Every finding on record at The Oaks at Byron Center

Based on observation, interview and record review, the facility failed to 1.) Provide Personal Protective Equipment (PPE) in the soiled utility rooms and resident rooms that were on transmission-based precautions (TBP) and enhanced barrier precautions (EBP) for Resident #67, #3, #29, and #53; 2.) [NAME] (put on) PPE when providing care for residents in EBP for Resident #5, #67, and #74; 3.) Clean and properly store nebulizer equipment for Resident #10; 4.) Ensure an active Water Management Plan specifically tailored to the facility. These deficient practices resulted in the potential for cross contamination and the spread of disease to all residents that reside in the facility. Findings include: Resident #10: During an observation on 12/01/2025 at 9:58 AM, Resident #10's nebulizer (medical device that converts liquid medication into a mist to deliver the medication) mask was on her bedside table in direct contact with the table and with no protective barrier. The nebulizer mask had white residue, streaks, and flakes on the inside of the mask. During an observation on 12/01/2025 at 1:25 PM, Resident #10's nebulizer mask remained in the same spot as earlier, 12/01/2025 at 9:58 AM. The nebulizer mask had white residue, streaks, and flakes on the inside of the mask and no protective barrier. During an observation on 12/01/2025 at 3:20 PM, Resident #10's nebulizer mask remained in the same spot as earlier, 12/01/2025 at 9:58 AM and 12/01/2025 at 1:25 PM. The nebulizer mask had white residue, streaks, and flakes on the inside of the mask and no protective barrier. During an observation on 12/02/2025 at 8:21 AM, Resident #10's nebulizer mask and other plastic pieces were sitting on paper towel next to the sink near the entry door of Resident #10's room. The nebulizer mask had white residue, streaks, and flakes on the inside of the mask. The soiled area was most prominent around the inner edges of the nebulizer mask. During an observation on 12/2/25 at 12:26 PM, Resident #10's nebulizer mask and plastic accessory parts were sitting on a paper towel directly next to the sink in her room, same as earlier, 12/02/2025 at 8:21 AM. The nebulizer mask had white residue, streaks, and flakes on the inside of the mask. There was a white cloth towel placed to the left of the sink and was partially covering the lower end of the mask in direct contact. During an observation on 12/03/2025 at 8:21 AM, Resident #10's nebulizer mask and plastic accessory parts remained on a paper towel directly next to the sink in her room. The nebulizer mask had white residue, streaks, and flakes on the inside of the mask. Review of Resident #10's physician order for ipratropium-albuterol (medication to make it easier to breathe), start date 9/23/25, indicated it was to be given twice a day by way of inhalation with use of a nebulizer (medical device that converts liquid medication into a mist to deliver the medication) for shortness of breath/wheezing. Review of Resident #10's medication administration history, dated 12/1/25-12/3/25, noted ipratropium-albuterol solution for nebulization order was provided twice a day on 12/1/25 and 12/2/25. Review of the facility's Respiratory Equipment policy, Review Date: 12/16/24, stated, To provide infection control guidelines to help prevent infections associated with respiratory therapy equipment and to prevent transmission of infections to residents and staff .Medications Nebulizers .After completion of therapy .Wipe mouthpiece (facility's nebulizer for Resident #10 used a mask) with damp paper towel or gauze sponge .Store circuit (disposable or reusable accessory portion of a nebulization system; includes mask) in plastic bag, marked with date and resident's name, between uses . Residents #3, #53, and #29: During an observation on 12/02/2025 at 9:55 AM, outside Resident #3 and #53's room a sign was posted to the left of the entry door. This sign was from the Centers for Disease and Control Prevention, undated, and stated, Droplet Precautions Everyone Must:.Make sure their eyes, nose and mouth are fully covered before room entry and showed two examples of appropriate eye protection (full face shield and appropriate goggles). Outside the room was also a bin which contained personal protective equipment (PPE) to be worn for entry into the room. The bin contained disposable gloves, sanitizer wipes, surgical masks, and gowns. There was no eye protection PPE available. During an observation on 12/02/2025 at 9:59 AM, Registered Nurse (RN) L entered Resident #3 and #53's room and interacted with Resident #3. RN L was only wearing personal eyeglasses (not personal protective equipment for eye protection) and a surgical mask. During an interview on 12/02/2025 at 10:02 AM, she reported Resident #53 had influenza A (the flu; a viral infection) and was the reason for droplet precautions. RN L confirmed there was no eye protection in the PPE bin or available outside the room for Resident #3 and #53's room which was under droplet precautions. RN L also confirmed Resident #29 had influenza A down the hall, was on droplet precautions, and the PPE bin outside that room also didn't have eye protection available. When asked where eye protection was RN L confirmed there was none on the unit and left the unit/hall looking for some. During an observation on 12/02/2025 at 9:57 AM, Resident #29's room had the same droplet precaution signage as Resident #3 and #53's room did. The bin of PPE outside of Resident #29's room had gloves, gowns, and surgical mask. There was no eye protection PPE available. Review of the facility's Guidelines for Droplet Precautions policy, revised 3/19/20, stated, Examples of infections requiring droplet Precautions include but are not limited to: .Influenza .Isolation Signs .Place a sign on the door indicating the description of the type of precautions . Resident #5 Review of an admission Record revealed Resident #5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes and venous insufficiency (condition where valves in the leg veins become damaged, causing blood to pool in the legs instead of flowing efficiently to the heart). Review of Resident #5's Orders revealed, Staff to use enhanced barrier precautions (EBP), wearing a gown and gloves at minimum during high-contact care activities. Special instructions: Venous ulcer to left shin and left heel. Start date: 10/6/25. In an observation on 12/01/2025 at 11:40 AM, Resident #5's room door had a sign indicating that Resident #5 was on EBP, and that staff were required to don a gown and gloves when providing high contact care. It was also noted that there was a cart outside of Resident #5's room with PPE in it for staff to don prior to entering Resident #5's room. In an observation on 12/01/2025 at 11:43 AM, Certified Nursing Assistant (CNA) E entered into Resident #5's room and applied gloves and made Resident #5's bed. It was noted that CNA E was not wearing a gown. In an observation on 12/02/2025 at 3:05 PM, Licensed Practical Nurse (LPN) D entered Resident #5's room and donned gloves. LPN E then removed Resident #5's socks on both of his feet and began cleaning Resident #5's right and left toes with wound cleanser. After cleaning Resident #5's toes with wound cleanser, LPN D dried Resident #5's right and left toes and applied skin prep (protective liquid applied to the skin to form a barrier, helping to prepare the skin for wound care, adhesive dressings, and other medical applications). It was noted that LPN D was not wearing a gown when providing wound care for Resident #5. In an interview on 12/02/25 at 3:25 PM, LPN D reported that she did not think Resident #5 was on EBP, and she did not know of any reason that Resident #5 would need to be on EBP. When this writer queried about Resident #5's wounds, and if that would be considered a reason for EBP, LPN D was unable to confirm if wounds would be an indication for a resident to be on EBP. Resident #74 Review of an admission Record revealed Resident # 74 was originally admitted to the facility on [DATE] with pertinent diagnoses which included hypertension (high blood pressure) and congestive heart failure (condition that happens when your heart can't pump blood well enough to give your body a normal supply). Review of Resident #74's Orders revealed, Staff to use EBP, wearing a gown and gloves at minimum during a high-contact care activities. Start date: 12/1/25. In an observation on 12/01/2025 at 11:20 AM, Resident #74's room door had a sign indicating that Resident #74 was on EBP, and that staff were required to don a gown and gloves when providing high contact care. It was also noted that there was a cart outside of Resident #74's room with PPE in it for staff to don prior to entering Resident #74's room. In an observation on 12/01/2025 at 11:27 AM, CNA E entered Resident #74's room without donning a gown or gloves and assisted Resident #74 to the restroom. Resident # 67 Review of an admission Record revealed Resident #67 was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes and Infection and inflammatory reaction due to indwelling urethral catheter (is a flexible tube inserted into the bladder to continuously drain urine). Review of Resident #67's Orders revealed, Staff to use enhanced barrier precautions (EBP), wearing a gown and gloves at minimum during high-contact care activities. Start date: 12/1/25. In an observation on 12/03/2025 at 8:25 AM, Resident #67's room door had a sign indicating that Resident #67 was on EBP, and that staff were required to don a gown and gloves when providing high contact care. It was also noted that there was not a cart of PPE next to Resident #67's door. In an observation on 12/03/2025 at 8:37 AM, Resident #67 was in his restroom yelling out for help. MDS RN (Registered Nurse) (MDS-RN) BB entered Resident #67's room to assist him in the restroom. It was noted that MDS-RN BB did not don a gown or gloves prior to entering Resident #67's room to assist him in the restroom. At 12/03/2025 at 8:42 AM, CNA KK and CC entered Resident #67's room to assist MDS-RN BB in caring for Resident #67. It was noted that CNA KK and CC did not don gown and gloves prior to entering Resident #67's room. In an interview on12/03/2025 at 8:51 AM, CNA CC confirmed that she and CNA KK did not don a gown prior to providing care with Resident #67, because she did not think that they needed to don a gown when providing care for Resident #67 unless they were emptying his catheter. In an interview on12/03/2025 at 9:00 AM, MDS-RN BB confirmed that Resident #67 did not have cart with PPE for staff to don prior to entering Resident #67's room. MD-RN BB reported that Resident #67 was on EBP, and that she and CNA CC and KK had overlooked this when providing care to Resident #67, so they had not donned PPE appropriately prior to providing care to Resident #67. Review of the facility's Enhanced Barrier Precautions policy last revised 4/2/24 revealed, Overview: Guidance for enhanced barrier precautions (EBP) to decrease risk of becoming colonized and developing infections with multidrug-resistant organism (MDRO) status. EBP does not replace existing guidance regarding the use of Contact precautions for other pathogens (ie: Cdiff, scabies, norovirus, ect). SOP (Standard operating procedure) Details: Enhanced Barrier Precautions (EBP) will be in place during high-care contact activities for residents with the following conditions: A. Residents an increased risk of MDRO acquisition which include I. All residents with chronic wounds, including but not limited to, pressure ulcers, diabetic foot ulcers. unhealed surgical wounds, and venous stasis ulcers. II. All residents with indwelling medical devices include but not limited to: catheters, central lines, feeding tubes, tracheostomy tubes . B. Residents known to be infected or colonized with MDRO. 2. Personal Protective Equipment should be used even if blood and body fluid is not anticipated. A. At minimum, Staff shall wear gloves and gowns during high-contact care activities. May include face protection if splashes or sprays are anticipated during care. 3. High-contact care activities include but are not limited to: morning and evening ADL (activities of daily living) care, toileting, and showers . On 12/1/25 at 11:19 AM, observation of the 500 Hall Soiled Utility room found an uncovered hopper (used for cleaning debris from soiled linens) with only one box of gloves, and no other available personal protective equipment (such as a gown and facemask) for easy use by staff. On 12/1/25 at 11:27 AM, observation of the 300 Hall Soiled Utility room found an uncovered hopper, an empty box of gloves on the wall, and no available gown or facemask for use. On 12/1/25 at 11:32 AM, observation of the 200 Hall Soiled Utility room found an uncovered hopper, no gloves, no gown, and no facemask for use. On 12/1/25 at 11:35 AM, observation of the 400 Hall Soiled Utility room found an uncovered hopper, no gloves, no gown, and no facemask for use. On 12/1/25 at 12:50 PM, an interview with Environmental Services Associate V found that staff on the floor do use the hoppers when they are needed. On 12/1/25 at 1:15 PM, the facilities Water Management Plan (WMP) binder was provided by the Nursing Home Administrator. On 12/1/25 at 1:20 PM, a review of the first document in the binder entitled Legionella Water Management Plan, not dated, found that it was not tailored to this facility, but rather referenced a sister facility, including the name, address and facility layout of this other location. Further review of the document found no documentation that an annual review had been performed. Under the heading Control Measures and Monitoring, the document states that, Monthly the Director of Plant Services test the cold and hot water for total hardness, total chlorine, free chlorine, total alkalinity, and pH using test strips. No results, logs, or documentation of control limits were found.

Based on interview and record review the facility failed to maintain complete and accurate medical records for 1 resident (Resident #9) of 24 sampled residents reviewed for complete and accurate medical records, resulting in inaccurate documentation of advance directives (personal choices of medical treatment options) and the potential for Resident 9's wishes to not be honored appropriately.Findings include:Review of a Face Sheet revealed Resident #9 was a male, with pertinent diagnoses which included: Alzheimer's disease, unspecified (a form of dementia) and unspecified dementia, unspecified severity, with other behavioral disturbance.Review of Resident #9's General Procedures DO-NOT-RESUSCITATE document revealed, .B. I authorize that in the event the declarant's heart and breathing should stop, no person shall attempt to resuscitate the declarant. signed by Family Member (FM) NN on [DATE] and Medical Doctor (MD) OO on [DATE].Review of Resident #9's Electronic Medical Record resident identifier banner (the banner at the top of the screen that lists resident name, age, and other pertinent information) revealed resident was DNR (do not resuscitate).Review of a Physician's Order for Resident #9 revealed, General [DATE] - Open Ended Code Status: FULL CODE CPR (cardiopulmonary resuscitation) MD OOIn an interview on [DATE] at 10:54 AM, Director of Nursing (DON) B reviewed Resident #9's electronic medical record with this surveyor. DON B reported Resident #9's banner indicated that Resident #9 was a DNR. DON B reported Resident #9's DNR paperwork indicated that Resident #9 was a DNR. DON B reported Resident #9's physician order was for Full Code CPR. DON B reported Resident #9 had just changed his code status the week before and the physician order did not get changed but should have. DON B reported it was her expectation that the paperwork, the banner, and the physician's order match.In an interview on [DATE] 9:32 AM, Nursing Home Administrator (NHA) A reported it was her expectation that all code status paperwork matched because if not, resident advance directive wishes may not be followed.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen. Findings include: During a tour of the facility, at 8:40 AM on 10/16/24, an interview with Food Service Director (FSD) F, found that hand washing should take place for 20 seconds. During an observation of lunch service, starting at 12:14 PM on 10/16/24, it was observed that [NAME] EE, was on the serving line going through the process of making and plating alternates and puree menu items. At this time, it was observed that [NAME] EE would occasionally use his apron for wiping his gloves off as they got soiled. It was also observed that [NAME] EE used a towel on a preparation table as well as a towel he placed on his apron, to occasionally wipe his gloved hands. Over the course of service, it was observed that [NAME] EE changed his gloves twice without washing his hands in between gloves changes. After the third time [NAME] EE changed his gloves, he was observed at the hand sink washing his hands for roughly five seconds before drying them with paper towel, donning gloves, and getting back on the line to plate more meals. According to the 2017 FDA Food Code section 2-301.12 Cleaning Procedure. (A) Except as specified in (D) of this section, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under S 5-202.12 and Subpart 6-301.(B) FOOD EMPLOYEES shall use the following cleaning procedure in the order stated to clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands and arms: (1) Rinse under clean, running warm water; (2) Apply an amount of cleaning compound recommended by the cleaning compound manufacturer; (3) Rub together vigorously for at least 10 to 15 seconds while: (a) Paying particular attention to removing soil from underneath the fingernails during the cleaning procedure, and (b) Creating friction on the surfaces of the hands and arms or surrogate prosthetic devices for hands and arms, finger tips, and areas between the fingers; (4) Thoroughly rinse under clean, running warm water; and (5) Immediately follow the cleaning procedure with thorough drying using a method as specified under S 6-301.12 . According to the 2017 FDA Food Code section 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: .(F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; .(H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. During a tour of the kitchen, at 9:05 AM on 10/16/24, it was observed that underneath the preparation sink area was found with an increased amount of debris and with an accumulation of yellow staining. During a tour of the kitchen, at 9:18 AM on 10/16/24, it was observed that under and behind the ice machine was found with increased dirt and debris. Observation of some kitchen utensils, including a fork, dessert cup, and plastic ramekin were found under and behind the machine. During a tour of the pop closet, at 9:30 AM on 10/16/24, found that the floor in this area had a heavy accumulation of syrup and sticky debris on the floor and under the syrup storage rack. During a tour of the drink station, at 9:32 AM on 10/16/24, it was found that non-food contact portions of the underside of the juice dispensers were found with orange and brown sticky debris accumulation. When asked how often this area gets cleaned, FSD F stated the spouts are cleaned every day. Further observation found brown and black accumulation on the backside of the ice machine spout. Unsure of how the ice spout gets taken off, FSD F stated he would have to reach out to the vendor and see how to service that part. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . Dish Machine - During a tour of the dish machine area, at 9:25 AM on 10/16/24, an interview with FSD F found that staff record the temperatures of the machine every morning to ensure it is working properly. No issues were noted on the October log, with the machine being checked once a day around 6:30 AM. Observation of the dish machine's data plate found that it stated the wash cycle temperature needed to be 160F or higher and the rinse temperature needed to be a minimum of 180F. At this time, the surveyor tested the machine with a dish plate thermometer and ran the unit three times. The unit was found to only achieve a wash temperature between 148F-155F and a rinse temperature of 175F-180F between the three full cycles observed. The dish plate thermometer, with a minimum contact of 160F, reached between 145F-152F during the three cycles. FSD F stated that they were getting someone out to service the machine. During a tour of the kitchen at 11:55 AM on 10/16/24, an interview with Dish Machine Vendor FF found that a thermostat in the unit was burned out and needed to be replaced. According to the 2017 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90C (194F), or less than: .(2) For all other machines, 82C (180F). According to the 2017 FDA Food Code section 4-501.15 Warewashing Machines, Manufacturers' Operating Instructions. (A) A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions. Observation of the 500 Hall central supply room, with Regional Director of Plant Operations DD and Director of Plant Operations E, at 2:28 PM on 10/16/24, found two bottles of Uti-Stat urinary tract supplement with a manufacture's expiration date of 17MARCH2024. One of the bottles was observed with an open date of today, 10/16/24. Regional Director of Plant Operations DD discarded both bottles. According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety .

Based on interview and record review, the facility failed to implement a system of infection control surveillance to identify possible infections or communicable diseases resulting in the potential for the development and transmission of communicable diseases and infections. Findings include: In an interview on 10/16/24 at 2:00 PM, Infection Preventionist (IP) CC reported that she was recently hired as the facility's full time infection preventionist. IP CC and Clinical Regional Support (CRS) AA reported that multiple staff members had been covering the Infection Preventionist Role over the last year. IP CC was asked to show and discuss what kind of infection prevention education had been provided to staff over the last year, and IP CC and CRS AA were not able to provide any evidence that the staff that had been covering the IP role over the last year had provided the staff with any education on infection prevention. CRS AA reported that all facility staff were provided with education at orientation and annually via the facility's online learning platform, but they did not know if any other education had been provided to staff. IP CC was asked to show and discuss the facility's infection control surveillance data for the last year. IP CC reported that she had not been keeping track of all residents with infections or possible infection symptoms, and only had a list of residents that had been prescribed an antibiotics to review. CRS AA reported that the facility had a way to run an infection event tracking report in the facility's EHR (Electronic Health Record). IP CC reported that any time the facility had a resident admitted or diagnosed with an infection, the event would be opened and tracking would occur through the EHR. IP CC confirmed that the infection even tracking was not created for residents with possible infection symptoms. IP CC was asked to show and discuss infection control audits that had been completed in the last year by the facility, and IP CC reported that she had not been documenting the audits that she had done. IP CC and CRS AA were not able to provide evidence of any infection control audits that had been completed in the last year. IP CC confirmed that she was still being trained by CRS AA, Director of Nursing (DON) B and an Infection Preventionist that had transferred to another building. IP AA reported that she had been trained on infection control surveillance and the process of monitoring infections and possible infections. During this interview, this surveyor requested documentation of infection surveillance, infection prevention and control education provided to staff in the last year, and infection prevention and control audits from the last year. CRS AA and IP CC reported that they would try to find the requested documents for this surveyor to review. During a follow up interview on 10/17/24 at 12:14 PM, IP CC showed this surveyor a binder the facility had used for 2024 which included line listings and mappings for infections. IP CC confirmed that the line listings and maps were not something IP CC had utilized. IP CC also provided a huddle note from 10/04/2024 that revealed Nurse topic: Infection prevention- medication and treatment cart : 1. Keep area clean and presentable. 2. Avoid personal belongings on stations such as food or drink. 3. When leaving station lock/close computer and medication drawers. 4. Label daily applesauce, pudding, water, cooler. 5. Check sharps container and change if full. 6. Night shift to stock straws, cups, spoons, med cups, ice, pudding, apple sauce . IP CC was not able to provide any other evidence of staff infection prevention education or infection control audits from the last year. During a follow up interview on 10/17/24 at 12:36 PM, this surveyor requested verification of staff infection prevention education and infection control audits from the last year to CRS AA. This surveyor queried CRS AA about the staff that had been responsible for the infection control program over the last year, and CRS AA reported that there had been several staff covering the program at different times, and she was not sure what each staff members method was for documenting infection control surveillance. On 8/17/24 at 3:16 PM, the facility provided additional documentation that the facility had educated staff on Enhanced Barrier Precautions on 4/2/24. The facility also provided a sign in sheet titled Education Huddle on Infection Control but there was no additional information included on what type of infection control education was provided. The facility did not provide any documentation of infection control audits prior to survey exit. Review of the facility's Infection Prevention and Control Program policy dated 12/31/23 revealed, .PURPOSE: To establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . 2. The campus shall designate a member of the clinical team to monitor the campus IPCP program to perform surveillance to identify, investigate, control, and prevent the spread of infection and reporting for the IPCP .b.Surveillance activities to identify, investigate, control, and prevent the spread of infection. Infections shall be tracked per hall/unit, type of infection, and monitor lab reports to identify organism(s). c. Reviews and critiques infection surveillance reports and statistics, recommending appropriate action for Healthcare Associated Infections (HAI) and Community Acquired Infections (CAI).Not limited to, documentation in resident ' s Electronic Health Record, reports available from lab vendor, and other reports available implementations and effectiveness of recommended actions. e. Monitors compliance with infection control practices and procedures. f. Ensures timely infection control education and training at orientation, regularly scheduled in-services and as needed in response to identified problems health status of residents (i.e., identifies those at risk for infection; reviews immunization status, etc.) .

