Every finding on record at The Orchards at Redford

Based on interview and record review, the facility failed to submit mandatory staffing data (direct care staffing information) to Centers for Medicare and Medicaid (CMS) based on the Pay Roll Based Journal (PBJ) data, affecting all 72 residents who resident in the facility. Findings include: Per a review of the PBJ report for the Fiscal year 2026 1st quarter (July1,2025- September 30,2025). The facility also triggered for a one star staffing rating (indicating a lack of reported staffing or inadequate staffing). On 4/9/6 at 12:30 pm in an interview with Staffing Scheduler F and Human Resources (HR) Director L about the PBJ report and submission. HR L stated The facility failed to submit their quarterly staffing numbers to CMS due to a clerical error. No explanation was provided related to the specifics of the clerical error.

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), to include flushing all inactive fixtures to eliminate stagnation, resulting in the potential for increased risk of respiratory infection among all residents in the facility. Findings include: On 4/8/26 at 9:30 AM, Maintenance Supervisor I was queried regarding the facility's Water Management Program. Maintenance Supervisor I stated they test annually, water temps done daily, flushing of unused fixtures is done by environmental services, and that the building has been checked for plumbing dead legs. On 4/8/26 at 10:00 AM, the shower room located on the [NAME] Hall was observed with a sign posted on the door that the room was not in use. The door to the shower room was observed to be locked. Maintenance Supervisor I stated he would have to find the key to unlock the door. Maintenance Supervisor I searched for a key to unlock the door to the unused shower room for approximately 30 minutes and eventually had to use a drill to drill through the lock to access the unused room. Maintenance Supervisor I stated that the water to the unused shower room had been shut off. There was a wall mounted shower arm observed, with no shower head attached. The shower knob was turned to check for the presence of water, and a rush of brown, rusty water shot out of the pipe. On 4/8/26 at 10:35 AM, room [ROOM NUMBER] on the [NAME] Unit was observed to be locked. Maintenance Supervisor I was queried and stated that he was unsure of what room [ROOM NUMBER] was used for. Maintenance Supervisor I unlocked the door, and there was a large, wheelchair washing unit located inside the room. Maintenance Supervisor I was queried at that time and stated that to his knowledge, the wheelchair washer was not used. When asked if the water supply to the wheelchair washer had been turned off, Maintenance Supervisor I stated that he was unsure. The machine was turned on, and water began to fill the unit. On 4/8/26 at 10:40 AM, Nurse Manager E was queried about the wheelchair washer located in locked room [ROOM NUMBER]. Nurse Manager E stated that she has worked at the facility for almost a year, and that they do not use the wheelchair washer located in room [ROOM NUMBER]. Review of the facility's undated Water Management Program-Legionnaires noted: 4. Maintain constant recirculation in hot-water distribution systems serving patient-care areas. 04/08/2026 12:42 PM the Infection Preventionist (IP) was queried if they were part of the facility's Water Management Team, and IP stated No. Review of the facility's undated Water Management Program-Legionnaires noted: Water Management Team: 2. Create the water management team- Members should include the: a. Administrator b. Owner Representative c. Maintenance Director d. Infection Preventionist e. other the facility deems appropriate to fully assess and address risk.

Based on observation and interview, the facility failed to maintain the mechanical ventilation system, for the [NAME] and North halls, and in the [NAME] soiled utility room. This deficient practice had the potential to affect all residents on the [NAME] and North halls. Findings include:On 04/08/2026 at 9:43 am, the [NAME] soiled utility room was observed with Maintenance Supervisor I. The soiled utility room had a strong, pungent odor. The mechanical ventilation was checked by placing a piece of toilet tissue against the ceiling vent grate. No suction was present, as the piece of toilet tissue did not cling to the ventilation grate cover. Maintenance Supervisor I confirmed that vent was not functional. The mechanical ventilation in the resident bathrooms on the [NAME] and North halls was also checked, and they were found to be non-functional. Maintenance Supervisor I confirmed that the same unit controlled the ventilation for the soiled utility room and the [NAME] and North Hall bathrooms and stated that it might be an issue with the belt.

Based on observation and interview, the facility failed to maintain the air conditioning unit and filter in a clean manner, for Resident #40, resulting in resident complaints with their living conditions. Findings include: On 4/8/26 at 2:30 PM, Resident #40 complained that the filter for the wall mounted air conditioning unit in her room is never cleaned. Resident #40 was visibly upset and stated that she is breathing in all that dust. Resident #40 further stated that she is on oxygen and already has a hard time breathing. The air conditioning unit was observed to be running and blowing air directly at the foot of the resident's bed. The outside front cover of the unit was observed to be coated with dust, and the interior filter was observed to be soiled with a buildup of dust. On 4/8/26 at 2:40 PM, Maintenance Supervisor I was queried about the cleaning of the air conditioner and stated that housekeeping was responsible for cleaning the exterior of the unit, and maintenance was responsible for cleaning the filter. Maintenance Supervisor I confirmed the dusty air conditioning unit but provided no further explanation.

Based on observation, interview, and record review, the facility failed to ensure timely showers and incontinence care were provided to dependent residents for one resident (R77) of three reviewed for Activities of Daily Living (ADL) care. Findings include: On 04/07/2026 at 12:00 PM, R77 was observed to be on their back in bed, dressed in a hospital style gown. R77 reported they had not received a shower the day before when they had asked staff. R77 reported they had asked staff for a shower this day and was told they were not signed up for a shower. R77 reported they had not had a shower in the three weeks they had been at the facility and due to their (Multiple Sclerosis) MS they needed assistance to take a shower. R77 also reported they pee a lot and their brief was currently wet. R77 activated their call light and Certified Nursing assistant (CNA) B entered the room and R77 asked about getting a shower. CNA B reported to R77 that as R77 had a wound they could not get a shower. CNA B also reported R77's showers were Monday and Thursday. A shower was not offered to R77. At 12:16 PM, R77 activated their call light. The dome light above the door did not activate nor was there an audible tone in the hallway. At 12:19 PM, a staff member entered and exited the room of R77. R77's brief was not changed. At 12:33 PM, Licensed Practical Nurse (LPN) G had brought medication to R77 and reported R77 had asked to be changed. At 12:53 PM, R77 reported they had not been changed and was wet with urine. The lunch tray had been set up on the tray table. At 2:25 PM, a shower had not been completed. At 3:48 PM, R77 reported they were soiled again and told someone who had not come back. At 4:35 PM, LPN G provided R77 with medication. At 4:41 PM, no staff had been seen to enter the room of R77 and R77 reported they had not been changed. On 04/09/2026 at 8:35 AM, R77 reported they were wet and soiled and had reported to staff they needed to be changed. It had been reported that breakfast was being served and could not be changed. At 9:30 AM, LPN H entered to complete wound care and reported R77 was wet and in need of a brief change. LPN H reported it was important to change R77 timely with the type of wound R77 had on their hip. A review of the progress notes and treatment administration records (TARs) documented a current open wound to the left hip and a recent wound to the buttocks which required daily wound care. A review of the facility records for R77 revealed R77 was admitted into the facility on [DATE]. Diagnoses included Unstageable Pressure Ulcer of the Left Hip, Multiple Sclerosis, and Paralysis. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 12/15 Brief Interview for Mental Status (BIMS) score and substantial/maximal staff assistance for toileting hygiene, to roll left and right in bed and lower body dressing. The active care plan revised 04/01/2026 documented, .incontinent of bowel and/or bladder .Assist me to the toilet before meals. Date Initiated: 03/16/2026. Check me at least every two hours during the day and change my brief if needed. Date Initiated: 03/16/2026. Keep me as clean and dry as possible . Date Initiated: 03/16/2026 . I have actual impairment to skin integrity of the Left hip. Date Initiated: 03/16/2026. Keep my skin clean and dry .On 04/09/2026 at 9:51 AM, the Director of Nursing (DON) reported they had visited R77 and typically staff should ensure residents are clean and dry before meals and during meals times resident would not typically be changed due to potential infection control concerns. The DON also noted the concerns related to incontinence care during meals times had been brought up in resident council and residents were encouraged to put their call light on before mealtimes when they needed care. A review of the previous six months of resident council minutes documented timely call light response concerns in March 2026 and February 2026 but not specifically address education related to the use of call lights by the residents. A review of the undated facility Nursing SOP (standard operating procedure) titled, Briefs and Under pads revealed, Purpose: To provide cleanliness, comfort to the resident, and to prevent physiological complications .A review of the undated facility Nursing SOP titled, Toileting revealed, Purpose: To help the resident maintain normal and adequate bowel and bladder habits as indicated by his or her condition .

Based on observation, interview, and record review, the facility failed to ensure sufficient staffing to meet the needs of the residents for three residents (R57, R2 and R39) of three residents reviewed for care needs being met. Findings include:R57 During an observation on 4/7/2026 at approximately 10:00 A.M. Resident (R57), who was alert and oriented, and cognitively intact, complained the facility did not have enough staff and during the night shift when the call light was pushed the Certified Nurse Assistants (CNAs) sometimes took as long as an hour to respond. R57 stated, I am at the end of the hall and when you need to be changed an hour is unacceptable. R2 On 4/7/26 at12:30 P.M. during a lunch meal observation R2 who was alert and oriented and cognitively intact, was interviewed concerning receiving cold food. R2 reported when returning from dialysis a meal tray was left on the bedside table and the food was cold, but no staff was available to reheat (R2) meal tray. R2 reported there is not enough staff on the night shift. The staff will not reheat my food, it's been going on for a while. When I am here my food is served warm but not on days of dialysis. Record reviews revealed R2 received dialysis three times a week on Tuesdays, Thursdays and Saturdays and returned to the facility around 7:00-7:30 P.M. R2 was identified as a nutritional risk and was underweight. The resident was prescribed a Regular diet with Double Protein at all meals. On 4/8/2026 at 5:00 P.M. in a follow up interview and observation, R2 again reported when returning from dialysis the previous night on 4/7/26 (R2) tray was at the bedside. No staff responded when the call light was turned on, and there was no available staff to heat R2's food. R2 stated, I just left the tray; no one should have to eat cold food after dialysis. On 4/8/2026 at approximately 5:15 P.M. Registered Dietitian (RD) O Presence was requested to observe the resident's dinner meal. RD O stated, R2's food should have been reheated by the nursing staff. Dietary staff leaves the unit after serving each meal. R39 On 4/8/2026 at 5:30 P.M. During an interview R39's legal guardian stated, I make daily visits to the facility to make sure he is fed and taken care of and when I cannot come, I send somebody from the family or a friend because the unit is frequently short staff. On 4/9/2026 at 12:50 P.M. Staffing Scheduler F (who is also a CNA) was interviewed regarding staff shortages. Staffing Scheduler F stated they are short of Certified Nurse Aides (CNA's) especially on the afternoon and midnight shifts. Six CNA's' are scheduled for orientation next week, the turnover is high. The new CNA's work and get through orientation but once they work the units they leave, sometimes without notice. This facility has a system that allows staff to get paid at the end of each day, so the CNAs may work two or three days and not return. The average census here runs in the 70's, which they try to schedule two to three CNAs on the (Day shift) on the [NAME] Unit and three to four CNAs in the afternoon. Frequently they must pull staff if there is a call-In on the TCU Unit. The facility does not use pool staff. When a CNA calls in sometimes, they stay and there are several other staff members that are also CNAs. On 4/9/26 at 9:23 AM, an interview was conducted with Certified Nurse Assistant (CNA) B, they were asked if they feel they had enough staff to do their job effectively and reported the facility only schedules two or three people for the unit and on two of the hallways where the residents require a lift which requires two person assistance. CNA B continued; saying they pass meal trays, assist people with meals and after mealtime they are expected to pick up trays and clean them off before sending them to the kitchen. The CNA reported the facility also requires them to do laundry for the residents and reports they have difficulty completing assigned tasks in eight-hours along with providing showers. On 4/9/26 at 9:32 AM, an interview was conducted with CNAC and reported they do not feel they have enough staff as the facility adds extra tasks onto us like assisting with dietary, housekeeping and they don't understand how or why they are responsible for resident laundry. On 4/9/26 at 9:58 AM, an interview was conducted with CNAA who reported they did not understand why the CNAs were responsible for the residents laundry when the facility has a laundry department. On 4/9/26 at 2:30 PM, an interview with the Director of Nursing (DON) and Administrator was conducted. They were asked about their facility assessment since it was noted that they required 3 nurses on the night shift. The DON was then asked how the nurses are scheduled per unit. The DON reported that there is one nurse on the Transition Care unit and two on the [NAME] unit and one nurse is to go the Greenhouse. The DON was then asked since there is one staff member (CNA) at the Greenhouse, that CNA knows to call the nurse if there is an emergency, saying, we tend to put our less complex medical needs in that unit. There was no additional information provided at the exit of the survey.

Based on interview and record review, the facility failed to provide timely dental services for one resident (R3) of one reviewed for provision of dental care. Findings include: On 04/08/2026 at 2:10 PM, R3 was asked about any recent dental visits and reported they had not been seen by a dentist recently. R3 reported a concern for a mouth infection and some redness to the lower gumline. A review of the most recent dental visit note dated 11/20/25 documented two teeth with fractures and seven missing teeth. A review of the Nurse Practitioner (NP) progress note dated 01/20/2026 at 13:09 (1:09 PM) revealed, (R3) was seen today for follow up on sore gums and left knee pain . (R3) (complaint of) c/o pain to (their) upper gumline, inspected oral cavity. Patient has tooth decay and has a tooth that has partly came off. There is no redness of the gums or swelling, tender to touch . Assessment/Plan: Dental caries/sore . gums: no signs of infection. Will start patient on orajel . Needs Dentist evaluation . A review of the facility records for R3 revealed R3 was admitted into the facility 03/19/24. Diagnoses included Dementia and Diabetes. The active care plan revised 10/13/25 documented, I need assistance with my (activities of daily living) ADLs . Personal Hygiene/Oral care: I require supervision from you for personal hygiene and oral care . On 04/09/2026 at 1:17 PM, Licensed Practical Nurse (LPN) K reported they were not aware of any dental concerns for R3 and asked the Unit manager, LPN E. A Dental Services order dated 02/02/26 entered by LPN E was reviewed with them. LPN E reported the dental service was on site monthly to follow up on dental service referrals. LPN E was asked for documentation that R3 had been followed up by the dental service. No documentation R3 was seen by the dental service in February 2026, or March 2026 was received prior to survey exit. It was also noted to LPN E the ordered Orajel had not been documented as given. Upon review of the January 2026 medication administration records (MARs), Orajel was documented as ordered from the pharmacy but not received. LPN E reported this was due to the Orajel being an over-the-counter medication and the family had brought it in for the resident. On 04/09/2026 at 9:51 AM, the Director of Nursing (DON) reported the Orajel was not a medication the facility kept on hand, and it needed to be ordered. A review of the undated Social Services (standard operating procedure) SOP titled, Dental revealed, Policy: It is the policy of this facility to assist residents in obtaining routine and 24 hour Emergency dental care to meet the needs of each resident .if routine service needed, the resident will be placed on the schedule to see the dentist at the next scheduled visit .

Based on observation, interview, and record review, the facility failed to provide coffee for two (R26, R62) of two residents reviewed for beverage preferences. Findings Include: On 4/7/2026 at 9:00 A.M., R26 was heard asking Unit manager (UM) E for a cup of coffee. R26 exchanged a few pleasantries with UM E and returned from the unit kitchen with a large cup of coffee. R26 proceeded to comment I never get coffee, it makes me feel so good in the morning, I miss my coffee. On 4/8/26 at 9:05 A.M., during a breakfast observation R26 asked Certified Nurse Assistant (CNA) R for a cup of coffee. CNA R acknowledged R26's, request gesturing give me a minute I am helping (name of R39). Hearing R26's request nurse S spoke out stating, I will get your coffee. R26 leaned over the table to R55 and asked Do you want coffee? I don't know why we do not get coffee at least for breakfast. Nurse S began offering coffee and condiments to other residents within the dining area. During the meal service coffee was observed on a side table with other assorted beverages but residents were not offered or given coffee. On 4/8/2026 at 5:00 P.M., review of the master menu provided by the facility revealed residents were to be served juice/beverage of their choice, and milk if desired. The menu was reviewed with Registered Dietitian (RD) O who was present during the meal observation. RD O reported coffee was sent to the units daily and could not provide any reason why nursing staff was not giving the residents coffee. On 4/9/2026 at 9:00 A.M. interview with Dietary Supervisor (DS) N and Regional Certified Dietary Manager (CDM) P concerning residents not being served or offered coffee for breakfast. Each reported coffee was sent to both units daily for breakfast and the nursing staff was responsible for providing residents with the beverage of their choice. Any time a resident wants something different nursing staff can always call the main kitchen and that includes coffee. DS N reported coffee should be served with the other beverages like juice and water and not at the end of the resident's meal. Dietary Aides serve food from the steam tables on each unit at each meal, the dietary staff do not pass food to the residents, only the CNAs on the unit. During an interview with an anonymous CNA, they confirmed, We cannot do it all. It is too much. R62 On 04/07/2026 at 11:40 AM, R62 was seated in a wheelchair in their room watching TV. R62 reported the facility had taken away their hotpot appliance that heated water for their coffee. R62 reported they missed having the appliance as they may get a cup of coffee in the morning but were unable to get one at other times during the day. R62 reported staff had told them no coffee was available when they had asked. No coffee cup was observed. On 04/08/2026 at 8:13 AM, R62 was dressed and seated in a wheelchair in their room with the TV on. A cup of coffee was not observed. On 04/08/2026 at 11:04 AM, the Director of Nursing (DON) reported the hotpot had been removed about a year ago, as it was a heat source which may cause a fire. On 04/08/2026 at 1:19 PM, Activity Aide Q reported coffee is available on most days on R62's unit. Activity Aide Q reported R62 does not come out of their room for the coffee hour and knows R62 does like their morning coffee but was not aware of other times. On 04/08/2026 at 1:49 PM, R62 was in their room, dressed and seated in their wheelchair watching TV. R62 reported they had stopped asking for coffee as the answer had generally been that it was unavailable outside of breakfast time. A review of the facility records for R62 revealed, R62 was admitted into the facility 02/14/23. Diagnoses included Diabetes, Heart Failure and Lung Disease. The active care plan revised 03/02/26 documented, I am dependent on staff for meeting, emotional, intellectual, physical and social needs . I need set up assistance by staff to eat .

Based on observation, interview, and record review, the facility failed to ensure a properly functioning communication system which relays the call directly to a staff member or to a centralized staff work area for one (R76) of one resident reviewed for a properly function call light system. Findings include:On 4/7/26 at 9:22 AM, an interview with R76 was conducted and they reported that since they returned from the hospital two weeks ago the call button does not work. R76 reported that the past two nights were extremely rough for them because they needed to use the restroom but depend on staff to assist them to the toilet and when they pushed the call bell no one came in and when staff finally decided to stroll in they were already a big mess (had a bowel movement on themselves). An observation of the room was made, the call light button was on residents' bed and the box for the button was detached from the wall. R76 did not have a bell or any other means to communicate to the facility if assistance was needed. R76 reported that not being able to get in contact with staff makes them feel uneasy at times. A review of the record revealed that R76 was admitted to the facility on [DATE] with a diagnoses of Chronic Obstructive Pulmonary Disease, Obstructive Sleep Apnea and Essential Hypertension. A Minimal Data Set (MDS)assessment completed on 3/30/26 with an brief interview for mental status score (BIMs) of 15 which indicated no cognitive impairment. On 4/8/26 at 11:20 AM, an interview was conducted with Licensed Practical Nurse (LPN) D and they were asked about the call light system and if it was functioning properly. LPN D reported that the call lights were working and that when a resident presses the call light the call goes to their pager and also displays on a screen located in office. LPN D was then asked to go to R76's room and demonstrate how the call light system works. LPN D pressed the call button and there was no alert to the pager they were assigned to. LPN D went to the office and the room number did display on the screen but there was no sound nor pager alert to let anyone know that assistance was needed. LPN D was then asked, was the call light working for this resident, LPN D reported, no. LPP D was not for sure why it was not functioning. The call light/response time policy was requested on 4/9/26 at 10:52 AM but not received prior to exit.

This citation pertains to intakes 2743619 and 2792857.Based on observation, interview, and record review, the facility failed to ensure care needs were met timely for five residents (R901, R905, R906, R907, R908) of eight residents reviewed for unmet care needs. Findings include:R901On 03/04/26 at 8:59 AM and 9:46 AM, R901was observed to be lying in bed, with the head of the bed up around 20 - 30 degrees and dressed in a hospital style gown. A pillow was under the bottom sheet at the right side. R901 was not supported by the pillow. R901 was oriented with their right side to the wall. The call light was under the covers at the right side of R901. At 10:28 AM, R901 continued in bed as before. R901's Responsible Party (RP) was at the bedside and expressed concerns with staff assistance with the resident's needs. At this time the RP was able to show R901's legs were contracted, R901's legs were flexed at the knees so that the heels were at the buttocks. The knees were pointed toward the left side of the bed with the torso turned so the shoulders of R901 rested on the bed. R901 had gauze dressings to both feet and the right hip visible. Bloody drainage had soaked through different parts of each dressing. R901 did not move the legs independently. The RP reported R901 had open pressure related wounds to both heels, the side of the feet, both hips and the buttocks. No devices or pillows were observed to pad the bony prominences of the knees or separate the feet from laying on top of each other and press against the buttocks area. R901 was on their left hip. At 12:31 PM, R901 continued in bed in a similar position as before with the knees toward the left side. The head of the bed was up around 30 degrees. R901's hand and arms moved about but no leg movement was observed.On 03/05/26 at 8:01 AM, R901 was again on their back in bed, dressed in a hospital style gown, with the head of the bed up around 20-30 degrees and the knees pointed toward the left. At 11:05 AM, continued in bed positioned as before. No specialty or low air loss mattress was in place. No pillow at the left side under sheet the call pad style call light was hanging over the headboard of the bed. At 12:17 PM, R901 continued on their back as before. The call light was over the headboard. A review of the record for R901 revealed R901 was admitted into the facility on [DATE]. Diagnoses included Multiple Sclerosis, Contracture of Muscle Lower Legs and Malnutrition. The progress note dated 01/10/26 at 7:19 PM documented, During morning rounds observed patient laying on floor mat near bedside . A Nurse Practitioner note date 01/16/26 documented, .Post fall continue to maintain and fall prevention protocol . A review of the active care plan documented, I had an actual fall. Date Initiated: 01/10/2026 . reposition resident frequently while in bed Date Initiated: 02/27/2026, Revision on: 02/27/2026, Concave mattress Date Initiated: 01/14/2026, Revision on: 01/21/2026 . A review of the Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition and the R901 was dependent on staff for all hygiene, toilet needs, dressing, rolling left and right in bed, and transfer to/from chair to bed.R905 On 03/04/26 at 8:32 AM, R905 was observed to be in bed with the head of the bed up around 30-45 degrees. The call light was on a table behind the head of the bed along with a hand and wrist splint. R905 was on their back in bed, dressed in a hospital style gown and their waist was down beyond the break for the head of the bed. R905 was asked about their position in bed and noted they can usually use the bed controller and sit themself up. The bed controller was hooked on the head of the bed. R905 did not remove the right hand from under the covers. At 9:52 AM, the breakfast tray was out of the room, and the head of the bed was around 20-30 degrees. The call light was at the left shoulder. At 12:18 PM, R905 attempted use of the bed control but only was able to get the bed slightly higher. R905 was not able to reach the call light at the left shoulder to activate the call light for assistance. At 3:24 PM, R905 was observed to be on their back in bed as before with the head of the head of bed up around 30-45 degrees. On 03/05/26 at 8:35 AM, staff were observed to enter and exit the room of R905. The call light was under the blankets at the left side of R905. R905 was on their back in bed. At 11:07 AM, R905 continued to be in bed, the room was dark, and the head of bed up around 30-45 degrees. A review of the record for R905 revealed R905 was admitted into the facility on [DATE]. Diagnoses included Alzheimer's, Heart Disease and Chronic Pain. A review of the active care plan documented, I need assistance with my ADLs . Bathing/Showering: I am dependent on staff . Bed Mobility: I require supervision by staff to reposition frequently . Eating: I am able to eat with setup assistance and require encouragement to eat by staff . Toilet use: I am dependent on you .R906On 03/04/26 at 9:07 AM, R906 reported the need for physical therapy. R906 was in bed and dressed. R906 had a dressing on the left foot. R906 expressed that the call lights were not working while pressing the call light multiple times with their thumb. No staff entered during the time of the conversation with R906. R906 noted their clock was not ticking and reported it had not worked for a while. The TV had an informational screen with words but no picture. At 9:47 AM staff were observed to enter the room of R906. At 10:45 R906 continued in their bed. At 12:28 PM, R906 was observed to be seated in a wheelchair with one footrest on the right side, outside their room. R906 was in a corner with their right side next to the wall and handrail. The legs were straight out and R906 had appeared to slide down in the chair, so the buttocks were at the edge of the chair and the shoulders at the top of the low back wheelchair. R906 had a grill cheese sandwich on a plate on a tray table in front of them. R903 reported they wanted to try and sit up but need to lock the wheelchair. R906 used only their right arm to try to push themselves up using the handrail or the arm of the wheelchair. R906 could not reach the brake on the left side of the wheelchair with eighter hand. The left hand and arm did not appear to have the range of motion to set the left brake as R906 reported they were attempting to do. R901 reported they needed someone to help. The aide was assisting a resident to eat in another resident's room; The nurse was in the nursing in office on the computer and the unit manager was out in the main dining area. At 12:40 PM, staff went around the unit to pick up the plates from breakfast. R901 continued in their wheelchair as before. On 03/05/26 at 8:05 AM and 11:07 AM, R906 was observed to be in bed dressed in the same clothes as the day before. The head of the bed was up around 20-30 degrees. At 12:20 PM, R906 was observed to be laying on their back in bed with the head of the bed up around 20-30 degrees. The feet of R906 were on the floor with the back of the knees at the edge of the bed. A review of the record for R906 revealed R906 was admitted into the facility on [DATE]. Diagnoses included Stroke, Heart Failure and Difficulty Swallowing. A review of the active care plan documented, I need assistance with my (Activities of Daily Living) ADLs . Bathing/Showering: I am dependent on you . Bed Mobility: I require substantial assistance by staff . Dressing: I require substantial assistance by staff . Eating: I need supervision by staff . Toilet use: I am dependent on you .R907On 03/04/26 at 9:27 AM, R907 was observed to be in bed in their room. R907 was on their back sitting up in bed with the head of the bed up around 45-60 degrees. R907's call light cord was looped over the call junction box on the wall. R907's bed was oriented perpendicular to and away from the wall the length of the bed plus a few feet. R907 had a hotel style desk bed on their tray table which was across their lap. R907 expressed concerns about getting changed timely when they were wet and pain in their shoulder for which the facility did not consistently do anything. R907 reported they had asked to get changed earlier when they woke up around five AM and it had not been done yet. R907 reported they can hear staff talking but not coming in. R907 was asked about the bell on the tray table and on the first two attempts the bell did not ring. R907 was prompted to tap the bell harder and it rang once and was silent. No staff immediately entered. At 9:45 LPN A entered the room to provide medications to R907. At 10:54 AM and 12:40 PM, R907 was in a similar position as before. On 03/05/25 at 8:06 AM, and 11:05 AM, R907 was observed to bed in bed with head of the bed around 20-30 degrees. A review of the record for R907 revealed R907 was admitted into the facility on [DATE]. Diagnoses included Traumatic Brain Injury, Epilepsy and Anxiety. A review of the active care plan documented, I need assistance with my (Activities of Daily Living) ADLs . Bathing/Showering: I am dependent on staff . Dressing: I am dependent on staff . Bed Mobility: I am dependent on staff . Dressing: I require substantial assistance by staff . Eating: I am able to feed myself with setup assistance . Toilet use: I am dependent on you .R908On 03/04/26 at 8:40 AM, R908 was observed to be in bed without pants but wearing a shirt. The call light was looped over the box attached to the wall opposite from R908's bed. R908' bed was against the wall on the left side of the room with the call box on the right wall. A secondary bell was not observed. R908 said they did not think it worked. The wall clock was not running and read 11:20. R908 remarked that the staff had missed giving them a shower on Tuesday and reported their normal shower days were Tuesday and Friday afternoons. R905 reported that staff had not come in to ask if they wanted a shower. R905 remarked there might have been only one nurse aide on for the afternoon. A urinal was hooked on the edge of the trash can and hanging inside the trash can. The urinal was around one third full. R908 commented they use it when they can but does not always feel it when they have to go and has had some accidents. R908 asked if staff should help them when then have accidents and commented was hard to get them to do so.On 03/05/26 at 8:40 AM, R908 was observed to be in bed with their head at the opposite end of the bed from the day before. A radio was on the bed near their head. A hotel desk type bell was observed on the tray table. The call light cord remained across room from bed hooked over the box. R908 reported they had urinated in their brief as they could not feel when they had to go and staff seemed aggravated and did not change it and after while it got wet more and then took them off has it had wet through to their pants also. R908 commented it did not make them feel good to have a wet brief. it was also observed that the clock was not running and read 11:20. At 1:02 the therapy manger reported R908 was currently on the therapy caseload since 01/16/26. R908 was reported to have weight gain and increased lethargy and need a lot of encouragement and setup. The Therapy manager recalled the nurse talked to him about R908 waiting for a brief change on 03/03/26. The Therapy further noted R908 was contact guard (touching) assist for transfer. A review of the record for R908 revealed R908 was admitted into the facility on [DATE]. Diagnoses included Dementia and Diabetes. A review of the active care plan documented, I need assistance with my (Activities of Daily Living) ADLs . Bathing/Showering: I need substantial assistance . Dressing: I require partial assistance . Eating: I am able to feed myself with setup Toilet use: I am dependent .On 03/04/26 at 9:23 AM, Licensed Practical Nurse (LPN) A reported R906 had not mentioned the call light not working. LPN A reported only one nurse was assigned to their unit to care for the 17 patients and that with 24 there is only one nurse assigned. LPN A further noted the call light had not worked properly in a long time and estimated it was more than six months. An audible tone was not heard upon activation of the call lights and the monitor was inside the nurse's office on top of the desk.On 03/04/26 at 10:55 AM, unit manager (UM) B was asked about physician visits by the doctor for R901 and reported they had been working at the facility since July 2025 and had not seen the physician visit. UM B reported the physician's NP did visit. It was further reported the unit had a combination of long term and short-term residents.On 03/04/26 at 12:41 PM, call lights were observed on the unit for the identified residents. The call monitoring station was observed to have two activated lights for rooms [ROOM NUMBERS]. Neither room had a light activated above the door and no chime was audible.On 03/05/26 at 1:21 PM, the call lights in the rooms of R901, R904, R905, R906, R907 and R908 and rooms [ROOM NUMBERS] were checked with the Maintenance Director. All the call lights showed on the monitor in the nurse office. The call for room [ROOM NUMBER] had been on for 20 minutes. LPN A reported the call lights had not been audible for months and thought the monitor should be outside of the office. The Maintenance Director looked at the monitoring station for a volume control, and none was found. On 03/05/26 at 1:37 PM, concerns were reviewed with the administrator and Director of Nursing (DON) and reported staff are available to meet the needs of the residents. A review of the undated nursing standard operating procedure titled, Bed Mobility revealed, Purpose: To provide improve or maintain the resident's self-performance in moving to and from lying position, turning side to side, and positioning him or herself in bed. A review of the facility policy titled Call Lights revised July 2018, documented, It is the policy of this facility to answer call lights as promptly as possible. The policy did not address the functionality of the call light system.

