Every finding on record at The Haven of Bridgeport

Based on interview and record review the facility failed to ensure they had sufficient staff to meet the needs of the residents timely for 4 of 4 (R1, R2, R13, and R14) residents reviewed for staffing in the sample of 14. This has the potential to affect all 67 residents who currently reside at the facility.Findings Include:The facility Resident Matrix dated 1/5/2026 documents 67 residents currently reside at the facility.1. R2's admission Record with a print date of 1/6/26 documents R2 was admitted to the facility on [DATE] with diagnoses that includes morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis.R2's MDS (Minimum Data Set) dated 10/31/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 is occasionally incontinent of bowel and bladder.R2's current Care Plan documents a Focus area of I am occasionally incontinent of bowel and bladder. Date Initiated: 11/01/2025. This Focus area includes interventions of, Apply barrier cream after each incontinent episode Date Initiated: 11/01/2025.Check and Change Q (every)2-3H (hours) and PRN (as needed). Date Initiated: 11/01/2025.Ensure call light is within reach and answer promptly. Date Initiated: 11/01/2025.On 1/5/26 at 3:38 PM, V9 (CNA/Certified Nursing Assistant) and V3 (CNA Supervisor) provided peri care to R2. R2's incontinence brief was removed and was saturated with urine. R2's buttocks, scrotum, and upper thighs were red, irritated, and had open bleeding spots. When asked about the irritation, R2 stated they put cream on it at times, but he wasn't sure how often they did it. V3 left the room and got V2 (Assistant Director of Nurses/Wound Nurse) to assess R2's buttocks. V2 stated it was moisture associated skin damage (MASD).On 1/5/26 at 11:38 AM, R2 stated it sometimes took a long time for facility staff to answer his call light. R2 stated he had waited an hour and a half once but was unable to recall the date or specific details of this occurrence.2. R1's admission Record with a print date of 1/6/26 documents R1 was admitted to the facility on [DATE] with diagnoses that include myasthenia gravis, diabetes, heart disease, unsteadiness on feet, neuropathy, and atrial fibrillation.R1's MDS dated [DATE] documents a BIMS score of 15, indicating R1 is cognitively intact. This same MDS documents R1 is dependent on staff for toileting and is continent of urine and occasionally incontinent of bowel.R1's current Care Plan documents a Focus area of, I am frequently incontinent of bowel and occasionally incontinent of bladder. Date Initiated: 04/23/2025. This Focus area includes interventions of, Check and change Q(every)2-3H (hours) and PRN (as needed). Date Initiated: 04/23/2025.Ensure call light is within reach and answer promptly. Date Initiated: 04/23/2025.On 1/5/26 at 12:20 PM, R1 was observed lying in bed. V5 (Family Member) was at R1's side. R1 did not respond to this surveyors' questions but shook his head giving approval for this surveyor to speak with V5. V5 stated they are short staffed on the weekends at times.On 1/5/26 at 12:24 PM, R12 stated he was R1's roommate and it had taken an hour before for the staff to answer the call light after R1 had pottied himself. R12 stated the unknown CNA's excuse at the time was they only had four CNA's working. R12 stated this occurred in mid-December was unable to remember the exact date.R12's admission Record with a print date of 1/7/26 documents R12 was admitted to the facility on [DATE]. R12's MDS dated [DATE] documents a BIMS score of 15, indicating R12 is cognitively intact.3. R13's admission Record with a print date of 1/7/26 documents R13 was admitted to the facility on [DATE] with diagnoses that include acute pyelonephritis, heart failure, hypertension, respiratory failure, stiffness of left knee, and right shoulder, and scoliosis.R13's MDS dated [DATE] documents a BIMS score of 13, indicating R13 is cognitively intact. This same MDS documents R13 is dependent on staff for toileting and is always incontinent of bowel and bladder.R13's current Care Plan documents a Focus area of, I am incontinent of bowel and bladder. Date Initiated: 05/31/2019. This same Focus area includes the following interventions, Apply barrier cream after each incontinent episode. Date Initiated: 05/31/2019. Clean peri-area with each incontinent episode. Date Initiated: 05/31/2019.Ensure call light is within reach and answer promptly. Date Initiated: 05/31/2029.On 1/5/26 at 2:25 PM, R13 stated they don't have enough staff. R13 stated when they don't have enough staff, they have to wait a long time for staff to answer call lights. R13 stated when that happens, she has to wait a long time to get up in the morning. R13 stated she has to wait a couple of hours for incontinence care at night.4. R14's admission Record with a print date of 1/7/26 documents R14 was admitted to the facility on [DATE] with diagnoses that include diabetes, osteoarthritis, hypertension, and heart disease.R14's MDS dated [DATE] documents a BIMS score of 15, indicating R14 is cognitively intact.R14's current Care Plan documents a Focus area of, I am always incontinent of bladder and bowel. Date Initiated: 03/09/2023. This Focus area includes the intervention of, Ensure call light is within reach and answered promptly. Date Initiated: 3/9/2023.On 1/5/26 at 2:28 PM, R14 stated when they don't have enough staff, she has to wait 30 to 45 minutes for care.On 1/5/26 at 4:19 PM, V8 (CNA/Certified Nursing Assistant) stated they don't have enough staff to meet the needs of the residents timely. V8 stated she works 2 pm to 10 pm. V8 stated around 4 pm they have to get residents ready for supper and answer call lights. V8 stated call lights aren't always answered timely.On 1/5/26 at 4:30 PM, V12 (CNA) stated she works 2 pm to 10 pm. V12 stated they sometimes have enough staff to meet the needs of the residents timely. V12 stated on weekends they have four CNA's, that is one per hall. V12 stated it is hard when there is a person who requires assist of two staff. V12 stated it can be hard to find someone to help assist. V12 stated getting the residents who take two assists to bed after dinner can be delayed and answering call lights timely can be an issue. V12 stated if she is a room for an excessive amount of time trying to meet a resident needs the call lights getting answered can be delayed.On 1/7/26 at 10:40 AM, V14 (anonymous) stated the call lights are answered as timely as they can be. V14 stated they have a lot of residents who require two person assist and if the staff is tied up in one room and the nurses are doing a medication pass it may take a while for the call lights to be answered. V14 stated she didn't think they had enough staff to meet the needs of the residents timely. V14 stated call lights aren't answered timely, and resident have to sit longer after incontinence episodes before care is provided.On 1/6/26 at 10:42 AM, V15 (Registered Nurse/RN) stated they have enough staff to provide care timely. When asked about staffing from 2 pm to 6 pm, V15 stated they have at least four CNA's and three nurses. V15 stated supper is around 5 pm and medications are administered from 4 to 5 pm. When asked if four CNA's were enough to assist residents to the dining room, answer call lights, provide incontinence care, and pass meal trays, V15 stated it is a very busy time frame and they could honestly use a couple more CNA's. V15 stated it is not always doable.On 1/6/26 at 1:09 PM, V2 (Assistant Director of Nurses) stated every place has a problem of call lights not being answered timely, at times. V2 stated they definitely have gotten better about answering the call lights timely. V2 stated they still have room for improvement, but it is getting better. V2 stated they have enough staff to meet the needs of the residents timely.On 1/6/26 at 1:28 PM, V1 (Administrator) stated they haven't changed anything in their staffing since the last time this surveyor was at the building.

Based on interview and record review the facility failed to ensure call lights were answered timely for 4 of 4 (R1, R2, R13, and R14) residents reviewed for call lights in the sample of 14. Findings Include:1. R2's admission Record with a print date of 1/6/25 documents R2 was admitted to the facility on [DATE] with diagnoses that includes morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis.R2's MDS (Minimum Data Set) dated 10/31/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 is occasionally incontinent of bowel and bladder.R2's current Care Plan documents a Focus area of I am occasionally incontinent of bowel and bladder. Date Initiated: 11/01/2025. This Focus area includes intervention of, .Ensure call light is within reach and answer promptly. Date Initiated: 11/01/2025.On 1/5/26 at 11:38 AM, R2 stated it sometimes takes a long time for facility staff to answer his call light. R2 stated he had waited an hour and a half once but was unable to recall the date or specific details of this occurrence.2. R1's admission Record with a print date of 1/6/26 documents R1 was admitted to the facility on [DATE] with diagnoses that include myasthenia gravis, diabetes, heart disease, unsteadiness on feet, neuropathy, and atrial fibrillation.R1's MDS dated [DATE] documents a BIMS score of 15, indicating R1 is cognitively intact. This same MDS documents R1 is dependent on staff for toileting and is continent of urine and occasionally incontinent of bowel.R1's current Care Plan documents a Focus area of, I am frequently incontinent of bowel and occasionally incontinent of bladder. Date Initiated: 04/23/2025. This Focus area includes intervention of, .Ensure call light is within reach and answer promptly. Date Initiated: 04/23/2025.On 1/5/26 at 12:20 PM, R1 was observed lying in bed. V5 (Family Member) was at R1's side. R1 did not respond to this surveyor's questions but shook his head giving approval for this surveyor to speak with V5. V5 stated the facility is short staffed on the weekends at times.On 1/5/26 at 12:24 PM, R12 stated he was R1's roommate and it had taken an hour before for the staff to answer the call light after R1 had pottied himself. R12 stated the unknown CNA's excuse at the time was they only had four CNA's working. R12 stated this occurred in mid-December but he was unable to remember the exact date.R12's admission Record with a print date of 1/7/26 documents R12 was admitted to the facility on [DATE]. R12's MDS dated [DATE] documents a BIMS score of 15, indicating R12 is cognitively intact.3. R13's admission Record with a print date of 1/7/26 documents R13 was admitted to the facility on [DATE] with diagnoses that include acute pyelonephritis, heart failure, hypertension, respiratory failure, stiffness of left knee, and right shoulder, and scoliosis.R13's MDS dated [DATE] documents a BIMS score of 13, indicating R13 is cognitively intact. This same MDS documents R13 is dependent on staff for toileting and is always incontinent of bowel and bladder.R13's current Care Plan documents a Focus area of, I am incontinent of bowel and bladder. Date Initiated: 05/31/2019. This same Focus area includes the following intervention, .Ensure call light is within reach and answer promptly. Date Initiated: 05/31/2019.On 1/5/26 at 2:25 PM, R13 stated they don't have enough staff, they have to wait a long time for staff to answer call lights.4. R14's admission Record with a print date of 1/7/26 documents R14 was admitted to the facility on [DATE] with diagnoses that include diabetes, osteoarthritis, hypertension, and heart disease.R14's MDS dated [DATE] documents a BIMS score of 15, indicating R14 is cognitively intact.R14's current Care Plan documents a Focus area of, I am always incontinent of bladder and bowel. Date Initiated: 03/09/2023. This Focus area includes the intervention of, Ensure call light is within reach and answered promptly. Date Initiated: 3/9/2023.On 1/5/26 at 2:28 PM, R14 stated when they don't have enough staff, she has to wait 30 to 45 minutes for care.On 1/5/26 at 4:19 PM, V8 (CNA/Certified Nursing Assistant) stated they don't have enough staff to meet the needs of the residents timely. V8 stated she works 2 pm to 10 pm. V8 stated around 4 pm they have to get residents ready for supper and answer call lights. V8 stated call lights aren't always answered timely.On 1/5/26 at 4:30 PM, V12 (CNA) said answering call lights timely can be an issue on the 2 pm to 10 pm shift when they only have four CNA's working.On 1/7/26 at 10:40 AM, V14 (anonymous) stated the call lights are answered as timely as they can be. V14 stated they have a lot of residents who require two persons assist and if the staff is tied up in one room and the nurses are doing a medication pass it may take a while for the call lights to be answered.On 1/6/26 at 1:09 PM, V2 (Assistant Director of Nurses) stated every place has a problem of call lights not being answered timely, at times. V2 stated they definitely have gotten better about answering the call lights timely. V2 stated they still have room for improvement, but it is getting better.On 1/6/26 at 1:28 PM, V1 (Administrator) stated they had an improvement in call lights being answered timely according to the last resident council meeting. V1 stated it is a work in progress but as of last month resident council meeting it had improved.The facility Answering the Call Light policy dated 8/2008 documents, The purpose of this procedure is to respond to the resident's requests and needs.8. Answer the resident's call as soon as possible.

