Every finding on record at The Orchards at Three Rivers

Based on observation, interview, and record review, the facility failed to A.) operationalize an effective infection control program B.) have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP) C.) follow transmission-based precaution (TBP) and enhanced barrier precautions (EBP) guidelines for 4 (Resident #7, #54, #35, and #87) residents resulting in the potential for the development and transmission of communicable diseases and infections. Findings include: Resident #7 Review of an admission Record revealed Resident #7 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care and muscle weakness. Review of Resident #7' Orders revealed, Enhanced Barrier Precautions r/t (related to) tube feeding (delivery of nutrients directly into the gastrointestinal tract through a feeding tube). Start date: 3/3/26. Review of Resident #7's February Treatment Administration Record (TAR) revealed, Enhanced barrier precautions: Providers and staff must wear gown and gloves for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, Device care: central line, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring dressing. every shift for PU (Pressure ulcer) . During a care observation on 3/05/2026 at 10:33 AM, Registered Nurse (RN) M entered Resident #7's room to provide wound care. RN M washed her hands, and donned (put on) gloves. RN M then cleaned Resident #7's left heel with a gauze and saline, let the heel dry and applied betadine (antiseptic solution) to Resident #7's heel. After completing wound care treatment, RN M repositioned Resident #7 in bed, assessed his oxygen saturation, and placed socks on Resident #7's feet. Noted that RN M was not wearing a gown as she provided the care to Resident #7. During an interview on 3/05/2026 at 11:22 AM, RN M reported Resident #7 was on enhanced barrier precautions, and that she did not think she needed to wear a gown to provide care to Resident #7 if she was not providing care related to his feeding tube. RN M then reported that she probably should have donned a gown either way. RN M reported that over the past weekend, she had sent Certified Nursing Assistant (CNA) DD home because she had come to the facility ill and had been vomiting at work. During an interview on 3/04/2026 at 1:35 PM, Infection Preventionist (IP) D reported that she had been overseeing the Infection Control program at the facility for the last month. IP D provided the facility's Line Listings (List of residents with potential infections) for January 2026, and some of February 2026, and reported she had not yet completed the facility's line listings for the month of February 2026. IP D reported that her process for providing infection surveillance for the facility was to review resident progress notes daily to oversee potential resident infections, but she was not always able to as she was also working as the facility's Director of Nursing (DON) and Unit Manager (UM). IP D was unable to provide any verification of staff education that had been completed in the last year related to infection control. IP D was unable to provide any verification that the facility had been conducting infection control audits that the facility had completed. IP D reported that she had been in the process of trying to educate staff on following transmission based and enhanced barrier precautions but was not able to provide verification of this education. IP D reported that staff were educated on signs/symptoms of illness that would prohibit them from working during orientation. IP D reported if staff were to call in due to illness, the staff member taking the call in was supposed to document the symptoms of the illness so the facility could monitor for potential illness outbreaks at the facility. IP D reported that she thought that Medical Records (MR) C was tracking staff illnesses, and that she had not been overseeing staff call ins when they were sick. IP D reported that she was not sure how often the facility was reviewing the infection control policies or the program. IP D was unable to report which communicable diseases were supposed to be reported to the local/state health authorities, or what the communication protocol for reporting communicable diseases was. IP D was not able to report how the facility's infection control program monitored for early detection of potential infections, how infections were monitored after identification, or how the facility was currently monitoring immunizations of residents. IP D reported the facility had several staff members overseeing the infection control program over the last few months, so there were multiple changes in how the facility had been monitoring and tracking of infections, and the facility was still working on a new process with corporate. During an interview on 3/05/2026 at 11:35 AM, MR C reported that she did monitor staff call ins, but that staff never really tell a reason that they are calling in. MR C reported that if a staff member called in due to an illness, she would let the nursing managers know. MR C reported that she was unaware that CNA DD had been sent home over the past weekend because she was ill. During a follow up interview on 3/05/2026 at 11:36 AM, IP D reported that she had heard that CNA DD had been sent home over the past weekend because she was ill. IP D reported that she had kept an eye on the residents that CNA DD had cared for, but she did not have any documentation regarding this because she was just watching out to see if any residents got sick. Resident #54: Review of Resident #54's admission Record, undated, revealed she was admitted on [DATE] with pertinent diagnoses that included enterocolitis (inflammation of the intestines) due to clostridium difficile (bacteria) and immunodeficiency (immune system is unable to function properly). Review of Resident #54's brief interview for mental status, dated 2/3/26, was scored 9 which reflected she had moderate cognitive impairment. Review of Resident #54's physician orders included an order for Contact Precautions with a start date of 3/2/26 and an end date of 3/4/26. During an observation and interview on 03/03/2026 at 10:35 AM, Resident #54's room had a Centers for Disease Control and Prevention (CDC) sign posted on the door that stated, CONTACT PRECAUTIONS (specific precautions intended to prevent the transmission of infectious agents) EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . Resident #54 reported she was on contact precautions because she had a clostridium difficile infection. During an observation on 03/03/2026 at 11:40 AM, Housekeeping Aide (HA) LL was in Resident #54's room without any personal protective equipment (PPE) on (no gown or gloves) and the contact precaution signage was posted on the entry door of the room. HA LL proceeded to clean throughout the room and in the process HA LL's clothing/body had contacted the resident living environment including Resident #54's bed and trash bin. HA LL with bare hands removed the trash bag from Resident #54's trash bin, placed it in the trash on her cart just outside the resident's room, grabbed a new empty trash bag, reentered the room, replaced the trash bag, exited the room, and started heading down the hall. No gown or gloves were worn by HA LL while in Resident #54's room and upon exiting no hand hygiene was completed. During an observation on 03/03/2026 at 12:55 PM, HA LL entered Resident #54's room that had contact precaution signage posted without putting on any PPE. There was a bin outside the room as well that contained PPE to use before room entry. HA LL proceeded to do various cleaning and contact of room items that included a medical basin, bedding, bedside table, bedside commode, and trash bin. At 1:04 PM HA LL coughed into her right hand inside the resident's room, exited the room, and started pushing the cart down the hall. No gown or gloves were worn by HA LL while in Resident #54's room and upon exiting no hand hygiene was completed. During an observation on 03/03/2026 at 1:05 PM, in the hallway outside of Resident #54's room HA LL was overheard telling another staff member that she didn't know Resident #54 was on contact precautions. Resident #35: Review of Resident #35's physician orders revealed an order dated 3/3/26 that stated, Contact precaution r/t (related to) MRSA (Methicillin-resistant Staphylococcus aureus; a type of bacteria) in urine. Review of Resident #35's urinary tract infection care plan, included an intervention of Contact precautions, dated 3/3/26. During an observation and interview on 03/04/2026 at 8:50 AM, Social Services Staff OO was inside Resident #35's room standing near the foot of the bed. There was contact precaution signage on Resident #35's door which stated, .Put on gloves before room entry.Put on gown before room entry. Social Services Staff OO proceeded to exit the room and reported he didn't put on gown or gloves before entering the room because he didn't touch or provide cares to the resident. Resident #87: Review of Resident #87's physician orders included an order of Enhanced barrier precautions r/t (related to) peritoneal dialysis (a form of dialysis using the abdominal lining to filter and remove waste) dated 2/23/26. Review of Resident #87's dialysis care plan, included an intervention, dated 1/22/26, that stated, Enhanced barrier precautions. During an observation and interview on 03/04/2026 at 11:19 AM, Certified Nurse Aide (CNA) AA pushed Resident #87 in her wheelchair from the hallway into her room. Resident #87's room had enhanced barrier precaution (EBP; an infection control strategy used during high-contact care activities) signage posted. No gown or gloves were put on by CNA AA, and she proceeded to transfer Resident #87 from her wheelchair to her bed. CNA AA handled Resident #87's oxygen supplies and switched the resident from her portable oxygen tank to her bedside oxygen concentrator. CNA AA confirmed Resident #87 was on enhanced barrier precautions, she did not wear any gown or gloves during the transfer for Resident #87 and reported nobody did. The posted CDC EBP signage on Resident #87's room entry stated, ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities .Transferring. During an interview on 03/05/2026 at 9:44 AM, Interim DON (IDON) D confirmed if staff entered a contact precaution room they needed to put on a gown and gloves. IDON D confirmed staff would need to put on a gown and gloves before transferring a resident who was on EBP. Review of the Centers for Disease Control and Prevention's resource (www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html), dated 4/2/2024, stated, Contact Precautions require the use of gown and gloves on every entry into a resident's room . Review of the facility's Enhanced Barrier Precautions (EBP) policy, undated, stated, The EBP requires the use of gowns and gloves during high-contact resident care activities .Examples of high-contact resident care activities requiring gown and glove use among residents that trigger EBP use include: .Transferring . The policy also stated, What are the differences between Enhanced Barier Precautions and Contact Precautions? Contact Precautions require the use of gown and gloves on every entry into a resident's room, regardless of the level of care being provided to the resident . During an observation and interview on 3/3/26 at 10:40 AM, Certified Nursing Assistant (CNA) GG sat at a table in the common area while 12 residents were participating with activities. CNA GG was wearing a pink-colored surgical mask below her nose and was coughing. During an interview on 3/03/2026 at 11:07 AM, CNA GG stated, I do not feel good. I feel heavy in my head, my nose is stuffy like a head cold, and I have a sore throat. I did not do a Covid-19 test before I came in or when I came in today. I cannot afford not to be here. I do have sick time I can use. I am working with the residents today. The facility provides masks and I put this one on when I got here today. I have been educated on how to wear the mask. I have never asked the facility what to do if I feel sick and come to work, and the facility has never said what to do if I feel sick and come to work. CNA GG was clearing her throat of phlegm and sniffing her nose. Observed on 3/3/26 at 12:31 PM, CNA GG assisting residents in Meadows (locked unit) dining room/common area eating lunch. CNA GG was wearing a mask and coughing. Observed on 3/3/26 at 12:35 PM, CNA GG was assisting a resident with eating lunch. CNA GG had a mask on and coughing while standing over the resident. During an interview on 3/3/26 at 12:36 PM, Laundry Aide QQ stated she has received information on what to do if she feels sick by contacting the facility and be willing to test for Covid-19 if asked. During an interview on 3/3/26 at 12:39 AM, Nursing Home Administrator (NHA) A stated, If a staff feels sick, they are to notify the nurse manager or DON (Director of Nursing). They are not to come to work if they feel sick or show signs and symptoms of being sick. On 3/3/26 at 1:35 PM, an interview with Maintenance (M) PP found that he flushes the facilities hot water supply weekly by running the fixtures at the end of the loop for a few minutes but does not run the cold. When asked if there is any disinfection sampling that is performed on the water supply, M PP stated there was no sampling being done. On 3/3/26 at 2:33 PM, observation of the View Court Shower room found a spa tub with an accumulation of dust and dead bugs in the bottom of the unit, indicating stagnant water for the hot and cold-water lines feeding the spa. On 3/3/26 at 2:55 PM, an interview with Environmental Services and Dietary Manager (ESDM) R found that the tub is not regularly used. On 3/5/26 at 9:19 AM, observation of the janitors' closet, near the administrator's office, found that the mop sink basin was filled with bags of pop bottles and containers of cleaning products. At this time, an interview with ESDM R found that staff do not use the mop sink and only use the one in the main housekeeping closet. When asked how long that has been going on, ESDM R stated about November. A record review of the provided document entitled Water Management Plan dated March 1, 2024, found that no evidence of an annual review had been performed on the plan and additional review found that the plan states it expires on 03/01/2025. Further review of the document found a page titled General Requirements that states the Water Management Plan (WMP) should have a Program Team to help oversee and carry out the WMP. No documentation of an updated team or meeting minutes were available. A review of page 26 found Control Measures: Hot and Cold Water Systems. The page states under Monitoring: that the facility should Identify dead legs and either remove or drain (identification is key). A review of page 33 found that the facility should Check for Residual (Free) Disinfection (Chlorine) Levels On 3/3/26 at 2:34 PM, observation of the half wall next to the shower found two towels stored on the wall, open and exposed to contamination. On 3/3/26 at 2:47 PM, observation of the Meadow Lane spa room found three towels stored out in the open next to the shower. On 3/3/26 at 2:55 PM, an interview with Environmental Services and Dietary Manager R found that when her or her staff find towels stored open and exposed, they put them in the soiled laundry. On 3/3/26 at 3:32 PM, observation of the basement storage found clean sanitary supplies stored under wastewater lines int he basement. These items were disposable cups and bath tissue.

Based on interview and record review, the facility failed to designate an Infection Preventionist (IP) that had adequate time to perform infection prevention responsibilities and oversee the infection control program. This deficient practice resulted in the potential for the spread of infection, cross-contamination, and disease transmission for all residents residing in the facility. Findings include: During an interview on 3/04/2026 at 1:35 PM, Infection Preventionist (IP) D reported that she had been overseeing the Infection Control program at the facility for the last month. IP D provided the facility's Line Listings (List of residents with potential infections) for January 2026, and some of February 2026, and reported she had not yet completed the facility's line listings for the month of February 2026. IP D reported that her process for providing infection surveillance for the facility was to review resident progress notes daily to oversee potential resident infections, but she was not always able to as she was also working as the facility's Director of Nursing (DON) and Unit Manager (UM). IP D was unable to report how much time she spent every day or week working on the facility's infection control program tasks. IP D reported she was trying to keep track of all of the infection control tracking, but since she was working in three different roles, she was not able to manage all of the infection control tasks and oversight. IP D could not provide any verification of staff education that had been completed in the last year related to infection control. IP D could not provide any verification that the facility had been conducting infection control audits that the facility had completed. IP D confirmed that she had not been completing infection control audits over the last month because she had not had the time to do so. IP D reported that she had been in the process of trying to educate staff on following transmission based (TBP) and enhanced barrier precautions (EBP) but was not able to provide verification of this education. IP D confirmed that there were ongoing concerns that the facility staff were not following TBP and EBP, and that this was an area that all staff needed re-education on. IP D reported that staff were educated on signs/symptoms of illness that would prohibit them from working during orientation. IP D reported if staff were to call in due to illness, the staff member taking the call in was supposed to document the symptoms of the illness so the facility could monitor for potential illness outbreaks at the facility. IP D reported that she thought that Medical Records (MR) C was tracking staff illnesses, and that she had not been overseeing staff call ins when they were sick. IP D reported that she was not sure how often the facility was reviewing the infection control policies or the program. IP D was unable to report which communicable diseases were supposed to be reported to the local/state health authorities, or what the communication protocol for reporting communicable diseases was. IP D could not report how the facility's infection control program monitored early detection of potential infections, how infections were monitored after identification, or how the facility was currently monitoring immunizations of residents. IP D reported the facility had several staff members overseeing the infection control program over the last few months, so there were multiple changes in how the facility had been monitoring and tracking of infections, and the facility was still working on a new process with corporate. Review of the facility's Infection Control binder during the meeting with IP D on 3/4/26 at 1:35 PM revealed Line Listings for January 2026, and some of February 2026. Noted that the line listings only included residents that had been prescribed antibiotics. The Infection Control binder did not have audits, education, or other documentation to verify ongoing infection control surveillance. For further information, please see F880.

Based on observation, interview, and record review the facility failed to ensure an orderly and clean living environment was maintained for 8 (Residents #30, 74, 87, 50, 70, 40, 41, and 2) of 8 residents reviewed for environment resulting in a dirty living environment and being dissatisfied with the level of cleanliness and order.Findings include: Resident #30: Review of Resident #30's Minimum Data Set, dated [DATE], indicated Resident #30 was admitted on [DATE] and her brief interview for mental status score was 13 which indicated she was cognitively intact. During an observation and interview on 03/03/2026 at 10:40 AM, Resident #30 reported that she thought her window glass was cracked and covered in tape. The window glass had an approximately 55-inch-long streak of old dried-up tape and tape residue extending from the top of the window down towards the bottom. Resident #30 reported the tape had been on the window since she was admitted . The window was not shattered but was partially covered in old tape and tape residue.During an observation on 03/04/2026 at 9:29 AM, Resident #30's window presented the same as it did on 3/3/26 at 10:40 AM. Resident #74: During an observation and interview on 03/03/2026 at 10:45 AM, Resident #74's room had a visibly soiled floor. There was paper debris, an unknown dime sized clear plastic lid, what appeared to be food debris of various colors and sizes, and lots of dust and debris heavily located under the bed and on the floor surrounding the bed. The bedside table had white debris across the top left side. Resident #74 appeared somewhat confused and was unable to report the last time the facility had cleaned her room and/or how it made her feel. During an observation on 03/03/2026 at 12:44 PM, Resident #74 was asleep in her room, and the room presented the same as it had on 3/3/26 at 10:45 AM. Resident #87: During an observation and interview on 03/03/2026 at 11:17 AM, Resident #87 was lying in bed in her room. Resident #87 appeared slightly confused and was unable to answer questions about the cleanliness of her room. There was trash/debris on the floor in various areas throughout the room that included in front of dressers, the television, and under the bed. Under Resident #87's bed was a large white crumpled up tissue/wipe along with white and brown debris accumulation. The floor mat next to the bed was visibly soiled with dried stains. There was a large, approximately 10 inches by 5 inches dried-up spill/stain on the floor in front and under the rack holding Resident #87's dialysis (filter blood when the kidneys are no longer able to function properly) equipment. There were trash, dust, and debris under the bed next to hers, but no other resident resided in the room at that time. There was a large gouge on the wall next to Resident #87's bed which measured approximately 5 inches tall and 1 inch wide. During an observation on 03/04/2026 at 9:05 AM, Resident #87's room presented the same as it had on 3/3/26 at 11:17 AM with each dirty and/or unorderly area unchanged. During an observation on 03/05/2026 at 9:16 AM, Resident #87's room still had the dried stain on the floor near the dialysis machine, there was debris on the floor, and the floor mat next to the bed was still soiled. Resident #50:Review of Resident #50's brief interview for mental status, dated 2/6/26, was scored 15 which reflected she was cognitively intact.During an observation and interview on 03/03/2026 at 11:54 AM, between Resident #50's window and the bed were three clear plastic bags tied up and on the floor. Resident #50 reported one contained soiled linens and the other two contained trash. Resident #50 reported it bothered her that the trash was still near her bed. On the floor near the trash bags and under the wall vent there was an old paper meal ticket with the date 3/1/2026 on it. There was trash on the floor under the bed, the area surrounding the bed, and in various areas throughout her half of the room. Resident #50 reported the staff would visit her room once a day for cleaning, but felt it required more attention. Resident #50 reported she wished they'd give her a broom so she could take care of it herself. Under Resident #50's roommate's bed there was trash that included a crumpled up used tissue/wipe and other miscellaneous trash and debris. During an interview on 03/04/2026 at 9:32 AM, Resident #50 was in her bed. Resident #50 reported last night staff removed the bagged trash and linens but didn't clean her floors until this morning. Resident #70: During an observation on 03/03/2026 at 12:29 PM, Resident #70's room had trash on the floor in various areas throughout the room. There were broken pieces of grey plastic between the door and his bed. There was white and grey debris on the floor next to the bed, in the middle of the room, and along the walls on the floor. When exiting Resident #70's room, in the hallway outside the room, there was trash on the floor which included brown debris, a hard grey plastic piece approximately the size of a dime, and various other debris. Proceeding down the 200s hall there was a large bundle of dust and debris built up to the size of approximately a golf ball outside of room [ROOM NUMBER]. Further down the hall, at the double doors just past room [ROOM NUMBER] were pieces of shattered grey plastic, small pieces of trash, dust, and debris of various sizes and colors, and a two-inch-long ball of dust/debris. Resident #40:During an observation on 03/04/2026 at 9:41 AM, Resident #40's floor in her room was soiled with spills, trash, and debris. The bedside floor mat was soiled with dried up material and white/brown debris accumulation. One dried up spill on the mat was approximately 3 inches in diameter. Under the bed there was an accumulation of dust and debris, a small disposable plastic medication cup, and what appeared to be a plastic cap. There were trash and debris on the floor in areas along the wall in various areas of the room. During an observation on 03/05/2026 at 9:27 AM, Resident #40 was asleep in bed with the floor mat next to the bed. The floor mat presented the same as it did on 3/4/2026 and remained dirty. The dust, debris and trash remained on the floor mat and under the bed with the exception that the medication cup was no longer present under the bed. Memory Care Unit: During an observation on 03/04/2026 at 9:39 AM, in the locked memory care unit at the double doors just before the dining room there was a heavy accumulation of dust and debris on the floor with one dust and debris ball measuring approximately 3 inches long and 1 inch wide. During an observation on 03/05/2026 at 9:24 AM, in the locked memory care unit at the double doors just before the dining room dust and debris accumulation remained as it had on 3/4/2026 at 9:39 AM. During an observation on 03/04/2026 at 9:47 AM, the dining room of the memory care unit had a heavy accumulation of dust, trash and debris in the corner behind the decorative tree. In various areas, along the floor and wall, there were areas of debris accumulation. During an observation on 03/05/2026 at 9:26 AM, the dining room of the memory care unit had a heavy accumulation of dust, trash and debris in the corner behind the decorative tree. In various areas, along the floor and wall, there were areas of debris accumulation. During an observation on 03/04/2026 at 9:54 AM, the two wall mounted fans in the hallway of the memory care unit with the resident's rooms had built up grey dust/debris on the fans' blade guards. In various areas of the hallway there was dust and debris accumulation on the floor in the areas closest to the walls. During an observation on 03/05/2026 at 9:29 AM, the wall mounted fans in the hallways of the memory care unit still had heavy accumulation of grey dust/debris on the fans' blade guards. During a confidential resident council meeting on 03/04/2026 at 1:10 PM, 3 out of 5 residents in attendance voiced their rooms and shared spaces weren't consistently kept clean. 2 out of 5 residents reported their bedding wasn't changed frequently enough. During an interview on 3/5/2026 at 10:56 AM, Ombudsman V reported facility cleanliness has been an ongoing concern that she has received complaints on. Ombudsman V reported in September 2025, October 2025, December 2025, and February 2026 she had received concerns submitted by both residents and families about facility cleanliness. Review of the facility's Daily Cleaning Procedures policy, undated, stated, Routine cleaning for each housekeeper and included a map which indicated one housekeeper was responsible for approximately half the building and the other housekeeper was responsible for the other half.Applying the reasonable person concept, an individual living at the nursing home would not want to live in a dirty environment. Many residents due to medical condition and/or impaired cognition were unable to respond with how the facility's state of uncleanliness impacted them. Resident #41 Review of an admission Record revealed Resident #41 was a female, with pertinent diagnoses which included dementia, need for assistance with personal care, depression, cognitive communication deficit (impaired communication due to underlying cognitive issues), and muscle weakness. Noted Family Member U was Resident #41's Power of Attorney (POA) for care, first emergency contact, and responsible party. In an interview on 3/3/26 at 8:00 AM, Family Member U reported concerns with housekeeping services at the facility and dirty resident rooms. In an observation on 3/3/26 at 2:07 PM, Resident #41 was sitting on the edge of her bed, in her room. Noted a padded floor mat along the right side of Resident #41's bed, with visible crumbs/debris in the cracks/seams of the mat. Noted a trash can nearby with several pieces of trash on the floor (including a plastic beverage cup and two empty medication cups). In an observation on 3/4/26 at 1:03 PM, Resident #41 was lying in her bed in her room. Noted a padded floor mat along the right side of Resident #41's bed, with visible crumbs/debris in the cracks/seams of the mat. Resident #2 Review of an admission Record revealed Resident #2 was a female, with pertinent diagnoses which included neurocognitive disorder (a brain condition involving a decline in cognitive function), anxiety, depression, aphasia (impaired ability to understand or produce speech), dementia, cognitive communication deficit (impaired communication due to underlying cognitive issues), and muscle weakness. In an observation on 3/4/26 at 12:26 PM, Resident #2 was noted in her bed in her room, with her head of bed elevated, eating her lunch meal. Noted that the right side of Resident #2's bed was positioned along the wall. Observed several small, brown stains/spots on the wall alongside Resident #2's bed. In an observation on 3/4/26 at 12:19 PM, observed the shared bathroom between room [ROOM NUMBER] and room [ROOM NUMBER]. Noted urine in the toilet bowl (unflushed). Observed a splattered brown substance on the back surface of the toilet bowl and the backside of the toilet seat. Observed dust/debris around the perimeter of the bathroom and noted that the bathroom floors appeared sticky/tacky when walked on. Observed grip strips on the floor in front of the toilet in poor condition, with sections torn and peeling off of the floor. Noted the caulk around the base of the toilet was in poor condition, with some sections of caulk peeling up and some missing altogether. No staff or residents present at this time. In an observation on 3/4/26 at 12:22 PM, observed room [ROOM NUMBER]. Noted grip strips along the side of bed two (near the window) which were in poor condition with sections visibly torn and peeling away from the floor. Observed a dried spill on the floor in front of the dresser near the foot of bed two. Noted visible dust/debris around the perimeter of the room and under bed two, along with multiple small pieces of trash/paper. No staff or residents present at this time. In an observation on 3/4/26 at 12:23 PM, observed the shared bathroom between room [ROOM NUMBER] and room [ROOM NUMBER]. Noted urine and some toilet paper in the toilet bowl (unflushed). Observed a brown smear on the front of the toilet seat, with additional brown splatter visible within the toilet bowl. Observed dust/debris around the perimeter of the bathroom and noted that the bathroom floors appeared sticky/tacky when walked on. Observed grip strips on the floor in front of the toilet in poor condition, with sections torn and peeling off of the floor. Noted darkened buildup around the base of the toilet. No staff or residents present in bathroom at this time. During an observation on 3/03/2026 at 11:30 AM, the resident shared bathroom between rooms [ROOM NUMBERS] had splatters of brown substances resembling fecal matter on toilet seat, floor, and toilet bowl. During an observation on 3/03/2026 at 11:35 AM, the resident shared bathroom for rooms [ROOM NUMBERS] had dried and partially wet brown substance resembling fecal matter on toilet bowl. During an interview on 3/03/2026 11:41 AM, Certified Nursing Assistant (CNA) Z reported the resident in room [ROOM NUMBER] had to be supervised to use the bathroom. CNA Z reported earlier that morning she had walked the resident in room [ROOM NUMBER] into the bathroom and helped him sit down on toilet then left him there to give him privacy. CNA Z further reported she did not go back in to help him clean up, pull his pants up, or walk out of bathroom, stating, He did that on his own. During an interview on 3/3/26 at 11:50 AM, Housekeeping MM stated, Me and my coworker (Housekeeping LL) work for an environmental cleaning agency The two of us clean all the rooms here at the facility daily (census 3/3/26 97 residents). The two of us clean all the rooms then go to Meadows (locked unit) to clean. We split that unit. Neither one of us have been to the locked unit yet today. I don't know when we will get there today or if we will. When a resident has a bowel movement or urine that goes on the floor or all over the toilet, the CNAs are to clean it and then housekeeping is to disinfect it. If the toilet has bowel movement on it or urine on the floor, we tell the CNAs and wait for them to wipe it up then we go behind them to disinfect the area. During an observation on 3/5/26 at 10:16 AM, the shared bathroom serving rooms [ROOM NUMBERS] revealed dirt and debris around the base of the toilet and along the baseboard of the room. The room smelled of stale urine and the floor was sticky. On the outside of the toilet seat, on the wall behind the toilet and immediately next to the toilet was a splattering of dried brown substances resembling fecal matter. During an observation on 3/25/26 at 10:19 AM, the shared bathroom serving rooms 121-123 revealed dirt and debris around the base of the toilet and along the baseboard of the room. The room smelled of stale urine and the floor was sticky. On the inside of the toilet bowl, on the wall behind the toilet and immediately next to the toilet was a splattering of dried brown substances resembling fecal matter. Two of the three grip strips on the floor immediately to the front of the toilet were peeled off leaving a residue and no grip. The toilet tank was cracked and the substance used to repair it was dirty and peeling. The nightlight that was recessed in the wall had flakes of rust and paint along with dirt and debris. On 3/3/26 at 2:32 PM, observation of the View Court Spa room found dust and dead bugs in the bottom the spa tub and an accumulation of brown crusted debris on the seat of the shower chair. Further review of the room found dozens of small slab ants on the floor of the spa room coming from behind the toilet and the floor juncture near the shower. On 3/3/26 at 2:46 PM, observation of the Meadow Lane shower room found an accumulation of white wet debris on the top of the shower chair resembling toilet paper. On 3/5/26 at 9:07 AM, an interview with Environmental Services and Dietary Manger R found that housekeeping does a deep clean of the spa rooms daily, while nursing staff should keep the spa rooms tidy between residents.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% in 2 of 4 residents (Resident #33 and #54) reviewed for medication administration, when wrong dosages of medications were administered, and medications that were not to be crushed were administered crushed, resulting in the potential for adverse medication side effects. Findings include:Resident #33 Review of an admission Record revealed Resident #33 was a female, with pertinent diagnoses which included heart failure, diabetes, heart disease, cognitive communication deficit (impaired communication due to underlying cognitive issues), anemia (a deficiency of healthy red blood cells or hemoglobin), depression, high blood pressure, kidney failure, and muscle weakness. In an observation and interview on 3/4/26 at 9:03 AM, Licensed Practical Nurse (LPN) I prepared scheduled medications for Resident #33. LPN I reported Resident #33 takes all her medications crushed in pudding due to difficulty swallowing pills. Observed LPN I prepare one tablet of Vitamin D3 125 mcg (micrograms) (which was equivalent to 5,000 International Units), one Metoprolol Succinate ER (Extended Release) 25 mg (milligrams) tablet, two Vitamin B-12 500 mcg tablets, one Imipramine HCl 50 mg tablet, and one Potassium Chloride ER 20 mEq (milliequivalent) tablet for Resident #33, crush the medications, mix the medications in pudding, and administer the medications to Resident #33 while she was seated in the dining area on the memory care unit. Review of an Order Summary Report for Resident #33 revealed the active physician order .Cholecalciferol (Vitamin D3) Tablet 1000 UNIT Give 2 tablet by mouth one time a day for supplement give 2000 units (50 mcg) TOTAL . with a start date of 12/27/25. Noted the Vitamin D3 administered to Resident #33 by LPN I on 3/4/26 at 9:03 AM was administered at the wrong dosage. Review of an Order Summary Report for Resident #33 revealed the active physician order .Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth one time a day for HTN (high blood pressure) . with a start date of 9/26/25. Review of an Order Summary Report for Resident #33 revealed the active physician order .Cyanocobalamin (Vitamin B-12) Tablet 500 MCG Give 1 tablet by mouth one time a day for supplement . with a start date of 1/9/26. Noted the Vitamin B-12 administered to Resident #33 by LPN I on 3/4/26 at 9:03 AM was administered at the wrong dosage. Review of an Order Summary Report for Resident #33 revealed the active physician order .Imipramine HCl Oral Tablet 50 MG (Imipramine HCl) Give 1 tablet by mouth one time a day for antidepressant related to DEPRESSION . with a start date of 9/26/25. Review of an Order Summary Report for Resident #33 revealed the active physician order .Potassium Chloride Crys (Crystals) ER Oral Tablet Extended Release 20 MEQ (Potassium Chloride Microencapsulated Crystals ER) Give 1 tablet by mouth one time a day for low potassium . with a start date of 10/11/25. Review of an Order Summary Report for Resident #33 revealed the active physician order .OK to crush allowable medications and administer together . dated 12/28/25. In an interview on 3/4/26 at 12:15 PM, Registered Nurse (RN) H reported nurses are to use their professional knowledge and judgement when deciding whether or not medications can be crushed. RN H reported residents have physician orders to crush allowable medications. RN H reported if the medication ordered is not able to be crushed, nurses should either leave those medications to the side and administer them whole or contact the physician to change the order or get a different version of the medication. RN H reported both Metoprolol ER and Potassium Chloride ER should not be crushed for administration. RN H reported there is a powdered (immediate-release) form of Potassium Chloride available if a resident is unable to swallow the extended-release tablet. In an interview on 3/5/26 at 8:31 AM, LPN I reported extended-release medications should not be crushed for administration. LPN I reported Resident #33's medications (including the extended-release medications) are crushed for administration due to difficulty swallowing pills. LPN I reported the physician was previously notified and gave orders to crush all of Resident #33's medications, even those that should not be crushed per pharmacy recommendations. In an interview on 3/5/26 at 8:48 AM, requested information from Unit Manager F regarding Resident #33's medication orders and any documentation that the physician was notified and gave orders/approval to crush Resident #33's medications (including those that should not be crushed per pharmacy recommendations). No documentation provided prior to survey exit that the physician gave orders/approval to crush Resident #33's extended-release medications. In an interview on 3/5/26 at 9:11 AM, Unit Manager F reported he spoke with the physician regarding the crushed extended-release medications for Resident #33, with new orders obtained to discontinue the Metoprolol ER 25 mg tablet and dissolve the Potassium Chloride ER in water prior to administration. In an interview on 3/5/26 at 11:44 AM, Pharmacist T reported the general rule of thumb is that extended-release medications should not be crushed prior to administration. Pharmacist T verified Metoprolol ER should not be crushed, and that there is an alternative form available (Metoprolol Tartrate) that would be able to be crushed. Pharmacist T verified Potassium Chloride ER should not be crushed, and that there is an alternative form available (dissolvable packet). Pharmacist T reported Imipramine HCl 50 mg tablets are also not recommended to be crushed, and that there is an alternative liquid formulation available. Resident #54 Review of an admission Record revealed Resident #54 was a female, with pertinent diagnoses which included protein-calorie malnutrition (a deficiency in caloric and/or protein intake leading to severe metabolic dysfunction, muscle wasting, and weakened immunity), kidney failure, and anemia. In an observation on 3/4/26 at 8:19 AM, LPN N prepared scheduled medications for Resident #54. Observed LPN N prepare one tablet of Ferrous Sulfate 325 mg (65 mg of elemental iron) and administer the medication to Resident #54 in the resident's room. Review of an Order Summary Report for Resident #54 revealed the active physician order .Ferrous Sulfate ER Oral Tablet Extended Release 45 MG (Ferrous Sulfate) Give 1 tablet by mouth one time a day for Supplement . with a start date of 1/31/26. Noted the Ferrous Sulfate administered to Resident #54 by LPN N on 3/4/26 at 8:19 AM was administered at the wrong dosage. A total of 32 opportunities for medication administration were observed, and 6 of the 32 medications were not administered in accordance with physician's orders and professional standards of practice, resulting in a medication error rate of 18.75%.