This citation pertains to intakes 2743619 and 2792857.Based on observation, interview and record review the facility failed to ensure call lights were fully functional for six residents (R901, R904, R905, R906, R907, R908) and two rooms of eight resident rooms reviewed for call light function. Findings include: R901On 03/04/26 at 8:59 AM and 9:46 AM, R901was observed to be lying in bed, with the head of the bed up around 20 - 30 degrees. The call light was under the covers at the right side of R901. At 10:28 AM, R901 continued in bed as before. R901's Responsible Party (RP) was at the bedside and expressed concerns for staff assistance with the resident's needs. On 03/05/26 at 8:01 AM, R901 was on their back in bed, the head of the bed up around 20 - 30 degrees. At 8:48 AM, staff were seated bedside. At 11:05 AM, R901 continued in bed positioned as before. The call pad style call light was hanging over the headboard of the bed. At 12:17 PM, R901 continued on their back as before. The call light was over the headboard. R904On 03/04/26 at 8:31 AM, R904 was observed to be eating breakfast in bed. At 9:53 AM, R904 continued in bed as before. At 11:58 AM, R904 was asked about the care and reported the call light did not work. At 3:22 PM, R904 continued in to be in bed. R904 was not observed to be out of bed during the survey.On 03/05/26 at 8:25 AM, R904 was observed to be in bed with the head of bed up around 30-45 degrees. R904 had a hotel style desk bell on the tray table. R904 reported the bell was given to them because the call light did not work. R904 pushed the call button with their thumb to activate the light. No chime was heard. The call monitoring station in the nurse office was observed to have the room number of R904 but no chime or bell was heard. room [ROOM NUMBER] had also been activated. R905 On 03/04/26 at 8:32 AM, R905 was observed to be in bed. The call light was on a table behind the head of the bed. At 9:52 AM, R905 was in bed with the call light at the left shoulder. R905 did not reach the call light when attempted. At 12:18 PM, R905 continued to be in bed. R905 was not able to reach the call light at the left shoulder to activate the call light for assistance. At 3:24 PM, R905 was observed to be on their back in bed. On 03/05/26 at 8:35 AM, staff were observed to enter and exit the room of R905. The call light was under the blankets at the left side of R905. R906On 03/04/26 at 9:07 AM, R906 reported the need for physical therapy. R906 expressed that the call lights were not working while pressing the call light multiple times with their thumb. No staff entered during the time of the conversation with R906. At 9:47 AM staff were observed to enter the room of R906. At 10:45 R906 continued in their bed.R907On 03/04/26 at 9:27 AM, R907 was observed to be in bed in their room. R907's call light cord was looped over the call junction box on the wall. R907 was oriented perpendicular to and away from the wall the length of the bed plus a few feet. R907 had a hotel style desk bed on their tray table which was across their lap. R907 expressed concerns about getting changed timely. R907 was asked about the bell on the tray table and on the first two attempts the bell did not ring. R907 was prompted to tap the bell harder, and it rang once and was silent. No staff immediately entered. At 9:45 LPN A entered the room to provide medications to R907. At 10:54 AM and 12:40 PM, R907 was in a similar position as before.R908On 03/04/26 at 8:40 AM, R908 was observed to be in bed. The call light was looped over the box attached to the wall opposite from R908's bed. R908's bed was against the wall on the left side of the room with the call box on the right wall. A secondary bell was not observed. R908 said they did not think the call light worked. On 03/05/26 at 8:40 AM, R908 was observed to be in bed with their head at the opposite end of the bed from the day before. A radio was on the bed near their head. A hotel desk type bell was observed on the tray table. The call light cord remained across room from bed hooked over the box. On 03/04/26 at 9:23 AM, Licensed Practical Nurse (LPN) A reported R906 had not mentioned the call light not working. LPN A reported only one nurse was assigned to their unit to care for the 17 patients and that with 24 there is only one nurse assigned. LPN A further noted the call light had not worked properly in a long time and estimated it was more than six months. An audible tone could not be heard upon activation of the call light.On 03/04/26 at 12:41 PM, call lights were observed on the Transitional Care Unit. The call monitoring station was observed to have two activated light room [ROOM NUMBER] and 110. Neither room had a light activated above the door and no chime was audible.On 03/05/26 at 1:21 PM, the call lights in the rooms of R901, R904, R905, R906, R907 and R908 and rooms [ROOM NUMBERS] were checked with the Maintenance Director. All the call lights showed on the monitor in the nurse office. The call station sat on top of the desk in the office. None off the call light activations triggered an audible sound. The call for room [ROOM NUMBER] had been on for 20 minutes. LPN A reported the call lights had not been audible for months and thought the monitor should be outside of the office. The Maintenance Director looked at the monitoring station for a volume control, and none was found. On 03/05/26 at 1:37 PM, the administrator reported they were not aware of the problem with the call lights. A review of the facility policy titled Call Lights revised July 2018, documented, It is the policy of this facility to answer call lights as promptly as possible. The policy did not address the functionality of the call light system.

This citation pertains to intakes 2743619 and 2792857.Based on observation, interview, and record review the facility failed to implement interventions for two residents (R901, R903) of three reviewed for falls. Findings include: R901On 03/04/26 at 8:59 AM and 9:46 AM, R901 was observed to be lying in bed, with the head of the bed up around 20 - 30 degrees and dressed in a hospital style gown. A pillow was under the bottom sheet at the right side. R901 was not supported by the pillow. A mat was on the left side of the bed and a urinary catheter bag hung on the left side of the bed frame toward the foot of the bed. The right side of the bed was against the wall. R901 was oriented with their right side to the wall. The call light was under the covers at the right side of R901. The resident answered questions in a hushed voice. It was not confirmed that R901 was assisted to eat their breakfast meal. R901 was skin and bones with minimal visible muscle tissue to the arms and collar bones and shoulder joints. At 10:28 AM, R901 continued in bed as before. R901's Responsible Party (RP) was at the bedside and expressed concerns for falls and physician visits and staff assistance with the resident's needs. The responsible party reported they had not talked directly to the assigned physician nor the medical practitioners. The RP noted the resident reported the facility was supposed implement a concave mattress with side bolsters help R901 to stay in bed. The RP was unsure how R901 could have fallen out bed and revealed R901 legs were contracted and flexed at the knees so that the heels were at the buttocks. The knees were pointed toward the left side of the bed with the torso turned so the shoulders of R901 rested on the bed. The RP reported they did not feel R901 could move sufficiently to have fallen out of bed onto the floor on their own. R901 did not move the legs independently and had decreased range of motion of the hands, arms and shoulders. The RP reported R901 had open pressure related wounds to both heels, the side of the feet, both hips and the buttocks. The leg anchor for the urinary catheter tubing was not secured to the leg of R901. No low air loss mattress or specialty mattress was in place. At 12:31 PM, R901 continued in bed in a similar position as before with the knees toward the left side. The head of the bed was up around 30 degrees. At 3:20 PM, R901 continued in bed positioned as before. R901's hand and arms moved about but no leg movement was observed.On 03/05/26 at 8:01 AM, R901 was on their back in bed, dressed in a hospital style gown, with the head of the bed up around 20-30 degrees and the knees pointed toward the left with the legs flexed. At 11:05 AM, R901 continued in bed positioned as before. No specialty or low air loss mattress was in place. No pillow was at either side of the torso. The call pad style call light was hanging over the headboard of the bed. At 12:17 PM, R901 continued on their back positioned as before. The call light was over the headboard. A review of the record for R901 revealed R901 was admitted into the facility on [DATE]. Diagnoses included Multiple Sclerosis, Contracture of Muscle Lower Legs and Malnutrition. The progress note dated 01/10/26 at 7:19 PM documented, During morning rounds observed patient laying on floor mat near bedside . A Nurse Practitioner note date 01/16/26 documented, .Post fall continue to maintain and fall prevention protocol . A review of the active care plan documented, I had an actual fall. Date Initiated: 01/10/2026 . reposition resident frequently while in bed Date Initiated: 02/27/2026, Revision on: 02/27/2026, Concave mattress Date Initiated: 01/14/2026, Revision on: 01/21/2026 . A review of the Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition and the R901 was dependent on staff for all hygiene, toilet needs, dressing, rolling left and right in bed, and transfer to/from chair to bed.R903A progress note dated 01/16/2026 at 7:58 AM, by Licensed Practical Nurse (LPN) E documented, Writer was summoned to resident room and observed resident sitting on the floor with (their) knees (bent). (Range of motion) ROM render (ed) no (complaint of) c/o of any discomfort of pain upon assisted resident in (wheelchair) w/c. Writer observed a hematoma (bruise) to forehead with bleeding superficial laceration and hematoma to left cheek with abrasion. Wound care rendered with pressure, resident responding appropriately and was educated not to touch forehead as (R903) kept picking at laceration.A progress noted dated 01/16/26 at 12:16 PM documented, resident had a fall this (AM) in bedroom, resident has a hematoma with laceration on forehead with active bleeding, with 2 cheek abrasions. resident does not complain of pain, but facial expressions show grimacing. Writer contacted granddaughter/guardian with no answer (medical doctor) MD notified and ordered labs . as well as x-rays of spine and skull. [NAME] (neurological assessment) checks initiated. Granddaughter reached out to writer and requested resident be sent to (emergency department) ED for CT Scan .A review of the physician progress noted dated 01/16/26 at 9:15 PM, noted R903 had a frontal hematoma (raised area front of head) and laceration to their head and was up feeding themself when examined and was stable. The physician noted the granddaughter wanted R901 sent to the hospital for scan of the head and therefore R901 was transferred to the hospital. On 03/04/26 at 2:34 PM, LPN G reported R903 tried to be self-sufficient but actually needed assistance and was wheelchair bound due to being unsteady. LPN G noted R903 would often get up to ambulate and disregard redirection and the intervention was to try and keep constantly monitoring R903. LPN G reported they had not witnessed any falls by R901. LPN G reported they did know they had one and went to the hospital and felt R903 did not change once they returned from the hospital. LPN G reported R903 was to be monitored. On 03/04/26 at 2:40 PM, LPN H reported R903 could be combative and would transfer themself in and out of their wheelchair and was generally non-compliant with assistance or following directions. LPN H reported on 01/16/26 the morning nurse found R901 on rounds just after first fall and R903 was sent out from the facility after the fall on 01/19/26 when R903 broke their hip. LPN H was asked why R903 was not sent out immediately after the fall on 01/16/26 and reported the facility likes to try to keep residents in house unless on they are on a blood thinner or had a mental status change. On 03/04/26 at 2:55 PM, Unit manager F reported they had known R903 for more than six months and had not had any prior falls. UM F noted during the week R903 fell three times since 01/16/26 with two on the same day. UM F reported R903 was more active and more difficult to educate, following directions less and suspected a urinary tract infection during the time of the falls. UM F reported they understand the fall on 01/16/26 happened between 6AM and 7AM and was found on the floor during rounds. UM F spoke with the daughter that morning and reported R903 showed no signs of a change in mentation and the daughter requested R903 to be sent out and R903 left the facility sometime after 12 PM. UM F reported after R903 came back the intervention was to keep R903 in the common areas. UM F reported the second fall occurred during an activity in the chapel and the third while in the common area. On 03/05/26 at 10:45, Activity Aide (AA) J reported R903 was in chapel sitting right next to them and just suddenly slid out of the chair. AA J reported they tried to grab R903 but R903 went onto the floor. AA J recalled a cushion in R903's wheelchair but did not recall if they saw any non-slip material (dycem) in the seat. On 03/04/26 at 9:23 AM, LPN A reported the call light had not worked properly in a long time on R901's unit and estimated it was more than six months. No audible tone was heard upon call light activation. R901 was not observed to activate their call light during the survey.On 03/04/26 at 11:49 AM, Certified Nursing Assistant (CNA) C reported R903 has some good and some bad days bad, saying R903 would fight them at times and would not take direction when asked to sit back into their wheelchair. CNA C reported R903 did not have good self-awareness of their needs and abilities. On 03/05/26 at 1:37 PM, the Administrator and Director of Nursing (DON) were asked about the falls experienced by R901 and R903. It was reported that the concave and low air loss mattress for R901 had been ordered two weeks ago. A copy of the order was requested at this time but not received prior to survey exit. The DON reported R903 was known to have severe cognitive deficits, wanted to be independent, would refuse care from staff a lot and at the time of the initial fall there was a more drastic cognitive decline. R903 was moving around more, was less directable and trying get out of their chair more and staff considered R903 may have a urinary tract infection. The DON reported staff were keeping R903 in the common area after the fall in the chapel on 01/19/26 and R903 continued to be impulsive and had a fall from their wheelchair in the common area later in the day. The DON reported the felt the left hip was injured at that time, and at the hospital R903 was found to have a hip fracture. R903 was admitted into the facility on [DATE]. Diagnoses included Alzheimer's, Dementia, Muscle Wasting and Difficulty Walking. R903's care plan documented, .at risk for falls related to weakness and gait imbalance, poor safety awareness and impulsivity, transfers without assistance, Date initiated 11/28/25. Revised 01/21/26. Interventions documented were: Ensure wheelchair wheels are locked when transferring; Ensure wearing appropriate footwear . need a safe environment . keep bed brakes locked . keep call light in reach . All initiated 11/28/25. The I have had an actual fall care plan initiated 06/23/22, documented interventions: Dycem to wheelchair initiated 11/18/25 .Revision 12/01/25 . Send to ED for CT scan per family request initiate 01/16/26 . be sure call light in reach .initiated 11/18/25 . encourage to lay down after meals .initiated 06/23/22 . encourage to participate in activities .initiated 05/28/24 . ensure wearing appropriate footwear .nonskin footwear .initiated 06/23/22 . need supervision so my whereabouts are known .initiated 05/28/24 . floor mat when in bed .initiated 05/14/24 . A therapy evaluation and therapy screen were also noted initiated in 2022 and 2025 respectively. No additional fall prevention interventions were documented prior to 01/19/26. A review of the undated Director of Nursing Standard Operating Procedure titled, Fall Management Guidelines documented, .12. The (Interdisciplinary Team) IDT will review/modify the plan of care to minimize the risk of repeat falls .

This citation pertains to Intake numbers 1293719 and 1293580.Based on observation, interview, and record review, the facility failed to answer a call light timely for one resident (R701) out of two reviewed for call lights. Findings include:On 7/9/2025 at 12:11 PM, R701 activated their call light. R701 stated they never answer the call light when it is activated and sometimes it will be on all night until the next day. R701 reported, the screen at the desk barely works. R701 reported the call light does not light up over the door, but rather shows up on a screen at the desk.A review of the medical record revealed that R701 admitted into the facility on 4/5/2024 with the following medical diagnoses, General Anxiety Disorder and Chronic Kidney Disease. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 14/15 indicating an intact cognition. R701 also required assistance with bed mobility and transfers. On 7/9/2025 at 12:18 and 12:26 PM, R701's call light was noted to still be activated. No one was observed to come and address the call light. On 7/9/2025 at 1:28 PM, R701's call light was still observed to be activated. R701 reported no one came into the room to address their concern. On 7/9/2025 at 1:35 PM, Activities Aide (AA) C was observed to be charting in the hallway. AA C was asked how they knew if call lights were activated. AA C reported they know there is a system up front and that they can check it and answer call lights if necessary.On 7/9/2025 at 1:38 PM, an interview was conducted with Licensed Practical Nurse (LPN) A. LPN A reported they look at the system behind the nurses' station and check if there are lights activated, as long as the system is working properly. On 7/9/2025 at 1:40 PM, an interview was conducted with Unit Manager (UM) B. UM B was shown that R701's call light had been activated since 12:11 PM and it was now 1:43 PM. UM B reported the call light should have been addressed and deactivated within 15 minutes of it going off, unless there is a dire emergency. UM B reported they would have to see what happened with R701's call light been addressed in a timely manner. A review of resident council notes from the last six months revealed that call lights being answered in a timely manner, particularly during the midnight shift, was a concern for the following months: January, February, March, May, and June. On 7/9/2025 at 2:54 PM, an interview was conducted with the Director of Nursing (DON). The DON indicated they have followed up on concerns with call light wait times and their expectation is that they are answered in a timely manner. The DON reported they believe that everyone should answer call lights and that it is everyone's responsibility. A review of a facility policy titled, Call Light Policy noted the following, .1.Call lights should be answered by available staff as promptly as possible.

Based on observation, interview and record review, the facility failed to ensure a dignified dining experience for six residents, of 13 residents reviewed for dining, resulting in the potential for embarrassment and disappointment with the dining experience. Findings include: On 4/1/25 from 12:16 PM until 12:55 PM, an observation of the lunch meal was conducted on the Transitional Care Unit. It was observed R#'s 59, 75, and 21 were seated together at a table. R59 and R75 were served their meals and began eating. R21 was not served their meal with R59 and 75. R59 and R75 finished their meals at 12:30 PM and their plates were collected and returned to the satellite kitchen. At approximately 12:35 PM, R21 was finally served their lunch meal. 38271 On 3/31/25 at approximately 12:15 p.m., Observations of the lunch meal were made and the following was observed: R44 was observed in the TCU (transitional care unit) dining room seated at a table. R44 was observed to have the front of their shirt completely covered in wetness with no clothing protector observed to be on them. The other residents surrounding them were observed to be eating their lunch meal with R44 watching them eat. At approximately 12:19 p.m., R44's meal ticket was observed and revealed the following: feeding assist No straws. At that time, three other residents observed at R44's table eating the lunch meal. R44 was still observed to be watching the other residents eat without being assisted with their meal. Only one resident at table was provided a beverage with the meal at that time. At approximately 12:24 p.m., R21 was observed in the TCU dining room seating at the dining table. R21 was observed to have their food in front of them without any feeding assistance being provided and unable to consume the meal on their own. Multiple other residents were observed eating their lunch meal. At approximately 12:26 p.m., R44 was finally served a beverage, but it contained a straw with it. At approximately 12:29 p.m., Nurse C observed trying to assist R44 with eating their meal, but was observed standing up next to them while proving the eating assistance to R44. On 3/31/25 at approximately 12:30 p.m., observations of the main dining room's lunch meal was conducted and the following was observed: At approximately 12:34 p.m., Two residents were observed eating the lunch meal with two other residents (R36 and R53) were observed to be watching them eat without being served their meal. At approximately 12:38 p.m., Certified Nursing Assistant G (CNA G) was queried why R36 and R53 had to watch other residents at their table eat the meal when they were not and CNA G reported (within hearing range of R36 and R53) that they were both feeders and have to wait for staff to help them. On 4/2/25 at approximately 11:43 a.m., during a conversation with the Administrator, The Administrator was informed of the observations that had been noted in both of the dining rooms on 3/31/25. The Administrator indicated that clothing protectors should be provided and that residents seated at the same table should be served the meal at the same time and staff should be mindful of who needs assistance with eating. The Administrator indicated they had recently started in the facility and they were looking at refining some processes for the dining rooms and communication with the resident Greenhouses. On 4/2/25 a facility document titled Resident Dignity and Personal Privacy was reviewed and revealed the following: Policy-The facility provides care for residents in a manner that respects and enhances each resident ' s dignity, individuality, and right to personal privacy. Fundamental Information Each resident ' s right to personal privacy includes the confidentiality of his or her personal and clinical affairs. Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth .

Based on observation, interview and record review the facility failed to ensure two residents (R44 and R69) were provided the option of an alternate entree, beverages and preferred deserts during the scheduled meals. This deficient practice has the potential to affect all of the 78 residents who eat meals prepared and served by the kitchen. Findings include: On 3/31/25 at approximately 12:15 p.m., Observations of the lunch meal were made and the following was observed: R44 was observed in the TCU (transitional care unit) dining room seated at a table. R44 was observed to have the front of their shirt completely covered in wetness with no clothing protector observed to be on them. The other residents surrounding them were observed to be eating their lunch meal with R44 watching them eat. At approximately 12:19 p.m., R44's meal ticket was observed and revealed the following: feeding assist No straws. At that time, three other residents observed at R44's table eating the lunch meal. R44 was still observed to be watching the other residents eat without being assisted with their meal. Only one resident at table was provided a beverage with the meal at that time. None of the other residents were provided a desert or beverage for the meal. At approximately 12:26 p.m., R44 was finally served a beverage, but it contained a straw with it. On 4/01/25 at approximately 12:31 p.m., during observations of the lunch meal in the [NAME] House Certified Nursing Assistant I (CNA I was queried why none of the residents eating the lunch meal were offered a desert with their lunch and they reported they (the staff) are never provided the deserts from the kitchen so the residents who live in the greenhouses do not get them. CNA I was queried pertaining to any alternate menus/entrees in the greenhouses and they reported that they get the ingredients/food from the main kitchen and then cook the entree in one of the houses. CNA I reported there are no alternate menus for the residents that resident in the Greenhouses. CNA I indicated all they had to offer the greenhouse residents was a bacon sandwich because that's all they had in the refrigerator. CNA I was queried again if they had an always available list of items or an alternate entree and they indicated they did not and all they had was bacon and if the residents did not want that, then they did not have anything else to offer them. On 4/01/25 at approximately 12:34 p.m., R69 was observed at the dining room table with their lunch meal not consumed. R69 was queired why they were not eating, and they reported they did not like the pot pie that was served. R69 indicated they would have some of the bacon that CNA I was going to make because that's the only thing they had left to eat. R69 was queried if they would have liked some desert and they indicated they would have, but did not get any. 34208 On 3/31/25 at 12:27 PM, an observation of the lunch meal on the Transitional Care Unit was conducted. R44 was observed seated at the table with their pureed lunch meal in front of them. Their meal consisted only of a pureed sweet potato and an unidentifiable light greenish/tan pureed food. R44 was eventually offered one-to-one assistance from Certified Nurse Aide (CNA 'B'). CNA 'B' was asked what the unknown pureed item was and said they did not know. They further indicated R44 was a vegetarian and did not receive pork that was on the menu for that day. Staff in the satellite kitchen on the unit were asked what R44 was served and said R44 was served a pureed sweet potato and pureed cabbage with green beans. On 4/1/25 at 12:20 PM, a second observation of the lunch meal on the Transitional Care Unit was conducted. R44 was observed seated in the dining room receiving one-to-one assistance with their lunch meal from Nurse 'A'. Nurse 'A' was asked what R44 received for lunch and said they received tomato soup and pureed lima beans. At the conclusion of the meal at approximately 12:45 PM, it was observed R44 was not provided with the dessert on the menu for the day. During the observation of the lunch meal, eight residents were observed in the dining room. At the conclusion of the meal, only two of the eight residents received the dessert (chocolate cake) item on the menu. At 12:55 PM, an interview was conducted with R281 and they were asked if they received dessert and said they did not, stating, That's not fair. On 4/2/25 a facility document titled Menus was reviewed and revealed the following: Standard: Menus will be planned in advance to meet the nutritional needs of the residents/ patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Guidelines: 1. Menu cycles will be developed and tailored to the needs and requirements of the facility. 2. Menus will be periodically presented for resident review, including the resident council, menu review meetings, or other review board as indicated by the center. The menu will identify the primary meal, the alternate meal, and any always offered food and beverage items. 3. Menu cycles will include standardized recipes. Recipes must be followed and scaled apporiately. 4. Menu cycles will include nutrient analysis to ensure that all client (adolescent, adult, geriatric) nutritional needs are met in accordance with the most recent edition of the Food and Nutrition Board, Institute of Medicine, National Academies, and the Dietary Guidelines for Americans, 2015-2020 edition. 5. A Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional reviews and approves the menus. The RDN or other clinically qualified nutrition professional will adjust the individual meal plan to meet the individual requests, including cultural, religious, or ethnic preferences, as appropriate. 6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. 7. A menu substitution log will be maintained on file. 8. Menus will be posted in the Dining Services department, dining rooms and resident/patient care areas. 9. Menus are kept on file per state regulations .

