgical area open. Treatment completed with daughter present. During an interview on 10/25/2024 at 11:51a.m., the Director of Nursing [DON] indicated resident was being treated for a wound on toe. The DON verbalized resident was seen by orthopedic physician and the toe had to be amputated because of osteomyelitis. During an interview on 10/28/2024 at 3:32 p.m , the Wound Treatment Nurse [TN] verbalized wound is to be measured weekly. The TN indicated the documentation of wound care and measurements should be documented on the wound observation sheet. The TN verbalized there were no measurements of resident's wounds since it was going to be amputated. During an interview on 10/28/2024 at 3:40 p.m., the DON verbalized would care and measurements should be documented on the weekly wound observation form and has not been completed. The DON verbalized the TN is responsible for ensuring documentation and measurements are completed.

Based on observation, interview, and record review, it was determined the facility failed to ensure interventions were consistently implemented to prevent further harm or injury to a resident who had a previous fall with a major injury for 1 (Resident #3) of 3 (Residents #1, #2 and #3) residents who were reviewed for falls. The findings are: A review of the Order Summary indicated the facility admitted Resident #3 with diagnoses of dementia and muscle wasting and atrophy. The 5-day Medicare Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/27/2024 indicated Resident #3 had a Brief Interview of Mental Status (BIMS) score of 3 (0-7 indicates severe cognitive impairment). Review of Resident #3's Care Plan, revised 04/22/2024, revealed the resident was at risk for falls and had an actual fall on 03/10/2024 and was to have non-skid strips to the bedside and a fall mat bedside the bed. A Nsg (nursing) I&A (incident and accident) note, dated 03/10/2024, indicated Resident #3 was sitting on the floor next to the bed and reportedly had slid off the bed. The resident complained of right hip pain and an x-ray was ordered for the right hip. A Nsg -Morse Fall Score form, dated 01/06/2024, indicated Resident #3 had a score of 75 (45 and higher indicated high risk for falls). A Nsg-[Named] Fall Score form, dated 03/10/2024, indicated Resident #3 had a score of 60. A Radiology Results Report, dated 03/11/2024, revealed Resident #3 had fractured the right proximal femur. An encounter, reviewed from a progress note dated 03/18/2024 at 00:00 (12 AM), revealed in the history of present illness section that Resident #3 had surgery that week on the right femur and would be participating in skilled therapy. On 06/13/2024 at 1:30 PM, Resident #3 was lying in bed in Resident #3's room with eyes closed, and there were no non-skid strips or a fall mat on the floor on Resident #3's side of the room. On 06/13/2024 at 2:05 PM, Certified Nursing Assistant (CNA) #1 entered Resident #3's room and during an interview she confirmed that she was familiar with the resident 's plan of care and that she thought the resident did have a past fall. She confirmed there were no non-skid strips or a fall mat on the floor at this time. When she was asked if the resident was supposed to have either item, she indicated that she was not sure. On 06/13/2024 at 2:14 PM, Licensed Practical Nurse (LPN) #2 entered the resident's room and during an interview she confirmed that she was familiar with Resident #3's plan of care and confirmed the resident had a fall in which a hip fracture occurred. She confirmed there was no fall mat or non-skid strips on the resident's floor and to her knowledge, she didn't think the resident was required to have either item. On 06/13/2024 at 2:42 PM, the MDS Coordinator provided a Visual / Bedside Kardex Report that indicated Resident #3 was to have a fall mat and non-skid strips to the bedside. An Incident and Accident Policy and Procedure, that was not dated, and provided by the Director of Nursing (DON) on 6/14/2024 specified, .Purpose: To assure that all persons who are involved in an incident or accident, or suspected to have had an incident or accident, are evaluated and receive treatment as indicated and are monitored for disposition of incident and accident . Procedure: .10. All incidents will be discussed daily with ID [interdisciplinary] team to include intervention and update of plan of care . The Fall Prevention Program Policy and Procedures, not dated, and provided by the DON on 06/14/2024 specified, .Purpose: The fall prevention program is an individualized plan to promote safety of residents who have been identified as high risk for falls via [by way of] ID team determination .6.All residents on the program will have a care plan addressing goals and approaches .

Based on observation and interview, the facility failed to ensure foods stored in the refrigerator, freezer and storage areas were sealed and dated, storage shelves were free of paint peelings, door frames, pillars, and floor tiles in the kitchen were intact to allow for thorough cleaning/disinfecting, kitchen and storage room floors were free of rust and wax build-up; the ice scoop holder was maintained in clean and sanitary condition; dietary staff washed their hands before handling clean equipment or food to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; cold foods were maintained at or below 41 degrees Fahrenheit. The failed practices had the potential to affect 86 residents who received meals from the kitchen. The findings are: 1. On 01/02/24 at 9:31 AM, the following observations were made in the kitchen area. a. An opened bag of classic coffee bag was on counter by the coffee maker. The bag was not sealed. Exposing it to air and potential cross contamination. b. The floor throughout the kitchen was stained. The door frames leading to the dish washing machine room, to the storage room and to the room where vegetable freezer and milk refrigerator were kept were chipped, exposing the metals and or cement. c. There were paint peelings around the exhaust fan above the 2-door refrigerator and milk box, exposing the cement. The area paint had peeled off had water damaged on it. d. There was a hole in the wall by the door leading to the outside. The floor tile around the kitchen closet was broken, exposing the concrete. e. A strip behind the food preparation sink had a mixture of rust, brown and black stains on it. f. Forty-five wood sections in the storage room where canned or dried food items were stored had a mixture of black, gray, and white paint peeling off, exposing the wood. g. A support pole attached to the ceiling by the steam table was peeling with paint, exposing the cement. The plywood attached to the dirty dish window had a sage color on it. h. The floor in front of the 3-door freezer was chipped. The area that was chipped was stained. The bodies of the 3-door freezers had brown stains on them. The Dietary supervisor stated, There were rust stains. i. The floor tile in front of the cold area of the steam table was missing, exposing the concrete. The floor tile in front of the hand washing sink paddle had rusty/brown stains on it. 2. On 01/02/24 at 9:33 AM, the following observations were made on a shelf in the refrigerator. a. An opened gallon of apple juice. There was no opening date on the gallon to indicate when it was opened. b. An opened plastic bag of sliced cheese was sitting on the top shelf of the refrigerator. The bag was not sealed and was not dated. 3. On 01/02/24 at 9:35 AM, the following observations were made on a shelf in the 3- door freezer. a. An opened box of bread sticks. The box was not covered, and the bag was not sealed. b. A clear bag of dumplings was sitting on a second shelf in the 3-door freezer. There was no date on the bag to indicate when it had been received. c. An opened box of corndogs. The box was not covered, and the bag was not sealed. d. There was a plastic bag that contained hamburger patties inside a box in the freezer. The bag had no date when it was opened. 4. On 01/02/24 at 10:02 AM, the following observations were made in the freezer in the extra storage room. a. An opened box of skinless chicken breast was sitting on a shelf in the freezer and had no received date. b. A bag of dinner rolls was sitting in an open box on a shelf and there was no date on the bag to indicate when it had been opened. The bag was twisted and not properly closed. 5. On 01/02/24 at 10:06 AM, the ice scoop holder on the left side of ice machine had yellow residue at the bottom of it. The surveyor asked the Dietary Supervisor to wipe the wet yellow residues and the wet yellow residues easily transferred to the paper towel. The surveyor asked the Dietary Supervisor to describe what was observed in the scoop holder. She said, it was yellow slimy. The surveyor asked the Dietary Supervisor how often the ice scoop holder is cleaned and who uses the ice from the machine. She stated, That's the ice the CNAs (Certified Nursing Assistant) use to fill the water pitchers in the resident ' s rooms. We use it in the kitchen to fill beverages served to the residents at meals. We clean it once a week. 6. On 01/02/24 at 10:20 AM, Dietary Employee #1 removed onions from the storage room and placed them on the cutting board. She peeled their skins off and without rinsing the onions, she sliced the onions and placed them on top of the bean to be used for bean salad. The surveyor asked DE #1 how you process onions before using them in food. She stated, I should have rinse them. 7. On 01/02/24 at 10:38 AM Dietary, Employee #2 was wearing gloves on her hands when she opened the refrigerator door and removed a bag that contained bell peppers. She removed the bell peppers from the bag, turned on the sink faucet and rinsed them. She placed them on the cutting board and without changing gloves and washing her hands, she sliced the bell peppers. At 10:42 AM when DE #2 was ready to pour sliced bell peppers on corn in a pan to be cooked for noon meal, the surveyor immediately asked her what should you have done after touching dirty objects and before handling food items? She stated, I should have washed my hands. 