Based on interview and record review, the facility failed to notify the resident/resident representative of the facility bed hold policy and provide a written copy upon hospital transfer for one resident (Resident #15) of two residents reviewed for hospitalization s, resulting in the potential of residents and/or resident representatives being uninformed of the bed hold policy. Findings include: Resident #15 (R15) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R15's admitted was 3/26/2019. Brief Interview for Mental Status (BIMS) score was a 99 which indicated her BIMS couldn't be completed due to cognition level. R15 was discharged to the emergency roiagnom on [DATE] due to chest pain and shortness of breath and returned to the facility on [DATE]. Review of the R15's chart revealed she had a guardian in place and there was no documentation that R15/her guardian received a written bed hold notice upon transfer to the hospital. During an interview on 10/17/2024 at 1:12 PM, Nursing Home Administrator (NHA) A stated that she couldn't find that a bed hold notice was given to R15/her guardian in her chart upon her transfer to the hospital on 6/28/2024. NHA A stated that it should have been given.

Based on interview and record review, the facility failed to ensure residents were screened for eligibility to receive pneumococcal and influenza vaccinations and receive vaccination if eligible for 2 (Resident #8 and #10) of 5 residents reviewed for vaccinations, resulting in the potential of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia and/or influenza. Findings include: Resident #8 Review of an Admission Record revealed Resident #8 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness. Review of Resident #8's Electronic Health Record (EHR) did not reveal Resident #8's pnuemococcal immunization administration record. During an interview on 10/16/24 at 2:00 PM, Infection Preventionist (IP) CC reported that Resident #8 had last received the PVC 13 (pneumococcal vaccine) on 11/8/22. IP CC reported that Resident #8 was due for the PVC 20 (pneumococcal vaccine). IP CC was not able to confirm if Resident #8 had been offered to receive the PVC 20 vaccine. Resident #10 Review of an Admission Record revealed Resident #10 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care. Review of Resident #10's Electronic Health Record (EHR) did not reveal Resident #10's influenza immunization administration record. During an interview on 10/16/24 at 2:00 PM, Infection Preventionist (IP) CC reported that Resident #10 had last received an influenza vaccine on 10/6/22. IP CC was not able to confirm if Resident #10 had been offered an influenza vaccine in 2023. IP CC reported that she had been working through getting all of the residents caught up on vaccines, as this was something that had been missed with multiple changes in staff that were monitoring the infection control program. A request for Resident #8 and Resident #10's immunization record was made to Nursing Home Administrator (NHA) A on 10/17/24 at 3:08 PM via email. On 10/17/24 at 3:10 PM, NHA A reported via email that the facility did not have immunization records for Resident #8 and #10. Review of the facility's Guidelines for Influenza, Pneumococcal, & COVID-19 Immunizations policy last revised 12/31/23 revealed, . PURPOSE: To establish an immunization program that facilitates providing education to residents and resident representative allowing them to make an informed decision regarding immunization and to follow through per their decision to receive or not to receive immunization unless medically contraindicated. PROCEDURES: 1. Upon admission each resident/resident representative will be provided with information regarding the risk and benefits of influenza, pneumococcal, and COVID-19 immunization. A copy will be retained in the medical record. 2. Upon admission, each resident/resident representative will sign an informed consent form indicating the acceptance/refusal of immunization. A copy will be retained in the medical record and results added to preventative health record in EHR .4. Each resident/responsible party will be provided annually with information regarding the risk and benefits of influenza vaccine and receive the immunization per their request, unless medically contraindicated .6. Each resident will be offered, unless medically contraindicated, or already vaccinated, a pneumococcal vaccine per attending physician ' s orders. a. The campus will make efforts to determine if the resident has already received a pneumococcal vaccine and date received. b.If a date and type of vaccine cannot be determined, the facility will offer to restart the series per the CDC recommendations .

Based on observation, interview, and record review, the facility failed to accommodate resident choice regarding morning schedule for 1 (Resident #8) of 14 sampled residents reviewed for resident choices, resulting in feelings of frustration and the potential for Resident #8 being unable to meet their highest practicable level of well-being. Findings include: Resident # 8 Review of an Admission Record revealed Resident #8 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 8/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #8 was cognitively intact. Review of Resident #8's Care Plan revealed, Profile Care Guide: Approach: Prefers to be up by 8:00 AM all days to have breakfast in AL (Assisted Living). Approach Start Dare: 6/23/22 . Review of Resident #8 Concern Forms revealed, Date 10/15/24 . Concerned Person: (Resident #8). Nature of Concern: (Resident #8) not being out of bed in morning. (Resident #8) requests to have her morning care started early. Resolution: Satisfactory. Will educate staff on (Resident #8's) request for care to start early morning. Profile care updated. Resolved by Director of Nursing (DON) B on 10/15/24 Review of Resident #8 Concern Forms revealed, Date: 9/25/24: Concerned Person: (Resident #8). Nature of Concern: Getting up for breakfast. (Resident #8) reports that she would like to be up and in her chair so that she can go over to AL to eat breakfast (as she does for lunch and dinner), but that she usually isn't up and in her chair until much later in the morning. (Resident #8) is requesting to be up in her chair by 7 am or at least have nursing staff in getting her up at 7 am . Resolution: Satisfactorily- Daily huddles are being done. Apologized to (Resident #8). Will continue with educating staff on providing good service. Resolved by DON B on 10/2/24 . During an observation and interview on 10/15/24 at 9:46 AM, Resident #8 was lying in her bed. It was noted that Resident #8 was in her pajamas and had not had morning care yet. Resident #8 reported that she liked to get up around 8:00 AM to eat breakfast, but she often had to wait until much later in the morning for staff to come assist her. Resident #8 reported that she had talked to the facility management about her desire to be up earlier in the morning several times. Resident #8 reported that the facility would accommodate her request for a few weeks but that the facility would always return to getting her up later than she desired. Resident #8 voiced frustration with being stuck in bed and waiting for staff assistance late in the morning, and missing the opportunity to eat breakfast in the dining room. During an interview on 10/17/24 at 11:21 AM, Licensed Practical Nurse (LPN) N reported that getting Resident #8 up at the time she desired was challenging for staff because the hall that Resident #8 was on had several residents that required assistance and staff struggled to get to residents on time. LPN N was not sure what interventions the facility had tried to accommodate Resident #8's request of getting up by 8:00 AM. LPN N confirmed that Resident #8 had voiced concern over not getting up at the time she would like multiple times, and that this was an ongoing issue for Resident #8 and the facility. During an interview on 10/17/24 at 12:36 PM, DON B reported that Resident #8's care profile directed staff to get Resident #8 up by 8:00 AM. DON B confirmed that she had completed a concern form for Resident #8 on 9/25/24 related to Resident #8's concern that her morning care was being given much later than she desired. DON B reported that she had educated staff regarding Resident #8's desire to be up for the day by 8:00 AM. DON B could not recall how she educated staff. DON B was not able to report why Resident #8 had not been provided morning care until after 9:45 AM on 10/15/24. DON B reported that she did not feel that the staffing on Resident #8's hall was an issue, and that staff were able to accommodate Resident #8's request if they prioritized resident care appropriately. DON B reported that the facility had not looked into any other interventions to assist with ensuring Resident #8 was receiving morning care at her desired time, as she (DON B) did not feel there was anything else that needed to be done.

Based on interview and record review, the facility failed to provide a written notice of transfer for one resident (Resident #15) of two residents reviewed for hospitalization s, resulting in the potential of residents and/or resident representatives being uninformed of the reason for transfer and their rights. Findings include: Resident #15 (R15) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R15's admitted was 3/26/2019. Brief Interview for Mental Status (BIMS) score was a 99 which indicated her BIMS couldn't be completed due to her cognition level. R15 was discharged to the emergency roiagnom on [DATE] due to chest pain and shortness of breath and returned to the facility on [DATE]. Review of R15's chart revealed she had a guardian and there was no evidence that R15/her guardian received a written notice of transfer when she went to the hospital and which included the following information: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged ; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. During an interview on 10/17/2024 at 1:12 PM, Nursing Home Administrator (NHA) A stated that R15's transfer notice wasn't completed and was forgotten by the nurse when she was sent out to the hospital on 6/28/2024.

Based on observation, interview, and record review, the facility failed to make sure the call light for two residents (Resident #35, Resident #5) of 14 residents reviewed had an operable call light, which could potentially result in delayed response and negative resident outcomes. Findings include: Resident #35 (R35) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R35 admitted to the facility on [DATE] with diagnoses of heart failure, depression, weakness and insomnia (difficulty falling and staying asleep). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated she was cognitively intact (13 to 15 cognitively intact). During an interview on 10/15/2024 at 11:01 AM, R35 stated that her call light wasn't working. This surveyor turned on her call light and observed that it wasn't turning on to alert staff she needed help. R35 said that her call light works and then doesn't work at times. During an observation on 10/15/2024 at 11:23 AM, Certified Nursing Assistant (CNA) C pressed R35's call light multiple times before it worked. CNA C' notified a nurse that the call light wasn't working and it was replaced. During an interview on 10/16/2024 at 8:39 AM, Director of Plant Operations (DPO) E stated that he gets work orders for call lights every now and then and has looked at R35's call light a few times and hasn't found a problem. DPO E said he received work orders for her in the past and would go in there and didn't find it wasn't working. DPO E stated that he had to replace the call light cord once but hasn't found an issue since then. When asked if he conducts audits on call lights, DPO E stated that he has not done any since he started working at the facility. During another interview on 10/16/2024 at 8:59 AM, DPO E clarified that he doesn't have any work orders regarding the call light for R35. DPO E said most concerns from staff are verbal and it's hard to get staff to fill out work orders. During another interview on 10/16/2024 at 9:08 AM, R35 stated that when she had an issue with call lights in the past, it took days for someone to come and check it out and she wasn't given a call bell. She stated that the communication to pass it on from the nurse to maintenance to get it fixed is not good. When asked what she does when she needs help when the call light isn't working, R35 stated that she grabs her walker and goes down the hall to find help but she said she was worried about other residents who can't do that. During an interview on 10/16/2024 at 9:39 AM, CNA O stated that R35 has told her about call light issues in the past. During an interview on 10/16/2024 at 11:05 AM, Nursing Home Administrator (NHA) A stated that there weren't any grievances regarding R35's call light until 10/15/2024 when this surveyor identified it wasn't working. Review of the Guidelines for Inoperable Light System Policy with an effective date of 5/11/2016 and a review date of 12/31/2023 revealed PROCEDURES: .3. A bell or other sound making device shall be provided for residents that are able to use the call system. 4. A staff member shall be assigned to round in the campus to identify residents requiring assistance. 35981 Resident #5 Review of an Admission Record revealed Resident # 5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: paralysis of the right side after a stroke. Review of a Minimum Data Set (MDS) assessment for Resident #5 with a reference date of 7/19/24 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #5 was cognitively intact. In an interview on 10/16/24 at 03:01 PM., Resident #5 reported she had fallen a weeks ago in her bedroom because the call light was not working. Resident #5 reported she had to yell out help help while she was on the floor after the fall. Resident #5 reported she had initially pressed the call light it to get up but no one came until she called for help. In an interview on 10/16/24 03:07 PM CNA GG reported a few weeks ago Resident #5 had fallen trying to get to get into her bed. CNA GG reported she recalled the call light was not working at the time of Resident #5's fall. CNA GG reported the call light had to be replaced after Resident #5 was assisted and assessed for injuries. CNA GG reported Resident #5 had no injuries from the fall. Review of Resident #5's Electronic Medical Record (EMR) nursing progress note revealed Nursing progress note-10/05/2024 07:37 PM., (Resident #5) was observed in supine position on floor, next to right side of bed. Her (Resident #5) head was at the foot of bed, with her feet facing head of bed. (Resident #5) did not have any socks or shoes on at the time of fall, as she removed them prior to self transferring. (Resident #5) stated she pushed her call light for assistance. Call light was not on at the time of fall, and it was noted to not be working properly when this nurse tested it. Call light was immediately exchanged for one that is functioning properly. Head to toe assessment completed on (Resident #5) with no apparent injuries observed (Resident #5) denies pain/discomfort r/t (related to) fall. With multiple staff assistance (Resident #5) was removed from floor and assisted to bed Review of Resident #5's Electronic Medical Record (EMR) nursing progress note revealed Nursing progress note-10/07/2024 IDT (Interdisciplinary Team) met on 10/7/24 to review fall that occurred on 10/5/24. (Resident #5) was observed on floor in her room next to her bed. IDT was informed by nurse that (Resident #5) was trying to self transfer from wheelchair into her bed and ended up falling. Nurse observed resident to have bare feet with no socks or shoes on at time of fall. (Resident #5) did state that she activated her call light but no one came to help her. Nurse assessed call light and observed that it was not functioning properly. (Resident #5) denied having any pain. A head to toe assessment done. No injuries observed. Neuros and vitals taken. Provider and family were notified. (Resident #5) has a BIMS of 14/15. She is diagnosed with hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysarthria following cerebral infarction vascular dementia Root Cause Analysis: (Resident #5) self transferred. She is a two person assist using sit to stand for transfers and is aware of this. Resident did not have on proper footwear during self transfer. Immediate intervention: Call light was immediately exchanged for one that is functioning properly. Intervention: Ensure resident has her grippy socks on or shoes with staff member assisting her with transfers. Intervention in place and care plan updated . 38905 An interview with Director of Plant Operations (DPO) E, at 2:45 PM on 10/16/24, found that call lights are on a wireless system and that DPO E gets notifications when there is an issue with some parts of the system not working, such as the battery dying on the wall mounted unit. DPO E went on to state that when the cord or light bulb is not working, that he only finds out through staff submitting work orders. When asked if he has ever come to fix a call light and found that the cord has been found partially pulled out of the socket and needed to be reinserted a fraction to work, DPO E stated its happened sometimes. When asked about other issues with call lights, DPO E stated that on occasion he has found that some residents are confused about how to use the call system and don't press the button and instead press the side of the handheld unit of the call system that doesn't engage the light. They also use back up bells when there are issues with call lights they are working on.

Based on observation and interview the facility failed to discard expired tube feeding supplements. These conditions resulted in an increased risk for contaminated foods and an increased risk of food borne illness for residents who might be prescribed these specific supplements. Findings include: During a tour of the 500 hall central supply storage room, at 11:15 AM on [DATE], it was observed that 35 bolus containers of Jevity supplement were found to all have a manufactures expiration date of 1MAY2024. At this time, Scheduling Coordinator G was going through the room discarding some expired product. An interview with Scheduling Coordinator G found that sometimes the facility doesn't have a resident who needs these items, and we don't end up going through them.

Based on interview and record review, the facility failed to ensure COVID-19 immunization were offered to 1 (Resident # 25) of 5 residents, reviewed for COVID-19 immunizations, resulting in the higher likelihood of infection and complications from COVID-19. Findings include: Resident #25 Review of an Admission Record revealed Resident #25 was originally admitted to the facility on [DATE] with pertinent diagnoses which included end stage renal disease. Review of Resident #25's Electronic Health Record (EHR) did not reveal Resident #25's Covid-19 immunization administration record. During an interview on 10/16/24 at 2:00 PM, Infection Preventionist (IP) CC reported that Resident #25 had last received a Covid-19 immunization on 10/6/22. IP CC was not able to report if Resident #25 had been offered a Covid-19 immunization in 2023. IP CC reported that she was currently trying to catch up all resident vaccines in the facility, as this was something that had been missed with multiple changes in staff covering the infection preventionist role. A request for Resident #8 and Resident #25's immunization record was made to Nursing Home Administrator (NHA) A on 10/17/24 at 3:08 PM via email. On 10/17/24 at 3:10 PM, NHA A reported via email that the facility did not have immunization records for Resident #25. Review of the facility's Guidelines for Influenza, Pneumococcal, & COVID-19 Immunizations policy last revised 12/31/23 revealed, PURPOSE: To establish an immunization program that facilitates providing education to residents and resident representative allowing them to make an informed decision regarding immunization and to follow through per their decision to receive or not to receive immunization unless medically contraindicated. PROCEDURES 1. Upon admission each resident/resident representative will be provided with information regarding the risk and benefits of influenza, pneumococcal, and COVID-19 immunization. A copy will be retained in the medical record .3. The campus Medical Director and/or Provider should review with the resident and/or resident representative recommendations for Influenza, pneumococcal, and COVID-19 vaccinations .13. COVID-19 Boosters will be offered and given based on current CDC recommendations .

Based on observation, interview, and record review, the facility failed to provide appropriate and adequate oxygen management and tubing care for 1 of 1 residents (R27) reviewed for respiratory and oxygen care, resulting in the potential of a vulnerable population being at risk for infection and harm. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R27 scored 9/15 (cognitively impaired) on her BIMS (Brief Interview Mental Status). The resident required extensive assistance of two-persons for positioning in bed and one-person for dressing and personal hygiene. Diagnoses included anxiety, depression, and chronic lung disease with Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere. Review of R27's Orders dated 11/23/2022 revealed Order Set O2- Oxygen @ 2L per nasal canola continuous Three Times A Day 06:00 AM - 06:00 PM, 06:00 PM - 10:00 PM, 10:00 PM - 06:00 AM. It was noted there was not an order for oxygen tubing to be changed. Review of R27's Care Plan Potential for SOB while lying flat r/t: interstitial pulmonary disease, oxygen dependent. The goal for the resident was to be free of complications from SOB (shortness of breath). Interventions to meet this goal included administering oxygen per MD (Medical Doctor) order and as needed and meds (medications) per MD order (12/28/2022). Review of R27's Care Plan Potential for Complications, functional and cognitive status decline related to respiratory disease r/t (related to) COPD, hx (history) respiratory failure with hypoxia, O2 (oxygen) dependent. The goal for the resident was to be free from complications and declines in functional and cognitive status related to respiratory disease. Interventions to meet this goal included administering oxygen per orders. During an observation on 9/19/23 at 12:17 PM R27 was supine in bed eyes closed, softly snoring. wearing oxygen delivered at 1.5 LPM (liters per minute) via nasal canula (tubing into nose). Oxygen tubing was not dated. The filter on the back of the oxygen concentrator was covered with lint and dust. During an observation on 9/20/2023 at 8:45 AM R27 was in bed wearing oxygen via nasal canula set at 1.5 LPM. The tubing had tape attached to it where it was connected to the concentrator dated 9-5-23. The labeling was not there the day before, 9/19/2023 at 12:17 PM. The filter on the back of the oxygen concentrator was covered with lint and dust. During an observation on 09/20/23 at 1:32 PM, R27 was in bed wearing oxygen via nasal canula running at 1.5 LPM. The tubing was dated 9/5/23. The filter on the back of the oxygen concentrator was covered with lint and dust. During an observation on 9/21/2023 at 8:20 AM, R27 was in her bed wearing oxygen via nasal canula set at 1.5 LPM. The tubing was dated was dated 9/5/23 The filter on the back of the oxygen concentrator was covered with lint and dust. Observed, interviewed, and reviewed R27's medical records on 9/21/2023 at 8:30 AM with Registered Nurse (RN) T regarding R27's oxygen delivery. The RN looked at the resident's oxygen concentrator stating, The oxygen flow is set at 1.5 LPM. The tubing is dated 9/5/2023. The filter does have lint and dust on it. I do not know when tubing is to be changed. Reviewed R27's Orders with RN T. RN stated, (R27's) oxygen should be set at 2 LPM. I checked her oxygen saturation this morning and it was 94%. I did not think to check what her oxygen was set at. I should have checked it. She needs to wear the oxygen continuously. During an interview on 9/21/2023 at 10:30 AM, Director of Nursing (DON)/Infection Control Preventionist B stated, It is on (R27's) MAR that the tubing should be changed monthly and as needed by a nurse. The tubing should be dated for infection control purposes. When a nurse checks a resident's oxygen level they should be checking the concentrator as well to make sure the resident is getting their prescribed amount of oxygen. It was noted, the DON was not looking at the resident's medical records to verify information. During an interview on 9//21/2023 at 10:40 AM, Nursing Home Administrator (NHA) A stated, Staff noticed on rounds when the survey started that (R27) did not have her tubing dated so it was corrected at that time. It was noted the survey started on 9/19/2023. During an interview and record review on 9/21/2023 at 12:00 PM of R27's MAR/TAR September 2023 with DON B who stated, I looked back at (R27's) MAR/TAR for September (2023) and there was no order for her oxygen tubing to be changed. I do not know the last time it was changed or the date it was changed. When she came back from the hospital the order must have gotten missed. Review of facility policy Oxygen Administration reviewed 12/21/2022, revealed, .Verify physician's order for the procedure .date the tubing for the date it was initiated .tubing should be changed monthly and PRN (as needed) .

Based on observation, interview, and record review, the facility failed to ensure food provided met nutritional needs for 1 (Resident #25) of 14 residents reviewed for nutrition, resulting in Resident #25 ingesting a known food allergen resulting in a potential for more than minimal harm. Findings include: Review of a Face Sheet for Resident #25 dated 5/15/22 revealed allergies to green/red peppers and pertinent diagnoses that included: Multiple Sclerosis (chronic, progressive disease resulting in nerve damage, numbness, slurred speech, and impaired muscle coordination), and Major Depressive Disorder with Psychotic Symptoms. Review of a Minimum Data Set (MDS) assessment for Resident #25 dated 8/4/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated the resident was cognitively intact. Section D revealed Resident #25 felt tired and had little energy 12-14 days during the 14 day assessment period. Section I of the MDS revealed Resident #25 had a diagnosis of depression. Review of a Care Plan for Resident #25 dated 2/13/20 revealed problem/goal/approach as follows: Problem: Resident has potential for alteration in nutritional status, Goal: Resident have personal food and dining preferences met, Approaches: Provide diet . as ordered. Review of Physician orders for Resident #25 dated 4/15/22 revealed listed within the category of allergies, green/red peppers. In an interview on 9/19/23 at 9:45am, Resident #25 reported feeling frustrated about having a meal served to him that contained his known food allergen. The resident reported he recognized the flavor of the allergen right away, asked the nurse who was assisting him to ask the kitchen staff about the content of the food, and received confirmed that the food allergen was mistakenly served to him. The resident reported he did not feel well after eating the allergen, had no obvious physical symptoms, but was worried he might develop a severe reaction. Resident #25 reported he felt helpless because he depended on the staff to ensure he didn't receive food might make him ill. During an observation on 9/20/23 at 12:25pm, Resident #25 sat supported in bed and was assisted with eating by a Certified Nursing Assistant (CENA) AA. Resident #25's meal ticket was on his lunch tray. Listed on the back of the meal ticket were Resident #25's food allergies: green/red peppers. In an interview on 9/20/23 at 2:18pm, Certified Nursing Assistant (CENA) AA (who fed Resident #25 lunch on this day) reported she was not aware of any residents who had food allergies. In an interview on 9/20/23 at 2:49pm Licensed Practical Nurse (LPN) FF reported she assisted Resident #25 with eating his meal on 9/2/23, during which the resident reported he suspected the meal contained his food allergen. LPN FF reported she was aware of Resident #25's food allergies,and immediately questioned dietary staff who confirmed the meal contained the food allergen. LPN FF assessed Resident #25, contacted the provider, received orders and provided medication as ordered to Resident #25. LPN FF reported Resident #25 was asymptomatic following ingestion of the allergen. In an interview on 9/21/23 at 11:49am, Director of Nursing (DON) B confirmed that Resident #25 received a meal that contained one of his known food allergens on 9/2/23. DON B reported the staff followed the appropriate protocol by contacting the provider for instruction, administering an antihistamine, and initiating monitoring of the Resident every 30 minutes for 24 hours. DON B reported Resident #25 was emotionally upset by the incident. In an interview on 9/21/23 at 11:16 am, Certified Nursing Assistant (CENA) MM reported she provided care to Resident #25 on 9/2/23 and did not observe the resident having any difficulty breathing, facial swelling or obvious effects related to his meal. CENA MM reported Resident #25's food allergy was listed on the back of his meal ticket at the time of the incident, and that Resident #25 worried about receiving meals that contained green/red peppers. In an interview, Family Member (FM) NN reported Resident #25 typically had gastric upset following ingestion of food allergens, and that it would be helpful for staff to know this information as they provided care to Resident #25. FM NN was not aware of Resident #25 having any more serious reaction to ingestion of food allergens, but reported Resident #25 preferred to avoid the food allergens and was frustrated by the situation on 9/2/23.