Based on observation, interview and record review, the facility failed to ensure post-dinner snacks were available and offered for 18 residents residing in the [NAME] Houses of a total of a total census of 78. Findings include: On 4/01/25 at approximately 12:31 p.m., during observations of the lunch meal in the [NAME] House Certified Nursing Assistant I (CNA I) was queried regarding post-dinner snacks for the residents in the [NAME] Houses. CNA I reported they did not have any snacks because the kitchen never sends them over to the houses. CNA I indicated that the kitchen is run by different staff and they do not give any snacks to the residents. On 4/01/25 at approximately 12:51 p.m., [NAME] House Manager F (GHM F) was queired regarding snacks for after the dinner meal and they reported the [NAME] Houses are not provided snacks from the Kitchen because the kitchen staff do not have a contract with the [NAME] Houses. GHM F was queried if they could remember the last time the [NAME] houses were provided evening snacks, and they indicated they have not had any snacks in a long time and could not remember the last time the main kitchen had been able to provide them with snacks. On 4/2/25 a facility document titled HS (evening) snacks was reviewed and revealed the following: Standard: Snacks and beverages will be provided as identified in the individual plans of care. Bedtime (a.k.a. HS) snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times. Guidelines: 1. The Dining Services department will collaborate with the residents/patients, nursing and management team to identify necessary beverage and snack items to be provided to each resident/patient. 2. The Dining Services department assembles on a daily basis snack items (food and beverages) for delivery to each resident/patient care area. 3. Snacks will be assembled, labeled, and dated in accordance with the individual plan of care for each resident and those items will be delivered to patient care areas in a timely manner. 4. The Dining Services department will assemble and deliver to each unit the individually planned snack items and bulk snack items to be offered at bedtime. 5. The Dining Services department provides a listing of the current diet orders and snacks for each resident to each care area. 6. Nursing Services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. 7. All snacks will be properly stored for time and temperature control, as appropriate. 22960 On 4/1/25 at 12:30 PM, the kitchen in the [NAME] House was observed with [NAME] House Manager (GHM) F. It was observed that there was an empty basket on the counter for snacks. In the refrigerator, there were 2 apple sauce cups, an opened package of bacon and a jar of mayonnaise. When queried about snacks for the residents, GHM F stated that the main kitchen will not give them any snacks. GHM F stated that they only give them enough food to prepare for the meals. GHM F stated, Even those 2 apple sauce cups in the refrigerator are saved for medication pass. GHM F stated that the residents are hungry, and that staff often buy snacks with their own money to feed the residents. Further review of the cupboards and dry storage area revealed no other food items. GHM F stated they don't even have a jar of peanut butter or lunch meat to make sandwiches. GHM F showed this surveyor a text message that had been sent to Certified Dietary Manager (CDM) E asking when they were going to get snacks for the [NAME] Houses, because the residents were hungry. There was no response from CDM E. On 4/1/25 at 1:45 PM, CDM E was queried about the provision of snacks to the residents that reside in the [NAME] Houses. CDM E stated that snacks were not really her responsibility, and referred this surveyor to speak to someone in the main kitchen.

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 had the potential to result in food borne illness among all residents of the [NAME] House that consume food from the kitchen. Findings include: On 04/01/25 at 12:45 PM, the [NAME] House dish machine was checked with [NAME] House Manager F. The dish machine was a low temperature, chemical sanitizing dish machine. When asked how staff checks the dish machine for sanitization, [NAME] House Manager F pointed to a dish machine log, and some Smart Power test strips (test strips used to test the levels of DDBSA and lactic acid sanitizer). Observation of the chemicals for the dish machine showed 1 bottle of liquid detergent, and 2 bottles of liquid rinse aide, hooked up to the automatic chemical dispenser for the dish machine. There was no sanitizer attached to the dish machine, to ensure that dishes were being sanitized. When asked how staff was checking for sanitizer level, when there was no liquid sanitizer hooked up to the dish machine, [NAME] House Manager F had no explanation. When asked why staff were using Smart Power test strips, which were for a chemical that was not being used, [NAME] House Manager F stated I'm not sure where those test strips came from. [NAME] House Manager F retrieved a bottle of chlorine sanitizer from the [NAME] House, and brought it to the [NAME] house. [NAME] House Manager F replaced the bottle of liquid rinse aid with the bottle of liquid chlorine sanitizer. [NAME] House Manager F then turned on the dish machine and tried to test with a chlorine test strip, but the strip did not change color to denote the presence of sanitizer. [NAME] House Manager F stated she would call maintenance to fix it. According to the 2017 FDA Food Code section 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization-Temperature, pH, Concentration, and Hardness, A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under S7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, P and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart; P.

Deficient Practice #1 Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (EBP) were in place and implemented by staff for one resident, (R66) of one resident reviewed for EBP, resulting in the potential for the development of infection. Findings include: On 3/31/25 at 10:45 AM, R66 was observed in their bed. R66 was not responsive to attempts at verbal communication. At that time, R66 was observed to have a urinary catheter, a feeding tube, a tracheostomy, and was receiving oxygen through a tracheostomy mask. An observation of the door to R66's room from the hallway did not reveal any signage to indicate R66 was on enhanced barrier precautions. On 3/31/25 at 1:55 PM, Nurse 'C' and Certified Nurse Aide (CNA) 'B' were observed entering R66's room; they did not don an isolation gown or gloves prior to entering the room. At approximately 1:59 PM, entry was made into the room. Nurse 'C' was observed in the room and CNA 'B' had used the adjoining bathroom to enter the room next door. At that time, Nurse 'C' was asked what type of care was being provided and said they were in the room cleaning the tube feeding pump and pole. They were asked if they provided any care to R66 and said they did not, but CNA 'C' had provided incontinence care prior to going next door. An observation of the trash can did not reveal any used personal protective equipment (PPE). On 4/1/25 at 9:56 AM, Nurse 'A' was observed in R66's room preparing a nebulizer treatment. After the preparation of the treatment, Nurse 'A' was observed to administer the breathing treatment via a facemask through R66's tracheostomy. Nurse 'A' was not observed to be wearing an isolation gown. On 4/1/25 at 3:05 PM, an interview was conducted with the facility's Director of Nursing (DON)/Infection Control Nurse. They were asked if R66 should be identified as requiring EBP and said they should. A review of a facility provided policy titled, Enhanced Barrier Precautions (EBP) was conducted and read, .The Enhanced Barrier Precautions (EBP) guidance expands to residents that trigger the use of EBP and indicates it should be followed for any resident in the facility ' s with: .Has an indwelling catheter for the duration of their stay .The EBP requires the use of gowns and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .Examples of high-contact resident care activities requiring gown and glove use among residents that trigger EBP use include: .Device care or use: central line, urinary catheter, feeding tube, tracheostomy care/ventilator . Deficient Practice #2 Based on observation, interview, and record review, the facility failed to store linens in a sanitary manner. This deficient practice had the potential to affect 13 residents on the [NAME] Unit. On 4/1/25 at 9:25 AM, a clean linen cart with a light blue plastic style covering was parked in the hallway outside room [ROOM NUMBER]. The top of the linen cart was observed to have a foam cup of a red beverage sitting on it. The back of the cover was lifted up and draped over the the top of the cart revealing supplies on the cart. Among the clean linen supplies was a large, blue plastic water bottle with ice water sitting on a stack of towels. Further inspection of the linen cart cover revealed brown stains drip dried down the side toward the bottom and on the back of the cover. It was further noted the cover had numerous holes. During the observation of the cart, Certified Nurse Aide (CNA) 'D' came out of room [ROOM NUMBER]. They were asked if they were using the cart and said they were. They were then asked if the water bottle stored in the cart was theirs and said it was. Next, they were asked where would be an appropriate place to store their personal water bottle and said it should have been in refrigerator, not on the clean linen cart. On 4/1/25 at 2:55 PM, the linen cart was again parked outside room [ROOM NUMBER]. The cover remained with the soiled brown stains and numerous holes. The top of the cart had two boxes of gloves, a toothbrush, and a tube of toothpaste stacked on it. On 4/1/25 at 3:05 PM, an interview was conducted with the facility's Director of Nursing (DON)/Infection Control Nurse. They were asked about the condition of the linen cart and cover and said nothing should be stored on top of the cart, staff should not store any of their personal items in the cart and the cover would be inspected for replacement. On 4/2/25 at approximately 1:30 PM, an observation of the linen cart on the [NAME] unit was conducted. The cover remained with the soiled brown stains and holes. At 1:33 PM, the DON said the Contract Company for housekeeping services tried to replace the cover but they did not have one that fit correctly. They were asked if anyone attempted to clean the brown stains from the cover and said they told housekeeping staff to clean it when it was brought to their attention on 4/1/25. They were made aware the linen cover remained with the stains and then said they were going to clean the cover themselves. A review of a facility provided policy titled, Sanitizing Linen Carts was reviewed, however; the policy did not address the cleanliness of the cart covers, staff storing food/beverages in the cart, or storage of items on the top of the cart.

Based on observation, interview and record review, the facility failed to ensure an environment with a functioning resident call system for four residents (R10, R16, R17 and R41) of seven residents reviewed for environmental concerns, of a total census of 78. Findings include: On 3/31/25 at approximately 9:11 a.m., R10 was observed in their room, up in their bed. R10's bathroom was observed to have an alert pull-cord tied to a non functioning piece of plastic on the alert box next to their toilet, rendering the cord to be unable to be used to call for assistance if needed. On 3/31/25 at approximately 10:55 a.m., R17 was observed in their room, up in their wheelchair. R17's bathroom was observed to have the Shower pull-cord that was connected to the alert system tied to a solid plastic piece on the box in a non-functional position, rendering the cord to be unable to be used to call for assistance if needed. On 3/31/25 at approximately 11:18 a.m., R41 was observed in their room, laying in their bed. R41's bathroom was observed to have a shower with the shower pull-cord detached from the alert system rendering it unable to be used by R41 or staff to call for assistance if needed. On 4/1/25 at approximately 8:44 a.m., R10 was observed in their room, laying in their bed. R10's pull-cord located next to their toilet was still observed tied to the end of the box in a non functioning position. R10's pull cord activator was not observed to have a cord attached to it to pull for assistance. On 4/1/25 at approximately 9:20 a.m., R41 was observed in their room, up in their bed. R41's shower was observed to contain their wheelchair and geri- chair. R41's shower pull-cord was not observed present on the alert activator. On 4/1/25 at approximately 9:25 a.m., R17's pull-cord for their call/alert system in their shower was observed wrapped around the grab bar and detached from the activator. On 4/1/25 at approximately 9:31 a.m., R17's call light in their room was tested with no response. the system did not flash on the door or on the system monitor. On 4/2/25 at approximately 11:57 a.m., The room for R10 was observed with Maintenance Director K (MD k). MD K was shown the alert pull-cord not attached to the activator on the toilet and they indicated that whoever installed the cord did it wrong and did not put it through the right hole on the alert box. On 4/2/25 at approximately 12:03 p.m., MD K was shown R41's room that did not contain a pull-cord attached to there alert box on the shower. MD K reported that they would have to put a new cord on it to make it functional. On 4/2/25 at approximately 12:04 p.m., R17's room pull-cord was reviewed with the MD K and they reported that the alert box next to R17's bed had a dead battery and that was why why alert system was not working. On 4/2/25 at approximately 12:06 p.m., R16's pull-cord was tested in their room and was observed to be non-functioning with the light next to the door and the monitor not indicating the cord had been pulled. MD K indicated it was the same thing that had occurred in R17's room in which the battery was dead in the alert light box. MD K reported that nobody had made them aware of the need for the alert systems to be fixed in any of the resident rooms.

Based on observation, interview, and record review, the facility failed to ensure urinary catheter care, assessment and monitoring was provided for one resident, (R66) of three residents reviewed for catheter care, resulting in the development of a urinary tract infection. Findings include: On 3/31/25 at 2:13 PM, R66 was observed in their bed. R66 was awake and alert, however; they did not respond to attempts at verbal conversation. It was observed R66 had an indwelling urinary catheter. The tubing connected to the collection bag revealed dark, cloudy urine with sediment built up in the tubing. A review of R66's clinical record revealed they admitted to the facility on [DATE] and most recently readmitted on [DATE]. R66's diagnoses included: respiratory failure, epilepsy, protein calorie malnutrition, neuromuscular dysfunction of the bladder and urinary tract infection. A review of R66's physician's orders, medication administration records, treatment administration records, and certified nurse aide tasks was conducted and did not reveal any orders or documentation for catheter care, assessment and monitoring. R66's physician's orders were noted to include an order dated 3/28/25 for Ciprofloxacin (antibiotic treatment for UTI) 500 milligrams every 12 hours for, UTI (urinary tract infection) for 7 days. Continued review of R66's record revealed the following notes: A nurses note dated 3/24/25 at 9:03 PM that read, .Urine collected this shift for U/A (urinalysis) C&S (culture and sensitivity) . A nurses note dated 3/27/25 at 3:36 PM that read, UA (urinalysis) returned, Large <sic> amount of Blood <sic> and Leukocytes <sic> (white blood cells) .Doc (Doctor) made aware order given to await Culture <sic> . A nurse note dated 3/28/25 at 12:54 PM that read, .Urine Culture High for bacteria, with susceptibility of Cipro (ciprofloxacin, antibiotic medication), Doc made aware order given to initiate ABT (antibiotic therapy) . On 4/1/25 at 3:05 PM, an interview was conducted with the facility's Director of Nursing. They were asked about catheter assessment, care and monitoring and said an order should be written and documentation of the care provided would be entered by the assigned nurse on the treatment administration record. A review of a facility provided policy titled, Indwelling Catheter Care was conducted and read, .Routine catheter care helps prevent infections and other complications, and is usually performed daily . The policy did not include documentation of the care provided.

This citation pertains to Intake: MI 487. Based on interview and record review the facility failed to consistently document, assess, and monitor for a change in condition for one sampled resident (R901) reviewed for a change in condition, resulting in a delay in treatment and hospitalization . Findings include: On 3/16/2021 at 9:32 AM, Family Member A explained that R901 was taken from the facility to the ER (emergency room ) on 3/9/2021 for a mental status change, and explained that once there, R901 was diagnosed with severe dehydration, and a urinary tract infection. Family Member A also explained that after speaking to the physician at the hospital, they felt as though R901 had been neglected. Family Member A indicated that R901 has yet to be discharged from the hospital. A review of R901's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R901's Minimum Data Set assessment revealed that the resident had a Brief Interview for Mental Status score of 1/15 indicating a Severely Impaired Cognition and required Extensive Assistance for all Activities of Daily Living. 2/23/2021 18:57 (6:57 PM) Admission Note Note Text: admission- resident is (identifying information) admitted by wheelchair .residents major complaint at admission is right hip fx (fracture) and Falls. [R901] is alert and orientated x1. [R901] can speak but displays broken conversation. Resident has a foley catheter due to urine retention. All medications were verified by MD (medical doctor). MD was at the facility to assess the resident. 2/23/2021 22:04 (10:04 AM). Physicians H&P (History and Physical) Late Entry: Note Text: Physician History and Physical. cc (chief complaint): weakness, right hip pain. HPI: Pt (patient) with PMH (past medical history) of debility and dementia who fell , went to hospital and had right hip fracture. Patient was evaluated by pt/ot (physical therapy/occupational therapy) and was deemed in need of rehab .Plan: cbc, cmp, tsh, a1c (labs) . 2/24/2021 11:49 (11:49 AM). Skin/Wound Note Note Text: Resident admitted to facility. Skin assessment completed. Old healed surgical incision to mid chest area, 16 FR Foley intact with clear amber urine. Plan of care: Monitor Right Hip surgical incisions for s/s (signs and symptoms) of infection Q (every) shift. [MEDICATION(S)] Q (every) Day to Coccyx/Sacral wounds. 2/24/2021 12:01 (12:01 PM) Nurses Note Note Text: vs (vital signs) 120/95, 63 ,97.2, p02 97%. Res (resident). alert to name, confusion noted, speaks in word salad. wound care rendered by treatment nurse. Foley cath noted, positioned below bladder, draining yellow amber urine .No s/s (signs and symptoms) of discomfort. Safety maintained, will cont. (continue) with POC (plan of care). 2/26/2021 15:14 (3:14 PM). Nurse Practioner Notes. Notes Text: Progress Note. CC (chief complaint): 1 week f/u (follow-up). HPI: Patient seen and examined. Nursing staff state that patient did not eat breakfast or lunch today. On assessment, patient is sleeping. [R901] awakens to voice. [R901] states that [R901] is good. [R901] does not grimace or moan as if s(they) were in pain. [R901] is unable to answer ROS (review of systems) questions. [R901] has a foley that was placed in hospital for urinary retention .Impression. 1. Debility 2. Urinary retention 3. Right femur fracture with fixation 4. [CONDITION(S)] [CONDITION(S)] 5. Dementia 6. HLD 7. Ataxia. Plan: 1. Medications reviewed. 2. Labs ordered 3. [MEDICATION(S)] as needed. C2 signed for [MEDICATION(S)] 4. Continue PT/OT 5. Foley placed in hospital d/t urinary retention. Will pull next week and monitor for retention 6. Continue to optimize medical and nutritional therapies. 3/2/2021 04:12 (4:12 AM) Health Status Note Note Text: Patient is confused, c/o (complain of) and showed sign of pain in left hip, patient was given pain med and the hip supported with pillow. Patient felt a little better .Will continue to monitor patient. 3/5/2021 10:14 Nutrition/Dietary Note Note Text: Res. appetite remains poor. Takes sips of liquids. Daughter brought in root beer pop which is a favorite. Very little consumed. Writer informed daughter of poor intake, potential for weight loss. Informed MD. Supplements ordered: Ensure Plus TID (three times a day), magic cup (nutritional snack) with lunch meal, along with protein supplement for wound healing. Continue to monitor. 3/8/2021 00:52 (12:52 AM) Health Status Note Note Text: Received patient in bed with eyes closed, responds to tactile stimulus. Patient repositioned and made comfortable in bed. Patient is weak and still resist care O2=96-94% 02 at 2 liters applied .O2=98%. Patient more alert Logged in doctors book. Will continue to monitor patient. 3/8/2021 12:07 (12:07 PM) Respiratory Therapy Note. Note Text: Resident seen by Skilled RT (respiratory Therapist). Resident has no known prior respiratory history. RT found resident on 2 liters 2 via nasal cannula. Nurse states midnight nurse placed resident on 02. Sp02 97%. HR 100 RR 20. Breath sounds bilateral and diminished. Respiration even and nonlabored .Resident did not respond to verbal commands. Continued oxygen support is indicated at this time . 3/8/2021 14:07 (2:07 PM). Nurses Note Note Text: Change in mental status noted this shift. Physician made aware. STAT CBC w diff, CMP, STAT CXR (chest x-ray), UA C&S (urinalysis), and 0.9 [MEDICATION(S)] solution @ (at) 70ml/hr. 3/8/2021 14:35 (2:35 PM). Nutrition/Dietary Note Note Text: Phone conference held with writer and social worker to follow up with daughter .in regards to res. current condition. Res. continues with poor PO (oral) intake, resistive to feeding assistance. Nutrition supplements ordered (correction of 3-5-21 nutrition note: Ensure Clear ordered as daughter stated [R901] disliked the Ensure Plus) MD aware of status, Per nurses note 3-8-21, HDC (Hypodermoclysis, used to administer fluids to the body) initiated, stat labs: CBC w/Diff, CMP, Stat CXR, UA C&S. Will continue current plan, await lab results. Staff encouraging fluids. 3/8/2021 16:14 (4:14 PM). physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] cc: confusion. HPI: Pt with PMH of debility and dementia who recently had hip fracture. [R901] is very confused .Patient denies any cp, fever, chills, nausea, vomiting, diarrhea, cough, [CONDITION(S)], dysuria .Impression: acute [CONDITION(S)], acute dehydration, decubitus ulcers, right hip fracture, debility, ataxia, cad (coronary artery disease), dementia, urinary retention chronic, [CONDITION(S)] (hypertension), [CONDITION(S)], HLD (hyperlipidemia). Plan: Will begin IV (intravenous) fluids, consult wound care, CXR stat ordered and reviewed, showed no acute, process, UA and CS ordered STAT . 3/8/2021 17:30 (5:30 PM) Skin/Wound Note Note Text: Resident has mental status change, eating, and wound change. Order for Stat CBC with diff, Stat CXR, UA C& S 0.9 NS @ 70 cc/HR. Wound has yellow slough with discoloration surrounding the wound. small serosanguinous drainage .Waiting on stat lab results. Nursing staff will continue to monitor. 3/8/2021 18:30 (6:30 PM) Nurses Note Note Text: Urine sample collected this shift for UA C&S. 3/9/2021 06:41 (6:41 AM) Health Status Note Note Text: Critical High labs reported to (medical doctor) at 6:00am-order received to transport pt. to hospital. Supervisor notified at 6:04am-she sent a text to .VS=132/74-106-18 t=97.2 SpO2=96% to O2. 6:22am EMS (emergency medical services) on the scene & with pt., documents & report. 6:27am pt taken to Unit- Rescue #1 . R901's medical record was missing nurse progress notes for the following dates: 2/25/21, 2/26/21, 2/27/21, 2/28/21, 3/1/21, 3/3/21, 3/4/21, 3/5/21, 3/6/21 and 3/7/21. A review of R901's hospital documentation dated for 3/9/21 revealed the following, Chief Complaint: Altered Mental Status. The ECF (extended care facility) noted the change yesterday, labs were drawn and [R901] was sent to the hospital with [CONDITION(S)] of 162. Currently patient is A&O x 0 and responds to only painful stimuli. Pertinent labs: Sodium 167, BUN (Blood Urea Nitrogen),135, Creatinine 4.73, Alkaline Phosphatase 318, AST (Aminotransferase) 40, ALT (Alanine Aminotransferase) 60, CK (Creatine Kinase) 449, Troponin 0.13 ->0.11, TSH 0.18, Lactic Acid 4.3 and Uric acid 14.1. Urinalysis: 4+ Bacteria. Physical Examination: GEN (general): Toxic Appearing, cachectic (loss of body weight and muscle mass), alert and oriented x 0. HENT (head, ears, nose, throat): Tracking no movement with eyes, dry mucous membranes Urinalysis Result: Color: yellow Clarity: Cloudy .Further review of hospital documentation revealed the following that R901 was diagnosed with Protein Calorie Malnutrition and was prescribed a NPO (nothing by mouth) diet and placed on enteral feeding. On 3/16/ at 10:45 AM, an interview was held with the Dietary Manager who was asked about R901's nutrition while at the facility, and explained that R901 would refuse to eat, and that their daughter brought in items that the resident would like but would not open their mouth for those items. The Dietary Manager also explained that multiple supplements were put in place to assist with calorie intake in addition to 1:1 feeding being put in place. The Dietary Manager was asked about any discussion with the resident's representative regarding enteral feedings and explained that the concern was placed into the doctor's log regarding this on 3/8/2021. On 3/16/2021 at 4:16 PM, an interview was completed with the Director of Nursing (DON). The DON was asked about R901 and their nutrition while at the facility. The DON explained that their daughter brought in root beer, and the wound care nurse would also go in and try to get them to eat. The DON explained that the resident was admitted into the facility not eating. The DON was asked at what point enteral feeding would have been discussed and explained that the resident's physician would have to be asked about that as she was unsure if that had been a discussion with the resident's family. The DON was informed of the lack of documentation missing in the resident's medical record and asked if nurses should be completing daily charting on residents, and stated, Yes. On 3/16/2021 at 4:41 PM, the Nursing Home Administrator was interviewed regarding R901's medical record and lack of documentation. The NHA explained that the facility was completing weekly weights, and charting was completed by the Certified Nursing Assistants regarding food intake. The NHA also referred to dietary progress notes in addition to R901 being resistant to feeding assistance and nutritional supplements. A review of the facility's Acute Change in Condition policy revealed the following, An Acute Change of Condition (ACOC) is a sudden, clinically important deviation from a resident's baseline in physical, cognition, behavioral or functional domains. 'Clinically important' means a deviation that, without intervention, may result in complications or death. 3. Changes (symptoms) in a resident's condition are communicated by any staff member to nurse via (see warning signs) . 4. Use care paths, document findings, assessments, and interventions on the change of condition 5. Changes (symptoms) are communicated to the physician via -Phone call (urgent) -Physician Log (non-urgent) -Physician Rounds Level of Consciousness Leve of consciousness is the degree of awakeness, i.e., alert, drowsy, lethargic, sporous and comatose .