8. On 01/02/24 at 11:38 AM, Dietary Employee #3 was wearing gloves when she picked up a scissors and used it to cut open a package of sliced cold turkey. Without changing gloves and washing her hands, she removed slices of turkey from the package and used her contaminated gloved hands to remove and placed them on top of each slice of bread laid out in a pan to prepare sandwiches to be served to the residents for lunch meal. The surveyor asked DE #3 what should you have done after touching dirty objects and before handling food items? She stated, I should have removed gloves and washed my hands. 9. On 01/02/24 at 12:13 PM, Dietary Employee #4 was wearing gloves on her hands when she picked up a bag of bread from the counter and untied it. Without changing gloves and washing her hands, she used her contaminated gloved hand to remove slices of bread and placed them into a pan to be used in making cold ham/turkey sandwiches to be served to the residents for lunch meal. At 12:27 PM, the surveyor asked Dietary Employee #4 what should you have done after touching dirty objects and before handling food? DE # stated, I should have washed my hands. 10. On 01/02/24 at 12:17 PM, DE #1 checked the temperatures of the cold food items that had been placed on the serving line on top of the pans of ice and hot food items that had been placed on the hot side of the steam table in preparation for the serving of noon meal service. The temperatures were as follows: a. Regular three bean salad 49 degrees Fahrenheit. b. Ground ham/turkey 57 degrees Fahrenheit. c. Regular ham/turkey sandwiches on ice 59 degrees Fahrenheit. d. Pureed cream corn 115 degrees Fahrenheit. e. Pureed cut green beans with peas 110 degrees Fahrenheit. The above food items were not reheated before being served to the residents for lunch. 11. The facility policy for hand hygiene policy and procedure provided by the Dietary Supervisor on 01/03/2024 at 04:02 PM documented, Before and after eating or handling food (hand wishing with soap and water). After handling soiled dietary equipment or resident dishes. and after handling soiled equipment or resident dishes.

Based on record review and interview the facility failed to ensure a Surety Bond was purchased, or there was an alternate means of assuring the security of all personal funds deposited in the Trust Fund Account managed by the facility, to prevent the financial loss for 75 residents who have individual Trust Fund Accounts. The findings are: a. On 01/03/24 at 3:18 PM, a review of [Named Facility] Trust - Current Account Balance of $32,218.21 as of 01/03/24. b. On 01/03/24 at 3:20 PM, a Surety Bond provided by [Surety Company Name] documented an amount of $30,000 this bond shall be effective beginning on the 1st day of June, 2023 and shall be deemed a part of the original bond, does not create a new obligation, and is executed upon the express condition and provision that the Surety's liability under the above-referenced bond, along with all Continuation Certificates issued in connection therewith, shall not be cumulative and that the Surety's aggregate liability under the bond on account of all defaults committed during the period(s) the bond has been and shall be in force, shall not in any event exceed the amount of the bond as hereinbefore set forth. c. On 01/04/24 at 1:30 PM, the Business Office Manager (BOM) was asked about why the Surety was not large enough to cover the Residents trust fund account? The BOM stated that he would have to get with his consultant and get the Surety Bond raised.

Based on observation, interviews and record reviews, the facility failed to ensure that hazardous chemicals were secured in a closed locked room from wondering residents. This failed practice had the potential to affect 2 sampled Residents #49, and #51 with the potential to affect 10 Residents who wonder. The facility also failed to ensure that Resident #238 ' s environment was free from accident and hazards by making sure lift pad/sling was free of fraying to prevent accidents. This failed practice had the potential to a affect 1 Resident (238) requiring mechanical lift transfer with the potential to affect 7 sampled Residents requiring lift assistants. The findings are: 1. a. On 1/2/24 at 1:25 PM, Surveyor observed Housekeeping Staff #1 exit room with bed pan and oxygen signs on door, but the door did not fully close. There was a key hanging on a string just outside the door. b. On 1/2/24 at 1:27 PM, Surveyor observed Maintenance Staff grab the key to enter room. Surveyor stopped Maintenance Staff prior to putting key into doorknob and asked him to push the door. c. On 1/2/24 at 1:27 PM, Surveyor asked Maintenance Staff was the door closed? Maintenance Staff stated No, but I didn't do it. The Surveyor asked Maintenance Staff should the door be open? Maintenance Staff stated no. Surveyor asked Maintenance Staff, why shouldn't the door be left open? Maintenance Staff stated, Hazardous chemicals residents could get to them. d. On 1/2/24 at 1:30 PM, the Surveyor indicated the room with the bed pan and oxygen sign on the door to Housekeeping Staff #1 and asked, what is in that room? Housekeeping Staff #1 stated, 'Our housekeeping stuff. Surveyor asked Housekeeping Staff #1, did you just exit that room? Housekeeping Staff #1 stated, Yes, about 5 minutes ago and I closed it. Surveyor showed Housekeeping Staff #1 pictures of the door open and the time stamp. Housekeeping Staff #1 stated, That was on me. I will start double checking to make sure it is closed so none of the resident meddle with the cleaning supplies. e. On 1/2/24 at 2:15 PM, the Surveyor asked the Director of Nursing (DON), the closet door on west hall that has bed pans and an oxygen sign on it, should it be left open? The DON stated, No, because there are chemicals in there and the residents can consume the chemicals. f. On 1/3/24 at 3:15 PM, the Director of Nursing stated that the facility did not have a policy on accident and hazards. 2. Resident #238 had diagnoses of fracture of the left lower leg, Cellulitis (infection of the skin), and Type 2 Diabetes Mellitus. The admission Medicare 5 day Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 10/17/2023, indicates a Brief Interview for Mental Status [BIMS] of 13 (13-15 indicates cognitive intact) and that resident requires maximal assistance for eating, and dependent for transfers, dressing, toileting, and personal care. a. On 01/03/2023 at 1:40 PM, the Surveyor observed Resident #238 being lifted from the chair to the bed with the mechanical lift for peri care by Certified Nursing Assistant [CNA] #6 and CNA #7. The Surveyor observed fraying trim in three areas below the top left loop, and bottom left loop. b. On 01/03/2024 at 1:51 PM, CNA #6 was asked to look at the sling pad with the Surveyor outside room. CNA #6 inspected the trim and three areas of fraying were observed on the edges of the lift pad. The Surveyor asked what procedure would be followed when a lift sling is fraying or has been used. CNA #6 said it would be sent to laundry, and they would probably throw it away due to the fraying on the edges. CNA #6 stated, I have never seen a lift pad tear. The Surveyor asked where they got the lift sling from that they were using on Resident #238. CNA #6 said the swings are stored in a closet. c. On 01/04/2024 at 9:20 AM, the Director of Nursing [DON] was asked for a copy of the user manual for the [named] Lift, and [named] lift policy. d. On 01/04/2024 at 10:00 AM, the DON provided a user manual (2011) titled Invacare Reliant documented, .Using the Sling (page 9) WARNING .After each laundering (in accordance with instructions on the sling(s) for wear, tears, and loose stitching, bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately . e. On 01/04/2024 at 11:00 AM, the DON provided a policy titled Transfer of Resident Using a Hoyer Lift Policy and Procedure documenting, .Purpose: To Provide resident safety with transfers. Policy: The facility will provide the resident a safe and easy method of transferring when they are unable to do so themselves . f. On 01/05/2024 at 09:00 AM, the Maintenance Director was asked where lift slings were stored. The Maintenance Director took the Surveyor to a closet on 500 hall and inspected 7 slings: 1 sling had a 3-inch frayed area on the material exposing white batting material, and below that frayed area a 4-inch area of frayed material. The Maintenance Director found two slings that had areas that were drawn up that he said was weaknesses in the material caused from going through the dryer. The Maintenance Director said lift pads were supposed to be washed and hung to dry, and lift/sling pads come through the laundry. They should be inspected and discarded if they have any damage. Then the Infection Preventionist should be notified so new ones can be ordered. The Maintenance Director stated, We have not had an in-service, but staff has been trained to follow this procedure. The Maintenance Director agreed that the 3 damaged lift pads/slings were not safe to use. g. On 01/05/2024 at 09:07 AM, the Director of Nursing [DON} was asked what process staff is expected to follow before using a lift pad or sling to lift a resident. The DON said staff should inspect the pad before use to make sure they are safe to prevent injuries. The Infection Preventionist [IP] said lift pads become damaged in the dryer and that is a safety issue, and the pad should be inspected before being used on a resident.