Based on observation, interview, and record review, the facility failed to develop and/or implement a person-centered care plan for 2 of 14 residents (Resident #25 and Resident #40) reviewed for care planning, resulting in unmet nutritional needs, feelings of frustration, and a potential for unmet needs related to the use of an anticoagulant. Findings include: Resident #25 Review of a Face Sheet for Resident #25 dated 5/15/22 revealed allergies to green/red peppers and pertinent diagnoses that included: Multiple Sclerosis (chronic, progressive disease resulting in nerve damage, numbness, slurred speech, and impaired muscle coordination), and Major Depressive Disorder with Psychotic Symptoms. Review of a Minimum Data Set (MDS) assessment for Resident #25 dated 8/4/23 revealed the resident scored 15/15 on a Brief Interview for Mental Status (BIMS) assessment which indicated he was cognitively intact. Review of a Care Plan for Resident #25 dated 2/13/20 revealed a problem/goal/approach as follows: Problem: Resident has potential for alteration in nutritional status related to .diet .Goal: Resident will have food and dining preferences met .Approach: Provide diet as ordered . The care plan did not identify Resident #25's food allergies, preventative steps to avoid exposure to food allergens, approaches to implement if an allergen exposure occurred. Review of Physician orders for Resident #25 dated 4/15/22 revealed listed within the category of allergies, green/red peppers. In an interview on 9/19/23 at 9:45am, Resident #25 reported he felt frustrated and angry after he received a meal that contained one of his known food allergens. Resident #25 reported the staff weren't always aware of his allergies when his food prepared and served. Resident #25 reported he had no obvious physical reaction after his recent exposure to a food allergen but didn't feel well, and was emotionally upset by the situation. In an interview on 9/20/23 at 2:24pm, Director of Food Services S reported Resident #25 received an evening meal that contained green peppers (food allergen) on 9/2/23. Director of Food Services S reported a new staff member, who was not aware of Resident #25's allergy, made an unapproved substitution during food preparation of the evening meal on 9/2/23. In an interview on 9/20/23 at 2:49pm, Licensed Practical Nurse (LPN) FF reported she assisted Resident #25 with eating during his evening meal on 9/2/23. LPN FF reported Resident #25 ate one bite of the main course and immediately voiced the food tasted like it had one of his allergens in it. LPN FF stopped feeding Resident #25 and approached dietary staff to determine if an error had been made. LPN FF confirmed the meal mistakenly contained a known food allergen for Resident #25 and contacted the provider for further instructions. LPN FF reported Resident #25 was upset but had no physical reaction to the food. LPN FF reported Resident #25's food allergens were listed on his meal ticket but did not know what information was in his care plan. In an interview on 9/21/23 at 11:49am, Director of Nursing (DON) B confirmed that Resident #25 received a meal that contained one of his known food allergens on 9/2/23. DON B reported the staff followed the appropriate protocol by contacting the provider for instruction, administering an antihistamine, and initiating monitoring of the Resident every 30 minutes for 24 hours. DON B acknowledged documentation of Resident #25's food allergens was on his meal ticket but not on his care plan. In an interview, Family Member (FM) NN reported Resident #25 typically had gastric upset following ingestion of food allergens and that it would be helpful for staff to know this information as they provided care to Resident #25. 47659 Resident #40 Review of an Admission Record revealed Resident #40 was originally admitted to the facility on [DATE] with pertinent diagnoses which included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident #40's Orders revealed, eliquis (Anticoagulant medication) 5 mg twice a day. Order start date 4/27/23. Review of Resident #40's Orders did not reveal orders for nursing to monitor Resident #40 for possible side effects from eliquis. Review of Resident #40's Care Plan did not reveal a care plan related to Resident #40's use of an anticoagulant medication. During an interview on 9/21/23 at 12:36 PM, Director of Nursing (DON) B reported that residents in the facility that were taking anticoagulant medications should have an order in place for nursing staff to monitor for potential side effects related to anticoagulant use and a care plan that specifically addressed anticoagulant use. DON B reported that Resident #40 did not have an anticoagulant care plan in place or any orders for nursing staff to monitor for potential side effects from anticoagulants. DON B reported that MDS Coordinator CC created care plans for each resident. DON B reported that the order for nursing staff to monitor for potential side effects was missed. During an interview on 9/21/23 at 12:49 PM, MDS Registered Nurse (MDS- RN) CC reported that nurses were responsible for entering the order for monitoring related to anticoagulant use, and that she (MDS-RN CC) was responsible for creating an anticoagulant care plan. MDS- RN CC reported that Resident #40 did not have an anticoagulant care plan in place, and that it was missed.

Based on observation, interview, and record review the facility failed to: 1.) notify a physician of missed medication doses and changed medication administration time, 2.) failed to assess a residents oxygen flow rate, and 3.) label and date oxygen tubing in 3 of 3 residents (Resident #10, Resident #307, and Resident #27) reviewed for standards of practice, resulting in the potential for worsening of health conditions. Findings include: Resident #10 Review of an Admission Record revealed Resident #10, was originally admitted to the facility on [DATE] with pertinent diagnoses which included age-related osteoporosis without current pathological fracture (a condition which bones become weak and brittle). During an observation and interview on 9/20/23 at 7:44 AM, Registered Nurse (RN) T reported that she was missing several medications for Resident #10, and planned to call pharmacy to check on the medications. During a subsequent interview on 9/20/23 at 12:34 PM, RN T reported that Resident #10 had received all of her scheduled medications except for her Calcium Citrate-Vitamin D3 supplement and Vitamin D3 supplement. RN T reported that nurses were able to request a refill in the electronic charting system or call pharmacy if there was a missing medication. RN T reported that all medications were automatically filled weekly by the pharmacy, so nursing staff should have contacted pharmacy if a medication was missing. RN T' reported that pharmacy would bring medications the following day after ordered, or they could drop ship an urgent order the same day. RN T did not know if anyone else had called the pharmacy prior to 9/20/23 to inquire about Resident #10's missing medications Review of Resident #10's Medication Administration Record revealed, Aspirin 81 mg; 1 tablet; twice a day. administration time: between 6:00 AM and 10:100 AM and between 6:00 PM- 10:00 PM. On 9/16/23 between 6:00 AM and 10:00 AM, the order was documented as Not administered: Drug/item unavailable. Comment: Pharmacy notified to send. On 9/16/23 between 6:00 PM and 10:00 PM, the order was documented as Not administered: Drug/item unavailable. Review of Resident #10's Medication Administration Record revealed, Atorvastatin (medication for high cholesterol) 10 mg tablet; once a day; administration time: between 6:00 AM and 10:00 AM. On 9/14/23 between 6:00 and 10:00 AM, the medication order was documented as Not Administered: Drug/item unavailable. On 9/16/23 between 6:00 and 10:00 AM, the medication order was documented as Not Administered: Drug/item unavailable. Comment: Pharmacy notified to send. Review of Resident #10's Medication Administration Record revealed, Calcium Citrate-Vitamin D3 315-6.25 mcg (250 units) 2 tablets; twice a day; administration time: between 6:00 AM and 10:00 AM and between 6:00 PM and 10:00 PM. On 9/14/23, between 6:00 AM and 10:00 AM the medication order was documented as Not administered: Drug/item unavailable. On 9/14/23, between 6:00 PM and 10:00 PM the medication order was documented as Not administered: Drug/item unavailable. On 9/15/23, between 6:00 AM and 10:00 AM the medication order was documented as Not administered: Drug/item unavailable. On 9/15/23, between 6:00 PM and 10:00 PM the medication order was documented as Not administered: Drug/item unavailable. On 9/16/23, between 6:00 AM and 10:00 AM the medication order was documented as Not administered: Drug/item unavailable. Comment: Pharmacy notified to send. On 9/16/23, between 6:00 PM and 10:00 PM the medication order was documented as Not administered: Drug/item unavailable. On 9/17/23, between 6:00 AM and 10:00 AM the medication order was documented as Not administered: Drug/item unavailable. On 9/17/23, between 6:00 PM and 10:00 PM the medication order was documented as Not administered: Drug/item unavailable. On 9/18/23, between 6:00 AM and 10:00 AM the medication order was documented as Not administered: Drug/item unavailable. Comment: Not delivered. On 9/20/23, between 6:00 AM and 10:00 AM the medication order was documented as Not administered: Drug/item unavailable. Review of Resident #10's Medication Administration Record revealed, Cholecalciferol (Vitamin D3) capsule; 25 mcg (1,000 units); 2 tablets; Once a day; administration time: between 6:00 AM- 10:00 AM. On 9/14/23, between 6:00 AM and 10:00 AM, the medication order was documented as Not administered: Drug/item unavailable. On 9/15/23, between 6:00 AM and 10:00 AM, the medication order was documented as Not administered: Drug/item unavailable. On 9/16/23, between 6:00 AM and 10:00 AM, the medication order was documented as Not administered: Drug/item unavailable. Comment: Pharmacy notified to send. On 9/17/23, between 6:00 AM and 10:00 AM, the medication order was documented as Not administered: Drug/item unavailable. Comment: Pharmacy notified to send. On 9/18/23, between 6:00 AM and 10:00 AM, the medication order was documented as Not administered: Drug/item unavailable. Comment: Not delivered 9/20/23, between 6:00 AM and 10:00 AM, the medication order was documented as Not administered: Drug/item unavailable. Review of Resident #10's Medication Administration Record revealed, Clopidogrel (anticoagulant medication) tablet; 75 mg; once a day; medication administration time: between 6:00 AM and 10:00 AM. On 9/16/23, between 6:00 AM and 10:00 AM the medication order was documented as not administered: Drug/item unavailable to send. Comment: Pharmacy notified to send. During an interview on 9/21/23 at 11:17 AM, Licensed Practical Nurse (LPN) FF reported that it was common for residents to miss doses of supplements and vitamins because the facility did not have access to vitamins or supplements in the back up supply. LPN FF reported all other medications were available in the back up supply so that residents would not have to miss a dose of medications. LPN FF reported that the provider should be notified if a resident were to miss a a dose of any medication, including supplements and vitamins. LPN FF' did not recall documenting that Resident #10 did not have the Calcium Citrate-Vitamin D3 315-6.25 or Vitamin D3 supplement. LPN FF reported that nurses did have access in the electronic health chart to review how many times a medication had been documented as missed due to being unavailable. LPN FF reported that she did not recall noticing a pattern of Resident #10 missing several doses of medications. LPN FF reported that the nurses were responsible for ensuring that residents received all medications, and ordering medications that were not available. During an interview on 9/20/23 at 1:55 PM, Director of Nursing (DON) B reported that the pharmacy that the facility utilized automatically refilled orders weekly, and that the pharmacy delivered medications daily. DON B reported that the facility expectation was for nurses to ensure that if a resident had not received a medication because it was unavailable, that they reach out to the pharmacy to ensure the medication is ordered. DON B reviewed Resident #10's medication administration record and reported that the nurses had missed ensuring that Resident #10 did not miss several doses of her medication because the medications were unavailable. During an interview on 9/20/23 at 3:50 PM, Pharmacist I reported that Resident #10's Calcium Citrate-Vitamin D3 315-6.25 was refilled on 9/5/23, so the medication order would have ran out on 9/13/23. Pharmacist I reported that the medication was not set for auto refill, so the medication was not refilled after 9/5/23. Pharmacist I reported that he did not see any notes regarding the facility reaching out to request refills for Resident #10's Calcium Citrate-Vitamin D3 315-6.25 or Vitamin D3 prior to 9/20/23. Pharmacist I reported that if the pharmacy had been contacted, any medications needed would have been sent within a day. Resident #307 Review of an Admission Record revealed Resident #307 was originally admitted to the facility on [DATE] with pertinent diagnoses which included acute chronic combined systolic and diastolic heart failure (a condition that develops when the heart cannot pump enough blood for the body's needs). Review of Resident #307's Medication Administration Record (MAR) revealed, lasix; 40 mg; Amount to administer: 1 tablet; Twice a day. Start date 9/19/23. End date 9/23/23. Resident #307's MAR indicated the medication order was documented as administered on the following dates: 9/19/23 between 6:00 PM-10:00 PM and 9/20/23 between 6:00 AM-10:00 AM. On 9/20/23 the order was documented as not given between 12:00 PM-2:00 PM. During an interview on 9/21/23 at 10:44 AM, LPN R reported that she had documented the lasix order on 09/20/23 between 12:00 PM-2:00 PM as not administered because the order was originally ordered to be given between 6:00 PM-10:00 PM, and the facility did not give lasix after 2:00 PM. LPN R reported that she changed the order for the medication to be administered between 12:00 PM-2:00 PM, and then skipped the dose. LPN R reported that she did not contact the provider on call to request permission to change the order time, or to inform that she was not administering the medication as ordered. LPN R reported that she should have contacted the provider to inform that she had omitted the medication, and changed the medication administration time. 38384 R27 According to the Minimum Data Set (MDS) dated [DATE], R27 scored 9/15 (cognitively impaired) on her BIMS (Brief Interview Mental Status). The resident required extensive assistance of two-persons for positioning in bed and one-person for dressing and personal hygiene. Diagnoses included anxiety, depression, and chronic lung disease with Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere. Review of R27's Orders dated 11/23/2022 (open ended) revealed Order Set O2- Oxygen @ 2L per nasal canula continuous Three Times A Day 06:00 AM - 06:00 PM, 06:00 PM - 10:00 PM, 10:00 PM - 06:00 AM. It was noted there was not an order for oxygen tubing to be changed. Review of R27's Care Plan Potential for SOB while lying flat r/t: interstitial pulmonary disease, oxygen dependent. The goal for the resident was to be free of complications from SOB (shortness of breath). Interventions to meet this goal included administering oxygen per MD (Medical Doctor) order and as needed and meds (medications) per MD order (12/28/2022). Review of R27's Care Plan Potential for Complications, functional and cognitive status decline related to respiratory disease r/t (related to) COPD, hx (history) respiratory failure with hypoxia, O2 (oxygen) dependent. The goal for the resident was to be free from complications and declines in functional and cognitive status related to respiratory disease. Interventions to meet this goal included administering oxygen per orders. During an observation on 9/19/23 at 12:17 PM R27 was supine in bed eyes closed, softly snoring. wearing oxygen delivered at 1.5 LPM (liters per minute) via nasal canula (tubing into nose). Oxygen tubing was not dated. During an observation on 9/20/2023 at 8:45 AM R27 was in bed wearing oxygen via nasal canula set at 1.5 LPM. The tubing had tape attached to it where it was connected to the concentrator dated 9-5-23. The labeling was not there the day before, 9/19/2023 at 12:17 PM. During an observation on 09/20/23 at 1:32 PM, R27 was in bed wearing oxygen via nasal canula running at 1.5 LPM. The tubing was dated 9/5/23. During an observation on 9/21/2023 at 8:20 AM, R27 was in her bed wearing oxygen via nasal canula set at 1.5 LPM. The tubing was dated was dated 9/5/23 Observed, interviewed, and reviewed R27's medical records on 9/21/2023 at 8:30 AM with Registered Nurse (RN) T regarding R27's oxygen delivery. The RN looked at the resident's oxygen concentrator stating, The oxygen flow is set at 1.5 LPM. The tubing is dated 9/5/2023. I do not know when tubing is to be changed. Reviewed R27's Orders with RN T. RN stated, (R27's) oxygen should be set at 2 LPM. I checked her oxygen saturation this morning and it was 94%. I did not think to check what her oxygen was set at on the concentrator. I should have checked it. She needs to wear the oxygen continuously. During an interview on 9/21/2023 at 10:30 AM, Director of Nursing (DON)/Infection Control Preventionist B stated, It is on (R27's) MAR that the tubing should be changed monthly and as needed by a nurse. The tubing should be dated for infection control purposes. When a nurse checks a resident's oxygen level they should be checking the concentrator as well to make sure the resident is getting their prescribed amount of oxygen. It was noted, the DON was not looking at the resident's medical records to verify information. During an interview on 9//21/2023 at 10:40 AM, Nursing Home Administrator (NHA) A stated, Staff noticed on rounds when the survey started that (R27) did not have her tubing dated so it was corrected at that time. It was noted the survey started on 9/19/2023. During an interview and record review on 9/21/2023 at 12:00 PM of R27's MAR/TAR September 2023 with DON B who stated, I looked back at (R27's) MAR/TAR for September (2023) and there was no order for her oxygen tubing to be changed. I do not know the last time it was changed or the date it was changed. When she came back from the hospital the order must have gotten missed. Further review of R27's MAR/TAR September 2023 reported that all nurses assigned to provide care and treatment for R27 had documented oxygen was set as prescribed rate of 2 LPM.

Based on interview and record review, the facility failed to prevent a significant medication error in 1 (Resident #307) of 4 residents reviewed for medication errors, resulting in Resident #307 receiving furosemide (a diuretic medication that treats fluid retention) at a greater dose than ordered. Findings include: Resident #307 Review of an Admission Record revealed Resident #307 was originally admitted to the facility on [DATE] with pertinent diagnoses which included acute chronic combined systolic and diastolic heart failure (a condition that develops when the heart cannot pump enough blood for the body's needs). During an observation and interview on 9/21/23 at 7:56 AM, Licensed Practical Nurse (LPN) Q reported that Resident #307 had two orders in place for furosemide (lasix) and the orders did not make sense to her, so she was going to investigate the orders before administering the medication to Resident #307. LPN Q reported that the first lasix order was 40 mg to be administered between 6 AM to 10 AM. The second order was lasix 40 mg to be administered twice a day, once between 6 AM to 10 AM, and once between 12:00 PM to 2:00 PM. Review of Resident #307's Medication Administration Record (MAR) revealed, lasix; 40 mg; Amount to administer: 1 tablet; Twice a day. Start date 9/19/23. End date 9/23/23. Resident #307's MAR indicated the medication order was documented as administered on the following dates: 9/19/23 between 6:00 PM-10:00 PM and 9/20/23 between 6:00 AM-10:00 AM. On 9/20/23 the order was documented as not given between 12:00 PM-2:00 PM. Review of Resident #307's Medication Administration Record (MAR) revealed, furosemide (lasix);40 mg; amount to administer 1 tablet, Once a day. Start date 9/19/23. End date 10/13/2023. Resident #307's MAR indicated that the medication order was documented as administered on 9/20/23 between 6:00 AM and 10:00 AM. Review of Resident #307's Hospital Discharge Summary which was printed on 9/19/23, revealed Discharge Medication list: furosemide 40 mg tablet. Take 1 tablet by mouth 2 times daily for 5 days, then 1 tablet daily for 25 days . During a subsequent interview on 9/21/23 at 10:16 AM, LPN Q reported that she had reviewed Resident #307's orders from the hospital, and discovered that the facility had entered the lasix order incorrectly, which resulted in Resident #307 receiving the incorrect dose of lasix on 9/20/23. LPN Q reported that Resident #307's orders were supposed to begin with lasix 40 mg twice a day for five days, and then decrease to lasix 40 mg daily on 9/24/23. LPN Q reported that Registered Nurse T had administered two doses of lasix on 9/20/23 between 6:00-10:00 AM. LPN Q reported that she notified MDS Registered Nurse (MDS-RN) CC of the error. During an interview on 9/21/23 at 11:27 AM, MDS-RN CC reported that she had been notified by LPN Q that a medication error had occurred. MDS-RN CC reported that she had reviewed the admission orders and discovered that the orders should have not been ordered to start on the same date. MDS-RN CC reported that Resident #307 should have received 40 mg of lasix twice daily for five days, and then the order should have been discontinued. MDS-RN CC reported that the second order for lasix 40 mg daily should have been ordered to begin on 9/24/23. MDS-RN CC reported that two nurses were suppose to verify the orders and initial the hospital discharge summary to verify that two nurses reviewed the orders. MDS-RN CC reported that nurses were not always initialing the hospital discharge summaries, so she was unable to identify if there was a second nurse that had reviewed Resident #307's medication orders. During an interview on 9/21/23 at 10:54 AM, LPN GG reported that she had entered Resident #307's admission medication orders. LPN GG reported that she had reviewed Resident #307's Hospital Discharge Summary with Nurse Practitioner (NP) K, and that NP K had approved the orders. LPN GG reported that there should have only been one order for lasix, which was supposed to be 40 mg twice daily for five days. LPN GG reported that after five days, the order was suppose to end, and the second order of lasix 40 mg daily would begin. LPN GG reported that she entered the orders incorrectly, and must have entered the start dates wrong so that both orders had started on the same day. LPN GG reported that a second nurse should have verified the orders after they were entered. LPN GG could not recall who the second nurse was that had verified Resident #307's orders. During an interview on 9/21/23 at 10:26 AM, RN T reported that she had administered two doses of lasix ,which was a total of 80 mg, to Resident #307 on 9/20/23 during the morning medication pass. RN T reported that she thought that 80 mg of lasix was a high dose, but she did not question it. RN T reported that she would usually question if an order was a duplicate if the order contained the same dose of medication to be given at the same time, but she did not question this order. During an interview on 9/21/23 at 10:44 AM, LPN R reported that she had documented the lasix on 9/20/23 order between 12:00 PM-2:00 PM as not administered because the order was originally ordered to be given between 6:00 PM-10:00 PM, and the facility did not give lasix after 2:00 PM. LPN R reported that she changed the order for the medication to be administered between 12:00 PM-2:00 PM, and then skipped the dose. LPN R reported that she did not contact the provider on call to request permission to change the order time, or to inform that she was not administering the medication as ordered. LPN R reported that she should have contacted to provider to inform that she had skipped Resident #307's lasix dose. LPN R reported that she did not notice that Resident #307 had two orders for lasix, but that if she had noticed, she would have questioned the order. During an interview on 9/21/23 at 12:15 PM, Nurse Practitioner (NP) K reported that she had approved Resident #307's admission orders. NP K reported that she had reviewed Resident #307's hospital discharge summary, and had marked a check mark next to lasix order to indicate that she wanted this order to be ordered as the hospital discharge summary noted, which was lasix 40 mg twice daily for five daily, then decreased to 40 mg daily. NP K reported that she did not review the orders in the electronic health chart (EHR). NP K reported that the lasix orders entered by LPN GG did not reflect what she had ordered. During an interview on 9/21/23 at 11:50 AM, Pharmacist L reported that the pharmacist that verified Resident #307's admission orders was on vacation. Pharmacist L reported that he would question the two separate lasix orders, especially since Resident #307 was newly admitted to the facility. Pharmacist L reported that he did not see any notes indicating the the pharmacist that verified Resident #307's orders had questioned the orders.