Based on observation, interview, and record review the facility to failed to ensure call lights were within reach for 1 (Resident #7) of18 residents reviewed for accommodation of needs, resulting in the potential for unmet care needs. Findings include: Resident #7 Review of an admission Record revealed Resident #7 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care and muscle weakness. Review of Resident #7's Care Plan revealed, (Resident #7) is at risk for falls r/t (related to) impulsiveness, TBI (Traumatic Brain Injury), agitation, weakness, confusion, history of falls, poor judgement and lacks insight into limitations . Date initiated: 12/31/24 . Interventions: . Clip call light on resident when he is in bed as he allows (post fall 11/15/25). Date initiated: 11/17/25 .Replace call light clip (post fall 12/15/25). Date initiated:12/18/25 .soft touch (type of call light device) call light in reach. Date initiated: 1/6/25 . Review of Resident #7's Progress Note dated 12/18/25 revealed, IDT (Interdisciplinary Team) met to review recent fall on 12/15/25. Resident observed laying on floor mat next to bed .IDT intervention to have call light clip replaced and is working to ensure staff is (sic) able to clip to resident as he allows . In an observation on 3/05/2026 at 10:07 AM, Resident #7 was lying in his bed. It was noted that Resident #7's call light was on the floor and out of his reach. During an interview on 3/05/2026 at 10:13 AM, Certified Nursing Assistant (CNA) JJ reported Resident #7 did use his call light when he needed assistance from staff. During a care observation 3/05/2026 at 10:33 AM, Registered Nurse (RN) M entered Resident #7's room and provided wound care to Resident #7. After RN M completed wound care treatment on Resident #7, RN M exited his room. It was noted that Resident #7's call light was on the floor and out of his reach. When this writer queried RN M about Resident #7's call light, she reported that she didn't know if Resident #7 could use his call light, but that he would yell out if he needs us. RN M confirmed that Resident #7 was at risk for falls and had a history of attempting to get up on his own when he needed assistance. During an observation on 3/05/2026 at 1:01 PM, Resident #7 was sitting in his room in his chair. It was noted that his touch pad call light was in reach, and he turned it on to request assistance from staff.

This citation pertains to Intake # 2749154. Based on interview, and record review, the facility failed to notify the responsible party of a change in resident condition in 1 of 1 resident (Resident #41) reviewed for notification of changes, resulting in the family/responsible party being unaware of a newly identified urinary tract infection and initiation of antibiotic treatment. Findings include:Resident #41 Review of an admission Record revealed Resident #41 was a female, with pertinent diagnoses which included dementia, need for assistance with personal care, depression, cognitive communication deficit (impaired communication due to underlying cognitive issues), and muscle weakness. Noted Family Member U was Resident #41's Power of Attorney (POA) for care, first emergency contact, and responsible party. Review of a Minimum Data Set (MDS) assessment for Resident #41, with a reference date of 12/4/25, revealed a Brief Interview for Mental Status (BIMS) of 4, out of a total possible score of 15, which indicated severe cognitive impairment. In an interview on 3/3/26 at 8:00 AM, Family Member U reported she was Resident #41's responsible party/POA, however, the facility has not been notifying her consistently with changes in Resident #41's condition. Family Member U reported during a recent visit with Resident #41, she discovered Resident #41 was being treated for a urinary tract infection (UTI) when the resident mentioned staff were .giving her shots . Review of a Physician Note for Resident #41, dated 2/12/26, revealed .REASON FOR EVALUATION: I am asked by the nursing staff to evaluate the patient's urine .LABS: The patient has pyuria (elevated number of white blood cells or pus in the urine indicating inflammation or infection in the urinary tract), bacteriuria (presence of bacteria in the urine), growth of greater than 100,000 organisms of proteus mirabilis (a type of bacteria), sensitive to Rocephin (a type of antibiotic) .ASSESSMENT: Pyuria, bacteriuria .PLAN: Rocephin 1 gram IM (intramuscular injection) with lidocaine one time a day . No documentation noted to indicate if the responsible party was notified of these lab findings or the new antibiotic orders. Review of an Order Summary Report for Resident #41 revealed the physician order .cefTRIAXone (Rocephin) Sodium Injection Solution Reconstituted 1 GM (gram) (Ceftriaxone Sodium) Inject 1 gram intramuscularly one time a day for (UTI) for 5 Days . with a start date of 2/13/26 and an end date of 2/18/26. Review of a Nurses Note for Resident #41, dated 2/14/26 at 11:07 AM, revealed .Resident on (IM) injection abx (antibiotics) r/t (related to) (UTI) gave in left trochanter (hip) no s/s (signs/symptoms) of adverse reaction to abx . Review of a Nurses Note for Resident #41, dated 2/16/26 at 10:55 AM, revealed .Resident on (IM) injection Rocephin, gave abx injection in right trochanter, no adverse reaction to abx therapy r/t (UTI) . Review of Resident #41's medical record revealed no documentation that Family Member U was notified of Resident #41's confirmed UTI on 2/12/26, or initiation of antibiotic therapy on 2/13/26. In an interview on 3/5/26 at 1:11 PM, Administrator A reported the facility was unable to locate documentation that Family Member U was notified of Resident #41's confirmed UTI and new antibiotic orders on 2/12/26. In an interview on 3/5/26 at 1:14 PM, Licensed Practical Nurse (LPN) RR reported when a resident is not their own responsible party, the resident representative should be notified for any newly identified infection. In an interview on 3/5/26 at 1:19 PM, Registered Nurse (RN) M reported for a cognitively impaired resident, the resident representative should be notified whenever there is a change in condition, with new physician orders, and with any abnormal lab results.

Based on interview and record review the facility failed to ensure the Notice of Transfer and Bed Hold documentation was provided in writing prior to transfer from facility for 1 (Resident #3) of 2 residents reviewed for hospitalization, resulting in the potential for the resident or resident representative to be uninformed of rights related to transfer to hospital and bed hold policy.Findings include: Resident #3Review of an admission Record revealed Resident #3 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: end stage renal disease (the final stage of renal disease where the kidneys can no longer function to sustain life without treatment), dependence on renal dialysis (a medical treatment that removes waste products, excess fluids, and toxins from the blood when the kidneys are unable to perform these functions) and dementia (a syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities).Review of Progress Notes for Resident #3 revealed on 2/7/26 at 18:45 (6:45 PM) and 2/17/26 at 17:34 (5:34 PM) Resident #3 was transferred to (Name Redacted) local emergency department for evaluation of an acute change in condition.Review of Resident #3's medical record on 3/4/26 revealed no noted Notice of Transfer for either transfer to the local emergency department.Review of Resident #3's medical record on 3/4/26 revealed documentation no Bed Hold information was provided to Resident #3 or his resident representative when he was transferred to the local emergency room on 2/17/26.In an interview on 3/4/26 at 2:20 PM, Medical Records/Scheduler (MR/S) C reviewed Resident #3's medical record and reported if she had been given a copy of the Bed Hold and Notice of Transfer forms provided to Resident #3 when he was transferred to the hospital, they would be uploaded into his medical record. MR/S C reviewed Resident #3's electronic record and confirmed there was neither a Notice of Transfer nor a Bed Hold form in Resident #3's record for neither the transfer on 2/7/26 nor 2/17/26.In an interview on 3/4/26 at 2:33 PM, Director of Nursing (DON) B reported she was unable to locate documentation indicating a Notice of Transfer was provided to Resident #3 prior to his transfer to the emergency room on 2/7/26 and 2/17/26, and DON B was unable to locate documentation indicating Bed Hold information was provided to Resident #3 prior to his transfer from the facility on 2/17/26.In an interview on 3/4/26 at 3:19 PM, Nursing Home Administrator (NHA) A reported a Notice of Transfer and Bed Hold should be given to either the resident or the resident representative in writing prior to the resident's transfer from the facility. NHA A reported she was unable to find a Notice of Transfer for Resident #3 dated 2/7/26 or 2/17/26 and she was unable to find a Bed Hold information from 2/17/26.No Notice of Transfer for Resident #3 was provided for 2/7/26 and 2/17/26 prior to survey exit.No Bed Hold for Resident #3 was provided for 2/17/26 prior to survey exit.Review of facility policy Social Service SOP Transfers and Discharges with no date revealed .The copies of the transfer form.are retained in the medical record.provide orientation for transfer or discharge to minimized anxiety and to ensure a safe and orderly transfer or discharge. Provide in a form and manner that the resident can understand.Review of facility policy Bed Hold Policy with no date revealed .a bed hold will be offered to all other residents upon their unplanned discharge and/or leave to assure a bed is available upon the resident's desirable return to the facility.immediately upon discharge for any reason, the bed hold policy and agreement will be provided to the residents and/or their representative and documented in the medical record to whom the form was given.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for medication administration in 1 of 4 residents (Resident #33) reviewed for medication administration, resulting in medications being crushed against pharmacy recommendations and the potential for adverse medication side effects. Findings include:Resident #33Review of an admission Record revealed Resident #33 was a female, with pertinent diagnoses which included heart failure, diabetes, heart disease, cognitive communication deficit (impaired communication due to underlying cognitive issues), anemia (a deficiency of healthy red blood cells or hemoglobin), depression, high blood pressure, kidney failure, and muscle weakness.In an observation and interview on 3/4/26 at 9:03 AM, Licensed Practical Nurse (LPN) I prepared scheduled medications for Resident #33. LPN I reported Resident #33 takes all her medications crushed in pudding due to difficulty swallowing pills. Observed LPN I prepare one Metoprolol Succinate ER (Extended Release) 25 mg (milligrams) tablet, one Imipramine HCl 50 mg tablet, and one Potassium Chloride ER 20 mEq (milliequivalent) tablet for Resident #33, crush the medications, mix the medications in pudding, and administer the medications to Resident #33 while she was seated in the dining area on the memory care unit.Review of an Order Summary Report for Resident #33 revealed the active physician order .Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth one time a day for HTN (high blood pressure) . with a start date of 9/26/25.Review of an Order Summary Report for Resident #33 revealed the active physician order .Imipramine HCl Oral Tablet 50 MG (Imipramine HCl) Give 1 tablet by mouth one time a day for antidepressant related to DEPRESSION . with a start date of 9/26/25.Review of an Order Summary Report for Resident #33 revealed the active physician order .Potassium Chloride Crys (Crystals) ER Oral Tablet Extended Release 20 MEQ (Potassium Chloride Microencapsulated Crystals ER) Give 1 tablet by mouth one time a day for low potassium . with a start date of 10/11/25.Review of an Order Summary Report for Resident #33 revealed the active physician order .OK to crush allowable medications and administer together . dated 12/28/25.In an interview on 3/4/26 at 12:15 PM, Registered Nurse (RN) H reported nurses are to use their professional knowledge and judgement when deciding whether or not medications can be crushed. RN H reported residents have physician orders to crush allowable medications. RN H reported if the medication ordered is not able to be crushed, nurses should either leave those medications to the side and administer them whole or contact the physician to change the order or get a different version of the medication. RN H reported both Metoprolol ER and Potassium Chloride ER should not be crushed for administration. RN H reported there is a powdered (immediate-release) form of Potassium Chloride available if a resident is unable to swallow the extended-release tablet.In an interview on 3/5/26 at 8:31 AM, LPN I reported extended-release medications should not be crushed for administration. LPN I reported Resident #33's medications (including the extended-release medications) are crushed for administration due to difficulty swallowing pills. LPN I reported the physician was previously notified and gave orders to crush all of Resident #33's medications, even those that should not be crushed per pharmacy recommendations.In an interview on 3/5/26 at 8:48 AM, requested information from Unit Manager F regarding Resident #33's medication orders and any documentation that the physician was notified and gave orders/approval to crush Resident #33's medications (including those that should not be crushed per pharmacy recommendations). No documentation provided prior to survey exit that the physician gave orders/approval to crush Resident #33's extended-release medications.In an interview on 3/5/26 at 9:11 AM, Unit Manager F reported he spoke with the physician regarding the crushed extended-release medications for Resident #33, with new orders obtained to discontinue the Metoprolol ER 25 mg tablet and dissolve the Potassium Chloride ER in water prior to administration.In an interview on 3/5/26 at 11:44 AM, Pharmacist T reported the general rule of thumb is that extended-release medications should not be crushed prior to administration. Pharmacist T verified Metoprolol ER should not be crushed, and that there is an alternative form available (Metoprolol Tartrate) that would be able to be crushed. Pharmacist T verified Potassium Chloride ER should not be crushed, and that there is an alternative form available (dissolvable packet). Pharmacist T reported Imipramine HCl 50 mg tablets are also not recommended to be crushed, and that there is an alternative liquid formulation available.Review of the policy/procedure Medication Administration - General Guidelines, dated May 2022, revealed .Tablet Crushing/Capsule Opening: Crushing tablets may require a physician's order, per facility policy. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines .An individualized approach should be used when altering dosage forms by crushing or opening capsules. Working with the resident or representative and appropriate clinicians (e.g., the consultant pharmacist, attending physician, medical director) the facility should determine the most appropriate method for administering medications which considers each resident's safety, needs, medication schedule, preferences, and functional ability .An order to crush medications may be required or preferred in accordance with State regulation (or) facility preference .Orders to crush medications should not be applied to medications which, if crushed, present a risk to the resident. For example: Long-acting or enteric-coated dosage forms should not be crushed; an alternative should be sought .The pharmacist should be contacted to review all medications being considered for crushing, whether a physician's order is present or not. The pharmacist can assist in finding appropriate alternatives to medications that should not be crushed. When identified, the prescriber shall be contacted for an order change .

Based on observation, interview and record review, the facility failed to assess and implement pressure ulcer preventative care, consistent with professional standards of practice, for 1 (Resident #7) of 3 residents reviewed for pressure ulcer prevention and treatment, resulting in the potential for the development of an pressure ulcer and potential for worsening of pressure wounds, and overall deterioration in health status. Findings include:Resident #7Review of an admission Record revealed Resident #7 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care and muscle weakness. Review of Resident #7's Braden Assessment (evidence-based tool used by healthcare professionals to assess a patient's risk of developing pressure injuries) dated 1/7/26 indicated that Resident #7 scored a 12 on the assessment, indicating that he was high risk for developing a pressure injury. Review of Resident #7's Progress Note dated 2/11/26 revealed, Left heel pressure wound, scant serosanguineous (thin, watery, light pink or pale red wound drainage). Applied skin prep (protective barrier that forms a breathable, transparent film on intact skin to reduce friction) and bordered foam dressing per wound nurse orders. Review of Resident #7's Skin and Wound Note dated 2/14/26 revealed, . Reason for visit: New skin and wound consult for resident . wound specialist re-consulted due to nursing concerns for bruising and possible DTI (deep tissue injury) to left heel .Wound assessment: Location: Left Heel Primary Etiology (cause): Pressure: Stage/Severity: DTI. Wound Status: new. Size: 2cm (centimeters) x2cm x0cm . Assessment: Pressure-induced deep tissue damage of left heel .f/u (follow up) in one week. Consider use of offloading boots when in chair and bed as tolerated . Review of Resident #7's Skin and Wound Note dated 2/18/26 revealed, .Wound assessment: Location: Left Heel. Etiology: Pressure. Stage/severity: Stage 2 . Size: 1.7 cmx0.7cmx0cm .Consider use of offloading boots when in chair and bed as tolerated . Review of Resident #7's Orders revealed, Left Heel: Apply BD (betadine antiseptic solution) two times daily for wound management. Start date: 2/25/26. Review of Resident #7's Orders revealed Left heel: Cleanse with wound wash, pat dry, apply a layer of xerofoam (type of dressing) and cover with comfort foam dressing daily and PRN (as needed). Every day shift for Wound Management. Start date: 2/19/25 (Noted missing documentation to indicate if the treatment had been completed on 2/19/26.) Review of Resident #7's Weekly Skin Assessments revealed that the last weekly skin assessment that had been documented for Resident #7 was 2/2/26. Review of Resident #7's Care Plan revealed, I (Resident #7) have impaired skin integrity on my left heel r/t (related to) pressure ulcer. Date initiated: 2/20/26. Inventions: Administer medications as ordered. Observe for side effects and effectiveness, administer my treatments as ordered and monitor for effectiveness, Assess/record/monitor my wound healing. Measure length, width and depth where possible. Assess and document status of my wound healing progress. Report my improvements to my Dr (Doctor), Assist in repositioning me frequently in my bed and chair, enhanced barrier precautions, I need a pressure reducing mattress, I need assistance to turn/reposition as least every 2 hours, more often as needed or requested, I need barrier cream applied to my skin, as needed , I require a pressure reducing device in my chair-including my geri chair (specialized chairs designed for patients with limited mobility), Observe and report any changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size, stage . date initiated: 2/20/26. During an observation on 03/03/2026 11:14 AM, Resident #7 was lying in his bed with his feet directly on his bed without a pillow under his feet to reduce pressure. During an observation on 3/05/2026 at 10:33 AM, Registered Nurse (RN) M entered Resident #7's room to provide wound care. Resident #7 was lying in his bed. RN M removed the blanket covering Resident #7's feet. Noted that Resident #7's feet were lying directly on his bed without a pillow under his feet to reduce pressure. RN M reported Resident #7's wound had recently closed, and that it was important for staff to make sure that they were placing pillows under his feet to reduce pressure. RN M confirmed that Resident #7 was at risk for his left heel wound to deteriorate in healing, especially if there was not pressure reducing measures in place when Resident #7 was in bed. During an interview on 3/05/2026 at 10:28 AM, Interim Director of Nursing (IDON) D reported Resident #7 had developed a pressure ulcer on his left heel that the facility had discovered in February 2026. IDON D reported Resident #7's staff were supposed to prop Resident #7's feet with pillows when he was in bed to reduce pressure. When this writer queried about offloading boots that had been recommended by the facility's wound care provider, IDON D reported she was supposed to look into getting boots for Resident #7, but she had not done that yet. IDON D reported that nurses were supposed to complete weekly skin assessments for each resident. IDON D reviewed Resident #7's Weekly Skin Assessments and confirmed that Resident had not had a Weekly Skin Assessment documented since 2/2/26. Review of the facility's Skin Management Facility Guidelines revealed, The facility is committed to providing care and services to prevent the development of skin breakdown. The following guidelines are in place to reach that goal: .3. Residents admitted with skin impairments will have: appropriate interventions implemented to promote healing .7. Place each resident on weekly head to toe skin assessment on PCC (Medical Records Program) and indicate day and shift on which the check will be conducted .