This citation pertains to intake MI 829. Based on interview and record review, the facility failed to provide wound treatments per order, coordinate care for impaired skin integrity on the heels, adequately monitor wound progression, and update the resident's care plan for one sampled resident (R#501) of three reviewed, resulting in the development and worsening of a gluteal (buttock) Stage 4 pressure ulcer and the development of deep tissue injury to the heels. Findings include: On 12/9/20 at 9:52 AM, Confidential Witness A was interviewed regarding R#501's care received in the facility. Witness A indicated the resident had a traumatic fall and had been in the hospital prior to coming to the facility. Witness A also explained that they had seen R#501 in the hospital prior to their transfer to the facility and that the resident had no skin issues. Witness A confirmed the following information found on intake 9: Resident was admitted to facility with no bed sores. On Oct. 31st (2020) resident was sent to Emergency for hemoglobin (protein in red blood cells) level being low, there was nothing else mentioned by the facility. When (R#501) was admitted up to a room at hospital, the nurse came in to do an assessment of (R#501's) body and found a pressure sore on (their) bottom. It measured 10in to 12in wide, they had to use an entire package of gauze to pack the hole, there was skin hanging and it looked awful .Resident also has a sore on the heel of (their) left foot. Witness A indicated that the severity of R#501's buttock(s) wound, and existence of heel issues were not relayed to them by the facility. Witness A stated, The bottom of (R#501's) feet were totally black at the hospital on 10/31. They didn't have to drain them. They did a debridement on the (buttock wound) 11/2 at the hospital .low hemoglobin was related to the ulcer, they said that on 11/5. Witness A indicated they had taken photos of the wounds when the resident got to the hospital on 10/31. A review of the photos attached to intake 9 revealed a large sacral wound extending over both buttocks packed with gauze, and a pink, open wound with darkened edges, covering the heel of a foot. A review of R#501's Minimum Data Set (MDS) assessments and medical record revealed the following: The resident was admitted into the facility on [DATE] and discharged on [DATE] with admitting [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. Further review revealed the resident was mildly cognitively impaired and required extensive assistance to total dependence on staff for bed mobility, transfers, dressing, eating, and hygiene/toileting. R#501's admission MDS assessment dated [DATE] indicated no skin issues upon admission, with the resident's discharge MDS assessment dated [DATE] indicating one Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). A review of R#501's hospital documentation prior to admission to the facility revealed no noted pressure ulcers on the resident's buttocks or heels. A review of R#501's progress notes revealed: 9/13/2020 19:52 (7:52 PM) Health Status Note .Patient with tetraplegia was found with skin tear on R (right) buttock area. Wound dressing with hydrogel was applied, patient repositioned Q2 hrs (every two hours). Safety for patient was maintained will continue to assess. an order for [REDACTED]. The physician progress notes [REDACTED]. A physician progress notes [REDACTED].Skin: decub (decubitus aka pressure ulcer) on right buttock seen today . The note included no further information regarding the wound. A physician progress notes [REDACTED]. dark red/purple discoloration noted on both heels today. No open areas seen DTI (deep tissue injury) b/l (bilateral) heels noted- continue offloading boots/elevate the heels . A nurse practitioner progress note dated 10/22/20 revealed: .DTI b/l heels - continue offloading boots, wound care team to evaluate this afternoon, Wound to buttock, continuel (sic) local skin/wound care, on liquid protein + ensure, being followed by RD (Dietitian). Xray of sacrum ordered . An X-ray dated 10/23/20 of R#501's coccyx was reviewed and read, .Multiple images of the sacrum/coccyx .Findings: Exam significantly limited by patient habitus/clinical condition/technique .The exam is markedly limited. CT or MRI is recommended for further evaluation . No further acknowledgement of the exam was noted in the record. A physician progress notes [REDACTED].(R#501) with hx (history) of severe spinal cord stenosis and compressions S/p (status [REDACTED].labs done yesterday revealed elevated WBC (white blood cell count) of 15 and Hgb (hemoglobin) of 7.9 (below normal range, resident's hgb was 10.5 in September 2020). Patient has decub which was debrided last week and has cloudy urine which is blood tinged as well. Dependent with ADLs (activities of daily living) .dark red/purple discoloration noted on both heels today. No open areas seen . A nurse practitioner progress note dated 10/29/20 revealed: Seen in f/u (follow up) of leukocytosis (elevated WBCs) for possible UTI (urinary tract infection) vs wound infections .Skin: sacral decub extensive with large amount of slough and serosanguinous drainage; seen in collaboration with wound care PA (physician assistant) today, see wound care notes for further description/measurements, B (bilateral) heels with dry/scabbed areas- no open areas or drainage . The following and final progress note in R#501's record was dated 10/31/20 and read: Order received to transfer resident to (acute care hospital) r/t (related to) hemoglobin-7.4. Rapid response transferring to hosp. A review of R#501's skin assessments and wound care documentation while in the facility revealed the following: -9/2/20: skin warm and dry with old scars from incision and few bruises. -9/9/20: skin intact with no alterations/impairments. -9/16/20, from Medicare Skilled Daily Charting: SKIN/ WOUND: 1. SKIN INTEGRITY 1a. No new changes to skin integrity noted. (box checked) 1b. Notable changes to skin integrity: No notable changes. 2. WOUND CARE: 2a. Resident has treatable wounds (box not checked) .#, type and location (i.e. #1, pressure, left buttock): (blank). 2b. Dressing changed as per treatment orders. (box not checked) 2c. Dressing change not required. (box not checked) 2d. Changes were noted to wound. (box not checked) 2e. Notable changes to wound: No notable changes. -9/16/20: Right buttock tx (treatment) in place. No measurements or further description of the wound was present. -9/23/20: Right buttock tx in place. No measurements or further description of the wound was present. -9/30/20: Buttock tx in place. No measurements or further description of the wound was present. -10/7/20: Buttock tx in place. No measurements or further description of the wound was present. -10/8/20: First noted encounter in R#501's record with wound care practitioner. Hard copy wound care documentation revealed, Wound #1: Left Glut(eal) Stage 3 .Length 1.5 (did not specify centimeters or inches), Width: 2.2 .Slough 0%, Eschar 0% .Red, Moist, Clean wound with: NS (normal saline) .Apply to wound bed: [MEDICATION NAME] .Cover with: Border Foam .Frequency: Q Day (every day) . Wound #2: Gluteal Cleft Stage 2 .Length 1.2, Width: 0.4 .Slough 0%, Eschar 0% .Red, Moist, Clean wound with: NS (normal saline) .Apply to wound bed: [MEDICATION NAME] .Cover with: Border Foam .Frequency: Q Day (every day) . -10/14/20: Buttock tx in place. No measurements or further description of the wound was present. No new skin areas were noted. -10/15/20: Second noted encounter in R#501's record with wound care practitioner. Hard copy wound care documentation revealed, Wound #1: Left Glut(eal) Stage 3 .Length 8.0 (did not specify centimeters or inches), Width: 12.0 .Eschar 60% soft, stable .Red, Moist, Attached .Clean wound with: NS (normal saline) .Apply to wound bed: [MEDICATION NAME] .Cover with: Border Foam .Frequency: Q Day (every day) . Wound #2: Gluteal Cleft Stage 2 .Merged with Glut 3 . -10/21/20: Buttock tx in place. No measurements or further description of the wound was present. No new skin areas were noted. -10/22/20 from Weekly Wound Healing Record-Wound Care Nurse: Date Family/NOK (next of kin)/POA (power of attorney) Notified/Last updated: 10/22/2020 .OBSERVATIONS/ DATA: Location: Left gluteal .Indicate whether this site was acquired during the residents stay or whether it was present on admission: Acquired .Date acquired: (blank) .3a. Type: Pressure .Current: IV (Stage 4) .Overall Impression: d. Worsening . -10/22/20 Third noted encounter in R#501's record with wound care practitioner. Hard copy wound care documentation revealed, Wound #1: Left Glut(eal) Stage 4 .Length 9.7 (did not specify centimeters or inches), Width: 16.0, Depth: 2.5 .Slough 40%, Eschar 20% .Eschar, Moist, Slough Unattached, Odor, Appears Infected .Clean wound with: Dakin's .Apply to wound bed: Dakin's soaked gauze .Cover with: Border Foam .Frequency: Q Day (every day) .APM (alternate pressure mattress), sacral x-ray r/o (rule out) osteo (osteo[DIAGNOSES REDACTED] - bone infection), Bactrim DS bid x 14d (twice a day for 14 days), heel boots, protein supp(lement) .Procedure: Escharotomy (surgical incision through the eschar to release [MEDICATION NAME]). The wound care information did not address the resident's heels. No order for Bactrim was found upon review of the resident's progress notes or physician orders. -10/28/20: Buttock tx in place. No measurements or further description of the wound was present. No new skin areas were noted. -10/29/20 from Weekly Wound Healing Record-Wound Care Nurse: Date Family/NOK (next of kin)/POA (power of attorney) Notified/Last updated: 10/29/2020 .Special Equipment/Preventative measures: Low loss mattress, frequent turning and repositioning, dietary supplement, heel protectors .OBSERVATIONS/ DATA: Location: Left gluteal .Indicate whether this site was acquired during the residents stay or whether it was present on admission: Acquired. 2b. Date acquired: (blank) 3a. Type: Pressure .Current: IV (Stage 4) 5. VISIBLE TISSUE 5a. Overall Impression: d. Worsening 5d. Slough tissue present (yellow, tan, white, stringy) 5e. Necrotic tissue present (brown, black, leather, scab-like) 5f. Moist 5h. Comments: (blank) 5i. Describe the extent (%) of necrosis and/or slough in the wound bed: (blank) 6. DRAINAGE 6a. Type: Serosanguinous (clear, pink tinged) 6b. Amount: Large . 8. WOUND MEASUREMENTS 8a. Length (cm) (centimeters): 11.5 8b. Width (cm): 16.0 8c. Depth (cm): 5.0 8d. Describe the extent of any tunneling and or undermining: @9-12 o'clock position max depth 5.0cm 9. PERI-WOUND TISSUE 9a. Description of peri-wound tissue: scarring, fragile 9b. Describe wound edges and shape .: irregular . Describe any changes to treatment plan in the last week: None noted . Wound Progress: Worsening . No mention of any other wounds was noted on this assessment. A review of R#501's orders revealed the following: an order for [REDACTED]. A review was conducted of the resident's Treatment Administration Record (TAR) for the order, Clean wound on R (right) buttock with normal saline, apply hydrogel and cover with [MEDICATION NAME]. two times a day for wound care, which started on 9/14/20. The following dates indicate missing documentation (blanks) of the order being carried out on the TAR: -Day administration: 9/14, 9/21. -Evening administration: 9/20, 9/27, 10/6, 10/7, 10/10, 10/13, 10/15, 10/19, 10/22, 10/23, and 10/29. -Both day and evening administrations: 9/23, 10/5, 10/8, and 10/30. A review of R#501's care plan revealed: Focus: I have potential for impaired skin integrity related to impaired mobility. I had a fall at home which result in spinal cord injury and [MEDICAL CONDITION]. I have a closed surgical incision to my neck. Date Initiated: 09/03/2020, Revision on: 09/03/2020. Interventions: Assist me with reposition frequently when in bed and chair. Date Initiated: 09/03/2020, Revision on: 10/20/2020. Follow your Skin Management Program. Date Initiated: 09/03/2020. I need barrier cream applied to my skin, as needed, after peri-care is provided. Date Initiated: 09/03/2020. Observe and report any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length X width X depth), stage. Date Initiated: 09/03/2020. Report to my nurse if you observe any new areas of impaired skin. Date Initiated: 09/03/2020. On 12/10/20 at 11:37 AM, the Wound Care Nurse (WCN) was interviewed regarding the development, treatment, and progression of R#501's wounds. The WCN indicated that she only looked at wounds on wound day, with the wound care practitioner and stated, I am not responsible for day to day care. We do not have a treatment nurse. The floor nurses are responsible for their treatments on a daily basis. They are responsible for reporting new skin conditions to me. They need to put in (medical record) for a wound care consult. Wound care documentation for R#501 was then reviewed with the WCN. The WCN indicated that she did not have hard copy wound care documentation for 10/29 for R#501. When queried regarding R#501 and their skin integrity, the WCN initially stated that the resident came to the facility with a wound but then corrected her statement. The WCN continued and said, (R#501) did come and did not have a wound. Then it looks like about 12 days something developed and it was noted by an afternoon nurse who put it in the chart and had initiated the wound care to the right buttocks. Then it got worse over time. When queried regarding the missing documentation for R#501's wound care order on the TAR, the WCN indicated that when treatments are carried out they are to be signed off and stated, (There are) quite a few holes on (R#501's) TAR. When queried regarding the results of the sacral x-ray that were ordered and if any follow-up testing was ordered, the WCN stated, I don't think so, that's the only one we have. When queried regarding the progression of R#501's wound, the WCN indicated she was unable to explain what happened with the wound and stated, I don't do the care every day, I don't get to round every time wound care comes. With the escharotomy, I didn't get to see that firsthand. I take the orders and try to make sure they get put in. The daily monitoring is done by whoever the charge nurse is. (R#501) did have some issues with nutrition, was a new quadriplegic. I believe that played a factor in how quickly it deteriorated but don't have a complete answer as to why. When queried regarding documentation of pressure ulcer interventions, the WCN stated, Interventions would be something placed on the care plan. There wouldn't be daily documentation unless (it's put in) daily nurse notes about turning and repositioning and things like that. I'm looking at the care plan right now. When asked if R#501's care plan should have been updated with the changes in skin integrity, along with any new interventions, the WCN indicated it should have. When queried regarding the care plan addressing the resident's heels, the WCN stated, No, we didn't have (R#501) as having any heel wounds that I'm aware of. The WCN was then asked to review the progress note dated 10/19 that mentioned the resident's heels. Upon review, the WCN stated, I didn't have knowledge about that. I just knew of the coccyx (buttocks) wound. I'm not sure who the nurse was on duty that day if it was reported. I don't know if something was reported to that nurse (from provider who wrote the note) but 10/22 was the next wound day and she (wound care practitioner) sees what she knows (the resident) has. It was not something communicated to me, so I didn't communicate to the wound doctor. I can see if it's on the weekly wound assessments . The WCN then reviewed R#501's record further and stated, Nope. Last skin assessment done before discharge had just the bottom .You were correct (nothing there for heels). The heels, I'm shocked to hear that. The WCN continued and stated, The nurses are typically liaisons between the doctors and wound care team. The attending doesn't do skin assessments by herself; she has a nurse with her so it's weird that nothing would've gotten put in after the DTI noted. The wound care team .we don't do a head-to-toe. We treat what we know is there. I know heel protectors are customary with risk factors such as (R#501's), that's a standard if they're in the bed. The ball must've been dropped with communication so it couldn't be tracked appropriately. And with me not doing wounds daily, it's not always on my radar. I can only do what they tell me. When asked if the wound treatment ever changed for R#501's buttock wound, the WCN stated, No, I don't think so, because (wound practitioner) did the escharotomy. The WCN was queried about what she would have expected to be done in regards to R#501's wounds and indicated that the TARs should have been complete, the heel condition better communicated, and the skin integrity care plan updated. On 12/10/20 at 3:24 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed and queried regarding R#501 and their wound development, treatment, and progression. The DON stated, I don't know a lot about the resident. I would've expected wound care to be given as ordered and care plan to have been updated. The DON and NHA indicated they were fairly new to the facility and did not provide further information regarding R#501. The DON and NHA indicated that relating to pressure ulcers and wound care, they would expect staff to follow policies, follow the care plan, and update the care plan when needed. A review of the facility's policy/procedure titled, Pressure Ulcer & Skin Care Management, undated, revealed: A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing .A licensed nurse checks the resident's body for the presence of pressure ulcers, wounds and other skin conditions: .weekly on residents, and prior to discharge .documents that the body check was completed .the presence of any pressure ulcer, wound or other skin condition is documented in the designated area .the interdisciplinary team reviews skin risk and initiates or updates care plans accordingly .will develop a care plan addressing risk factors and periodically review and update the care plan as needed to minimize risk and promote healing .the nursing staff reviews the pressure ulcer prevention and treatment procedures with the resident's physician, they select the treatment procedures appropriate for the resident and the type of pressure ulcer or wound, the licensed nurse implements the wound care treatment procedures in accordance with current standards of practice .A licensed nurse assesses and documents that status of existing wounds weekly .the interdisciplinary team will review residents with skin conditions regularly to monitor treatment and support effectiveness and recommend changes as needed .document skin status in the resident record.

Based on observation, interview, and record review the facility failed to place Resident 701 (R701) on 14 day droplet/isolation precautions after roommate R711 tested positive for COVID-19. Resident R701 remained in room [ROOM NUMBER] (non isolation unit) and was observed sitting outside of their room wearing their mask under their chin not covering the nose and mouth and failed to consistently monitor residents for Covid-19 signs and symptoms, resulting in 12 residents (#'s 702, 703, 704, 705, 707, 708, 709, 710, 711, 712, 713, and 714) and 10 staff testing positive for Covid-19 from 11/11/20 - 11/25/20, four residents (#'s 702, 704, 706, 707) being sent to the emergency room for [MEDICAL CONDITION] (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level), one death (#R705), sustained spread of COVID-19 to a total of 23 residents and staff, the likelihood for continued transmission of COVID-19, and a decline in overall health, serious illness, and or death. The Immediate Jeopardy (IJ) started on 11/11/2020 and was identified on 11/25/2020. The Nursing Home Director of Clinical Operations was notified of the Immediate Jeopardy on 11/25/2020 at 12:18 PM and was asked for a plan to remove the immediacy. The IJ was removed on 11/25/2020, based on the facility's implementation of the removal plan as verified onsite on 11/25/2020. Although the immediacy was removed, the facility's deficient practice remained widespread with actual harm that is not immediate jeopardy. Findings include: On 11/24/20 at 9:00 AM, during a tour of the facility, R701 was observed sitting in hallway with a blue surgical mask observed under their chin and an over bed table in front of them. R701 had their head resting on the handrail and appeared asleep. Staff was not observed to redirect R701 to cover their nose and mouth with the mask during this time. R701's room door was observed to be without isolation precaution signs and without a isolation cart. On 11/24/20 at 12:39 PM, R701 was observed sitting in a wheelchair on the outside of room [ROOM NUMBER] with an over bed table in front of them. R701's mask was observed hanging off their ear and resting on the side of R701's face. During an interview, R701 explained that they were having a good day and that lunch was good. Staff was not observed to redirect R701 to place mask on properly or enter room. R701's room door was observed to be without isolation precaution signs and without a isolation cart. On 11/24/20 at 10:32 AM, the Infection Control Preventionist (ICP) was interviewed about R701 and the residents who tested positive. The residents records were also reviewed with the ICP and revealed the following: R711 tested positive for Covid-19 on 11/23/20 and that the staff reported R711 with symptoms of lethargy and sleeping more. The ICP reported that R711 was relocated on the positive Covid-19 isolation unit. The ICP was asked if R711 had a roommate, the ICP stated, Yes (R701). (R701) is still in room [ROOM NUMBER]-1, (R701) tested negative. The ICP was asked if R701 was placed on observation or isolation due to their roommates positive results. The ICP stated, No, just monitoring for signs and symptoms, same thing we are doing for everyone. A review of R711's medical record revealed: R711 was admitted to the facility on [DATE]. A physician order [REDACTED]. Droplet Isolation related to DX (diagnosis) of Covid-19 11/23/20. Vital signs q 8 hrs (every 8 hours), call MD (medical doctor) if SpO2 (Oxygen saturation) <92% every 8 hours for Covid 19 11/23/20. Continued review of R711's record revealed, that R711's Covid-19 Monitoring Assessments and vitals were not consistently completed daily as ordered. A review of R701's medical record revealed, R701 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R701's Minimum Data Set (MDS) assessment dated [DATE] noted, impaired cognition and assistance with activities of daily living. R701's medical record also noted, R701 did not have a physician order [REDACTED]. Further review revealed, documentation for COVID-19 Monitoring Assessments and vitals were not consistently completed daily as ordered. R702 was admitted to the facility on [DATE] and tested positive for Covid-19 on 11/11/20. The ICP stated that R702's symptoms were loss of taste, sore throat, and fever. A review of R702's medical record noted, Orders: COVID-19 screening every night shift for COVID, start date 3/24/2020. Monthly vital signs one time a day every 1 month(s) starting on the 20th for 1 day(s). 7/13/2020. Pulse ox (oxygen) q6 11/13/2020. VS (vital signs) every 6 hours for Covid 19, start date 1/12/20. Droplet Isolation related to Dx of Covid-19, start date 11/11/2020. Further review of R702's record noted, COVID-19 Monitoring Assessments and vitals were not completed daily. The ICP reported R702 was sent to the emergency room due to [MEDICAL CONDITION] on 11/14/20. A review of R702's nursing note revealed, 11/15/20 03:45 (AM) Note Text: during rounds resident observed sitting in chair with O2 in place at 2 L (liters). Resident's neck hyperextended, rise and fall of chest noted. Resident unresponsive to name being called x3. BP (blood pressure) 69/43, HR (heart rate) 110, RR (respiration rate) 17, Pox (pulse oxygen) 88, oxygen tubing noted to be twisted and air flow blocked . New order given to transfer resident to ER (emergency room ) for [MEDICAL CONDITIONS]. 911 alerted to need of service . Transferred to ER at 3:40 a.m . R703 was admitted on [DATE] and tested positive for Covid-19 on 11/11/20. The ICP reported R703's symptoms were loss of taste, fever, poor intake, and loss of appetite. A review of R703's orders revealed, Routine vital signs monthly, start date 7/23. COVID - 19 screening tool-two times a day for COVID - 19, screening tool related to pressure ulcer of sacral region, stage 4, start date 4/19 end indefinite. Droplet Isolation related to Dx of Covid-19, start date 11/11/20. Further review of R703's record noted, COVID-19 Monitoring Assessments and vitals were not consistently completed daily as ordered. R704 was admitted to the facility on [DATE] and tested positive for Covid-19 on 11/11/20. The ICP reported that R704's symptoms were fever, cough, lethargy and [MEDICAL CONDITION]. A review of R704's medical record revealed, Order: Droplet Isolation related to Dx of Covid-19, start date 11/11/2020. Vital signs q6hrs-fever/Covid 19 every 6 hours for Covid 19, start date 11/13/20. Further review of R704's record noted, vitals and covid assessments were not consistently completed daily as ordered. R705 was admitted to the facility on [DATE] and admitted to the observation unit after an outside appointment on 10/27/20. R705 tested positive for Covid-19 on 11/11/20 per the ICP. R705 passed away on 11/21/20. A review of R705's medical record noted, 11/21/20 22:45 Nurse Note Text: At time of rounds resident was absent of vital signs. 2nd Nurse verified Absence of vital signs. On call doctor notified. Residents guardian notified . Further review of R705's physician orders [REDACTED]. Droplet Isolation related to Dx of Covid-19, start date 11/11/20. Vital Signs q 8 hrs every 8 hours for Covid 19 positive, start date 11/11. Oxygen at 2 liters per nasal cannula at all times. every shift for [MEDICAL CONDITION] Observe for usage as ordered, start date 11/16. Further review of R705's record noted, COVID-19 monitoring assessments and vitals were not consistently completed daily as ordered for the months of October and November. R706 was admitted to the facility on [DATE] and tested positive for Covid-19 upon being transferred to the hospital on [DATE]. A review of R706's admission progress note revealed, 10/31/20 Admission Note Text: Resident admitted to facility from (local hospital) after being treated for [REDACTED]. Resident A&O x 3 (alert and oriented, times 3 to person, place, and time), able to verbalize all needs . Resident vital signs stable. BP (blood pressure) 130/72, HR (Heart rate), R-16 (Respiration), T-98.6 (Temperature), Spo2-93% (Oxygen saturations) on 2 L . R706 was sent out to the hospital for respiratory distress and tested positive at the hospital. A review of R706's Physician history and physical, dated 11/2/20, noted, . Summary: Acute hypoxic [MEDICAL CONDITION] on chronic patient continued to be hypoxic despite breathing treatment and increase in oxygen. (R706) was evaluated by RT (Respiratory Therapy) as well. Patient will be transferred to the hospital . R706's record did not reveal daily monitoring for Covid-19 signs and symptoms. The ICP then explained that during the second week of testing the first staff (Staff A) tested positive on November 16, 2020. Staff A reported to the ICP symptoms as shortness of breath (SOB) with difficulty in breathing. The ICP stated, that the second staff person that tested positive was Staff B and that they worked on the South unit. The ICP was asked were there any residents that tested positive from that unit, the ICP stated, Yes. (R707, R708, R709, and R710). R707 was admitted to the facility on [DATE] and tested positive for Covid-19 on 11/12/20. The ICP reported that the day of the test R707 reported symptoms of decreased appetite, loose stool, and [MEDICAL CONDITION]. R707's physician orders [REDACTED]. Vital signs qs (every shift) Covid + (positive), every 8 hours for monitoring/Covid +, start date 11/12/20. Droplet Isolation related to Dx of Covid-19, start date 11/12. Oxygen at 3 liters per nasal cannula at all times, every shift observe for usage as ordered, start date 11/16. Transfer to the hospital for acute hypoxic [MEDICAL CONDITION], start date 11/23. Further review of R707's medical record revealed, covid-19 monitoring assessments and vitals were not consistently completed daily as ordered. R708 was admitted to the facility on [DATE] and tested positive for Covid-19 on 11/12/20. The ICP reported that R708's symptoms were a low grade temp, stuffy nose, loss of smell, and cough. Further review of R708's medical record noted, Order: Vital signs once a month start 8/1/18. COVID -19 screening two times a day for COVID -19 screening related to [MEDICAL CONDITION], start date 4/19/20. Droplet Isolation related to Dx of Covid-19, start date 11/16. VS (vital signs) q 8 hrs every 8 hours for COVID infection, start date 11/16. O2 (oxygen) @ (at) 2 L to maintain Pox (pulse oxygen) above 90%, start date 11/23. A review of R708's record revealed Covid monitoring assessments and vitals were not consistently completed daily as ordered. R709 was admitted to the facility on [DATE] and tested positive for Covid-19 on 11/16/20. The ICP reported that R709's symptoms were increased confusion and R709's roommate (R710) tested positive on the same day. A review of R709's physician orders [REDACTED]. Droplet Isolation related to Dx (diagnosis) of Covid-19, start date 11/17. Further review of R709's record revealed that vitals and Covid monitoring assessments were not consistently completed daily as ordered. R710 was admitted to the facility on [DATE] and tested positive for Covid-19 on 11/16/20. A review of R710's orders noted, Vital signs monitor two times a day, start date 11/25/20. Droplet isolation related to Dx of Covid-19, start date 11/17/20. Further review of R710's record revealed that vitals and Covid monitoring assessments were not consistently completed daily as ordered. R712 was admitted to the facility on [DATE] and tested positive for Covid-19 on 11/23/20, along with roommate R713. The ICP reported that R712's symptoms were a fever and cough. R712's orders noted, Covid - 19 screening one time a day, start date 3/18/20. Monthly vital signs, start date 7/13/20. Vital signs qs x 72 hours, start date 11/19/20. Droplet Isolation related to Dx of Covid-19, start date 11/23/20. Further review of R712's record revealed that vitals and Covid monitoring assessments were not consistently completed daily as ordered. R713 was admitted to the facility on [DATE] and tested positive for Covid -19 on 11/23/20. The ICP reported that R713's symptom was lethargy. Further review of R713's record revealed that vitals and Covid monitoring assessments were not consistently completed daily as ordered. The ICP also reported the following staff that tested positive for Covid-19: 11/17/20 Staff C on the south unit. Staff D who reported SOB tired and achy a day after results. Staff E Staff F reported symptoms of fatigue, body ache, and nausea. 11/19/20 Staff G 11/23/20 Staff H shared space with Staff A, reported symptoms of stuffy nose on the day of testing. Staff I reported symptoms of no taste or smell, day of test. On 11/25/20 at 9:00 AM, the Administrator and Director of Nursing (DON) were made aware of the missing assessments, orders, and vitals for the identified residents and the DON stated, Let me go and check and get back with you. The Administrator was asked for the facility's policy for monitoring residents for signs and symptoms of Covid-19. The Administrator later provided a policy titled, Documentation During the COVID Pandemic that noted .All residents should have a daily narrative nursing note. The note includes: Vital signs, assessment of reason for Medicare coverage, skilled nursing intervention provided, and response to treatment . All other residents should have at least 1 x (time) per day COVID-19 assessment. On 11/25/20 at 1:20 PM, the ICP was asked if there were any new residents that tested positive. The ICP stated, Yes we have one new resident for today (11/25/20), (R714). A review of R714's medical record revealed, R714 was admitted to the facility on [DATE]. A review of R714's orders noted, Covid-19 screening two times a day for Covid, start date 4/19/20. Vital signs monitor two times a day, start date 11/25/20. Further review of R714's record revealed that vitals and Covid monitoring assessments were not consistently completed daily as ordered. On 11/25/20 at 4:00 PM, the DON was informed the concerns of the inconsistent documentation for monitoring of signs and symptoms for covid-19. The DON stated that the staff may not all be completing the documentation in the area of the medical record. The DON also confirmed that there was inconsistent documentation with the assessments and vital of the sampled residents. The Administrator explained that systems are in place and will be reviewed to improve the monitoring of the residents covid-19 symptoms. The DON and Administrator were asked for a facility policy to address the procedure for roommates of a positive resident. The DON stated, (R701) is in a room alone and we are monitoring (R701). The DON was asked if R701 was placed on droplet isolation precautions and if the facility posted the signs on R701's door to alert staff. The DON explained that R701 was not placed on droplet precautions, but they kept R701 in a room alone and that they were monitoring the resident. The Administrator and DON were asked for the policy for isolation of a roommate exposed to covid-19 and presented a document titled Michigan Department of Licensing and Regulatory Affairs Bureau of Community and Health Systems (BCHS), Resident-Related Infection Prevention and Control Scenarios last updated 10/08/2020. The DON was asked if this was the facility's policy, the DON and Administrator explained this is was what the facility is using. The document was observed to have handwritten notes and underlines under the words The roommate(s) must be restricted to their room. The DON was informed that R701 was observed outside of the room. The DON explained that the resident wheels out of the room and has to be redirected back in. The DON was informed that R701 was not observed to be redirected and was sleeping in the hallway with their head on the handrail, and that staff was observed on the unit during that time. A review of the facility's provided documentation titled, COVID-19 INTERIM PANDEMIC GUIDELINES, updated March 27, 2020, noted, . Management of Outbreak of Communicable Diseases (COVID-19) . Resident Tests Positive: . Increase resident monitoring for signs & symptoms or change in condition to twice per shift . Identify staff members who have had close contact with the resident, identifying for 5 days prior to the onset of symptoms if possible . A review of the facility's documentation titled, (Name of facility) Interim Pandemic Guidelines 2020. Documentation During the COVID Pandemic All residents should have a daily narrative nursing note, The note includes: Vital signs, assessment of reason for Medicare coverage, skilled nursing intervention provided, and response to treatment. Transferring a person to the isolation unit, Need for a doctor order-transfer resident to isolation unit d/t (due to) (symptoms). Family should be contacted and updated on condition (document who spoke to). Update the care plan. If the resident is being admitted under COVID positive or Surveillance, the following is recommended documentation in the narrative area of the COVID assessment. Expand Covid 19 assessment, Narrative note could include: Review of vital signs. Description and nature of symptoms: (i.e. cough - dry or productive, headache - dull or pounding etc.). Lung sounds: clear, wheezing, congested, absent. Description of breathing and Spo2 level - flow, interventions provided and effect. Use of oxygen: how many liters, is the resident keeping it on? Skin color: particularly around the mouth and nail beds. pink, pale blushing color. Skin turgor: or if have a ZOE machine fluid measurement. Appetite and fluid intake. Interventions currently provided. Response to treatments provided - follow up from previous shift . All other residents should have at least 1 x per day COVID-19 assessment, weekly skin assessment . A review of the facility's provided document titled Michigan Department of Licensing and Regulatory Affairs Bureau of Community and Health Systems (BCHS), Resident-Related Infection Prevention and Control Scenarios last updated 10/08/2020, noted, Source Control Measures: Residents face covering or face mask that covers the residents nose and mouth must be worn by a resident in transmission based precautions whenever a resident leaves their room including for procedures treatments or appointments outside the facility. Cloth face covering or face mask that covers the resident nose and mouth should be worn by all other residents whenever they leave their room .For a resident with a known exposure that occur inside the facility: New facility onset COVID 19 case in a resident. A roommate(s) of a resident with COVID-19 must be considered exposed and not sharing room with other resident(s). The roommate(s) must be observed for 14 days after the last exposure to monitor for development of signs and symptoms. The roommate(s) must be restricted to their room. All residents should be restricted to their room to the extent possible, all residents must be observed for 14 days to monitor for development of signs and symptoms .Other important notes: Known exposure means an individual that was within six feet for 15 minutes or longer with another individual with confirmed [DIAGNOSES REDACTED] -CoV-2 infection, regardless of whether the individuals have symptoms . Abatement Plan for F880 Compliance Date: 11/25/20 - Any residents identified to have signs and symptoms for COVID will be placed in precautions per guidelines. - Any residents to have tested positive for COVID -19 will be placed in precautions per Guidelines. - Roommates of any residents who have tested positive will be continuously assessed for signs and symptoms of COVID 19 and placed in precautions per guidelines. - Residents in house are continuously being tested weekly per guidelines and Local Health Dept Guidance. - The 62 residents in house will be immediately assessed for signs and symptoms of COVID utilizing our COVID assessment tool daily. Nurses will be re-educated on how to appropriately complete assessment. - The 62 residents in house will be encouraged to wear mask correctly. Care plans will be reviewed and updated as necessary. - Upon entrance, Staff are being screened utilizing facility comprehensive screening tool as well as thermo scanned. The employee entrance off McCumber unit will be the only entrance used for staff to enter and leave entrance immediately.