Based on observation, interview and record review, the facility failed to provide care to prevent the development and/or worsening of pressure ulcers, consistent with professional standards of practice in 2 of 3 residents (Resident #46 and #50) reviewed for pressure injuries, resulting in the development of a pressure ulcer for Resident #46, and the potential for infection and overall deterioration in health status for all residents at risk for deterioration in skin integrity. Findings include: Resident #46 Review of a Face Sheet revealed Resident #46 was originally admitted to the facility with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #46, with a reference date of 6/20/22 revealed a Brief Interview for Mental Status (BIMS) score of 1, out of a total possible score of 15, which indicated Resident #46 was cognitively impaired. Review of the Functional Status revealed that Resident #46 required extensive assistance of 2 people for bed mobility (how resident moves to and from lying positions, turns side to side, and positions body while in bed or other alternate sleep furniture) and was completely dependant on staff for transfers. Review of Resident #46's Care Plan revealed, Skin Integrity: At risk for skin breakdown R/T (related to): decreased mobility and incontinence .Problem start date 12/20/2018. Approach (intervention): Blue Boots to Bilateral feet/heels while in bed, Encourage to float heels, Approach Start Date 5/4/2021 .Avoid shearing skin during positioning, turning, and transferring, Conduct weekly skin assessment. Pay particular attention to bony prominences, Encourage and assist to turn and reposition for comfort and as needed, Keep linens clean and dry, Keep resident as clean and dry as possible, Minimize skin exposure to moisture, Pressure reducing cushion to chair, Pressure reducing mattress to bed, Use lifting device as needed for bed mobility (e.g. lift sheet, etc.), Use moisture barrier product to perineal area as needed, Approach Start Date 12/20/2018 Review of Resident #46's current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Start date 12/22/21, Blue Boots to Bilateral feet/heels while in bed. Special Instructions: Blue Boots to bilateral feet/heels while in bed. Preventative cares .Start date 12/13/20 Review of Resident #46's Braden Scale for Predicting Pressure Sore Risk dated 3/24/22 indicated that Resident #46 was at moderate risk. During an observation on 7/12/22 at 8:46 A.M. Resident #46 was sitting in her broda chair (specialty wheelchair to assist with positioning), in her room, slightly leaning to her right with a blanket over her legs. During an observation on 7/12/22 at 10:05 A.M. Resident #46 was sitting in her broda chair, in her room. During an observation on 7/12/22 at 11:20 A.M. Resident #46 was sitting in her broda chair in her room. During an observation on 7/12/22 at 11:46 A.M. Resident #46 was sitting in her broda chair in the dining room. Resident #46 had been observed in the same position and without incontinence care for approximately 3 hours. During an observation on 7/12/22 at 1:00 P.M. Resident #46 was sitting in her broda chair in the dining room. During an observation on 7/12/22 at 1:50 P.M. Resident #46 was sitting in her broda chair in the activities room, and leaning more to her right side than previously observed. Resident #46 had been observed in the same position and without incontinence care for approximately 5 hours. During an interview on 7/12/22 at 1:50 P.M., Certified Resident Care Assistant (CRCA) U reported that Resident #46 is always the first resident up in the morning, then she gets put in bed for incontinence care just before lunch, then right back up in her chair, until second shift lays her down after supper. CRCA U reported that the start of first shift is 6:00 A.M. CRCA U provided this surveyor with clarification and reported yes that Resident #46 stays in her chair for all of first shift, except for incontinence care just before lunch and stated, .her bottom looks good .no wounds . CRCA U reported that Resident #46 is a 2 person assist for cares. CRCA U reported that he did not provide incontinence care to Resident #46 before lunch today and stated, .I hope that (Resident Care Aide (RCA K) did . During an interview on 7/12/22 at 1:59 P.M. RCA K reported that she did not provide cares to Resident #46 today and reported that CRCA U had the resident today. During an observation and interview on 7/12/22 at 2:55 P.M., Resident #46 was still sitting in her broda chair in the activity room, and was noted slumped over to her right side. Resident #46 gave no verbal response to this surveyor. Based on the interview above with CRCA U, Resident #46 had been in the same position and without incontinence care for 8-9 hours. During an interview on 7/12/22 at 2:56 P.M., Licensed Practical Nurse (LPN) W reported that she would find someone to provide cares for Resident #46. During an observation and interview on 7/12/22 at 3:09 P.M. CRCA C and CRCA F (second shift staff) entered Resident #46's room to transfer her into bed and provide incontinence care. During the transfer it was observed that Resident #46's broda chair had no added cushion or padding on the seat for comfort or pressure relief as noted in care plan. During incontinence care Resident #46's pants were observed wet with urine and her incontinence brief was heavily saturated with urine. Resident #46's buttocks and mid-back were observed red with deep [NAME] from pressure. Resident #46's left coccyx was observed with a dark red wound approximately 3 cm in diameter with a small open area covered in slough (whitish yellow dead tissue), and 3 dark purple papules within the wound. When the CRCA's cleaned the skin near the wound, Resident #46 winced in pain and jerked her body away from the touch. CRCA C applied skin barrier cream to the wound, a clean brief and then transferred Resident #46 back into her broda chair. CRCA C reported that she would notify the nurse of Resident #46's new wound. Review of Resident #46's Weekly Skin Observation Record from 6/14/22-7/14/22 indicated no new skin impairments. Review of Resident #46's Wound Management Record indicated no wounds as of 7/12/22 at 3:45 P.M. During an interview on 7/12/22 at 3:47 P.M., Resident #46's Power of Attorney (POA) BB reported that it is difficult to get information from facility staff and stated, .like when the last time someone has checked on (Resident #46) .to reposition .give her water .we don't know if she is getting assistance . POA BB reported that she has not received any notification about any wounds on Resident #46's buttocks. Review of Resident #46's Progress Note dated 7/12/22 at 5:18 P.M. revealed, CRCA notified this nurse of skin change on resident. Skin assessed and noted 1 x 2 cm open area to right (sic) sacrum with slough. Peri (surrounding) would intact with surrounding blanchable redness. Provider, hospice, and family notified. Provider order [MEDICATION(S)] (Dermaseptin: topical moisture barrier) to wound with [MEDICATION(S)] (padded bandage) dressing daily. Hospice will come to evaluate and order air mattress. Treatment completed and tolerated well by resident. Resident currently resting in bed. Discussed risk vs benefits with family from keeping resident up in chair for a long periods of time. Family is okay with resident lying down after breakfast and dinner. Family does like to visit around 2pm-7pm and prefers resident to be up in chair during this time. Review of Resident #46's Wound Management Detail Report dated 7/14/22 at 7:40 A.M. revealed, .Wound Type: Unstageable, Location: sacrum, Present on admission/readmission: No, Date identified: 7/12/22 at 4:15 P.M . Review of Resident #46's newly developed Pressure Ulcer Care Plan revealed, Resident has a pressure ulcer to sacrum. Problem Start Date: 07/12/2022. Approach: Administer analgesics per MD order .Assess and record the condition of the skin surrounding the pressure ulcer .Encourage fluids unless contraindicated .Observe and report signs of infection (e.g., localized pain, redness, swelling, tenderness, drainage, odor, and fever) .Observe for and report signs of pain r/t (related to) pressure ulcer .Obtain a dietary consult .Pressure reducing cushion to chair .Pressure reducing mattress .Provide diet, supplements, vitamins and minerals as ordered .Treatment per MD order. Notify MD if treatment is not effective .Weekly skin assessment, measurement, and observation of the pressure ulcer and record. Approach Start Date: 07/12/2022. During an observation on 7/13/22 at 8:00 A.M. Resident #46 was sitting in her broda chair in her room. During an observation and interview on 7/13/22 at 10:43 A.M. Resident #46 was still sitting in her broda chair in her room. Registered Nurse (RN) P offered Resident #46 a drink of ensure and the resident drank the entire container. RN P reported that she was waiting for the aide to transfer Resident #46 into bed, so that she could look at the wounds on Resident #46's buttocks and back and stated, .(Resident #46) has been up in her chair since before 7:00 A.M . During an observation on 7/13/22 at 11:20 A.M., Resident #46 was still sitting in her broda chair in her room. During an observation and interview on 7/13/22 at 12:05 P.M., Medication Technician (MT) X, Assistant Director of Health Services (ADHS) S and Hospice Nurse (HN) Z transferred Resident #46 into bed. Resident #46 had been sitting in her broda chair for more than 5 hours. Resident #46's left coccyx and mid back were observed both with wound bandages covering the areas. ADHS S reported that there was some redness on her back and that the bandage was just there to protect the area from worsening. HN Z removed the bandage from Resident #46's coccyx and reported that it was a Stage 3 pressure ulcer. ADHS S cleansed the wound, applied Santyl (topical used to remove dead tissue from wounds), and a new dressing. During an interview on 7/13/22 at 12:05 P.M., HN Z reported that she has been visiting Resident #46 regularly for the last year and Resident #46 did not have a wound on her coccyx prior to today. During an observation on 7/13/22 at 1:46 P.M. Resident #46 was sitting in her broda chair in her room. It was noted that an air mattress was being set up in the room. During an interview on 7/13/22 at 2:50 P.M., Director of Health Services (DHS) B reported that it is an expectation of RCRA's and a standard of care, to provide incontinence care and repositioning for dependent residents at least every 2 hours. DHS B reported that Resident #46's family preferred that the resident was up and about for meals and activities, but that regular incontinence care and repositioning for pressure relief should still provided. During an observation on 7/14/22 at 8:26 A.M. Resident #46 was lying flat on her back in her bed with a pillow under her right arm. There were no other pillows observed for positioning and she was not wearing her blue boots (protection against pressure). The blue boots were observed next to the bed on the dresser. During an observation on 7/14/22 at 9:02 A.M. Resident #46 was lying flat on her back in her bed with a pillow under her right arm. There were no other pillows observed for positioning and she was not wearing her blue boots. During an observation on 7/14/22 at 10:08 A.M. Resident #46 was lying flat on her back in her bed with a pillow under her right arm. There were no other pillows observed for positioning and she was not wearing her blue boots. During an observation on 7/14/22 at 11:09 A.M. Resident #46 was lying flat on her back in her bed with a pillow under her right arm. There were no other pillows observed for positioning and she was not wearing her blue boots. During an observation on 7/14/22 at 11:30 A.M. Resident #46 was lying flat on her back in her bed with a pillow under her right arm. There were no other pillows observed for positioning and she was not wearing her blue boots. The blue boots were observed next to the bed on the dresser. During an observation and interview on 7/14/22 at 12:00 P.M. Director of Health Services (DHS) B, Regional Consultant (RC) CC, CRCA V and CRCA J were all present in Resident #46's room and preparing to transfer the resident into her broda chair. DHS B reported that incontinence care had been provided prior to this surveyor entering the residents room. CRCA J was changing Resident #46's socks; Resident #46's feet were observed with red round pressure areas visible on both heels. Resident #46 was heard reporting to DHS B that her feet were sore. CRCA V reported that Resident #46's blue protective boots were removed with morning cares at the beginning of the shift. There was no protective cushion observed in Resident #46's broda chair. Resident #46's care plan indicated blue boots to be on while in bed. Resident #50 Review of a Face Sheet revealed Resident #50 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #50, with a reference date of 6/21/22 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated Resident #50 was cognitively impaired. Review of the Functional Status revealed that Resident #50 required extensive assistance of 2 people for bed mobility. Review of Resident #50's Care Plan revealed, Resident admitted to facility with pressure ulcer to left buttock. Problem Start Date: 6/20/2022. Approach (Intervention): Administer analgesics per MD order, Assess and record the condition of the skin surrounding the pressure ulcer, Encourage fluids unless contraindicated, Observe and report signs of infection (e.g., localized pain, redness, swelling, tenderness, drainage, odor, and fever), Observe for and report signs of pain r/t pressure ulcer, Obtain a dietary consult as needed, Pressure reducing cushion to chair, Pressure reducing mattress, Provide diet, supplements, vitamins and minerals as ordered, Treatment per MD order. Notify MD if treatment is not effective, Weekly skin assessment, measurement, and observation of the pressure ulcer and record. Approach Start Date: 6/20/2022. Review of Resident #50's Care Plan revealed, Resident admitted to facility with a pressure ulcer to right buttock. Problem Start Date: 7/12/2022. The approaches were exactly the same as the previous care plan for the pressure ulcer on the left buttock. The approach start date was 7/12/22. Review of Resident #50's Care Plan revealed, Resident admitted to facility with pressure ulcer to sacrum. Problem Start Date: 7/12/2022. The approaches were exactly the same as for the previous care plans. The approach start date was 7/12/22. Review of Resident #50's Care Plan revealed, Resident experiences episodes of incontinence R/T (related to)diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Problem Start Date: 11/19/2021. Approach: Encourage Fluids unless contraindicated, Observe for signs and symptoms of [CONDITION(S)] and notify MD as needed, Observe skin and report any signs of breakdown as needed, Offer and assist with toileting as needed and/or per request, Provide incontinence care as needed, Provide incontinence products as needed. Approach Start date 11/19/21. Review of Resident #50's Care Plan revealed, Category: Skin Integrity At risk for skin breakdown R/T limited mobility, incontinence, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Problem Start Date: 11/19/2021. Approach: Avoid shearing skin during positioning, turning, and transferring, Conduct weekly skin assessment, Pay particular attention to bony prominences, Encourage and assist to turn and reposition for comfort and as needed, Float heels as needed, Keep linens clean and dry, Keep resident as clean and dry as possible, Minimize skin exposure to moisture, Pressure reducing cushion to chair, Pressure reducing mattress to bed, Use lifting device as needed for bed mobility (e.g. lift sheet, etc.), Use moisture barrier product to perineal area as needed. Approach Start Date 11/19/21 Review of Resident #50's Braden Scale for Predicting Pressure Sore Risk dated 6/19/22 indicated that Resident #50 was at high risk. During an observation and interview on 7/13/22 at 10:53 A.M., Resident #50 was lying on his back in his bed, there were no pillows observed for positioning or off loading of his coccyx wound. Resident #50 reported that he had sores on his bottom and stated, .no they don't take care of them .there's pain .I think I am wet I need some kind of medication for the pain .I have no problem laying on my side, I just need some help . During an observation and interview on 7/13/22 at 11:01 A.M. Physical Therapy Assistant (PTA) AA entered Resident #50's room to get the resident up for therapy. PTA AA checked Resident #50's brief and reported that Resident #50 was not wet, therefore PTA AA would proceed with therapy. PTA AA assisted Resident #50 to sit on the edge of the bed; Resident #50's back was observed red and covered with wrinkled skin from pressure. When Resident #50 was transferred into the wheelchair, his brief was observed soiled with urine and a light red spot that had soaked through on the back of the brief. At 11:10 A.M. RC CC assisted PTA AA to removed Resident #50's brief; there was BM (feces) in the brief and on Resident #50's buttocks. RC CC reported that the light red spot in the brief was from the resident's pink barrier cream soaking through the brief. RC CC reported that she would find CRCA U to further assist and provide incontinence care to Resident #50. During an observation and interview on 7/13/22 at 11:32 A.M. Resident #50 was in his bathroom and CRCA U was cleaning his bottom, and PTA AA was assisting. Resident #50's pressure wound on the coccyx was not covered with a dressing. At 11:44 A.M. Resident #50 was transferred into bed to finish incontinence care, due to him becoming too weak to stand. CRCA U reported that Resident #50 was supposed to have a new cream for his bottom, but that it had not came in yet. DHS B was in the room and reported that she would go check to see if the cream had arrived, so that they could use in after incontinence care. During an interview on 7/13/22 at 11:53 A.M. CRCA U reported that Resident #50 had slept through his morning incontinence cares earlier in the day, and that Resident #50's wound was very red and stated, .it was not open .but maybe going to open soon . CRCA U reported that he had applied the blue colored EPC (extra protective cream) to Resident #50's coccyx that morning, but that the cream was being changed to something different today. CRCA U then reported that he did not actually provide care to Resident #50 himself, but that the other CRCA I did Resident #50's care that morning. During a subsequent observation on 7/13/22 at 11:58 A.M. in Resident #50's room, DHS B provided a new tube of Dermaseptin ointment (pink skin barrier) to CRCA U. Resident #50's pressure wound on the coccyx was observed covering the entire surface of the coccyx, dark red, denuded (top layer of skin gone), with multiple areas of superficial bleeding. CRCA U applied the Dermaseptin (pink in color) to the entire area. During an interview on 7/13/22 at 12:38 P.M., CRCA I reported that she completed Resident #50's morning cares and stated, he was very awake and responsive through it all .his bottom looked a little red on the top .no open wounds . CRCA I reported that she applied the blue EPC cream to Resident #50's buttocks just before 7:00 A.M. this morning and stated, .I didn't know about a pink cream . It was noted that Resident #50's last incontinence care was more than 5 hours prior. During an observation on 7/14/22 at 8:26 A.M. Resident #50 was lying in bed on his back with his eyes closed and the HOB (head of bed) at approximately 20 degrees. There was a pillow observed slightly positioned under Resident #50's left buttock. There was a blue foot cushion observed sitting at the bottom of the bed and not being used. During an observation on 7/14/22 at 9:11 A.M. Resident #50 was lying in bed on his back with his eyes closed and the HOB at approximately 20 degrees. There was a pillow observed slightly positioned under Resident #50's left buttock. There was a blue foot cushion observed sitting at the bottom of the bed and not being used. During an observation and interview on 7/14/22 at 9:20 A.M. CRCA V came out of Resident #50's room with his breakfast tray and reported that Resident #50 ate a banana, watermelon and drank his water. During an observation at 7/14/22 at 9:25 A.M. Resident #50 was observed in bed with HOB at 90 degrees and his feet pressed firmly again the foot board at the end of the bed. During an observation and interview at 7/14/22 at 9:31 A.M. Resident #50 was observed in the same position in his bed. Resident #50 reported that he was uncomfortable and could not lift his arms to push his call light. During an observation on 7/14/22 at 9:54 A.M., Resident #50 was in the same position in his bed. During an observation and interview on 7/14/22 at 10:08 A.M., Licensed Practical Nurse (LPN) Y and CRCA V entered Resident #50's room to check his brief and reposition him in bed. CRCA V was observed to feel and look at the outside of the incontinence brief and stated, .he is dry . Resident #50's incontinence brief was then removed at this surveyors request, and revealed 2 additional thick disposable incontinence pads placed inside of the incontinence brief. CRCA V reported that she and CRCA J had provided incontinence care earlier in the day and placed the pads inside of the brief. Resident #50's pressure ulcer on his coccyx was observed covered in pink barrier cream, but still with visible dark red fragile intact skin over the coccyx and surrounding tissue. LPN Y reported that she needed to talk with DHS B regarding Resident #50's wound and the use of double pads inside of the brief and stated, .that is not O.K . Review of Resident #50's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M. revealed, .[CONDITION(S)] (urinary tract infection) Was recently diagnosed in hospital, Continue on [MEDICATION(S)] (antibiotic) until 7/12 .Buttocks Wound .Continue q2h turns, daily monitoring .Ointment to be placed to sores .Patient is seen today for follow up evaluation. He is resting in bed and appears in no acute distress. He reports that he is having some pain in his buttocks. Per nursing, he has areas of pressure and was seen at the wound clinic. Per nursing, family no longer wants him to go to wound clinic and would like this to be managed here .

Based on observation, interview, and record review the facility failed to ensure food items were discarded after the use by date and ensure kitchen equipment was maintained in a sanitary manner with the potential to affect those consuming food or fluids from the kitchen out of the facility census of 53 resulting in the potential for food-borne illness or physical contamination of food. Findings include: Food Dating: During an observation and interview on [DATE] 07:22 AM, in the walk-in refrigerator in the kitchen a container labeled cranberry sauce had an opened on/prepared date of [DATE] and discard date of [DATE]. Director of Nutrition Services D confirmed the cranberry sauce was last used on Thursday ([DATE]). During an observation on [DATE] at 07:25 AM, a container of beef base, with a lid that didn't cover the opening completely, had a label that indicated it was opened on [DATE] and was to be used by [DATE]. During an observation on [DATE] at 07:33 AM, in the kitchen in the bottom shelf of the sandwich station's cooler there was a container of food labeled Brunch prep, which appeared to have roasted red pepper in it, with prepared date [DATE] and use by date of [DATE]. During an observation on [DATE] at 07:46 AM, the refrigerator in the kitchenette just outside the kitchen had an unopened [Carbohydrate controlled name brand of oral nutritional supplement] with a use by date of [DATE] and on the label it stated USE BY DATE ON TOP OF CARTON. There was an unopened blueberry Greek yogurt on the top shelf with a use by date of [DATE]. During an interview on [DATE] at 11:41 AM, Director of Nutrition Services D confirmed both the nutrition supplement and the Greek yogurt from the kitchenette were expired. Unsanitary Equipment: During an observation and interview on [DATE] at 07:25 AM, in the kitchen the microwave near the ice cream freezer was visibly soiled with red and white debris on all interior walls including the top that could fall into food. Director of Nutrition Services D confirmed the microwave wasn't used to make anything for breakfast that morning and stated, They should have cleaned it last night before they left. During an observation on [DATE] at 07:31 AM, in the kitchen the microwave on the preparation table across from the grill/stove area was visibly soiled with white and red debris on all surfaces included the inside top above the food cooking area. During an observation on [DATE] at 11:04 AM, in the kitchen the microwave near the ice cream freezer had the upper inner surface area visibly soiled with white and red debris. The area was wiped with a clean paper towel and debris came off onto the paper towel. During an interview on [DATE] at 11:07 AM, in the kitchen the microwave near the preparation table across from the grill/stove area was visibly soiled with unknown food debris varying in color including white, gray, and red. During an observation on [DATE] at 07:27 AM, the food processor's lid's inside (which comes in contact with food) next to the microwave on the food preparation table was soiled with white build up. During an observation and interview on [DATE] at 07:28 AM, the blender next to the food processor on the food preparation table in the kitchen had some, unknown number of milliliters, standing water in the bottom of the blender container. The blades were still visibly wet and was set out ready for use. Director of Nutrition Services D confirmed food preparation items are to be air dried in the kitchen. During an observation on [DATE] at 07:40 AM, an ice cream scoop next to the label CLEAN SCOOP above the ice cream freezer had standing water, unknown number of milliliters, in the scoop. During an observation on [DATE] at 07:43 AM, in the black built-up silverware bin on the bottom shelf of the food preparation table four utensils were still visibly wet. During an observation on [DATE] at 11:12 AM, in the black built-up silverware bin on the bottom shelf of the food preparation table there was standing water, unknown number of milliliters, in direct contact with utensils. Review of the 2013 Food and Drug Administration's Food Code stated, ,d+[DATE].11 Equipment Food-Contact Surfaces and Utensils. (5) At any time during the operation when contamination may have occurred. Review of the 2013 Food and Drug Administration's Food Code stated, ,d+[DATE].13 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the 2013 Food and Drug Administration's Food Code stated, ,d+[DATE].11 Equipment, Utensils, Linens, and Single Service and Single-Use Articles .(B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: .In a self-draining position that allows air drying . Review of the 2013 Food and Drug Administration's Food Code stated, ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking .(A) . refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded .for a maximum of 7 days. The day of preparation shall be counted as Day 1 .(B) .refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded .and: . (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.