Based on observation, interview, and record review, the facility failed to ensure adequate care for residents who received enteral nutrition (delivery of nutrients directly into the gastrointestinal tract through a feeding tube) in 1 (Resident #7) of 1 resident reviewed for tube feeding, resulting in the potential for aspiration pneumonia. Findings include: Resident #7 Review of an admission Record revealed Resident #7 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dysphagia following a cerebral infarction (difficulty swallowing after a stroke) and pneumonitis due to inhalation of food and vomit (lung inflammation caused by aspirating food, liquid, or gastric contents into the airways). Review of Resident #7's Orders revealed, Enteral Feed Order: Every shift for nutrition. Jevity (type of enteral feed formula) 1.5 continuous feed at 50ml/hr (milliliters per hour). Review of Resident #7's Care Plan revealed, (Resident #7) is dependent on tube feeding (device used to provide nutrition to someone that cannot eat by mouth) r/t (related to) dysphagia, swallowing problem. Date initiated: 12/31/25. Interventions: I need my HOB (head of bed) elevated to 45 degrees during and thirty minutes after tube feed. Date initiated: 12/31/25 . During an observation on 3/05/2026 at 10:07 AM, Resident #7 was in his room lying in his bed on his back. Resident #7's head of bed was not elevated to 45 degrees. Noted that Resident #7's enteral feeding was running at 50 mL/hr. During a care observation and interview on 3/05/2026 at 10:33 AM, Registered Nurse (RN) M entered Resident #7's room and adjusted the head of Resident #7's bed to 45 degrees. Noted that Resident #7 was coughing prior to RN M adjusting the head of his bed. RN M confirmed that Resident #7's head of bed needed to be elevated to at least 45 degrees when his enteral feed was running to prevent Resident #7 from aspirating. RN M confirmed that Resident #7's head of bed was not elevated to 45 degrees when she entered Resident #7's room. RN M reported that the aides at the facility were not good at ensuring that Resident #7's head of bed was elevated to 45 degrees when they would provide care for Resident #7, and that she was often reminding staff that Resident #7 could not lie flat when his enteral feed was running. Review of the facility's Enteral Nutrition Guidelines policy revealed, Procedure: . 8. The resident should be in semi-Fowlers (patient posture in which the head and upper body are elevated 30 to 45 degrees while lying on the back) position and for 30 minutes to one hour after to prevent aspiration .

Based on observation, interview, and record review the facility failed to maintain oxygen equipment in a sanitary manner and follow physician's oxygen orders for 1 (Resident #87) of 1 resident reviewed for respiratory care resulting in the potential for excessive oxygen levels and/or an infection.Findings include:Review of Resident #87's admission Record, print date 3/5/26, indicated she was readmitted on [DATE] and had a power of attorney (authorized person to make decisions for another individual) for medical care. The admission record included medical diagnoses of chronic respiratory failure, other disorders of lung, and other forms of dyspnea (shortness of breath). Review of Resident #87's physician order for oxygen, dated 2/23/26, stated, Oxygen @ 2L (at 2 Liters per minute) via NC (nasal cannula/oxygen tubing) .During an observation on 03/03/2026 at 11:17 AM, Resident #87 was in her bed receiving supplemental oxygen from the bedside oxygen concentrator at a flow rate of 2 liters per minute. Resident #87's wheelchair was positioned just past the privacy curtain (out of reach of the resident), had a portable oxygen tank on the back with separate oxygen tubing attached, and the tubing including the part that went into the nostrils was coiled up and resting directly on the wheelchair seat pad. During an observation on 03/04/2026 at 9:03 AM, Resident #87 was in her bed receiving supplemental oxygen from the bedside oxygen concentrator at a flow rate of 4 liters per minute. Resident #87's wheelchair was positioned just past the privacy curtain (out of reach of the resident), had a portable oxygen tank on the back with separate oxygen tubing attached, and the tubing including the part that went into the nostrils was coiled up and resting directly on the wheelchair seat pad. During an observation on 03/04/2026 at 9:05 AM, Registered Nurse (RN) H entered Resident #87's room, removed her meal tray, and then exited the room. No adjustment to the oxygen concentrator's flow rate or fixing the tubing on the wheelchair pad was done at that time. During an interview on 03/04/2026 at 11:01 AM, RN H confirmed Resident #87's oxygen order was for a flow rate of 2 liters per minute and reported she had observed her oxygen concentrator incorrectly set to 4 liters per minute at around 9:30 or 10:00 AM that morning. RN H reported the night staff from the shift prior had not made report about issues requiring a higher oxygen flow rate for Resident #87. RN H reported if a resident needed an increased oxygen flow rate, the nurse should call the doctor to discuss it, get a new oxygen order, and then increase the oxygen flow rate to meet resident need. RN H confirmed oxygen tubing should be stored in a bag between uses and it shouldn't be left on the resident's wheelchair seat pad. RN H reported Resident #87 required staff assistance transferring from wheelchair to bed and the staff would have been the one handling the oxygen tubing.During an interview on 03/05/2026 at 9:44 AM, Interim Director of Nursing (IDON) D (who also had infection preventionist certification) confirmed residents' oxygen tubing should be stored in a bag between uses when the tubing wasn't on the resident's face. IDON D reported if a nurse was to increase oxygen from 2 liters per minute to 4 liters per minute they could do so in an emergency, but they should be contacting the doctor and getting an order for the increased oxygen flow rate. IDON D confirmed Resident #87's physician order for oxygen was to be at 2 liters per minute and staff should not have been giving it at 4 liters per minute. IDON D confirmed there wasn't documentation present that addressed Resident #87 having their oxygen increased from 2 liters per minute to 4 liters per minute.During an interview on 03/05/2026 at 11:30 AM, Licensed Practical Nurse (LPN) K reported she had raised Resident #87's oxygen rate from 2 liters per minute to 4 liters per minute on 3/4/26 around approximately 3:50 AM. LPN K reported she thought Resident #87's oxygen order had parameters that would have allowed this and thought possibly she could have looked at the wrong order. Resident #87's oxygen order was reviewed with LPN K, and the order didn't include parameters that addressed increasing the flow rate. LPN K confirmed she did not contact a physician for a new oxygen order for Resident #87 and hadn't made a note addressing the change in oxygen flow rate or reasons for it. Review of Resident #87's respiratory care plan, revised 1/23/26, included an intervention of OXYGEN SETTINGS: O2 (oxygen) via nasal cannula as ordered. Review of Resident #87's O2 Sats (oxygen saturation; an indicator of how well oxygen is being delivered to the body) Summary, had noted the oxygen was running at 4L/Min (4 liters per minute) on 3/4/26 at 3:50 AM by LPN K. Review of the facility's Oxygen Administration policy, undated, stated, A resident will receive oxygen per physician's orders.Turn the unit on to the desired flow rate.

Based on interview, and record review, the facility failed to maintain complete and accurate medical records in 2 of 18 residents (Resident #61 & #7) reviewed for accuracy of medical records, resulting in inaccurate code status information within the electronic health record and missing documentation in the treatment record with the potential for advanced directive/code status preferences to not be honored and deterioration in resident status.Findings include:Resident #61 Review of an admission Record revealed Resident #61 was a female, with pertinent diagnoses which included high blood pressure, paraplegia (impairment or loss of motor and sensory function in the lower half of the body), muscle weakness, depression, anxiety, and chronic kidney disease. Noted Resident #61 was her own responsible party. Review of a Minimum Data Set (MDS) assessment for Resident #61, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, indicating she was cognitively intact. Review of a Medical Treatment Decisions/Advanced Directives form for Resident #61, signed by the resident on [DATE], revealed a check next to .I DO .Wish to have Cardiopulmonary Resuscitation (CPR) . Noted this form was also signed by two witnesses and the physician. Review of an Order Summary Report for Resident #61 revealed the active physician order .Do Not Resuscitate - DNR . dated [DATE]. Note these orders conflict with Resident #61's most recent preferences identified on her Medical Treatment Decisions/Advanced Directives form completed on [DATE]. Review of a current Care Plan for Resident #61 revealed the focus .Advance Directive - Resident and family have elected DNR . with interventions which included .Honor and respect resident and resident's family's wishes regarding code status . initiated [DATE]. Note the information within this Care Plan conflicts with Resident #61's most recent preferences identified on her Medical Treatment Decisions/Advanced Directives form completed on [DATE]. In an interview on [DATE] at 8:51 AM, Social Services Director OO reported advanced directives should be reviewed and updated upon admission, readmission, quarterly, and with any changes. Social Services Director OO reported when there is a change in code status, the physician orders should be updated to reflect the change. In an interview on [DATE] at 12:52 PM, Social Services Director OO reported he spoke with Resident #61 to confirm her wishes regarding her advanced directives/code status, and the orders have been updated to reflect her choice to be FULL CODE (receive CPR). Resident #7 Review of an admission Record revealed Resident #7 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care and muscle weakness. Review of Resident #7's Weekly Skin Assessments revealed that the last weekly skin assessment that had been documented for Resident #7 was [DATE]. Review of Resident #7's February 2026 Treatment Administration Record (TAR) revealed, Left heel: Cleanse with wound wash . everyday shift for wound management. (Noted missing documentation to indicate if the treatment had been completed on [DATE].) Weekly Weight every day shift every Thurs (Thursday). (Noted missing documentation to indicate if the treatment had been completed on [DATE], and [DATE].) Weights: Weekly r/t (related to) weight loss.one time a day every Mon (Monday). (Noted missing documentation to indicate if the treatment had been completed on [DATE].) During an interview on [DATE] at 10:28 AM, Interim Director of Nursing (IDON) D reported nurses were supposed to complete weekly skin assessments for all residents and document their assessment findings under Weekly Skin Assessments in the resident's medical record. IDON D reviewed Resident #7's Weekly Skin Assessments with this writer and confirmed that Resident #7 had not had a documented weekly skin assessment since [DATE]. IDON D reported nurses were expected to document the completion or reason a treatment was missed in the TAR.

Based on interview and record review, the facility failed to ensure they educated, offered and administered COVID-19 vaccines or maintained valid declination in the medical record for 1(Resident #87) of 5 residents reviewed for Covid-19 immunizations resulting in the increased likelihood of severe infection and complications/death related to COVID-19. Findings include:Resident #87 Review of an admission Record revealed Resident #87 was originally admitted to the facility on [DATE] with pertinent diagnoses which included pneumonia (an infection that inflames the air sacs in one or both lungs) and pulmonary hypertension (condition characterized by high blood pressure in the lungs' arteries, causing the right side of the heart to work too hard, leading to weakening and potential failure). Review of Resident #87's Immunization Record revealed, SARS-COV-2 (COVID-19)-Dose 2. Date administered: (there was no date indicated). Status: Pending historical . During an interview on 3/04/2026 at 10:22 AM, Infection Preventionist (IP) D reported that Resident #87's immunization history should have been reviewed when she was admitted to the facility to determine if she was eligible for Covid-19 immunization, and if Resident #87 was eligible, the facility should have offered and administered the vaccine. IP D confirmed that the facility had not assessed Resident #87's vaccinations to determine if Resident #87 was eligible and wanted to receive the second dose of COVID-19 immunization. IP D was unable to report how the facility had missed assessing Resident #87's immunization record since Resident #87's admission.

Based on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.Findings include: In an observation and interview on 12/17/25 at 11:43 AM, within the main kitchen, noted Dietary Services Aide MM standing beside the tray line (with lunch service in progress) with no hair net or hair restraint worn. Dietary Services Aide MM reported the lunch today was fried chicken, mashed potatoes and gravy and carrots, with rice and pork (leftover from 12/16/25) available as alternate menu items. Observed the stated food items were present in trays on the steam table. In an observation and interview on 12/17/25 at 11:53 AM, lunch service was in progress for the main dining room. Noted the leftover pork that had been reheated and placed in a tray on the steam table to serve as an alternative menu item. Dietary Services Aide NN reported she was unaware if the leftover pork was properly cooled the day before (12/16/25) and could not provide information related to a cooling log or confirm that temperatures were checked to ensure the pork was cooled properly. Dietary Services Aide MM reported she was not aware of a cooling log or the need to check temperatures when cooling/saving leftover food items. Observed a large puddle of water below a shelf in the dry storage area of the kitchen, along with a bed blanket covering a puddle of water on the floor outside the utility closet (within the kitchen). Dietary Services Aide MM reported there was a leak coming from the utility closet and maintenance staff were notified. In an interview on 12/17/25 at 12:17 PM, Dietary Services Aide MM reported they are currently out of Magic Cups (a fortified, high-protein frozen dessert) and yogurt. Dietary Services Aide MM reported they are waiting on those items with the next food order. Dietary Services Aide MM reported food deliveries are on Tuesdays and Fridays. During a tour of the kitchen on 12/18/25 with Assistant Manager Dietary Services (AMDS) PP the following observations/interviews were conducted: General Cleanliness of the Kitchen At 2:20 PM in the pantry area, it was noted that there was water on the pantry floor underneath the storage racks. AMDS PP reported the water was leaking from the supply closet and maintenance had been notified. At 2:36 PM in the pantry area, it was noted that the leaking water was also now in the middle of the pantry floor. At 2:57 PM in the River Drive nourishment room refrigerator, noted an opened container of honey thickened water that was placed on its side not securely sealed such that the beverage was leaking out onto the bottom shelf of the refrigerator. AMDS PP reported housekeeping or whoever noticed the spillage should have cleaned it up. Handwashing In an observation and interview on 2/18/25 at 2:38 PM, observed AMDS PP mop up some of the water on the floor in the pantry area with a mop. She then walked over to the handwashing sink next to the freezer and rinsed her hands for approximately 5 seconds. She did not use soap. AMDS PP reported staff should wash their hands with soap and water for 20 seconds. In an observation on 2/18/25 at 3:16 PM, observed AMDS PP touch her face mask with her hand. She then retrieved some clean trays from the clean side of the dish area and stacked the trays with other clean trays in the clean tray area. AMDS PP did not perform hand hygiene after touching her mask before touching the clean trays. Labeling and Dating of Food Product At 2:20 PM in the pantry area, observed the following items that were opened but were not labeled with an opened or discard date: a box of cornstarch, a bottle of vegetable salad oil, and a container of teriyaki sauce. There was a bag of baking powder that was opened but not securely sealed; the opened and discard dates were rubbed off the label and were illegible. AMDS PP reported opened items should be labeled with an opened and discard date. At 2:32 PM in the freezer, there was a container of a brown frozen product that was not labeled with product identification or a prepared or discard date. AMDS PP reported the item should have been labeled with product identification information as well as the prepared and discard dates. AMDS PP discarded the item. At 2:39 PM in the walk-in cooler, observed the following items that were opened but were not labeled with an opened or discard date: a jar of pickle chips, a jar of enchilada sauce, a container of vinaigrette dressing, a container of coleslaw dressing, a container of mayonnaise, and cooked spinach in serving bowls. There was a container of Worcestershire sauce labeled with a use by date of 10/2025. There was a container of soy sauce that was not securely stored with a lid. There was a container of thawed frozen strawberries with an opened date of 12/7/25 and a use by date of 12/12/25. There was a container of applesauce with an opened date of 12/10/25 and a discard date of 12/16/25. AMDS PP reported opened items should be labeled with an opened and discard date. AMDS PP reported items outside of the use by date should have already been discarded. At 2:57 PM in the River Drive nourishment room, observed the following items that were opened but not labeled with an opened or discard date: an opened container of (beverage brand omitted), an opened container of nectar thickened apple juice and an opened container of honey thickened water. There were portioned cups of chocolate pudding and a fruit fluff dessert that were not labeled with prepared or discard dates. There were several peanut butter and jelly sandwiches that were not labeled with prepared or discard dates. At 3:06 PM in the Meadow nourishment room, noted portioned cups of applesauce and fruit fluff' dessert that were not labeled with prepared or discard dates. There were several cheese sandwiches that were not labeled with prepared or discard dates. There was an opened box of nectar thickened fruit punch that was not labeled with an opened or discard date. At 3:10 PM in the View nourishment room, noted several cheese sandwiches that were not labeled with prepared or discard dates. The following items were noted to be opened but were not labeled with opened or discard dates: an opened box of nectar thickened apple juice, a container of nutrition supplement (brand name omitted), and a bottle of apple juice. At 3:15 PM, AMDS PP reported everything should be labeled with an opened and a discard date. Nourishment Room Refrigerator Temperatures Review of the View nourishment refrigerator temperature log revealed recorded temperatures above 41 degrees in the AM on 12/4, 12/5, 12/7, 12/9, 12/10, 12/12, 12/13, 12/14, 12/17, 12/18 and in the PM on 12/3, 12/4, 12/6, 12/8, 12/9, 12/10, 12/11, 12/12, 12/13, 12/16, and 12/17. Review of the River nourishment refrigerator temperature log revealed recorded temperatures above 41 degrees in the AM on 12/6, 12/11, 12/12, 12/14 (with a remedy notation of turned down), 12/16, 12/17, 12/18 and in the PM on 12/1, 12/4, 12/5, 12/6, 12/7, 12/8, 12/9, 12/12. In an interview on 12/18/25 at 3:10 PM, AMDS PP reported if the nourishment room refrigerator temperature is above 41 degrees, staff are supposed to call maintenance to look at it. AMDS PP reported she also needed to know why it was so high (referring to above 41 degrees). In an interview on 12/23/25 at 1:04 PM, Maintenance Director (MD) RR reported maintenance did not have any involvement in maintaining the nourishment room refrigerators. MD RR reported maintenance did not get notified if the temperature of the nourishment room refrigerators are above what they should be or if the refrigerator freezes up. MD RR reported he was pretty sure housekeeping was responsible for the refrigerators. In an interview on 12/23/25 at 1:15 PM, Registered Nurse (RN) UU reported whoever remembers during the day and the night are responsible for recording the temp of the nourishment room fridge. RN UU reported if the temperature is above 41 degrees, maintenance should be called to come and check it out and fix it. In an interview on 12/23/25 at 1:22 PM, Dietary and Housekeeping Manager (DHM) VV reported housekeeping didn't do anything with the nourishment room refrigerators except clean them and defrost them. DHM VV reported housekeeping didn't have anything to do with managing the temperature of the nourishment room refrigerators. DHM VV reported if the temperature of the nourishment room refrigerator is too high, items in the refrigerator should be discarded and then the temperature would need to be reset after it was defrosted. DHM VV reported if items in the nourishment room refrigerator are discarded due to high temperature, the facility did not document that anywhere. On 12/22/25 starting at 9:27 AM, an interview with Assistant Manager of Dietary Services (AMDS) PP found that most food items are dated for a three-day discard date. On 12/22/25 at 9:36 AM, observation of the walk-in cooler found three egg salad sandwiches dated 12/16 to 12/18, two unopened bags of cabbage with best by dates of 12/19/25, a container of cooked macaroni dated 12/16 to 12/19, and an open bag of cubed potatoes dated 12/18-12/21. Further review of the walk-in cooler found a half full flat of shell eggs stored on the top shelf over blueberries and an open bag of green onions (that looked brown and slimy in texture). On 12/22/25 at 9:50 AM, observation of the two-door reach in cooler found two boxes of nutritional shakes, one vanilla with 23 cartons and one chocolate with 20 cartons. A review of the supplements found that they are good for 14 days once thawed. At this time there was no date to indicate how long the vanilla box of shakes had been under refrigeration, however the chocolate box had the date 9-8 written in marker. A review of each box found that the vanilla was delivered on 9/23/25 and the chocolate was delivered on 8/26/25. On 12/22/25 at 10:06 AM, observation of the under-counter freezer found a box of frozen chocolate nutritional shakes with a delivery date of 9/23/25. No other nutritional supplements were observed frozen. The surveyor informed AMDS PP of the expired shakes. On 12/22/25 at 10:24 AM, observation of the River Pantry found a container of, what appeared to be, resident leftovers in a gelato container dated 12/15. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . On 12/22/25 at 9:38 AM, observation of the walk-in cooler floor found a quarter inch to three quarter inch gap running most of the back floor juncture leaving area for pests to enter and cold air to escape. Further review of the walk-in cooler found accumulation of dirt and debris on bottom wire storage racks and the floor of the unit. Food items such as onions and creamers were found among the debris. Upon leaving the walk-in cooler the handle latch was observed loose and not allowing for a tight seal of the door when held closed. As the surveyor ran their hand along the perimeter of the door, cool air was able to be felt. On 12/22/25 at 9:47 AM, observation of a storage rack at the end of the cooking line found stacked pots and pans. An interview with AMDS PP found that this is where clean pots and pans are stored. Further review of five sheet pans found them with encrusted grease deposits in the seams and corners. On 12/22/25 at 9:53 AM, observation of the kitchen wall, shared with the dining room, found three wall mounted A/C inverter units used to help maintain temperature in the kitchen. Using a flashlight, the inside of these three units were found to have heavy accumulation of black spotted debris. The three units were placed pointing at or near food preparation and serving areas when in operation. According to the 2022 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. According to the 2022 FDA Food Code section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair. According to the 2022 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 12/22/25 at 9:58 AM, observation of the dish machine found that the pressure gauge was showing pressure exceeding the manufacture requirement of 15-25 pressure per square inch (psi), listed on the data plate. Unsure of the integrity of the gauge, and interview with Dietary Service Aide (DSA) TT, found that staff mainly look at the temperature gauges on the dish machine and not the pressure gauge in the back top of the machine. When asked if the kitchen had a dish machine thermometer, thermo-tape, or another way to ensure proper working temperatures of the dish machine, DSA TT was not aware of anything they use to test the dish machine to ensure accurate temperatures. According to the 2022 FDA Food Code section 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing. (B) In hot water mechanical WAREWASHING operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the UTENSIL surface temperature. According to the 2022 FDA Food Code section 4-501.113 Mechanical Warewashing Equipment, Sanitization Pressure. The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the [NAME] ne manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch). On 12/22/25 at 10:02 AM, observation of the freezer found food stored open and exposed. Boxes of carrots, cookie dough, and spinach were found open to air with no observed covering, wrapping, or sealing of the containers between uses. According to the 2022 FDA Food Code section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by:. (4) Except as specified under Subparagraph 3-501.15(B)(2) and in ¶ (B) of this section, storing the FOOD in packages, covered containers, or wrappings. On 12/22/25 at 10:12 AM, observation of the dry storage shelf found an open container of Teriyaki marinade, 1/3 gone, and a date of 12/15/25 as opened. Further review of the item found that it requires refrigeration after opening. The surveyor informed AMDS PP and the item was placed to the side. According to the 2022 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, and except as specified under ¶ (B) and in ¶ (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above, except that roasts cooked to a temperature and for a time specified in ¶ 3-401.11(B) or reheated as specified in ¶ 3-403.11(E) may be held at a temperature of 54C (130F) or above; or (2) At 5C (41F) or less. On 12/22/25 at 9:25 AM, An interview with AMDS PP found that the kitchen was having some plumbing issues the last few days and that they are in the middle of a repair, but currently the water is shut off to the mop sink and one of the two hand sinks in the kitchen. The surveyor was able to observe the hand sink near the cook line and preparation area was currently out of order and not working. Only one hand sink was available for use, near the back dish area. No other alternative means for easily accessible hand washing was set up. On 12/22/25 at 11:32 AM, observation of the only hand sink available for use by kitchen staff found it blocked by wheeled carts. The surveyor moved three carts out of the way to reach the hand sink. On 12/22/25 at 11:59 AM, observation of DSA SS found the staff member wearing artificial nails with no gloves. During tray line DSA SS was observed getting ice, opening cans of pop, and placing drinks for trays as they pass. On 12/22/25 at 12:19 PM, observation of AMDS PP found that she stepped off the serving line, took her gloves off, went to the cook line to help fill items back up on the serving line, put gloves back on, and was not observed washing her hands in between glove changes. On 12/22/25 at 12:30 PM, observation of DSA MM, who was loading trays with desserts onto the steam table so that they could be plated, was observed checking her phone in the kitchen, leaving to go into the dining room, coming back into the kitchen and continuing to load and pass trays without washing her hands. On 12/22/25 at 12:41 PM, DSA MM, was observed running tasks off the line for staff in the dining room and answering her cell phone while on the tray line. No hand washing was observed after these changes in tasks. According to the 2022 FDA Food Code section 2-301.14 When to Wash.FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room;.after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco products, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. According to the 2022 FDA Food Code section 2-302.11 Maintenance of Fingernails (A) FOOD EMPLOYEES shall keep their fingernails trimmed, filed, and maintained so the edges and surfaces are cleanable and not rough. (B) Unless wearing intact gloves in good repair, a FOOD EMPLOYEE may not wear fingernail polish or artificial fingernails when working with exposed FOOD. According to the 2022 FDA Food Code section 5-205.11 Using a Handwashing Sink. (A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use.(B) A HANDWASHING SINK may not be used for purposes other than handwashing. (C) An automatic handwashing facility shall be used in accordance with manufacturer's instructions.

This citation pertains to intake 2689916.Based on interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and failed to implement effective corrective interventions for known issues involving staffing and meal service, with the potential to impact all residents who reside at the facility, resulting in insufficient staff to meet resident needs and poor food quality.Findings include:Refer to noncompliance cited at F677, F725, and F804.In an interview on 12/16/25 at 12:09 PM, Resident #103 stated in regard to staffing .we have no help in here at all. The aides are great, but they are overworked . Resident #103 reported she experienced long call light wait times, especially on third shift. Resident #103 reported staff will often respond to the call light and turn the light off, saying they will be back later, but .they don't come back . Resident #103 reported call light wait times as long as an hour. Resident #103 reported some days she was unable to get up in her power chair because there were not enough staff to assist with the transfer/care. Resident #103 reported there often is not enough staff to get her shower on Tuesday afternoon. Resident #103 reported Administration is aware of the staffing concerns and stated .nothing is being done . Resident #103 reported the portion sizes at the facility are too small and described them as .toddler portions . Resident #103 reported the food is often unrecognizable and described a green soup that was served the night before. Resident #103 reported she refused to eat the soup, and instead requested a peanut butter and jelly sandwich, but was told the kitchen was out of bread. Resident #103 reported the kitchen ended up making her the sandwich using a hamburger bun. Resident #103 reported she was served waffles recently with no syrup .because they didn't have any . Resident #103 reported the food served is often inconsistent with the menu posted in the main dining room. Resident #103 reported that she has discussed her concerns with management staff, and nothing has improved.In an interview on 12/17/25 at 10:03 AM, Ombudsman FF reported she had received many complaints from residents and family members regarding the quality of the food served at the facility and small portion sizes. Ombudsman FF reported concerns with staffing and call light response. Ombudsman FF reported issues locating staff when onsite and stated .I've had staff members call and say staffing is an issue . Ombudsman FF reported she has expressed her concerns to the management/administrative staff, and nothing has changed.In an interview on 12/17/25 at 3:52 PM, Licensed Practical Nurse (LPN) E reported concerns with staffing and scheduling at the facility. LPN E reported holes in the schedule often go unfilled. LPN E reported there were times on night shift where there were only two nurses for the entire building. LPN E reported staff were directed not to contact Director of Nursing (DON) B for staffing concerns. LPN E reported on night shift there were times with one nurse covering both the View Unit and the Memory Care Unit, assigned to more than 50 residents. LPN E reported the Memory Care Unit has many residents at risk for falls and often residents with different sleep schedules and stated .It's pretty scary . LPN E reported showers are not completed on a regular basis and stated on the View Unit .Any time we had only two CNAs showers were never done. It is too much . LPN E reported Administrator A and DON B do not put forth an effort to fill open positions on the schedule and expect staff to work short. LPN E stated .They only fill (a hole in the schedule) if they absolutely have to .In an interview on 12/18/25 at 9:13 AM, Registered Nurse (RN) V reported concerns with the food at the facility and stated .It's only gotten worse . since the change in facility ownership. RN V reported residents often do not receive ordered diets, supplements are not provided, the food is cold, the portion sizes are small, and the food is sometimes not edible. RN V reported Administrator A is aware of the food concerns, however, there has been no improvement. RN V stated .There will be no magic cups (for days), so supplements are not provided .In an interview on 12/23/25 at 1:26 PM, Administrator A and DON B reported they were aware of concerns regarding missed showers and were in the process of addressing the issue. Administrator A reported he was aware of the expressed food concerns and reported he fills out concern forms and takes the concerns directly to Dietary Manager VV and her supervisor. Administrator A reported the kitchen (dietary services) was outsourced (contracted with a separate company) on 11/1/25. Administrator A and DON B reported they were aware of the staffing concerns and in the process of addressing the issue. Administrator A reported they are monitoring staffing levels to ensure that they are meeting the required state minimums. Administrator A and DON B reported the lowest staffing they would deem acceptable for day shift would be two CNAs on each unit. DON B reported they did a review of their staffing and acuity and determined the River Unit should have three CNAs, as it has a higher acuity of residents. Inquired about the staffing levels for the River Unit yesterday (12/22/25) on day shift, as there was only one CNA on the unit for a period of time, and DON B reported she was notified of that situation today (12/23/25).