Based on observation, interview, and record review the facility failed to provide restorative therapy, access, monitor, and implement treatment for one sampled resident (#32) of six reviewed for limited range of motion, resulting in decreased range of motion and the development of right hand contractures. Findings include: On 9/01/20 at 10:02 AM, Resident #32 was observed sitting in a wheelchair in the front lobby. Resident #32's right arm was observed inward touching their body, with the right hand into a close fist. Resident #32's right hand fingernails were not visible and curled under into Resident #32's palm. Resident #32 hand was not observed with a hand brace/splint. On 9/01/20 at 10:10 AM, Certified Nursing Assistant (CNA J) was asked if Resident #32 had a hand splint or brace for their impaired hand. CNA J stated, No (R32) has never had one. On 9/01/20 at 12:23 PM, Resident #32 was observed with their right arm inward touching their body, with the right hand into a close fist. Resident #32 hand was not observed with a hand brace/splint. On 9/02/20 at 8:30 AM, Resident #32 was observed sitting in a wheelchair in their room with a breakfast tray on a overbed table with activities aide. Resident #32's right arm was observed inward touching their body, with the right hand into a close fist without a brace or splint present. A review of Resident #32's medical record revealed the Resident was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) assessment dated , 4/9/19 noted, Resident #32 with an impaired cognition and required extensive assistance to perform Activities of Daily Living (ADLs). Functional limitation in range of motion marked as, No impairment - Upper and lower extremity upper extremity (shoulder, elbow, wrist, hand). A review of Resident #32's hospital referral 4/2/2019 noted, Physical therapy (PT) evaluation-Acute care . general observations of patient . right handed . with relevant history of hypertension; presented with neurologic symptoms of right [MEDICAL CONDITION], and we were consulted for possible stroke . (Resident #32) woke up at 5 or 6 am this AM and currently presents with right [MEDICAL CONDITION] arm > leg. Prior to presentation, the patient was on no med as a stroke preventive medication . (Resident #32) states prior never needed the assistance of a can or walker . Planned therapy interventions (PT) ROM . RUE (right upper extremity) grossly 1/5 with weak hand grip . Therapy screen assessment dated , 5/13/19 notes, Occupational therapy . 10. Joint contractures: impaired . 13. Opening/closing hands: WFL (Within Functional Limits). A review of the facility's therapy documentation revealed, Occupational Therapy (OT)Evaluation & Plan of Treatment: Certification period: 6/29/2020 - 7/28/2020 . RUE (Right Upper Extremity) Strength = Impaired, General RUE strength =2-/5; shoulder = impaired; elbow/forearm = impaired; wrist = impaired. Contractures: Functional Limitations Present d/t (do to) contractures = No. A review of Resident #32's referral for restorative therapy noted, Therapy to restorative nursing transfer form dated, 7/27/2020 Program goals: To prevent any RUE and lower extremity tightness. On 9/02/20 at 12:28 PM, Therapy Director was asked if Resident #32's had a brace or splint for their contracted hand. The Director of Therapy looked into Resident #32's medical record and reviewed the last discharge summary from Therapy dated 6/29 to 7/27 and explained, It does not look like contractor management was part of this case load. It was more for ADLs like self feeding. On 9/02/20 at 12:40 PM, Nurse B was asked if Resident #32 had a hand splint or brace for their contracted hand. Nurse B stated, (Resident #32) I don't think so. I don't remember ever seeing a brace on (Resident #32). On 9/03/20 at 10:06 AM, the Therapy Director, stated, I completed a screening for (Resident #32's) hand. I will be recommending OT to completed an eval for a hand brace. During the screening (Resident #32) was able to stretch out (their) arm, but had a hard time with (their) hand. The Therapy Director was asked if there was any screenings for Resident #32's right hand prior to this day, the Therapy Director stated, No. I did not see any. Resident #32's contracted hand had ever been addressed by therapy. The Therapy Director explained, they did not find any documentation regarding contractures management, only goals for ADLs. A review of the Therapy Director's screening revealed, Rehab admission screen: . 3. Does the patient require intervention for positioning or contractures? Yes. Comments: Evaluation by OTR recommended for R hand to assess for contractures and possible splinting. Signature: (Therapy Director) date: 9/2/2020. No other documentation was provided or found in the medical record that addressed Resident #32's right hand contractures. On 9/03/20 at 11:40 AM, Nurse B was asked to observe Resident #32's impaired right hand. Nurse B gathered supplies and assisted Resident #32 to their room. Nurse B' was observed to pull Resident #32's fingers out from a tight fist. Resident #32 yelled out in pain. Nurse B continued to pull open Resident #32's hand. Resident #32 grabbed at their right hand with their left hand and yelled out again. Nurse B cleaned Resident #32's hand. Resident #32's nails appeared to be long and pressed into the palm of Resident #32's hand. Further review of Resident #32's medical record revealed. Physician order: 7/28/2020 07:26 Restorative Weekly Progress Notes Note Text: Resident admitted to restorative nursing to prevent any right upper extremity and lower extremity tightness. On 9/3/20 at 1:04 PM, Nurse O was interviewed regarding Resident #32's restorative program, Nurse O stated, On 6/23/20 (Resident #32) was skilled before and was discharged from that and picked up for restorative. Nurse O read the order and stated, The Initial was on 7/27/20, admit to restorative three times a week for 12 weeks to prevent any right upper extremity and lower extremity tightness. Nurse O was asked how many aides worked in the restorative department. Nurse O explained the facility has one full time that was on vacation and one part time. Nurse O was asked for documentation of therapy and stated, That would be under task tab. Nurse O was observed to look in under the task tab and verified that a restorative tab was not located in that section for Resident #32 and stated, Let me go and see if this is where they document. I just became the Restorative Nurse today. On 9/03/20 at 1:42 PM, Nurse O stated, It looks like the task was not put into PCC (electronic medical record) for the CNAs (Certified Nursing Assistant) to document. Nurse O was asked if there was a way to know if was Resident #32 restorative was completed as ordered, Nurse O stated, According to the documentation no. On 9/03/20 at 1:43 PM, The Therapy Director provided documentation, I looked in the (electronic medical record) it looks like they only uploaded the Doctor signature page. Looking through the goals it does not look like there was any goals for contractor management or splinting. On 9/03/20 at 1:57 PM, MDS Nurse was asked if Resident #32 had a plan of care to address their contracted right hand or splinting. The MDS Nurse stated, We would do an assessment and determine the plan of care and document why or why not the splint is needed. On 9/3/20 at 2:38 PM, the Restorative Nurse Manager was asked for the process of for the Restorative program, the Nurse stated, We put the order in and it should be on the task tab for the CNA. The Restorative Nurse was asked the importance of the process, the Nurse stated, Ensure therapy is given as plan. I know they work with (Resident #32) but it's not documented. The Restorative Nurse was asked how does the facility monitor contractures for worsening, the Nurse stated, Weekly assessments and daily exercise with them. On 9/3/20 at 2:40 PM, the Director of Nursing was asked the facility's expectation for residents with hand contractures and if the facility used hand carrots (device that offers painless positioning of severely contracted hands for better patient comfort and easier caregiving.) The DON stated, Yes that (carrot) would be helpful. The DON was asked if a carrot required a physician order, the DON stated, No we can just do that. A review of the facility's policy titled, Establishing a Nursing Restorative Care Program dated, Identifying residents for the program: Residents who could benefit from receiving Nursing Restorative Care can be identified in the following ways: On admission, From information on the MDS, From the 24-hour report and change of shift report, At the facility's morning meeting, At care planning and other resident-focused meetings, At the weekly Quality of Life meeting, During daily rounds and Nursing Grand Rounds . Admission guidelines to restorative care Those who are ready to finish a skilled rehabilitation therapy program . Residents who require minimum to moderate assistance with standing, walking transferring, bathing, grooming, etc .

Based on observation, interview, and record review, the facility failed to maintain washing functionality and sanitizing temperatures of the dish machine, continued to distribute food on un-washed/un-sanitized dishware, and maintain kitchen environment in a sanitary condition and in good repair, resulting in the high likelihood of spreading communicable diseases among residents, resulting in an immediate jeopardy affecting 59 residents that receive food from the kitchen. Immediate Jeopardy was identified: 08/28/19 at 11:20 AM. It began on 08/28/19 at 11:20 AM. The Administrator was notified of the Immediate Jeopardy: 08/28/19 at 2:26PM The Facility was requested for a written plan of correction for abatement: 08/28/19 at 2:26 PM Although the Immediate Jeopardy was removed on 08/29/19, the deficient practice continued to cause no actual harm with potential for more than minimal harm that is not immediate jeopardy on a widespread scale. Facts Supporting Immediate Jeopardy: On 08/28/19 at 10:00 AM, during an inspection of the dish washing area, the dish machine was observed to be soiled with food debris, grease and mineral deposits, standing water, and pink slime/mold-like growth. Water was observed to drip from the ceiling tile directly next to the dish machine exhaust vent, onto the dish machine. On 08/28/19 at 10:03 AM, during an inspection of the dish washing area, Dishwasher B stated to Maintenance Director A that the dish machine detergent was not dispensing. On 08/28/19 at 10:11 AM, a bin of clear plastic cups, stored on the clean dish drying rack, were observed to be mostly coated with a brownish residue. Two plastic bins were observed to be soiled with food debris, on the drying rack. Dietary Manager D immediately told staff to throw away the dishware. During an interview on 08/28/19 at 10:28 AM, Dishwasher B was queried on the dish machine detergent dispenser and stated that it has not been working, at least a week and a half. Dishwasher B continued to state that normally, when the detergent dispenser is working, the detergent must be refilled in the morning, and again around noon. Dishwasher B stated that he has not refilled the detergent in around a week and a half to two weeks. At the time of the interview, the chemical feed line going from the detergent dispenser to the dish machine, was not observed to have flowing water, when a dish machine cycle was engaged. On 08/28/19 at 11:18 AM, during a review of the facility's Dish Machine Temperature Log - (High Temperature), dated, 8-14-19 for the location of Kitchen, it was observed to be pre-filled out for 8/28/19 with the dish machine temperatures for the afternoon and evening temperature slots: Morning Wash Temperature - 168; Morning Sanitize Temperature - 180; Afternoon Wash Temperature - 165; Afternoon Sanitize Temperature - 190; Evening Wash Temperature - 165; Evening Sanitize Temperature - 188. At this time, no color changing temperature test strips were observed to be recorded on the temperature log. This policy also noted, **Hot Water sanitizer must be 180-190 degrees F. Dish Machine cannot be used to sanitize if these levels are not reached prior to wash or any dishes. ** Report levels out of range to manager and maintenance immediately and wait for directions related to continued use. On 08/28/19 at 11:19 AM, Dishwasher B was queried on if they use irreversible color changing temperature test strips (sticker-style test strips that changes color to indicate the dish in the dish machine has reached a sanitizing temperature of 160 degrees) to test the sanitizing hot water cycle of the dish machine and stated that the temperature of the sanitizing water is not where it is even supposed to be, so there is no point of using the test strips. Dishwasher B was then queried on how long the dish machine was not sanitizing and stated, Almost a month, he (referring to the dish machine technician) came out, fixed it, then it went right back out again. On 08/28/19 at 11:20 AM, two color changing temperature test strips were placed on a ceramic plate by Dishwasher B and were put through the dish machine; neither of the test strips were observed to change color. On 08/28/19 at 11:34 AM, the Surveyor notified the Dietary Manager D that the dish machine was not washing or sanitizing dishware. On 08/28/19 at 12:35 PM, the Nursing Home Administrator (NHA) brought a color changing test strip, that successfully changed color, to the Surveyor and stated that it was now sanitizing. On 08/28/19 at 1:11 PM, the residents in all the dining rooms in the main building were observed to be eating with and drinking out of the facility's plastic and ceramic dishware. On 08/28/19 at 1:17 PM, during a reinspection of the dish washing area, a third-party technician stated that the dish machine electronic controller lost its programming, resulting in the hot water cycle to not work properly, and that it takes a few cycles to get up to the proper temperature. Regional Dietary Director F proceeded to place a color changing temperature test strip through the dish machine and it was observed to not change color. At 1:19 PM, a second test strip was put through the machine and it did not turn color to indicate the proper temperature has been met. At 1:21 PM, four racks were ran through the dish machine to give the dish machine the opportunity to get up to the proper temperature, and the next test strip did not change color. At 1:23 PM, the Surveyor used their own color changing temperature test strips, of a different brand, and it was not observed to change color. During a review of the kitchen dish machine service report from (Sanitation Company), dated 8/14/19, it noted, Kitchen: Comments Lots of silverware and plastic in the bottom of the wash tank. MACHINE OBSERVATIONS . Arms blocked/clogged . CAUSE| Procedures| ACTION & BENEFITS| o Fixed to Improve Cleaning. The dish machine service report also noted, POINT OF OBSERVATION| Machine| CONDITION| Lime Build Up/scaled| CAUSE| Water| ACTION & BENEFITS| Recommended to Optimize Performance2 | . 2. Machine was very dirty, mainly the pre wash tank. All screens were 100% clogged, floats covered in grease causing machine fill to stay on. According to the 2013 FDA Food Code Section 4-501.17 Warewashing Equipment, Cleaning Agents. When used for WAREWASHING, the wash compartment of a sink, mechanical warewasher, or wash receptacle of alternative manual WAREWASHING EQUIPMENT as specified in 4-301.12(C), shall contain a wash solution of soap, detergent, acid cleaner, alkaline cleaner, degreaser, abrasive cleaner, or other cleaning agent according to the cleaning agent manufacturer's label instructions. According to the 2013 FDA Food Code Section 4-501.14 Warewashing Equipment, Cleaning Frequency. A WAREWASHING machine; the compartments of sinks, basins, or other receptacles used for washing and rinsing EQUIPMENT, UTENSILS, or raw FOODS, or laundering wiping cloths; and drainboards or other EQUIPMENT used to substitute for drainboards as specified under § 4-301.13 shall be cleaned: (A) Before use; (B) Throughout the day at a frequency necessary to prevent recontamination of EQUIPMENT and UTENSILS and to ensure that the EQUIPMENT performs its intended function; and (C) If used, at least every 24 hours. According to the 2013 FDA Food Code Section 4-701.10 Food-Contact Surfaces and Utensils. EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED. According to the 2013 FDA Food Code Section 4-703.11 Hot Water and Chemical. After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: . (B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under §§ 4-501.15, 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71oC (160oF) as measured by an irreversible registering temperature indicator; . According to the 2013 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, NonfoodContact Surfaces, and Utensils. A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (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. Facility Removal Plan: Element 1) The following steps were taken to immediately address the dish machine. Dietary Staff As of 2:45 pm on 8/28/2019 the dish machine is not to be used. As a result, you should utilize disposable items (to include plates, bowls, cups and flatware) for all Guest needs. Further the dish machine shall not be used until a service repair company has performed service on the machine and documents that the machine is in an appropriate stated of functionality. (Service Company Manager) arrived in the facility at or around 4:15 pm and has started to service the dish machine. As of the time of this document being composed (5:00 pm) (Service Company Manager) is still servicing / testing the dish machine. (business card attached in (service company ) attachment) Large scale kitchen equipment has been cleaned and sanitized per policy and procedure, while small scale kitchen items have been cleaned and sanitized per three compartment sink. Element 2) As this citation is not related to a specific Guest, element 1 above shall also serve as corrective action for the entire population. Element 3) There are 31 dietary staff on (Facility)'s payroll. As of this time re-education has begun and 8 of 31 staff have completed the education and taken the post test. (25 percent of staff and all staff on current shift) As of the time of this document being composed (5:00 pm) three additional staff have completed the education. (35 percent of staff and all staff on current shift) Further education will be completed with dietary staff prior to the engagement of kitchen specific tasks for their work day if not prior. Please note the kitchen sanitation education attachment as well as post test are attached to this document and labeled as such. Element 4) Dietary Manager or designee shall complete the dietary / culinary services infection control audit. This audit shall be done daily x4 weeks and then weekly thereafter for at least 3 months. The outcomes of all audits shall then be reported to QAPI team monthly. Note the audit will verify appropriate functionality of the high temperature dish machine and both documents (dietary infection control audit and dish machine temperature log) are attached to this document. On 08/28/19 at 9:45 AM, during an inspection of the kitchen, a countless number of small flies were observed near the juice machine. Dried juice spills were observed around the juice machine, and juice spills and water were observed on the floor. The catch tray for the juice machine was observed to be removed from the machine and not in place to catch splash or spills. Additionally, a plastic wrap covered cup, with an unidentified liquid in it, what appeared to be a homemade fly trap, was observed on the counter by the juice machine. On 08/28/19 at 9:48 AM, small flies were observed to be around the floor drain near the coffee machine. At the time of the observation Maintenance Director A stated that the facility has three different pest control companies that come to the facility on various frequencies. On 08/28/19 at 9:58 AM, a second homemade fly trap was observed underneath the dirty dish drain board in the dish washing area. On 08/28/19 at 10:00 AM, small flies were observed to be flying around the dish machine On 08/28/19 at 10:11 AM, the screen to the open window in the kitchen was observed to be ripped at the bottom, leaving a hole large enough for insects to enter. Additionally, the screen was observed to be improperly sized, leaving a one-inch gap at the top of the screen. On 08/28/19 at 11:36 AM, the exterior door, located by the kitchen entrance door, was observed to have a significant gap on the bottom edge, allowing light to shine through from the exterior, and large enough for an ink pen to fit through. Additionally, the kitchen entrance door was observed to not have any door sweep. According to the 2013 FDA Food Code Section 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (A) Routinely inspecting incoming shipments of FOOD and supplies; (B) Routinely inspecting the PREMISES for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under §§ 7-202.12, 7-206.12, and 7-206.13; Pf and (D) Eliminating harborage conditions. According to the 2013 FDA Food Code Section 6-202.15 Outer Openings, Protected. (A) Except as specified in (B), (C), and (E) and under (D) of this section, outer openings of a FOOD ESTABLISHMENT shall be protected against the entry of insects and rodents by: (1) Filling or closing holes and other gaps along floors, walls, and ceilings; (2) Closed, tight-fitting windows; and (3) Solid, self-closing, tight-fitting doors . (D) Except as specified in (B) and (E) of this section, if the windows or doors of a FOOD ESTABLISHMENT, or of a larger structure within which a FOOD ESTABLISHMENT is located, are kept open for ventilation or other purposes or a TEMPORARY FOOD ESTABLISHMENT is not provided with windows and doors as specified under (A) of this section, the openings shall be protected against the entry of insects and rodents by: (1) 16 mesh to 25.4 mm (16 mesh to 1 inch) screens; (2) Properly designed and installed air curtains to control flying insects; or (3) Other effective means. On 08/28/19 at 9:49 AM, during an inspection of the kitchen, the hand sink closest to the cookline was observed to be leaking profusely from the drain line when the water was turned on. Some of the leaking water was observed to collect in the cupboard where the drain lines are located, while another portion of the water disappeared into the hole in the wall, where the drain line goes into. On 08/28/19 at 9:56 AM, the wash and rinse basin drain lines of the three-compartment sink were observed to be continuously leaking water, when the sinks were full. At the time of the observation, Dishwasher B was queried on how long the drain lines were leaking and stated, Quite a while. At least six months. On 08/28/19 at 10:15 AM, the pressure vacuum breaker (a plumbing device used to prevent backflow of contaminants into the domestic water supply), located on the cookline near the tilt kettle, was observed to be leaking water out of the atmospheric port. According to the 2013 FDA Food Code Section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; P and (B) Maintained in good repair. According to the 2013 FDA Food Code Section 5-202.14 Backflow Prevention Device, Design Standard. A backflow or backsiphonage prevention device installed on a water supply system shall meet American Society of Sanitary Engineering ([NAME]S.S.E.) standards for construction, installation, maintenance, inspection, and testing for that specific application and type of device. On 8/28/19 at 9:54 AM, observed the grease trap with layers of grease and debris sitting on top. The drain lines, provided for the garbage disposal, above the grease trap were observed to be soiled with grease splash and food debris. Maintenance Director A was queried on if the grease trap has recently backed up and did not confirm nor deny the suspected back up. On 8/28/19 at 9:57 AM, observed a plate cart covered with a plastic cover, next to the open window, containing standing yellowish water with food debris and bugs surrounding it. Dietary Manager D was observed to immediately run the plastic cover through the dish machine. On 8/28/19 at 9:58 AM, a black sludge like substance was observed at the wall/floor juncture underneath the dish machine drain board. Maintenance Director A was queried on the condition and stated, yeah, I've seen that the other day. Additionally, a strongly offensive odor, resembling sewer gas and food waste, was observed to be coming from the once-existing garbage disposal. The garbage disposal was observed to be removed and was replaced with a four-inch plastic drain pipe. On 8/28/19 at 10:10 AM, observed the hood vent filters above the fryer and flat top grill with layers of dust and grease. When queried, Maintenance Director A advised the hood vent is not working and they are in the process of getting it repaired. On 8/28/19 at 10:12 AM, pooling, solidified grease was observed to be accumulating under the equipment on the cookline. Dietary Manager D was queried on the process for floor clean and stated that porters do a deck scrub on the floors. On 8/28/19 at 10:15 AM, observed the tilt kettle soiled with food debris inside and on top of the cover. Standing water and food debris was also observed under the grill along with small flies surrounding the standing water. When queried, Dietary Staff C advised that the tilt kettle was used last night. On 8/28/19 at 10:23 AM, observed blocked on ice on the floor of the walk-in freezer, along with ice on top of four boxes containing food product. When queried, Maintenance Director A advised the ice is condensation from opening the freezer and this isn't the first time this has happened, but he will have it removed. On 8/28/19 at 10:45 AM, black spots were observed in the bottom of the ice scoop holder in the dining room service area. Additionally, two juice pitchers were observed in the handwashing sink, along with two wiping cloth buckets. A plate was also observed to be stored under the handsink in the cupboard. According to the 2013 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, NonfoodContact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (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 2013 FDA Food Code Section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair. According to the 2013 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. On 8/28/19 at 10:52 AM, three boxes of cereal were observed in the TCU dining room underneath the hand sink. Additionally, the steam table drain line was observed to be directly connected to the handsink drain line, with no air gap provided to prevent backflow of contaminants into the steam table plumbing. According to the 2013 FDA Food Code Section 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. According to the 2013 FDA Food Code Section 5-203.14 Backflow Prevention Device, When Required. A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose bibb if a hose is attached or on a hose bibb if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap as specified under § 5-202.13 P; . On 08/28/19 at 1:40 PM, during an inspection of the[NAME]House, Dietary Manager D stated that he was notified this morning that that the[NAME]House dish machine wasn't sanitizing properly, and therefore the[NAME]House was using paper products for meal service. At the time of the interview, paperware was observed available for meal service. Dietary Manager D was requested to run a dish washing cycle to test the chlorine sanitizer, which was not present, as explained by Dietary Manager D. On 08/28/19 at 1:45 PM, Green House Manager [NAME] stated that she had called (dish machine company) when it was discovered that the[NAME]House dish machine wasn't sanitizing. At the time of the interview, The Surveyor opened the cupboard that contained the chemical bottles that feed into the dish machine, and observed that a detergent (Super Trump detergent) was being used in place of where the sanitizer is supposed to feed into the dish machine, resulting in two dish detergents and one rinse aid being fed into the dish machine, with no sanitizing solution. According to the 2013 FDA Food Code Section 2-102.11 Demonstration. Based on the RISKS inherent to the FOOD operation, during inspections and upon request the PERSON IN CHARGE shall demonstrate to the REGULATORY AUTHORITY knowledge of foodborne disease prevention, application of the HAZARD Analysis and CRITICAL CONTROL POINT principles, and the requirements of this Code. The PERSON IN CHARGE shall demonstrate this knowledge by: (A) Complying with this Code by having no violations of PRIORITY ITEMS during the current inspection; Pf (B) Being a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM;Pf or (C) Responding correctly to the inspector's questions as they relate to the specific FOOD operation. The areas of knowledge include: . (13) Identifying POISONOUS OR TOXIC MATERIALS in the FOOD ESTABLISHMENT and the procedures necessary to ensure that they are safely stored, dispensed, used, and disposed of according to LAW;