Based on observation, interview, and record review, the facility failed to maintain professional standards, provide adequate incontinence care, and proper infection control practices during incontinence care in 3 of 3 residents (Resident #46, #50 and #42) reviewed for bowel and bladder incontinence, resulting in an increased risk for [CONDITION(S)] (urinary tract infection) and [CONDITION(S)] (life threatening condition caused by an infection), and the potential for skin breakdown. Findings include: Resident #46 Review of a Face Sheet revealed Resident #46 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #46's Care Plan revealed, Skin Integrity: At risk for skin breakdown R/T (related to): decreased mobility and incontinence .Problem start date 12/20/2018. Approach (intervention): .Encourage and assist to turn and reposition for comfort and as needed, Keep linens clean and dry, Keep resident as clean and dry as possible, Minimize skin exposure to moisture .Use moisture barrier product to perineal area as needed, Approach Start Date 12/20/2018 During an observation on 7/12/22 at 8:46 A.M. Resident #46 was sitting in her broda chair (specialty wheelchair to assist with positioning), in her room, slightly leaning to her right with a blanket over her legs. During an observation on 7/12/22 at 10:05 A.M. Resident #46 was sitting in her broda chair, in her room. During an observation on 7/12/22 at 11:20 A.M. Resident #46 was sitting in her broda chair in her room. During an observation on 7/12/22 at 11:46 A.M. Resident #46 was sitting in her broda chair in the dining room. Resident #46 had been observed in the same position and without incontinence care for approximately 3 hours. During an observation on 7/12/22 at 1:00 P.M. Resident #46 was sitting in her broda chair in the dining room. During an observation on 7/12/22 at 1:50 P.M. Resident #46 was sitting in her broda chair in the activities room. Resident #46 had been observed in the same position and without incontinence care for approximately 5 hours. During an interview on 7/12/22 at 1:50 P.M., Certified Resident Care Assistant (CRCA) U reported that Resident #46 is always the first resident up in the morning, then she gets put in bed for incontinence care just before lunch, then right back up in her chair, until second shift lays her down after supper. CRCA U reported that the start of first shift is 6:00 A.M. CRCA U provided this surveyor with clarification and reported yes that Resident #46 stays in her chair for all of first shift, except for incontinence care just before lunch and stated, .her bottom looks good .no wounds . CRCA U reported that Resident #46 is a 2 person assist for cares. CRCA U reported that he did not provide incontinence care to Resident #46 before lunch today and stated, .I hope that (Resident Care Aide (RCA K) did . During an interview on 7/12/22 at 1:59 P.M. RCA K reported that she did not provide cares to Resident #46 today and reported that CRCA U had the resident today. During an observation and interview on 7/12/22 at 2:55 P.M., Resident #46 was still sitting in her broda chair in the activity room, and was noted slumped over to her right side. Resident #46 gave no verbal response to this surveyor. Based on the interview above with CRCA U, Resident #46 had been in the same position and without incontinence care for 8-9 hours. During an interview on 7/12/22 at 2:56 P.M., Licensed Practical Nurse (LPN) W reported that she would find someone to provide cares for Resident #46. During an observation and interview on 7/12/22 at 3:09 P.M. CRCA C and CRCA F (second shift staff) entered Resident #46's room to transfer her into bed and provide incontinence care. During the transfer it was observed that Resident #46's broda chair had no added cushion or padding on the seat for comfort or pressure relief as noted in care plan. During incontinence care Resident #46's pants were observed wet with urine and her incontinence brief was heavily saturated with urine. During an interview on 7/12/22 at 3:47 P.M., Resident #46's Power of Attorney (POA) BB reported that it is difficult to get information from facility staff and stated, .like when the last time someone has checked on (Resident #46) .to reposition .give her water .we don't know if she is getting assistance . During an observation on 7/13/22 at 8:00 A.M. Resident #46 is sitting in her broda chair in her room. During an observation and interview on 7/13/22 at 10:43 A.M. Resident #46 was still sitting in her broda chair in her room. Registered Nurse (RN) P offered Resident #46 a drink of ensure and the resident drank the entire container. RN P reported that she was waiting for the aide to transfer Resident #46 into bed, so that she could look at the wounds on Resident #46's buttocks and back and stated, .(Resident #46) has been up in her chair since before 7:00 A.M . During an observation on 7/13/22 at 11:20 A.M., Resident #46 was still sitting in her broda chair in her room. During an observation and interview on 7/13/22 at 12:05 P.M., Medication Technician (MT) X, Assistant Director of Health Services (ADHS) S and Hospice Nurse (HN) Z transferred Resident #46 into bed to provide incontinence and wound care. Resident #46 had been without incontinence care for more than 5 hours. During an interview on 7/13/22 at 2:50 P.M., Director of Health Services (DHS) B reported that it is an expectation of CRCA's and a standard of care, to provide incontinence care and repositioning for dependent residents at least every 2 hours. DHS B reported that Resident #46's family preferred that the resident was up and about for meals and activities, but that regular incontinence care and repositioning for pressure relief should still provided. Resident #50 Review of a Face Sheet revealed Resident #50 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #50's Care Plan revealed, Resident experiences episodes of incontinence R/T (related to)diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Problem Start Date: 11/19/2021. Approach: Encourage Fluids unless contraindicated, Observe for signs and symptoms of [CONDITION(S)] and notify MD as needed, Observe skin and report any signs of breakdown as needed, Offer and assist with toileting as needed and/or per request, Provide incontinence care as needed, Provide incontinence products as needed. Approach Start date 11/19/21. Review of Resident #50's Care Plan revealed, Category: Skin Integrity At risk for skin breakdown R/T limited mobility, incontinence, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Problem Start Date: 11/19/2021. Approach: .Keep linens clean and dry, Keep resident as clean and dry as possible, Minimize skin exposure to moisture Use moisture barrier product to perineal area as needed. Approach Start Date 11/19/21 During an observation and interview on 7/13/22 at 10:53 A.M., Resident #50 was lying on his back in his bed. Resident #50 reported that he had sores on his bottom and stated, .no they don't take care of them .there's pain .I think I am wet I need some kind of medication for the pain .I have no problem laying on my side, I just need some help . During an observation and interview on 7/13/22 at 11:01 A.M. Physical Therapy Assistant (PTA) AA entered Resident #50's room to get the resident up for therapy. PTA AA checked Resident #50's brief and reported that Resident #50 was not wet, therefore PTA AA would proceed with therapy. PTA AA assisted Resident #50 to sit on the edge of the bed; Resident #50's back was observed red and covered with wrinkled skin from pressure. When Resident #50 was transferred into the wheelchair, his brief was observed soiled with urine and a light red spot that had soaked through on the back of the brief. At 11:10 A.M. RC CC assisted PTA AA to removed Resident #50's brief; there was BM (feces) in the brief and on Resident #50's buttocks. RC CC reported that the light red spot in the brief was from the resident's pink barrier cream soaking through the brief. RC CC reported that she would find CRCA U to further assist and provide incontinence care to Resident #50. During an observation and interview on 7/13/22 at 11:32 A.M. Resident #50 was in his bathroom and CRCA U was cleaning his bottom. At 11:44 A.M. Resident #50 was transferred into bed to finish incontinence care, due to him becoming too weak to stand. During an interview on 7/13/22 at 11:53 A.M. CRCA U reported that Resident #50 had slept through his morning incontinence cares earlier in the day. CRCA U then reported that he did not actually provide care to Resident #50 himself, but that the other CRCA I did Resident #50's cares that morning. During an interview on 7/13/22 at 12:38 P.M., CRCA I reported that she completed Resident #50's morning cares just before 7:00 A.M. and stated, he was very awake and responsive through it all .his bottom looked a little red on the top .no open wounds . Resident #50 had been without incontinence care for more than 4 hours. During an observation and interview on 7/14/22 at 10:08 A.M., Licensed Practical Nurse (LPN) Y and CRCA V entered Resident #50's room to check his brief and reposition him in bed. CRCA V was observed to feel and look at the outside of the incontinence brief and stated, .he is dry . Resident #50's incontinence brief was then removed at this surveyors request, and revealed 2 additional thick disposable incontinence pads placed inside of the incontinence brief. CRCA V reported that she and CRCA J had provided incontinence care earlier in the day and placed the pads inside of Resident #50's brief. LPN Y reported that she needed to talk with DHS B regarding the use of double pads inside of the brief and stated, .that is not O.K . During an interview on 7/14/22 at 10:19 A.M., CRCA V reported that Resident #50 last had incontinence care about 8:00 A.M. CRCA V reported that staff frequently use the double pads inside of the incontinence brief and stated, .I don't think it is necessary . Review of Resident #50's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M. revealed, .[CONDITION(S)] Was recently diagnosed in hospital, Continue on [MEDICATION(S)] (antibiotic) until 7/12 . Resident #42 Review of a Face Sheet revealed Resident #42 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #42's Care Plan revealed, Resident has potential for [CONDITION(S)] related to history of urinary tract infection. Problem Start Date: 6/06/19. Approach: .If resident is incontinent, provide peri care as needed and cleanse from front to back, Keep perineal area clean and dry. Use a front to back wiping technique .Use principles of infection control and universal/standard precautions. Approach Start Date: 6/06/19 . Review of Resident #42's Care Plan revealed, Bowel and Bladder Resident experiences episodes of incontinence R/T decreased mobility and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Approach: .Offer and assist with toileting frequently with rounding and as needed. Check for and change incontinence episodes frequently with rounding and as needed, Provide incontinence care as needed .Approach Start Date: 8/11/17 . During an interview on 7/14/22 at 11:12 A.M., CRCA V reported that Resident #42 was completely incontinent of bowel and bladder. CRCA V reported that she herself provided Resident #42 incontinence care early this morning, before breakfast and that CRCA J had provided Resident #42 incontinence care at 11:00 A.M. During an interview on 7/14/22 at 11:13 A.M., CRCA J reported that she had not provided incontinence care to Resident #42 today. CRCA J and CRCA V did not have a clear understanding of Resident #42's last incontinence care. It had been greater than 2 hours since Resident #42 last had incontinence care. During an observation on 7/14/22 at 11:14 A.M. Resident #42 was lying in her bed and CRCA V and CRCA J were preparing to provide incontinence care. Both CRCA's donned gloves. CRCA J pulled down the front of Resident #42's incontinence brief and pushed it between Resident #42's legs. Resident #42's front groin area was bright red, with a whitish cheesy drainage observed in the creases and folds of skin. Resident #42's brief was heavily saturated with urine. CRCA V wash, rinsed, and dried Resident #42's front groin and vaginal area. Resident #42 was positioned on her left side; BM (feces) was noted on Resident #42's buttocks and brief. CRCA V washed, rinsed, and dried Resident #42's buttocks and rectal area. CRCA V did not remove her soiled gloves, then applied A & D ointment (skin protectant) and a clean brief to Resident #42. CRCA V had soiled gloves on this entire time, and did not remove them until she was exiting Resident #42's room. During an interview on 7/14/22 at 11:25 A.M., CRCA V reported that she should have removed her gloves when they became visibly soiled and stated, .after cleaning up the BM . CRCA V reported that she should not have applied the ointment with soiled gloves. CRCA V reported that she had removed her gloves after handling the soiled linen and will perform hand hygiene after bringing the soiled linen to the utility room. Review of Resident #42's Progress Note dated 6/30/22 at 2:45 P.M. revealed, .Resident arrived at approximately 2:45PM via Ambucab from (hospital name omitted). Resident was dx (diagnosed ) with [CONDITION(S)] secondary to [CONDITION(S)] and continues to receive abx (antibiotic) . Review of Resident #42's Progress Note dated 6/27/2022 at 9:39 A.M. revealed, .IDT (interdisciplinary team): resident admitted to hospital with dx of [CONDITION(S)].

Based on observation, interview, and record review the facility failed to ensure tube feeding was labeled appropriately and that the head of the bed was at the appropriate angle for 2 of 2 residents (Resident #34 and 28) reviewed for tube feeding, resulting in the potential for food-borne illness, receiving the incorrect formula amount or flow rate, or aspiration. Findings include: Resident #34: During an observation on 07/12/22 at 08:33 AM, Resident #34 was laying with the head of the bed elevated as the ready to hang tube feeding formula container was actively infusing into the resident. There were approximately 250 milliliters of formula remaining and the feeding pump was on. The ready to hang tube feeding formula container had no label or writing on the manufacturer's label. There was nothing to indicate the resident name, room, formula flow rate, date, or time the feeding was initiated/hung. The free water bag was hanging with approximately 375 milliliters remaining and there was no label to indicate when (date or time) this water was hung. During an observation on 07/13/22 at 08:16 AM, Resident #34 was laying with the head of the bed elevated as the ready to hang tube feeding formula container was actively infusing into the resident. There were approximately 350 milliliters of formula remaining and the feeding pump was on. The ready to hang tube feeding formula container had no label or writing on the manufacturer's label. There was nothing to indicate the resident name, room, formula flow rate, date, or time the feeding was initiated/hung. The areas on the manufacturer's label on the ready to hang tube feeding formula container were blank for resident name, room, date, start time, and rate (milliliters per hour). Review of Resident #34's physician order, dated 2/6/22, stated, Order Set TF (tube feeding)- Enteral Feeding: Formula: [Name Brand of Formula] Strength: 1.5 (calories per milliliter) Flow Rate: 60 mls (milliliters) x (for) 18hr (hour) Flush with 45ml H20 (water) q 1 hr (every hour) during TF run time, Special Instructions: ON at 1700 (5:00 PM), Off at 1100 (11:00 AM). Review of the tube feeding formula manufacturer's ready to hang instructions, dated 1/2015, stated, Fill in information on label (ie (that is), patient name, room, date, start time, and rate). Also mark feeding set with start date and time . IMPORTANT: Proper identification and dating are essential for patient safety. Use formula, container, and tubing for 24 hours, or up to 48 hours after initial connection, when clean technique and only one new feeding set are used. Review of Resident #34's nutrition care plan, dated 1/24/22, stated, Resident requires a feeding tube to meet their nutrition and hydration needs and to support overall metabolic demands. with an intervention of Administer tube feeding as ordered by physician. Resident #28 Review of an Admission Record revealed Resident #28 admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #28, with a reference date of 5/27/2022 revealed Resident #28 was severely cognitively impaired and unable to complete a Brief Interview for Mental Status (BIMS). In an observation on 7/13/22 at 8:23 A.M., observed Resident #28 in his bed in room [ROOM NUMBER] with feeding tube hooked up to feeding pump, not yet disconnected by nursing staff after his prescribed tube feeding had finished. Observed that Resident #28's head of bed was elevated to 23 degrees (verified by phone level application). In an observation and interview on 7/13/2022 at 8:39 A.M., Registered Nurse (RN) Assistant Director of Health Services (ADHS) S reported that she was not sure what facility policy required for head of bed elevation during tube feeding. Registered Nurse S reported that Resident #28's head of bed should be higher than the current level. Registered Nurse S immediately elevated Resident #28's head of bed. In an interview on 7/13/2022 at 8:41 A.M., Licensed Practical Nurse (LPN) Y reported that the bed should be elevated during tube feeding to at least 30 degrees. In an interview on 7/13/2022 at 8:41 A.M., Licensed Practical Nurse (LPN) Y reported that the only way she has to determine the head of bed degree of elevation is by looking. Review of facility policy/procedure Administering Gastric/Jejunostomy Tube Medications, reviewed 9/17/2018, revealed .assist the resident to semi or high-Fowler's position (30 to 45 degrees), if tolerated by the resident's physical or medical condition . have the resident maintain the semi or high-Fowler's position for at least 30 minutes, if tolerated by the resident's physical or medical condition .

Based on interview and record review, the facility failed to supervise, implement interventions to prevent, document, investigate and develop new interventions to prevent falls for one resident (Resident #2), out of 2 residents reviewed for falls, from a total sample of 10 residents, resulting in ongoing falls with the potential for serious injury. Findings include: According to a facility face sheet (not date noted) revealed Resident #2 was a [AGE] year old female admitted into the facility on [DATE] with the Diagnosis: [REDACTED]. Review of a facility Fall Risk Assessment for Resident #2 dated, 7/25/16 reflected Resident #2's fall risk score was 15 indicating that Resident #2 was High Risk for a fall. During an interview and record review with Director of Nursing (DON) B on 7/20/17 at 12:40 p.m., DON B revealed that Resident #2 had experienced 12 falls from 8/6/27 to 6/17/17. DON B had developed a timeline of Resident #2's falls and this was reviewed with her. Review of this timeline, incident/accident reports, progress notes and care plans with DON B reflected: 8/6/16 at 1:00 p.m., Resident #2 had an unwitnessed fall in her room. An alarm was sounding. Resident stated she was trying to transfer self from wheelchair to bed. Review of the incident accident report reveals that it was not completed. DON B confirms that this was not done. DON B confirms there is no documentation that family members were notified of this fall. Resident #2 was injured and had a head laceration (cut). The collection of detailed, patient/resident specific information can be valuable in terms of adjustments to the individual plan of care and decisions to provide assistive devices such as canes, walkers, shower chairs, etc. However, there is additional value in analyzing aggregated fall data. Detailed trending and analysis of all reported fall incidents may lead to improvements in the organization-wide fall prevention program and overall patient/resident safety. As part of the fall review process, evaluate whether standard fall-prevention interventions were in place at the time of the fall. These may include: bed locked in low position with rails up, call light, assistive devices and personal items within the patient's reach, nonskid patient footwear, clutter-free room and adequate lighting, patient and family education, and evidence of regular rounding. http://www.mcknights.com/marketplace/patient-falls--what-is-your-incident-reporting-process/article/ 9/ Review of a facility policy titled, Falls Management dated effective 5/31/17 reflected, Should the resident experience a fall the attending nurse shall complete the 'Fall Event'. this includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT (Interdisciplinary Team) to evaluate thoroughness of the investigation and appropriateness of the interventions. The attending physician or medical director in the absence of the attending physician and the responsible party should be notified. The resident care plan should be updated to reflect any new or change in interventions. Nursing staff will monitor and document continued resident response and effectiveness of the interventions for 72 hours. Discuss risks and interventions with resident and or responsible party . 9/26/16 at 12:21 a.m., Resident #2 again experienced an unwitnessed fall in her room. An alarm was sounding. Review of the incident accident report reveals that it was not completed. DON B confirms that this was not done. DON B confirmed there was no documentation that family members were notified of this fall. DON B also confirmed there was no new intervention to prevent another fall developed in regards to the root cause of the fall and added to the care plan. 10/13/16 at 12:36 p.m., Resident #2 was assisted to the toilet. DON B stated Resident #2 was left in the bathroom alone and when the staff had returned, Resident #2 had fallen. DON B confirmed there was no documentation in the nursing progress notes that the fall had occurred. DON B was asked if a resident was considered a fall risk, are they to be left alone in the bathroom. DON B stated if a resident is a fall risk, they should not be left alone in the bathroom. Safety measures had not been followed. 11/15/16 at 9:30 a.m., facility staff heard Resident #2 fall in her room. The intervention added to the care plan was to toilet Resident #2 every two hours. DON B confirmed that Certified Nurses Aids (CNA's) regularly toilet residents every two hours. The intervention implemented was not new to prevent a fall for Resident #2. Resident #2 fractured a cervical (neck) vertebrae. 11/18/16 at 4:30 a.m., Resident #2 experienced a fall. Resident #2 had put on her call light because she had spilled water in her bed. There is no mention of a bed alarm sounding in the incident accident report. No mention if the alarm was present or operational. 12/18/16 at 10:43 a.m., Resident #2 experienced an unwitnessed fall. Review of the medical record revealed there was no nursing progress note regarding the fall. The intervention to prevent any further falls was offer out of room activities, gym shoes. DON B stated that these interventions were not added to Resident #2's care plan to be implemented and that Resident #2's family had not been notified of the fall. 1/20/17 at 11:23 p.m., Resident #2 fell forward while ambulating and staff lowered her to the ground. DON B was asked if a gait belt was being used. DON B stated she did not know. DON B was asked what new intervention was devised and added to the care plan. DON B confirmed that no new interventions had been devised or added to the care plan to prevent a fall for Resident #2. 2/12/17 at 9::39 p.m., Resident #2 fell in the bathroom. DON B was asked if Resident #2 was supposed to be left alone in the bathroom. DON B stated, no. Review of the incident accident report reflected a family member had been in the room but no witness statement was noted in the investigation of the fall. The care plan for Resident #2 reflected no new interventions to prevent a fall and the progress notes and incident and accident did not reflect that Resident #2's family had been notified of Resident #2 fall. DON B was asked if Resident #2's family had been notified of the fall and DON B stated, There's no mention (of it in the progress notes or incident accident report). 2/16/17 at 12:35 p.m., Resident #2 was assisted to the bathroom by staff and fell and hit her head on a dresser. DON B was asked if a gait belt was used. DON B stated there was no mention. The facility intervention to prevent another fall was a physical therapy evaluation. No immediate intervention was devised and implemented to prevent a fall. DON B was asked if Resident #2's family was notified of the fall. DON B stated, No ma'am. DON B stated the IDT intervention added later to prevent a fall was use of a gait belt. Use of a gait belt is a standard of practice overtime a resident who is at risk for a fall ambulates. 4/9/17 at 9:40 p.m., Resident #2 fell in the bathroom. DON B was asked if Resident #2 was left alone in the bathroom and she replied, yes. The intervention to prevent a fall for Resident #2 was anti rollbacks brakes added to her wheelchair and educate staff not to leave alone in the bathroom. Not leaving a resident who at risk for a fall in the bathroom is an expectation of the facility and the anti rollback brakes were not added to Resident #2's care plan. 6/12/17 at 2:35 a.m., Resident #2 was worried about her room mate and got out of bed and fell . The facility devised the intervention to add a pressure alarm to Resident #2's bed and leave a dim light on. DON B confirmed that the intervention to leave a dim light on at night was not added to Resident #2's care plan. DON B was asked if Resident #2's family was notified of the fall. DON B stated, (It's) not documented.