This citation pertains to Intake # 2670974, 2689916, & 2646054.Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable, homelike environment in 3 of 5 residents (Resident #102, #103, & #108) reviewed for a safe/clean environment, resulting in refusal of care due to uncomfortable water temperatures and dissatisfaction with the living conditions.Findings include:Resident #102 Review of an admission Record revealed Resident #102 was a male, with pertinent diagnoses which included Parkinson's disease (a progressive brain disorder affecting movement), major depression, legal blindness, need for assistance with personal care, dementia, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 11/7/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, indicating he was cognitively intact. In an interview on 12/16/25 at 12:50 PM, Resident #102 reported he does not receive his showers as scheduled, partly due to issues with the facility not having enough hot water. Resident #102 reported the issue with the hot water has been going on for .months . Resident #102 reported he is supposed to get a shower twice a week, on Mondays and Fridays. Resident #102 reported he missed one last Friday (12/12/25) because there was no hot water. Resident #102 reported he did receive a shower yesterday, but the water started to get cold about halfway through the shower. Resident #103 Review of an admission Record revealed Resident #103 was a female, with pertinent diagnoses which included cerebral palsy (a neurological disorder affecting movement, posture, and coordination), major depression, muscle weakness, and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 12/3/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, indicating she was cognitively intact. In an observation and interview on 12/16/25 at 12:09 PM, Resident #103 was in bed in her room. Noted significant peeling paint on the wall near her headboard, with a pile of chipped/flaked paint on the floor along the wall behind her bed. Resident #103 reported the facility often does not have hot water in the shower room, or the hot water will run out partway through the shower. In an observation on 12/22/25 at 11:20 AM, Resident #103 was noted in bed in her room. Observed significant amounts of peeling paint on the wall behind Resident #103's headboard, with a visible pile of paint chips and debris on the floor along the wall behind Resident #103's bed. Resident #108 Review of an admission Record revealed Resident #108 was a male, with pertinent diagnoses which included diabetes (a chronic condition where blood sugar levels are too high), high blood pressure, and debility (physical weakness). Review of an admission Note for Resident #108, dated 10/16/25 at 7:59 PM, revealed .patient arrived to facility .assisted from car to wheelchair and into room .alert and oriented x 3 . In an interview on 12/16/25 at 3:28 PM, Resident #108 reported concerns with the physical environment while at the facility. Resident #108 reported significant amounts of chipped paint on the walls of his room. Resident #108 reported his room was dirty, and there was a dirty pillow on the floor under his bed when he first admitted . In an observation on 12/17/25 at 1:54 PM, noted the door was open to the Meadow Lane Spa room. Observed the left side of the door frame (near the base) was rusted out with visible pieces of rust and debris on the floor. Observed chipped tile along the wall. Noted a foul odor coming from the spa room and observed a three-compartment hopper which contained bags of trash. In an observation on 12/23/25 at 8:18 AM, noted a flagpole in the front parking area near the main entrance to the facility. Noted the American flag was in poor condition, visibly faded with multiple rips/tears in the fabric of the flag. Observed several discarded rubber gloves laying on the driveway. On 12/22/25 at 10:28 AM, an interview with LPN X found that the 100-hall shower room has shown some hot water issues within the last couple months. On 12/22/25, at 10:53 AM, an interview with Maintenance Director (MD) RR found that there should be enough hot water to maintain shower temperatures. When asked why the complaints regarding hot water are being heard, MD RR stated that he has trained staff that they need to let the water warm up for one minute.

This citation pertains to Intake # 2670974 & 2689916.Based on interview, and record review, the facility failed to ensure showers/baths were provided per resident preference and plan of care in in 4 of 7 residents (Resident #101, #102, #103, & #113) reviewed for showers/bathing, resulting in dissatisfaction with the care provided and the potential for discomfort and feelings of impaired self-worth.Findings include:Personal hygiene affects patients' comfort, safety, and well-being. Hygiene care includes cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities such as taking a bath or shower and brushing and flossing the teeth also promote comfort and relaxation, foster a positive self-image, promote healthy skin, and help prevent infection and disease. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 50742-50744). Elsevier Health Sciences. Kindle Edition.Resident #101Review of an admission Record revealed Resident #101 was a male, with pertinent diagnoses which included stroke, aphasia (a language disorder that impairs speaking, understanding, reading, and writing), need for assistance with personal care, and muscle weakness.Review of a Minimum Data Set (MDS) assessment for Resident #101, dated 9/20/25, revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, indicating he had moderate cognitive impairment.Review of a current Care Plan for Resident #101 revealed the focus .The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Right sided hemiplegia (paralysis affecting one side of the body) d/t (due to) CVA (stroke), Right foot drop, Seizures, Impaired Mobility, Right hand contracture . revised 12/19/23, with interventions which included .BATHING/SHOWERING: assist x1 . revised 12/2/25.In an interview on 12/22/25 at 3:27 PM, Resident #101 reported he did not receive his showers as scheduled. Resident #101 reported he did not get two showers per week, which was his preference.Review of a Concern Form for Resident #101, dated 11/12/25, revealed .Resident is not getting his showers in a timely manner. Resident wants his showers on his preferred shower days . Noted the form indicated that the problem was .ongoing . Under the section Facility Response, noted Resident #101 was interviewed about his shower preferences, had his shower schedule updated, and was offered a shower on 11/14/25.Review of an Order Summary Report for Resident #101 revealed the active physician order .SHOWER DAYS: Document in Progress note completed shower/bed bath/refusal and complete weekly skin assessment in (electronic medical record) .every evening shift every Wed (Wednesday), Sat (Saturday) for Shower . with a start date of 4/5/25.Review of the unit Bath Schedule revealed Resident #101 was scheduled to receive baths/showers on Wednesdays and Saturdays, on second shift.Reviewed provided shower documentation for Resident #101 from 11/15/25 to 12/22/25. Noted missed showers (no documentation) on Wednesday 11/26/25, Saturday 12/13/25, and Wednesday 12/17/25.Resident #102Review of an admission Record revealed Resident #102 was a male, with pertinent diagnoses which included Parkinson's disease, major depression, legal blindness, need for assistance with personal care, dementia, and anxiety.Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 11/7/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, indicating he was cognitively intact.Review of a current Care Plan for Resident #102 revealed the focus .The resident has an ADL (Activities of Daily Living) self-care performance deficit . revised 11/14/25, with interventions which included .BATHING/SHOWERING: Usual performance supervision/touching assistance . revised 12/2/25.In an interview on 12/16/25 at 12:50 PM, Resident #102 reported he does not receive his showers as scheduled, partly due to issues with the facility not having enough hot water. Resident #102 reported the issue with the hot water has been going on for .months . Resident #102 reported he is supposed to get a shower twice a week, on Mondays and Fridays. Resident #102 reported he missed one last Friday (12/12/25) because there was no hot water. Resident #102 reported he did receive a shower yesterday, but the water started to get cold about halfway through the shower. Resident #102 reported he is very particular about his hygiene and doesn't want anyone to think he smells bad. Resident #102 reported the combination of short-staffing, and the lack of hot water has made getting showers as scheduled .difficult .In an interview on 12/17/25 at 10:44 AM, Family Member DD reported Resident #102 does not receive his showers as scheduled. Family Member DD reported they often pick Resident #102 up on Sundays and stated .It's nothing for him to smell nasty and greasy like he hasn't been bathed in days . Family Member DD described an instance where the family gave Resident #102 a shower at home because of the issues with his hygiene.Review of an Order Summary Report for Resident #102 revealed the active physician order .SHOWER DAYS: Document in Progress note completed shower/bed bath/refusal and complete weekly skin assessment in (electronic medical record) .every evening shift every Mon (Monday), Fri (Friday) for Shower . with a start date of 4/4/25.Reviewed of the unit Bath Schedule revealed Resident #102 was scheduled to receive baths/showers on Mondays and Fridays, on second shift.Review of a Shower Sheet for Resident #102, dated Friday 12/12/25, revealed a shower was not provided with the explanation .Water was not hot/warm. Only wanted to be shaved .Reviewed provided shower documentation for Resident #102 from 11/15/25 to 12/22/25. Noted a missed shower (no documentation) on Friday 12/5/25. Also, noted Resident #102 did not receive his scheduled shower on Friday 12/12/25 due to a lack of hot water.Resident #103Review of an admission Record revealed Resident #103 was a female, with pertinent diagnoses which included cerebral palsy (a neurological disorder affecting movement, posture, and coordination), major depression, muscle weakness, and need for assistance with personal care.Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 12/3/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, indicating she was cognitively intact.Review of a current Care Plan for Resident #103 revealed the focus .The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) inability to bear weight on lower extremities, Cerebral palsy, incontinence, and debility . revised 9/2/25, with interventions which included .BATHING/SHOWERING: Usual performance Dependent . revised 12/2/25.In an interview on 12/16/25 at 12:09 PM, Resident #103 reported the facility often does not have hot water in the shower room, or the hot water will run out partway through the shower. Resident #103 reported issues with receiving scheduled showers. Resident #103 stated .If there is no hot water, you don't want to get in there (the shower) anyway . Resident #103 reported she had a shower the previous Saturday (12/13/25) and stated .The water was lukewarm and getting colder . Resident #103 reported her showers are scheduled on Tuesdays and Saturdays, on second shift. Resident #103 reported there often is not enough staff to get her shower on Tuesday afternoon.Review of an Order Summary Report for Resident #103 revealed the active physician order .SHOWER DAYS: Document in Progress note completed shower/bed bath/refusal and complete weekly skin assessment in (electronic medical record) .every evening shift every Tue (Tuesday), Sat (Saturday) for Shower . with a start date of 4/5/25.Reviewed of the unit Bath Schedule revealed Resident #103 was scheduled to receive baths/showers on Tuesdays and Saturdays, on second shift.Reviewed provided shower documentation for Resident #103 from 11/15/25 to 12/22/25. Noted missed showers (no documentation) on Saturday 11/29/25 and Tuesday 12/16/25.In an interview on 12/17/25 at 10:59 AM, Resident #103 reported she did not get her scheduled shower yesterday (Tuesday afternoon) because there were only two aides on the hall. Resident #103 stated .Now I have to wait until Saturday. They won't do it today. (If) you miss your shower day you have to wait for the next one .Resident #113Review of an admission Record revealed Resident #113 was a male, with pertinent diagnoses which included Huntington's disease (a brain disorder causing nerve cells to break down, leading to uncontrolled movements, cognitive decline, and psychiatric issues), dysphagia (difficulty swallowing), anxiety, depression, high blood pressure, muscle weakness, difficulty walking, and need for assistance with personal care.Review of a Minimum Data Set (MDS) assessment for Resident #113, with a reference date of 11/25/25, revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, indicating he had moderate cognitive impairment.Review of a current Care Plan for Resident #113 revealed the focus .(Resident #113) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Huntington's, weakness, unstable gait . revised 8/28/25, with interventions which included .BATHING/SHOWERING: The resident requires max assistance by 1 staff with bathing/showering . revised 12/2/25.In an interview on 12/17/25 at 4:07 PM, Family Member KK reported concerns with missed showers for Resident #113.Reviewed of the unit Bath Schedule revealed Resident #113 was scheduled to receive baths/showers on Tuesdays and Saturdays, on first shift.Reviewed provided shower documentation for Resident #113 from 11/15/25 to 12/22/25. Noted missed showers (no documentation) on Saturday 11/22/25, Saturday 11/29/25, Tuesday 12/2/25, and Saturday 12/13/25.In an interview on 12/22/25 at 11:35 AM, Unit Manager Q reported each unit has a schedule for resident showers. Unit Manager Q reported staff follow the shower schedule, and make changes as needed based on preference. Unit Manager Q reported for each shower, CNAs complete a shower sheet. Unit Manager Q reported the primary method of shower documentation was shower sheets. Unit Manager Q stated .We were doing an order in the computer for the nurses to sign off. We are slowly going away from that . Unit Manager Q reported shower/bath refusals would still be documented on a shower sheet, and the nurse would be notified.

This citation pertains to Intake # 2670974, 2689916, 2646054, 2639254, & 2693899.Based on interview, and record review, the facility failed to ensure sufficient staffing to meet resident needs in 4 of 6 residents (Resident #102, #103, #108, & #109) reviewed for sufficient staffing and timely response to resident needs, resulting in long call light wait times, missed showers, and the potential for unmet needs.Findings include:Resident #102Review of an admission Record revealed Resident #102 was a male, with pertinent diagnoses which included Parkinson's disease, major depression, legal blindness, need for assistance with personal care, dementia, and anxiety.Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 11/7/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, indicating he was cognitively intact.In an interview on 12/16/25 at 12:50 PM, Resident #102 reported he does not receive his showers as scheduled, partly due to issues with the facility not having enough hot water. Resident #102 reported he is supposed to get a shower twice a week, on Mondays and Fridays. Resident #102 reported he is very particular about his hygiene and doesn't want anyone to think he smells bad. Resident #102 reported the combination of short-staffing, and the lack of hot water has made getting showers as scheduled .difficult .Reviewed provided shower documentation for Resident #102 from 11/15/25 to 12/22/25. Noted a missed shower (no documentation) on Friday 12/5/25. Also, noted Resident #102 did not receive his scheduled shower on Friday 12/12/25 due to a lack of hot water.Resident #103Review of an admission Record revealed Resident #103 was a female, with pertinent diagnoses which included cerebral palsy (a neurological disorder affecting movement, posture, and coordination), major depression, muscle weakness, and need for assistance with personal care.Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 12/3/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, indicating she was cognitively intact.In an interview on 12/16/25 at 12:09 PM, Resident #103 stated in regard to staffing .we have no help in here at all. The aides are great, but they are overworked . Resident #103 reported she experienced long call light wait times, especially on third shift. Resident #103 reported staff will often respond to the call light and turn the light off, saying they will be back later, but .they don't come back . Resident #103 reported call light wait times as long as an hour. Resident #103 reported some days she was unable to get up in her power chair because there were not enough staff to assist with the transfer/care. Resident #103 reported there often is not enough staff to get her shower on Tuesday afternoon. Resident #103 reported Administration is aware of the staffing concerns, and stated .nothing is being done .In an interview on 12/17/25 at 10:59 AM, Resident #103 reported she did not get her scheduled shower yesterday (Tuesday afternoon) because there were only two aides on the hall. Resident #103 stated .Now I have to wait until Saturday. They won't do it today. (If) you miss your shower day you have to wait for the next one .Reviewed provided shower documentation for Resident #103 from 11/15/25 to 12/22/25. Noted missed showers (no documentation) on Saturday 11/29/25 and Tuesday 12/16/25.Resident #108Review of an admission Record revealed Resident #108 was a male, with pertinent diagnoses which included diabetes, high blood pressure, and debility (physical weakness).Review of an admission Note for Resident #108, dated 10/16/25 at 7:59 PM, revealed .patient arrived to facility .assisted from car to wheelchair and into room .alert and oriented x 3 .In an interview on 12/16/25 at 3:28 PM, Resident #108 reported concerns with staffing at the facility. Resident #108 reported concerns with long call light wait times, up to 45 minutes.Resident #109Review of an admission Record revealed Resident #109 was a female, with pertinent diagnoses which included depression, obesity, high blood pressure, obstructive lung disease, and heart failure.Review of a Minimum Data Set (MDS) assessment for Resident #109, with a reference date of 10/3/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, indicating she was cognitively intact.In an interview on 12/16/25 at 2:18 PM, Family Member II reported the facility was short-staffed and stated .They put (Resident #109) in a diaper and told her to go in that . Family Member II reported staff told Resident #109 they were short-handed, and that they would get to her when they could. Family Member II reported Resident #109 often experienced long call light wait times, up to 45 minutes.In an interview on 12/17/25 at 1:46 PM, Registered Nurse (RN) C reported when she arrived for her shift this morning, it was just her and two Certified Nursing Assistants (CNAs) on the hall for the View Unit. RN C reported one of the CNAs was on light duty and could only assist with waters and vital signs. RN C reported the Unit Manager came in around 8:45 AM to cover as a floor nurse. RN C reported there should be a minimum of two nurses and two CNAs on the View Unit for day shift. RN C reported an additional CNA was assigned to the hall later in the day but reported overall the facility did not have enough staff. RN C reported the hall was scheduled with only one nurse on day shift (indicating there was an unfilled hole in the schedule that was not filled prior to the start of the shift). RN C reported it was a difficult morning, as there were many two person transfers and residents who needed to get up for dialysis. RN C reported when short-staffed, they do the best they can to meet resident needs, but showers are .the first thing to go . RN C reported staffing has been an ongoing issue at the facility.In an interview on 12/17/25 at 2:14 PM, Licensed Practical Nurse (LPN) D reported they are short-staffed on the River Unit today and indicated there were only two CNAs on the hall when there should be three CNAs. LPN D reported they are not able to complete scheduled showers when there are only two CNAs.In an interview on 12/17/25 at 3:52 PM, Licensed Practical Nurse (LPN) E reported concerns with staffing and scheduling at the facility. LPN E reported holes in the schedule often go unfilled. LPN E reported there were times on night shift where there were only two nurses for the entire building. LPN E reported staff were directed not to contact Director of Nursing (DON) B for staffing concerns. LPN E reported on night shift there were times with one nurse covering both the View Unit and the Memory Care Unit, assigned to more than 50 residents. LPN E reported the Memory Care Unit has many residents at risk for falls and often residents with different sleep schedules and stated .It's pretty scary . LPN E reported showers are not completed on a regular basis and stated on the View Unit .Any time we had only two CNAs showers were never done. It is too much .In an interview on 12/18/25 at 9:13 AM, Registered Nurse (RN) V reported staffing concerns at the facility and stated .It's been a huge problem . RN V reported the facility is often short Certified Nursing Assistants (CNAs) and has less CNAs on each unit than they should. RN V reported when there are call ins or holes in the schedule, management doesn't even attempt to fill the open positions or call staff in to assist. RN V reported Administrator A and Director of Nursing (DON) B rarely come out of their offices to assist staff during the day. RN V reported due to short staffing, showers are not completed as scheduled and residents are not being changed timely when incontinent.In an interview on 12/18/25 at 10:48 AM, LPN K reported there were currently two nurses and two CNAs on the View Unit for day shift. LPN K reported this level of staffing was insufficient to provide quality resident care. LPN K reported the View Unit needs three CNAs on day shift to complete resident care timely.In an interview on 12/18/25 at 10:57 AM, LPN D reported they are short-staffed on the River Unit again today and indicated there were only two CNAs on the hall when there should be three CNAs. LPN D reported this level of staffing is insufficient to provide timely resident care.In an interview on 12/18/25 at 3:03 PM, CNA O reported there were two CNAs on the View Unit today, which was insufficient to provide timely care for the residents. CNA O reported when there were two CNAs on the View Unit, showers were missed and residents were often frustrated with their care. CNA O reported there are often holes in the schedule that go unfilled.In an interview on 12/22/25 at 11:09 AM, CNA N reported there were only two aides on the River Unit today which was insufficient to provide timely resident care. CNA N reported at the beginning of the shift, between 6:00 AM and 8:00 AM, she was the only CNA on the unit until the second CNA came in at 8:00 AM. CNA N reported there should be three CNAs on the River Unit to provide timely, quality care to the residents. CNA N reported the CNA that came in at 8:00 AM wasn't even on the schedule and only came in because she (CNA N) asked her to come in and help because they were short-staffed. CNA N reported management makes minimal attempts to fill holes and open positions on the schedule, and she (CNA N) often has to make calls herself to fill open positions when short-staffed.In an interview on 12/23/25 at 12:56 PM, Scheduler WW described the staffing expectations for each shift. Scheduler WW reported typical staffing on day shift for the River Unit would include two nurses (12-hour shifts) and three CNAs for both first and second shift. Scheduler WW reported typical staffing on day shift for the View Unit would include two nurses (12-hour shifts) and three CNAs for both first and second shift. Scheduler WW reported when there are call ins, they try to fill the open spots before working below the stated staffing levels. Scheduler WW reported if the call-in is off hours, there is a call list at each nursing station with phone numbers that staff can use to try and fill the open position. Scheduler WW reported once she and the Unit Manager are notified of a call in, they can send a mass text requesting assistance filling the open spot on the schedule. Scheduler WW reported both the River Unit, and the View Unit can work with two CNAs on first and second shift if necessary, but it is the expectation that management help on the floor with waters and meal pass. Scheduler WW reported she does experience some difficulty filling holes/open positions when developing the schedule. Scheduler WW reported if a hole is not filled, the Unit Manager should be working on the floor. Scheduler WW stated in regard to the schedule on 12/22/25 and there being only one CNA on the River Unit between 6:00 AM to 8:00 AM .The Unit Manager should have been here . to cover that time frame.Review of the Facility Assessment, dated 8/1/25, revealed an average daily census of 78 residents. Further review of the Facility Assessment revealed .Individual staff assignments are determined in order to promote continuity of care for residents within and across the assignments in the following ways: Staffing plans are based off resident volume. Special consideration is taken when residents with special needs or care requirements are present on admission or develop during stay at facility. Our staffing mix is flexible to accommodate increased acuity based on IDT (Interdisciplinary Team) assessment . Noted the section Staffing Needs as per Shift indicated a need for 1 RN (Registered Nurse), 1 LPN (Licensed Practical Nurse), and 6 CNAs (Certified Nursing Assistants) on night shift, 1 RN, 4 LPN, and 8 CNAs on day shift, and 1 RN, 2 LPN, and 8 CNAs on evening shift.In an interview on 12/23/25 at 1:26 PM, Administrator A and DON B reported they were aware of the staffing concerns and in the process of addressing the issue. Administrator A reported they are monitoring staffing levels to ensure that they are meeting the required state minimums. Administrator A and DON B reported the lowest staffing they would deem acceptable for day shift would be two CNAs on each unit. DON B reported they did a review of their staffing and acuity and determined the River Unit should have three CNAs, as it has a higher acuity of residents. Inquired about the staffing levels for the River Unit yesterday (12/22/25) on day shift, as there was only one CNA on the unit for a period of time, and DON B reported she was notified of that situation today (12/23/25).In an interview on 12/17/25 at 10:03 AM, Ombudsman FF reported concerns with staffing and call light response. Ombudsman FF reported issues locating staff when onsite and stated .I've had staff members call and say staffing is an issue .Review of the policy/procedure Staffing and Posting, revised 1/2025, revealed .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment .Review of the policy/procedure Call Light, dated 7/2018, revealed .Call lights should be answered by available staff as promptly as possible . When answering the call light, the staff member should inquire as to the need, and if possible, meet that need as soon as practicable .

This citation pertains to Intake # 2689916.Based on observation, interview, and record review, the facility failed to follow the menu and serve food items from the menu as scheduled, post the current menu for residents to review, and update the menu with changes when they occurred, in 1 of 8 residents (Resident #103) reviewed for food, with the potential to affect all residents who receive meals from the kitchen, resulting in frustration with the food service process and the potential for decreased intake.Findings include:Resident #103 Review of an admission Record revealed Resident #103 was a female, with pertinent diagnoses which included cerebral palsy (a neurological disorder affecting movement, posture, and coordination), major depression, muscle weakness, and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 12/3/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, indicating she was cognitively intact. In an interview on 12/16/25 at 12:09 PM, Resident #103 reported the food served is often inconsistent with the menu posted in the main dining room. Resident #103 reported she often doesn't know what will be served until the meal tray arrives. In an observation on 12/16/25 at 1:26 PM, noted two pages of menus (double-sided copies) posted on the wall of the main dining room. The menu visible on the outside was for Week 4. Note the pages were stapled together and would require a person to flip through the remaining pages to view the menus for Week 1 through Week 3. No dates on menu to indicate if Week 4 was the current week for the menu cycle. In an observation on 12/17/25 at 11:34 AM, noted two pages of menus (double-sided copies) posted on the wall of the main dining room. The menu visible on the outside was for Week 4. Note the pages were stapled together and would require a person to flip through the remaining pages to view the menus for Week 1 through Week 3. No dates on menu to indicate if Week 4 was the current week for the menu cycle. In an observation and interview on 12/17/25 at 11:43 AM, within the main kitchen, Dietary Services Aide MM reported the lunch today was fried chicken, mashed potatoes and gravy and carrots, with rice and pork (leftover from 12/16/25) available as alternate menu items. Observed the stated food items were present in trays on the steam table. In an interview on 12/17/25 at 11:49 AM, Dietary Services Aide MM reported they were currently on the Week 1 menu cycle. The scheduled Week 1 meal for Wednesday (12/17/25) included pork as the main entree. Dietary Services Aide MM reported they served pork yesterday (12/16/25) because they didn't have the chicken that was scheduled for Tuesday (12/16/25). Noted the chicken scheduled to be served on 12/16/25 was supposed to be teriyaki chicken. Dietary Services Aide MM reported they served fried chicken today (12/17/25) because they didn't have any teriyaki sauce. In an observation on 12/18/25 at 10:50 AM, noted two pages of menus (double-sided copies) posted on the wall of the main dining room. The menu visible on the outside was for Week 4. Note the pages were stapled together and would require a person to flip through the remaining pages to view the menus for Week 1 through Week 3. No dates on menu to indicate if Week 4 was the current week for the menu cycle. In an observation on 12/22/25 at 11:05 AM, noted two pages of menus (double-sided copies) posted on the wall of the main dining room. The menu visible on the outside was for Week 4. Note the pages were stapled together and would require a person to flip through the remaining pages to view the menus for Week 1 through Week 3. No dates on menu to indicate if Week 4 was the current week for the menu cycle. On 12/22/25 at 9:31 AM, an interview with Assistant Manager of Dietary Services (AMDS) PP, regarding menu inconsistency, found that some newer staff have had issues following which week of the menu the facility has been on, and instead have made meals from different weeks. This not only doesn't follow the menu but can change what the kitchen has available to make for the meals on the menu that week.