Based on observation, record review and interview, the facility failed to ensure that meals were prepared and served according to the planned written menu and recipe to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 5 residents who received pureed diets and 23 residents from 1 of 1 kitchen. The findings are: 1. The menu for the 01/02/2024 noon meal documented a #6 dip (6 ounces) for pureed sandwich. a. On 01/02/24 at 12:30 PM, the Dietary Supervisor #2 used a 4-ounce spoon to serve a single portion of pureed cold ham/turkey sandwich for the residents on pureed diets a difference of 2 ounces. b. On 01/02/24 at 2:24 PM, the surveyor asked Dietary Supervisor #2 what spoon serve she had used to serve pureed sandwich and how many servings she gave to each resident. She stated, I used a -4-ounce spoon and gave a serving each. 2. The facility recipe for fortified sweetened oatmeal provided by the Dietary Supervisor on 01/03/24 at 8:39 AM documented, for 10 servings used 4 cups of water, one cup of non-fat dry milk, 1/2 cup of evaporated milk, 2 cups dry oatmeal cereal, 4 tablespoons of margarine, one cup of light brown sugar and 2 cups of granulated white sugar. a. On 01/02/24 at 7:20 AM, the surveyor asked Dietary Employee #1 how she prepared fortified cereal. DE #1 stated, I used water, salt, half bag of brown sugar and 8 ounces of butter. The surveyor asked DE #1 the reason she did not use milk. DE #1 stated, I was told to use dry milk, but we didn't have it. I didn't use any milk. b. There was no non-fat dry milk, evaporated milk, more margarine and granulated white sugar used in the preparation of fortified sweetened oatmeal.

Based on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 2 meals observed. The failed practices had the potential to affect 21 residents who received their meal trays their rooms on 500 Hall, 10 residents who received meals in their rooms on [NAME] Hall 7 residents who received meals in their rooms on North Hall. The findings are: 1. Resident #68 with a diagnosis of paraplegia (paralysis of all or part of your trunk, legs, and pelvic), hypokalemia, and vitamin D deficiency. The quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 12/19/2023 indicates a Brief Interview Mental Status [BIMS] score of 15 (13 to 15 suggest cognition is intact). Resident #68 requires set up assistance for meals and oral hygiene, and is dependent for dressing, transfers, toileting, and personal hygiene. a. A Physicians Order dated 09/14/2023 documented . Regular diet, regular texture and regular consistency . b. On 01/02/24 at 11:29 AM, Resident #68 complained that breakfast is almost always cold, and sometimes lunch is cold. The Surveyor asked if Resident #68 had ever told someone the food is cold or filed a grievance. Resident #68 said she has complained to staff before that food is cold but has never filed a grievance. 2. On 01/03/24 at 07:26 AM, an unheated food cart that contained 21 trays for the breakfast meal was in 500 Hall. On 01/03/24 7:48 AM immediately after the last resident received tray in their room, the surveyor asked the Dietary Supervisor to check the temperatures of the food items on the trays. Dietary Supervisor said the following: a. Milk 50.1 degrees Fahrenheit. b. Pancake 114 degrees Fahrenheit. 2. On 01/03/24 at 7:41 AM, an unheated food cart that contained 10 trays for the breakfast meal was delivered to the [NAME] Hall. On 01/03/24 8:00 AM, immediately after the last resident received tray in their room. The surveyor asked the Dietary Supervisor to check the temperatures of the food items on the trays. The Dietary Supervisor said the following: a. Milk 49.1 degrees Fahrenheit. b. Pancake 111.5 degrees Fahrenheit. c. Ground sausage with gravy 112.6 degrees Fahrenheit. 4. 01/03/24 07:52 AM an unheated food cart that contained 7 trays for the breakfast meal was delivered to the North Hall. 01/03/24 08:00 AM Immediately after the last resident received tray in their room. The surveyor asked the Dietary Supervisor to check the temperatures of the food items on the trays. Which she did and stated, The Dietary Supervisor said the following: a. Milk 48.7 degrees Fahrenheit. b. Pancake 111.5 degrees Fahrenheit, c. Scrambled eggs 100 degrees Fahrenheit. d. Gravy 100.2 degrees Fahrenheit

Based on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 7 residents who received pureed diets and 2 residents who received pureed meat only. The findings are: 1. On 01/02/24 at 12:12 PM, Dietary Employee (DE) #1 used a regular spoon to put 6 servings of cream corn into a blender, added whole milk and pureed. At 12:14 PM, DE #1 poured the pureed cream of corn, into a pan and placed it on the steam table to be served to the residents on pureed diets for lunch. The consistency of the pureed cream corn was runny and not formed. 2. On 01/02/24 at 7:15 AM, the following food items were served to the residents on pureed diets. a. Pureed ham served to the residents pureed diets was gritty and not smooth. b. Pureed oatmeal served to the residents on pureed diets was runny and was not formed. At 8:21 AM, the surveyor asked the Dietary Supervisor to describe the consistency of the pureed ham and pureed oatmeal served to the residents on pureed diets. She stated, Pureed oatmeal was loose and pureed ham was gritty.

Based on observations, interviews, and record review the facility failed to ensure that Resident #66 received privacy during incontinence care. The Findings are: 1. Resident #66 had a diagnosis of Alzheimer's Disease and according to Annual Minimum Data Set (MDS) with an Assessment Reference Date (ADR) of 11/8/23 the resident scored 01 (0-7 indicates severe impairment) on the Brief Interview Mental Status (BIMS) and was always incontinent of bowel and bladder. a. On 01/02/24 at 1:35 PM, Surveyor observed Certified Nursing Assistant #1 and #2 providing incontinence care with the privacy curtain partially pulled. b. On 01/02/24 at 1:45 PM, Surveyor asked CNA #1 If someone entered the room right now with the curtain partially pulled what would they see? CNA #1 stated Her being changed. c. On 01/02/24 at 2:15 PM, Surveyor asked Director of Nursing (DON) if a Resident is receiving incontinence care with the curtain pulled only between the Resident but not all the way around to the door what would someone entering the room see immediately upon entering the room? The DON stated they are going to see the Resident receiving care and that is a dignity issue. d. On 1/2/24 at 12:40 PM, the Administrator provided Surveyor with a admission packet section c titled Patient's Rights-State Laws 9 states the Resident has the right to have privacy in treatment and in caring for personal needs, to close room doors and to have facility personnel knock before entering the room except in the case of an emergency or unless medically contraindicated, and to security in storing and using personal possessions. Privacy of the Patient's body shall be maintained during, but not limited to, toileting, bathing, and other activities of personal hygiene, except as needed for patient safety or assistance.