This refers to MI 364 and MI 948. This citation has 2 Deficiency Practice Statements, A and B. Deficiency Practice Statement A Based on observation, interview, and record review, the facility failed to ensure the safety and prevent the elopement of 1 of 1 sampled residents reviewed for elopement (Resident #5), from a total of 5 sampled residents, resulting in an immediate jeopardy when Resident #5, who was a known elopement risk, left the building unbeknownst by facility staff on 4/2/17 between 4:30 p.m. and 4:45 p.m. and was returned to the facility by a visitor. This deficient practice placed 6 additional residents identified to be at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: According to the facility admission record, dated 4/6/17, Resident #5 was a [AGE] year old resident who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. According to Resident #5's Minimum Data Set (MDS) (a tool used to evaluate a resident's cognitive, emotional, and physical needs) dated 1/27/17, Resident #5 had a Brief Interview for Mental Status (BIMS) (a tool use to determine a resident's cognitive status) score of 3 which indicated Resident #5 was severely cognitively impaired. According to Resident #5's elopement risk assessment, dated 12/28/16, Resident #5 scored a 25 which indicated Resident #5 was a High Risk for Elopement. According to a physician's orders [REDACTED].#5 was to have WanderGuard bracelet (a device used to set off an alarm when resident who is an elopement risk tries to exit an alarmed door) to the right ankle. According to Resident #5's Treatment Administration Record (TAR), dated 4/2/17, Resident #5's WanderGuard bracelet on her right ankle was checked at 2:00 p.m. and functioning. According to the facility's Incident Note dated 4/2/17, (Resident #5) was observed by another resident's family member (Visitor C) in the facility parking lot. (Visitor C) recognized that (Resident #5) lived at the facility and immediately escorted her back into the building. Per (Visitor C), she was returning her mother to the facility at approximately 4:35pm from an outing when she observed (Resident #5) entering the facility lobby from the main facility hallway and sitting in a lobby chair. (Visitor C) proceeded to take her mother to her room and returned to the lobby area at approximately 4:45pm. (Visitor C) states that there were no alarms sounding at this time. She proceeded from the lobby out into the parking lot where she observed (Resident #5) standing with her arms folded across her chest. (Visitor C) states that the door alarms began to sound as she escorted (Resident #5) back into the facility, and a facility staff member (Certified Nurse Aide (CNA) F) immediately escorted (Resident #5) the rest of the way from the lobby double doors to the nurses station. (CNA F) immediately notified (Registered Nurse (RN) G) that (Resident #5) had exited the building. During an interview on 4/5/17 at 2:55 p.m., Maintenance (MT) E stated, On Saturday (4/1/17), I got a call between 5;00 p.m. and 6:00 p.m. They (facility staff) said they couldn't get the alarm off because they had a resident leave with family. I came and and saw they were trying to shut off the door alarm (Wanderguard) at the fire panel (where the separate exit door alarms, not Wanderguard alarms are reset). I told them (facility staff) that wasn't the right way to shut them off. I brought them out front and showed them how to shut it off. I checked it several times and it was working fine on Saturday (4/1/17). (Director of Nursing (DON) B) called me on Sunday (4/2/17) and said we had an elopement. I came in and checked the alarm and it was working fine. I think it was on her (Resident #5) ankle and it was out of frequency range. That's why it didn't go off when she went out. I test it (the Wanderguard system) every day. I hadn't noticed it not going off except if it (the Wanderguard bracelet) was 5 inches or less from the ground it wouldn't go off every time. But if it was higher, it would. During an interview on 4/5/17 at 5:45 p.m., Visitor C stated, I saw (Resident #5) in the lobby sitting in a chair looking outside. I asked her if she was looking for something. She said 'Sault Ste. Marie.' I was in and out bringing things from my car into the building. My car was parked right out front on the service drive. The door closed behind me each time. On my last trip out, I saw she (Resident #5) wasn't sitting there anymore. I thought she may have gone back inside near the nurse's station since I didn't hear an alarm go off. When I went outside, I saw her standing in the parking lot. She wasn't right out front. She was toward the left near the light in the parking lot itself. She looked confused as to where she was. She was just looking around. It was probably in the 50's, but I could see she (Resident #5) was cold. She was shivering. I called to her and got her to come over. I asked her if she was all right. She said she was looking for 'Sault Ste. Marie'. I walked her back in the building. She walked right in. When we got past the first set of doors and I opened the second set of doors, the alarm immediately went off. When we came inside, staff were standing there looking around like they were trying to figure out where the alarm was coming from. It was probably about 5 or 10 minutes from the time I saw her (Resident #5) in the chair to the time I saw her outside. It must have been around 4:45 p.m. when I saw her outside. During an interview on 4/6/17 at 10:35 a.m., CNA F stated, I was on my way to the kitchen to let them know a resident had returned from a birthday party. This was around 4:30 p.m. I saw (Resident #5) sitting at the nurse's station between 2 ladies talking. After I had told them in the kitchen the resident was back, I was in the service corridor and I heard the alarms going off. I went from the service corridor door to the inside double doors to the lobby. When I opened them, I saw (Resident #5) with a visitor. The visitor said she saw her (Resident #5) right out the door. I don't know if the alarms went off before I saw (Resident #5) with the visitor. I was in the kitchen and it was noisy. I walked (Resident #5) and the visitor down the hallway and sat (Resident #5) in the chair I had seen her in before. I then told the female nurse what happened. I don't remember the nurse's name. During an interview on 4/6/17 at 1:40 p.m., Licensed Practical Nurse (LPN) H (Resident #5's assigned nurse at the time of the elopement per the staffing schedule, dated 4/2/17) stated, I know somebody (Resident #5) got out (of the building) and a family member brought them back in. I heard about it after the fact. One of the staff members, I don't know who, told me. I asked about the alarms. They (facility staff) said something about the alarms not working on the door. I don't know who told me. That was after they (family member and facility staff) brought her (Resident #5) back in. I don't remember having to re-direct anyone from the doors that day. During a second interview on 4/6/17 at 2:00 p.m., MT E stated, It was on Sunday (4/2/17) that I started to test the alarm (Wanderguard) at ankle height and it didn't work. That's when we switched all of the bracelets (Wanderguard) to the wrists. During an interview on 4/6/17 at 2:15 p.m., Resident #5 stated she did not recall having exited the facility on 4/2/17. Resident #5 stated that it had been awhile since she left the facility. During an interview on 4/7/17 at 8:00 a.m., RN G stated, On Saturday (4/1/17) the alarms wouldn't stop ringing for a half hour. I called maintenance and he came in. He said to reset it at the breaker when it went off. On Sunday (4/2/17), I was in the dining room watching the residents. An aide, I don't know her name, came up and said we need to talk. She told me a resident (Resident #5) had walked out of the building and a visitor saw them as they (the visitor) was coming in. They (the visitor) brought them (Resident #5) back in. I called the DON (DON B). When they, the DON and maintenance guy, came in they check her (Resident #5's) Wanderguard and it wasn't working. On 4/6/17, the facility was notified of an Immediate Jeopardy that began on 4/2/17 when Resident #5 eloped from the facility unbeknownst to facility staff and was returned to the facility by a visitor. On 4/7/17, this surveyor confirmed the facility Immediacy was removed on 4/3/17 when the facility had the following in place: 1. On 4/2/17 at 4:45 p.m., Resident #5 was brought into the building and assessed for injuries. None were noted. 2. On 4/2/17 at 6:10 p.m., Resident #5's Wanderguard bracelet was moved from her ankle to her wrist. 3. On 4/2/17 starting at 6:10 p.m., all residents who were at risk for elopement were re-assessed and Wanderguard bracelets were switched from ankles to wrists on all residents who had them on their ankles. 4. On 4/2/17, from 6:10 p.m. to 9:00 p.m., the Wanderguard system at the main entrance to the facility was tested and re-tested to ensure functionality. The Wanderguard system functioned consistently after Wanderguard bracelets were moved to wrists. 5. On 4/2/17 during 2nd shift (2:00 p.m. to 10:30 p.m.) staff education was begun regarding elopements and Wanderguard policies and procedures. Education is on-going. 6. On 4/3/17 and concluding on 4/4/17, maintenance installed pull apart screecher alarms (alarms that sound when a magnetic connection is broken) on all exit doors that do not have the Wanderguard system. 7. On 4/3/17, the facility's elopement book was updated. Although the Immediate Jeopardy was removed on 4/03/17, the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified and the facility was out of compliance at tag F323 for safety concerns related to a fall. Deficiency Practice Statement B Based on interview and record review, the facility failed to prevent a fall for 1 of 2 residents (Resident #1) reviewed for falls, from a total sample of 5 residents, resulting in Resident #1 experiencing a potentially avoidable fall. Findings include: According to Resident #1's admission record, dated 4/5/17, Resident #1 was a [AGE] year old resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. According to Resident #1's nursing progress note, dated 3/6/17 at 0035 (12:35 a.m.), At 11:50 p.m., this nurse responds to resident's (Resident #5) call light and observed (name of Certified Nursing Assistant (CNA) K) and resident (Resident #5) on the floor in the bathroom both sitting on there (sic) bottoms by the sink facing the toilet. Resident is in a t-shirt and a towel is covering her peri-area. Brief is around her ankles. This nurse asks what happened, resident responds, I don't know. I'm really dizzy and lost my balance. No gait belt is attached to resident. CNA (CNA K) explains, She (Resident #5) is usually so much better at keeping her balance, I lowered her to the ground when she fell . Resident states, My right leg hurts. States pain is mild. CNA (CNA K) states, She did not hit her head. She was gently lowered to the ground. According to Resident #1's nursing progress note, dated 3/6/17 at 0035 (a second note), Gait belt is to be used with every transfer. Staff member (CNA K) is educated on importance of using gait belt for all residents who are a fall risk. Understanding noted, I will use a gait belt on everyone who needs help transferring or ambulating. On 4/5/17 at 1:15 p.m., this Surveyor requested CNA K's education for gait belt use from Licensed Practical Nurse Consultant (LPNC) L. On 4/5/17 at 1:20 p.m., this Surveyor requested the facility's policy and procedure on gait belt use from Director of Nursing (DON) B. On 4/5/17 at 3:00 p.m., DON B stated, We don't have a policy and procedure on gait belt use. DON B indicated the expectation is staff will use gait belts at all times while assisting a resident with transferring or ambulating. DON B also stated, There isn't any proof of education, besides the nursing progress note, for (CNA K) not using a gait belt with (Resident #1).

This refers to MI 246. Based on observation, interview, and record review, the facility failed to prevent a pressure ulcer from developing and failed to prevent a pressure ulcer from deteriorating for 1 of 2 resident (Resident #104) reviewed for pressure ulcers from a total sample of 5 residents, resulting in the development and deterioration of a pressure ulcer for Resident #104. Findings include: According to the admission record, dated 11/21/16, Resident #104 was a [AGE] year old resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. In addition, Resident #104's admission record indicated Resident #104 was discharged on [DATE] (destination not indicated). According to Resident #104's's Minimum Data Set (MDS) (a tool used to assess a resident and help determine the amount, or level, of care they need) assessment, dated 8/18/16, Resident #104 had a Brief Interview for Mental Status (BIMS) (a tool used to determine a resident's cognitive ability) score of 7 which indicated Resident #104 was severely cognitively impaired. In addition, Resident #104's MDS indicated Resident #104 needed extensive assistance (resident involved in activity and staff providing weight-bearing support) of 2 staff members for bed mobility (turning and repositioning in bed), transferring from one surface to another (e.g. from the bed to a wheelchair), and toileting. In addition, Resident #104 needed extensive assistance of 1 staff member for personal hygiene. Resident #104's MDS also indicated Resident #104 was at risk of developing a pressure ulcer and had developed a Stage 2 pressure ulcer at the facility on 3/7/16 that was still present. According to Resident #104's Braden Scale (a scale used to determine the risk of developing a pressure ulcer, dated 4/3/16, Resident #104 scored a 14 which indicated Resident #14 was at a moderate risk of developing a pressure ulcer. According to Resident #104's wound evaluation forms, dated 7/5/16 to 9/13/16, the following information was revealed: - 7/5/16- Resident #104 had a facility acquired Stage II (2) pressure ulcer to the coccyx (tailbone) measuring 1 cm (centimeter) x (by) 0.2 cm x 0.5 cm (length x width x depth). - 7/25/16- Resident #104 had a facility acquired Stage III (3) pressure ulcer to the coccyx measuring 0.7 cm x 0.5 cm x 0.3 cm. - 8/5/16- Resident #104 had a facility acquired Stage II pressure ulcer to the sacrum (tailbone) measuring 0.7 cm x 0.5 cm x 0.3 cm. - 8/19/16- Resident #104 had a facility acquired Stage II pressure ulcer to the coccyx measuring 0.5 cm x 0.5 cm x 0.2 cm. - 8/29/16- Resident #104 had a facility acquired Stage II pressure ulcer to the coccyx measuring 0.4 cm x 0.4 cm x 0.2 cm. - 9/13/16- Resident #104 had a facility acquired Stage II pressure ulcer to the coccyx measuring 0.4 cm x 0.4 cm x 0.2 cm. According to Resident #104's wound documentation forms, dated 9/21/16 to 10/25/16, the following information was revealed: - 9/21/16- Resident #104 had a Stage III (3) pressure ulcer to the coccyx (tailbone) measuring 1.3 cm (centimeters) x (by) 0.3 cm x 0.8 cm (length x width x depth) with undermining (opening under the skin at the 6 o'clock position (bottom of the wound) measuring 1.1 cm deep. - 9/28/16- Resident #104 had a Stage III pressure ulcer to the coccyx measuring 2.2 cm x 0.8 cm x 1.1 cm with undermining at the 12 o'clock to 1 o'clock positions (top of the wound) measuring 1.3 cm deep. - 10/6/16- Resident #104 had a Stage III pressure ulcer to the coccyx measuring 2.6 cm x 0.5 cm x 0.7 cm with tunneling at the 3 o'clock position (right side of wound) measuring 2 cm deep and the 10 o'clock position (left side of the wound) measuring 0.6 cm deep. - 10/13/16- Resident #104 had a pressure ulcer (not staged, presumably Stage III) to the coccyx measuring 3.2 cm x 1.3 cm x 1.7 cm with tunneling at the 12 o'clock position measuring 1.5 cm deep, at the 3 o'clock position measuring 2.5 cm deep, at the 5 o'clock position measuring 1.9 cm deep, and at the 9 o'clock position measuring 1.7 cm deep. - 10/19/16- Resident #104 had a Stage IV (4) pressure ulcer to the coccyx measuring 3.2 cm x 2.4 cm x 1.8 cm with undermining at the 12 o'clock position measuring 0.4 cm deep and undermining at the 9 o'clock position measuring 1.8 cm deep. - 10/25/16- Resident #104 was at the hospital and an assessment and measurements were not performed. According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear .A Stage II pressure ulcer is defined as partial thickness loss of dermis (top layer of skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (skin shedding off). May also present as an intact or open/ruptured serum-filled blister .A Stage III pressure ulcer is defined as Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling .Bone/tendon is not visible or directly palpable. A pressure ulcer develops from Stage I (one) to Stage IV (four). (www.npuap.org, 2007) According to Resident #104's activity note, dated 9/1/16, Resident with stage 2 pressure ulcer on coccyx, with slow progress in healing; Related to incontinence in BM (bowel movement) and immobility secondary to [MEDICAL CONDITION]. (sic) According to Resident #104's nursing progress note, dated 10/19/16, Resident #104 was transferred to the hospital emergency room at 9:45 a.m. because Resident (Resident #104) is currently being treated for [REDACTED]. He appears to be septic this morning. His color is grayish and his eyes appear sunken . His blood sugar is 344 (extremely high). During an interview on 11/21/16 at 3:30 p.m., Assistant Director of Nursing (ADON) J stated, I don't know if it (Resident #104's coccyx pressure ulcer) was acquired here or he was admitted with it. He had a coccyx pressure ulcer. It went from a Stage III to a Stage IV. ADON J indicated that prior to 9/21/16, Resident #104's wound measurements and documentation was not consistent. ( )