This citation pertains to Intake # 2670974, 2689916, 2671774, 2667436, 2646054, 2639254, 2599079, 2693899, & 2693872.Based on observation, interview, and record review, the facility failed to provide adequate portions of palatable food, served at an appetizing temperature in 8 of 9 residents (Resident #102, #103, #105, #108, #109, #110, #111, & #113) reviewed for food quality, resulting in dissatisfaction with the meals served, frustration with the food service process, and the potential for decreased meal intake and weight loss.Findings include:In an interview on 12/17/25 at 10:03 AM, Ombudsman FF reported she had received many complaints from residents and family members regarding the quality of the food served at the facility and small portion sizes. Resident #102 Review of an admission Record revealed Resident #102 was a male, with pertinent diagnoses which included Parkinson's disease (a progressive brain disorder affecting movement), major depression, legal blindness, need for assistance with personal care, dementia, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 11/7/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, indicating he was cognitively intact. In an interview on 12/16/25 at 12:50 PM, Resident #102 reported the food served from the kitchen is .terrible . Resident #102 stated .They tried to serve some soup last night that was green . which he refused to eat. Resident #102 reported staff will serve the food and when he asks what it is (because he is visually impaired) the staff don't know what is being served. Resident #102 stated .If they don't know what it is, I'm not going to eat it . Resident #102 the food is often bland and flavorless, and served lukewarm. Resident #102 reported he believes a menu is posted in the dining room, but due to his visual impairment he is unable to read it. In an interview on 12/17/25 at 10:44 AM, Family Member DD reported the food served at the facility is .horrendous . Family Member DD reported at times, the facility serves whatever they have left, describing one time Resident #102 was served Brussel sprouts mixed with black-eyed peas. Family Member DD reported recently Resident #102 was served .something green to eat . and when he asked what it was staff told him they didn't know and to just eat it. Family Member DD reported luckily that day, the facility had hot dogs, so the resident was able to get an alternative food item. Family Member DD stated .Half the time they don't have peanut butter when residents ask for a sandwich. The food is awful . Resident #103 Review of an admission Record revealed Resident #103 was a female, with pertinent diagnoses which included cerebral palsy (a neurological disorder affecting movement, posture, and coordination), major depression, muscle weakness, and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 12/3/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, indicating she was cognitively intact. In an interview on 12/16/25 at 12:09 PM, Resident #103 reported the portion sizes at the facility are too small and described them as .toddler portions . Resident #103 reported the food is often unrecognizable and described a green soup that was served the night before. Resident #103 reported she refused to eat the soup, and instead requested a peanut butter and jelly sandwich, but was told the kitchen was out of bread. Resident #103 reported the kitchen ended up making her the sandwich using a hamburger bun. Resident #103 reported she was served waffles recently with no syrup .because they didn't have any . In an interview on 12/17/25 at 10:59 AM, Resident #103 reported she was served a pork chop yesterday (Tuesday) for lunch that was dry and tough. Resident #103 reported the lunch was .barely warm . by the time it was served, and stated .but everything is barely warm by the time we get it because we are the last ones served . In an interview on 12/22/25 at 11:20 AM, Resident #103 reported for breakfast that morning she received one piece of French toast and one piece of sausage. Resident #103 reported yesterday they couldn't get coffee at breakfast time, and when she asked about it was told .they didn't make any . In an observation on 12/23/25 at 11:37 AM, a test tray was obtained from the main facility kitchen. Noted the main entree consisted of a breaded pork chop, cheese rice, and spinach and onions, with what appeared to be a chocolate brownie for dessert. Noted the rice was dry/hard and undercooked, and lukewarm. Observed the pork chop was breaded but lacked flavor/seasoning. Observed the brownie was crumbled/dry and served as a pile of broken pieces on the same plate as the main entree. In an observation and interview on 12/23/25 at 12:50 PM, Resident #103 was noted in bed in her room, with her lunch tray on the table in front of her. Resident #103 reported she was unsure what type of meat was served and initially believed it to be chicken. Noted Resident #103's brownie was served on the same plate as the rest of her food, and Resident #103 reported the brownie was dry. Observed Resident #103 had been served mixed vegetables instead of spinach and onions. Resident #103 reported she generally likes spinach when cooked correctly. Observed Resident #103's tray ticket and noted spinach was not listed as a dislike. Resident #103 reported she would have liked to try the spinach and onions, stating .That would have been good . Resident #103 stated her food was .barely warm . Resident #103 reported the meat .doesn't really have much taste . and the rice .is kind of dry but that is the way we usually get it . Resident #105 Review of an admission Record revealed Resident #105 was a male, with pertinent diagnoses which included diabetes (a chronic condition where blood sugar levels are too high), heart disease, major depression, anxiety, anemia (a blood disorder resulting in fatigue, weakness, pale skin, and dizziness), kidney disease, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 11/17/25, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, indicating he was cognitively intact. In an observation and interview on 12/16/25 at 12:33 PM, Resident #105 was noted in bed with his lunch tray on the table in front of him. Resident #105 reported the food served .is usually something that you can't recognize . Noted he was served two vegetable burgers and a bowl of soup. Resident #105 stated .It would be nice to have ketchup or something (for the burgers) . No condiments or toppings served with the burgers. Resident #105 ate a spoonful of the soup and stated it was terrible and described the flavor as bitter. Resident #105 reported the portion sizes for the meals are often too small. Resident #108 Review of an admission Record revealed Resident #108 was a male, with pertinent diagnoses which included diabetes (a chronic condition where blood sugar levels are too high), high blood pressure, and debility (physical weakness). Review of an admission Note for Resident #108, dated 10/16/25 at 7:59 PM, revealed .patient arrived to facility .assisted from car to wheelchair and into room .alert and oriented x 3 . In an interview on 12/16/25 at 3:28 PM, Resident #108 reported he admitted to the facility around dinner time, and the meal served was .The worst that I have ever eaten . Resident #108 reported he could not finish the meal because .it was terrible . Resident #108 reported the meal served was .some kind of hash that they put together . with poor consistency and no flavor. Resident #109 Review of an admission Record revealed Resident #109 was a female, with pertinent diagnoses which included depression, obesity, high blood pressure, obstructive lung disease, and heart failure. Review of a Minimum Data Set (MDS) assessment for Resident #109, with a reference date of 10/3/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, indicating she was cognitively intact. In an interview on 12/16/25 at 2:18 PM, Family Member II reported the portion sizes for meals were too small, and one day for breakfast Resident #109 was served half a glass of orange juice, a hard-boiled egg, and a piece of toast. Family Member II stated .That is not even enough for a bird . Family Member II reported they questioned the portion sizes and were told that was what was served. Resident #110 Review of an admission Record revealed Resident #110 was a female, with pertinent diagnoses which included major depression, anxiety, chronic respiratory failure, diabetes (a chronic condition where blood sugar levels are too high), heart disease, and high blood pressure. Review of a Minimum Data Set (MDS) assessment for Resident #110, with a reference date of 12/10/25, revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, indicating she had moderate cognitive impairment. In an interview on 12/16/25 at 2:47 PM, Family Member JJ reported the portion sizes for the meals served at the facility are too small, and stated Resident #110 .likes to eat and she needs to eat . Resident #111 Review of an admission Record revealed Resident #111 was a male, with pertinent diagnoses which included diabetes (a chronic condition where blood sugar levels are too high), high blood pressure, and heart disease. Review of a Minimum Data Set (MDS) assessment for Resident #111, with a reference date of 12/9/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, indicating he was cognitively intact. In an interview on 12/17/25 at 2:17 PM, Resident #111 reported the food served at the facility is not good and the portion sizes are too small. Resident #113 Review of an admission Record revealed Resident #113 was a male, with pertinent diagnoses which included Huntington's disease (a brain disorder causing nerve cells to break down, leading to uncontrolled movements, cognitive decline, and psychiatric issues), dysphagia (difficulty swallowing), anxiety, depression, high blood pressure, muscle weakness, difficulty walking, and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #113, with a reference date of 11/25/25, revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, indicating he had moderate cognitive impairment. In an interview on 12/17/25 at 4:07 PM, Family Member KK reported concerns with the food served at the facility. Family Member KK reported she has been present when Resident #113 was served his meals, and his portion sizes are too small. Family Member KK reported they specifically requested extra portions because Resident #113 needed the extra food due to his medical conditions, but the kitchen is inconsistent with serving the additional portions. Family Member KK reported at times the kitchen served Resident #113 food that was inconsistent with his ordered diet. Family Member KK reported she is concerned the kitchen is not reading instructions before serving residents and stated .They are just dishing up food and sending it out and it's up to the nursing staff to make sure (Resident #113) is getting what he should get . Family Member KK reported there have been times he was served ground meat for a sandwich with no gravy or sauce (indicating the meat was too dry). Family Member KK reported she requested gravy from the kitchen for Resident #113 and was told they had run out, so she had to moisten the meat with mayonnaise packets. In an interview on 12/17/25 at 12:17 PM, Dietary Services Aide MM reported they are currently out of Magic Cups (a fortified, high-protein frozen dessert) and yogurt. Dietary Services Aide MM reported they are waiting on those items with the next food order. In an interview on 12/18/25 at 9:13 AM, Registered Nurse (RN) V reported concerns with the food at the facility and stated .It's only gotten worse . since the change in facility ownership. RN V reported residents often do not receive ordered diets, supplements are not provided, the food is cold, the portion sizes are small, and the food is sometimes not edible. RN V stated .There will be no magic cups (for days), so supplements are not provided . On 12/22/25 at 11:52 AM, an interview with Assistant Manager of Dietary Services (AMDS) PP, found that no residents requested items off the always available menu today for lunch service. When asked what temperatures she would like to see for hot food on the steam table, AMDS PP stated 160 to 180 degrees. On 12/22/25 at 12:46 PM, a regular test tray was plated and placed as one of the first trays on a meal cart going as the last cart to the River unit. On 12/22/25 at 12:52 PM, the meal cart was delivered to the River unit and trays were being passed. On 12/22/25 at 1:06 PM, all trays on the meal cart were passed and the test tray was back in the conference room with the following temperatures noted using a rapid read thermometer: Chicken tenders 104F, Grean Beans 113F, and the stuffing was 128F.

This citation pertains to intakes #2658740, #2635653 and #2671515Based on observation, interview, and record review, the facility failed to implement interventions to reduce hazards for 5 residents (Resident #103, Resident #106, Resident #107, Resident #108, and Resident #101) of 5 residents reviewed for accidents, resulting in: 1. Resident #103 suffering a second degree burn when she was provided hot coffee without being assessed for her ability to manage a hot beverage and Resident #106, #107 and #108 being given a hot beverage without being assessed for their ability to safety handle it. 2. Resident #101 experiencing multiple falls due to a lack of monitoring for effectiveness of interventions and modification of interventions.Findings include:Resident #103Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: altered mental status (a change in a person's cognitive status), muscle weakness, and cognitive communication deficit (communication challenge caused by impaired thinking skills).Review of a Minimum Data Set (MDS) assessment for Resident #103 with a reference date of 10/1/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 12 /15, which indicated the resident was moderately cognitively impaired.Review of a Care Plan for Resident # with a reference date of 11/13/25 revealed the following focus/goal/interventions: Focus: (Resident #103) is at risk for injury from spills of hot liquids r/t (related to) weakness, Goal: (Resident #103) will remain free from complications related to hot liquids through next review. Interventions: Encourage resident to allow staff assistance with hot liquids.Encourage resident to wear clothing protector.Review of a Hot Liquids Guidelines policy with a reference date of 11/13/25 revealed .Initial and Ongoing Assessments: Each resident will be assessed for their ability to handle hot liquids by the admitting nurse during the nursing assessment.MDS Nurse will reassess the resident every quarter and upon any significant change.Determination Categories: Based on these assessments, resident will be categorized as follows:.Clothing Protector- Resident should use a vinyl-backed clothing protector when consuming hot liquids and should have lid for their cup.Review of Hot Liquids Safety Assessments for Resident #103 revealed the resident was assessed on 4/1/25 and again on 11/13/25, which left a 7-month time span in which the resident was not assessed for safety while handling hot liquids.Review of a Hot Liquids Safety Assessment for Resident #103 with a reference date of 11/13/25 revealed 1. RISK FACTORS: a. COGNITION, b. MOOD, c. BEHAVIORS.f. STRENGTH.2. Is a Hot Liquids Safety intervention plan indicated for this resident? A. Yes, see intervention plan below.intervention: Encourage resident to allow staff assistance with hot liquids.Encourage resident to drink hot liquids while sitting at table.Encourage resident to wear clothing protector.Review of an Incident Report for Resident #103 with a reference date of 11/13/25 at 8:00am, revealed Nursing Description: Resident heard yelling oww(sic), I'm in pain.resident had spilled hot coffee on herself.clothing removed and the affected area was rinsed with cold water, aloe burn gel applied to wound.injury type: burn, injury location: chest, 1.3 open injury to chest.During an observation and interview on 11/18/25 at 10:34am, Resident #103 sat in her bed with the head of bed elevated to 30 degrees. A white bandage, approximately 2x2 was present on her upper chest. Resident #103 was alert but when spoken to, only responded by asking the writer's name several times.In an interview on 11/18/25 at 10:11am, Licensed Practical Nurse (LPN) C reported on 11/13/25 at approximately 8:00am, she was standing at the medication cart, outside Resident #103's room when she heard the resident yelling it hurts, it hurts. LPN C ran into Resident #103's room and found the resident has spilled an entire cup of hot coffee on her chest. While assessing Resident #103, LPN C noted and hand sized reddened area of skin on Resident #103's torso and an open burn approximately the size of a quarter. LPN C reported Resident #103 had fluctuating cognitive skills, at times was disoriented and unaware of her surroundings at her baseline.According to the Mayo Foundation for Medical Education and Research, 1998-2012, when the first layer of skin has been burned through and the second layer of skin (dermis) also is burned, the injury is called a second-degree burn, blisters develop, skin takes on an intensely reddened, splotchy appearance and there is severe pain and swelling. (www.mayoclinic.com/health/first-aid-burns) In an interview on 11/20/25 at 1:31pm, Registered Nurse (RN) RR reported the facility had zero vinyl backed clothing protectors and the kitchen continued to not provide cup lids on the food carts, despite both items being identified as interventions in the Hot Liquids Safety policy.In an interview on 11/24/25 at 11:46am, MDS Nurse KK reported she was unsure who completed Hot Liquid Assessments but it was not something she had been assigned.In an interview on 11/25/25 at 10:24am, Director of Nursing (DON) B reported it was the expectation that each resident be assessed using the Hot Liquids Safety Assessment upon admission, quarterly and with change of condition. DON B confirmed it was the responsibility of the MDS nurse to complete these assessments. DON B confirmed Resident #103 had not been assessed as required.Resident #106Review of an admission Record revealed Resident # 106 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis or loss of movement of dominant side after a stroke), and patient's noncompliance with other medical treatment and regimen for other reason.Review of Resident #106's care plan revealed no focus/goal/interventions related to his ability to safely manage hot liquids.During an observation and interview on 11/19/25 at 8:40am, Resident #106 sat alone in his room, wearing a hospital gown and no clothing protector, with a cup of hot coffee in front of him on his bedside table. There was no lid on the cup. When queried, Resident #106 reported the coffee was plenty hot. Resident #106 used his left hand to pick up the cup.Review of Resident #106's electronic health record (EHR) revealed no Hot Liquids Safety assessment had been completed at his admission, and none was present as of 11/20/25.Resident #107Review of an admission Record revealed Resident #107 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Hypertensive Encephalopathy(diagnosed 11/14/25) (brain dysfunction caused by high blood pressure), muscle weakness, cerebral infarction (stroke), attention and concentration deficits following cerebral infarction, and unspecified dementia(diagnosed 11/14/25)(progressive or persistent loss of intellectual functioning).Review of Resident #107 care plan revealed no focus/goal/interventions related to her ability to safely manage hot liquids.During an observation on 11/19/25 at 8:44am, Resident #107 sat alone in her room with a hot beverage in front of her on her bedside table. There was no lid on the cup. Resident #107 was not wearing a clothing protector.Review of Hot Liquids Safety Assessments for Resident #107 revealed the resident had not been assessed for safety since 1/29/25.Resident #108Review of an admission Record revealed Resident # 108 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: traumatic subarachnoid hemorrhage (bleeding into the space around the brain caused by head trauma), and neuropathy (nerve damage that causes pain, numbness and muscle weakness).Review of a Care Plan for Resident #108 with a reference date of 11/15/25 revealed the following focus/goal/interventions: Focus: The resident has limited physical mobility r/t (related to) generalized weakness, intermittent dizziness. Goal: The resident will remain free from complications.Interventions: The resident requires assistance by staff as necessary.During an observation on 11/19/25 at 8:24am, Resident #108 sat alone in her room, wearing a hospital gown and no clothing protector as she sipped a hot beverage from a blue cup. There was no lid on the cup.Review of Resident #108's EHR revealed the resident had not been assessed for safety with hot liquids.Resident #101Review of an admission Record revealed Resident # 101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: traumatic subarachnoid hemorrhage (bleeding into the space around the brain caused by head trauma), difficulty walking, need for assistance with personal care and unspecified dementia (persistent or progressive loss of intellectual functioning).Review of a Minimum Data Set (MDS) assessment for Resident #101 with a reference date of 8/28/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 4/15, which indicated the resident was severely cognitively impaired.Review of a Care Plan for Resident #101 with a reference date of 5/22/25 revealed the following focus/goal/interventions: Focus: (Resident #101) is at risk for falls r/t (related to) cognitive impairment, frequently incontinent, hx (history) of falls, poor safety awareness.Goal: The resident's risk of serious injury will be minimized.Interventions: .bolters (bolsters) to bed to provide tactile border, bowel medication time moved to early in the day(10/3/25).Offer toileting upon rising, before and after meals, at hs (night time) and prn (as needed) in addition to 1-2hr (hour) toileting (10/7/25).Review of Incident Reports for Resident #101 revealed the resident fell 11 times between 8/24/25-11/20/25. 8 of the 11 incident descriptions reflected the resident experienced a fall while trying to complete toileting tasks without staff assistance.During an observation on 11/17/25 at 9:27am, Resident #101 sat alone at the edge of his bed. Resident #101's bed was parallel to an interior wall, to the right of the door, with the head of the bed facing the hallway. Resident #101's bathroom door was directly across from his bed on the opposite wall. The bathroom door opened toward the left, which was also toward the hallway. Upon entering the resident's bathroom, the toilet was to the right of the bathroom door. Entering the bathroom required a right turn.In an interview on 11/24/25 at 10:37am, Durable Power of Attorney (DPOA) PP of Resident #101 reported the resident suffered from longstanding urinary urgency that resulted in him needing to empty his bladder quickly to avoid being incontinent. DPOA PP reported prior to coming to the facility, Resident #101 kept a container nearby that he could use when he needed to empty his bladder because he wanted to avoid having incontinence accidents. DPOA PP reported she was frustrated when she came to visit Resident #101 because his urinal was often not left in reach and despite her telling the staff that he needed his supplies nearby, the issue persisted. When queried about Resident #101's falls, DPOA PP stated I've told them repeatedly that Resident #101 had a balance problem for decades and frequently lost his balance when he turned toward the right. DPOA PP reported she last told staff about Resident #101's balance problems at his care conference in September of this year. DPOA PP confirmed that Resident #101 had to turn right to access his bathroom and it would be worth considering moving him to another room. DPOA PP reported she spent time with Resident #101 several times a week and had witnessed incidents in which the staff didn't offer Resident #101 with assistance for toileting for 3-4 hours at a time.Review of a Care Conference Summary for Resident #101 with a reference date of 9/26/25 revealed Attendance at Meeting: .k. Family.During an observation on 11/24/25 at 2:15pm, Resident #101 was lying in bed with his belongings stored by the head of his bed. No urinal was within reach.In an interview on 11/24/25 at 2:24pm, Unit Manager (UM)/Licensed Practical Nurse (LPN) U reported an intervention for assist with toileting every 1-2 hours was added to Resident #101's care plan on 10/7/25. UM/LPN U confirmed there was no documentation that supported Resident #101 being offered assistance with toileting every hour. UM/LPN U reported she was aware that staff had not complied with this expectation when Resident #101 was visiting with DPOA PP. When queried, UM/LPN U reported she was not aware Resident #101 had a longstanding history of losing his balance when he turned toward the right or a history of urinary urgency. When queried regarding the development of fall prevention interventions, UM/LPN U reported the facility usually did not involve floor staff unless the Interdisciplinary Team (IDT) was struggling to develop ideas.In an interview on 11/24/25 at 12:08pm, Certified Nursing Assistant (CNA) G reported she worked 3rd shift and had noted that Resident #101 needed to use the restroom very frequently. CNA G reported Resident #101 was aware of the need to urinate/have a bowel movement and became upset when he soiled himself. CNA G reported when Resident #101 soiled himself, he would attempt to clean himself up but could not remember to activate the call light and wait for help. CNA G confirmed she was not involved in developing interventions to reduce Resident #101's fall risk.In an interview on 11/24/25 at 11:50am, CNA F reported Resident #101 became stressed when he soiled himself and would attempt to clean himself up. CNA F reported Resident #101 at times appeared to have difficulty urinating when he tried to do so while on the toilet. CNA F also reported she noticed Resident #101 consistently leaned to the left when sitting, standing and transferring.In an interview on 11/24/25 at 8:24am, CNA AA reported nursing assistants were not involved in developing care interventions but added that he felt could provide information that would benefit the residents if asked.In an interview on 11/24/25 at 10:21am, CNA JJ stated (Resident #101) does not like to be soiled. If he is wet, he takes off his brief and tries to walk to the bathroom.In an interview on 11/20/25 at 9:25am, CNA P confirmed Resident #101 displayed that it was important to him to be clean and dry because he expressed emotional distress when his brief was soiled.In an interview on 11/24/25 at 3:10pm RN BB reported Resident #101 frequently got up and tried to assist himself to the bathroom if his brief was soiled. RN BB reported sometimes the schedule for checking and changing Resident #101 ran late and he got up on his own.In an interview on 11/25/25 at 4:10pm, DON B reported the facility could not confirm Resident #101 was being assisted with toileting every 1-2 hours per his care plan because the staff had not been asked to document when they assisted him. DON B reported the IDT discussed changing the time Resident #101 received tamsulosin hydrochloride (medication used to treat urinary urgency by relaxing the muscles in the prostate and bladder), which was currently ordered to be given at 6:00pm, but had not done so. DON B reported the facility's pharmacist verified the medication could be given during the day if needed. DON B reported she had no knowledge of Resident #101 having urinary urgency or a longstanding history of losing his balance when he turned toward his right. DON B confirmed Resident #101 was still getting up several times a night to urinate. When further queried, DON B reported if Resident #101 has urinary urgency his care needs related to this issue should be included in his plan of care.Review of Physician Orders for Resident #101 with a reference date of 8/14/25 revealed Resident #101 was prescribed tamulosin HCI 4mg (milligrams) for benign prostatic hyperplasia (non-cancerous enlargement of the prostate causing difficulty starting urination .increased frequency and feeling of incomplete bladder emptying .).In an interview on 11/24/25 at 1:45pm, Nurse Practitioner (NP) NN reported she recently reviewed Resident #101's medications after he had multiple falls. NP NN she had not considered changing medication administration time of Resident #101's tamsulosin hydrochloride because she was unsure if the medication could only be given at night.In an interview on 11/24/25 at 1:17pm, Pharmacist QQ reported the peak time of effective for tamsulosin hydrochloride was 4-6 hours after it was given which would result in the resident feeling a strong urge to urinate. Pharmacist QQ reported if a resident was at high risk for falling, the facility should consider giving the medication during the day.