Based on observation, interview and record review, the facility failed to ensure person centered nail care was provided to promote good hygiene and reduce the risk for infection in 1 (Resident #4) of 8 sampled residents on 500 hall requiring fingernail care assistance. The findings are: a. Resident #4 has an activity of daily living [ADL] self-care performance deficit . The resident requires assistance from staff with showering 3 x/week and as necessary . The resident requires assistance by staff with personal hygiene and oral care . b. On 01/02/24 at 10:08 AM, the Surveyor observed Resident #4's fingernails are long and has very faded red nail polish. The Surveyor asked Resident #4 what she thinks about her nails. Resident #4 said she would like to have her nails cut, and said her polish is almost gone. The Surveyor asked who normally takes care of Resident #4's fingernails and Resident #4 said, The nurse. c. On 01/02/24 at 3:21 PM, the Surveyor observed Resident #4 coloring at the bedside, with long fingernails and small patches of red nail polish. d. On 01/03/24 at 9:38 AM, Certified Nursing Assistant [CNA] #3 was observed at the bedside. The Surveyor asked CNA #3 how often Resident #4 gets showers, and do they provide nail care on shower day. CNA #3 said Resident #4 gets 3 showers a week, and if she is not on the diabetic list they should provide nail care, including removal of old polish. The Surveyor asked Resident #4 if she likes her fingernails, and she said she would like them to be trimmed and repainted. CNA #3 was asked to describe the Resident ' s nails and was provided a ruler to measure the tip of the finger to the end of the fingernail on her right pointer finger. CNA #3 said, she needs some attention, and if she is not a diabetic and does not refuse, we can trim and polish Resident #4's nails. CNA #3 agreed the right pointer fingernail measuring just below 1/2 cm from the end of the pointer finger to the tip of the fingernail. e. On 01/04/24 at 09:46 AM, during an interview with the Director of Nursing [DON] the Surveyor asked what process the facility uses to ensure residents get nailcare. The DON said the shower aids trim resident nails on shower days. The Surveyor asked if a resident is not capable of knowing when or how to ask for care and how do staff address their nailcare. The DON said if a resident's nails look like they need attention then the shower team should just address it and clip the nails. The DON said occasionally a podiatrist comes into the facility. The DON was asked for a nail care policy. f. On 01/04/2024 at 01:45 PM, The Chief Nursing Officer [CNO] provided a policy titled Nail Care Policy and Procedure documenting, .Purpose: 1. To provide cleanliness. Policy: All residents will have nails cleaned and trimmed once weekly or as needed per resident request. Procedure: 1. Explain to resident the procedure. 2. Take needed supplies to the room. 3. Trim nails. 4. Discard of disposable equipment. Equipment: 1. Fingernail clippers 2. File .

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set [MDS] assessment accurately reflected a level II Preadmission Screening and Resident Review [PASARR] evaluation with recommendations to facilitate the ability to plan, coordinate and provide necessary care for 1(Resident #52) of 16 residents who have a level II PASRR. The findings are: 1. Resident #52 with a diagnosis of intracranial injury with loss of consciousness of duration, Epilepsy, and seizures and Schizoaffective disorder. The significant change minimum data set [MDS] with an assessment reference date [ARD] of 09/04/2023 indicated a brief interview for mental status [BIMS] score of 09 (8-12 suggest moderately impaired). a. A care plan with a (Revision, 10/11/2023) documented .state designated authority has approved admittance to facility see approval packet . monitor and document behaviors. b. On 01/02/2024 at 08:01 PM, the Surveyor observed a Level II PASARR evaluation for Resident #52 with serious mental illness, dated 03/18/2022. c. 01/04/24 10:00 AM, MDS nurse #1 and MDS nurse #2 were asked if Resident #52 had a PASARR II, and asked MDS nurse #1 to observe Resident #52 MDS is coded for a PASARR II. MDS nurse #1 showed a 02/22/2022 letter that indicated resident was non-PASARR, and a level II evaluation letter dated 03/18/2023. MDS nurse #1 pointed out it No specialized services. MDS nurse #1 then checked the significant MDS with an assessment reference date [ARD] of 09/04/2023 and stated, A 1500 says no, that would be no if he is a level 1, right? The MDS nurse was asked if she has anything she uses as a guide or manual for reference. The MDS nurse #2 told the Surveyor they have the Resident Assessment Instrument [RAI] manual online. d. On 01/05.2023 on 11:05 AM, the DON was asked why it is important to code correctly to the minimum data set [MDS]. The DON said she does not know a lot about the MDS but knows that it is mandatory, affects financials, flows to the care plan, and reflects resident ' s care.

Based on observations, interviews and record review, the facility failed to ensure that Resident #66 received proper incontinence care. This failed practice had the potential to cause skin breakdown, poor hygiene, and/or infection. The Findings are: 1. Resident #66 had a diagnosis of Alzheimer's Disease and according to Annual Minimum Data Set (MDS) with an Assessment Reference Date (ADR) of 11/8/23 the resident scored 01 (0-7 indicates severe impairment) on the Brief Interview Mental Status (BIMS) and was always incontinent of bowel and bladder. a. On 01/02/24 at 1:30 PM, the Surveyor observed Certified Nursing Assistant (CNA) #1 and #2 transferring Resident #66 from chair to bed via lift. Surveyor observed incontinence brief lying in the bed and CNA #1 and #2 placed Resident #66 and lift pad on top of the clean brief. CNA #1 and #2 rolled Resident #66 from side to side, removed lift pad with incontinence brief, and pulled brief that was under Resident in place. Surveyor observed blue line on incontinence brief that indicate that Resident #66 was incontinent of bladder prior to CNA #1 putting the brief in the trash. Neither CNA #1 nor #2 wiped or provided incontinence care to Resident #66 prior to putting on another brief. Surveyor observed CNA #2 moved bedside table with dirty gloves after care was complete. b. On 01/02/24 at 1:32 PM, the Surveyor asked both CNAs, was the Resident incontinent of bladder? CNA #1 stated yes. The Surveyor asked, how do you perform incontinence care? CNA #2 stated, Wipe across, down the thighs and in between and front to back. The Surveyor asked, why did you not do that on when providing care to this resident? CNA #2 stated, Because we didn't have any wipes. The Surveyor asked, when should you change gloves? CNA #2 stated, After each wipe. The Surveyor asked, why didn't you change your gloves? CNA #2 stated, Because I did not have anymore. The Surveyor asked, why did you not bring wipes and extra gloves in to provide incontinence care? CNA #1 stated, Because she is usually dry. c. On 01/02/24 at 2:15 PM, the Surveyor asked Director of Nursing (DON) If a Resident is incontinent of bladder should they be wiped or provided incontinent care? DON stated Don't tell me they didn't wipe at all. Yeah, they should be wiped. d. On 01/02/24 at 3:09 PM, Director of Nursing provided Surveyor with a policy titled perineal care policy and procedure. Purpose: To cleanse the perineum and external genitalia to prevent infection and odor.