Based on observation, interview, and record review the facility failed to provide appropriate sized incontinence briefs for 2 of 4 (R2 and R13) residents reviewed for accommodation of needs in the sample of 13.Findings Include: 1.R2's admission Record with a print date of 1/6/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis.R2's MDS (Minimum Data Set) dated 10/31/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 is occasionally incontinent of bowel and bladder.R2's current Care Plan documents a Focus area of I am occasionally incontinent of bowel and bladder. Date Initiated: 11/01/2025. This Focus area includes interventions of, Apply barrier cream after each incontinent episode Date Initiated: 11/01/2025.Check and Change Q (every)2-3H (hours) and PRN (as needed). Date Initiated: 11/01/2025.On 1/5/26 at 11:38 AM, R2 stated recently they did not have the correct size incontinence briefs for him to wear. R2 stated the briefs they had were too tight. R2 stated they have the correct size now. R2 stated he would have to rip the sides of the briefs so they would fit him.On 1/7/26 at 10:17 AM, V3 (Certified Nursing Assistant/CNA Supervisor) stated R2 wears extra-large incontinence briefs.2. R13's admission Record with a print date of 1/7/26 documents R13 was admitted to the facility on [DATE] with diagnoses that include acute pyelonephritis, heart failure, hypertension, respiratory failure, stiffness of left knee, and right shoulder, and scoliosis.R13's MDS dated [DATE] documents a BIMS score of 13, indicating R13 is cognitively intact. This same MDS documents R13 is dependent on staff for toileting and is always incontinent of bowel and bladder.R13's current Care Plan documents a Focus area of, I am incontinent of bowel and bladder. Date Initiated: 05/31/2019. This same Focus area includes the following interventions, Apply barrier cream after each incontinent episode. Date Initiated: 05/31/2019. Clean peri-area with each incontinent episode. Date Initiated: 05/31/2019.On 1/5/26 at 2:25 PM, R13 stated she wears incontinence briefs, and they never have the right size. R13 stated they use what they have and then she wets through them.On 1/5/26 at 1:50 PM, V3 (CNA Supervisor) stated they have enough supplies, but she is aware some CNA's bring their own supplies to the facility to use. When asked why they would do that, V3 stated because some CNAs like to use a lot or leave them in rooms and then forget where they left them. V3 stated they have enough of the correct size briefs and if they don't have them inside, they have them in the shed outside. When asked if they had recently been out of different sized briefs, V3 stated they had not. This surveyor reviewed with her R2 and R13's interview stating they didn't have the correct size briefs and V3 stated it must have been a CNA not knowing which size to use.On 1/5/26 at 4:52 PM, V2 (Assistant Director of Nurses) walked with this surveyor to the supply's closets, shower rooms, and tub room looking for incontinence briefs. One supply closet held 8 packages of size large briefs, 5 packages of size medium briefs, and two individual extra-large briefs. There were partial packages of large and medium briefs located on linen carts in each hallway. There were no packages of small, extra-large, or double extra-large incontinence briefs.On 1/5/26 at 4:55 PM, V3 (CNA Supervisor) stated R13 uses extra large briefs. This surveyor walked with V3 to R13's room and there were three incontinence briefs located in her room.On 1/5/26 at 4:19 PM, V8 (CNA) stated they didn't always have the correct size incontinence briefs for the residents. V8 stated she had brought her own in to use at times.On 1/5/26 at 4:30 PM, V12 (CNA) stated they don't always have the correct size of incontinence briefs and residents have to use incorrect sizes.On 1/5/26 at 4:43 PM, V9 (CNA) stated they run low on supplies right before the order comes in. V9 stated she can usually find the correct size incontinence briefs to use for the residents.On 1/7/26 at 10:17 AM, V3 (CNA Supervisor) stated she makes a list of any items they need on Monday's and gives it to the receptionist who orders the needed items. V3 stated the order is made on Monday and delivered to the facility around 10 am on Tuesday. V3 stated they typically receive all items ordered. When asked if there were any incontinence briefs located in the storage shed on 1/5/26 at the time of the observations, V3 stated there were not. When asked why she believed they didn't have incontinence briefs in size large and extra-large, V3 stated she went back to the rooms after this surveyor left and located more briefs. V3 stated the residents don't wear briefs to bed at night and so they would have had enough to make it until the order was delivered. V3 stated they don't have any residents who wear size small incontinence briefs.On 1/7/26 at 10:42 AM, V15 (RN/Registered Nurse) stated she had not had any complaints/concerns brought to her related to not having the correct size incontinence briefs for residents. When asked if residents wore incontinence briefs to bed, V15 stated she thought a lot of them did.On 1/6/26 at 1:09 PM, V2 (Assistant Director of Nurses) stated she had not had any concerns reported to her related to not having the correct size incontinence briefs.On 1/6/26 at 1:28 PM, V1 (Administrator) stated she had not had any concerns reported to her related to not having the correct size incontinence briefs for residents.

Based on observation, interview, and record review the facility failed to ensure residents skin was free from moisture associated skin damage (MASD) for 2 of 3 (R2 and R3) residents reviewed for skin care in the sample of 14.Findings Include:Findings Include:1.R2's admission Record with a print date of 1/6/25 documents R2 was admitted to the facility on [DATE] with diagnoses that includes morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis.R2's MDS (Minimum Data Set) dated 10/31/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 is occasionally incontinent of bowel and bladder.R2's current Care Plan documents a Focus area of I am occasionally incontinent of bowel and bladder. Date Initiated: 11/01/2025. This Focus area includes interventions of, Apply barrier cream after each incontinent episode Date Initiated: 11/01/2025.Check and Change Q (every)2-3H (hours) and PRN (as needed). Date Initiated: 11/01/2025.On 1/5/26 at 3:38 PM, V9 (CNA/Certified Nursing Assistant) and V3 (CNA Supervisor) provided peri care to R2. R2's buttocks, scrotum, and upper thighs were red, irritated, and had open bleeding spots. When asked about the irritation, R2 stated they put cream on it at times, but he wasn't sure how often they did it. V3 left the room and got V2 (Assistant Director of Nurses/Wound Nurse) to assess R2's buttocks. When V2 entered the room, R2 stated they were supposed to tell you about this days ago. V2 stated, this is the first I have heard of it. V2 cleaned the areas and applied cream. V2 stated it was moisture associated skin damage (MASD).R2's Progress Note dated 1/5/26 at 4:14 PM documents, Staff notified this nurse of bleeding noted to buttocks. This nurse assessed resident et (and) noted MASD to bilateral buttocks, upper thighs, et scrotum. Non emergent sent to (name of physician). Will have (name of wound specialist) pick resident back up for wound. Zinc oxide cream applied to areas.R2's Skin Observation Tool dated 1/1/26 documents yes next to the question, One or more wounds or injuries present. There is no identification of the type of wound, where the wound is located, or an assessment of the wound documented.R2's Treatment Administration Record (TAR) dated 12/1/25 to 12/31/25 documents a physician order for Calmoseptine External Ointment (Menthol-Zinc Oxide) to be applied to buttocks every day and night shift for excoriation, with a start date of 10/28/25. This physician order is signed as administered each day and night shift throughout the month of December. This same TAR documents the following physician order, Skin assessment weekly one time a day every Tue (Tuesday), Sun (Sunday) if skin is not intact, document findings in Progress Notes under Skin note type. Start Dated 11/02/2025. This order is signed as completed every Tuesday and Sunday with an n documented on each day except 12/30/25 where yes is documented. There is no corresponding progress note documenting an assessment of skin breakdown on 12/30/25.R2's TAR dated 1/1/26 to 1/31/26 documents a physician order for Calmoseptine External Ointment to be applied to buttocks topically every day and night shift with a start date of 10/28/25. This order is signed as administered every day and night shift from 1/1/26 to 1/6/26 except on 1/2/26 day shift, which has no initials indicating the treatment was not administered on that day and time. This same TAR does not document a physician order for weekly skin assessments.On 1/6/26 at 1:09 PM, V2 (ADON/Assistant Director of Nurses) stated she was not aware R2 had MASD until she assessed him during the observation on 1/5/26 at 3:38 PM. V2 stated R2's skin was red when he admitted , and he had an order for cream to be applied twice daily to prevent further skin breakdown. V2 stated she spoke with R2's nurse on 1/5/26 and she stated she was not aware of the MASD. When asked what caused MASD, V2 stated R2 was incontinent, and it looked like moisture associated breakdown. V2 stated the last time she assessed R2's buttocks was 12/30/25. V2 stated they do skin assessments weekly but when they switched systems the order didn't get carried over to every resident's record. V2 stated they have been working on getting that corrected. V2 stated if the nurse was applying the cream as ordered they should have assessed the areas and documented the assessment. V2 was not able to locate any new skin assessments documenting the MASD on R2's buttocks.2. R3's admission Record with a print date of 1/6/26 documents R3 was admitted to the facility on [DATE] with diagnoses that include diabetes, malignant neoplasm of left breast, osteoarthritis, hypertension, and stress incontinence.R3's MDS dated [DATE] documents a BIMS score of 09, indicating a moderate cognitive deficit. This same MDS documents R3 is dependent on staff for toileting and is always incontinent of bowel and bladder.R3's current Care Plan documents a Focus area of, I have a potential for impairment to skin integrity r/t (related to) aging/disease process redness/Gaulding to buttocks. Date Initiated: 07/14/2023. This Focus area includes the following interventions, Assess/record changes in skin status Date Initiated: 07/14/2023.On 1/5/26 at 3:17 PM, V3 (CNA Supervisor) and V7 (CNA) provided incontinence care to R3. While cleaning R3's peri area R3 stated the area was sore and asked if it was red. V3 (CNA Supervisor) told her it was a little red and she would get her some cream for it. This surveyor observed R3's peri area to be red and irritated in appearance.On 1/6/26 at 1:09 PM, V2 (Wound Nurse/Assistant Director of Nursing) stated V3 and/or V7 had not reported to her that R3's peri area was red, irritated, and sore. When asked if she would expect them to, V2 stated, Absolutely.R3's Progress Note dated 11/19/25 documents, (name of wound specialist company) MD (physician) in facility this am to perform facility wide skin sweep. No new skin issues noted. There is no documentation in R3's progress notes related to the peri area being red and sore during the observation on 1/5/26.On 1/6/26 at 1:28 PM, V1 (Administrator) stated she had not had any complaints/concerns brought to her related to skin issues.The facility Pressure/Skin Breakdown-Clinical Protocol dated January 2017 documents, .In addition, the nurse shall assess and document/report the following: a. Full assessment of skin condition including but not limited to location, stage or partial/full thickness, length, width, presence of exudate or necrotic tissue.