Based on observation, interview, and record review, the facility failed to ensure turning an repositioning was done to offload pressure on Pressure Ulcer (PU) and/or ensure through skin assessments were done for two (#803 & #807) of seven residents reviewed for PUs out of a total of 16 sampled residents, resulting in the reopening of PUs, and delays detection and treatment. Findings include: Resident #803 On 11/13/17 at 9:00 AM, during the initial tour, Resident #803 was observed lying in bed on her back with a pillow under the left arm. Resident #803 had a [MEDICAL CONDITION], the tube feeding and the tube feeding pump was off. Resident #803 was observed lying on her back at 1:30 PM and 3:45 PM. On 11/13/17 at 3:30 PM, a review of the clinical record revealed that Resident #803 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #803 had severely impaired cognition and was totally dependent of staff to complete activities of daily living, including bed mobility. A review of the nursing care plan revealed that Resident #803 was supposed to be turned frequently, but failed to indicate the parameters when it should be done. On 11/14/17 at 8:10 AM, during the medication pass observation, Resident #803 was observed lying on her back. At 11:43 AM, during the observation with the wound team, Resident #803 was observed to have a recurrent stage 3 PU on the right buttocks. (Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) Wound Care Physician M stated, Oh it opened back up. The PU measured 2.0 centimeter (cm) long X 1.8 cm wide X 0.01 cm deep. The PU had irregular edges, peri-wound scarring, and small amount of serous drainage. Resident #803's brief was saturated with urine and the bed linens were wet. On 11/15/17 at 8:05 AM, the door to Resident #803's room was closed. Upon knocking and entering, Resident #803's was observed in the bed on her back, the bed was in high position, there was a pillow under the left arm, and her heels rested on a pillow. The tube feeding pump was infusing [MEDICATION NAME] 1.5 at 70 cc/hour. Resident #803 was observed in bed on her back at 9:24 AM, 11:05 AM, 1:10 PM. Resident #803 was observed positioned on her back and tilted of the area of the PU from 8:05 AM to 1:10 PM. On 11/15/17 at 11:20 PM, further review of the clinical record revealed on 7/18/17 Resident #803 was seen by the wound care consultant. The Consultant note stated, Right buttock is a stage 3 PU .resolved. The wound consultant note, dated 10/3/17, stated,Para-sacral with fragile cicatrix (scar tissue). The clinical record was reviewed for weekly skin assessment documentation after 7/18/17. However, Weekly head-to-toe assessments, dated 4/11/17 and 5/23/17 were the only ones seen. At 12:25 PM, the DON reviewed the Electronic Medical Record (EMR) and revealed the weekly skin assessments had not been done. The DON stated, It (weekly skin assessments) was supposed to be put on the UDA board (I don't know what that stands for) on admission, but it didn't, so the assessments were never scheduled. The DON presented Medicare-Skilled Charting, dated 11/1/17, that indicated Resident #803 was known to have a stage 2 PU to the sacrum, however a review of the treatment administration record presented by the DON failed to document that a treatment had been initiated. The wound notes, dated 11/15/17, documented, Right buttock, acquired 11/14/17, stage 3 originally and remained a stage 3. The Certified Nurse Aide (CNA) documentation for November 2017, under Monitor - Skin Observation, documented that Resident #803 was observed to have a new red area on 11/1/17 on the day shift (6 AM-2 PM). Unit Manager N, also present during the interview with the DON, was asked about Resident #803 lying on her back from 8:05 AM to 1:13 PM. Unit Manager N stated, I know they adjusted her because I looked at her. We moved the pillow that was under her arm from the right side to the left. Unit Manager N was asked how Resident #803 was offloaded off the PU on the sacrum when she was still lying on her back. Unit Manager N stated, That's how we resolved it when she had some break down before. Resident #807 On 11/13/17 4:13 PM, a review of the clinical record revealed that Resident #807 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated that Resident #807 was cognitively intact, but required extensive to total assistance from staff to complete activities of daily living. Further review of the clinical record revealed the Weekly Head-to-toe Assessment-Licensed Nurses form, dated 10/9/17, documented that Resident #807 had small excoriated area to upper right back, const. (continue with tx (treatment) as ordered to affected areas, protective measures cont. However, a Weekly Healing Record-Wound Care Nurse, dated 10/10/17, documented that Resident #807 had 3 PUs: #1 Left [MEDICATION NAME] spine that was acquired on 10/10/17 at a stage 3, had necrotic midcore tissue, moderate serosanguinous drainage, and measured 2.0 cm long X 4.2 cm wide X 0.0 cm deep; #2 Left Flank acquired on 10/10/17 at a stage 3, had dark discolored base, and measured 2.7 cm long X 4.2 cm wide X 0.0 cm deep; #3 Right buttock that was acquired 10/10/17 at a stage 3, had a necrotic midcore and measured 3.2 cm long X 6.0 cm wide X 0.8 cm deep. On 11/14/17 at 1253 p.m., Nurse J was observed as a dressing change was done for Resident #807' pressure ulcers. Resident #807 had soggy dressings on her right upper back, sacral area and right buttocks. The PUs were malodorus. Left upper scapula (shoulder blade) unstageable the size of a quarter, the PU on Resident #807's sacrum and right buttock had dark purple appearance at the base. CNA O, who was holding Resident #807 on her side, stated, They smell really bad. (Unstageable Bed Sore: A bedsore that has full tissue loss and the base of the sore is covered with dead cells and hard scabs with fluid that excretes out of them to hide how deep they are in the skin. Source: https://www.bedsorefaq.com/bed-sore-glossary/#S) On 11/15/17 at 11:44 AM, Unit Manager B was asked about Resident #807's pressure ulcers. Unit Manager B stated, The PUs came last month around the 10th with the right gluteal . A review of the progress noted, dated 10/6/17, documented, Writer summoned to resident room to observed resident lying on very firm (hard) low air loss mattress, maintenance request made to check out mattress, resident in the mean time noted with excoriated area to left upper back and lower right buttock . On 11/15/17 at 12:25 PM, the DON was ask about Resident #807 having excoriated areas on the right upper back on 10/9/17 that progressed to three stage 3 PUs the following day, but weren't noted on the skin assessments. The DON revealed she did not know, but agreed the PU had opened before 10/10/17 and had not been reported. The DON was asked if there had been a problem with getting the weekly skin assessments done. The DON stated, Yes. We need to do some in-servicing. The DON had no explanation for the inconsistencies in the skin assessments and documented observations related to residents' skin conditions. On 11/15/17 at 2:30 PM, a review of the facility's undated Pressure Ulcer & Skin Care Management Policy, stated, .a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing .A licensed nurse checks the resident's body for the presence of pressure ulcers, wounds and other skin conditions .weekly .The licensed nurse documents that the body check was completed on a resident's weekly head to toe skin record .The licensed nurse assesses and documents that status of existing wounds weekly .

Based on interview and record review the facility failed to ensure safety during Activities of daily living (ADL) care and maintain the bed in a locked position for one (#804) of three residents reviewed for falls, out of a total of 16 sampled residents, resulting in a and a skin tear on the elbow and a laceration across the forehead that required stitches to close the open wound. Findings include: On 11/14/17 at 12:15 p.m., a review of Resident #804 medical record revealed the following: Incident and Accident report, date of incident, 10/24/17, 8:50 a.m., Writer summoned to Res (Resident's) room to observe lying on her back beside her be picking at her left elbow observed at small skin tear to elbow . Incident and Accident report, date of incident, 10/24/17, 4:30 p.m., Writer observed resident lying on her left side on the floor between the wall and bed . sporadic bleeding on left upper arm from pervious fall. Incident and Accident report, date of incident, 11/5/17, 7:35 a.m., CENA (Certified Nursing Assistant) informed writer resident had a fall while getting her dress upon assessment resident on floor on her side next to bed. Once in safe position noticed bleeding to side of left head and left elbow. Pressure applied until EMT's arrived .resident having having increased bleeding . On 11/14/17 at 1:30 p.m., a review of the clinical record revealed that Resident #804 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Date Set (MDS), dated [DATE], indicated that Resident #804 had severely impaired cognition and was totally dependent of staff to complete activities of daily living, including bed mobility. Interviews on the Fall out of the bed on 10/24/17: On 11/14/17 at 3:30 p.m., during an interview, Nurse O was asked to explain the observation made on 10/24/17. Nurse O said, I was going to take vitals because of the earlier fall. The last time I saw her was in the dining area someone came in to do an assessment and took Resident #804 back to the room. I went into the room and did not see her. I went back to the front to look for her and didn't see her. I then went back to the room and noticed that the bed was off the wall a little. I then looked over the bed, were the opening was and saw Resident #804 was laying on the floor between the wall and bed. Nurse O further explained the bed was not locked and it was not in the correct position against the wall. Nurse O said, the bed should have been locked. On 11/14/17 at 3:38 p.m., during an interview, Unit Manager B said, Resident #804 was taken to her room for physical assessment by an outside agency, they pulled the bed away from the wall. They didn't put the bed back on the wall, Resident #804 had one bolster at the time for side of the bed open to the floor. Unit manager continued and said, They (the outside agency) don't know her like we do. Resident #804 has two bed bolsters now. On 11/14/17 at 4:43 p.m., during an interview, the DON was asked if there is an expectation/procedure for the facility staff to go into Resident #804's room after an assessment by an outside agency. The DON, said There will be now. I am not sure if something was in place for checking with that type of visit. Interviews on Head laceration on 11/5/17: On 11/14/17 at 4:11p.m., during an interview, the Director of Nursing (DON) said, she (Resident #804) has had a decline in trunk control. The CNA reported to the Nurse right away. It was explained that CNA P turned her back to grab another shirt and Reside #804 fell . The DON was asked the expectations for dressing or providing care by a CNA. The DON said, during care they should have all the stuff there, easily accessible. That's how they are trained and is that how we watch them. On 11/14/17 at 4:30 p.m., during an interview, CNA P said, Yes It was a big mistake, I turned for a split second and as I was turning back around she was falling. I couldn't stop it. I should have had all her stuff on the bed. On 11/14/17 at 2:30 p.m., a review of the facility's undated Morning And Bed Time Care Policy and Fall Management Guidelines. The policies did not address the incidents that occurred with Resident #804.

Based on interview and record review, the facility failed to ensure that excessive doses of anticoagulant medications (blood thinners- medications that inhibit clotting) were not given for one (#301) of three residents reviewed for anticoagulant therapy out of a total sample of four, resulting in transfer to the hospital for [MEDICAL CONDITION] (dangerously low blood pressure), a critically low amount of red blood cells (Hemoglobin and Hemocrit), critically delayed blood clotting ability ( as measured by laboratory tests for the blood's ability to form a clot, PT- [MEDICATION NAME] time, INR - International Normalized Ratio, and PTT - Partial [MEDICAL CONDITION] Time). Findings include: On 10/14/14 at 10:35 A.M., Resident #301's clinical record was reviewed, and revealed the following: Resident #301 was admitted into the facility from the hospital on [DATE] , with [DIAGNOSES REDACTED]. Diff - a potentially fatal infectious diarrhea), [MEDICAL CONDITION] ([MEDICAL CONDITION]- blood clot in a deep vein), Pleural Effusion (water on the lungs) Pneumonia, and [MEDICAL CONDITIONS]. Hospital "Patient Discharge Instructions", dated 4/10/14 at 3:28 P.M. (four days before Resident #301 was discharged from the hospital and transferred to the facility) documented Resident #301's "Medications To Be Continued" included the following anticoagulants (blood thinners- anti clotting medications): "[MEDICATION NAME] (a drug which decreases the ability to clot) 60 milligrams (mg) subcutaneous injection (subq) once a day (qd) for five days", and , "[MEDICATION NAME] ( a medication with a Food and Drug Administration "Black Box Warning" regarding the risk of death from excessive bleeding) 2 mg oral tablet, 2 mg by mouth daily (qd) 30 days." The hospital physician progress notes [REDACTED].#301 was "currently" on [MEDICATION NAME] 2 mg daily with Levonox to bridge". The physician progress notes [REDACTED]. This progress note does not reveal that [MEDICATION NAME] was administered on this date. These progress notes also did not include the dosage of the [MEDICATION NAME], route of administration, and length of time it was to be continued. " Hospital laboratory test results (labs) for Resident #301, also dated 4/10/14 documented that on the date the "Patient Discharge Instructions" were written, " Resident #301 had chronic [MEDICAL CONDITION] with low lab values which were stable (hemoglobin lab value was 9.1 and Hematocrit lab value was 27.8) and the resident ' s INR test ... " (test used to measure the effectiveness of the anticoagulant, [MEDICATION NAME]) was 1.3 (normal range = 0.5 - 1.5, therapeutic range for prevention of embolism or treatment and prevention of venous [MEDICAL CONDITION] = 2.0-3.0). Labs for Resident #301, dated 4/14/14 at 5:20 A.M. (the day Resident #301 was discharged from the hospital) documented the INR was 3.2 (therapeutic range for prevention of embolism or treatment and prevention of venous [MEDICAL CONDITION] = 2.0 - 3.0), increased since 4/13/14 at 4:15 A.M. (the day before), documented as 2.9. The PT ([MEDICATION NAME] time) on 4/14/14 was documented as 33.3 seconds ( normal = 9.2-12.6), increased from 30.6 seconds since 4/13/14. Hard copy (paper prescriptions that can be honored by a pharmacy) hospital discharge prescriptions dated 4/14/14 included, "[MEDICATION NAME] 3 mg oral tablet, give (sig) one half daily for 30 days." (dose = 1/5 mg, and did not include a hard copy prescription for [MEDICATION NAME] injection. Review of the facility Admission MEDICATION ORDERS FOR [REDACTED]" (last day on 4/18/14), and, "[MEDICATION NAME] 2.0 mg tablet (tab) by mouth (po) qd for 30 days." On 10/14/14 at 11:35 A.M., the Director of Nursing (DON) was asked why there were two different hospital discharge prescriptions for [MEDICATION NAME], and how admission medication orders were obtained for new residents. The DON stated, "The admission nurse reviews the discharge medication orders from the hospital and calls them in to the doctor and gets the orders. The nurse is supposed to use the "Medications to be Continued list" on the hospital discharge instructions for the admission orders [REDACTED]"Medications to be Continued" list (dated 4 days before discharge.) When asked if the physician might have written a prescription for a lower dose of [MEDICATION NAME] on 4/14/14 because the INR and PT results on 4/14/14 were too high. the DON stated, "I can't say." On 10/14/14 at 11:35 A.M., a nursing admission assessment for Resident #301, dated 4/14/14 at 5:30 P.M., was reviewed with the DON, and noted , "Multiple bruising to upper and lower extremities, chest, abdomen, and perineal area (crotch). Resident #301's Hospital "Patient Discharge Instructions", dated 4/10/14, included, "[MEDICATION NAME] is a prescription medication that delays normal blood clotting. Medical conditions which increase your clotting time (increased risk of uncontrolled bleeding) include diarrhea. The risk of bleeding increases as the INR rises above the desired limit. Patients on [MEDICATION NAME] should report signs or symptoms of bleeding or unusual bruising." When asked if "multiple bruising" to most of the resident's body was evidence of "unusual bruising", the DON stated that the nurse had noted this, and had tested Resident #301's INR on 4/15/14, and notified the physician that Resident #301's INR was 3.1 ( above 3.0). Review of a physician's orders [REDACTED]. Give [MEDICATION NAME] two mg tonight. Recheck INR on Friday (4/18/14)." When asked why the physician ordered a three mg dosage of [MEDICATION NAME] to be held, when there was no order for the resident to receive three mg, the DON stated, "I don't know, we'll have to ask the nurse who wrote the order." On 10/14/14 at 11:45 A.M., Resident #301's Nursing Notes, Medication Administration Record [REDACTED]. The following results were noted: 4/15/14 : INR = 3.1 . [MEDICATION NAME] 2.0 mg given, [MEDICATION NAME] 60 mg subq given. 4/16/14: [MEDICATION NAME] 2.0 mg given,[MEDICATION NAME] 60 mg sub q given. 4/17/14 :[MEDICATION NAME] 2.0 mg given,[MEDICATION NAME] 60 mg sub q given. 4/18/14: INR = 5.6. [MEDICATION NAME] 2 mg held, [MEDICATION NAME] 60 mg sub q given. 4/19/14: INR = 6.2 [MEDICATION NAME] 2 mg held, [MEDICATION NAME] 60 mg sub q given. 4/20/14: [MEDICATION NAME] 2 mg held, [MEDICATION NAME] 60 mg sub q given. 4/21/14 INR > 8.0. [MEDICATION NAME] 2 mg held, [MEDICATION NAME] 60 mg sub q given. The DON was asked at this time why the [MEDICATION NAME] 60 mg sub q injection was administered to Resident #301 for seven days, instead of the five days ordered by the physician, The DON stated, "The nurse who transcribed the order to the MAR forgot to box out the day it was supposed to be discontinued." On 10/14/14 at 4:15 P.M., Dr "C", the partner of Resident #301's physician "F" , who was unavailable at the time of the survey, was interviewed. Dr "C" stated, "(Resident #301) wasn't ready for discharge from the hospital as she was on a full dose of [MEDICATION NAME] and [MEDICATION NAME], and had an INR of 3.2. We usually hold the [MEDICATION NAME] for an INR of 3.1. I don't understand that order.(Order dated 4/15/14 to "Hold [MEDICATION NAME] three mg today. Give [MEDICATION NAME] two mg tonight"). I don't want to put words in anyone's mouth, but it sounds like he didn't know what dose she was on." On 10/14/14 at 4:30 P.M., Licensed Practical Nurse (LPN) "E" was interviewed in the presence of the DON and Unit Manager (UM) "A", regarding the telephone order she obtained for Resident #301 from Dr. F" on 4/15/14 to ""Hold (don't give) [MEDICATION NAME] three mg today. Give [MEDICATION NAME] two mg tonight." LPN "E" stated, " I called the doctor with her INR results and he asked me what dosage of [MEDICATION NAME] she was on. I always look at the hospital orders." LPN "E" pointed to the hospital discharge hard copy prescription for "[MEDICATION NAME] three mg oral tablet, sig 0.5 tablet daily", and said, "It says right here , [MEDICATION NAME] three mg daily." When asked, LPN "E" stated that she could not remember if she notified the physician that Resident #301 also received 60 mg of [MEDICATION NAME] subq daily, and had multiple bruising over a large area of her body, and was unable to provide any documentation she had done so. When asked, LPN "E" stated that she had not notified the physician that Resident #301 was taking [MEDICATION NAME], a medication which may interact with [MEDICATION NAME] and increase the INR. When queried, LPN "E" stated that she had not notified the physician that Resident #301 had c.diff diarrhea. LPN "E" stated that she had no knowledge that diarrhea and [MEDICATION NAME] could interact with [MEDICATION NAME] and increase INR. Record review with the DON and UM "A" revealed that Dr. "F" had not seen Resident #301. The Progress notes and History and Physical were completed by a Nurse Practitioner, and Resident #301's orders had been obtained from Dr "F" by telephone. On 10/16/14 at 10:30 A.M., the facility's consultant pharmacist "B" was interviewed by telephone regarding Resident #301 and stated, "Usually the [MEDICATION NAME] injection is given to bridge the anticoagulant therapy until the [MEDICATION NAME] levels are up to the therapeutic level. When the [MEDICATION NAME] becomes therapeutic, the [MEDICATION NAME] should be discontinued (d/ced). They usually start the patient on [MEDICATION NAME] in hospital, and titrate the [MEDICATION NAME] dosage until it becomes therapeutic. It takes three days to see the effects of holding or decreasing the [MEDICATION NAME] dose. Resident #301 had [DIAGNOSES REDACTED] diarrhea. That can cause increases in the INR. On 10/16/14 at 11:00 A.M., review of physician's orders [REDACTED].#301 revealed the following: A Nursing note dated 4/21/14 at 9:00 A.M., noted, " INR > 8.0. Color of skin pale, yellowish. Vitamin K (antidote to [MEDICATION NAME]) five mg injected intra muscularly (IM)." A telephone order dated 4/21/14 at 10:00 A.M., noted "Send to emergency room ". On 10/17/14 at 3:00 P.M., Resident #301 emergency room records dated 4/21/14 were reviewed and revealed the following: A Resident Transfer Form (ambulance run sheet), dated 4/21/14 documented that Resident #301 was transferred from the facility to the hospital emergency room (ER) for a "change in the level of consciousness", and an "INR >8.0. " The Transfer form documented that the resident had symptoms of shock, with a hypothermic (abnormally low) axillary temperature of 95.4 degrees (normal = 98.1 - 97.6 degrees), a pulse rate of 100 (normal = 60- 100), and a blood pressure of 76/39 (normal = 90/60 - 140/90). Additional pertinent information was noted as, "multiple bruising to upper and lower extremities, chest, peri-area, abdomen - on admission. Vitamin K (used to reverse [MEDICATION NAME] overdose) 5 milligrams (mg) given for INR of > 8.0." " Ambulance Care Report dated 4/21/14 documented the patient ' s radial pulses as ' absent ' at the beginning of the report and level of consciousness as ' semi-conscious ' . Subsequent documentation in the report revealed pulses were present and weak. The location of these pulses was not indicated. " An ER History and Exam dated 4/21/14 at 10:49 A.M., documented the following for Resident #301, " skin, pale appearing, large areas of tension (swelling) and ecchymosis (areas of blood leaking into the tissues) to her left shoulder, left breast, left chest and left hip/ thigh. [MEDICAL CONDITION] (abnormally low blood pressure). Resident #301's blood pressure was documented as 71/30 on 4/21/14 at 11:05 A.M. ER records dated 4/21/14 revealed that Resident #301 received two units of packed red blood cells (blood transfusion), two liters of normal saline bolus ( given rapidly), [MEDICATION NAME] 8 mg in 250 mg D5W (solution) Intravenous (IV) (medicine to raise blood pressure), 10 mg of vitamin K IV, one unit of fresh frozen plasma (contains clotting factors), and emergency intubation (breathing tube). ER lab results dated 4/21/14 revealed the following "critical values", PT = 145.6 (reference range 9.2-12.6), INR = 12.67 (recommended therapeutic range for prevention of recurrent embolism or patients with mechanical prosthetic intravascular valves = 2.5 - 3.5), and PTT 83 seconds (reference range 24-35). ER lab values dated 4/21/14 at 1;29 P.M., documented that Resident #301 ws extremely anemic with a red blood cell count (RBC) of 1.78 (normal = 3.93-5.22), a Hemoglobin level of 5.2 (normal = 11.2 -15.7), and a Hematocrit of 16.4 (normal = 34.1 - 44.9). Resident #301 was pronounced dead on 4/21/14 at 2:46 P.M. ( )