This citation pertains to MI 489. Based on observation, interview, and record review, the facility failed to ensure that 2 of 4 residents reviewed for transfers (#103 and 105) and 1 of 4 residents reviewed for bed positioning (#104), from a total sample of 6 residents received adequate supervision and assistance to prevent falls, resulting in a fall with a fractured right tibia and fibula (lower leg), extensive bruising of the chest and right side and subsequent death for resident #103 and falls without injury for Residents #104 and #105. Findings include: Resident #103 Based on the face sheet and the Minimum Data Set (MDS) assessment, dated [DATE], Resident #103 was an [AGE] year old severely cognitively impaired female whose [DIAGNOSES REDACTED]. Based on the MDS Resident #103 required two staff assist for transfers, toileting, bathing and dressing and had a Brief Interview for Mental Status (BIMS) score of ,[DATE] indicating severe cognitive impairment. Based on interviews with (multiple staff) Resident #103 was able to communicate her needs through some speech, questions and gestures and was very clear about what she liked and disliked. Based on the facility Fall report, dated [DATE] at 6:33 PM, Resident #103 fell in the bathroom while a Certified Nurse Aide (identified as CNA B) was assisting the Resident off the toilet. The same report reflected during the initial assessment Resident #103 denied any pain and had range of motion of her joints within normal limits for the resident. At about 10:45 AM Resident #103 began to complain of pain (hurts a whole lot on the Faces pain assessment tool) in the right leg. Swelling but no bruising was noted. The written statement by Licensed Practical Nurse (LPN) A, dated [DATE] at 2:10 PM, reflected the above and that the physician was notified and a Xray of the leg was ordered. The Xray report, dated [DATE] and read by the radiologist at 6:38 PM reflected Results: .fractures involving right proximal fibula and tibia metaphysis with mild displacement. The joint shows no dislocation. There is associated joint effusion. Osteopenia is present which limits the detection of nondisplaced fractures. Conclusion: Acute right knee fractures as described above. The nursing notes, dated [DATE] at 10:46 PM, reflected Resident #103 was sent to the hospital emergency room for evaluation and treatment. Review of the care plan related to Activities of Daily Living, dated [DATE] and updated on [DATE], the intervention for toileting was The resident requires TOTAL assistance of two staff for toileting ([DATE]) and the interventions for transfers were The resident requires extensive assistance by two staff to move between surfaces. Bears weight on left leg ([DATE]) and The residents requires SARA (sit to stand) lift with two staff assistance for transfer . The care plan related to fall risk, dated [DATE], reflected the intervention use two person assist with all transfers. The Kardex in use at the time of the fall reflected under the toileting section The resident requires TOTAL assistance of two staff for toileting. Review of the Physical Therapy Discharge Summary, dated [DATE], the Discharge Status for transfers was SARA lift. The Occupational Therapy Discharge Summary, dated [DATE], the Discharge Status for transfers was SARA lift transfers min (minimal)-mod (moderate) assist x (times) 2. Review of the facility Gait Belt Policy, dated [DATE], reflected All patient care providers will use gait belts when ambulating or transferring patients who are unsafe/unable to ambulate, or transfer independently . The purpose of the using a gait belt was To make transferring and walking clients safer and more efficient for both the resident and the caregiver. Support at the waist allows for less chance of injury, ease of transfer, and allows for more control when ambulating/transferring a resident. The Additional Information section reflected Care providers will use gait belts on the following residents: 1.) Any resident who is care planned that a gait belt is to be used on them. 2.) Any resident who has been identified by PT/OT that the patient is at a fall risk, or should have a gait belt used on them. 3.) Any resident on fall precautions. 4.) Any resident for whom it is unsafe to ambulate/transfer independently. If resident or family refuses the use of the gait belt, this will be documented and recorded accordingly in the resident's file CNA B signed a copy of the policy on [DATE]. Review of CNA B's written statement with the Fall report, dated [DATE] at 9:30 AM, reflected Resident was on the toilet and had turned the bathroom light on for service. Resident refused the use of gait belt (a canvas belt placed around a resident's waist during transfers to assist staff in controlling resident movement for safe transfers) as she usually does. While transferring resident from toilet to w/c (wheelchair), resident was holding onto bathroom grab bar. Her, knees buckled and I slid my arms under hers and caught her on my chest and lowered her to my knees. I pulled the bathroom light and the nurse came in. The care plan for a safe transfer for Resident #103 was not followed. On [DATE] at 8:46 AM CNA B was interviewed by telephone. CNA B stated that after breakfast on [DATE] it was very busy on the unit and Resident #103's bathroom call light had been on for a while and I answered it. CNA B stated she asked for assistance with transferring Resident #103 and other CNAs were busy and told her Resident #103 was a one person transfer. CNA B stated everyone was one-person transferring her on the day shift but on the second shift (which she had been working) Resident #103 had been a two person pivot transfer in the bathroom and a sit to stand mechanical lift from the bed to wheelchair and back. CNA B stated Resident #103 was a difficult transfer at times. CNA B stated she was talking to Resident #103 in the bathroom while waiting for assistance when the Resident became agitated that no one was coming and started to get up using the grab bar on the wall. CNA B stated that while Resident #103 was standing at the grab bar she was pulling up the Resident's pants when the Resident's knees buckled and CNA B wrapped her arms around the Resident's chest/breasts under her armpits and slid Resident #103 to the floor down the CNA's body pulling the leg with the splint on (right) out from behind the resident so both legs were in front of the Resident when she was on the floor. CNA B stated she then pulled the call light for assistance. CNA B stated she was written up for not following the Kardex, a guide the CNAs use when giving resident care, and had training related to using a gate belt for transfers along with all the other CNAs at the facility. CNA B stated that at the time of the fall things went too fast. I was waiting for help and wasn't prepared to transfer the Resident. On [DATE], review of the employee file for CNA B reflected a COACHING AND COUNSELING FORM verbal waring, dated [DATE], for .incorrect mode of transfer resulting in resident fall was given by Unit Manager C and signed by CNA B. Resident #103 was admitted to the hospital on [DATE] and readmitted to the facility on [DATE] at 6:30 PM (nursing progress note dated [DATE] at 4:10 AM). The Admission/Readmission Assessment, dated [DATE] at 1:21 AM, reflected Bruising on the chest and front of the lower right leg. The extent and color of the bruising was not documented. On [DATE] at 2:45 PM LPN A stated Resident #103 had bruising on her right side breast and thigh and around the chest area on readmission. On [DATE] at 8:46 AM CNA B was interviewed by telephone and stated that when Resident #103 was readmitted their was bruising along the rib cage and toward the front of the chest on one side and a smaller amount on the other side. CNA was not able to recall which side had more bruising. CNA B stated I was upset because I didn't think feel like I held her hard enough to cause that severe bruising. Review of the laboratory testing reflected Resident #103's hemoglobin was 13.7 gm/dl (normal range ,[DATE]) on [DATE] and had decreased to 10.9 gm/dl as of [DATE] related to extensive bleeding into the tissues (bruising) from the trauma of the fall. Review of the nursing progress notes dated [DATE]-[DATE] reflected the bruising remained stable (did not increase). Review of the nursing progress notes dated [DATE]-[DATE] reflected Resident #103 slowly returned to her usual activity level and was propelling herself in her wheelchair as of [DATE]. On [DATE] between 12:,[DATE]:00 AM (the exact time was not documented) Resident #103 had an increased heart rate of 106 beats per minute, shortness of breath, and her oxygen saturation was 74% (normal range above 90%) on room air. Oxygen at 3L/min by nasal cannula and a bronchodilating respiratory treatment at 3:00 AM did not increase Resident #103's oxygen saturation. Resident #103 was sent to the emergency room between 3:,[DATE]:30 AM. The Internal Medicine Hospitalist Death Summary, dated [DATE], reflected Resident #103 had blood clots in both lungs (blocks the circulation to the lung that delivers oxygen) and did not respond to high flow oxygen (oxygen saturations remained in the 70s-80s %) and anticoagulation. The above document reflected Resident #103 had not been placed on anticoagulants after her fracture related to her extensive bruising, non-ambulatory status and previous difficulty with anticoagulation. According to the same document Resident #103 declined intubation and ventilator support or BiPAP (forced inspiration of air/oxygen through a face mask) and chose to discontinue the high flow oxygen after discussion with palliative care and Hospice. Resident #103 expired at 11:54 PM on [DATE]. The medical examiner's Certificate of Death, dated [DATE], reflected Resident #103 died of medical complications [REDACTED]. Resident #105 Based on the Minimum Data Set (MDS) assessment, dated [DATE], Resident #105 was a [AGE] year old severely cognitively impaired female whose [DIAGNOSES REDACTED]. Based on the MDS Resident #105 was dependent of two staff to assist with transfers, toileting and dressing and had a Brief Interview for Mental Status (BIMS) score of ,[DATE] indicating severe cognitive impairment. Based on Fall reports, dated [DATE]-[DATE], Resident #105 had 10 falls without injury, seven of which were rolling/getting out of a low bed onto a floor mat. On [DATE] at 11:30 AM Resident #105 was observed being transferred from her wheelchair to the toilet in the shower room . CNAs H and I placed a gait belt around the Resident's waist and cued her to stand at the grab bar on the wall while the wheelchair was moved away and the commode chair was moved under her. Resident #105 was able to stand at the bar with extensive assistance from CNA H while CNA I moved the equipment. Resident #105 had little ability to maintain her balance without physical assistance from the CNAs and use of the gailt belt. Review of the Fall report, dated [DATE] at 10:56 AM, reflected Resident #105 was lowered to the floor in the bathroom after she impulsively slid to the edge of the toilet seat and when she attempted to stand her knees buckled. Review of the care plan related to Activities of Daily Living, dated [DATE] and updated on [DATE], the intervention for toileting was total care x 2 for check and change. Toilet if allows ([DATE]) and the intervention for transfers was extensive to total assist by two staff. ([DATE]) The care plan related to fall risk related to impaired balance, poor coordination and non-compliance with mobility aide use, dated [DATE] and updated on [DATE], reflected the intervention assist x 2 with gait belt for all transfers. The Kardex in use at the time of the fall reflected the same instructions under the toileting section. Review of the facility Gait Belt Policy, dated [DATE], reflected All patient care providers will use gait belts when ambulating or transferring patients who are unsafe/unable to ambulate, or transfer independently . The purpose of the using a gait belt was To make transferring and walking clients safer and more efficient for both the resident and the caregiver. Support at the waist allows for less chance of injury, ease of transfer, and allows for more control when ambulating/transferring a resident. The Additional Information section reflected Care providers will use gait belts on the following residents: 1.) Any resident who is care planned that a gait belt is to be used on them. 2.) Any resident who has been identified by PT/OT that the patient is at a fall risk, or should have a gait belt used on them. 3.) Any resident on fall precautions. 4.) Any resident for whom it is unsafe to ambulate/transfer independently. If resident or family refuses the use of the gait belt, this will be documented and recorded accordingly in the resident's file On [DATE] at 12:47 PM CNA D was interviewed by telephone. CNA D stated that at about 6:30 AM on [DATE] CNA D and Resident #105 were in the bathroom as CNA D was getting the Resident dressed for the day. CNA D stated Resident #105 had a habit of randomly standing up and CNA D had taken the Resident into the bathroom alone as the Resident was a one-person assist. CNA D stated Resident #105 had no gait belt on as she was getting dressed. CNA D stated Resident #105 was seated on the toilet and was squatting down putting the Resident's pants on then turned to get her shoes when Resident #105 stood up and held onto the grab bar on the wall. CNAD stated Resident #105's feet began to slide and the CNA was unable to get the Resident to release her grip on the bar to assist her back to the toilet. CNA D stated she was on the side and behind the resident and they both slid to the floor. CNA D did not follow the care plan for transfers/toileting for Resident #105. In addition, there was no Post Fall Assessment Form detailing an investigation of the circumstances of the fall. On [DATE] at 12:25 PM Unit Manager LPN C stated she was not involved in the investigation of falls at the time of the occurrence and confirmed there should have been a Post Fall Assessment Form with the Fall report. Resident #104 Based on the Minimum Data Set (MDS) assessment, dated [DATE], Resident #104 was a [AGE] year old severely cognitively impaired female whose [DIAGNOSES REDACTED]. Based on the MDS Resident #104 was dependent of two staff to assist with transfers, toileting and dressing and had a Brief Interview for Mental Status (BIMS) score of ,[DATE] indicating severe cognitive impairment. Based on the Fall report, dated [DATE] at 4:51 AM, Resident #104 rolled out of bed during repositioning by CNA E without injury. The Investigation Statement written by CNA E on [DATE] at 4:20 AM and attached to the above Falls report reflected When I did my 2 hour rounds I found (resident's name) at the edge of the bed about to slide off the mattress. I attempted to bring her back over but she slid down anyway . On [DATE] at 9:14 AM CNA E was interviewed briefly by telephone and stated I found (resident's name) was almost falling out of bed toward the wall. I tried to to hold her from the other side of the bed. I couldn't get around the bed. CNA E had to terminate the conversation before further details were discussed such as why the CNA could not get around the bed. CNA E was not available for the remainder of the survey. The Investigation Statement written by LPN F on [DATE] at 4:30 AM and attached to the above Falls report reflected CENA (competency evaluated nursing aide) notified nurse that pt (patient) was on the floor. Nurse noted pt on the floor on the left side of the bed. Pt was unable to give details to what transpired. CENA stated that while turning (resident) to the left side of the bed and CENA standing on the right side of the bed pt rolled out of bed. Pt was safely in bed before CENA turned her and resulted in fall is what CENA stated to nurse. On [DATE] at 8:39 AM LPN F was interviewed by telephone and stated Resident # 104 was on the floor between the bed and the wall (left side of the bed) when he entered the room at 4:30 AM on [DATE]. LPN F stated CNA E told him she was turning Resident #104 toward the wall onto her left side while the CNA was standing behind the Resident. LPN F stated Resident #104 had never rolled out of bed either before or after her fractured hip. LPN F stated there was no reason CNA E could not have gotten to the left (wall) side of the bed as there was no equipment/furniture in the way. The Coaching and Counseling Form, dated [DATE], and signed by the the Interim Director of Nursing G at the time reflected CNA E was given a verbal warning for improper repositioning of Resident #104. The counseling stated the CNA should have been on the same side of the bed the Resident was facing in order to prevent Resident #104 from rolling off the edge of the bed. The facility policy Turning and Repositioning, dated ,[DATE], did not address how to safely turn/reposition a resident in bed. ( )

This citation pertains to intake number MI 951. Based on observation, interview, and record review, the facility failed to provide treatments to a pressure ulcer, as ordered by the physician, for 1 out of 2 residents sampled for pressure ulcers (Resident #504), out of a total sample of 5, resulting in the pressure ulcer not healing and becoming bigger. Findings Include: Per the facility face sheet Resident #504 was a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a Minimum Data Set ((MDS) dated [DATE] revealed that Resident #504 had a BIMS score of 13 out of 15, and a Braden score of 19 (at risk for pressure ulcers) as assessed on 4/16/2015. Review of a care plan dated 3/17/2015 for skin impairment revealed that Resident #504 was to have treatment to her coccyx pressure ulcers (PU) per the physician orders. Review of physician orders [REDACTED].#504 was to have her PU cleansed with normal saline and covered with a dressing every three days. Physician orders [REDACTED].#504 was to have a Dakins (medicated) solution and gauze placed onto her PU and changed daily. Review of a Treatment Administration Records (TARs) for the month of March 2015 revealed, Resident #504 was to have a treatment completed on 3/14/2015. The treatment was not documented as being competed. Review of a TAR for the month of April 2015 revealed that dated 3/31/2015 Resident #504 was to have a treatment done to her coccyx PU at 6:00 AM daily beginning 3/31/2015. The TAR revealed that on 4/4, 4/5, 4/6, & 4/12/2015 the treatment was not done. On 4/15/2015 Resident #504 was ordered to have a treatment done to her coccyx wound from 4/15 through 4/17/2015, the treatment was not done on 4/16/2015. On 4/21/2015 the TAR revealed an order for [REDACTED]. Review of a Michigan Wound Evaluation Form dated 3/11/2015 revealed that Resident #504 had been readmitted , from the hospital, with a PU on her coccyx that measured 0.3 cm in length x 0.7 in width and cm x 0.1 cm in depth, and measured at a stage II PU. No other wound evaluation form was found for the month of March 2015. The next wound evaluation form was dated 4/10/2015 and revealed that Resident #504's coccyx PU had gotten bigger and measured 3.5 cm x 5.0 cm x 0.2 cm, and remained at a stage II. The next wound evaluation form was dated 4/17/2015 and revealed Resident #504's PU measured 3.8 cm x 5.2 cm x 0.2 cm and was staged at a stage III. On 4/20/2015 a wound evaluation form dated 4/20/2015 revealed Resident #504's coccyx U measured at 4.5 cm x 5.8 cm x 1.0 cm and was a stage III. Observation of Resident #504's PU on 4/27/2015 at 2:15 PM revealed a large amount of brown eschar (dead tissue) that was draining out of the wound. The wound was red around the edges and was observed to be deep. In an interview on 4/27/2015 at 1:30 PM, Physician Assistant (PA) #5 said last week the eschar on Resident #504's PU was solid, but had an odor. PA #5 said contact was made with the wound clinic to have Resident #504's PU debrided, and stated that the eschar was draining from the wound and he could see the bed of the wound, which PA #5 said was a stage 4 wound. PA #5 said Resident #504 did have an issue with her nutritional intake and would not take recommended medication, but also stated that he was made aware, by Licensed Practical Nurse (LPN) #6 that Resident #504 had some wound dressing changes that had been missed. In an interview on 4/27/2015 at 1:55 PM, LPN #6 said the first two weeks of March 2015 she did Resident #504's dressing change. LPN #6 said she had been absent from her employment at the facility beginning the second week of March and was gone for about 1 and 1/2 weeks. LPN #6 said before she left she had spilt up the wound dressing changes to the nurses to complete. LPN #6 said when she returned to her employment with the facility she checked to see if the dressing changes were done on residents with wounds. LPN #6 said she measured Resident #504's wound on the 9th or 10th of April and the would was larger. LPN #6 said she did not investigate to see why Resident #504's wound dressing changes had been missed, nor provided any education to nurses.( )

This citation pertains to MI 850 and MI 172. Based on interviews and record review, the facility failed to ensure residents were treated with dignity when residents were not assisted to the bathroom in a timely manner in 3 of 8 residents (Residents #104, #106, and #108), from a total sample of 9 residents, resulting in the potential for loss of self-esteem and self-worth when they were not toileted in a timely manner and urinated themselves. Findings include: In an interview, during the initial tour on 3/7/13 at 9:45 AM, Licensed Practical Nurse (LPN) #4 stated that Resident #104, #106, and #108 was interviewable and could answer questions. Resident #106 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #106 was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #106 was cognitively intact and required limited to extensive staff assistance with activities of daily living. In an interview and observation on 3/7/13 at 1:20 PM, Resident #106 was dressed and laying in her bed. Resident #106 stated that she had waited as long as 30 minutes for someone to assist her to the bathroom. Resident #106 stated, "I can't get out of my bed by myself and if I have to wait to long I will have an accident (become incontinent of urine)." Resident #106 stated that a month ago she wet herself and it felt, "terrible, I feel like they don't like me." In an interview on 3/15/13 at 11:40 PM, Resident #106's Son stated that he found his mother crying for help, not getting toileted, and had to wait half hour to get assistance to use the bathroom, "It broke my heart to see my mother cry," so he made out a complaint form and gave it to the social worker. Review of "Resident Concern Form" dated 2/9/13, Resident #106's Son documented that he was told the call lights would be responded to within 3-5 minutes, Resident #106 was made to sit in a wet diaper,and is not getting cleaned and getting more frequent infections due to the lack of aides (certified nurse assistant). Resident #104 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #104 was a year old 91 female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #104 was cognitively intact and required limited staff assistance with activities of daily living. In an interview and observation on 3/7/13 at 2:15 PM, Resident #104 was dressed and seated in a recliner chair in her room. Resident #104 stated she needed assistance to use the bathroom and put her call light on. Resident #104 stated that she waited for over 20 minutes and when the pressure got so bad, "I called out to them, come please, I'm desperate." Resident #104 stated, "Sometimes at night you have to wait, and wait and wait...they need a lot more help than what they got. I've told the Director of Nursing (DON) and he agrees." Resident #104 stated, "One time I got to the john (bathroom) and I exploded (incontinence of urine) and it went all over the floor...I felt very embarrassed." Resident #108 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #108 was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #104 had moderate cognitive impairment and required limited to extensive staff assistance with activities of daily living. In an interview on 3/15/13 at 11:30 PM, Resident #108 stated, "I put on the call light to use the bathroom and they don't come early enough...sometimes wait 1/2 hour. Sometimes, I couldn't help it, I have gone in my pants...it made me feel this big (resident put up her fingers indicating very small)." (# )

Based on observation, interview, and record review, the Facility failed to ensure residents were treated with dignity when residents were not assisted to the bathroom in a timely manner for 2 of 7 total sampled residents (#202 and #204), resulting in the potential for a loss of self-esteem and self-worth when they were not toileted in a timely manner and urinated themselves. Findings include: Resident #202 In an interview, on 5/14/13 at 1:30 PM, when asked if the staff provide the assistance to her husband when he needs to go to the bathroom, Resident #202's wife said, "I buzzed at 1:15 PM and she came but said she wasn't allowed to move him alone because he needs 2 people." Resident #201's wife said he needed to use the bathroom after lunch but since he has the "pad" on, they don't worry about him going in his pants. Resident #202's wife said she comes in daily to visit her husband and said, "they don't have enough aides." An observation at 1:45 PM on 5/14/13, revealed Certified Nurse Assistant (CNA# 3 and CNA#4), entered Resident #202's room to assist him to the bathroom, 30 minutes after Resident #202's wife requested assistance to the bathroom. Review of the face sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #202 was an [AGE] year old man who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #202 had severe cognitive impairment and required limited to extensive staff assistance with activities of daily living. According to the Face Sheet, Resident #202 had a Durable Power of Attorney (DPOA). Resident #204 Review of the face sheet and MDS dated [DATE] revealed Resident #204 was an [AGE] year old woman admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. According to the MDS, Resident #204 was cognitively intact and required limited to extensive staff assistance with activities of daily living. In an interview on 5/14/13 at 1:55 PM, during a revisit investigation, when asked if staff were answering call lights better in the last 2 weeks, Resident #204 said, not in the evening. Resident #204 said, "Just last week I still had to wait a good half hour. There isn't enough aides because the aides are in the dinging room at supper time." Resident #204 said if you eat in your room, there isn't anyone available to help you when you need to go to the bathroom. An observation, at the time of the interview, revealed a frail-looking woman, in a wheelchair, with 5 family members in her room. Resident #204 said she just got back from her husband's funeral. Resident #204's son-in-law said he visits in the evening and said there isn't any staff on the floors, during the meal time and residents who are in there room need help. #

This citation pertains to intake number MI 850, MI 172, and MI 424. Based on observation, interviews, and record review, the facility failed to assess fall risk, implement appropriate interventions and provide adequate supervision and accessible assistive devices to prevent falls in 3 of 5 residents (Resident #101, #105 and #107), from a total sample of 9 residents, resulting in falls with fractures and the potential for future falls with injury. Findings include: Resident #101 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #101 had severe cognitive impairment and required limited to extensive staff assistance with activities of daily living. In an observation on 3/11/13 at 9:40 AM, Resident #101 was observed resting in the bed and was unable to answer questions. Review of the "Fall Risk Evaluation" dated 12/31/12 revealed a fall risk score of "15" which represents high risk for falls if score is greater than 10. Review of the Physician orders [REDACTED]. Review of "Accident/Incident Report" dated 2/6/13 at 1:45 AM, revealed Licensed Practical Nurse #29 documented that she observed Resident #101 walking out of her room, independently, when her feet slipped from under her and she fell landing on her bottom in the door way of her room. Resident #101 sustained a skin tear to both arms. Under the interventions initiated to prevent further falls section "tab alarm while in room" was documented. Review of the "Fall Risk Evaluation" revealed no new assessment after the fall on 2/6/13. Review of the "Fall Risk" care plan dated 12/21/12 did not include the tab alarm while in room nor did it include any new interventions or changes in interventions listed after the fall on 2/6/13. Review of "Accident/Incident Report" dated 2/18/13 at 9:30 PM, revealed that Resident #101 had an unwitnessed fall and was found on the floor of her room, by the bed. Review of the "Fall Risk Evaluation" revealed no new assessment after the fall on 2/18/13. Review of "Accident/Incident Report" dated 2/21/13 at 11:45 AM, revealed Resident #101 had an unwitnessed fall and was found on the floor of her room, next to her bed. Documented under the section of interventions initiated to prevent further falls revealed "sensor pad in recliner" was written and crossed out and in a different witting it was documented, "discontinued...staff will initiate every 2 hour toilting and get up to wheelchair under staff's supervision when restless." In an interview on 3/11/13 at 11:20 AM, LPN #11 stated that after the fall on 2/21/13 she immediately initiated a sensor pad to Resident #101's recliner chair because, "my first choice was an alarm because she was known to get up on her own about 1-2 times a day and come walking out into the hall or we would catch her up walking around her room without assistance...if she had the alarm on we would hear it and assist her." LPN #11 stated that Director of Nursing (DON) crossed the sensor pad off the intervention section of the "Accident/Incident Report" and made the change to the intervention. Review of "Accident/Incident Report" dated 3/5/13 at 5:20 PM, revealed Resident #101 had an unwitnessed fall and was found on the floor of her room next to the bathroom door. Resident #101's walker was found in the bathroom. Resident #101's right leg was noted to be externally rotated and yelled out in pain. Resident #101 was sent to the hospital for further evaluation and treatment. In an interview on 3/11/13 at 11:50 AM, LPN #4 stated the new intervention, "initiate every 2 hour toileting" is not a new intervention, it is the current standard. LPN #4 stated on 3/5/13 Resident #101 must have gotten up on her own in her room, ambulated to her bathroom, used the bathroom and attempted to return to her chair when she fell . LPN #4 stated that Resident #101 had left her walker in the bathroom. LPN #4 stated, "If she had an alarm on the chair or bed it would have been helpful," it would have sounded and they could have helped her to the bathroom and could have prevented the fall. Review of the "Fall Risk" care plan dated 12/21/12 did not include any new interventions or changes in interventions listed after the fall on 3/5/13. Review of the hospital "Discharge Summary" dated 3/9/13 indicated that Resident #101 fractured the right hip and right humerus (arm) but was a high risk for surgical intervention so she was transferred back to the facility on [DATE]. In an interview on 3/11/13 at 11:20 PM, Licensed Practical Nurse (LPN ) #11 stated that Resident #101 would attempt 1-2 times daily to ambulated independently without out staff assist, "I would see her come walking out of her room, into the hall or find her in her room walking alone." LPN #11 stated that resident #101 did have a sensor alarm until December 2012, but it was discontinued. In an interview on 3/11/13 at 10:00 AM, Housekeeper #9 stated that Resident #101 was disoriented and unsteady and would attempt to get up on her own with out the assist of staff or her walker. Housekeeper #9 stated that Resident #101 did have an chair sensor that alerted the staff so they could assist Resident #101 but it was discontinued in December of 2012 even though Resident #101 continued to attempt to ambulate independently without the staff assistance. In an interview on 3/12/13 at 12:15 PM, Certified Nurse Assistant (CNA) #6 stated that Resident #101 was unsteady and needed the assist of one with her walker to ambulated but she had a poor memory and would often get up on her own without staff assistance. Review of the "State of Michigan Certificate of Death" dated 3/15/13, Resident #101 passed away at the facility on 3/11/13 at 8:15 PM, and the cause of death was "medical complications [REDACTED]." Resident #105 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #105 was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #105 had moderate cognitive impairment and required limited to extensive staff assistance with activities of daily living. According to the Face Sheet, Resident #105 had a Durable Power of Attorney (DPOA). Review of "Accident/Incident Report" dated 12/16/13 at 4:40 PM, revealed Resident #105 had an unwitnessed fall and was found on the floor of her room next to her chair. Resident #105 blood sugar at the time of the fall was 53 (low blood sugar according to reference range of 65-99 mg/dl). Review of "Accident/Incident Report" dated 12/25/13 at 10:30 AM, revealed Resident #105 had an unwitnessed fall and was found on the floor in doorway of Activities Room, "stated she was getting up and walking." Under the section of identify factors that may have attributed to fall indicated that Resident #105 was attempting to walk without staff assistance. In an interview on 3/12/13 at 3:20 PM, DON #3 stated that Resident #105 was unsteady and "she is not to ambulate alone". DON #5 stated that the following intervention was added to Resident #105's care plan after the fall on 12/25/12, "Resident in view of staff when out of room." Review of the "Falls Risk Evaluation" dated 12/25/13 revealed a score of "18" which represents high risk for falls if score is greater than 10. Review of "Accident/Incident Report" dated 2/12/13 at 8:00 PM, revealed Resident #105 had an unwitnessed fall and was found on the floor of another residents bathroom. Resident #105 sustained a skin tear to the left knee and reported pain subsequently she was transferred to the hospital. In an interview on 3/12/13 at 3:20 PM, DON #3 stated that before Resident #105 fell on [DATE], she exited the dining room, walked past the nurses desk and made her way into the bathroom of the last room on hall #1, unseen by staff. When asked if Resident #105 was to be walking in the hall alone DON #3 stated, "No, only with supervision. When asked if the care plan intervention of "Resident in view of staff when out of room" was followed, DON #3 stated "No." Review of the hospital records "Computed Tomography Report" dated 2/12/13, revealed that Resident #105 sustained a "tiny minimally depressed lateral tibial plateau fracture" (small break of the left leg). Review of "physician's orders [REDACTED]." In an interview and observation on 3/12/13 at 2:50 PM, Resident #105 was observed sitting in the recliner chair of the room, the chair sensor pad was placed under Resident #105 but the cord was not connected to the alarm box. Licensed Practical Nurse (LPN) #15 stated the sensor alarm would not sound if not connected to the alarm box and then was observed plugging the chair sensor cord into the alarm box. Resident #105 also had a tab alarm clipped to her shirt and the tab alarm box was unsecured and resting beside of her in the chair. LPN #15 explained that if Resident #105 were to stand the tab alarm would pull away from the alarm box and sound. This Surveyor pulled up on the string attached to Resident #105 and the unsecured alarm box dangled from the string and did not pull away or alarm. LPN #5 stated that it would not work if the tab alarm box is not secured to something and was then observed securing the tab alarm box to the dresser drawer. Resident #107 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #107 was a year old 85 male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #107 had severe cognitive impairment and required limited to extensive staff assistance with activities of daily living. According to the Face Sheet, Resident #107 had a Durable Power of Attorney (DPOA). In an interview on 3/11/13 at 1:40 PM, Resident #107's DPOA stated that Resident #107 had a fall/incident in February regarding a shower stool. Review of the "Nurses Notes" dated 2:13 AM at 8 AM, the nurse documented "Resident lowered to floor during shower." Review of the "Fall Risk Evaluation" dated 2/13/13 revealed Resident #107 had a fall and the fall assessment indicated a new score of "17" which represents high risk for falls if score is greater than 10. In an interview on 3/15/13 at 3:50, DON #3 stated, "We have no incident/accident report for Resident #107 during the period of December 2012 through March 2013." DON #3 stated there was no investigation for the fall on 2/13/13. Review of facility policy titled, "Accident/Incident Reporting" last revised 4/09, revealed "It is the policy of the facility to actively investigate any accident/incident, witnessed and unwitnessed, and to put a plan of care in place that will assist in preventing further accidents/incidents." Review of the "Fall" care plan dated 1/13/13 did not include any new interventions or changes in the interventions. In an interview and observation on 3/14/13 at 10:00 AM, Resident #107 was observed sitting in a wheel chair is his room and his call light was approximately 4 feet away laying across the bed. When asked if Resident #107 uses his call light LPN # 4 stated, "yes". When asked if he could reach his call light, LPN #4 stated, "no I'll move it." LPN #4 was observed moving the call light to the handle of the wheel chair. Review of the "Fall" care plan dated 1/13/13 revealed the intervention of "keep call light and most frequently used personal items within reach." (# )