Based on observation, interview, and record review the facility failed to ensure incontinence care was provided using current standards of practice for 2 of 2 residents (R2 and R13) reviewed for incontinence care in the sample of 14.Findings Include:1. R2's admission Record with a print date of 1/6/25 documents R2 was admitted to the facility on [DATE] with diagnoses that includes morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis.R2's MDS (Minimum Data Set) dated 10/31/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 is occasionally incontinent of bowel and bladder.R2's current Care Plan documents a Focus area of I am occasionally incontinent of bowel and bladder. Date Initiated: 11/01/2025. This Focus area includes interventions of, Apply barrier cream after each incontinent episode Date Initiated: 11/01/2025.Check and Change Q (every)2-3H (hours) and PRN (as needed). Date Initiated: 11/01/2025.On 1/5/26 at 3:38 PM, V9 (CNA/Certified Nursing Assistant) and V3 (CNA Supervisor) provided peri care to R2. R2's incontinence brief was removed and was saturated with urine. V9 used wash cloths with warm water and no rinse peri care solution to clean R2's penis, groin, and scrotum. V9 wiped up and down turning the cloth multiple times and at times using the same side of the cloth to clean different areas. V9 changed her gloves after cleaning R2's groin/penis area and before cleaning R2's buttocks. V9 changed her gloves after cleaning R2's buttocks and before drying the area. V9 did not hand sanitize between glove changes. R2's buttocks, scrotum, and upper thighs were red, irritated, and had open bleeding spots. When asked about the irritation, R2 stated they put cream on it at times, but he wasn't sure how often they did it. V3 left the room and got V2 (Assistant Director of Nurses/Wound Nurse) to assess R2's buttocks. When V2 entered the room, R2 stated they were supposed to tell you about this days ago. V2 stated, this is the first I have heard of it. V2 cleaned the areas and applied cream. V2 stated it was moisture associated skin damage (MASD).On 1/5/26 at 4:43 PM, V9 stated she did not hand sanitize between glove changes because she forgot to.On 1/6/26 at 1:09 PM, V2 (ADON/Assistant Director of Nurses) stated she was not aware R2 had MASD until she assessed him during the observation on 1/5/26 at 3:38 PM. V3 stated R2's skin was red when he admitted , and he had an order for cream to be applied twice daily to prevent further skin breakdown. V2 stated she spoke with R2's nurse on 1/5/26 and she stated she was not aware of the MASD. When asked what caused MASD, V2 stated R2 was incontinent, and it looked like moisture associated breakdown.On 1/6/26 at 1:28 PM, V1 (Administrator) stated she had not had any complaints/concerns brought to her related to incontinence care. 2. R13's admission Record with a print date of 1/7/26 documents R13 was admitted to the facility on [DATE] with diagnoses that include acute pyelonephritis, heart failure, hypertension, respiratory failure, stiffness of left knee, and right shoulder, and scoliosis.R13's MDS dated [DATE] documents a BIMS score of 13, indicating R13 is cognitively intact. This same MDS documents R13 is dependent on staff for toileting and is always incontinent of bowel and bladder.R13's current Care Plan documents a Focus area of, I am incontinent of bowel and bladder. Date Initiated: 05/31/2019. This same Focus area includes the following interventions, Apply barrier cream after each incontinent episode. Date Initiated: 05/31/2019. Clean peri-area with each incontinent episode. Date Initiated: 05/31/2019.On 1/5/26 at 3:28 PM, V8 (CNA) and V3 (CNA Supervisor) provided incontinence care to R13 using current standards of practice. V8 changed her gloves after cleaning R13's peri area, after cleaning R13's buttocks, and after drying the areas. V8 did not hand sanitize after removing soiled gloves and/or before donning clean gloves.On 1/5/26 at 4:19 PM, V8 stated she didn't hand sanitize between glove changes because she just forgot.On 1/7/26 at 3:45 PM, V2 (ADON) stated she would expect staff to hand sanitize between glove changes.The facility Hand-Washing/Hand Hygiene Policy dated March 2020 documents, Policy: It is the policy of the facility to assure staff practice recognized hand-washing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. Alcohol based hand rubs (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or bodily fluids.When hands are not visibly soiled, employees may use an alcohol-based hand rub (foam, gel, liquid) contained at least 60% alcohol in all of the following situations.h. before and after putting on and upon removal of PPE (personal protective equipment), including gloves.

Based on interview and record review the facility failed to ensure residents were free of falls during a mechanical lift transfer for 1 of 3 (R6) residents reviewed for falls in the sample of 19.This past non-compliance occurred between 10/1/25 and 10/8/2025.Findings Include:R6's admission Record with a print date of 11/29/25 documents R6 was admitted to the facility on [DATE] with diagnoses that include peripheral vascular disease, acquired absence of left leg, hypertension, anemia, history of falls, unsteadiness on feet, abnormal posture.R6's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 09, indicating a moderate cognitive deficit. This same MDS documents R6 is dependent on staff for transfers.R6's current Care Plan documents a Focus area of I have an ADL (activities of daily living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day right BKA (below knee amputation) with activity throughout the day right BKA with wound infection, PVD (peripheral vascular disease), Anemia, CKD (chronic kidney disease) stage 3, unsteadiness on feet, HTN (hypertension), history of falls, uses a wheelchair for mobility. Date Initiated: 01/18/2022. This Focus area includes the intervention of, .Transfers: (R6) requires Mechanical Lift Hoyer Lift with 2 staff assistance for transfers. Date Initiated: 01/21/2020 R6's Progress Notes dated 10/1/2025 documents, CNA (Certified Nursing Assistant) approached this nurse in tears asking for help. CNA was attempting to transfer resident from wheelchair to bed with (mechanical lift) and according to her she noticed that the resident had started to fall backward due to strap not being connected. She then held and guided res (resident) to floor. Upon entering room this nurse observed resident laying on her back on the floor. Res denied any pain. No injuries were reported by res and none were observed. Res did hit head on floor. Vitals were taken, all WNL (within normal limits). Neuro (neurological) checks were initiated, all WNL. Resident assured this nurse and CNA that she was not in pain. Residents POA (power of attorney) was notified and non emergent was sent to (name of physician).R6's Progress Note titled IDT (Interdisciplinary Team) Note dated 10/02/2025 documents, CNA was attempting to transfer resident from wheelchair to bed with (mechanical) lift and according to CNA she noticed that the resident had started to fall backward due to strap not being connected. She then held and guided res to floor. Upon Nurse entering room she observed resident laying on her back on the floor. Res denied any pain. No injuries were reported by resident, and none were observed by assessment. Inservice for facility policy and procedure for (mechanical) lift transfers and CNA transfer observations.On 11/29/25 at 10:34 AM, V12 (CNA) stated she was transferring R6 using the mechanical lift and she assumed she forgot to hook one of the straps. V12 stated during the transfer she realized there was something wrong, so she went under R6, hugged her, and lowered her to the ground. V12 stated she got the nurse and R6 was assessed and had no injuries. V12 stated it was the first time she had attempted to transfer a resident without a second staff member present. V12 stated after the incident she was retrained by her supervisor and so were the other CNA's. V12 stated they also had to demonstrate they knew how to transfer a resident using a mechanical lift.On 12/01/25 at 4:29 PM, V1 (Administrator) stated she had not had any complaints/concerns related to unsafe transfers other than the incident of V12 attempting to transfer R6 using a mechanical lift without assistance of another staff member. V1 stated the facility policy is that all mechanical lift transfers be done with assist of two staff. V1 stated after the incident they retrained staff, had all CNA's demonstrate a transfer using a mechanical lift, and put monitoring in place to ensure staff were transferring residents safely.The facility policy titled Lifting Machine, Using a Portable dated August 2008 documents, The purpose of this procedure is to help lift residents using manual lift device The portable lift should be used by two staff members .Prior to the survey date of 12/2/2025, the facility had taken the following actions to correct the deficient practice:1. The facility's Inservice Sheet dated 10/1/2025 documents CNA's were trained on (Mechanical) Lift Transfers To provide safe transfers using the (mechanical) lift. (Mechanical) lift policy and procedures .2. The facility's (Mechanical) Lift check off in-service sign in sheet dated 10/2/2025 documents signatures of CNA's who attended the inservice as titled.3. The facility's observational audit sheets titled Free of Accidents/Hazards/Supervision/Devices document audits began 10/8/2025.4. The facility's Past Noncompliance Corrective Action Template dated 10/1/2025 documents, Noncompliance issue: Safe (Mechanical) lift transfers . Resident(s) name: (R6) Immediate Intervention: Education- training on policy and procedure regarding proper use of a manual lift device and two person required. Residents who may be affected by the noncompliance: List all residents who may be affected by the noncompliance. Resident would need utilization of a (mechanical) lift device could be effected [sic]. Trends and concerns: One person transfer. Root Cause: Waiting on other CNA to provide two assist help. Corrective Actions: Review the resident's care plan for transfer type, discussed with IDT (Interdisciplinary Team) and updated. Two staff member present for all (mechanical) lift transfers for all residents who require (mechanical) lift device. Audits made three residents weekly for six weeks or until compliance made. All concerns discussed at QAPI (Quality Assurance and Performance Improvement), Physician and POA (power of attorney) notified. Staff Training . Education CNA's were educated on policy and procedure regarding proper use of a manual lift device and two person required Follow up Investigation completed, resident received no harm, risk management completed. Administrator/DON (Director of Nurses) and or designee will perform random safe resident handling while utilizing mechanical lift audits weekly to assure resident safety. Also, the results of the above audits will be reviewed in the Quality Assurance Meeting monthly until 100% compliance is achieved for 3 consecutive months. The QAA Committee will identify any trends .

Based on interview, observation and record review, the facility failed to answer call lights in a timely manner for 3 of 12 residents (R6, R7, R8) reviewed for call light response times in a sample of 12. Findings include: 1. On 3/31/2025 at 11:47am, R7 activated her call light and at 12:15pm, V2 (Director of Nursing) responded. On 3/31/2025 at 12:25pm, R7 who was alert to person, place and time stated staff do not answer the call lights very quickly and she frequently has to wait 25-30 minutes for her call light to be answered. R7 said it doesn't matter what time of day it is or who is working, call lights are not answered very quickly. R7 said the resident council brings up the call light issue, but nothing has changed. 2. On 3/31/2025 at 10:55am, R6 who was alert to person, place and time stated she usually has to wait about 30 minutes for her call light to be answered. R6 said resident's have complained in resident council about the call light response times. 3. On 3/31/2025 at 12:00pm, R8 who was alert to person, place and time stated staff do not answer her call light very fast and she waits about 30 minutes to get her call light answered. 4. Resident council meeting minutes dated 1/29/2025 documented the residents brought forth complaints to administration concerning call light response times. Resident council meeting minutes dated 2/25/2025 documented the residents again brought forth complaints to administration concerning call light response times. On 4/3/2025, V2 (Director of Nursing) said she knows call lights have been a problem lately. V2 said they will re-educate staff on timely call light response times. V2 said she expected the residents call light to be answered in 15 minutes or less.