Based on observation, interview and record review the facility failed to ensure a bed was set at the appropriate firmness to prevent the development of a pressure ulcer and failed to maintain an inflated Roho cushion for one resident (#901) of six residents reviewed for pressure ulcers, from a total sample of 17, resulting in the development of an avoidable pressure ulcer and the worsening of an existing pressure ulcer. Findings include: On 10/22/13 at 9:25 a.m., During the initial tour of the facility with certified nursing assistant, CNA "F" resident #901 was observed sitting in a wheel chair. CNA "F" stated, "she is dependent on staff for care. She has hip ulcers." Resident #901 appeared very thin and unable to answer questions appropriately. The resident was sitting on a cushion in her wheelchair that appeared to be flat. The resident's room was observed her bed to have a specialty airflo mattress in place. The resident's bed comfort level was noted to be a nine which corresponded to a resident weight of 350 pounds. On 10/23/13 at 9:20 a.m., Resident #901 was observed sitting in her wheel chair at the dining room table feeding herself breakfast. The resident's wheel chair cushion appeared to be flat. On 10/23/13 at approximately 12:30 p.m., Resident #901 was observed sitting in her wheel chair at the dining room table. The resident was feeding herself lunch. The resident's wheel chair cushion appeared to be flat. On 10/24/13 at 12:30 p.m. and 2:30 p.m., Resident #901 was observed sitting in her wheelchair on the flattened cushion. On 10/25/13 at 8:30 a.m., Resident #901 was observed lying on her left side in bed. The resident's bed setting was at a nine. Staff nurse, Nurse "G" was queried regarding Resident #901's bed settings and stated "I don't know anything about that bed." On 10/25/13 at 9:00 a.m., Resident #901's usual care giver, certified nursing assistant, CNA "F" was queried regarding the settings on resident #901's bed. CNA "F" stated, "We don't do anything with the bed. The rep (bed representative) comes out and sets it up. We don't make any changes from there." Resident #901's wheel chair and wheel chair cushion were observed in the resident's bathroom. The specialty cushion was visibly deflated. On 10/25/13 at 9:15 a.m., Resident #901's specialty wheel chair cushion was observed with the facility's rehab director, Director "E." Director "E" stated, "it's flat. It is a Roho cushion ( a physician ordered specialty cushion for the use of comfort and pressure relief) but it's not inflated. It is completely flat." On 10/25/13 at 9:17 a.m., CNA "F" was queried regarding the wheel chair cushion and stated, "we don't know anything about the cushion. There is a pump but we have not been trained on how to use it. The therapists come over and do it." On 10/25/13 at 9:25 a.m., Resident #901's specialty bed setting and wheel chair cushion were observed with the facility's Director of Nursing, "DON." The "DON" stated, "I will check the policy on the setting on air mattresses and training of staff for inflation of the specialty cushion." On 10/25/13 at 9:35 a.m., Director "E" and the facility's Inservice Director were queried regarding the training of staff on the specialty cushions and Director "E" stated, "once ordered we pump it up and send it over with the pump. I don't know who trains the staff on how to do it." The Inservice Director stated, "they give us the pump and I don't know from there. I am really at a loss." On 10/25/13 at 10:30 a.m., Resident #901's medical record was reviewed with the wound care nurse, Nurse "D." Resident #901's face sheet revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's minimum data set assessments (MDS) dated , 5/9/13, 6/17/13 and 9/13/13 revealed that the resident's cognition was severely impaired and required extensive assistance for activities of daily living. The resident's weight log for the year 2013 was reviewed and revealed a weight of 104 pounds on 9/5/13. Nurse "D" was queried regarding the development of resident #901's pressure ulcers and stated, "she came from another facility. She has always had an issue from the beginning with hematomas and skin tears. She has had a specialty mattress put into place since the beginning. The mattress gets adjusted to whatever she likes. We ask her. Usually the shebaz (CNA) does. The bed does not have to be at any certain level. It is an alternating air flow bed, it's what is relieving some of the pressure. No matter what setting it is at it is still going to be circulating air. We found an abrasion in May. The abrasion opened in June and I ordered a wound consult and they have been following her ever since." Resident #901's "Weekly head to toe skin checks," sheet dated, 5/6/13 and 5/13/13 revealed that resident #901's skin was "intact." Resident #901's "Nurse's Notes," dated 5/14/13 at 11 a.m., revealed "Writer notes elder (right) upper buttock evaluated by wound care team noted incident of wound by elder sudden drop to raised toilet seat which has backing. Area viewed as scab with blanchable surrounding skin." Review of resident #901's "Weekly Measurement Documentation," dated 5/14/13, revealed "right buttock stage 2 (partial thickness loss of skin). Type P (pressure). Size 2 by 2 cm (centimeters). Small amount of serous drainage." Resident #901's wound care consult, dated 6/5/13 revealed "Consult. Trunk wound. [MEDICATION NAME] 3.8 (normal range). Right buttocks 2.0 by 2.0 cm, pale yellow base with yellow necrotic midcore with moderate serosanguinous drainage with irregular wound edges. Diagnosis: [REDACTED]. Recommendations: 1) Santyl (a [MEDICATION NAME] agent) and [MEDICATION NAME] (antibiotic) ointment every day and as needed for 14 days to right buttock." Resident #901's physician order [REDACTED]. clean right buttocks with wound cleaner apply Santyl with [MEDICATION NAME] ointment daily and as needed for 14 days. Roho cushion to wheel chair. Air mattress to bed, turn every 2 hours while in bed." Nurse "D" was queried about the order for the air mattress and stated, "oh, I thought she had it all along." Resident #901's treatment record for June 2013 revealed no documentation that the ordered treatment was given on 6/8/13 or 6/14/13. Resident #901's wound care consult, dated 6/12/13, revealed "Recommendations: 1) Santyl and [MEDICATION NAME] ointment q day and prn for 7 days." Resident #901's physician order [REDACTED]. Resident #901's treatment record revealed no wound treatment to the right buttocks for 6/19/13, 6/20/13 or 6/21/13. Resident #901's wound care consult, dated 6/19/13 revealed "Recommendations: 1) Santyl q day and pm(every day and evening) to right buttock." Resident #901's physician order [REDACTED]. Frequently reposition." Resident #901's treatment record revealed no morning treatments documented for the right buttock on 6/21/13 and no evening treatments for 6/22/13, 6/25/13, 6/28/13 and 6/30/13. Resident #901's wound care consult, dated 6/26/13, revealed "Recommendations: Santyl every day and as needed to right buttocks." Resident #901's physician orders [REDACTED]. Resident #901's wound care consult, dated 7/2/13, revealed "Diagnosis: [REDACTED]. 2) Deep tissue injury Left parasacral. Recommendations: 1) Santyl q day and prn to right buttock. 2) Allevyn q 2 days and prn to left parasacral." Resident #901's physician orders, dated 7/2/13, revealed "d/c'd (discontinued) Santyl to right buttocks bid (twice daily), change to Santyl to right buttocks daily and as needed." Resident #901's treatment record for July 2013 was reviewed and revealed no documentation that the resident received the treatment to the right buttock on 7/3/13, 7/7/13 or 7/10/13. Resident #901's wound care consult, dated 7/10/13, revealed "wound sites: Right hip (previously mislabeled as right buttock) 1.1 by 2.5 cm pink base, minimal slough, minimal necrosis at core, moderate serous drainage, mild peri wound [DIAGNOSES REDACTED]. Right parasacral (previously mislabeled as left parasacral) 1.4 by 1.2 cm pale yellow base, moderate serous drainage. Diagnosis: [REDACTED]. Recommendations: Santyl/Allevyn every 2 days and prn right hip, right parasacral." Review of resident #901's physician orders, revealed no order for the recommendations from wound consult dated 7/10/13. Review of resident #901's treatment record revealed no documentation that the treatment was done on 7/19/13. Review of resident #901's wound consult, dated 7/24/13, revealed "Diagnosis: [REDACTED]. Recommendations: Santyl and [MEDICATION NAME] ointment daily and prn to right hip and right parasacral." Review of resident #901's treatment record revealed no documentation of wound treatment to the right hip on 7/26/13, 7/28/13, 7/29/13, 7/31/13, 8/1/13, 8/4/13, 8/5/13, 8/8/13, 8/12/13, 8/15/13, 8/16/13, 8/18/13, 8/19/13, or 8/20/13. There was no wound treatment documentation for the right parasacral on 7/26/13, 7/28/13, 7/29/13, 7/31/13, 8/1/13 through 8/5/13, 8/7/13, 8/8/13, or 8/15/13-8/20/13. Review of resident #901's wound consult, dated 8/21/13, revealed "Right hip 7.2 by 4.0 cm, 2 wounds with a bridge of yellow necrotic base with fluctuance (bacterial infection) with moderate yellowish drainage with irregular wound edges... wound overlaying bony prominence. Right parasacral: 0.6 by 0.5 cm. Diagnosis: [REDACTED]. Recommendations: Santyl q day and prn to right hip, right parasacral." Resident #901's treatment record revealed no documentation of treatments to the right hip on 8/25/13, 8/27-8/30/13, or 9/6/13. There was no documentation of treatments to the right parasacral area on 8/25/13 and 8/27-8/30/13. Resident #901's wound consult, dated 9/11/13, revealed "Santyl and [MEDICATION NAME] powder daily and prn to right hip. Review of resident #901's treatment record revealed no documentation that the treatment was provided to the right hip on 9/14-9/17/13. Resident #901's wound consult, dated 9/18/13, revealed "Santyl with [MEDICATION NAME] 500 mg crushed q day and prn for one week." Resident #901's physician order, dated 9/18/13, revealed "increase [MEDICATION NAME] from 250 mg to 500 mg daily to right hip wound. Mix together with Santyl to right hip wound." Resident #901's treatment record revealed no documentation that the treatment was given on 9/27-9/30/13. Resident #901's wound consult, dated 10/2/13, revealed "right hip 2.5 by 3.4 by 1.4 cm. distal tunneling of 3 cm. yellow necrotic base, heavy serous drainage. Left hip: 0.5 by 0.5 cm. Recommendations: Santyl with crushed [MEDICATION NAME] daily and prn to right hip times one week. Allevyn every 2 days to left hip." Resident #901's physician order, dated 10/2/13, revealed "clean right hip with wound cleaner apply santyl with 500 milligram of [MEDICATION NAME] crushed daily and as needed times one week. Apply Allevyn to left hip every 2 days and prn." Review of resident #901's treatment record revealed no documentation that the treatment to the right hip was provided on 10/4/13 or 10/9/13. Resident #901's physician order, dated 10/11/13, revealed "500 mg [MEDICATION NAME] daily and prn to right hip. Discontinued santyl to right hip. Cleans left hip with [MEDICATION NAME] and cover." Review of resident #901's treatment record revealed no documentation that the treatment to the right hip was provided on 10/11-10/16/13, or 10/18/13. There was no documentation that the treatment to the left hip was provided on 10/16/13 and 10/21/13. Resident #901's wound consult, dated 10/16/13, revealed "right hip 2.5 by 2.2 by 1.2 cm, proximal tunneling of 2.5 cm, yellow necrotic base, heavy serous drainage, irregular edges. Left hip 6.5 by 2.0 cm, multiple wounds, necrotic bases, moderate serous drainage. Diagnosis: [REDACTED]. Pressure ulcer stage 3 left hip." Review of resident #901's Braden scale-for predicting pressure sore risk revealed that the resident was assessed at mild to moderate risk for pressure ulcer development for 1/13/13, 4/22/13, 7/30/13 and 10/25/13. Nurse "D" was queried regarding the missing documentation and information about resident #901's interventions and stated, "I don't always do the treatment so I can't speak for anyone else. I was on vacation for a little while. I periodically look at the cushion." The company's name and number as well as product information was requested for resident #901's specialty bed. On 10/25/13 at 2:15 p.m., Nurse "D" stated, "she was on a rental bed from another company. That bed had comfort settings, they were not set up with the patients weight. A new bed was brought in in September. so the settings are according to weight but we were not aware." Review of the user manual for resident #901's specialty bed page 19 was reviewed and revealed "The comfort control LED displays the patient comfort pressure levels from 0 to 9 and provides a guide to the caregiver to set approximate comfort pressure level depending on the patient weight." Resident #901's care plans were reviewed but revealed no thorough documentation of interventions/approaches put into place before or after the development of the resident's stage 3 or stage 4 pressure ulcers. Review of the facility's policy titled "Pressure Ulcer Prevention and Management Policy," dated 5/30/13, revealed "It is the policy of the (facility) to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and service to promote healing, prevent infection and prevent new sores from developing. B. Prevention: Complete the Braden Scale...to identify pressure sore risk. Develop and implement a care plan to address risks identified through assessment. D. Documentation: Staff nurse 3. Document treatment orders on the physician order [REDACTED]. Management/Monitoring: 6) Request or provide in service training when applicable." ( ) ,

BASED ON OBSERVATION , INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT FALL SAFETY DEVICES AND/OR PROVIDE ADEQUATE SUPERVISION FOR SIX (#'S 204, 205, 206, 208, 212, AND 213) OF 10 SAMPLED RESIDENTS REVIEWED FOR ACCIDENTS FROM A TOTAL OF 16, RESULTING IN FRACTURES, FALLS, LACERATIONS, AND SKIN TEARS. FINDINGS INCLUDE: ON 8/2/12 AT 3:30 PM, AN INCIDENT/ACCIDENT (I/A) REPORT FOR RESIDENT #213 WAS REVIEWED WITH THE DIRECTOR OF NURSING (DON). THE I/A REPORT NOTED THAT THE RESIDENT WAS LEFT ALONE IN THE BATHROOM AT AN UNDOCUMENTED DATE AND TIME BY AN UNIDENTIFIED NURSE AIDE, GOT UP FROM THE TOILET UNASSISTED, AND "AS (THE NURSE AIDE) RETURNED TO RESTROOM, HEARD (THE RESIDENT) FALL....(THE RESIDENT) VOICED DISCOMFORT TO RIGHT LOWER EXTREMITY...." THE STEPS TAKEN TO PREVENT RECURRENCE: "(RESIDENT) TO BE OBSERVED IN RESTROOM AT ALL TIMES." THE I/A REPORT WAS WRITTEN BY NURSE 'H', WHO SIGNED AND DATED THE REPORT ON 4/25/12. THE REPORT WAS SIGNED BY THE DON ON 4/27/12, THE MEDICAL DIRECTOR (NO DATE), AND THE ADMINISTRATOR ON 5/1/12. THERE WAS NO DOCUMENTED STATEMENT BY THE ADMINISTRATOR INCLUDED. IN ADDITION TO THE DATE AND TIME OF THE INCIDENT MISSING AND THE NURSE AIDE INVOLVED NOT BEING IDENTIFIED, THERE WAS NO DOCUMENTED STATEMENT BY RESIDENT #213 AS TO WHAT MAY HAVE OCCURRED. AN X-RAY REPORT, THAT WAS ATTACHED TO THE I/A REPORT, NOTED THAT AN X-RAY WAS TAKEN OF RESIDENT #213'S RIGHT HIP DUE TO COMPLAINTS OF PAIN ON 4/25/12 (NO TIME NOTED) WHICH SHOWED, "NO DEFINITE EVIDENCE OF ACUTE FRACTURE OR DISLOCATION. IF SYMPTOMS PERSIST, CONSIDER FOLLOW-UP (X-RAYS)...." THE ADMISSION FACE SHEET IN RESIDENT #213'S CLINICAL RECORD NOTED THAT THE RESIDENT WAS SENT TO THE hospital on [DATE] AND RETURNED ON 5/23/12. NURSES NOTES DATED 5/23/12 DOCUMENTED: THE RESIDENT RETURNED FROM THE HOSPITAL, "RIGHT INTERTROCHANTER (HIP) REMAINS FRACTURED," AND SURGICAL REPAIR WAS NOT PERFORMED BECAUSE OF THE RISKS VERSUS THE BENEFITS. WHEN DETAILS OF THE HIP FRACTURE WERE REQUESTED, THE DON DEFERRED TO NURSE 'H' AND STATED THAT HE WOULD LOOK FOR FURTHER INFORMATION. ON 8/2/12 AT 3:40 PM, NURSE 'H' WAS QUERIED REGARDING RESIDENT #213'S HIP FRACTURE. THE NURSE SAID, "(RESIDENT) WAS FOUND ON THE FLOOR. THEY DID AN X-RAY BUT IT WAS NEGATIVE. (RESIDENT) KEPT COMPLAINING OF PAIN. WHEN THEY DID A REPEAT X-RAY, IT SHOWED A FRACTURE AND (RESIDENT) WAS SENT TO THE HOSPITAL. IT WAS A COUPLE OF WEEKS BETWEEN THE FALL (IDENTIFIED ON THE I/A REPORT SIGNED BY NURSE 'H' ON 4/25/12) AND THE REPEAT X-RAY." ON 8/2/12 AT 3:50 PM, THE DON PRESENTED AN X-RAY REPORT FOR RESIDENT #213 DATED 5/19/12 WHICH SHOWED "....COMPLETE INTERTROCHANTERIC FRACTURE PRESENT WITH DISPLACEMENT...." AN INVESTIGATION OF THE FRACTURE AND WRITTEN CONCLUSION WERE REQUESTED. THE DON SAID, "THERE WAS NO INVESTIGATION OR CONCLUSION." THE DON STATED THAT THE FRACTURE FOUND ON 5/19/12 WAS RELATED TO THE FALL ON 4/25/12. HE SAID, "(RESIDENT) DIDN'T HAVE ANYMORE FALLS AFTER THAT (4/25/12)." THE DON WAS ASKED WHY THE REPEAT X-RAY WAS NOT TAKEN FOR THREE WEEKS. HE SAID, "(RESIDENT #213) WAS GOING TO THERAPY AFTER THAT." WHEN ASKED WHY THE INCOMPLETE I/A REPORT FOR THE FALL ON 4/25/12 WAS SIGNED BY FACILITY MANAGEMENT, THE DON SAID IT WAS SIGNED, "BECAUSE WE AGREED WITH THE CORRECTIVE ACTION (NOT TO LEAVE THE RESIDENT ALONE IN THE BATHROOM)." A FALL CARE PLAN FOR RESIDENT #213, DATED 10/18/11, WAS NOT UPDATED TO INCLUDE THE INTERVENTION OF NOT LEAVING THE RESIDENT ALONE IN THE BATHROOM. THERE WAS NO OTHER AVAILABLE FALL CARE PLAN PRIOR TO 5/23/12. FURTHER REVIEW OF RESIDENT #213'S CLINICAL RECORD WITH THE DON REVEALED: THE RESIDENT WAS RE-admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE], NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, WAS NON-AMBULATORY, AND REQUIRED EXTENSIVE ASSISTANCE FOR TRANSFERS AND MOBILITY. A FALL RISK ASSESSMENT FOR RESIDENT #213 DATED 10/17/11 NOTED A SCORE OF 13. A SCORE OF 10 OR MORE=HIGH RISK. OTHER THAN THE I/A REPORT, THERE WAS NO AVAILABLE DOCUMENTATION OF THE FALL ON 4/25/12 OR ANY NOTES AFTER THAT DATE UNTIL THE RESIDENT RETURNED FROM THE hospital on [DATE]. WITH THE EXCEPTION OF ONE PAGE OF NURSES NOTES DATED 10/29/11 THRU 2/14/12, ALL OF THE RESIDENT'S CLINICAL RECORDS FOR 12/2011 THRU 5/22/12, WERE MISSING. THE DON WAS UNABLE TO EXPLAIN WHY. ( ) ON 8/2/12 AT 9:15 AM, RESIDENT #205 WAS OBSERVED RECEIVING INCONTINENCE CARE AND A BED BATH BY NURSE AIDE 'I.' THE RESIDENT HAD A GASTRIC FEEDING TUBE INSERTED. THE RESIDENT WAS ALERT, BUT IMMOBILE. PRIOR TO GATHERING SUPPLIES FOR THE CARE, THE AIDE ELEVATED THE BED TO WAIST HEIGHT LEVEL AND TURNED THE RESIDENT TO THE RIGHT SIDE. THE AIDE THEN LEFT THE RESIDENT ALONE, WITHOUT SUPERVISION, ON THE ELEVATED BED TO GO DOWN THE HALL TO GATHER SUPPLIES TO BATHE THE RESIDENT. WHEN AIDE 'I' RETURNED TO RESIDENT #205'S ROOM, THE RESIDENT BEGAN TO URINATE AND SOIL THE BED LINEN. THE AIDE PROCEEDED TO CLEAN AND BATHE THE RESIDENT, AND BEGAN TO STRIP THE BED OF THE SOILED LINEN. WHILE BATHING THE RESIDENT, AIDE 'I' NOTICED A RAW AREA ON THE RESIDENT'S CHEST AND STATED THAT SHE HAD TO LEAVE THE ROOM TO INFORM THE NURSE. THE AIDE LEFT THE RESIDENT ALONE, WITHOUT SUPERVISION, A SECOND TIME ON THE ELEVATED BED, WENT DOWN THE HALL TO TALK TO NURSE 'J,' AND RETURNED TO THE ROOM TO COMPLETE CARE AND DRESS THE RESIDENT. THE AIDE LEFT THE RESIDENT A THIRD TIME, UNATTENDED WITH THE BED RAISED, TO GET MORE LINEN, RETURNED TO THE ROOM, AND BEGAN CHANGING THE BED. FOLLOWING THE OBSERVATION, AIDE 'I' WAS QUERIED ABOUT LEAVING THE RESIDENT ALONE THREE TIMES ON THE ELEVATED BED CREATING AN ACCIDENT HAZARD DUE TO LACK OF SUPERVISION. THE AIDE WAS UNABLE TO RESPOND. ON 8/2/12 AT 11:40 AM, WHEN INFORMED OF AIDE 'I' LEAVING THE RESIDENT UNATTENDED ON THE ELEVATED BED TO GATHER SUPPLIES, THE DIRECTOR OF NURSING (DON) DID NOT RESPOND. A REVIEW OF RESIDENT #205'S CLINICAL RECORD WITH THE DON REVEALED: THE RESIDENT WAS ORIGINALLY admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM (MDS) data set [DATE] NOTED THAT THE RESIDENT HAD COGNITIVE IMPAIRMENT AND WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING. RESIDENT #205'S FALL RISK SCORE DATED 6/21/12, WAS REVIEWED. THE SCORE WAS 12. THE DON WAS QUERIED REGARDING A FALL RISK CARE PLAN FOR THE RESIDENT. THE DON LOOKED IN THE RESIDENT'S CHART AND SAID, "I DON'T SEE ONE HERE. THAT'S THE PURPOSE OF A FALL RISK ASSESSMENT. THERE SHOULD BE ONE." PER REVIEW OF THE FACILITY'S POLICY ON "FALL RISK ASSESSMENT" DATED 2003: "IT IS THE POLICY OF (THE FACILITY) TO ENSURE THAT THE RESIDENT ENVIRONMENT REMAINS AS FREE OF ACCIDENT HAZARDS AS IS POSSIBLE AND THAT EACH RESIDENT RECEIVES ADEQUATE SUPERVISION....CARE PLANS ARE UPDATED REFLECTING (SAFETY) INTERVENTIONS." ( ) RECORD REVIEW REVEALED THAT RESIDENT #204 WAS ORIGINALLY admitted INto the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. A REVIEW OF THE MOST RECENT QUARTERLY MINIMUM DATA SET ((MDS) dated [DATE] REVEALED THE RESIDENT WAS SEVERELY COGNITIVELY IMPAIRED AND WAS UNABLE TO MAKE HER NEEDS KNOWN. THE RESIDENT REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS AND ALL ACTIVITIES OF DAILY LIVING, EXCEPT EATING. THE FALL RISK assessment dated [DATE], RATED THE RESIDENT AT AN 18, WHICH INDICATED A HIGH RISK FOR FALLS. A REVIEW OF RESIDENT #204'S CARE PLAN UPDATED 6/12/12, NOTED RESIDENT WAS AT RISK FOR FALLS/INJURY RELATED TO HISTORY OF FALLS, POOR SAFETY AWARENESS, AND DECREASED COGNITION. INTERVENTIONS INCLUDED: " FALL MAT, LOW BED AND SENSOR ALARM FOR BED; MONITOR FOR SAFETY PRECAUTIONS EACH SHIFT AND PRN. " ON 8/1/12 AT 8:15 A.M., RESIDENT #204 WAS OBSERVED SEATED IN HER WHEELCHAIR AT THE DINING ROOM TABLE, ASLEEP. THERE WAS NO TAB ALARM ATTACHED TO THE RESIDENT ' S PERSON OR WHEELCHAIR. WHEN QUERIED ABOUT THE TAB ALARM, STAFF "H" STATED, "THEY DIDN'T PUT THE TAB ALARM ON HER? THEY SHOULD HAVE, IT'S ORDERED." STAFF "D" WAS QUERIED REGARDING THE TAB ALARM AND STATED, "NO, SHE DOESN'T HAVE A TAB ALARM, NOT ON HER CHAIR, JUST THE BED ALARM." ON 8/1/12 AT 1:10 PM, AN INCIDENT/ACCIDENT (I/A) REPORT DATED 5/5/12 AT 7:00 P.M. FOR RESIDENT #204 WAS REVIEWED WITH THE DIRECTOR OF NURSING (DON). THE I/A REPORT NOTED THAT THE EXACT LOCATION OF THE INCIDENT/ACCIDENT AS "UNKNOWN." A DESCRIPTION OF THE INCIDENT NOTED THE RESIDENT'S RIGHT THUMB WAS OBSERVED TO BE "REDDISH-BLUE, PAINFUL TO TOUCH, UNKNOWN WHAT HAPPEN TO THUMB, ELDER WITH CONFUSION UNABLE TO STATE WHAT HAPPENED." A RADIOLOGY REPORT (X-RAY) DATED 5/5/12 CONCLUDED "ACUTE FRACTURE OF THE BASE OF THE DISTAL PHALANX OF THE RIGHT THUMB, WITH MILD DISPLACEMENT AND ANGULATION." ON 5/10/12 AT 11:30 A.M. - "ELDER SELF PROPELLED AROUND COURTYARD, WHEEL OF WHEELCHAIR CAUGHT BETWEEN SIDEWALK AND DIRT OF FLOWER BED TUMBLING ELDER INTO FLOWER BED. ELDER HAS ABRASION TO LEFT SIDE KNEE. STEPS TAKEN TO PREVENT RECURRENCE: "MONITOR ELDER WHEN IN GARDEN AREA." ON 6/12/12 AT 6:10 P.M. - "AT 6:05 P.M. SHAHBAZ (NURSING ASSISTANT) ASSISTED ELDER OUT OF THE KITCHEN AREA, SHE THOUGHT ELDER WENT TO FRONT. ELDER EVIDENTLY WENT TO THE BACK WHEN SHE DIDN'T SEE HER IN THE FRONT SHE WENT TO FIND HER WENT OUT OF BACK DOOR AND (ELDER) WAS SITTING ON THE GROUND IN PATIO AREA ON HER BUTTOCKS." STEPS TAKEN TO PREVENT RECURRENCE INCLUDED CONSIDERATION OF A DOOR ALARM TO THE PATIO AREA. ON 6/29/12 AT 9:00 A.M. - "RIGHT LATERAL ARM SKIN TEAR OCCURRED DURING TRANSPORT IN WHEELCHAIR. ELDERS ARM BUMPED ON HALLWAY GUARD RAIL. STEPS TAKEN TO PREVENT RECURRENCE: INCREASE AWARENESS OF ELDERS ARM POSITION RELATED TO GUARDRAIL DURING TRANSFERS. ON 8/1/12 AT 3:35 P.M., STAFF "F" WAS INTERVIEWED REGARDING THE INCIDENTS FOR RESIDENT #204. WHEN QUERIED AS TO WHY THE COGNITIVELY IMPAIRED RESIDENT WAS ALLOWED TO BE OUT OF DOORS WITHOUT SUPERVISION, THE GREENHOUSE GUIDE STATED, "I DON'T KNOW WHAT TO TELL YOU." RECORD REVIEW REVEALED THAT RESIDENT #206 WAS ORIGINALLY admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT MDS dated [DATE] NOTED THE RESIDENTS COGNITION TO BE MODERATELY IMPAIRED. RESIDENT #206 REQUIRED ONE PERSON ASSISTANCE WITH ACTIVITIES OF DAILY LIVING, AND WAS ABLE TO MAKE HER NEEDS KNOWN. THE FALL RISK assessment dated [DATE] NOTED A SCORE OF 16, INDICATING THE RESIDENT TO BE AT HIGH RISK FOR FALLS. RESIDENT #206 ' S CARE PLANNED INTERVENTIONS INCLUDED FALL MAT, LOW BED, TAB ALARM FOR BED, TAB ALARM FOR WHEELCHAIR, SENSOR ALARM FOR BED AND WHEELCHAIR. ON 8/1/12 AT 9:30 A.M., RESIDENT #206 WAS OBSERVED SEATED IN HER WHEELCHAIR IN THE DINING ROOM. THERE WAS NO ALARM ATTACHED TO THE RESIDENT ' S PERSON OR WHEELCHAIR, NOR WAS THERE A SENSOR ALARM IN THE SEAT OF THE WHEELCHAIR. ON 8/1/12 AT 10:50 A.M., STAFF " O " (UNIT MANAGER) WAS QUERIED ABOUT THE ALARMS TO THE RESIDENT ' S CHAIR AND BED AND STATED, " YES, SHE IS SUPPOSED TO HAVE ONE. THEY ARE SUPPOSED TO PUT THEM ON AS SOON AS THEY GET THEM UP. " THE UNIT MANAGER PROCEEDED TO RESIDENT #206 ' S ROOM TO CHECK FOR THE ALARM PADS. NO ALARM PAD WAS OBSERVED ON THE RESIDENT ' S BED. AN ALARM PAD WAS TAKEN FROM THE ROOMMATES BED AND PLACED ON RESIDENT #206 ' S BED. THE UNIT MANAGER SEARCHED RESIDENT #206 ' S BUREAU DRAWER AND OBSERVED THE BED AND CHAIR PAD ALARMS AND STATED, " THESE AIN'T EVEN SUPPOSED TO BE HERE. HERE ' S THE CHAIR PAD TOO, IN THE DRAWER. SHE (THE RESIDENT) PROBABLY PUT IT IN HERE." A REVIEW OF THE CERTIFIED NURSE ASSISTANT (CNA) GUIDE FOR RESIDENT #206 DID NOT SPECIFY THE USE OF ALARMS. SPECIAL EQUIPMENT NOTED WAS WHEELCHAIR, GLASSES, AND DENTURES. AN INCIDENT AND ACCIDENT REPORT DATED 7/31/12 AT 5:00 A.M., NOTED " RESIDENT ( #206) OBSERVED SITTING ON FLOOR IN BATHROOM. ALARM HAD BEEN REMOVED BY RESIDENT. RESIDENT WALKED OR CRAWL TO BATHROOM. STAFF HAD TOILET X 2 ASSISTED BACK TO BED. (RESIDENT) COMPLAINED OF HIGH PAIN IN LEFT LEG AND STATES SHE HIT HER HEAD. " STEPS TAKEN TO PREVENT RECURRENCE: " ENCOURAGE RESIDENT TO USE CALL LIGHT WHEN NEEDING TO TRANSFER. " RECORD REVIEW REVEALED THAT RESIDENT #212 WAS ORIGINALLY admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT QUARTERLY MINIMUM (MDS) data set [DATE] INDICATED THE RESIDENT TO BE SEVERELY COGNITIVELY IMPAIRED AND REQUIRING SUPERVISION WHEN AMBULATING AND PHYSICAL HELP WITH BATHING. RESIDENT #212 WAS ABLE TO MAKE HER NEEDS KNOWN. THE FALL RISK assessment dated [DATE] NOTED A SCORE OF 15 WHICH INDICATED A HIGH RISK FOR FALLS. THE FALL CARE PLAN INTERVENTIONS INCLUDED: " FALL MAT, LOW BED, TAB ALARM FOR BED, AND ELDER INSTRUCTED TO WEAR PROPER/APPROPRIATE FITTING SHOES. " ON 8/2/12 RESIDENT #212 WAS OBSERVED WEARING SOFT SOLED BLUE/GREY CLOTH SHOES WHILE AT THE TABLE. THE RESIDENT WAS SITTING IN A REGULAR DINING ROOM CHAIR. A REVIEW OF THE INCIDENT AND ACCIDENT REPORTS FOR RESIDENT # 212 REVEALED THE FOLLOWING: ON 3/1/12 AT 3:30 P.M., " ELDER STATED SHE USED THE TOILET, THEN DECIDED TO CLEAN THE TOILET, BECAUSE UNSTEADY ON FEET CAUGHT THE TOILET SEAT AND IT CAME OFF THE TOILET. SHE THEN CAUGHT THE SIDE DOOR AND IT GAVE AWAY. SHE LANDED ON FLOOR ON BUTTOCKS IN HER BEDROOM. STEPS TAKEN TO PREVENT RECURRENCE: " ADJUSTMENT OF RAISED TOILET SEAT AND REPLACEMENT IF UNABLE TO ADJUST. ADJUSTMENT OF GRAB BAR TO COMFORTABLE POSITION FOR ELDER. ON 7/2/12 AT 6:20 P.M., "WRITER WAS CALLED AT 6:30 P.M. BY SHAHBAZ (NURSING ASSISTANT)...STATED ELDER HAS HAD FALLEN OUTSIDE WHILE BEING BROUGHT BACK FROM HAVING HER NAILS DONE BY THE NAIL CARE PROVIDER. ASSISTED LIVING NURSE WAS CALLED TO THE SITE...ASSESSED ELDER FOR INJURY AND ASSISTED (RESIDENT) TO (UNIT). NAIL CARE PROVIDER SAID RESIDENT WAS SETTING ON HER BUTTOCKS ON THE GROUND. ELDER STATES SHE SLIPPED ON HER HOUSE SHOES." STAFF "F" WAS QUERIED ABOUT SUPERVISION DURING TRANSPORT OF RESIDENTS TO AND FROM THE BEAUTY SHOP AND STATED, "THE NAIL TECHNICIAN CAN SUPERVISE, ASSIST, BUT THEY CANNOT PHYSICALLY TRANSPORT A RESIDENT, WE PREFER THEM TO CALL THE UNIT FOR TRANSPORTATION ASSISTANCE." ( ) ON 7/31/12 AT 10:10 A.M., DURING THE INITIAL TOUR OF THE MCCOMBER UNIT WITH UNIT MANAGER "O", RESIDENT #208 WAS OBSERVED IN A HIGHBACK WHEELCHAIR IN THE COMMON AREA WITH STERISTRIPS TO THE LEFT SIDE OF HIS FOREHEAD. THE RESIDENT DID NOT RESPOND VERBALLY TO HIS NAME, ONLY OPENED HIS EYES. WHEN ASKED WHAT HAPPENED TO THE RESIDENT. UNIT MANAGER "O" STATED " HE HAD A DIFFERENT WHEELCHAIR AND HE WOULD LEAN FORWARD AT TIMES. HE fell OUT OF THE CHAIR AND BUMPED HIS HEAD A OF COUPLE OF WEEKS AGO. THE RESIDENT DID NOT HAVE AN ALARM ON. ON 8/1/12 AT 8:40 A.M., RESIDENT #208 WAS UP IN A WHEELCHAIR IN THE DINING AREA. THE RESIDENT DID NOT HAVE AN ALARM ON THE WHEELCHAIR. AT 09:00 A.M., RESIDENT #208'S ACTIVE CLINICAL RECORD WAS REVIEWED. THE FACE SHEET, INDICATED THE RESIDENT WAS admitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE MINIMUM (MDS) data set [DATE] INDICATED THE RESIDENTS COGNITION WAS SEVERELY IMPAIRED AND RELIED EXTENSIVELY ON STAFF TO TRANSFER FROM BED TO WHEELCHAIR. A FALL RISK assessment dated [DATE], RATED THE RESIDENT AT 13, HIGH RISK FOR FALLS. A FALL CARE PLAN DATED 5/29/12, DOCUMENTED INTERVENTION AS " FALL MAT, LOW BED AND TAB ALARM TO BED AND WHEELCHAIR." AT 10:50 A.M., UNIT MANAGER "O" WAS QUERIED AS TO WHETHER RESIDENT #208 WAS SUPPOSE TO HAVE AN ALARM ON AND IF SO, WHERE WAS THE ALARM? UNIT MANAGER "O" EXAMINED THE RESIDENT'S WHEELCHAIR AND WAS UNABLE TO LOCATE AN ALARM AND STATED " HE (RESIDENT #208) SHOULD HAVE AN ALARM ON". MANAGER "O" WAS UNABLE TO EXPLAIN WHY A RESIDENT WHO HAD FALLEN A COUPLE WEEKS AGO AND SUSTAINED AN INJURY TO IS HEAD DID NOT HAVE AN ALARM ON. AT 11:00 A.M., CERTIFIED NURSING ASSISTANT (CNA) "Q" WHO WAS ASSIGNED TO RESIDENT #208 WAS QUERIED CONCERNING THE RESIDENT'S ALARM. CNA "Q" STATED "HE HAD AN ALARM WITH HIS OLD WHEELCHAIR . WHEN I CAME IN TODAY THERE WASN'T AN ALARM IN HIS ROOM OR ON THE CHAIR, WHEN I WENT TO GET HIM UP". WHEN ASKED WHAT SHE SHOULD DO WHEN A RESIDENT IS SUPPOSE TO HAVE AN ALARM BUT DOESN'T HAVE ONE? CNA "Q" RESPONDED " I SHOULD LET THE NURSE KNOW, SO SHE CAN GET ONE. BUT I DIDN'T TELL HER." ( )