Based on record review, and interview, the facility failed to ensure the physician was immediately consulted regarding a sudden increase in the frequency and severity of a resident's pain after an incident in which a Certified Nursing Assistant heard a loud pop from the resident's leg during repositioning the resident in bed, to prevent potential delays in [DIAGNOSES REDACTED].#10) of 5 (Residents #4, #9, #10, #11, and #13) case mix residents who sustained fractures or other significant changes in condition in the past 3 months. The failed practices resulted in past noncompliance due to a pattern of harm for Resident #10, whose increased pain was not immediately reported to the physician, which resulted in a delay in diagnosing and treating a femur fracture. The failed practice had the potential to cause more than minimal harm to 6 residents who sustained fractures in the past 3 months, as documented on a list provided by the Director of Nursing on 11/4/16. The findings are: Resident #10 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 5/23/16 documented the resident scored 4 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status, required extensive assistance of 2-plus persons for bed mobility, transfer and toilet use, was always incontinent of bladder and bowel, denied pain or hurting, and had no functional limitation in range of motion in any extremity. a. A Care Plan dated 5/24/16 documented, .Focus .ADL (Activities of Daily Living) self-care performance deficit related to Dementia . Limited Mobility, Confusion, impaired balance . Interventions/Tasks . Bed Mobility . requires assistance by 2 staff to turn and reposition in bed . Side Rails . half rails up as per Dr's (doctor's) order for safety during care provision . Transfer . the resident requires extensive assistance by 2 staff to move between surfaces as necessary . Monitor/document/report PRN (as needed) any changes, reasons for self-care deficit, expected course, declines in function . There was no documentation of risk for pain or complaint of pain in the resident's care plan dated 5/24/16. b. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 8/15/16 documented the following: Page 4: .On 8/12/16 at approximately 0645 (6:45 a.m.) (Certified Nursing Assistant (CNA) #4) went into (Resident #10's room to provide incontinent care and requested that Resident turn herself over utilizing the assist bars on her bed. When resident turned herself (CNA #4) heard a loud pop and immediately reported it to nurse (Licensed Practical Nurse (LPN) #2). On 8/12/16 at approximately 0645 (6:45 a.m.) (LPN #2) assessed resident leg and found no evidence of swelling or signs of a significant injury. Resident was medicated with [MEDICATION NAME] per (physician's) orders which was noted as being effective . Two nurses administered [MEDICATION NAME] on 8/13/16 for left hip / knee pain which were noted as effective. (Registered Nurse (RN) #1) assessed resident's left hip / leg and noted trace [MEDICAL CONDITION] but nothing that would indicate a significant injury . On 8/14/16 (CNA #5) reported to (LPN #1) resident's leg had significantly increased in size, with warmth noted, and pain . Page 3: Summary of Incident . On 8/15/16 at approximately 9:30 a.m., (CNA #3) requested that (LPN #1) look at (Resident #10's) left knee due to swelling. After assessing resident's left knee, (LPN #1) contacted (Physician) to inform him of the swollen knee. (Physician) ordered an X-Ray of the left knee onsite. X-Ray was completed at approximately 1:20 p.m., with results showing a displaced [MEDICAL CONDITION] femur. (Physician) ordered resident to be sent to (Hospital) ER (emergency room ) for evaluation and 10 mg. (milligrams) of [MEDICATION NAME] IM (intramuscularly) prior to the ambulance transfer for pain. (Resident #10) unable to tell staff what happened to her left leg due to cognitive impairment . The facility's investigation included a Witness Statement completed by LPN #2 on 8/18/16, which documented, .Nurse done making rounds .CNA stated that (Resident #10) needed a (pain) pill for her hip / L (left) knee. Assessed resident for pain when going in. Nurse asked where she was hurting. Resident stated her hip / knee point to her left side. Resident doesn't seem to be in any more pain than usual. Resident always states that she hurts on that side from where a car hit her . A Witness Statement dated 8/12/16 (not timed), written by CNA #7, documented, On Friday 8/12/16, I was making my round on (Resident #10) and she was complaining about her knee was paining so bad, and went and reported it to the nurse, and the nurse said she was going to give her some pain medicine, but after my next round, (Resident #10) was still complaining about her knee! c. The August 2016 Medication Administration Record [REDACTED].), 1 tablet by mouth every 6 hours as needed for pain, and to assess for pain using a 1 to 10 scale every shift. The August 2016 MAR indicated [REDACTED] Beginning on 8/12/16 after the incident occurred in which the CNA heard a pop while the resident was repositioning in bed, the August 2016 MAR indicated [REDACTED] 8/12/16: Three doses of [MEDICATION NAME] were administered (One at 6:56 a.m. for a pain scale of 8; complained of left hip pain, comfort measures not effective; one at 4:36 p.m. for a pain scale of 8; complained of left knee/hip pain; comfort measures not effective; and one at 7:32 p.m. for a pain scale of 6; complained of leg pain, no [MEDICAL CONDITION] at this time). 8/13/16: Two doses of [MEDICATION NAME] were administered (One at 12:27 p.m. for a pain scale of 9; complained of pain in legs and knees; and one at 7:53 p.m. for a pain scale of 7; complained of right knee pain, trace [MEDICAL CONDITION] noted). 8/14/16: No [MEDICATION NAME] administration was documented on this date. 8/15/16: No [MEDICATION NAME] administration was documented on this date; however, there was a pain scale level of 6 documented on the day shift that was not timed. d. Nurses Progress Notes dated 8/12/16 did not document any information regarding the CNA reporting to the nurse that she heard a pop when the resident repositioned in bed or of consulting the physician regarding a possible injury; however, the following entries were documented: .6:56 a.m., [MEDICATION NAME] HCI tablet 50 mg . c/o (complained of) left knee hip px (pain); comfort measures not effective . 8:11 a.m., .Administration was: Effective . This note was signed by LPN #2. There was no documentation of physician notification at this time. .4:46 p.m., [MEDICATION NAME] HCI tablet 50 mg . c/o (complained of) left knee/hip px (pain): comfort measures not effective. This note was signed by LPN #2. There was no documentation of physician notification at this time. .7:32 p.m., [MEDICATION NAME] HCI tablet 50 mg . leg pain no [MEDICAL CONDITION] at this time . (signed by LPN #2) . 8:45 p.m. administration was: Effective . (signed by RN #1) . There was no documentation the physician was consulted regarding the increased frequency and severity of the resident's complaints of pain. e. The Nurses Progress Notes dated 8/13/16 documented the following entries: At 12:27 p.m.: .[MEDICATION NAME] HCI tablet 50 mg give 1 tablet by mouth every 6 hours as needed for PAIN c/o pain in legs and knees 9/10 (pain scale 9 on a scale of 1 to 10) . This note was signed by LPN #1. At 3:56 p.m.: .[MEDICATION NAME] HCI tablet 50 mg give 1 tablet by mouth every 6 hours as needed for PAIN; prn (as needed) administration was: Effective . This note was signed by LPN #1. At 7:53 p.m.: .[MEDICATION NAME] HCI tablet 50 mg give 1 tablet by mouth every 6 hours as needed for PAIN; c/o of right knee pain, trace [MEDICAL CONDITION] noted . 