Based on observation, interview, and record review the facility failed to ensure a resident was properly restrained while being transported in the facility van for 2 (R1 and R4) of 4 residents reviewed for accidents in a sample of 4. This failure resulted in R1 sustaining a laceration to her head requiring 14 staples and 8 sutures, a fracture to the second digit of the right foot, left nasal bone fracture with deviation of the septum, and bruising to the lower abdomen and upper thighs. Findings include: 1. R1's Admission Record documented an admitted [DATE] with diagnoses that included Parkinson's disease, difficulty in walking, unsteadiness on feet. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. On 12/19/24 at 10:25 AM, R1 was sitting in a wheelchair and had bruising noted below both eyes and a pink scar on her forehead disappearing into her hair line. R1 said she was involved in an accident in the facility transport van. R1 said she was buckled in her wheelchair with a belt on her lap. R1 said when the accident occurred R1 was thrown from her wheelchair and landed in the floor of the transportation van. On 12/19/24 at 2:49 PM, R1 said there was no seatbelt over her shoulder when the accident occurred. R1 said she was only restrained by the lap belt. R1 said when she had been thrown from her wheelchair her foot had gotten tangled in the lap belt causing pain. On 12/19/24 at 11:13 AM, V3 (Certified Nursing Assistant/CNA) said that on 11/27/24, she had transported R1 to the hospital for an appointment and was on the way to pick up another resident with R1 in the transportation van. V3 said while she was driving, she hydroplaned and thought someone had rearended the transportation van and then hit another vehicle that was stopped in the road. V3 said during the accident R1 had fallen out of her wheelchair into the floor of the transportation van. V3 said she did not know how R1 had fallen out of her wheelchair because R1 was buckled in. V3 said the seatbelts in the new transportation van are hooked to the rear brackets in the floor that hold the rear wheelchair wheels. V3 then demonstrated while sitting in a chair how the seatbelt is passed under the armrests of a wheelchair and buckle around the lower abdomen. V3 said the new transportation van did not have any seatbelt that went over the resident's shoulder. V3 said residents have the ability to unbuckle the seat belt but the transportation van has a sensor that tells you if the resident's seatbelt is unbuckled. V3 said the sensor was not on alerting her of R1's seatbelt being unbuckled. V3 said R1 had never unbuckled the seatbelt. V3 said some residents will unbuckle themselves when they arrive at their destination while V3 is getting the wheelchair ramp out but R1 never unbuckled herself. V3 said R1 would never unbuckle herself while the transportation van was moving. On 12/19/24 at 11:45 AM, V3 returned with V1 (Administrator) and said she was confused earlier and R1 had been wearing a seatbelt that went over R1's shoulder at the time of the accident. V3 said the new transportation van held two wheelchairs and the wheelchair in the middle of the van did not have a seatbelt that went over the resident's shoulder, but the back wheelchair area did have a seatbelt that went over the resident's shoulder. V3 said R1 had been wearing the over the shoulder seat belt when the accident had happened. On 12/19/24 at 1:40 PM, V4 (Chief of Police) said he was the first to respond to the accident on 11/27/24. V4 said when he arrived, V3 was standing outside of the transportation van on the phone. V4 said R1 was lying in the floor of the transportation van with quite a bit of blood coming from her head wound. V4 said when the paramedics arrived, V4 had removed the wheelchair from the transportation van and did not recall R1's wheelchair having a seatbelt that went over R1's shoulder. V4 asked how would R1 have been thrown out of her wheelchair if she was wearing a seatbelt that went over her shoulder. On 12/19/24 at 2:53 PM, V5 (Registered Nurse/ RN) said when R1 returned to the facility after the 11/27/24 vehicle accident, R1 had bruising to her lower abdomen and upper thighs and had taken pictures of the bruising. V5 said R1 did not have any similar bruising to the shoulder or chest area that looked like it had come from a seatbelt like the bruising to R1's lower abdomen and upper thighs. On 12/20/24 at 10:02 AM, V3 said the facility had received the new transportation van around the end of October 2024. V3 said she had not received any training on how to properly secure residents in the new transportation van. On 12/20/24 at 12:17 PM, V9 (Physician) said he treated R1 at the hospital after the vehicle accident. V9 said he did not see any signs of seatbelt bruising to R1's shoulder and chest area. V9 said if R1 had been properly restrained, R1 would not have been thrown out of her wheelchair sustaining injuries. V9 said any person not properly restrained in a motor vehicle accident has a probability of dismemberment or death. The facility's Report to the State Survey Agency's Regional Office of the 11/27/24 incident documented in part . ON 11/27/24 at 4:15 PM, facility was notified by facility transportation driver (V3) that a vehicle accident had occurred during transporting resident (R1) from appointment with (sic) resulted in resident injury. Resident was assessed by EMT (Emergency Medical Technicians) at the scene of the accident as (sic) was transported via ambulance to (Hospital) to (evaluate) and treat. Resident returned to facility via facility transport at 9:45 PM the same day with diagnosis: 14 staples and 11 stiches to top of forehead, minimally displaced left nasal bone fracture, potentially acute second distal phalanx fracture . V3's written statement dated 11/27/24 documented in part . I slammed on the brakes to stop quick and (R1) went forward in her (wheelchair) hitting her head on the center console of the van and sliding out of her (wheelchair) onto the back floor of the van. I called the Administrator and let her know that I was in a wreck and then called 911 while checking on the patient that I had (R1). The police showed up and then the ambulance showed up and took over . R1's Emergency Medical Services (EMS) ambulance report dated 11/27/24 documented in part . Upon arrival EMS observed a wheelchair transport van with moderate front end damage. Law Enforcement on scene advised the van purposedly hydroplaned and struck the vehicle in front of it. The driver (V3) was uninjured. The passenger (R1) . was lying prone in back of van with moderate bleeding from her head. (R1) was seated in a wheelchair during the incident. It is unknown if she was wearing a seat belt. (R1) advised she went forward and struck her head and complained of head pain . Large laceration to top of head. Approximately 4 inches in length. Skull can be seen. Moderate bleeding . R1's hospital record dated 11/27/24 documented in part .presents after MVA (Motor Vehicle Accident) involving a facility wheelchair van. The patient was not restrained in the wheelchair and sustained a head injury after hitting the center console. She denies losing consciousness during the accident . complains of pain in her head, right ankle, both shoulders, and nose. She reports the ankle pain is new following the accident The patient's shoulders are tender from the fall, and she describes her nose pain as feeling like someone hit her . ED (Emergency Department) Course . (R1's) imaging was notable for a left nasal bone fracture with deviation of the septum to the right . also has a questionable right ankle fracture and 2nd digit fracture of the right foot . (R1's) right ankle is mildly tender to palpation. We will place in a walking boot and have the patient follow up. Her laceration was repaired without complication. Due to the fact that part of the laceration involved the scalp and part of it involved the forehead (R1) received 14 staples for the portion of the laceration that involved the scalp, and 8 sutures for the portion of the laceration that involved her forehead . The facility provided an undated manufacture's User Instruction guide for securing passengers in the transportation van documenting in part . Secure Passenger . 1. Attach Lap Belts- Use integrated stiffeners to feed belts through openings between seat back and bottoms, and/or armrests to ensure proper belt fit around occupant. A. On the aisle side, attach belt with female buckle to the rear tie-down pin connector . ensuring buckle rests on passenger's hip. B. On the window-side, attach belt with male tongue to rear tie-down pin connector . and insert into female buckle. 2. Attach Shoulder Belt- Extend shoulder belt over passenger's shoulder and across upper torso . and fasten pin connector onto lap belt . 3. Ensure belts are adjusted as firmly as possible, but consistent with user comfort . Warning . Never rely on wheelchair's lap belt or a postural support belt unless properly approved & crash tested . The facility's undated Motor Vehicle Safety Program documented in part .H. Seat belts and should harnesses (occupant restraint systems) shall be worn or used whenever the vehicle is in operation. The vehicle may not move until all passengers have fastened their restraints . 2. R4's Admission Record documented an admitted [DATE] with diagnoses that included cerebral infarction, anxiety disorder, hemiplegia. R4's 10/28/24 MDS documented a BIMS score of 14, indicating R4 was cognitively intact. R4's Electronic Medical Record (EMR) documented R4 was transported to a medical appointment on 11/5/24. On 12/20/24 at 12:30 PM, R4 said he had been transported to an appointment in the new facility transportation van in his wheelchair. R4 said there was a seatbelt that went across his lap but there was no seatbelt that went over his shoulder.

Based on observation, interview, and record review the facility failed to ensure residents received timely assistance with toileting and showers for 2 (R1 and R4) of 4 residents reviewed for Activities of Daily Living (ADL's) in the sample of 10. Findings Include: 1. R4's Admission Record with a print date of 10/23/24 documents R4 was admitted to the facility on [DATE] with diagnoses that include sepsis, polyosteoarthritis, malignant neoplasm, dysthymic disorder, hypertension, heart disease, atrial fibrillation, syncope and collapse. R4's MDS (Minimum Data Set) dated 10/16/24 documents a BIMS (Brief Interview for Mental Status) score of 13 which indicates R4 is cognitively intact. This same MDS documents R4 requires substantial/maximal assistance with toilet transfer and moving from a sitting to standing position. R4's current Care Plan documents a Focus Area of I have an ADL (Activities of Daily Living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) NSTEMI (non-ST elevation myocardial infarction), poly osteoarthritis, obesity, depression, AIB (abnormal illness behavior), heart disease. Date Initiated: 02/28/24 The interventions documented for this Focus Area include; If resident resists with ADL's, reassure resident, leave and return 5-10 minutes later and try again. Date Initiated: 02/28/2024 .Toilet hygiene: My usual performance is partial/moderate assistance. Date Initiated: 02/28/2024 Toilet transfer: My usual performance is substantial/maximal assistance. Date Initiated: 02/28/2024 . This same Care Plan documents a Focus Area of I am frequently incontinent of bladder .Date Initiated: 03/03/2024 The interventions documented for this Focus area include, Check and change Q (every) 2-3 H (hours) and PRN (as needed). Date Initiated: 03/03/2024 On 10/21/24 at 10:45 AM, R4 was sitting in a recliner covered with a blanket and there was an odor of urine noted by this surveyor. R4 stated she sleeps in her recliner. R4 stated she was sitting in wet clothes and had been since she got up that morning. R4 stated she couldn't remember what time, but V3 (Certified Nursing Assistant/CNA) came in and turned the call light off. R4 stated she couldn't go to the bathroom by herself and no one had helped her up yet this morning. R4 stated she wears a brief for incontinence. On 10/21/24 at 10:49 AM, V3 (CNA) stated she was the CNA providing care to R4 today. V3 stated she had not assisted R4 with toileting since she came on duty at 6:00 AM. V4 stated she turned the call light off in R4's room around 10:30 AM, the floor had been mopped and was wet and she told R4 she would come back after the floor dried. V3 stated R4 normally tells staff when she had to go to the bathroom and R4 hadn't asked V3 to assist her with toileting. This surveyor walked with V3 to R4's room. V3 removed the blanket covering R4's legs and assisted R4 to stand. R4's gown was saturated with urine with a brown ring around the edges, up to her waist. R4's chair (that she sleeps in) had two bed pads on it, both pads were saturated with urine with brown rings around them. V3 removed the bed pads from R4's chair and the chair was wet in the seat and halfway up the back. R4 ambulated to the bathroom and removed her incontinence brief that was saturated with urine and brown/dark yellow in color. On 10/23/24 at 1:30 PM, V2 (Director of Nurses/DON) stated her expectation would be that every resident be checked on every two hours. V2 stated that means not just looking in the room but asking the resident if they need anything. V2 stated she didn't know why staff didn't offer to assist R4 with toileting. The facility Bowel and Bladder- Assessment and Toileting Programs dated 11/28/12 documents, Purpose: Based on the resident's comprehensive assessment the facility will ensure that each resident with bowel or bladder incontinence will receive appropriate treatment and services to restore as much normal bowel or bladder functioning as possible Types of Incontinence programs include: .3) Check and Change: Using the information obtained from the voiding pattern data the decision may be made to not place the resident on a scheduled toileting program. Instead the facility implements a care plan whereby the resident is checked frequently and cleaned as necessary. The facility may use supplies such as adult disposable briefs 2. R1's Admission Record with a print date of 10/23/24 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, cirrhosis of liver, unsteadiness on feet, hypertension, heart failure, acute kidney failure, and osteoporosis. R1's MDS dated [DATE] documents a BIMS score of 14, indicating R1 is cognitively intact. This same MDS documents R1 is dependent on staff for showers. R1's current Care Plan documents a Focus Area of, I have an ADL self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t NSTEMI, CHF (congestive heart failure), CAD (coronary artery disease), HTN (hypertension), NASH liver cirrhosis, DM2 (diabetes mellitus type 2), peripheral neuropathy, arthritis. Date Initiated: 09/20/2024 . The interventions for this Focus area include,Shower/Bathe self: I take a shower/bath/bath at sink/bed bath my usual performance is dependent. Date Initiated: 09/20/2024 R1's facility record did not document R1 was assisted with a shower or bath throughout her stay at the facility from 9/19/24 through 9/25/24. On 10/23/24 at 2:30 PM, V2 (DON) stated R1 was admitted to the facility on [DATE] and her shower days were on Tuesdays and Thursdays. V2 stated there is no documentation R1 received assistance with a shower/bath from 9/19/24 to 9/25/24. The facility Shower and Tub Bath policy dated 11/28/12 documents, Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. Guidelines: A shower, tub bath or bed/sponge bath will be offered according to resident's preference two times per week or according to the resident's preferred frequency and as needed or requested .