This citation pertains to MI 738 Based on observation, interview and record review, the facility failed to provide supervision to prevent falls in 4 of 5 sampled residents (Resident 101, 102, 103, 105) resulting in resident #101 falling and sustaining a fracture of her pelvis, resident 102 falling and sustaining a skin tear to her nose, right eye and left knee, residents 103 and 105 being at risk for falls with injury, and failing to provide supervision to prevent respiratory distress for 1 (#104)of 5 sampled residents, resulting in resident 104 being at risk for unwitnessed respiratory distress,and hypoxia (low blood oxygen level). Findings include: Resident #101: A review of resident 101's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility nurse's notes dated 7/26/10 documented that resident 101 tried to self transfer, fell and was found on her buttocks on the floor next to the bed. Facility nurse's notes dated 9/18/10 documented that resident 101 was found lying on her back in the bathroom and complained of severe pain in the back of her head and left hip area. Facility nurse's notes dated 9/19/10 at 1:30 am, documented that resident 101 was crying out in pain when care was being given. Facility nurse's notes dated 9/19/10 at 10:30 pm documented that resident 101 was moaning and yelling out in pain through out the shift and that 15 minute checks continued. Facility nurse's notes dated 9/23/10 documented that resident 101 self transferred and found in her bathroom on the toilet. 9/26/10 and 9/30/10 nurse's notes documented that resident 101 was crying loudly in pain. Facility nurse's notes dated 9/30/10 documented that resident 101's alarms were sounding and she transferred self to wheelchair. Facility nurse's notes dated 10/2/10 documented that resident 101 tried to self transfer from wheelchair to toilet and fell on the floor. Facility care plan for resident 101 identified her to have potential for falls with interventions listed to include 30 minute checks, which were discontinued on 9/18/10 and 15 minute checks started. Xray results dated 9/19/10 documented that resident 101 had a fracture (break in the bone) of the left inferior pubic ramus (pelvis bone). Facility occurrence report dated 7/26/10 documented that staff heard alarms going off, ran to resident 101's room and found resident 101 on the floor on her buttocks next to the bed. Facility occurrence report dated 9/18/10 documented that resident 101's alarms were sounding and was found by CNA lying on her back on the floor in the bathroom with fracture listed as an injury and 15 minute checks listed as a preventative measure/corrective action. Facility occurrence report dated 10/2/10 documented resident 101 attempted to self transfer and fell . A review of facility 30 minute resident check lists from 8/16/10 to 9/13/10 for resident 101 revealed multiple days with no checks documented and multiple hours of checks not documented on the days which had 30 minute checks documented. A review of facility 15 minute resident check lists from 9/3/10 to 9/20/10 document only 4 days of partial documentation of 15 minute checks being done for resident 101. There were no documented 15 minute or 30 minute checks of resident 101 after 9/20/10. In an interview on 10/13/10 at 11:55 am, the Director of Nursing (DON) stated that resident 101 was on 30 minute checks prior to her fall on 9/18/10. The Director of Nursing stated she personally told the nursing staff that resident 101 was to be placed on 15 minute checks while in her wheelchair in her room, after her fall on 9/18/10. She (DON) stated the 15 minute checks did get written on the nursing care plan for resident 101, but did not get written on the certified nurse aide's (CNA) care plan, so the 15 minute checks were not followed up on with the CNA's who are the ones that do the 15 minute checks. The Director of Nursing stated that 15 minute checks were not done for resident 101. The Director of Nursing stated while she was looking for 15 and 30 minute check documentation for resident 101 and 102 as requested by the surveyor, she noticed that all documentation of checks was missing. The Director of Nursing then stated that approximately a month ago she had implemented a new documentation form for the Nurse Aides, and since that time they have not been doing any 15 or 30 minute checks. The Director of Nursing stated that all residents who were supposed to be on 15 or 30 minute checks had not been getting checked by staff since she implemented the new form. During an observation on 10/15/10 from 9:50 am to 10:25 am, resident 101 was observed by the surveyor to be in her room with no staff present and was not checked on by any staff member of the facility, for a total of 35 minutes of being unsupervised in her room. Resident 102: A review of resident 102's medical record revealed an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurse's notes dated 8/1/10 documented that resident 102 called out, alarms sounded and she was found on the floor in her room with 15 minute checks started. Nurse's notes dated 9/16/10 documented that resident 102 attempted to self transfer and fell sustaining skin tears to the bridge of her nose, left eye and left knee. Nurse's notes dated 9/21/10 documented that resident 102 stood up from her wheelchair and fell to the floor, landing on her bottom. Facility care plan for resident 102 documented she was at risk for falls with interventions listed to include 30 minute checks, which were increased to 15 minute checks on 8/2/10. Facility occurrence report dated 8/1/10 documented that resident 102's alarms were sounding, she was found on the floor on her back and that resident 102 stated she got up out of wheelchair and hit her head on the floor and that resident 102 complained of head and right shoulder pain. Preventative measures/corrective action listed on the occurrence report dated 8/1/10 were "increase checks to 15 minutes". Facility occurrence report dated 9/16/10 documented that resident 102 stood up from wheelchair, fell to floor and sustained skin tears to her nose, left eye and left knee. Facility incident report dated 9/21/10 documented that resident 102 stood up from wheelchair and fell to the floor onto her buttock. A review of facility 30 minute resident check lists from 7/31/10 to 8/14/10 for resident 102 revealed multiple days with no checks documented and multiple hours of checks not documented on the days which had 30 minute checks documented. There were no documented checks for resident 102 after 8/14/10. There were no documented 15 minute checks for resident 102. During an observation on 10/15/10 from 9:50 am to 10:25 am, resident 102 was observed by the surveyor to be in her room with no staff present and was not checked on by any staff member of the facility, for a total of 35 minutes of being unsupervised in her room. Resident 103: A review of resident 103's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurse's notes dated 9/29/10 documented that resident 103 was found on the floor in the bathroom. Facility care plan for resident 103 identified her to be at risk for falls with interventions listed to include sensor pad and tab alarm on bed and wheelchair at all times, toilet every 2 hours, educate resident to use call light. There were no documented 15 or 30 minute checks in the chart for resident 103. Facility incident report dated 9/29/10 documented that resident 103's alarms sounded and resident 103 was found on the floor in her bathroom, with intervention documented to be 15 minute checks when in room alone. In an observation on 10/14/10 from 10:45 am to 11:10 am, resident 103 was observed to be alone in her room with no staff present. In an interview on 10/14/10 at 11:10 am, staff #9 stated that resident 103 does not require 15 or 30 minute checks and that the only special order for resident 103 is to keep her feet elevated. In an interview on 10/14/10 at 10:45 am, resident 103 stated she fell at home and came to the facility for rehabilitation. Resident 103 stated she wanted to go home as soon as possible, but that she fell again in the facility while in the bathroom. Resident 103 showed the surveyor a bruise on her right leg that started in her inner groin area and ran the full length of her upper right leg to the knee. The bruise was dark purple in color and covered the entire inner aspect of her right upper leg. Resident 103 stated the bruise was painful, but she could tolerate it. Resident 104: A review of resident 104's medical record revealed an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility physician orders [REDACTED]. Resident 104's minimum data set ((MDS) dated [DATE] documented that she was totally dependent on staff for transfers, mobility, eating and hygiene. Facility care plan for resident 104 documented a listed intervention of 15 minute checks dated 8/4/09. In an interview on 10/13/10 at 12:10 pm, the Director of Nursing stated that since the implementation of new charting for certified nurse aides (CNA) over a month ago, the CNA's have not been doing 15 or 30 minute checks. The Director of Nursing stated that resident 104 was not on 15 minute checks for falls prevention, but because she had an artificial airway (tracheostomy) with an oxygen mask and her room is at the end of the hall, far away from the nurse's station. The Director of Nursing stated that resident 104's family requested the room, but since resident 104 requires close monitoring of her respiratory condition, she was placed on 15 minute checks. The Director of Nursing stated the 15 minute checks for resident 104 had not been done since the first of September 2010. A review of facility 15 minute resident check lists from 8/1/10 to 8/22/10 revealed multiple days with no checks documented and multiple hours of checks not documented on the days which had 15 minute checks documented. There were no documented checks for resident 102 after 8/22/10. In an observation on 10/14/10 from 12:20 pm to 1:00 pm, resident 104 was observed to be alone in her room with no staff present. Resident 105: A review of resident 105's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility care plan for resident 105 documented that she was at risk for falls with interventions listed to include tab alarms and sensor alarms at all times, blue mat next to bed and nonskid footwear. There were no documented 15 or 30 minute checks in the record of resident 105. Facility occurrence report dated 8/10/10 documented that resident 105 fell from bed and sustained a skin tear (location and size not documented). Facility incident report dated 8/21/10 documented resident 105's alarms were sounding and resident 105 was found on the floor next to the bed with preventative measures/corrective action documented as initiate 30 minute safety checks and continue use of safety alarms. In an interview on 10/13/10 at 2:00 pm, Facility Clinical Coordinator stated that the intervention of 30 minute safety checks was "missed" and never put on the nursing care plan, not put on the nurse aides care plan and never started. The clinical coordinator then wrote the 30 minute checks on the care plan for resident 105 in front of the surveyor. In an interview on 10/14/10 at 10:00 am, the Director of Nursing stated that the surveyor had a copy of all documented 15 minute and 30 minute checks for the last 3 months for all residents who were to be checked. #

This citation pertains to intake MI 738 Based on observations, interviews and records review, the facility failed to monitor 5 (101,102,103,104,105) of 5 sampled residents who had been identified to require frequent checks for safety (30 minute or 15 minute), resulting in resident #101 falling and sustaining a fracture of her pelvis, resident 102 falling and sustaining a skin tear to her nose, right eye and left knee, residents 103 and 105 being at risk for falls with injury, and 104 being at risk for unwitnessed respiratory distress,and [MEDICAL CONDITION] (low blood oxygen level). Findings include: Resident #101: A review of resident 101's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility nurse's notes dated 7/26/10 documented that resident 101 tried to self transfer, fell and was found on her buttocks on the floor next to the bed. Facility nurse's notes dated 9/18/10 documented that resident 101 was found lying on her back in the bathroom and complained of severe pain in the back of her head and left hip area. Facility nurse's notes dated 9/19/10 at 1:30 am, documented that resident 101 was crying out in pain when care was being given. Facility nurse's notes dated 9/19/10 at 10:30 pm documented that resident 101 was moaning and yelling out in pain through out the shift and that 15 minute checks continued. Facility nurse's notes dated 9/23/10 documented that resident 101 self transferred and was found in her bathroom, on the toilet. 9/26/10 and 9/30/10 nurse's notes documented that resident 101 was crying loudly in pain. Facility nurse's notes dated 9/30/10 documented that resident 101's alarms were sounding and she transferred self to wheelchair. Facility nurse's notes dated 10/2/10 documented that resident 101 tried to self transfer from wheelchair to toilet and fell on the floor. Facility care plan for resident 101 identified her to have potential for falls with interventions listed to include 30 minute checks, which were discontinued on 9/18/10 and 15 minute checks started. Xray results dated 9/19/10 documented that resident 101 had a fracture (break in the bone) of the left inferior pubic ramus (pelvis bone). Facility occurrence report dated 7/26/10 documented that staff heard alarms going off, ran to resident 101's room and found resident 101 on the floor on her buttocks next to the bed. Facility occurrence report dated 9/18/10 documented that resident 101's alarms were sounding and was found by CNA lying on her back on the floor in the bathroom with fracture listed as an injury and 15 minute checks listed as a preventative measure/corrective action. Facility occurrence report dated 10/2/10 documented resident 101 attempted to self transfer and fell . A review of facility 30 minute resident check lists from 8/16/10 to 9/13/10 for resident 101 revealed multiple days with no checks documented and multiple hours of checks not documented on the days which had 30 minute checks documented. A review of facility 15 minute resident check lists from 9/3/10 to 9/20/10 document only 4 days of partial documentation of 15 minute checks being done for resident 101. There were no documented 15 minute or 30 minute checks of resident 101 after 9/20/10. In an interview on 10/13/10 at 11:55 am, the Director of Nursing (DON) stated that resident 101 was on 30 minute checks prior to her fall on 9/18/10. The Director of Nursing stated she personally told the nursing staff that resident 101 was to be placed on 15 minute checks while in her wheelchair in her room, after her fall on 9/18/10. She (DON) stated the 15 minute checks did get written on the nursing care plan for resident 101, but did not get written on the certified nurse aide's (CNA) care plan, so the 15 minute checks were not followed up on with the CNA's who are the ones that do the 15 minute checks. The Director of Nursing stated that 15 minute checks were not done for resident 101. The Director of Nursing stated while she was looking for 15 an 30 minute check documentation for resident 101 and 102 as requested by the surveyor, she noticed that all documentation of checks was missing. The Director of Nursing then stated that approximately a month ago she had implemented a new documentation form for the Nurse Aides, and since that time they have not been doing any 15 or 30 minute checks. The Director of Nursing stated that all residents who were supposed to be on 15 or 30 minute checks had not been getting checked by staff since she implemented the new form. During an observation on 10/15/10 from 9:50 am to 10:25 am, resident 101 was observed by the surveyor to be in her room with no staff present and was not checked on by any staff member of the facility, for a total of 35 minutes of being unsupervised in her room. Resident 102: A review of resident 102's medical record revealed an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurse's notes dated 8/1/10 documented that resident 102 called out, alarms sounded and she was found on the floor in her room with 15 minute checks started. Nurse's notes dated 9/16/10 documented that resident 102 attempted to self transfer and fell sustaining skin tears to the bridge of her nose, left eye and left knee. Nurse's notes dated 9/21/10 documented that resident 102 stood up from her wheelchair and fell to the floor, landing on her bottom. Facility care plan for resident 102 documented she was at risk for falls with interventions listed to include 30 minute checks, which were increased to 15 minute checks on 8/2/10. Facility occurrence report dated 8/1/10 documented that resident 102's alarms were sounding, she was found on the floor on her back and that resident 102 stated she got up out of wheelchair and hit her head on the floor and that resident 102 complained of head and right shoulder pain. Preventative measures/corrective action listed on the occurrence report dated 8/1/10 were "increase checks to 15 minutes". Facility occurrence report dated 9/16/10 documented that resident 102 stood up from wheelchair, fell to floor and sustained skin tears to her nose, left eye and left knee. Facility incident report dated 9/21/10 documented that resident 102 stood up from wheelchair and fell to the floor onto her buttock. A review of facility 30 minute resident check lists from 7/31/10 to 8/14/10 for resident 102 revealed multiple days with no checks documented and multiple hours of checks not documented on the days which had 30 minute checks documented. There were no documented checks for resident 102 after 8/14/10. There were no documented 15 minute checks for resident 102. During an observation on 10/15/10 from 9:50 am to 10:25 am, resident 102 was observed by the surveyor to be in her room with no staff present and was not checked on by any staff member of the facility, for a total of 35 minutes of being unsupervised in her room. Resident 103: A review of resident 103's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurse's notes dated 9/29/10 documented that resident 103 was found on the floor in the bathroom. Facility care plan for resident 103 identified her to be at risk for falls with interventions listed to include sensor pad and tab alarm on bed and wheelchair at all times, toilet every 2 hours, educate resident to use call light. There were no documented 15 or 30 minute checks in the chart for resident 103. Facility incident report dated 9/29/10 documented that resident 103's alarms sounded and resident 103 was found on the floor in her bathroom, with intervention documented to be 15 minute checks when in room alone. In an observation on 10/14/10 from 10:45 am to 11:10 am, resident 103 was observed to be alone in her room with no staff present. In an interview on 10/14/10 at 11:10 am, staff #9 stated that resident 103 does not require 15 or 30 minute checks and that the only special order for resident 103 is to keep her feet elevated. In an interview on 10/14/10 at 10:45 am, resident 103 stated she fell at home and came to the facility for rehabilitation. Resident 103 stated she wanted to go home as soon as possible, but that she fell again in the facility while in the bathroom. Resident 103 showed the surveyor a bruise on her right leg that started in her inner groin area and ran the full length of her upper right leg to the knee. The bruise was dark purple in color and covered the entire inner aspect of her right upper leg. Resident 103 stated the bruise was painful, but she could tolerate it. Resident 104: A review of resident 1043's medical record revealed an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility physician orders [REDACTED]. Resident 104's minimum data set ((MDS) dated [DATE] documented that she was totally dependent on staff for transfers, mobility, eating and hygiene. Facility care plan for resident 104 documented a listed intervention of 15 minute checks dated 8/4/09. In an interview on 10/13/10 at 12:10 pm, the Director of Nursing stated that since the implementation of new charting for certified nurse aides (CNA) over a month ago, the CNA's have not been doing 15 or 30 minute checks. The Director of Nursing stated that resident 104 was not on 15 minute checks for falls prevention, but because she had an artificial airway ([MEDICAL CONDITION]) with an oxygen mask and her room is at the end of the hall, far away from the nurse's station. The Director of Nursing stated that resident 104's family requested the room, but since resident 104 requires close monitoring of her respiratory condition, she was placed on 15 minute checks. The Director of Nursing stated the 15 minute checks for resident 104 had not been done since the first of September 2010. A review of facility 15 minute resident check lists from 8/1/10 to 8/22/10 revealed multiple days with no checks documented and multiple hours of checks not documented on the days which had 15 minute checks documented. There were no documented checks for resident 102 after 8/22/10. In an observation on 10/14/10 from 12:20 pm to 1:00 pm, resident 104 was observed to be alone in her room with no staff present. Resident 105: A review of resident 105's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility care plan for resident 105 documented that she was at risk for falls with interventions listed to include tab alarms and sensor alarms at all times, blue mat next to bed and nonskid footwear. There were no documented 15 or 30 minute checks in the record of resident 105. Facility occurrence report dated 8/10/10 documented that resident 105 fell from bed and sustained a skin tear (location and size not documented). Facility incident report dated 8/21/10 documented resident 105's alarms were sounding and resident 105 was found on the floor next to the bed with preventative measures/corrective action documented as initiate 30 minute safety checks and continue use of safety alarms. In an interview on 10/13/10 at 2:00 pm, Facility Clinical Coordinator stated that the intervention of 30 minute safety checks was "missed" and never put on the nursing care plan, not put on the nurse aides care plan and never started. The clinical coordinator then wrote the 30 minute checks on the care plan for resident 105 in front of the surveyor. In an interview on 10/14/10 at 10:00 am, the Director of Nursing stated that the surveyor had a copy of all documented 15 minute and 30 minute checks for the last 3 months for all residents who were to be checked. #