This citation pertains to intake number: 2640123Based on observation, interview, and record review, the facility failed to prevent the use of psychotropic medications without adequate indication for use and without resident monitoring in one (R102) of two residents reviewed for psychotropic medications, resulting in an immediate jeopardy when beginning on 9/16/25, R102 was prescribed psychotropic medications, who then experienced increased sedation, weight loss, and decreased ability to communicate. Findings include:Resident #102 (R102) was prescribed Haldol solution injection intramuscular (IM) daily as needed PRN and Olanzapine (Zyprexa) 5mg by mouth (PO) daily at night beginning 9/16/25. The Olanzapine was increased to 10 mg PO daily at night on 10/20/25. R102 experienced falls, some with injuries, beginning 9/16/25 after having no falls since 9/11/25 admission. Resident #102 did not have a psychiatric diagnosis to indicate the need for two psychotropic medications. On 10/22/25, R102 was observed with increased lethargy, inability to eat or drink, weight loss, and altered mental status. The resident was transferred to a neuro psychiatric hospital on [DATE], where he was evaluated upon admission to be medically unstable and transferred to an acute hospital where he weighed 101pounds and was dehydrated. The Immediate Jeopardy (IJ) began on 9/16/25 when R102 was prescribed psychotropic medications without adequate indication for use and without resident monitoring, who then experienced increased sedation, weight loss, and decreased ability to communicate.Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on 10/23/25 at 2:30 PM. The surveyor confirmed by interview and record review the Immediate Jeopardy was removed on 10/27/25, but noncompliance remains at actual harm due to not all staff having received education and sustained compliance had not been verified by the State Agency. Review of R102's Minimum Data Set (MDS) dated [DATE], revealed the resident had been admitted on [DATE] with a severe cognitive impairment indicated by a BIMS (Brief Interview Mental Status) score of 3/15 and the ability to feed himself. Diagnoses included other sequelae of cerebral infarction (resulting conditions after a stroke has occurred), dementia unspecified severity with other behavioral disturbance (a group of systems that affect memory, thinking, and social abilities to interfere with daily life), vascular dementia severe with other behavioral disturbance (vascular major cognitive impairment), and adjustment disorder with mixed disturbance of emotions and conduct. It was noted there were no psychiatric diagnoses. Review of R102's Progress Notes regarding the resident's behavior and cognition, a Social [NAME] admission History note, dated 9/12/25 10:50 AM, indicated R102 and representative were present along with IDT (interdisciplinary team) members. The note indicated a cognitive summary was reviewed which included mental status changes and evaluation of behaviors if present. No verbal or physical behaviors were documented. The note identified R102 was unaware of where he was and what was going on. Review of R102's Care Plan did not reveal a focus/goal/intervention for a mental health diagnosis (es) nor did it reveal PASARR documentation for a mental health diagnosis(es) that would indicate antipsychotic medications were needed. Further review of R102's Care Plan did reveal a focus stating the resident uses psychotropic medications (antipsychotic) related to behavior management dated 9/22/25. The goal was to remain free of psychotropic drug related complications using interventions including administering the psychotropic medications and monitoring for side effects. The care plan's treatment did not indicate a mental health diagnosis(es) nor name the antipsychotic medications. Interventions stated the ongoing need for the use of psychotropic medications would be discussed with the Medical Director and the family. Regarding the incident on 9/16/25, R101's Guardian EE stated during an interview on 10/23/25 at 8:26 AM, I told staff he was picked on by a group of younger women from the facility he was at before here. If they left him alone, he never had any problems. I told staff that the name [NAME] is a trigger for him and asked staff if they could not say that name loudly or near (R102). [NAME] was (R102's) ex-wife's name and she was mean and abusive to him. I don't think the staff at this facility listens to me when I tell them what sets (R102) off. I also told staff at admission (R102) like Pepsi, chocolate, coffee, and to go for walks. I don't think staff did those suggestions before he got the Haldol shots. Review of R102's Care Plan, dated 9/15/25, focus of Activities of Daily Living (ADL) indicated the resident goal was to maintain functional ability and was able to feed himself. Review of R102's Care Plan, dated 9/22/25, focus of Potential Fluid Deficit, goal was to be free of symptoms of dehydration and maintain moist mucous membranes, and good skin turgor. Interventions to meet this goal included encouraging the resident to drink fluids of choice and to ensure access to fluids whenever possible. Also, observe as needed any signs or symptoms of dehydration including strong urine smell, new onset confusion, dizziness on sitting/standing, fatigue/weakness, and recent/sudden weight loss. Review of R102's Order Summary dated:-9/16/25 Olanzapine 5 mg tablet PO (by mouth) in the evening for psychotic disorder discontinued 10/23/25. It was noted there was no psychotic diagnosis. -9/16/25 Haloperidol Lactate (Haldol) injection solution 5 mg/ml inject 1 milliliter (ml) intramuscular (IM) as needed for aggression for 14 days. Give 1 ml IM everyday PRN (as needed) for aggression (end date 9/16/25). Administered once on 9/16/25. Review of R102 Progress Notes dated 9/16/25 at 1:45 PM indicated at 10:15 AM R102's behavior towards staff continued to escalate until staff took him outside for a walk. During the walk, R101 was able to calm himself down with no further agitation/aggression noted. The Nurse Practitioner (NP) GG was contacted with a new order of Haldol 5mg/ml solution IM one time for aggression and Olanzapine 5 mg PO once daily. The Haldol 5mg/ml IM was also ordered as needed daily for agitation. When R101 returned from his walk outside he was taken to the sensory room and was administered the IM of Haldol while staff held him. It was noted that Haldol IM, an antipsychotic medication, was given after R101 had been taken outside for a walk and no longer agitated per documentation. According to Drugs.com, with references from the package insert, Olanzapine, brand name Zyprexa, is an atypical antipsychotic medication used to treat adults with schizophrenia or bipolar 1 disorder. Olanzapine carries a Boxed Warning for an increased risk of death in elderly patients with dementia-related psychosis. Olanzapine may cause serious side effects such as an increased risk of death or stroke in elderly patients with dementia. Common side effects of Olanzapine that affect 5% or more people who take it include postural hypotension (a drop in blood pressure when going from a lying or sitting position to standing) include dizziness, personality disorder, restlessness, sedation, abdominal pain, tiredness/lack of energy, and dry mouth. It was noted that R102 did not have a diagnosis of schizophrenia or bipolar 1 disorder. His diagnoses consisted of dementia, unspecified severity and vascular dementia both with other behavioral disturbance. Review of R102's Care Plans, dated 9/17/25, indicated R102 required a quieter, low stimulated environment. When R102 displays aggression, a calm walk and conversation to de-escalate, offer the sensory room, and use the sensory objects available to calm and recenter focus in a positive way. Add to sensory group three days a week and implement sensory plan for redirection. Reapproach for needs when he is calm. Will continue to support his social needs as he tolerates. The goal was to maintain involvement in cognitive stimulation and social activities. Interventions listed included offering to go outside and use sensory room or low lighting for low stimulus to calm resident if they escalated. It was noted non-pharmacological interventions were not developed until the day after R102 began to receive Haldol injections IM. Review of R102's Order Summary dated 9/18/25 Haldol injection solution 5 mg/ml inject 1 ml intramuscular (IM) as needed for aggression for 14 days, give 1 mil IM everyday PRN for aggression (end date 10/2/25). Review of September 2025 MAR reflected R102 was given Haldol IM once on 9/29/25. Review of R102's Progress Note dated 9/29/25 08:00 AM revealed physician was requested by nurse to see resident for having aggressive behaviors. It was stated R102 received a PRN Haldol injection IM. It was noted there was no nursing note for the incident to describe the behaviors or non-pharmacological interventions. Review of R102's Order Summary dated 10/9/25 Haldol injection solution 5 mg/ml inject 1 ml IM every 24 hours PRN for agitation/aggression (end date 10/9/25). October 2025 MAR reflected R102 was given Haldo IM one time on 10/9. Review of R102's Progress Note 10/9/25 5:57 PM revealed was agitated and becoming increasingly agitated towards other residents and staff in the dining room. Redirection and removing from dining room was not effective. No other non-pharmacological interventions were attempted according to documentation. R102 received a PRN Haldol injection IM. Review of R102's Order Summary dated 10/9/25 revealed R102 was ordered Haldol injection solution 5 mg/ml inject 1 ml IM every 24 hours PRN for agitation/aggression for 14 days (end date 10/23/25). October 2025 MAR reflected R102 was given the PRN Haldol four times on 10/14, 10/18, 10/20, and 10/21. Review of R102's Progress Note dated 10/14/25 at 0:15 AM indicated the resident was observed on the floor by his closet where his personal box of cola (Pepsi) was kept. An assessment discovered R102 had sustained an abrasion to his left elbow. Review of R102's Progress Note dated 10/14/25 at 8:00 AM indicated the resident was displaying agitated and aggressive behaviors, was given a PRN Haldol IM injection and sent to the hospital for further evaluation. R102 was sent back to the facility with no new diagnoses. No attempted non-pharmacological interventions were documented. It was noted Olanzapine 5 mg was administered at 7:00 PM the prior evening. Review of R102's Medication Administration Record (MAR) dated 10/14/25 and 10/18/25, revealed the resident was given a PRN Haldol injection IM. No Progress Note was written on 10/18/25 to document why the PRN Haldol was given or if any non-pharmacological interventions were attempted. Review of R102's Order Summary dated 10/20/25 revealed Olanzapine 10 mg tablet give 1 tablet by mouth in the evening related to dementia/vascular dementia and Haldol 0.5 mg tablet give 1 tablet PO three times a day related to dementia/vascular dementia with behavioral disturbances. Review of R102's MAR dated 10/20/25 indicated the resident received Haldol injection solution 5mg/ml 1 ml IM documented at 2:22 AM. It was noted Olanzapine 5 mg was administered at 7:00 PM the prior evening. Review of R102's Progress Note 10/20/25 08:00, Nurse Practitioner (NP) stated resident was seen after hospital visit for aggressive behaviors. R102 also had a fall that morning. R102 continued to have agitation and aggression issues so the NP increased the Olanzapine 10 mg daily and added scheduled Haldol PO 0.5 mg 1 tablet at 6:00 AM, 2:00 PM, and 10:00 PM. Review of R102's Progress Note dated 10/20/25 12:03 PM indicated the resident had an unwitnessed fall in his bedroom and was found on the floor next to his bed wet and soiled. Review of R102's Progress Note dated 10/20/25 2:55 PM indicated the resident fell out of his wheelchair in the dining room reopening a skin tear to his elbow and causing it to bleed. During an observation, interview, and record review on 10/20/25 at 10:00 AM, with Licensed Practical Nurse (LPN) W who stated while this writer was observing 5 syringes containing Haldol solution 5mg/ml and container of Olanzapine tablets, The Haldol and Olanzapine in the medication cart (Meadows locked dementia unit) are for (R102). He hits staff when they try to change his brief, so he needs these medications. LPN W stated, The Haldol and Olanzapine are for (R102). He hits staff when they try to change his brief. I've not seen (R102) go after other residents. I don't think he likes female staff changing him. I try to sit next to him when he gets agitated after staff change him. I'll talk to him and rub his shoulder. But since you (State Surveyor) have been here, I'm behind in my medication pass and I don't have time to spend with (R102) so it was necessary to give him the Haldol and Olanzapine to keep him calm. There is a lot to do on this unit (locked dementia) for 2 CNAs and 1 nurse. Review of R102's MAR dated 10/21/25, revealed the resident was given a PRN Haldol injection IM. No Progress Note was written to document why the PRN Haldol was given or if any non-pharmacological interventions were attempted. Observed on 10/21/25 at 9:00 AM, 10:00 AM, and 11:30 AM, R102 in bed dressed in a brief and a T-shirt with only a thin sheet covering him. The head-of-the-bed (HOB) was raised to approximately 45 degrees with the foot of the bed raised so that the bed was shaped in a V. R102 was wedged down in the V in a fetal position moaning. The smell of urine was heavy in R101's bed area. LPN W entered the room and commented, He won't get out of bed that way. LPN W then asked CNA T to change R102. CNA T stated, I'm not assigned to him, but I'll change him. Aides have been very busy today. During an interview on 10/21/25 at 10:05 AM, with Unit Manager (UM) E stated, (R102) gets agitated with staff when they change him. He swings his arms and hands at them but not directly at them. He waves them in the air. (R102) and his roommate get up during the night and have had falls. I've suggested having a CNA stationed at each end of the hall to help watch residents at night, but I got shot down by management. CNAs can't watch or see what is going on at the end of the hall by (R102's) room if they are in common area or in the break room. Haldol is dangerous for the elderly. I do not think (R102) needs all that medication. There needs to be more staff on this unit to assist with residents. (R102) is not the only resident that gets upset or agitated, he is just the most challenging especially when State is in the building. Observed on 10/21/25 at 10:05 AM, R102 eyes closed in bed, fidgeting with hands on bed sheet. Resident was lying on his left side with both legs over the edge of the bed with feet touching the floor. During an observation and interview on 10/21/25 at 1:30 PM, LPN W and Unit Manager (UM) E were outside of R102's room, LPN W stated, (R102) is lethargic. He gets 0.5 ml of injectable Haldol because he swings at staff. He does not swing at residents, just staff during cares. I've had dementia training and non-pharmacological interventions cannot always be used because of short staffing. UM F stated, (R102) has had increased behaviors towards staff. He gets 0.5 mg of Haldol PO three times a day Olanzapine at night, plus PRN Haldol IM. Haldol is a hard drug for elderly and not safe for them to have. LPN W stated, I gave (R102) an IM of Haldol at 11:46 AM today. One staff member held down his arm while I gave him the IM. I did not ask him if he wanted it. He was struggling with staff while he was getting changed and dressed. I tried non-pharmacological interventions like talking to him. He was trying to get out of bed. It was almost lunch time, and he wanted to get out of bed. So that is why he got the PRN Haldol. Staff did not try to get him out of bed because staff were busy. I did not notify his guardian. UM E stated, (R102) guardian should have been notified when he got the PRN Haldol. He was not on psychotropic medications before he came to this facility. (R102) should have been brought down for activities today, but all Activities was doing was painting fingernails. He would not want that done. GuideStar, the in-house behavior and psychology services looked at (R102) medications when he was first ordered the Haldol PRN, but not since he was ordered Haldol three times a day or the Olanzapine. (R102's) guardian has not been contacted about his behaviors. LPN W stated, I was behind in passing medications today because of you (State Surveyor), so I gave (R102) PRN Haldol because I did not have time to sit with him. He only had two sips of liquid yesterday. I did not have time to offer him drinks nor did the CNAs. I did not see any drink cups in his room today. I've not been offering him Pepsi that his guardian brought in for him. I did not check (R102's) skin turgor yesterday or today. I know he came in dehydrated. UM F shook her head and went to the nurse's station and brought R102 a cup with Pepsi in it. She held the straw and cup while offering R102 a drink. R102 took several sips of the drink offered. During an interview on 10/21/25 at 4:30 PM NP GG stated, I saw (R102) Monday (10/20/25) in the dining room. He must be fed by staff. The floor in his room is worn, and he tries to pick it up which means he hallucinates a lot. Yesterday, (Monday, 10/20/25) he was screaming and swinging at the aides that were trying to get him up for breakfast. The LPN W tried to feed him dinner, and he spit at her that is why he didn't get dinner. Noted LPN W did not tell surveyor this. NP stated staff told her all of this. NP GG continued stating, (R102) didn't eat breakfast yesterday. I did not know he got the IM -of Haldol yesterday. I do not have a work phone. I work here on Monday, Tuesday, Wednesday and Friday 9-3. I was here yesterday 9-3 when (R102) got Haldol IM PRN. I don't know why staff did not come looking for me to tell me. (R102) came directly over from the other facility. I do not know what medications he was taking prior to coming here or what medications he was ordered when he arrived at this facility. I don't know what physician did (R102's) medication reconciliation. I am not specialized in psychiatry. I would think (R102's) non-pharm interventions are redirection from staff, try to reposition him while in bed, ask if he needs to go to bathroom, ask him if he is in pain, which he never communicates he is in pain. I have documentation of his diagnoses being dementia with hallucination specific with behaviors. All my notes on (R102) are on my computer that is not connected to the facility's system. I've not sent my notes over to the facility yet, so I think the diagnoses (R102) have not been added to the facility's charting yet. I've never seen him act out; this is what staff tell me. I'm going to tell you again; I am not a board-certified psychiatrist. During an interview on 10/22/25 at 3:00 PM CNA T stated, (R102) was not on my group yesterday, 10/21/25 but I did help with him. (R102) had been twisted in his bed with his bed up in a V like that all day. I think he was in pain and told LPN W. He does a lot of swinging when changing him and undressing. (CNA R) and I tried to change him, clean him up, and make him comfortable. He was not with it. His eyes were closed. He did not come to this facility like that. He has declined since he has been here. CNAs do not know what medications residents get unless they are asked to help with IMs like (R102) gets. He was difficult and challenging since he came. He is not the only one like that though. He needs more care than others. There are other residents that strike out but they do not get IMs that I've helped with. I just talk to (R102) to get him to calm down. It's all about how you approach him. He does not comprehend anything. He was struggling and fighting when I was asked to change him yesterday. He was hunched over and seemed in pain yesterday. He has called some of the female residents witches. But there must be a reason. Now he does not go after any residents. There is a female resident named [NAME] on this same unit as (R102) and she is just a few doors down from (R102). New admissions are to be weighed once a month. Everyone is weighed once a month, and Meadows (locked dementia unit) have not done them yet this month (October). During an interview on 10/22/25 at 3:00 PM, CNA R stated, I worked with (R102), yesterday. He showed a decline in behavior. Lethargic and out of it, not responsive, bent over in pain. Staff kept his bed in a V so he couldn't get out. They were busy. He has expressed he does not like women, he says they are witches. I've not seen him attack other residents. He was only combative with staff, swings his fists and cusses us out. I stayed calm and explained to him what staff was doing. We offered him breakfast and lunch yesterday and he did not eat. He showed quite a decline yesterday. He used to eat 25-75% by himself. Now he needs help eating and drinking and barely does either. If he pushes staff's hand away while eating, some staff say he is swinging at them and put him back in his room. Review of R102's Progress Note dated 10/22/25 5:18 PM, revealed the Medical Director was contacted in relation to resident's weight loss, decreased intakes, increased lethargy; possible side effects to psychotropics. During an interview on 10/22/25 at 9:42 AM, Medical Director (MD) FF stated, I am the Medical Director of the facility. I oversee the medical treatment of residents that live there. I am not a board-certified psychiatrist. It is not my specialty. I believe that residents that are on psychotropic or anti-psychotropic medications should be seen by a board-certified psychiatrist. (NP GG) ordered (R102's) medications. (R102) was only on the PRN Haldol. When MD FF was informed (R102) was on scheduled Haldol three times a day and Olanzapine which was increased from 5 mg to 10 mg with no board-certified psychiatrist referral he stated, I only knew (R102) got the PRN Haldol once. I didn't know he was getting Haldol scheduled three times a day. I didn't know about Zyprexa (Olanzapine) either. Haldol is a medication that can cause problems for the elderly. (NP GG) is not a board-certified psychiatrist. She is agency staff. Review of R102's Progress Note dated 10/23/25 at 4:16 PM, indicated R102 had a poor appetite and staff could not get R102 to eat. He drank a small amount of water from a spoon and was given medications crushed in pudding via a spoon because resident was unable to keep pills in his mouth. During an observation and interview on 10/23/25 at 9:15 AM with Certified Nursing Assistants (CNAs) M and KK were assisting (R102) into his room and transferring from wheelchair to bed. CNA KK stated, (R102) was fine Saturday (10/18/25). He was eating and drinking, talking and sitting up straight. Now he is struggling to do all those things. It is like he forgot how to do them. (R102's) nose was dripping and he wiped it with his hand. He was offered a tissue by CNA KK who stated, Saturday he could have grabbed the tissue and wiped his nose. Today he cannot. I don't know what is wrong with him, but he looks drugged. CNA M stated, I was with (R102) last week and he was not like this. He told me there was too many damn women in the common area. During an interview on 10/23/25 at 1:07 PM, Guardian EE stated, Two weeks ago, (R102) was not the same as he is now. I signed consent forms for some kind of psychotropic medication, but staff never told me they were changing his medications. I knew about PRN medication. I've seen him swing once at the hospital. He was directly swinging at me or anyone else. He was dehydrated and not feeling good. The way he is now is not the way he behaved before he came here or even 2 weeks ago. His face looks like a skeleton. He did not look like this two weeks ago. Reviewed Zyprexa and Haldol consent form with Guardian dated 10/10/25 at 1436 (2:36 PM). No dosage was given. Indicated that the guardian had given verbal consent to give R102 the medication. Upon viewing the form, Guardian EE stated, I never got a call from the facility about the medication. Guardian then reviewed her phone and no calls from the facility were received on 10/10/25. The Guardian then checked her phone history, and no calls were received from the facility. I did not know about the scheduled Haldol at all. I only knew about the PRN Haldol shots when (R102) first got them in September. I am so upset that the facility did not call me or talk to me about the medication changes. They call me about his falls why did they not tell me about changes with his medications? Review of R102's Psychotropic Consent forms for Olanzapine and Haldol, revealed were verbal consent dated 10/10/25. No dose, route, or frequency was indicated with the diagnosis of vascular dementia with severe behavior disturbance, which is not a psychotic disorder. Further review of the consent form did not have the expected benefit(s) of the medication intervention completed nor were specific side effects noted to be explained to the guardian. Review of R102's Progress Noted dated 10/24/25 at 3:26 PM indicated resident was transferred to a neuropsychiatric hospital. Review of the Hospital emergency room record dated 10/24/25 revealed R102 arrived at the hospital from local behavioral health hospital with dry mucous membranes, elevated sodium, and elevated Creatinine with acute kidney injury which were indicative of dehydration. History and Physical revealed R102 was normally conversant, oriented to self and family and able to eat independently. Pt. (patient) is unable to provide history, is ridged in room and not answering questions. Per notes from behavioral health hospital, he has not been eating or drinking lately. During an interview and record review on 10/20/25 at 1:58 PM, of R102's medical chart with GuideStar Elder Care NP HH, who stated, I have only seen (R102) one time. Another NP saw him one time before me. I saw him 10/18 and have not finished my note on him yet. The other NP noted vascular dementia, irritable mood with aphasia related to stroke and easily agitated. GuideStar would be responsible for psychotropic medications along with primary care. (R102) He did not even speak to me when I saw him. I barely got a yes or no. Staff told me he does not like women and prefers men caregivers. His medications (Haldol and Olanzapine) seem extreme. That is on (R102's) primary care providers ordering those two medications and not coming from GuideStar, psych services. I've not seen anyone get that much Haldol who was elderly and combative. When I saw (R102) he was only on the Haldol PRN. The goal is to keep the elderly off psychotropic medications. Olanzapine (Zyprexa) is not for dementia. I am going to ask the facility if there is documentation of (R102) having delusions/hallucinations. The Haldol, any route, seems excessive. (R102) is going to be super sedated and that is not safe. Haldol and Zyprexa are two antipsychotics that can be dangerous together. During an interview and record review 10/22/25 at 4:22 PM, with Director of Nursing (DON) B stated, In between the prior Social Worker and the new Social Worker starting, all the IDT (interdisciplinary team) reviewed psychotropic medications every morning during the morning meeting. (UM E) was following the psychotropic medications for (R102) and the locked dementia unit. I feel it is appropriate for (R102's) behaviors for him to get Haldol and Olanzapine. I see in notes he gets agitated towards staff. Staff did not discuss (R102's) and the increase in Olanzapine he was ordered this morning. A new admission is weighed upon admission, once a week for 4 weeks, then monthly. (R102) was weighed 9/11/25 at 116.0 and then weighed at 1:21 PM today, 10/22/25, he weighed 108.0 which is an 8-pound weight loss since admission. There is no excuse for staff not getting their work done. (R102) should have been weighed and then the weight loss might have been found. I did not know he was not eating or drinking. Reviewed orders and DON did not find orders to weigh R102 per admission guidelines. DON B stated, It was not ordered. The UM would be responsible for making sure his weights were done and I'm responsible for the UM to make sure she does her job. I did not follow her. I did not know (R102) does not like women care givers and prefers men care givers. I did not know the name [NAME] makes him angry. Haldol IM PRN was given to (R102) for agitation and is the only resident that receives Haldol for agitation and there are other residents that are combative with cares that do not get Haldol. There are things staff should do before giving Haldol. They should be attempting non-pharmacological redirection, ask if he is in pain, or hungry. I believe he is dehydrated again because he has not been drinking. Labs were collected today. He was rigid and stiff. It is a side effect of the psych meds, or it could be he is in pain. The psychotropic consents were done for (R102) by the UM E. I don't know what they say. They should have the dose, route, and frequency on each one of them. A new consent I think is done with each medication change. Review of R102's medical chart revealed admission weight was 116.0 pounds on 9/11/25. The only other weight taken for R102 was on 10/22/25 at 108.0 pounds. A loss of 8 pounds. During an interview on 10/27/25 at 9:00 AM, with Guardian EE stated, I was told on Friday (10/24/25) the facility was sending (R102) to a special psychiatric hospital. When I called that hospital, I was told they were told by the facility (R102) had not eaten in 72 hours and indicated he was not medically stable to be there, so they sent him immediately to the acute care hospital. He only weighed 101 pounds! How could the facility not know he was not eating! How could they not tell he was losing weight. I feel like they were killing him with the medications, and he was not eating or drinking. During an interview on 10/27/25 at 10:00 AM, with NHA A who reported R102 was aggressive towards staff and Guardian EE on Thursday October 24 when Guardian came to visit. NHA A did not witness R102's alleged behaviors and was told by staff. He did not speak with R102's guardian. NHA A reported the facility's Medical Director, petitioned R102 to the psych/behavioral health hospital then from there R102 was sent to an acute care hospital. Facility policy Behavioral Health Services, date implemented 3/4/25, revealed, It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well-being. Non-pharmacological intervention refers to approaches to care that do not involve medications, generally directed towards stabilizing and/or improving a resident's mental, physical, and psychosocial well-being.The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.The Social Services Director shall serve as the facility's contact person for questions regarding behavioral services provided by the facility and outside sources such as physician, psychiatrists, or neurologists. The Immediate Jeopardy that began on 9/16/25 was removed on 10/27/25 when the facility took the following actions to remove the immediacy: 1. The DON obtained an order from the facility Psychiatrist/Resident's Physician to discontinue medication. 2. Added 1:1 for safety of self and other residents due to increased aggression. 3. The DON or designee completed a chart audit on all residents currently prescribed a antipsychotic medication to ensure an adequate indication for use and appropriate documentation was present to support use of the medication. 4. An audit of all residents who receive antipsych[TRUN