Based on observation, interview, and record review the facility failed to properly label/cover food items and prevent cross contamination. This failure has the potential to affect all 67 residents residing in the facility. The Findings Include: On 5/28/24 at 10:00 AM, during the initial tour of the kitchen, the following items were found not to be labeled and/or covered in the refrigerators: drink pitchers not labeled, desert bowls that were covered but not labeled, shredded cheese not labeled, and salad not labeled. The cake was found to be uncovered on a tray and not labeled. During the initial kitchen tour, the bulk sugar container had a cup with no handle in the container. Other food debris that was brown in color was seen in a bulk sugar container, and the lid to sugar container was sticky and had dust and food substance stuck to it. On 5/28/24 at 11:00 AM, V12 (Cook) stated that she will correct these concerns as they have recently lost their dietary manager and they are working through that. The food storage policy dated 2020 documents .1. General storage guidelines to be followed: all food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded Review of the Long-Term Care Facility Application for Medicare and Medicaid dated 5/28/24 documented 67 residents reside in the facility.

Based on interview and record review the facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASARR) for 3 (R40, R15 and R43) of 3 residents reviewed for PASARR's in the sample of 33. Findings Include: 1. R40's Admission Record documents an admitted [DATE] and documents diagnoses including: Bipolar disorder, current episode mixed, unspecified, with diagnosis date of 5/25/22, Major Depressive Disorder, single episode unspecified, with diagnosis date 11/02/2021, and Unspecified Dementia with a diagnosis date of 11/02/2021. R40's current Level 1 PASARR dated 11/03/2021 documents long term care placement was appropriate. 2. R43's Admission Record documents an admitted [DATE] and documents diagnoses including: Major Depressive Disorder recurrent, unspecified with diagnosis date of 04/21/2019, and Psychotic disorder with delusions due to known physiological condition with diagnosis date of 06/12/2019. R43's current Level I PASARR dated 05/10/2023 documents a diagnosis of Major Depression but did not include Psychotic disorder with delusions. The document goes on to say No Level II Required. On 05/30/2024 at 2:25 P.M. V1 (Administrator) stated that she was unaware that R40 and R43 needed a Level II Screen. V1 stated that V12 (Bookkeeper) and V13 (Social Service) do the screens. On 5/30/24 at 2:30 P.M., V12 and V13 were interviewed. V12 stated that she was not aware that R40 and R43 had a diagnosis that would need a Level II. V12 stated that she was not aware that R40 had a new diagnosis but would go run new screens immediately. V13 stated that she would ensure it get completed as she was unaware of his diagnosis. 36384 3. R15's Admission Record documents an admitted [DATE]. This admission record includes the following diagnoses: visual hallucinations with an onset date of 7/11/23 and bipolar disorder with onset date of 4/26/23. R15's current PASARR (Preadmission Screening and Resident Review) level one was completed as an OBRA (Omnibus Budget Reconciliation Act)-1 initial screen on 4/19/16 documenting that R15 was not suspected for Mental Illness or Developmental Disease. On 5/31/24 at 10:30 AM, V12 (Bookkeeper) stated that she was unaware of the added diagnoses for mental illness so she will submit for a level 2 PASARR today. The policy Preadmission Screening and Annual Resident Review (PASARR) dated 11/28/2012 with a revision date of 11/13/2018 documents The objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASARR will be evaluated annually and upon any significant change for those individuals.

Based on interview and record review the facility failed to ensure dependent residents received timely assistance for toileting needs for 2 of 2 residents (R48 and R55) reviewed for Activities of Daily Living in the sample of 33. The findings include: 1. R48's Admission Record documented an original admitted to the facility as 11/30/2022. R48 is documented with diagnoses including Parkinson's Disease, Blindness, one eye, Difficulty walking, Pain in right knee and unsteadiness on feet. R48's Minimum Data Set (MDS) with an Assessment Reference Date of 05/26/2024 documented a Brief Interview for Mental Status Score of 15, indicating R48 is cognitively intact. The same MDS documented in Section GG0130, toileting assistance is documented as substantial / maximal assistance. Section GG0170 also documented substantial / maximal assistance status for toileting transfers. Section H0300 documented R48 as being occasionally incontinent. R48's Plan of Care documented a focus area of ADL (Activities of Daily Living) Self Care / Mobility Performance Deficit with a date initiated as 12/10/2021. Interventions listed for this focus area document, (R48's) usual performance for toileting is substantial / maximal assistance. On 05/28/24 at 10:59 AM, R48 was observed sitting in her wheelchair in her room. R48 was observed being alert and oriented to person, place, and time. R48 stated she has concerns with the facility and the amount of time it takes staff to answer call lights. R48 stated that the average time it takes for call lights to be answered is 30 minutes up to one hour. R48 stated she can confirm these times by the use of the clocks in her room, which were visualized during this interview. R48 stated it isn't a specific day or time when this occurs. R48 stated she has experienced incontinence episodes waiting for staff to take her to the restroom. R48 stated she finds it frustrating and embarrassing when she experiences incontinence and has to have her clothes changed. 2. R55's Admission Record documented an original admitted to the facility as 01/10/2022. R55 is documented with diagnoses including Morbid Obesity, Chronic Kidney disease, Difficulty walking, and unsteadiness on feet. R55's Minimum Data Set (MDS) with an Assessment Reference Date of 03/13/2024 documented a Brief Interview for Mental Status Score of 15, indicating R55 is cognitively intact. The same MDS documented in Section GG0130, dependent status for toileting. Section GG0170 also documented dependent status for toileting transfer. Section H0300 documented R55 as being frequently incontinent. R55's Plan of Care documented a focus area of ADL (Activities of Daily Living) Self Care / Mobility Performance Deficit with a date initiated as 04/22/2022. Interventions listed for this focus area document, (R55's) usual performance for toileting is dependent, may use sit to stand with 2 people. On 05/28/2024 at 10:59 AM, R48 was observed in her bed, and was alert and oriented. R48 stated she has experienced incontinence episodes waiting for staff to take her to the restroom. R48 stated that she has noted it taking up to 30 minutes for staff to respond to the call lights. R48 stated she finds it frustrating and embarrassing when she experiences incontinence episodes while waiting to be placed on the bed pan. On 5/31/2024 at 9:30 AM, V1 (Administrator) stated that her expectation is that call lights be acknowledged by staff within 10-15 minutes. V1 stated that she is aware of the call light complaints from resident council and has started QA (Quality Assurance) rounds on call light monitoring. V1 stated that call light times are monitored, and staff are educated regarding call light answering. V1 stated that any staff member can answer a call light. On 05/31/2024 at 12:35 PM, V2 (Director of Nursing) stated it is her expectation that call lights are answered within 5 minutes of them being pushed. Review of the Resident Council meeting minutes for December 2023 to April 2024, as provided by the facility document the following concerns: 12/27/23 - Nursing: Ignore Lights. 1/24/24 - Nursing: Passing up call lights. 2/28/24 - Nursing: Residents stated at times call lights are not being answered in a timely manner. 4/27/24 - Nursing: Call lights, sometimes have to wait to be answered. The facility policy titled Call Light with a revision date of 02/02/2018, documents under Guidelines that Resident call lights will be answered in a timely manner.

Based on interview and record review the facility failed to implement interventions to prevent falls with injuries for 1 of 1 (R169) residents reviewed for falls in a sample of 33. The Findings Include: R169's Admission Record documents an admitted [DATE]. The admission record also includes the following diagnoses: unsteadiness on feet, abnormalities of gait and mobility, and lack of coordination. R169's admission MDS (Minimum Data Set) dated 5/27/24 documents that R169 has a BIMS (Brief Interview of Mental Status) score of 15, indicating that R169 is cognitively intact. This same MDS documents in Section GG that R169 needs supervision/touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R169's Care Plan under the focus area of I have an ADL (Activities of Daily Living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day related to recent history of closed fracture of neck of left femur. The Interventions for this focus area include for sit/lying and toileting that partial/moderate assistance is needed. These interventions have an initiation date of 5/28/24. The initial fall occurrence dated 5/27/24 at 22:00 (10:00 PM) documents that the location of the fall occurred in the resident's room and that the nurse was called down to the resident's room to assess a fall that occurred as he was being assisted to the restroom by V11 with his walker when he lost his balance and fell backwards. R169 hit his head on the edge of the bed in the room causing a 3 centimeter laceration on the back of his head, and hit his left elbow causing a large skin tear to both areas. The action taken immediately per this report was that R169 was sent to emergency room for evaluation. On 5/30/24 at 1:50 PM, V2 (Director of Nursing) stated that V11 (Certified Nurse Assistant) let go of R169 to turn the call light off and when she did that he fell backward. V2 went on to state that he had a line placement that day and still may have been groggy from that. V2 stated that she has since educated the staff on proper transfers with a 'hemi' walker. V2 stated that R169 was not admitted to the hospital after evaluation he was sent back with no injuries or new orders. V2 stated that R169 returned to the facility at 5:00 AM on 5/28/24. V2 stated that R169 has the skin tear to his elbow and his head required no orders other than to keep clean and dry. On 5/30/24 at 2:00 PM, V11 stated that she went to assist R169 to the bathroom and let go of him to turn on the bathroom light. When she did he fell and hit his head on the bed and scratched his arm. V11 stated that she thinks maybe his slip on shoes may have been part of the problem, but it happened so fast she isn't sure why he slipped and fell . V11 stated that she has never worked with R169 prior to this day, nor had she worked with any resident that used this type of walker. V11 stated that R169 didn't have a gait belt on either because of the type of walker that he uses. On 5/30/24 at 2:30 PM, V15 (Therapy Director) stated that a resident who is coded as a supervision/or touching assistance should not be left unattended for the potential of a fall. V15 also stated at this time that a gait belt should be used on R169 when he is up walking with his 'hemi' walker or at any time due to his unsteadiness. The Fall Prevention Program policy, dated 11/21/17, documents the purpose of this policy is to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The Transfers-Manual Gait Belt and Mechanical Lift policy, with a revision date of 1/19/18, documents 9. use of gait belt for all physical assists transfers is mandatory .