8:56 p.m.administration was effective . This note was signed by RN #2. There was no documentation the physician was consulted regarding the increased frequency and severity of the resident's complaints of pain on 8/13/16. f. Witness Statements from staff who worked with the resident on 8/14/16 documented the following: 1.) A Witness Statement dated 8/15/16 at 8:36 a.m., written by CNA #6, documented, Last night when we went to do our round on North Hall in N-2 (Resident #10's room) with (Resident #10) I asked (Resident #10) how she was doing and she said her knee hurt so bad, so we changed her. I turned her but (Resident #10) always complains about her knees hurt. But 8/14/16, which was Sunday, she said legs was hurting so bad. 2.) A Witness Statement dated 8/15/16 at 1:30 p.m., written by CNA #5, documented, I went in (Resident #10's) room yesterday (8/14/16). As my partner, (CNA #3) and I turned her (resident), she complained, screamed and cried that her left leg was hurting. It was swollen. So, I reported to Nurse (LPN #1) that she was in pain. There were no Nurses Progress Notes for 8/14/16 in the resident's clinical record. g. Nurses Progress Notes dated 8/15/16 documented the following entries: At 1:24 p.m.: .X-Ray tech (technician) here to perform X-ray of left knee / femur /tib (tibia) / fib (fibula). X-ray technician called this LPN to R's (resident's) room to ask how much we wanted R (resident) to be moved. This LPN then looked at the screen and noted the femur bone broken. DON (Director of Nursing) called to room at this time. MD (Medical Doctor) notified at this time. Awaiting new orders . This note was signed by LPN #1. At 1:55 p.m.: .X-Ray results: AP (anteroposterior) and lateral projections of the left femur were presented for review. A moderately displaced oblique [MEDICAL CONDITION]-shaft of the left femur is noted. The left hip arthroplasty appears unremarkable. No evidence for fracture extension to the level of the femoral stem of the arthroplasty. Displace oblique [MEDICAL CONDITION] diaphysis of the left femur. No evidence of involvement of the femoral portion of the left hip arthroplasty. MD aware. Awaiting new orders . This note was signed by LPN #1. (The August 2016 MAR indicated [REDACTED].[MEDICATION NAME] Solution 10 mg/ml (milligrams per milliliter) Inject 1 ml (milliliter) intramuscularly one time only for pain, severe; transfer to (Hospital) .) At 2:31 p.m.: R (resident) out to (Hospital) via Ambulance d/t (due to) X-ray results. MD and Family aware . This note was signed by LPN #1. At 3:00 p.m.: .Staff reports (resident) complained of pain and [MEDICAL CONDITION] to left knee. MD notified, (New order) for x-ray. Results found fracture to mid shaft femur. MD notified. (New Order), transfer to (hospital) ER. Medicated with 10mg/ml [MEDICATION NAME] IM (intramuscular) at approximate 1:50 p.m. emergency room notified at approximately 1:56 p.m. Ambulance notified at approximately 1:58 p.m. Ambulance arrived at approximately 2:00 p.m. Resident put on spine board and traction to left leg. Ambulance left facility at approximately 2:45 p.m. h. The emergency room (ER) Hospital Admission Record dated 8/15/16 documented, .the patient is not able to provide any history, but information that is related to me from the emergency room was that the patient was found to have some swelling of her left thigh and had radiographs taken which showed a left femur fracture . Radiographs of the left femur were obtained, which showed a displaced spiral [MEDICAL CONDITION] femur . PLAN . I have recommended surgical treatment with open reduction internal fixation of the left femur fracture . The patient has been admitted and placed in Buck's traction . my expectation is that it will be later in the week before the patient will be ready for surgery . i. On 11/2/16 at 2:20 p.m., CNA #4 was interviewed via telephone. She was asked if she was working the 7:00 a.m. to 3:00 p.m. (7-3) shift on 8/12/16. She stated, Yes, I had gone in to get (Resident #10) cleaned up and brief changed and up for breakfast. When I asked the resident to help roll over, (Resident #10) helped roll herself over by using the side rail, and at that time, I heard the resident's left leg make a loud 'pop' sound. She was asked if she had reported this to anyone. She stated, As luck would have it, (LPN #2) was making her rounds on the hall and walked in (Resident #10's) room right after I heard the pop. So, I immediately told her what had happened. Once I finished changing her brief, she said she was hurting, and (LPN #4) brought her a pain pill. I did not work with (Resident #10) again till after she had gone to hospital, and I heard she had a fractured leg. j. On 11/2/16 at 2:10 p.m., LPN # 2 was asked if she remembered when she had first been made aware that Resident #10's leg had made a loud popping sound during repositioning. She stated, No, not off the top of my head. I really don't remember. I was asked to do a witness statement around 8/15/16 by the Administrator, and he asked me if anything was different with (Resident #10), and I told him I gave her something for pain. She was asked if any staff had reported to her hearing a 'pop' in the resident's leg on 8/12/16, and she stated, To my knowledge, I don't remember that. k. On 11/2/16 at 11:26 a.m., the Director of Nursing (DON) was asked if the Nurses completed 24-Hour Reports to report incidents or changes in the residents' conditions to the oncoming shift. She stated, Oh, yes. I will print them off for you. The DON was asked to print the 24-Hour Reports from 8/12/16 through 8/15/16. The 24-Hour Reports provided by the DON on 11/2/16 documented repeated administrations of the [MEDICATION NAME] to the resident, but did not document any notification to the physician regarding the 'pop' that was heard by the CNA or the resident's subsequent and repeated complaints of pain on 8/12/16 and 8/13/16. l. The facility corrected the failed practices on 8/15/16 by implementing the following corrective action plan, as provided by the Administrator on 11/3/16 at 10:35 p.m.: On 8/15/16, (Resident #10) was immediately assessed with [REDACTED]. The resident's family and physician were made aware of the pain and physical indicators identified. Pain management orders were requested and initiated as appropriate, and the resident was subsequently transferred to the hospital via EMS (Emergency Medical Services) for further evaluation and treatment. The facility immediately initiated investigation of the resident's injury of unknown origin, and MD, family, local law enforcement, and OLTC (Office of Long Term Care) notifications were made as appropriate. On 8/15/16, the DON/designee(s) evaluated current pain assessments for all residents to identify if any other residents exhibited any new, or worsened, pain levels necessitating further evaluation and/or MD notification. No negative findings were identified with these audits. Licensed Nurse retraining was initiated regarding resident assessment findings, reporting changes of condition, including new or worsened pain, [MEDICAL CONDITION], etc. (et cetera). Observation and ongoing monitoring will be completed by the Director of Nurses/designee(s) during daily clinical start up, including review of pain assessment findings, review pain management, with medication regimens, MD notifications of any new or worsened pain utilizing pain summary, alert listing, and medication administration routines. Any abnormal findings identified with start-up reviews will be immediately addressed with staff retraining completed immediately upon discovery and taken to QAA (Quality Assessment and Assurance) for additional plan development as needed. m. The following documentation was reviewed to validate that the facility followed their corrective action plans and corrected the failed practice prior to the survey date: 1.) The QA&A Agenda notes dated 8/26/16, 9/29/16 and 10/27/16 documented discussion of, .resident pain assessments, 'New Issues Identified', DON reviewing clinical alerts of pain assessment findings during daily start up, review pain management with medication regimens, MD notifications of any new or worsened pain utilizing pain summary, and alert listing and medication administration routines. No negative findings. 2.) An in-service sheet dated 8/15/16, received from the Director of Nursing on 11/3/16 at 11:40 a.m., documented, Be sure to report any change of condition to charge nurse promptly. Example: Increase complaint of pain, [MEDICAL CONDITION], etc. Re-education on proper transfer, follow closet care plan when providing care to residents, Use caution when repositioning and providing care to residents, MD notification for change of conditions (pain). This in-service was signed by 9 nurses, 19 CNAs, 1 Housekeeper and 1 Social Services person. 3.) An in-service dated 11/2/16, received from the Director of Nursing on 11/3/16 at 11:40 a.m., documented, Be sure to address and follow-up on any pain rating above 6 out of scale 0 - 10. Call MD if pain medication is ineffective, reassess, try another non-pharmacological intervention, then, notify MD if pain continues . This in-service was signed by 8 nurses.