This citation pertains to intakes MI00142592 and MI00142727. Based on interview and record review, the facility failed to assess an acute change of condition in 1 of 4 residents (R102) and failed to provide appropriate skin care for open wounds in 1 of 4 residents (R103) reviewed for quality of care, resulting in a delay in assessment, treatment and subsequent hospitalization for for dehydration and hypernatremia (elevated sodium) for R102 and the potential for infection for R103. Findings include: According to the Minimum Data Set (MDS), [DATE], R102 was reported to have a memory problem with her cognitive skills for daily decision making severely cognitively impaired with a BIMS (Brief Interview Mental Status) score of ,d+[DATE]. Her diagnoses included Alzheimer's disease, dementia, and adult failure to thrive. Review of R102's Order Summary [DATE]-[DATE], reported for 14-days, the resident was placed on droplet isolation and was to remain in room with the door closed for Covid-19 exposure. Review of R102's Advance Directives, [DATE], revealed: -Do Not wish to have Cardiopulmonary Resuscitation (CPR) -I Do wish to be hospitalized -I Do wish to IV hydration fluid (Intravenous placement) along with IV antibiotic treatments if necessary -I Do want medication for comfort During an interview on [DATE] at 2:15 PM, Certified Nursing Assistant (CNA) E stated, (R102) is pleasantly confused and will talk to you but she may not be able to answer your questions. She can have nothing in her mouth to eat or drink. It is kind of sad because she liked to drink water before she went to the hospital. She would drink water, but staff had to urge her to drink. Staff was to offer her water when they did her check and change every 2 hours. I do not know if it was documented every time she drank or how much. In an interview on [DATE] at 11:26 AM, Registered Nurse (RN) F stated, I worked on [DATE] but not River Unit (R102's). My aide (CNA) came back from River and told me (R102) was dying. I as in shock because I had seen no indications the last day, I worked with her. I went right over to that unit and observed (R102) trying to talk and could not talk. Her left hand was shaking. I went to talk to her nurse, (LPN G), who told me the resident was dying. (LPN G) told me she called the son who was coming but had not called the physician to tell him about the change in condition or ask for orders. I called the physician for Roxanol (morphine sulfate for treating severe, chronic pain) because the resident looked scared with possible stroke-like symptoms. I did not know what she had done for (R102). I do not know if vitals or an assessment was done. I went back to my unit and waited for the physician to call back. When the physician did call back, he wanted to talk to (LPN G). She had difficulty understanding the electronic process for paperwork. It was overwhelming for her. I had helped her out numerous times. I was there when the physician called and put him on speaker. (LPN G) said (R102) was DNR and the physician asked if she was able to be hospitalization . (LPN G) told him No. I saw the paperwork and (R102) wished for hospitalization . Family got to the facility around 7:30 PM. The son, (Family Member (FM) H) knew me from me working with (R102). I was paged numerous times by the on-coming nurse (LPN J) about what was happening with (R102). She only got report from (LPN G) that (R102) was dying. When the order came from the physician for Roxanol, I got the code to get it out of the Cubex (controlled substance storage). I pulled it and gave it to (LPN J). she said I had a better repoire with the family and wanted me to go to (R102's) room. (LPN G) was at the desk supposedly doing medication count and end of shift paperwork. I talked to the resident's family and they wanted to know why (R102) had not been seen by a physician and was not sent out to the hospital. I did not know because I was not her nurse, (LPN G) was. The family requested (R102) to be sent to the ER, I told (LPN G). (LPN J) and I started the transfer paperwork. (LPN G) did not help with the transfer. (LPN J) called the physician to tell him and then called the hospital to give report. When the EMTs (Emergency Medical Technician) came to transport (R102), they asked me why she was being sent out. I told them I thought (R102) was having a stroke. The EMTs asked why the resident was not sent out earlier if the signs/symptoms had started around 4:00 PM and it was now around 7:45 PM. (LPN G) sat observing this and did not help. She said (R102) was a DNR and did not need to go to the hospital. After (R102) had been sent out, her CNAs told me they had told (LPN G) (R102) had not been drinking or talking. On Monday, [DATE], I told the Nursing Home Administrator (NHA A) and the DON (Director of Nursing B) what happened. I also told them (LPN G) did not listen to CNAs when they told her residents had a change in condition or needed something. During an interview on [DATE] at 2:18 PM, CNA K stated, I was working on the unit with (LPN G and R102) on February 3rd ([DATE]). I got report from another CNA that R102 was acting off all week. On [DATE] (R102) was not very talkative and did not want to eat or drink. She was out of it like sitting and staring off. Usually, she is pretty alert and waves at you. She is 1 person assist and will help you roll and turn. She was not able to help on [DATE]. (LPN G) was her nurse on ,d+[DATE] and did not assess on (R102) when I told her about the change in behavior. (Unit Manager (UM) D) was working as a CNA on the unit and I told her (R102) did not want to eat or drink or help move. When I was in the dining room that weekend and told four different nurses including (LPN G, UM D, and LPN J) them all about (R102) acting differently. When I came in on [DATE] in the morning, the report said (R102) was acting kind of off, that she was worse. She was not making sense when she talked and was lethargic. Staff would do tactical touch, like touch her arm with no response. She was making funky sounds like maybe some fluid was in her upper chest. You could hear it from the bedside. She did not eat, drink or help roll. I went and found (LPN G) at the desk and I told her specifically (R102) was not doing well. First thing that morning she was worse than the day before (,d+[DATE]) but by afternoon that day (,d+[DATE]) she was total care. (LPN G) did not get up to look at (R102). She not seemed concerned. (CNA L) came on shift around 3 pm and saw (R102) and called me to come look at her. She was concerned and told (LPN G) (R102) had been like that all weekend. (CNA L) kept telling (LPN G) that (R102) looked like she was dying and finally got (LPN G) to look (R102). After (LPN G) could not get (R102) to respond to her she went to her med cart and asked me what to do. (RN F) came over from another unit and decided to look at the resident then called the physician and was waiting for the physician to call back. (LPN G) did not take vitals or ask one of us CNAs to do them. The family came and were upset that the decision to have (R102) sent out was not made. In (R102's) chart it said she wanted hospitalization and was not sent to the hospital until the family insisted. During an interview and record review on [DATE] at 3:01 PM, LPN/Unit Manager (UM) D stated, I am the UM for (R102's) unit. I worked on the unit as a CNA on Saturday [DATE] and assisted (R102) to eat breakfast. She did decent with eating maybe 50% of meal and drank 2 cups of liquid. There was no change in her normal condition. That was about 8:30 am ish. I do not recall anyone saying anything to me about her having a change in condition. I worked primarily the back section of that hall and not really with (R102) except for meals. (LPN G) was the nurse on that day. When a resident has a change in condition, the nurse should do an assessment and call the physician. (LPN G) did not do that with (R102) on that day ([DATE]), she waited until another nurse came from another unit to see what was going on. During an interview on [DATE] at 8:05 AM, LPN J stated, I work the night (NOC) shift 7 PM to 7 AM on [DATE] and [DATE]. I did not notice any change of condition for (R102) on [DATE]. An aide did tell me (R102) was not wanting to eat, but she took her medications from me, and I did not think anything of it. When I started my shift on [DATE], I walked past (R102's) room and saw her with a washcloth on her forehead and family around her. She was unresponsive. I thought what the heck is going on with her. It was a shock to see the family in the room. I took report from (LPN G). RN F came over from another unit, telling me she was going to call the doctor for (R102) then come back. After report with (LPN G) we were counting medications at the med (medication) cart when (RN F) came back. The family was still in the room. One of the sons was talking on the phone with another son. The son that was on the phone and not in the room wanted (R102) sent to the ER (emergency room ). I was confused about everything that was going on. I thought why was this going on now, when I was told (R102) had this change in condition earlier in the day. Why wasn't something done earlier? I asked (RN F) to help with the transfer paperwork even though (LPN G) was still at the nursing station. I pulled (R102's) advanced directives to see if she could go to the hospital because (LPN G) told me the resident was dying. Plus, the doctor would want to know code status and if it was the resident's wishes to be sent to the hospital. The doctor was called and said it was okay to send (R102) to the hospital. (RN F) and I got paperwork around and sent the resident to the hospital. (LPN G) was upset because she said (R102) was to be DNR, but the Advanced Directives stated she could to the hospital and that is what her representative said to do. During an interview on [DATE] at 11:31 AM, Nursing Home Administrator (NHA) A stated, On February 4th (2024), (R102) had a change in condition and (LPN G's) initial observation led her to believe the resident was passing and that is what she reported to the family and medical director. Initially, I as was not aware of any concerns. (FM H) arrived at around 5 PM that evening and shortly after 7 pm they were sending the resident to the hospital. The following morning (FM I) called me with concerns that his mother had not been seen by a physician or sent to the hospital earlier. It was (LPN G's) attention to (R102's) change of condition that was the concern. During an interview on [DATE] at 12:18 PM, FM I stated, On February 4th (2024), I got a call saying the facility was preparing my mother for end-of-life from my brother. I asked questions and found out she was not seen by a doctor, only the nurse. I wanted mother to see a doctor so the facility transferred her to the ER. There, they found she was severely dehydrated and had a UTI. She was transferred to from there to a larger hospital. They found my mother had a swallowing issue. I spoke to the facility Administrator who told me they felt the incident was mishandled because of the lack of all-around medical treatment and mother should have seen a doctor before telling us she was dying. During an interview on [DATE] at 12:36 PM, FM H stated, I got a call on February 4th (2024) from (LPN G) that my mother was dying. I wondered why they did not call earlier since she was a DNR and could go to the hospital. When I got to the facility, (LPN G) told me mother was dying and there was no point in doing anything for her. I asked if the facility had called an ambulance. (LPN G) tried repeatedly to talk me out of sending my mother to the hospital because nothing could be done for her she thought. Another nurse told me she thought my mother had a stroke. (LPN G) was was so frazzled I called all my relatives telling them mom was dying. I got ahold of my older brother, and he said to get her to the hospital immediately. (LPN G) was wondering why I would have her sent to the hospital when mother was DNR. Turns out mom was severely dehydrated. Mom had a problem with her throat and was not eating or drinking much. She perked up right away when the ER gave her fluids then shipped her to another hospital. There, they found she had a kidney infection from built up of salt in her system which took two weeks to stabilize. The facility was not keeping her hydrated. I was told by the facility's Administrator and Director of Nursing that I should not have been told by (LPN G) my mother was dying. My concern was the medical issue that (LPN G) basically ignored because she though my mother was dying and not wanting to send her to the hospital. Seems like the facility should have known mother was not eating and drinking and she had dehydration and a bad kidney infection. Review of R102's Progress Note dated [DATE] at 17:38 (5:38 PM), reported LPN G was notified at 4:11 pm by a CNA that R102 was not looking well. When the LPN entered the resident's room it was noted the resident was cyanotic (bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood), eyes sunken, warm to the touch, right hand shaking, and not responding to verbal stimulation. Unable to get vital signs. Family Member (FM) H arrived at facility at 5:15 PM. Review of R102's Progress Note dated [DATE] at 20:47 (8:47 PM), reported LPN J entered the resident's room at 7:05 PM to administer PRN (as needed) morphine sulfate. Family stated they wanted the resident to be sent to the hospital. The LPN notified the facility's physician, received an order to send R102 to the hospital. R102 left the facility at 7:58 PM with EMS (emergency medical services) to a local hospital. Review of R102's Medical Record Control Report dated [DATE] at 2016 (8:16 PM), reported the resident was seen at the ER as a priority 1, with a blood pressure (BP) reading of ,d+[DATE] (normal readings lower than ,d+[DATE]), Pulse 140 (normal readings lower than 70 beats per minute), stroke-like symptoms since 4 pm, pinpoint pupils, was not alert and oriented with minimal responses. Review of R102's ED (emergency department) Summary Report dated [DATE], revealed on [DATE] at 20:24 (8:24 PM) after receiving fluids during transfer, the resident's vital signs were BP ,d+[DATE], P 80, respirations (R) 24, and oxygen saturation (PO2) 96% on room air (RA). History of present illness .altered mental status (AMS) . was sent in for evaluation for a possible stroke because she was not responding appropriately and had sunken in eyes. Upon arrival she was able to respond to simple yes or no questions, follow minimal commands, and appeared to be following in conversation .Initial concern was for patient nearing the end of her life as patient is a DNR and had been steadily declining since being at her rehab facility. This was also the impression given to hospital by staff at the nursing home. However, upon speaking to family, they stated that this shift in her condition was sudden over the past few days. Due to this, further workup was performed. Workup was notable for a leukocytosis (high white blood cell count), significant hemoconcentration (abnormally high concentration of blood, thickened or concentrated) likely due to dehydration (caused by not drinking enough fluid or by losing more fluid than you take in). AKI (acute kidney injury) (abrupt decrease in kidney function) is present with a creatinine of 3.4 (0.97 near normal in elderly) and GFR (glomerular filtration rate) (chief measure of kidney function) of 13, (near normal 75) with no reported history of kidney disease. Patient was noted to be significantly hypernatremic (lower level than normal sodium in blood caused by limited fluid intake, presents as confused and fatigued, and requires hospitalization ) at 166 (normal ,d+[DATE]), with an elevated chloride of 124 (normal ,d+[DATE]) (sign of dehydration), and elevated serum osmolality at 343 (normal ,d+[DATE]) (sign of dehydration. Patient was straight cathed for a urine sample and was found to have extremely concentrated urine with evidence of an infection (UTI) .Foley catheter was inserted to accurately monitor urine output . Patient was transferred in stable but critical condition to (name of larger acute care hospital) ICU (intensive care unit) .Diagnoses included dehydration, AMS, AKI, acute UTI. This surveyor attempted to interview Licensed Practical Nurse (LPN) G on [DATE] at 10:17 AM but was unable to leave a voicemail due to it being full. R103 According to the Minimum Data Set (MDS), R103 scored 4 /15 (severely cognitively impaired) on his BIMS (Brief Interview Mental Status), with diagnoses that included metabolic encephalopathy and need for assistance with personal cares. Review of R103's Incident Report (IR) dated [DATE] at 5:45 AM, indicated the resident was found in his room lying on the floor next to his bed. No injuries reported at that time. Review of R103's IR dated [DATE] at 06:00 AM, indicated the resident was found in his room sitting on the floor in front of a couch. A skin tear 2 x 2 cm (centimeters) was noted on his right lower leg/shin. First aid was applied to the right shin. Review of R103's Order Summary, dated [DATE], indicated two abrasions to the resident's right lower leg was to be cleaned with normal saline, patted dry, with triple antibiotic ointment applied then covered with a border foam dressing every other day and as needed. Monitoring for infection every 2 hours. Review of R103's Order Summary, dated [DATE], indicated a new right shin skin tear to the resident's right shin that was to be cleaned with normal saline, patted dry, with mepiplex (absorbent dressing) applied every other day on the evening shift. It was noted an addendum to the Order Summary was added also on [DATE] to monitor the new skin tear to right shin daily for signs and symptoms of infection on every shift. Review of R103's Order Summary, dated [DATE], indicated a new skin tear to the resident's right shin that was to be cleaned with normal saline, patted dry, and covered with a comfort foam dressing every other day and as needed. Monitoring for infection was to be done every 24 hours. Further review of R103's Order Summary did not indicate or contain physician's orders for skin tears, abrasions, or wounds to the resident's left leg. Review of R103's Medication Administration Record/Treatment Administration Record (MAR/TAR) dated [DATE]-[DATE] indicated: -[DATE] Cleanse abrasions x2 to the RLE (right lower extremity) with NS (normal saline), pat dry, apply TAO (triple antibiotic ointment) and comfort foam drsg (dressing) every other day and as needed ([DATE]). Monitor for infection every day shift every other day. Start date [DATE] 0700 (AM). It was noted this was placed on the MAR/TAR two days after the physician's order was obtained. Review of R103's MAR/TAR dated [DATE]-[DATE] indicated: -Cleanse NEW R (right) shin ST (skin tear) w/NS (with normal saline), pat dry, apply comfort foam drsg every other day and as needed. Monitor for infection every evening shift every other day for wound care. Start date [DATE] 1900 (7 PM). It was noted, the order was not documented as being completed on [DATE]. Review of R103's MAR/TAR dated [DATE]-[DATE] indicated: -Skin Assessment weekly on Saturday every day shift every Saturday. Start date [DATE] 0700. It was noted this was documented as being completed on [DATE] and [DATE] with only vital signs being entered. Review of R103's Care Plan, dated [DATE], indicated the focus of Potential Skin Breakdown related to fragility of skin and multiple abrasions. The goal was for current abrasion to heal without complications. To meet this goal, interventions included providing treatments to abrasions as ordered. Observed on [DATE] at 11:22 AM, R103 with 2 border-form dressings on both shins, dated ,d+[DATE]. Observed on [DATE] at 9:08 AM, R103 with 2 border-form dressings on both shins, dated ,d+[DATE]. Observed on [DATE] at 8:20 AM, R103 with 2 border-form dressing on both shins, dated ,d+[DATE]. During an observation and interview on [DATE] at 8:30 AM, Registered Nurse (RN) C entered R103's room with surveyor and looked at the resident's shins. On each of his shins, right and left, were two border-foam dressings labeled ,d+[DATE]. RN C stated, Today's date is ,d+[DATE]. During observation, interview, and record review on [DATE] at 8:35 AM, Unit Manager (UM) D entered R103's room with surveyor. UM looked at the resident's shins stating, (R103) has two border-foam dressings on each shin that are dated ,d+[DATE]. The UM stated, ,d+[DATE] was three days ago. After leaving the resident's room, UM reviewed R103's medical record, Order Summary and MAR/TAR, stating, (R103) does not have an order for the two dressings on his left shin. Nurses will not know to monitor and change the dressing if the treatment order is not put in the MAR. UM D further reviewed the Order Summary and MAR/TAR stating, (R103) should have his dressing changed on his right shin every other day. It does not state on what shift. If a time is not indicated on an order, the treatment may get missed and the wound could get worse.

Based on observation, interview and record review, the facility failed to prevent the development of 2 facility acquired pressure ulcers and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of policy Prevention of Pressure Ulcers/Injuries revised July 2017, revealed, .Risk Assessment .e. Reposition resident as indicated on the care plan .Mobility/Repositioning .3. Reposition residents who are reclining and dependent on staff for repositioning .4. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort . Review of an Face Sheet revealed Resident #38 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #38, with a reference date of 3/23/21 revealed a Brief Interview for Mental Status (BIMS) score of 5 out of a total possible score of 15, which indicated Resident #38 was severely cognitively impaired. The MDS revealed, .Section G - Functional Status .Bed Mobility: Self-performance .3. Extensive assistance - resident involved in activity; staff provide weight-bearing support .3. Two+person physical assist .Section GG - Functional Abilities and Goals .Roll left and right .2. Substantial/maximal assistance .Sit to Lying .88. No attempted due to medical condition or safety concerns .Lying to sitting on bed side .88. No attempted due to medical condition or safety concerns . Review of Braden Risk Assessment Report dated 10/24/2020, revealed, .Risk Score: 16 .Risk level: Mild .Activity: Chair Fast - Ability to walk severely limited or non-existent. Cannot bear weight and/or must be assisted into chair or wheelchair .Friction & Shear: Problem - Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance . Review of Braden Risk Assessment Report dated 3/22/21, revealed, .Risk score: 13 .Risk level: Moderate .Moisture: Very Moist - Skin is often, but not always, moist. Linen must be changed at least once a shift .Activity: Chair Fast - Ability to walk severely limited or non-existent. Cannot bear weight and/or must be assisted into chair or wheelchair .Friction & Shear: Problem - Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance . Review of CNA (Certified Nursing Assistant) Care Guide dated 4/13/21, revealed, .(Resident 38) E1 for Bed Mobility .AM (Air mattress) .PUREED fortified, shakes with meals .Reposition q2h (every 2 hours) to bilateral buttocks . Review of Progress Notes dated 3/5/21 10:28 PM, revealed, .Resident repositioned every two hours thus far this shift with incontinence check/care as needed and will con't (continue) throughout the night; bilat buttocks and posterior scrotum washed well with soap and water followed by [MEDICATION(S)] ointment for barrier; Open areas are well healing but slowly . Review of Progress Notes dated 3/9/21 at 4:08 PM, revealed, .MD notified R/T open areas 1. Monitor st(stage) 2 PU's to bilat ischial tub(urosity) for s/sx of infection QD (4 times daily) 2. Cleanse bilat ischial tub with NS (normal saline), pat dry, apply [MEDICATION(S)] and comfort QD . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Wound assessment dated [DATE] revealed, .Wound Location: Left buttock, ischial tuberosity .Stage: Unstageable due to slough/eschar .Drainage: Serosanguineous, small .Measurements: Length - 1.50 CM, Width - 0.50 CM, Depth - No entry .Wound bed: Epithelial Tissue - 50.00%, Granulation Tissue - 25.00%, Slough - 25.00%, Eschar - No entry .Wound Edges - Well Defined, Description - Normal healthy skin .Current Weight - 188.50 . Review of Wound assessment dated [DATE] revealed, .Wound Location: .Right Buttock .Stage: Unstageable due to slough/eschar .Drainage: Serosanguineous, scant .Measurements: Length - 1.70 CM, Width - 0.70 CM, Depth - No entry .Wound Bed: Epithelial tissue: 50.00%, Granulation Tissue - 20.00%, Slough - 30.00% .Weight - 188.50 .Treatments: 3/9/21 Promod Liquid Protein Give 30 ml by mouth twice daily, Wound healing, 3/9/21 Monitor ST(stage) 2 Pressure Ulcers to Bilat ischial Tub for s/sx of infection daily, 3/9/21 cleanse bilat ischial tub pressure ulcers with ns, pat dry, apply [MEDICATION(S)] and comfort drsg daily, 10/10/20 - Air mattress to bed - verify placement and inflation every shift . Review of Resident Incident Report dated 3/9/21, revealed, .Incident type: Acq (Acquired) Pressure Ulcer .assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] .R (right) ischial tuberosity, L (left) ischial tuberosity .assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] .Medical Risk Factors possible related to incident: Confusion/Disorientation, Incontinency, B&B (Bowel & Bladder) Urgency .Immediate Post Incident Action: Prostat, ROHO cushion . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nutritional Risk Review and assessment dated [DATE] (9 days after pressure ulcer development), revealed, .Type of Review: Change of Condition .Skin Integrity: Skin Not-Intact, PU (pressure ulcer) left buttock, unstageable (1.5x0.5), PU RT (right) buttock, Stage 2 (1.7x0.7), excoriation to sacrum (3x2cm) .Skin Condition: Stage III or IV pressure ulcer or multiple impaired areas .Relevant conditions and Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .Nutrition Pressure Ulcer Risk Score: 3 or more = High Risk . Review of Progress Notes dated 3/19/21 at 6:06 AM, ' .Unstageable to bilat ischial tuberosities TX completed, no s/sx of infection .Res repositioned with incontinence care q 2 hours and PRN . Review of Progress Notes dated 3/23/21 at 1:42 PM, .Resident reports constant pain rated 10/10 . Review of Wound assessment dated [DATE] revealed, .Left buttock, ischial tuberosity .Stage: Unstageable due to slough/eschar .Drainage: Serosanguineous, scant .Measurements: Length - 2.50 CM, Width - 1.20 CM, Depth - No entry .Wound bed: Epithelial tissue - 50.00%, Granulation - 25.00%, Slough - 15.00%, Eschar - 10.00% .Weight - 177.50 . The documentation indicated worsening of the pressure ulcer from 3/9/21. Review of Wound assessment dated [DATE] revealed, .Right Buttock .Stage: Unstageable due to slough/eschar .Drainage: Serosanguineous, scant .Measurements: Length - 1.40 CM, Width - 0.60 CM, Depth - No entry .Wound Bed: Epithelial tissue: 50.00%, Granulation Tissue - 20.00%, Slough - 30.00% .Weight - 177.50 . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Progress Notes dated 4/2/21 at 10:05 AM, revealed, .Resident is turned and repositioned Q2 (every) hours and PRN (as needed) . Review of Progress Notes dated 04/5/21 at 12:51PM, revealed, .Patient position changed every two hours and needs are initiated by staff . Review of Progress Notes dated 04/6/21 at 3:15 PM, revealed, .Resident repositioned throughout shift . Review of Progress Notes dated 04/7/21 at 10:24 PM, revealed, .Resident repositioned every two hours so far this shift .Resident rated his pain at 5 earlier in shift with PRN [MEDICATION(S)] utilized and effective . Review of Progress Notes dated 04/8/21 at 4:25 PM, revealed, .Resident repositioned every 2 hours and incontinent care provided as needed . During an observation on 4/11/21 at 10:49 AM, Resident 38 was observed in his bed laying on his back, flat in the bed. During an observation on 04/11/21 at 11:30 AM, Resident 38 observed laying in his bed on his back, head of the bed elevated approximately 20 degrees. During an observation on 04/11/21 at 12:09 PM, Resident 38 observed laying in bed on his back. During an observation on 04/11/21 at 02:44 PM, Resident 38 was observed laying flat on his back in his bed. During an observation on 04/11/21 at 03:26 PM , Resident 38 observed laying flat on his back in his bed. During an observation on 04/12/21 at 08:55 AM, Resident 38 was observed laying flat on his back in his bed with his eyes closed. During an observation on 04/12/21 at 09:10 AM, Resident 38 was observed laying flat on his back in his bed with his eyes closed. During an observation on 04/12/21 at 11:32 AM, Resident 38 observed laying on his back in his bed. Resident was laying flat in bed. In an interview on 04/11/21 at 10:06 AM, Licensed Practical Nurse (LPN) H reported the dressings were changed daily and were just completed on third shift last night.(Resident 38) was assessed weekly and every quarter .The pressure ulcer on the right side was healed .Resident was to be repositioned every 2 hours .(Resident 38) doesn't want to get up anymore . During an observation on 04/12/21 at 12:48 PM, Certified Nursing Assistant (CNA) I was assisting resident with his lunch. Resident 38 was laying on his back with the head of the bed elevated approximately 60 degrees. CNA I reported he has not been eating much. Resident 38 observed eating a few bites of mashed potatoes and gravy. During an observation on 04/12/21 at 02:04 PM, Resident 38 was observed in his bed laying on his back with his eyes closed. Resident 38 has the blue bolster under his knees causing his knees to bend approximately 20 degrees. Review of Progress Notes dated 4/12/21 at 4:40 PM, revealed, .Resident repositioned every 2 hours and incontinent care provided as needed. Dressing to rt ischial tuberosities changed and is C/D/I with on s/sx of infection. Resident utilized PRN [MEDICATION(S)] during this shift . During an observation on 04/13/21 at 09:25 AM, Resident 38 was observed laying in bed on his back, knees bent upward. Activity Director W entered the room and asked resident what he needed, informed her he had .to go potty . and she turned on the call light for Resident 38. Activity Director W lowered resident's bed to the lowest position. During an observation on 04/13/21 at 12:33 PM, Resident 38 observed in his bed laying on his back, head of the bed is elevated approximately 80 degrees, and was drinking apple juice. During an observation on 04/13/21 at 02:13 PM, Resident 38 was observed laying on his back in his bed with the head of the bed elevated approximately 40 degrees. During an observation on 04/13/21 at 02:52 PM, Resident 38 observed laying on his back in his bed. During an observation on 04/14/21 at 10:57 AM, Resident 38 was observed sitting in his wheelchair next to his bed. Resident 38 asked if he was done with therapy so he could get back into bed .Resident 38 pressed call light . He was trying to pull oxygen tubing out from under his wheelchair wheels. During an observation and interview on 04/14/21 at 11:05 AM, Resident 38 stated that his bottom hurt bad, and he is in pain and his legs hurt. Resident 38 stated that he wanted to get back in bed. Registered Nurse (RN) G entered the room and was asking the resident about his pain level. Resident 38 indicated he had a lot of pain. RN G informed resident she would get him something for the pain and replace his oxygen tubing as it had been on the floor. Rehabilitation Manager DD entered the room with an oxygen tank to take Resident 38 to therapy. Review of Care Plan as of 4/14/21 revealed, .Resident is at risk for skin breakdown r/t (related to) A. Fib (Atrial Fibrillation), decreased mobility, incontinence, CHF (congestive heart failure), pulmonary [CONDITION(S)] (hypertension) [CONDITION(S)], hospice, pressure ulcers . with the intervention of .Assist with Bed Mobility as needed .Fluctuates from extensive to total assistance .Requires two-person assistance at times .Turn and reposition as needed . Review of Wound assessment dated [DATE] revealed, .Left buttock, ischial tuberosity .Wound Status: Deteriorated .Stage: Unstageable due to slough/eschar .Drainage: Serosanguineous, scant .Measurements: Length - 1.40 CM, Width - .90 CM, Depth - .70 CM .Wound bed: Epithelial tissue - 50.00%, Granulation - 25.00%, Slough - 25.00%, Eschar - 0.00% .Weight - 164.00 .