Based on observation, interview, and record review, the facility failed to ensure therapeutic diets were provided as ordered for 1 of 2 residents (R18) reviewed for therapeutic diets in the sample of 33. The Findings Include: R18's Admission Record documents an admitted [DATE]. Admission diagnoses listed include: Atrial Fibrillation, Atherosclerotic heart disease if native coronary artery, heart failure, and essential hypertension. R18's Physician's Order Sheet documents a dietary order of NAS (No Added Salt), regular texture, regular consistency dated 1/30/24. On 05/28/2024 at 11:57 A.M. R18 stated that she never receives the diet that is on the card. R18 stated that she always gets other foods not on the card. Tray diet card documents R18's diet as Heart Healthy. The tray card stated R18 should receive Meatballs with spiral noodles, Italian blend vegetables, garlic bread, beverage and butterscotch bars. At this time, R18 received Ravioli, Italian blend vegetables, garlic bread, and pudding. The facility Diet Spreadsheet documents on day 24, Tuesday (5/28/24), the Regular Diet for lunch served is beef ravioli w/ (with) marinara sauce, Italian blend vegetables, butterscotch bars, garlic bread, and beverage. The Heart Healthy Diet served for lunch on the same date documents Meatballs w/ spiral noodles, Italian blend vegetables, butterscotch bars, bread, and beverage. On 05/29/2024 at 12:09 P.M. R18's tray card documented she should receive Hot pork on bun, Sweet potato fries, fiesta blend vegetables, glazed applesauce cake, and beverage. R18's lunch tray observed at this time contained the following items: Bratwurst on bun, potato wedges, fiesta blend vegetables, applesauce cake, and beverage. The facility Diet Spreadsheet documents on day 25, Wednesday (5/29/24), the Regular Diet for lunch is Bratwurst on a bun, sweet potato fries, fiesta blend vegetables, glazed apple sauce cake, and beverage. The Heart Healthy Diet served for lunch the same date documents hot pork on a bun, fiesta blend vegetables, glazed applesauce cake, and beverage. On 05/29/2024 at 12:16 P.M. V2 (Director of Nursing) stated that the residents should receive the diet that is printed on the card. V2 stated if the menu had changed the residents should have been notified. V2 stated in the past the diets served has been the same as what the diet card shows. V2 stated that there has been a change in leaders in the dietary department that happened recently and this could have caused some confusion. On 05/29/2024 at 12:21 P.M. V14 (cook) stated the menu was different today because the proper food items were not ordered by the dietary manager who recently quit. V14 stated they made substitutions with alternatives they have until a new order comes in.

Based on observation, interview and record review, the facility failed to safely transfer and immediately report a fall for one (R22) of seven residents reviewed for risk of falls in the sample of 34. This failure resulted in R22 falling against the toilet during a one assist transfer and sustaining a rib fracture with resulting pain. This past noncompliance occurred between 6/17/23 and 7/12/23. Findings include: R22's Face Sheet documented an admitted [DATE] and diagnoses including Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, Diabetes Type 2, and Heart Failure. R22's 6/30/23 Care Plan dated documented a problem area, I am at risk for falls related to unsteady gait/balance, (and a) history of falls. R22's Fall Risk assessment dated [DATE] documented a score of 11, indicating that R22 is at risk for falls. R22's Minimum Data Set, dated dated dated [DATE] documented that R22 requires extensive assistance from at least two staff members for transfers and toileting. Nurses Notes documented the following: 6/17/23 at 5:46pm: Resident started complaining of left rib pain after being transferred from shower chair to wheelchair. Family requested that the resident be sent out to (hospital) for xrays of ribs. I contacted (V8, Physician) who is on call for (V9, Physician) this weekend and he gave orders for left side rib xray and chest xray. Resident left facility via our transportation department. 6/17/23 6:30pm: Resident returned from having xray of left rib area and chest. 6/18/23 at 4:58am: Nurse went to check on resident and she was observed holding her left side and moaning in pain, (as needed) pain med(ications) given for discomfort. 6/18/23 at 11:14am: This nurse got xray results back for resident and xray results showed a Left 11th thoracic rib fracture. This nurse reported to (V8) which had called to check up on resident which was the Medical Doctor that gave orders to get xray. This nurse called (V11, POA/Power of Attorney) to inform them of the results. This nurse did let (V8) know that resident was doing normal activities when this nurse got results back and went to check up on pain level, but resident was participating in church activity. At this time resident has (as needed) Tylenol as ordered for the pain. A Fall Investigation dated 6/17/23 at 5:30pm documented, Residents POA approached this nurse regarding this resident experiencing a significant amount of pain in the left side rib area. POA stated to this nurse that she spoke to (V10, Certified Nursing Assistant/CNA) and (V10) stated to POA that she (V10) was trying to transfer the resident by herself and was unable to transfer her completely and sat her roughly on the toilet. This was not reported to the nurse (me) until the POA brought this to my attention. I assessed the resident in the area she was complaining of pain in. I did not note any significant marks on the resident at the time. I called (V8) who was on call for (V9) this weekend and explained the situation. (V8) gave orders to send the resident for xrays. Resident is unable to provide information at this time. An Xray Report dated 6/17/23 documented, Exam Description: Xray ribs left chest. Reason for study: Left lower ribs hurt after an aid helped her up .Findings: Left anterior 11th rib fracture. R22's Physicians Orders for June 2023 and July 2023 documented an order for Acetaminophen Extra Strength Oral Tablet 500 mg (milligrams), give 1 tablet by mouth every 6 hours as needed for pain. A MAR (Medication Administration Record) for June 2023 documented that the Acetaminophen was given on the following dates: 6/17/23 at 9:57pm, pain level '3' (On a zero to ten scale). Administration effective. 6/18/23 at 5:02am, pain level '3' Administration effective. 6/18/23 at 4:53pm, pain level '7' Administration effective. 6/28/23 at 11:58pm, pain level '3' Administration effective. 6/30/23 at 7:20pm, pain level; '5' Administration effective. A MAR for July 2023 documented that the Acetaminophen was not administered from 7/1/23 through 7/25/23. A document entitled Behavior Reports dated 6/17/23 handwritten and authored by V10 documented the following: Had resident on the toilet, my partner had to go do something, (I) tried to stand her (R22) up to clean her off and she fell sideways onto the toilet. My partner was outside the door and (I) had her help me get her off the toilet. She can stand up sometimes, and sometimes she can't. On 07/23/23 at 10:55am, R22 was observed in her room, sitting in a high backed wheelchair. R22 was alert and oriented only to herself. R22 stated she does not think she has sustained any falls at the facility. R22 had no complaints. On 7/25/23 at 1:31pm, V2 (Director of Nurses) stated on 6/17/23 at some time in the morning, V10 was trying to get R22 off the toilet by herself and R22 fell backward onto the toilet. V2 stated the Nurses Note dated 6/17/23 at 5:46pm stating the transfer from shower chair to wheelchair is inaccurate. V2 stated R22 was to be transferred by two staff and that V10 should have been aware of that when V10 got report at the beginning of her shift that morning. V2 stated V10 did not report the incident to the nurse when it happened but did report it to V11 (POA) in the afternoon of the same day when R22 complained of rib pain, with V11 reporting it to R22's nurse. V2 stated V8, the Physician covering for V9 (R22's Physician) gave the order to send R22 for x-rays, where it was discovered R22 had fractured a rib. V2 stated the new intervention added after the fall is that R22 is always to be transferred with two staff to assist, and V2 stated all staff were re-educated to do this. V2 stated all staff were also educated that falls are to be reported immediately. V2 stated R22 did not display sequelae from the fracture with the exception of some complaints of pain immediately after which were resolved with administration of Acetaminophen. On 07/25/23 at 02:01 PM, V10 stated that on 6/17/23 at some point in the morning, she and another CNA transferred R22 onto the toilet and the other CNA then went to answer a call light. V10 stated R22 wanted to get off the toilet, so V10 stood her up, but R22 stumbled backward, and her buttocks hit the seat 'pretty hard.' V10 stated she did not witness R22's chest make contact with the toilet. V10 stated she waited till the other CNA returned and they then transferred R22 off the toilet without incident. V10 stated she was busy and did not report the incident to the charge nurse. V10 stated V11 reported to V10 that R22 was having rib pain, V10 told V11 about the transfer incident and V11 reported it to the charge nurse. V10 stated she does not know why the 6/17/23 Nurses Note stated the resident was being transferred from the shower chair to the wheelchair. V10 stated she was aware R22 was to be transferred with two staff. V10 stated after the incident, all staff were re-educated that R22 is to always be transferred by at least two staff members, and falls are to be reported immediately. On 7/26/23 at 1:54pm, V9 (Physician) stated R22 was admitted on [DATE] as a transfer from another facility. V9 stated the facility notified her about the 6/17/23 injury as described above. V9 stated it is definitely possible the rib fractured occurred during the 6/17/23 fall. V9 stated R22 has no known history of osteoporosis, and there was no sequelae associated with the fall except complaints of pain relieved by Tylenol. V9 stated to her knowledge, R22 had no previous rib fractures and no previous complaints of rib pain. On 7/26/23 at 2:35pm, V1 (Administrator) stated all nursing and CNA staff were re-educated that R22 is to be transferred with two staff, and falls are to be reported immediately to the charge nurse. V1 stated the Quality Assurance interdisciplinary team met and discussed the fall and implemented the action of adding residents' transfer status prominently in the CNAs charting section so that when they log into the residents record, the transfer status is immediately seen. V1 stated V2 (DON) met with V10 three times weekly and provided transfer observation on the floor which occurred without incident, and V1 stated V10 has met her re-training objectives. V1 stated V10 is a seasoned CNA, and a dependable employee and administrative staff believe there will be no further issues with V10 performing unsafe transfers. On 07/27/23 at 8:33am, V11 (POA) stated she came to see R22 around lunchtime on 6/17/23. V11 stated R22 began complaining that her left side hurt. When V11 questioned R22, R22 stated, I was going to the bathroom, and they dropped me. V11 stated she questioned V10, who initially denied anything had occurred. V11 stated V10 finally admitted , She was taking (R22) to the bathroom, and she slipped out of her (V10's) hands. V11 stated V10 admitted she had not told any other staff members about this. V11 stated she informed the charge nurse, who knew nothing about it, and R22 was sent for an xray, which showed a rib fracture. V11 stated R22 complained about pain for a few days, but the pain resolved. V11 stated R22 has no history of rib fractures or rib pain. V11 stated when R22 was admitted to the facility, she recalls specifically telling V10 that R22 required the assistance of two staff for transfers. V11 stated it is her understanding that administration re-educated staff that R22 is always supposed to be transferred with two staff, and falls are to be immediately reported. V11 stated she has now noticed there are always two staff present during R22's care. A Fall Prevention Program Policy dated 11/21/17 documented, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary .All assigned nursing personnel are responsible for ensuring ongoing precautions are put into place and consistently maintained. Fall/safety interventions may include but are not limited to: .Transfer conveyances shall be used to transfer residents in accordance with the plan of care. Residents at risk of falling will be assisted with toileting needs as identified during the assessment process and as addressed in the plan of care. Prior to the survey date, the facility took the following actions to correct the non-compliance: 1. From 6/23/23 through 6/30/23, all nursing and CNA staff were inserviced that R22's transfers are to be with the assistance of two staff at all times, and difficulty with any transfers are to be reported to the residents nurse immediately. Staff signed off on the attendance sheet, including V10. 2. For a total of four weeks, from 6/20/23 through 7/22/23, V10's resident transfers were audited three times weekly, with V10 demonstrating proficiency in all observations. 3. R22 is engaged in therapy services twice weekly to assist with core strengthening, transfers, and ADL's. (Activities of Daily Living). 4. The facility's electronic health records system has been updated so that when CNAs initially log into the system to document, resident's transfer status is prominently displayed. 5. On 7/12/23, the facility's Quality Assurance Committee met to review the above referenced fall. The Committee approved of the corrective Action Plan that had been submitted and reviewed the status of the plan without corrections. 39025

Based on observation, interview and record review, the facility failed to properly sanitize dishware. This has the potential to affect all 61 residents residing in the facility. Findings include: On 07/23/23 at 11:30 AM, the chemical sanitizer level in the dish machine was checked by V13 (Dietary Aide) for chlorine sanitizer and did not register any sanitizer on the test strip. After looking at the container of sanitizer and seeing it was empty, V13 (Dietary Aide) stated, the container ran out last night (07/22/23). On 07/23/23 at 11:50 AM, a new container of sodium hypochlorite solution (chlorine) sanitizer was brought into the kitchen and utilized for the dish machine. V13 (Dietary Aide) had to purge the dish machine for approximately two minutes before the sanitizer was pulled from the sanitizer container to the output into the water of the dish machine, indicating there was no sanitizer in the line. On 07/23/23 at 1:00 PM, V7 (Dietary Manager) stated there should be sanitizer in the dish machine, they are working out new procedures with her being new and some of the staff being new, but they should have notified her it was out and it should have been changed. V7 stated the breakfast dishes were washed with no sanitizer and maybe some of the evening dishes, she is not aware of when the sanitizer ran out. They should be checking it at the beginning of each shift. The facility document dated 2020 titled, Sanitation of Dining and Food Service Area documents: The dining services staff will uphold sanitation of the dining areas according to a thorough, written schedule. 2. Tasks will be designated to specific departmental positions (refer to sample cleaning schedule forms - daily, weekly, and monthly). Sample cleaning schedule documents: 15. Prep. (preparation) equipment/dishes/uteensils are effectively sanitized and properlyy stored. The Resident Census and Conditions of Residents dated 07/23/23 documents 61 residents residing at the facility.