THIS CITATION HAS MULTIPLE DEFICIENT PRACTICES: 1. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PERFORM PROPER TRANSFER TECHNIQUES BY NOT TRANSFERRING A STROKE RESIDENT ON HER UNAFFECTED SIDE FOR ONE (#508) OF 16 RESIDENTS WHO REQUIRED ASSISTANCE WITH TRANSFERS, OUT OF A TOTAL SAMPLE OF 16 RESIDENTS, RESULTING RESIDENT TWO FRACTURES OF THE LEFT LEG. FINDINGS INCLUDE: ON 10/11/11 AT 9:10 A.M., DURING THE INITIAL TOUR WITH THE UNIT MANAGER (EMPLOYEE "K" ), RESIDENT #508 WAS OBSERVED IN BED ASLEEP. EMPLOYEE "K" REPORTED THAT SHE IS A LONG TERM CARE RESIDENT AND RECENTLY SHE HAS BEEN HAVING MEDICAL ISSUES SUCH A FRACTURE TO HER LEG DURING A TRANSFER. ON 10/13/11 AT 10:15 A.M., RESIDENT #508 WAS OBSERVED SITTING IN HER WHEELCHAIR ALERT AND ANSWERED SIMPLE QUESTIONS APPROPRIATELY. A FULL LEG (THIGH AREA TO HALF OF LEFT FOOT) CAST TO THE LEFT LEG WAS INTACT. ON 10/13/11 AT 11:20 A.M., REVIEW OF THE FACILITY'S POLICY ENTITLED, "TRANSFER ACTIVITIES," REVISED 5/2010, INDICATED, "RESIDENT SHOULD MOVE TOWARD THE UNAFFECTED SIDE (EXCEPTION: GETTING INTO BATH TUB) ..." REVIEW OF THE FACE SHEET REVEALED AN ORIGINAL ADMISSION INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #508 WAS readmitted INto the facility on [DATE] WITH AN ADDITIONAL [DIAGNOSES REDACTED]. THE RESIDENT'S MOST RECENT MINIMUM DATA SET (MDS), dated [DATE], INDICATED A MILDLY IMPAIRED COGNITION, DEPENDENT UPON STAFF FOR TRANSFERS, AND REQUIRED EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF LIVING EXCEPT EATING. REVIEW OF A NURSE'S NOTE, DATED 10/2/11 AT 7:45 P.M., DOCUMENTED, "WRITER WAS CALLED TO ELDER'S (RESIDENT #508) ROOM. ELDER ASKED ME TO CHECK HER LEFT LEG AND FOOT BECAUSE SHABAZ (CNA) HAD FALLEN ON HER FOOT AND HER FOOT AND LEG WAS PAINING HER. LEG WAS EXAMINED, PALPITATION WITH RANGE OF MOTION DONE. NO S/S (SIGNS/SYMPTOMS) OF SKIN TEARS OR ADDITIONAL SWELLING NOTED." REVIEW OF AN INCIDENT AND ACCIDENT REPORT DATED 10/2/11 AT 7:45 P.M. READ, "SHABAZ (CERTIFIED NURSING ASSISTANT FOR THE GREEN HOUSES) SAID ELDER'S (RESIDENT #508) FOOT WAS TWISTED DURING TRANSFER FROM WHEELCHAIR TO HER BED." REVIEW OF RESIDENT #508 A RADIOLOGY REPORT, DATED 10/2/11, INDICATED "THERE IS AN ACUTE MILDLY DISPLACED COMMINUTED [MEDICAL CONDITION] TIBIAL METAPHYSIS. THERE IS ALSO A MINIMALLY DISPLACE ACUTE [MEDICAL CONDITION] SHAFT OF FIBULA." ON 10/13/11 AT 11 A.M., THE CERTIFIED NURSING ASSISTANT "O" (CNA) WAS QUERIED REGARDING THE INCIDENT WITH RESIDENT #508. CNA "O" STATED, "I WAS TRANSFERRING HER (#508) TO THE BED. I MISTAKENLY DONE IT ON THE WRONG SIDE. WHEN I TURNED TO SIT HER ON THE BED, HER LEFT FOOT GOT TWISTED, STUCK OR DID NOT MOVE WHILE SHE WAS TRANSFERRED. I TRANSFERRED HER ON HER WRONG LEG/FOOT. SHE COULD STAND ON THE RIGHT FOOT, BUT I HAD HER RIGHT LEG BETWEEN MY LEGS INSTEAD OF HER LEFT LEG/FOOT, WHICH WAS HER BAD LEG. I TRANSFERED HER ON THE WRONG SIDE WHICH WAS THE LEFT SIDE." ON 10/13/11 AT 10:50 A.M., RESIDENT #508'S SON WAS INTERVIEWED REGARDING THE INCIDENT. THE SON STATED, "LAST SUNDAY MY MOM'S LEG WAS FRACTURED IN TWO PLACES DURING A TRANSFER AT THE FACILITY. SHE DID NOT FALL. THE LADY TRANSFERRED HER AND CAUSED THE FRACTURE. I KNOW USUALLY WHEN WE (THE FAMILY) TRANSFER HER; IF WE MEET RESISTANCE DURING THE TRANSFER WE STOP THE TRANSFER. I DON'T KNOW WHY SHE (CNA) CONTINUED THE TRANSFER. REVIEW OF THE "PHYSICAL THERAPY CARE PLAN," DATED 7/27/11, DID NOT REVEAL INTERVENTIONS TO TRANSFER RESIDENT #508 ON HER UNAFFECTED SIDE. THE "AT RISK FOR FALLS/INJURY," CARE PLAN DATED 7/28/11 DID NOT INCLUDE INTERVENTION TO TRANSFER RESIDENT ON HER UNAFFECTED SIDE. ON 10/12/11 AT 10 A.M., THE FACILITY'S FULL INVESTIGATION OF THE INCIDENT WAS REQUESTED. THE FACILITY PRESENTED A TYPED UNDATED AND UNSIGNED ONE PAGE TYPED SYNOPSIS OF THE ALLEGED INCIDENT ON A BLANK SHEET OF PAPER WITHOUT THE FACILITY ' S LETTERHEAD. ON 10/12/11 AT 1 P.M., THE ADMINISTRATOR AND THE DIRECTOR OF NURSES (DON) WERE BOTH INTERVIEWED TOGETHER REGARDING THE INCIDENT. THE DON WAS QUERIED REGARDING ANY OTHER STAFF THAT WAS INTERVIEWED REGARDING THE INCIDENT. THE DON REPORTED SHE INTERVIEWED THE CNA, STAFF NURSE, RESIDENT, AND THE UNIT MANAGER. THE DON REPORTED THE INCIDENT OCCURRED ON THE AFTERNOON SHIFT WHEN THE SHABAZ (CNA) WAS PUTTING RESIDENT #508 TO BED WHEN HER FOOT GOT TWISTED WHICH CAUSED THE FRACTURES TO THE LEFT LEG. THE DON REPORTED THAT RESIDENT #508 WAS A ONE PERSON TRANSFER AND STATED, "SHE WAS BEING TRANSFERRED FROM HER WHEELCHAIR TO BED WHEN HER FOOT GOT TWISTED." ON 10/12/11 AT 2:15 P.M., THE UNIT MANAGER (EMPLOYEE "K") STATED IN REGARDS TO RESIDENT #508, "SHE IS LIMITED ON HER LEFT SIDE. SHE HAS FOOT DROP. THEY (CNA/SHABAZ) SHOULD HAVE KNOWN." ON 10/13/11 AT 11:05 A.M., NURSE "J" WAS QUERIED REGARDING CARE GUIDES FOR RESIDENTS (ELDERS). NURSE "J" STATED, " WE DON ' T HAVE CARE GUIDES. WE DO WALKING ROUNDS." NURSE "J" WAS ALSO QUERIED ON HOW THE STAFF IS INSTRUCTED AND/OR INFORMED ON HOW TO TRANSFER A RESIDENT (ELDER). NURSE "J" REPORTED THAT IT IS ON THE physician's orders [REDACTED]. THE FACILITY PROVIDED NO EXPLANATION BY THE TIME OF THE SURVEY EXIT FOR THE DISCREPANCIES IN DETAILS RELATED TO THE INCIDENT. ( ) 2. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADMINISTER PRESCRIBED MEDICATIONS USING THE MOST CURRENT MEDICATION ADMINISTRATION RECORD (MAR) FOR ONE (#508) OF FIVE RESIDENTS REVIEWED FOR THE MEDICATION PASS OBSERVATION, OUT OF A TOTAL OF 16 SAMPLED RESIDENTS, RESULTING IN THE POTENTIAL FOR MEDICATION ERRORS AND ADVERSE DRUG REACTIONS. FINDINGS INCLUDE: ON 10/12/11 AT 8:45 A.M., NURSE "J" WAS OBSERVED ADMINISTERING PRESCRIBED MEDICATIONS TO RESIDENT #508 WHILE REFERENCING A SEPTEMBER 2011 MEDICATION ADMINISTRATION RECORD (MAR). NURSE "J" REFERRED TO THE SEPTEMBER MAR AND GAVE THE MEDICATIONS ACCORDING TO SEPTEMBER'S MEDICATION ORDERS. NURSE "J" SIGNED OUT THE ADMINISTRATION OF MEDICATIONS FOR THE MORNING OF 10/12/11 ON THE DATE INDICATED AS SEPTEMBER 30, 2011 DATE (NOT THE ACTUAL DATE OF THE MEDICATION ADMINISTRATION). NURSE "J" DID NOT HAVE THE OCTOBER 2011 MAR WHILE ADMINISTERING PRESCRIBED MEDICATIONS TO RESIDENT #508. ON 10/12/11 AT 8:55 A.M., NURSE "J" WAS QUERIED WHY SHE USED THE SEPTEMBER 2011 MAR INSTEAD OF THE OCTOBER 2011 MAR TO ADMINISTER RESIDENT #508'S PRESCRIBED MEDICATIONS. NURSE "J" STATED, "I DID NOT NOTICE IT WAS THE SEPTEMBER MAR. I GRABBED THE WRONG BOOK." REVIEW OF RESIDENT #508'S FACE SHEET REVEALED AN ORIGINAL ADMISSION INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #508 WAS readmitted INto the facility on [DATE] WITH AN ADDITIONAL [DIAGNOSES REDACTED]. THE RESIDENT'S MOST RECENT MINIMUM DATA SET (MDS), dated [DATE], INDICATED A MILDLY IMPAIRED COGNITION, DEPENDENT UPON STAFF FOR TRANSFERS, AND REQUIRED EXTENSIVE ASSISTANCE WITH ACTIVITIES OF LIVING. ON 10/12/11 AT 10:10 A.M., REVIEW OF THE FACILITY'S POLICY ENTITLED, "MEDICATION ADMINISTRATION," EFFECTIVE DATE 2/20/2009, REVEALED DOCUMENTATION THAT READ, "ALL NURSES ADMINISTERING MEDICATIONS MUST SIGN AND INITIAL THE DESIGNATED AREA OF EACH RESIDENT'S MEDICATION/TREATMENT ADMINISTRATION RECORD..." ON 10/12/11 AT 10:20 A.M., THE DIRECTOR OF NURSES (DON) WAS INFORMED OF THE INCIDENT. THE DON OFFERED NO EXPLANATION. ( ) 3. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO FOLLOW A physician's orders [REDACTED].#512) OF 16 SAMPLED RESIDENTS RESULTING IN THE POTENTIAL FOR ADVERSE REACTIONS. FINDINGS INCLUDE: ON 10/13/11 AT 8:45 A.M., RESIDENT #512 WAS OBSERVED SITTING IN HER WHEELCHAIR IN THE HALLWAY OUTSIDE OF THE DINNING ROOM. THE HALLWAY WAS ACCESSIBLE TO VISITORS, RESIDENTS AND STAFF. RESIDENT #512 WAS HANDED A [MEDICATION NAME] INHALER (ORAL INHALATION THAT RELAXES THE AIRWAYS) BY NURSE "F", RESIDENT #512 INHALED ON THE INHALER (WITHOUT INSTRUCTION) AND HANDED IT BACK TO NURSE "F". NURSE "F" RETURNED THE INHALER BACK INTO THE MEDICATION CART WITHOUT WIPING OFF THE INHALER MOUTH PIECE. RESIDENT #512 DID NOT RINSE AFTER THE ADMINISTRATION OF THE INHALER PUFF. A REVIEW OF THE ACTIVE MEDICAL RECORDS ON 10/13/11 AT 8:55 A.M., REVEALED THAT THE RESIDENT #512 WAS admitted INto the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ASSESSMENT (MDS), WITH AN ASSESSMENT REFERENCE DATE OF 7/13/11, IDENTIFIED THE RESIDENT AS COGNITIVELY INTACT AND REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS, DRESSING AND HYGIENE FURTHER REVIEW OF THE MEDICAL RECORD ON 10/13/11 AT 10:00 A.M., REVEALED THAT RESIDENT #512 WAS SEEN BY THE EAR, NOSE AND THROAT PHYSICIAN (ENT) ON 9/27/11 FOR DIFFICULTY BREATHING AND SLEEP DISTURBANCE. RECOMMENDATIONS WERE TO "START [MEDICATION NAME] ONE CAPSULE/PUFF DAILY IN AM. NURSE TO ASSIST PATIENT IN TAKING [MEDICATION NAME]. RINSE MOUTH AFTER TAKING [MEDICATION NAME]". A MONTHLY PHYSICIAN'S PROGRESS NOTE, DATED 10/4/11 DOCUMENTED THE FOLLOWING; ...SHE HAS BEEN COMPLAINING OF A SORE THROAT AND DRY TONGUE. SHE STATES THAT IS STARTED ABOUT THREE DAYS AGO. SHE HAS DISCOMFORT ON HER UPPER AND LOWER GUMS...". "ASSESSMENT AND PLAN: 1. ORAL THRUSH WITH APHTLOUS (MOUTH ULCERS) [MEDICAL CONDITION]. THE PATIENT HAS JUST STARTED [MEDICATION NAME] THAT CONTRIBUTED TO HER SYMPTOMS. WE WILL RESTART [MEDICATION NAME] (ANTIFUNGAL TREATMENT) FOUR TIMES A DAY AND ENCOURAGE TO RINSE MOUTH WELL AFTER USING THE [MEDICATION NAME]". A physician's orders [REDACTED]. UNIT MANAGER "C" WAS UNABLE TO EXPLAIN WHY STAFF NURSE "F" DID NOT ASSIST AND INSTRUCT RESIDENT #512 WITH HER MORNING ADMINISTRATION OF THE SPIRIVIA INHALER. PER THE FACILITY'S "ORAL INHALATIONS ADMINISTRATION PROCEDURE", DATED 3/09; "HAVE RESIDENT RINSE HIS/HER MOUTH AND SPIT OUT THE RINSE WATER...WIPE MOUTHPIECE WITH ALCOHOL WIPES AFTER EACH USE..." ( )