Based on record review and interview, the facility failed to ensure necessary care and services were provided to attain or maintain the highest practicable physical well-being for Resident #10, as evidenced by failure to ensure a thorough assessment and prompt treatment were provided after the resident complained of increased pain after an incident; failure to ensure the physician was immediately consulted regarding the sudden increase in the frequency and severity of the resident's pain; and, failure to ensure consistent monitoring of the resident's condition was conducted after the change in condition occurred in order to provide effective pain management and prevent potential exacerbation of any existing injury for 1 Resident (Resident #10) of 5 (Residents #4, #9, #10, #11, and #13) case mix residents who sustained fractures or other significant changes in condition in the past 3 months. The failed practices resulted in past noncompliance due to a pattern of harm for Resident #10, who experienced increased pain after an incident which was not immediately reported to the physician, which resulted in a delay in diagnosing and treating a femur fracture and in effectively managing the resident's pain. The failed practices had the potential to cause more than minimal harm to 6 residents who sustained fractures in the past 3 months, as documented on a list provided by the Director of Nursing on 11/4/16. The findings are: Resident #10 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 5/23/16 documented the resident scored 4 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status, required extensive assistance of 2-plus persons for bed mobility, transfer and toilet use, was always incontinent of bladder and bowel, denied pain or hurting, and had no functional limitation in range of motion in any extremity. a. A Care Plan dated 5/24/16 documented, .Focus .ADL (Activities of Daily Living) self-care performance deficit related to Dementia . Limited Mobility, Confusion, impaired balance . Interventions/Tasks . Bed Mobility . requires assistance by 2 staff to turn and reposition in bed . Side Rails . half rails up as per Dr's (doctor's) order for safety during care provision . Transfer . the resident requires extensive assistance by 2 staff to move between surfaces as necessary . Monitor/document/report PRN (as needed) any changes, reasons for self-care deficit, expected course, declines in function . There was no documentation on the resident's care plan of 5/24/16 related to pain, risk for pain, or assess for pain. b. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 8/15/16 documented the following: Page 4: .On 8/12/16 at approximately 0645 (6:45 a.m.) (Certified Nursing Assistant (CNA) #4) went into (Resident #10's) room to provide incontinent care and requested that Resident turn herself over utilizing the assist bars on her bed. When resident turned herself (CNA #4) heard a loud pop and immediately reported it to nurse (Licensed Practical Nurse (LPN) #2). On 8/12/16 at approximately 0645 (6:45 a.m.) (LPN #2) assessed resident leg and found no evidence of swelling or signs of a significant injury. Resident was medicated with [MEDICATION NAME] per (physician's) orders which was noted as being effective . Two nurses administered [MEDICATION NAME] on 8/13/16 for left hip / knee pain which were noted as effective. (Registered Nurse (RN) #1) assessed resident's left hip / leg and noted trace [MEDICAL CONDITION] but nothing that would indicate a significant injury . On 8/14/16 (CNA #5) reported to (LPN #1) resident's leg had significantly increased in size, with warmth noted, and pain . Page 3: Summary of Incident . On 8/15/16 at approximately 9:30 a.m., (CNA #3) requested that (LPN #1) look at (Resident #10's) left knee due to swelling. After assessing resident's left knee, (LPN #1) contacted (Physician) to inform him of the swollen knee. (Physician) ordered an X-Ray of the left knee onsite. X-Ray was completed at approximately 1:20 p.m., with results showing a displaced [MEDICAL CONDITION] femur. (Physician) ordered resident to be sent to (Hospital) ER (emergency room ) for evaluation and 10 mg. (milligrams) of [MEDICATION NAME] IM (intramuscularly) prior to the ambulance transfer for pain. (Resident #10) unable to tell staff what happened to her left leg due to cognitive impairment . The facility's investigation included a Witness Statement completed by LPN #2 on 8/18/16, which documented, .Nurse done making rounds .CNA stated that (Resident #10) needed a (pain) pill for her hip / L (left) knee. Assessed resident for pain when going in. Nurse asked where she was hurting. Resident stated her hip / knee point to her left side. Resident doesn't seem to be in any more pain than usual. Resident always states that she hurts on that side from where a car hit her . A Witness Statement dated 8/12/16 (not timed), written by CNA #7, documented, On Friday 8/12/16, I was making my round on (Resident #10) and she was complaining about her knee was paining so bad, and went and reported it to the nurse, and the nurse said she was going to give her some pain medicine, but after my next round, (Resident #10) was still complaining about her knee! c. The August 2016 Medication Administration Record [REDACTED].), 1 tablet by mouth every 6 hours as needed for pain, and to assess for pain using a 1 to 10 scale every shift. The August 2016 MAR indicated [REDACTED]. Beginning on 8/12/16, after the incident occurred in which the CNA heard a pop while the resident was repositioning in bed, the August 2016 MAR indicated [REDACTED] 8/12/16: Three doses of [MEDICATION NAME] were administered (One at 6:56 a.m. for a pain scale of 8; one at 4:36 p.m. for a pain scale of 8; and one at 7:32 p.m. for a pain scale of 6). 8/13/16: Two doses of [MEDICATION NAME] were administered (One at 12:27 p.m. for a pain scale of 6 and one at 7:53 p.m. for a pain scale of 7). 8/14/16: No [MEDICATION NAME] administration was documented on this date. 8/15/16: No [MEDICATION NAME] administration was documented on this date; however, there was a pain scale level of 6 documented on the day shift that was not timed. d. Nurses Progress Notes dated 8/12/16 did not document any information regarding the CNA reporting to the nurse that she heard a pop when the resident repositioned in bed or of any assessment for possible injury; however, the following entries were documented: .6:56 a.m., [MEDICATION NAME] HCI tablet 50 mg .c/o (complained of) left knee hip px (pain); comfort measures not effective . 8:11 a.m., .Administration was: Effective . This note was signed by LPN #2. There was no documentation of an assessment of the resident's left knee or hip for signs and symptoms of injury, such as bruising, swelling, or redness, at this time. .4:46 p.m., [MEDICATION NAME] HCI tablet 50 mg . c/o (complained of) left knee/hip px (pain): comfort measures not effective. This note was signed by LPN #2. There was no documentation of an assessment of the left knee or hip for signs and symptoms of injury, such as bruising, redness or swelling, at this time, and no documentation the physician was consulted regarding the increased frequency and severity of the resident's complaints of pain. .7:32 p.m., [MEDICATION NAME] HCI tablet 50 mg . leg pain no [MEDICAL CONDITION] at this time . (signed by LPN #2) . 8:45 p.m. administration was: Effective . (signed by RN #1) . There was no documentation the physician was consulted regarding the increased frequency and severity of the resident's complaints of pain. e. The Nurses Progress Notes dated 8/13/16 documented the following entries: At 12:27 p.m.: .[MEDICATION NAME] HCI tablet 50 mg give 1 tablet by mouth every 6 hours as needed for PAIN c/o pain in legs and knees 9/10 (pain scale 9 on a scale of 1 to 10) . This note was signed by LPN #1. At 3:56 p.m.: .[MEDICATION NAME] HCI tablet 50 mg give 1 tablet by mouth every 6 hours as needed for PAIN; prn (as needed) administration was: Effective . This note was signed by LPN #1. At 7:53 p.m.: .[MEDICATION NAME] HCI tablet 50 mg give 1 tablet by mouth every 6 hours as needed for PAIN; c/o of right knee pain, trace [MEDICAL CONDITION] noted . 