Based on observation, interview and record review, the facility failed to update restraint assessments and consents for one (R35) of one resident reviewed for restraints in the sample of 34. Findings include: On 07/23/23 at 10:20am, R35 was observed in his room sitting in a high back wheelchair wearing a lap belt. R35 was awake and alert but did not respond verbally. R35's Face Sheet documented an admitted [DATE], and diagnoses including Personal History of Traumatic Brain Injury, Abnormal Posture, and Unspecified Behavioral Syndromes Associated with Physiological Disturbances and Physical Factors. R35's Care Plan dated 6/26/23 documented a problem area, I use physical restraints: wheelchair seat belt related to uncontrolled body movements. (I am) To wear seatbelt when up in the wheelchair for safety and positioning, with a corresponding intervention, Ensure valid consent on chart prior to initiating restraint. R35's Minimum Data Set, dated dated dated [DATE] documented that R35 has a Brief Interview for Mental Status Score of zero, indicating the resident is rarely or never understood, and requires daily use of a trunk restraint. R35's July 2023 Physicians Orders documented an order, Resident to wear seatbelt when up in the wheelchair for safety and positioning. Will release every 2 hours for 15 minutes and at meals if safe for the resident at that time. R35's medical record contained a Physical Restraint Informed Consent, signed by R35's POA (Power of Attorney) on 1/22/19. The record also contained a Restraint Evaluation Review dated 9/12/22. A Restraints Policy dated 5/24/18 documented, Purpose: To ensure that each resident is to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints .Periodic assessments shall address the resident's status in an effort to reduce or eliminate restraints whenever possible and assure the (least) restrictive method is used which allows the resident to function at their highest practicable level .The use of restraints will be reviewed by the Interdisciplinary Team periodically and at least quarterly thereafter .When alternatives to the use of restraints are ineffective, the physician will be contacted and further directions/orders requested to maintain a safe environment for the resident. If alternative measures have been unsuccessful and a determination that a physical restraint is necessary, then the use of the restraint including risks, possible negative outcomes, and benefits must first be explained to the resident, family member, or legal representative and written and/or verbal consent for use obtained. On 07/25/23 at 8:54am, V2 (Director of Nurses) stated Restraint Assessments and Restraint Consents are to be updated quarterly per facility policy. V2 acknowledged R35's consent and assessment had not been updated per policy and provided a Physical Restraint Informed Consent and Restraint Evaluation Review both dated 7/24/23, which she stated she updated yesterday.

Based on observation, interview and record review, the facility failed to ensure the correct textured diet was provided to one (R9) of one resident reviewed for pureed diets in a sample of 34. This past non-compliance occurred on 06/26/23. R9's Diagnoses Sheet documents admission to this facility on 06/05/09 with a primary diagnosis of Alzheimer's dementia with hemiplegia, and an additional diagnosis of dysphagia dated 06/30/23. Her most recent Minimum Data Set (MDS) dated [DATE] indicates she is moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 8. She is assessed to require set-up with supervision only for eating. R9's Care Plan dated 02/16/15 and updated most recently includes - (R9) has a swallowing problem r/t (related to) loss of food/liquids from mouth while eating. NAS (no added salt), mechanical soft pureed meat, honey thickened liquids, patient may have one sip of liquid from cup at a time, staff to supervise during all intake, 8 oz (ounce) of fortified milk with meals, puree meats and fruits except bananas, add fortified pudding with lunch and supper - Revised 8/3/2022; (R9) has a swallowing problem r/t loss of food/liquids from mouth while eating. NAS, mechanical soft pureed meat, honey thickened liquids, patient may have one sip of liquid from cup at a time, staff to supervise during all intake, 8 oz of fortified milk with meals, puree meats and fruits except bananas, add fortified pudding or equivalent with lunch and supper - Revised 6/15/2023. R9's July 2023 Physician's Order Sheet (POS) documents - NAS diet, Mechanical Soft, pureed meat texture, honey consistency, pureed fruit except bananas, super cereal with breakfast and fortified pudding or equivalent with lunch and supper for diet, start dated 01/26/23. R9's meal card dated 07/26/23 documents the same orders as on the July 2023 POS. R9's facility Incident Report dated 06/26/23 at 12:32 PM includes - Incident Description: Observed resident holding her throat. Resident leaned forward and encouraged to cough. Resident spit up 2 large hunks of cantaloupe. Incident Location: Dining Room. Person Preparing Report: V15 (Licensed Practical Nurse/LPN) Resident Description: Swallowed cantaloupe. Immediate Action Taken: Vitals, lung sounds, encouraged to cough up cantaloupe. Resident Taken to Hospital: No. Injuries Observed at Time of Incident: No injuries observed at time of incident. Level of Consciousness: Alert. Mobility: Wheelchair bound. Mental Status: Alert to person. Injuries Report Post Incident: No injuries observed post incident . Notes: 06/26/23 - Observed resident holding her throat. Resident leaned forward and encouraged to cough. Resident spit up 2 large hunks of cantaloupe. V16 (Physician)/V2 (Director of Nursing - DON) made aware. 06/26/23 - Diet reviewed. Resident fruit to be pureed. Met with dietary department for education and alerts noted on menu card. Alert will be highlighted on resident's menu. R9's progress note dated 6/26/2023 at 12:25 PM by V15 (LPN) documents - . Resident choked on cantaloupe in the dining room. This nurse encouraged her to cough and lean forward. Resident spit up 2 chunks and was able to clear throat. Lungs clear at this time. Resident also spit up lots of clear phlegm. MD (Medical Doctor) and DON made aware. On 07/26/23 at 12:29 PM, V15 stated, I was down the hall passing meds and staff brought (R9) to the nursing station and she was kind of foaming at the mouth and gagging. I instructed (R9) to lean forward and cough to try and clear her throat. V15 stated R9 ultimately spit up/vomited and chunks of cantaloupe came up. V15 stated at that time she was not aware of R9's diet orders but when she checked with speech therapy, she confirmed she was supposed to be receiving pureed fruit other than bananas. V15 stated after R9's choking incident she listened to her lungs to ensure she hadn't aspirated any food. V15 stated she believed there was a new dietary staff in the kitchen that had passed R9's lunch tray that day and apparently was not aware of the orders. V15 stated for the next 2 days a respiratory assessment was performed on V9 with negative findings. R9's Respiratory Assessments dated 06/26/23 and 06/27/23 were reviewed with no residual effects documented after R9 choked on the pieces of cantaloupe. On 07/26/23 at 12:41 PM, V12 (Dietary Aide) stated, It was my first 3-4 days of working in the dining room by myself and I was very unfamiliar with who eats what and at that time we did not have a supervisor over us. I was going based off another lady's word. I had asked V14 (Former Cook) if I was able to give (R9) cantaloupe because she was asking for it. I had not been trained and did not really know it had to be pureed. The nursing supervisor was upset and brought it to our attention that (R9) was not supposed to have cantaloupe that was not pureed. We were educated on the orders and talked to about the incident. When asked if she had looked at the meal card that day, V12 stated she just missed where it said, pureed fruit other than bananas because the meal card was confusing. When asked if she knew the difference between the different texture consistencies such as mechanical soft versus puree and how to ensure the correct food was on the resident tray, V12 stated, I do now. On 07/26/23 at 12:57 PM, V7 (Dietary Manager) stated, I started here about 3 weeks ago as the Dietary Manager. I think the staff coming into this were not well educated on the differences in mechanical soft versus pureed. I am not aware of when (R9's) order was put into place, but cantaloupe would not have been appropriate unless it is puree as ordered. On 07/26/23 at 1:19 PM, R9 stated she does remember choking on the cantaloupe on 06/26/23 but confirmed she has no residual effects from that incident. She stated, It just happened and has not happened since then. On 07/26/23 at 1:49 PM, V2 (DON) confirmed R9's dietary card did document she was to have pureed fruit (other than bananas) on 06/26/23 but stated the cantaloupe had not been pureed as ordered that day. On 07/26/23, V1 (Administrator) provided documentation outlining the actions taken by the facility prior to this survey date to correct the noncompliance. Prior to the survey date, the facility took the following actions to correct the deficient practice: 1. An IDT (Interdisciplinary Team) meeting was held on 06/26/23 at 1:53 PM with the following management staff - V2 (DON), V5 (LPN/Wound Nurse), V15 (LPN), and V17 (ST - Speech Therapy). a) Summary of IDT meeting: Resident was observed holding her throat and choking in the dining room. Resident leaned over and was coughing. Resident encouraged to cough and clear airway. Chunks of cantaloupe was coughed up. Nurse immediately done respiratory assessment. Resident could speak and had no further complaints after incident. MD notified. Respiratory assessment each shift for the next 2 days. ST to eval and treat. Resident will be monitored at all meals in the dining room. 2. A Quality Assurance and Performance Improvement meeting was held on 06/26/23. In attendance - V1, V2, and V7. Actions Steps Include: a) Provide education to dietary staff. Educated staff to read resident's dietary tray card with the actual food served at each meal. Responsible Person(s): V2, V7. Target Date: New hires monthly. B: Supervisor or designated staff will monitor dining room compliance. Responsible Person(s): V1, V2. Target Date: 06/26/23 and all meals. 3. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents have the potential to be affected. 4. Measures put into place/systematic changes to ensure the deficient practice does not recur: V1 and V2 provided in-service with sign-in sheets to dietary staff regarding resident diet - Educate on diet types and alerts on place cards. Alerts to be highlighted.