8:56 p.m.administration was effective . This note was signed by RN #2. f. Witness Statements from staff who worked with the resident on 8/14/16 documented the following: 1.) A Witness Statement dated 8/15/16 at 8:36 a.m., written by CNA #6, documented, Last night when we went to do our round on North Hall in N-2 (Resident #10's room) with (Resident #10) I asked (Resident #10) how she was doing and she said her knee hurt so bad, so we changed her. I turned her but (Resident #10) always complains about her knees hurt. 2.) A Witness Statement dated 8/15/16 at 1:30 p.m., written by CNA #5, documented, I went in (Resident #10's) room yesterday (8/14/16). As my partner, (CNA #3) and I turned her (resident), she complained, screamed and cried that her left leg was hurting. It was swollen. So, I reported to Nurse (LPN #1) that she was in pain. There were no Nurses Progress Notes dated 8/14/16 in the resident's clinical record; however, the facility's investigation documentation indicated that CNA #5 reported to the nurse that the resident's leg had significantly increased in size as of that date. g. Nurses Progress Notes dated 8/15/16 documented the following entries: At 1:24 p.m.,: .X-Ray tech (technician) here to perform X-ray of left knee / femur /tib (tibia) / fib (fibula). X-ray technician called this LPN to R's (resident's) room to ask how much we wanted R (resident) to be moved. This LPN then looked at the screen and noted the femur bone broken. DON (Director of Nursing) called to room at this time. MD (Medical Doctor) notified at this time. Awaiting new orders . This note was signed by LPN #1. At 1:55 p.m.: .X-Ray results: AP (anteroposterior) and lateral projections of the left femur were presented for review. A moderately displaced oblique [MEDICAL CONDITION]-shaft of the left femur is noted. The left hip arthroplasty appears unremarkable. No evidence for fracture extension to the level of the femoral stem of the arthroplasty. Displace oblique [MEDICAL CONDITION] diaphysis of the left femur. No evidence of involvement of the femoral portion of the left hip arthroplasty. MD aware. Awaiting new orders . This note was signed by LPN #1. (The August 2016 MAR indicated [REDACTED].[MEDICATION NAME] Solution 10 mg/ml (milligrams per milliliter) Inject 1 ml (milliliter) intramuscularly one time only for pain, severe; transfer to (Hospital) .) At 2:31 p.m.: R (resident) out to (Hospital) via Ambulance d/t (due to) X-ray results. MD and Family aware . This note was signed by LPN #1. At 3:00 p.m.: .Staff reports (Resident) complained of pain and [MEDICAL CONDITION] to left knee. MD notified, (New order) for x-ray. Results found fracture to mid shaft femur. (physician) notified. (New Order), transfer to (hospital) ER (emergency room ). Medicated with 10mg/ml [MEDICATION NAME] IM (intramuscular) at approximate 1:50 p.m. emergency room notified at approximately 1:56 p.m. Ambulance notified at approximately 1:58 p.m. Ambulance arrived at approximately 2:00 p.m. Resident put on spine board and traction to left leg. Ambulance left facility at approximately 2:45 p.m . h. The emergency room (ER) Hospital Admission Record dated 8/15/16 documented, .the patient is not able to provide any history, but information that is related to me from the emergency room was that the patient was found to have some swelling of her left thigh and had radiographs taken which showed a left femur fracture . Radiographs of the left femur were obtained, which showed a displaced spiral [MEDICAL CONDITION] femur . PLAN . I have recommended surgical treatment with open reduction internal fixation of the left femur fracture . The patient has been admitted and placed in Buck's traction . my expectation is that it will be later in the week before the patient will be ready for surgery . i. On 11/2/16 at 2:20 p.m., CNA #4 was interviewed via telephone. She was asked if she was working the 7:00 a.m. to 3:00 p.m. (7-3) shift on 8/12/16. She stated, Yes, I had gone in to get (Resident #10) cleaned up and brief changed and up for breakfast. When I asked the resident to help roll over, (Resident #10) helped roll herself over by using the side rail, and at that time, I heard the resident's left leg make a loud 'pop' sound. She was asked if she had reported this to anyone. She stated, As luck would have it, (LPN #2) was making her rounds on the hall and walked in (Resident #10's) room right after I heard the pop. So, I immediately told her what had happened. Once I finished changing her brief, she said she was hurting, and (LPN #4) brought her a pain pill. I did not work with (Resident #10) again till after she had gone to hospital, and I heard she had a fractured leg. j. On 11/2/16 at 2:10 p.m., LPN # 2 was asked if she remembered when she had first been made aware that Resident #10's leg had made a loud popping sound during repositioning. She stated, No, not off the top of my head. I really don't remember. I was asked to do a witness statement around 8/15/16 by the Administrator, and he asked me if anything was different with (Resident #10), and I told him I gave her something for pain. She was asked if any staff had reported to her hearing a 'pop' in the resident's leg on 8/12/16, and she stated, To my knowledge, I don't remember that. k. On 11/2/16 at 11:26 a.m., the Director of Nursing (DON) was asked if the Nurses completed 24-Hour Reports to report incidents or changes in the residents' conditions to the oncoming shift. She stated, Oh, yes. I will print them off for you. The DON was asked to print the 24-Hour Reports from 8/12/16 through 8/15/16. The 24-Hour Reports provided by the DON on 11/2/16 documented repeated administrations of the [MEDICATION NAME] to the resident, but did not document any notification to the physician regarding the 'pop' that was heard by the CNA or the resident's subsequent and repeated complaints of pain on 8/12/16 and 8/13/16. l. The facility corrected the failed practices on 8/15/16 by implementing the following corrective action plan, as provided by the Administrator on 11/3/16 at 10:35 p.m.: On 8/15/16, (Resident #10) was immediately assessed with [REDACTED]. The resident's family and physician were made aware of the pain and physical indicators identified. Pain management orders were requested and initiated as appropriate, and the resident was subsequently transferred to the hospital via EMS (Emergency Medical Services) for further evaluation and treatment. The facility immediately initiated investigation of the resident's injury of unknown origin, and MD, family, local law enforcement, and OLTC (Office of Long Term Care) notifications were made as appropriate. On 8/15/16, the DON/designee(s) evaluated current pain assessments for all residents to identify if any other residents exhibited any new, or worsened, pain levels necessitating further evaluation and/or MD notification. No negative findings were identified with these audits. Licensed Nurse retraining was initiated regarding resident assessment findings, reporting changes of condition, including new or worsened pain, [MEDICAL CONDITION], etc. (et cetera). Observation and ongoing monitoring will be completed by the Director of Nurses/designee(s) during daily clinical start up, including review of pain assessment findings, review pain management, with medication regimens, MD notifications of any new or worsened pain utilizing pain summary, alert listing, and medication administration routines. Any abnormal findings identified with start-up reviews will be immediately addressed with staff retraining completed immediately upon discovery and taken to QAA (Quality Assessment and Assurance) for additional plan development as needed. m. The following additional documentation was reviewed to validate that the facility followed their corrective action plan and corrected the failed practices prior to the survey: 1.) The QA&A notes dated 8/26/16, 9/29/16 and 10/27/16 documented discussion of resident pain assessments and, .New Issues Identified . DON reviewing clinical alerts of pain assessment findings during daily start up, review pain management with medication regimens, MD notifications of any new or worsened pain utilizing pain summary, and alert listing and medication administration routines. No negative findings. 2.) An in-service sheet dated 8/15/16, received from the Director of Nursing at 11:40 a.m., documented, Be sure to report any change of condition to charge nurse promptly. Example: Increase complaint of pain, [MEDICAL CONDITION], etc. Re-education on proper transfer, follow closet care plan when providing care to residents, Use caution when repositioning and providing care to residents, MD notification for change of conditions (pain). This in-service was signed by 9 nurses, 19 CNAs, 1 Housekeeper and 1 Social Services person. 3.) An in-service sheet dated 11/2/16, received from the Director of Nursing at 11:40 a.m., documented, Be sure to address and follow-up on any pain rating above 6 out of scale 0 - 10. Call MD if pain medication is ineffective, reassess, try another non-pharmacological intervention, then, notify MD if pain continues . This in-service was signed by 8 nurses.