Based on interview and record review, the facility failed to update and implement the Pneumococcal Immunization policy and failed to provide Pneumococcal Immunization in accordance with CDC (Centers for Disease Control and Prevention) recommendations for 14 of 15 residents (R7, R16, R17, R42, R13, R28, R35, R10, R31, R22, R26, R11, R5, R33) reviewed for Pneumococcal Immunizations in the sample of 35. Findings include: On 8/10/22 at 3:30 PM, V2 (Director of Nursing) stated she's aware that the Pneumonia vaccines have not been given and the information regarding the resident Pneumonia vaccines hasn't been done. V2 stated they concentrated on taking care of the Covid-19 vaccines and all the documentation associated with Covid-19. V2 also stated they hired V3 (Registered Nurse/Infection Preventionist), and she will be focusing on the Flu and Pneumonia education and vaccines. On 8/9/22 at 1:00 PM, R42 stated that no one talked to her about getting the pneumonia vaccine. R24's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 12, indicating R42 is cognitively intact with some forgetfulness. On 8/10/22 at 2:00 PM, R7 stated she had one pneumonia vaccine but hasn't had anyone say anything about a second pneumonia vaccine. R7's MDS dated [DATE] documents a BIMS score of 13, indicating R7 is cognitively intact. The facility's Immunization Report from 1/1/2010 through 8/10/22 documents the following: R7 had the 23-valent pneumococcal polysaccharide vaccine (PPSV23) vaccination on 10/30/15 but there is no documentation a Pneumococcal Conjugate Vaccine was offered or given. R42 had a Pneumococcal Conjugate Vaccine on 12/3/2020 but there is no documentation that R42 was offered or given the PPSV23 vaccine. R17 was given the PPSV23 on 10/30/15 but was not offered or given a Pneumococcal Conjugate Vaccine. R28 was given a Pneumococcal Conjugate Vaccine on 10/09/18 but was not offered or given the PPSV23. R35 was given a Pneumococcal Conjugate Vaccine on 3/24/14 but was not offered the PPSV23 vaccine. R5, R10, R11, R13, R16, R22, R26, R31 and R33 were not offered or given the Pneumococcal Conjugate Vaccine or PPSV23. The facility's policy on Pneumococcal Immunization, dated 3/8/2017 documents. 1. Before offering the pneumococcal immunization, each resident or the resident's representative will be provided education regarding the benefits and potential side effects of the immunization. 2. Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized; A second pneumococcal vaccine will be offered only when necessary, according to the CDC guidelines. 3. The resident or the resident's representation has the opportunity to refuse immunization. 4. The resident's medical record includes documentation that indicates, at a minimum, the following: That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization. That the resident either received or did not receive the pneumococcal immunization due to medical contraindications or refusal. Review of current CDC recommendations, available at https://www.cdc.gov/vaccines/hcp/vis/vis-statements/pcv.html and dated 2/4/22, documents the following: Pneumococcal conjugate vaccine helps protect against bacteria that cause pneumococcal disease. There are three pneumococcal conjugate vaccines (PCV13, PCV15, and PCV20). The different vaccines are recommended for different people based on their age and medical status. PCV13: Infants and young children usually need 4 doses of PCV13, at ages 2, 4, 6, and 12-15 months. Older children (through age 59 months) may be vaccinated with PCV13 if they did not receive the recommended doses. Children and adolescents 6-[AGE] years of age with certain medical conditions should receive a single dose of PCV13 if they did not already receive PCV13. PCV15 or PCV20: Adults 19 through [AGE] years old with certain medical conditions or other risk factors who have not already received a pneumococcal conjugate vaccine should receive either: -a single dose of PCV15 followed by a dose of pneumococcal polysaccharide vaccine (PPSV23), or -a single dose of PCV20. Adults [AGE] years or older who have not already received a pneumococcal conjugate vaccine should receive either: -a single dose of PCV15 followed by a dose of PPSV23, or -a single dose of PCV20. According to https://www.cdc.gov/mmwr/volumes/71/wr/mm7104a1.htm, on October 20, 2021, the Advisory Committee on Immunization Practices recommended 15-valent PCV (PCV15) or 20-valent PCV (PCV20) for PCV-naïve adults who are either aged =[AGE] years or aged 19-[AGE] years with certain underlying conditions. When PCV15 is used, it should be followed by a dose of PPSV23, typically =1 year later.

Based on observation, interview and record review, the facility failed to ensure that there was no cross contamination during medication pass for 2 of 5 residents (R45, R49) reviewed for infection control in the sample of 35. On 8/9/22 at 8:30 AM, V4 (Licensed Practical Nurse) was observed administering medications to R45 and R49 and did not wash her hands or use alcohol gel between each resident. On 8/10/22 at 3:45 PM, V2 (Director of Nursing) stated she will in-service the nurses again on handwashing and infection control. V2 stated V4 has access to hand gel and should have used it between residents. The facility's undated Medications Administration Oral policy documents under Important Points: line #2 Hand washing is to be performed before beginning, and after each resident contact unless antibacterial agent is used.

Based on observation, record review and interview the facility failed to maintain all resident access hot water fixtures at safe temperatures for 1 of 13 sampled residents ( R13) reviewed for accident hazards and 9 residents (R16 - R24) in the supplemental sample. This failure resulted in hot water in excess of 136 degrees Fahrenheit being available to 10 ambulatory and confused residents identified by E2 (Director of Nursing) on 5/5/14 at 3:55pm. This failure resulted in an Immediate Jeopardy . During a tour of the facility on 5/5/14 beginning at 2:15 pm, hot water temperatures were available to residents in resident rooms and the 100 hall common women's toilet and shower room from 120 degrees Fahrenheit to 136.9 degrees Fahrenheit. Table 1 in the F323 42 CFR Code 483. 25 (h) states third degree burns may occur with exposure to hot water temperatures with exposure of 120 degree Fahrenheit water for 5 minutes and 133 degree Fahrenheit water in 15 seconds. These times can vary but burns can occur at temperatures below these levels depending on an individual's condition and length of exposure. While the Immediacy was removed on 5/5/14 at 5:20pm, the facility remains out of compliance at a Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of their interventions to ensure resident safety with exposure to hot water in the facility. Hot water temperatures were taken and recorded with the surveyor's thermometer that was calibrated by the ice point method to + or -2 degree Fahrenheit on site. The hot water temperatures were taken and verified by E10 (facility maintenance) and found to be accurate against E10's facility thermometer. All temperatures were taken and reported in degrees Fahrenheit. Water temperatures were taken on 5/5/14: Resident room 49 lavatory - hot water 122 degrees at 2:22 pm Resident room 45 lavatory- hot water 121 degrees at 2:25pm Women's common bath lavatory - hot water 128 degrees at 2:35pm Women's common bath lavatory- hot water 134 degrees at 2:45 pm Women's common bath lavatory- hot water 134 degrees at 2:50pm This was equal to E10's thermometer. The facility was made aware of the excessive hot water temperatures as noted above and verified by E10. E10 identified two water heaters on the 200 hall that were believed to service the women's common toilet and bathing area with the excessive hot water temperatures. The other areas identified by E10 as serviced by this hot water source were tested and found to have temperatures no greater than 104 degrees. At 3:20pm the women's common bathroom door was shut but unlocked. There were no staff in the area at the time and the water temperatures were taken again. The women's common bath lavatories measured 136.9 degrees at this time and the shower temperature was 130 degrees. E2 (Director of Nursing) was notified that the excessively hot water was still accessible to residents at these fixtures. At that time, E2 and E10 took steps to limit access to this area. The lock on the door was changed to a key lock to prevent resident access. E10 was asked to provide water temperature records. E10 indicated that water temperatures are taken and recorded on the record sheets weekly. The record sheets record the date, time and water temperatures at four fixtures within the building. The records were provided and reviewed on 5/5/14. The record sheets were monthly from July 2013 to present. Hot water temperatures of 118 degrees to 120 degrees were routinely recorded at various times throughout the time frame reviewed.. Interview with E10 on 5/6/14 at 9:15am found that the licensed plumber had been to the facility on [DATE] and repairs were made to a mixing valve for a water heater in the maintenance room just West of the women's common bath. E10 stated at that time that he was mistaken as to which water heater was servicing the area with the excessively hot water. E10 indicated that he has been employed with the facility for about a year. When questioned about the training he had received about the hot water in the facility E10 indicated he thought the allowable hot water temperature was up to 120 degrees. E1 (Administrator) and E2 were notified of the Immediate Jeopardy on 5/5/14 at 4:00pm. The Immediate Jeopardy was determined to have begun on 5/5/14 when the excessively hot water temperatures were discovered in the women's common bath at 2:35pm /128 degrees, 2:45pm and 2:50pm / 134 degrees. The surveyor confirmed through interview, observation and record review that the facility took the following action to remove the Immediate Jeopardy. A. The women's common restroom door was equipped with a locking door knob and is only to be opened by maintenance personnel. A "DO NOT USE" sign was placed on the door. B. Any residents in need of showers were to be showered in alternative shower rooms or toileted in other toilet rooms. C. Initial education of facility staff was begun by E1 and E2 for the staff on duty and completed at 5:20pm.. Further education for staff reporting to work until 7:00pm would be conducted by E11 (Registered Nurse, RN) and by E12 (RN) until 11:00pm and by E13 (RN) until 7am. The education was recorded through the 3 - 11pm shifts. D. A licensed plumber was contacted and would be making a visit and potential corrections at 8:00pm on 5/5/14. The licensed plumber arrived the evening of 5/5/14 and repaired the mixing valve for the water heater servicing the affected hot water. The invoice for this service was reviewed on 5/8/14. B. Based on record review and interview the facility failed to up-date and implement new approaches to prevent falls for 2 of 8 residents (R4 and R7) reviewed for falls in the sample of 15. The findings include: 1. A review of medical and admission records for R4 found R4 is a [AGE] year old resident with [DIAGNOSES REDACTED]. R4's current care plan dated 9/16/13 under the topic of Falls, includes approaches to prevent falls: Frequent checks of resident, toileting assistance every 2 hours, bed, pad and seat alarms, anticipating the residents needs, encourage and assist resident to go for a walk. Further approaches were added from 9/23/13 to 2/3/14 that included: monitoring behaviors, keep in a supervised area and 1:1 when available. Incident reports from September 2013 to May of 2014 were reviewed and found R4 had fallen 15 times since admission. The 15 incident reports and fall investigations did not indicate what interventions were in place and / or working at the time of the falls. There were no additional interventions added to the care plan after an entry on 2/3/14 that states "cont all previous approaches". R4 has fallen 3 additional times 2/24, 4/29, and 5/2/14 since the comment added on 2/3/14 and no new or revised interventions have been added to the care plan and no new or revised interventions were noted on the fall incident reports or investigations. 2. The facility's Accident and Incident Logs for December 2013 thru May 2014 indicate that R7 has had 4 falls since December 2013. The admission sheet in the medical record notes an admission date of [DATE]. The [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] notes a Brief Interview for Mental Status (BIMS) of a 3 out of 15. (Severely Impaired). The facility's Post Accident Investigations for falls and Post Fall Huddle Forms notes the following: 1. The accident/fall on 12-16-13 occurred while trying to get to their wheel chair. The cause was noted to be loss of balance. Suggested changes to prevent future falls was teaching related to use of call light for assistance. 2. The accident/fall 4-2-14 occurred while trying to walk in sock feet and slid to floor. The cause was noted to be unsteady gait and sock feet. Contributing factors included poor balance, confusion, and inadequate footwear. Suggested changes to prevent future falls was remind to ask for staff assistance. 3. The accident/fall on 4-21-14 occurred in their room after walking from the bathroom to bed and was trying to fix the covers on their bed. The cause was noted to be the resident was in socks with the contributing factors of poor balance. Suggested changes to prevent future was encourage resident to have on proper foot wear and use call light for assistance. 4. The accident/fall on 4-27-14 in their bathroom. The cause of the fall was noted to be slippery socks. Suggested changes to prevent future falls was non skid socks and shoes. The suggested changes to prevent future falls were ineffective yet continued to be noted as an intervention. This was confirmed in an interview with E2, (Director of Nursing) at 11:40AM on 5-8-14.