This citation includes intake MI 2472. Based on observation, interview, and record review, the facility failed to prevent multiple elopements of one (Resident #1) of one reviewed for elopement, resulting in immediate jeopardy when Resident #1, who was a known exit seeker, eloped out of a window unbeknownst to staff on 1/9/19, 3/14/19, and 3/22/19 and the likelihood for serious harm, serious injury, serious impairment or death. This deficient practice places 11 residents whom the facility identified at risk for elopement, at risk for serious harm, serious injury, serious impairment, or death. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 (R1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed R1 scored 7 out of 15 (indicating severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and wandered daily. R1 was admitted into one of the facility's locked behavioral care units. Review of R1's baseline care plan dated 1/8/19, revealed I am at risk for elopement as evidenced by: elopement while at home, wandering, verbally expressed desire to go home, and one or more of the following Diagnoses: [REDACTED]. The goal was listed as will remain in facility unless accompanied by staff or family. The approaches/interventions were listed as: elopement risk assessment, ensure staff is aware of resident's wander risk, utilization of check in/out log, exit and stairwell alarms, secure unit, review medications, and add resident photo to wander list. R1's Activities of Daily Living (ADL) care plan dated 1/8/19, revealed R1 needed assistance with transfers and ambulation. Review of R1's medical record revealed an elopement risk assessment was not completed. 1/9/19 (first elopement from the facility): Review of the Nurse's Notes dated 1/9/19 at 7:08 PM, revealed resident increasingly anxious to leave, states there is nothing wrong with him. Frequently requesting to call wife. After 4 calls home this shift, resident verbally aggressive towards wife and given diversional activities, easy to redirect. No aggression with staff. When asked to call prior to dinner, resident distracted with food coming soon. States thank you, thnk (sic) you, God bless and returns to room. Within 5 minutes staff report his window to be open and resident had climbed out into courtyard .resident provided one on one activity at all times following. In a telephone interview on 4/8/19 at 11:51 AM, Licensed Practical Nurse (LPN) K reported he was working when R1 eloped on 1/9/19. LPN K reported R1 had gone to the dining room and asked to call his wife. LPN K reported he told R1 that the meal trays were coming and they would eat and then try to call R1's wife again. LPN K reported R1 was then in his room. LPN K reported he was sitting with another resident, reading, when Unit Manager (UM) D came to the unit and asked if they were missing anyone. LPN K reported no alarms were sounding so he did not think anyone was missing. LPN K reported when he observed R1's window, there was a silver lock in place, but if the lock was not pushed down or screwed down all the way, the lock could move. LPN K reported it looked like R1 popped the window out of place, over the lock, and climbed outside. When asked what was done to prevent recurrence, LPN K reported R1 was placed on one on one supervision. LPN K reported he thought R1 was outside less than 5 minutes between going outside and when (UM D) saw him. He (R1) had on 3 shirts and 2 pair of pants. He had bundled up. When asked if residents from the locked unit were allowed in the courtyard, LPN K stated not without staff . In an interview on 4/11/19 at 2:16 PM, (Certified Nursing Assistant (CNA) S reported that on 1/9/19, UM D came to the Magnolia Unit and asked where R1 was. CNA S reported he was not aware R1 had eloped from his window. When asked if R1 voiced wanting to leave the facility that day, CNA S stated probably, he always does. CNA S reported R1 was able to move the window locking mechanisms. CNA S stated R1 will keep opening the window and it will budge the lock about a half inch at a time. There was one time where he went to the dining room window and could budge the lock a half inch at a time and get his head out. CNA S reported R1 was so strong that he could open the magnetic door. Review of the Nurse's Note dated 1/10/19, revealed .the resident had exited his unit on multiple occasions (3 times as of now) . The Nurse's Note dated 1/16/19, revealed Dr (doctor) in to see resident regarding recent aggressive behavior, exit seeking and wandering . The Nurse's note date 1/21/19, revealed R1 was exit seeking and wanders frequently. The Nurse's Note dated 1/25/19, revealed resident expresses desire to go home with wife and expresses the desire to get out of here with questioning as to why he is here. (Resident) displays intermittent periods of increased anxiety/agitation. The Nurse's Note dated 1/26/19, revealed R1 has been exit seeking all day. The only time resident hasn't been exit seeking is the 2 hours residents wife was here. The Nurses Notes dated 1/27/19, 2/2/19, and 2/5/19, revealed R1 was exit seeking. Review of the Nurse's Notes dated 3/2/19, 3/5/19 revealed R1 expressed desire to leave the facility. Review of the Nurse's Note dated 3/12/19, revealed Resident was able to open doors between magnolia hall and view hall. Resident then ran down view hall, with staff right behind resident trying to redirect. Resident was then able to open the door beside view nursing station and went outside. Staff was with resident as he went outside . Review of the Risk for Falls care plan dated 1/21/19, revealed R1 was at risk for falls related to [MEDICAL CONDITION], poor safety awareness, behaviors, and personality disorder and required supervision with ambulation. Review of the Behavior care plan dated 1/21/19, revealed Resident exhibits inappropriate behavior of exiting the behavioral unit related to not thinking he needs to be here. Resident is verbally and physically aggressive and having delusions . Interventions included: redirect resident when agitated or exit seeking, provide diversional activities for resident when upset for various reasons including: talking about GM and cars, old country music, conversation, coffee, and connect 4, offer a snack or drink. 3/14/19 (second elopement from the facility): Review of the Nurse's Note dated 3/14/19, revealed at approximately 1:30pm CENA (Certified Nursing Assistant) heard noise in room [ROOM NUMBER]. Went to determine the cause of the noise when another resident exited room [ROOM NUMBER] and stated that crazy man is in my bed, he just went out the window. CENA observed resident walking at a brisk pace outside of the facility. Elopement procedure initiated and resident was redirected back into the facility . In an interview on 4/8/19 at 11:23 AM, LPN I reported she was working on 3/14/19. LPN I reported the Nurse Practitioner (NP) had just finished assessing R1. LPN I reported she walked to the end of the hall, let the NP into the office and then told CNA F that she was going to get a pop out of the vending machine (off the unit). LPN I reported CNA M was in training and sitting in the dining room monitoring. LPN I reported R1 eloped from the window in room [ROOM NUMBER] (another resident's room) on 3/14/19. LPN I reported the window slightly opened and R1 took the window of the tracks even though the window had a locking mechanism in place. When asked what was being done to prevent another elopement, LPN I stated the medicine is working more .we do a lot of distraction, therapeutic communication, try to keep his mind busy. LPN I did not mention increased supervision. In an interview on 4/8/19 at 12:02 PM, CNA M reported that on 3/14/19, she was in training and was sitting in the Magnolia dining room, completing online training when R1 eloped. In a telephone interview on 4/10/19 at 11:50 AM, CNA J reported she was working on a different hallway on 3/14/19 when R1 eloped from the facility. CNA J reported CNA F came to meadow hall and said R1 got out and was over the fence. CNA J stated if you look out Meadow (unit) there is a fence and he (R1) was beyond that. In an interview on 4/11/19 at 2:00 PM, CNA F stated on 3/14/19, I was in the hallway standing there. I never even saw (R1) get up. All of a sudden I heard something fall so I made my way down there. (Resident's name) in room [ROOM NUMBER] was like 'I told him to get out of my bed' so I kept walking and got to room [ROOM NUMBER] and saw (R1) out the window .I don't know why I didn't say it on my walkie talkie. Out of instinct I ran to Meadow and told them, and then ran to View Hall and let the nurses know and then I went out there (outside). When asked if anyone else was on the unit at the time, CNA F reported LPN I had just left to get a pop and CNA M was in the dining room doing her charting and watching the residents in the dining room. When asked where R1 was when staff arrived outside, CNA F stated there is black fencing out back and then there is a path that leads back. There is a white house and he was a little bit past there. When asked if R1 came back into the facility easily, CNA F stated No. He was scared. You could see it in his eyes. He didn't know where he was. He had it in his mind that he needed to get to a highway and get home .He was freaked out because he didn't know where he was and didn't recognize anything. Review of the Behavior Care Plan dated 1/21/19, revealed 3/14/19, increased supervision initiated. Med changes per NP (Nurse Practitioner) was added. There was no indication this intervention was ever discontinued. Review of the Social Services Note dated 3/15/19, revealed R1 mentioned going home to his wife. The Nurse's Note dated 3/17/19, revealed After breakfast resident went through fire doors by hitting door with all body weight, staff stopped resident at the view nurses station and was able to redirect resident back to magnolia unit .Resident calmed down for one hour laid down in bed then hit door open again . The Social Services Note dated 3/18/19, revealed Resident has been continuously agitated and anxious this morning. Resident is still exit seeking and has been calling his wife to come and get him, and that needs a ride home . Review of the Social Services Interdisciplinary Team Meeting Note dated 3/18/19, revealed .increased supervision initiated, windows on unit adusted (sic) .resident wanders frequently. Review of the Social Services Note dated 3/21/19, revealed .The residents wife, (name), came to the facility on ,[DATE], 3/19, and 3/20. The resident was anxious, delusional, and exit seeking upon her leaving . The Social Services Note dated 3/21/19 at 7:35 PM, revealed Resident exited the unit during 1st shift and stated that he had to leave and need to get to his car. Social worker took the resident to a window to see that his car was not in the parking lot and that his wife had the vehicle .The resident continued to be exit seeking throughout the social workers shift. The resident had delusions that he was at GM (General Motors) and had a meeting to go to. Resident was redirectable, but the delusions continued. 3/22/19 (third elopement from the facility) Review of the Nurse's Note dated 3/23/19 at 12:53 AM, revealed At about 7:15pm (on 3/22/19) this nurse was informed that the res (resident) was in the front parking lot. This nurse remained on the unit while (Licensed Practical Nurse (LPN) H) and other various staff members assisted in retrieving the res. Upon further investigation it appears that the res had exited the facility via a window in another residents room. The res had eloped returned with staff at about 7:30pm . In a telephone interview on 4/8/19 at 1:15 PM, LPN H reported she was working when R1 eloped on 3/22/19. LPN H stated I hadn't worked with him a lot. Throughout the day he was agitated and kept asking to leave. I redirected him, put on movies, did a puzzle. It would work for about 20 minutes and he would get agitated again. LPN H reported at shift change, herself and the oncoming nurse were in the dining room counting narcotics when R1 came up and asked when the bus left tonight. LPN H reported she told R1 it was too late and no more buses were coming tonight. LPN H reported R1 then asked I can't leave?. LPN H reported she told R1 it was too late, walked R1 to his room, and told him he could stay there for the night. LPN H reported R1 said ok and sat on the bed. LPN H reported she then went back to the dining room to finish counting narcotics and then 5 to 6 minutes later, she heard code pink. LPN H stated when I went to help is when I realized he got out of a window. LPN H reported it was the window in room [ROOM NUMBER]. LPN H reported she was not aware of R1 eloping from a window prior to 3/22/19. When asked what interventions were in place on 3/22/19, LPN H stated I believe just a lot of redirection. Just trying to redirect him into activities. LPN H did not mention increased supervision. LPN H reported R1 got the window over the locking mechanism. He used force and broke the mechanism. LPN H reported there was talk of placing double locks on the windows. LPN H reported since then, R1 kicked the screen out of a dining room window. In a telephone interview on 4/15/19 at 3:11 PM, LPN L reported on 3/22/19, she was in the dining room doing report and counting narcotics with LPN H. LPN L reported the unit hallway was not visible from the dining room. LPN L reported it was possible CNA S went to break since two nurses were on the unit. When asked if she was aware R1 had a history of [REDACTED]. He was forcing windows open. He needed a closer eye, that was a mistake. In an interview on 4/11/19 at 2:16 PM, CNA S reported he worked when R1 eloped on 1/9/19 and on 3/22/19. When asked about the elopement on 3/22/19, CNA S reported he went to break while there were two nurses on the unit. CNA S reported approximately 10 to 15 minutes into his break, another aide came and reported R1 had gotten out of the building. CNA S reported R1 got out of the window in room [ROOM NUMBER] and stated even with the bolts on it and the lock, he got it over the lock .That was like his 'go to room'. In an interview on 4/11/19 at 2:33 PM, Occupational Therapist (OT) T reported on 3/22/19 he attended the facility's staff gala and was not working. OT T reported at approximately 7:20 PM, him and his wife were pulling out of the parking lot after the gala. OT T stated I happened to look to the right, did a double take, and noticed (R1) on the side of the building. I pulled up and started walking towards him. OT T reported R1 was approximately 6 to 7 feet back on the side of the building, on the sidewalk. OT T reported R1 stated he was in a hurry and trying to get home. OT T reported he then called the facility and staff responded. Review of the Behavior Care Plan dated 1/21/19, revealed on 3/22/19 Increased supervision, med review per NP was added again. There was no indication this intervention was ever discontinued. Another undated intervention included increased supervision at time, requires maintaining distance to decrease agitation and/or aggression. In an interview on 4/11/19 at 2:39 PM, Maintenance Director (MD) C reported initially, all the windows on the Magnolia Unit could open 3 inches. MD C reported the first window adjustment was pushing the locking mechanisms closer so that the windows could not be opened. MD C reported he tried to open the windows for 5 to 10 minutes without success so he knew R1 must have had some time to work on the opening the windows. MD C reported on 3/14/19, R1 must have jiggled the window and lifted it up over the lock. MD C stated once you get it over the lock, you can push it. When asked about the 3/22/19 elopement, MD C stated he had the one lock all the way up against it and then two screws in the track so you couldn't pick it (the window) up. I couldn't try it, but obviously he had a lot of time to try it. I lifted it up and couldn't get it to move. When asked about window audits, MD C reported he thought audits were done every 3 months and knows they were not done monthly. When asked about the locking mechanisms, MD C stated the locks on the bottom are set screws and don't go through the track. You can bang it and bang it and move it. If you really want it open, you can get it open. The locks can move. An observation on 4/8/19 at 12:14 PM revealed R1 was sitting at a dining room table, next to the window eating lunch. Both dining room windows were opened approximately 2.5 inches. One window had a broken screen. All other windows on the unit had a locking mechanism in place at the window base along with screws at the top of the windows. room [ROOM NUMBER] had two locking mechanisms in place at the base of the window along with screws at the top. In an interview on 4/8/19 at 12:21 PM, Director of Nursing (DON) B reported the facility held Interdisciplinary Team meetings weekly and R1 triggers for exit seeking every week. On 4/8/19 at 12:30 PM, DON B reported an elopement risk assessment was not completed for R1. An observation on 4/8/19 at 4:50 PM, revealed the facility's parking lot was paved and included potholes and uneven pavement. The speed limit on the road out front is 50 mph. In an interview on 4/8/19 at 2:23 PM, Nursing Home Administrator (NHA) A and DON B reported increased supervision was one on one supervision. NHA A and DON B reported R1 was still on one on one supervision during first and second shifts, but not on third shift. NHA A reported when R1 got into the courtyard on 1/9/19, no adjustments were made to the windows, rather R1 was put on one on one supervision to monitor his behaviors. NHA A reported the incident on 1/9/19 was not considered an elopement because R1 got into the enclosed courtyard and then walked back into the building. NHA A reported R1 was not unsafe. An observation on 4/8/19 at 9:07 AM, revealed R1 was walking through the hall alone. At 9:10 AM, R1 was observed sitting on a couch in the dining room. At 9:12 AM, R1 was observed ambulating back to his room with a staff member. At 9:15 AM, R1 was observed lying awake in his bed. There was not a staff member in his room. In a telephone interview on 4/15/19 at 10:19 AM, CNA O reported she was scheduled to be one on one with R1 on 4/8/19. CNA O reported she never received training regarding one on one supervision. CNA O reported when she got to work on 4/8/19, she was told by another aide that she would have to help with other residents because it was too much work for one other CNA to handle. NHA A was presented with Immediate Jeopardy Notification on 4/8/19 at 3:05 PM, due to the facility's failure to prevent multiple elopements of one (Resident #1) of one reviewed for elopement, resulting in Resident #1, who was a known exit seeker, eloped out of a window unbeknownst to staff on 1/9/19, 3/14/19, and 3/22/19 and the potential for serious harm, serious injury, serious impairment or death. A corrective action plan was requested from the facility to remove the immediate jeopardy. Immediate Jeopardy was removed on 4/8/19 when the facility had the following in place: 1. Resident #1 was assessed by the MDS Coordinator on 04/08/19 with no signs or symptoms of injury related to the incident. 04/08/19 the 1:1 staff member was immediately re-educated by the Director of Nursing to ensure appropriate 1:1 supervision is in place for the resident. 2. The staff member assigned to 1:1 supervision of Resident #1 on 04/08/19 for first shift was suspended by the Director of Nursing pending investigation. 3. Physician Assessment was completed on the morning of 04/08/19. Based upon consultation with the Interdisciplinary Team and Psych services, recommendation and new orders were obtained to transfer resident to inpatient Psychiatric treatment for [REDACTED]. Physician discussion with Director of Nursing revealed adverse reaction to recent medication adjustment. The 1:1 supervision remained in place until the resident was transferred. Resident was transferred to (name of neuropsychiatric hospital) at 9:45 pm. 4. Nurse Managers were re-educated by the Regional Director of Clinical Services on completion of the Elopement Risk Assessment on 04/08/19. An Elopement Risk Assessment was completed by Nurse Managers for all residents on Magnolia Lane secured behavioral support unit on 04/08/19 with 11 residents identified as at risk for elopement. No other residents were identified to need 1:1 supervision. 5. Care Plans were updated on 04/08/19 by the Nurse Managers to reflect Risk Assessments and appropriate interventions. Elopement Risk Assessments will be completed upon Admission, and with Quarterly Assessments. 6. A [MEDICATION NAME] was placed on all windows on Magnolia Lane per the 5 day submission for the incident dated 03/14/19. The [MEDICATION NAME] was moved closer, so the windows could not be opened as far, per the 5 day submission for the incident dated 03/22/19. A second window [MEDICATION NAME] was installed on all windows on Magnolia Lane on 04/08/19 by the Maintenance Assistant and both [MEDICATION NAME] are flush against the window to prevent the window from being opened. The Maintenance Director or Manager on Duty will complete daily rounds X4 weeks, and weekly rounds X8 weeks of Magnolia Lane to assess each window for security. Changes to the auditing process will be determined by the Quality Assurance Performance Improvement Committee. 7. All staff were educated by Department Managers on the requirements for 1:1 supervision on 04/08/19. Staff who were not educated on 04/08/19 will not work until the education has been completed. A 1:1 supervision tracking log was initiated on 04/08/19 while residents require 1:1 supervision. The Director of Nursing will be responsible to review these logs daily X 3 months. Any changes to the auditing process will be determined by the Quality Assurance Performance Improvement Committee. 8. Elopement Drills will be completed on all shifts by 04/09/19. Elopement drills will be completed on all shifts monthly X 3 months and reported to the Quality Assurance Performance Improvement Committee. 9. On 04/09/18 the Maintenance Director inspected the Mag Locks on the Magnolia Lane secured unit doors. Doors are noted to be functioning appropriately. The Maintenance Director will continue to inspect the secured unit mag locks monthly, through the (name of maintenance request) system. Although the Immediate Jeopardy was removed on 4/8/19, the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the State Agency.

This citation pertains to intake MI 863. Based on interview and record review, the facility failed to provide adequate staffing on the Magnolia Lane unit, affecting up to 8 residents residing on the unit, in 1 of 4 residents reviewed for falls (Resident #,[DATE]), resulting in injuries from falls, facial fractures, and contributing to residents death. Findings include: Departmental Notes [DATE] at 5:47 PM indicated Resident #,[DATE] (R,[DATE]) arrived to the facility with his daughter and an alarm to his wheelchair and bed were put into place per daughters request. R,[DATE]'s Minimum Data Set (MDS) 3.0, dated [DATE] revealed he was admitted to the facility on [DATE], and the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, was 6 (score of ,[DATE] indicated severe impairment). The same MDS assessment indicated R,[DATE] required extensive assistance (resident involved in activity, staff provide weight-bearing support) of one person physical assist in Bed Mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), Transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), Eating, Toilet Use (how resident uses the toilet or urinal, transfers on/off toilet, cleanses self after elimination; adjusts clothes), Personal Hygiene (combing hair, brushing teeth, shaving, washing/drying face and hands). The same MDS assessment revealed R,[DATE] had the [DIAGNOSES REDACTED]. R,[DATE]'s Admission MDS assessment dated [DATE] indicated, during a 7-day look back period, he was occasionally incontinent (less than 7 episodes of incontinence) of bladder and a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) had not been attempted on admission/entry or reentry or since urinary incontinence was noted in the facility. The same MDS assessment revealed R,[DATE] was continent of bowel. R,[DATE]'s fall care plan dated [DATE] instructed I require extensive assist for transfers and toileting PRN (as needed) and the risk for skin breakdown dated [DATE] instructed to Provide incontinence care as needed . Resident Incident Report and investigation dated [DATE] at 5:00 PM revealed R,[DATE] was found on the floor in his room, on his hands and knees, sustained a skin tear to his left elbow, and was unwitnessed by facility staff. The same investigation indicated R,[DATE] had to use the restroom, that his alarm was sounding, he was attempting to self transfer and became weak and fell to the floor. The same investigation included the interdisciplinary department team's (IDT) interventions/corrective actions taken, that included R,[DATE]'s door was to remain open at all times as resident allowed. R,[DATE]'s Risk for Falls care plan dated [DATE] indicated he was stand-by-assist for all ambulation. In an interview on [DATE] at 10:45 AM, Registered Nurse (RN) D stated R-401 was constantly trying to get up out of his wheelchair. Resident Incident Report and investigation dated [DATE] at 9:15 AM revealed R,[DATE] had fell in the hallway, alarm sounding as resident was attempting to get up from his wheelchair, sustained an abrasion to the left knee and his fall was unwitnessed. Resident Incident Report and investigation dated [DATE] at 4:45 PM, revealed R,[DATE] had fell on his left side in the dining room hitting a stationary chair before he fell to the floor and sustained a hematoma (collection of blood outside blood vessels, a bump) on the left side of his forehead, redness on the left shoulder, back and cheek. The same report revealed R,[DATE]'s alarm had been sounding prior to his fall. Resident Incident Report and investigation dated [DATE] at 6:15 PM revealed R,[DATE] had fell in his room, alarm was sounding, and staff were unable to reach resident prior to the fall, the fall was not witnessed. The same investigation indicated R,[DATE] was referred to hospice and a medication review was going to be completed to prevent future falls. Departmental Notes dated [DATE] at 5:40 PM, indicated R,[DATE] had been working with therapy on gait training. R,[DATE]'s Physician's Telephone Orders dated [DATE] at 8:00 PM, indicated therapy was discontinued effective [DATE]. DON B was interviewed on [DATE] at 12:05 PM and stated a scheduled walking program was not developed for R,[DATE] following the discontinue of therapy services. Resident Incident Report and investigation dated [DATE] at 12:45 PM revealed R,[DATE] had fell when he tripped over his wheelchair foot pedals in the dining room. In the Certified Nurse Assistant's (CNA) statement attached to the [DATE] fall investigation, R,[DATE] was sitting in the in his wheelchair in the dining room eating his lunch when the CNA left to assist another resident in their room, CNA heard R,[DATE]'s chair alarm sounding, the CNA responded to the alarm in the dining room and found R,[DATE] on the lying on the floor. Resident Incident Report and investigation dated [DATE] at 2:15 PM revealed R,[DATE] had fell in the dining room and had injured his left elbow again presenting as a skin tear, and was unwitnessed. Resident Incident Report and investigation dated [DATE] at 11:45 PM revealed R,[DATE] had fell in the dining room and sustained a laceration to his left eyebrow when .trying to stand up from Broda chair. The same investigation report indicated the fall was unwitnessed and the alarm was not on per care plan. Resident Incident Report and investigation dated [DATE] at 6:30 AM revealed R,[DATE] had fell in the dining room and was unwitnessed. The same investigation indicated the night shift CNA had just left the unit and the day shift CNA was in another resident's room providing care. Resident Incident Report and investigation dated [DATE] at 6:45 PM revealed R,[DATE] had fell in the dining room and was unwitnessed. The same investigation revealed R,[DATE] had finished eating dinner at 6:30 PM and was alone and unattended. The same investigation included the nurse's statement that indicated she was tending to another resident at the time of R,[DATE]'s fall. Resident Incident Report and investigation dated [DATE] at 2:30 PM revealed R,[DATE] had fell from his bed in his room, his brief was wet, the fall was unwitnessed and the bed alarm was not in use at the time of the fall as instructed on the care plan. IDT review of actions taken following the fall included moving the bed against the wall. Resident Incident Report and investigation dated [DATE] at 9:30 AM revealed R,[DATE] had fell in the dining room, alarm was sounding, fall was unwitnessed. Resident Incident Report and investigation dated [DATE] at 1:00 PM revealed R,[DATE] had fell in the dining room when attempting to pick food off the floor while in the Broda chair and the Broda chair tipped over on the its side. The same report revealed R,[DATE] sustained a abrasion on his left cheek. The same report indicated the CNA was making a resident's bed and the nurse was feeding another resident in that residents room at the time of R,[DATE]'s fall. Resident Incident Report and investigation dated [DATE] at 7:41 AM revealed R,[DATE] was found in the dining room lying face down on the left side of his face in blood, sustained a laceration to the left side of his forehead and the fall was unwitnessed. The same report indicated prior to the fall, R,[DATE] was left alone and unattended in the dining room drinking coffee. Facility Departmental Notes dated [DATE] at 12:08 PM revealed R,[DATE] was .found laying on the left side of his face in blood on floor, flat with his eyes not moving approx (approximately) one min. (minute) extremities not moving. Possible neck injury. Gauze applied to left eye with light pressure without moving resident to determine active bleeding. Facility Departmental Notes dated [DATE] at 12:13 PM indicated R,[DATE]'s fall occurred [DATE] at 7:40 AM. According to a CNA statement, attached to R,[DATE]'s incident report dated [DATE] at 7:40 AM, R,[DATE] was in the dining room prior to R,[DATE]'s fall and he .continuely (sic) tried to stand up out of his chair but was unsucessful (sic) . and at around 7:30 AM another resident turned on his call light and began yelling; Nurse Assistant reported to the nurse that she was going to help another resident in his room. The same statement indicated that the nurse was at the medication cart counting medications with another nurse; and while the Nurse Assistant was helping the other resident, R,[DATE] .was able to get out of chair an (and) was found on floor by nurse. [DATE] at 9:35 AM Licensed Practical Nurse (LPN) K was interviewed and stated she worked the night shift, on [DATE] through [DATE] (11:00 PM to 7:00 AM shift), and had left the Magnolia Lane unit prior to R,[DATE]'s fall on [DATE] at 7:40 AM. LPN K stated during the same interview, she was at the view nurses station when she heard a page related to a fall on Magnolia Lane. Post-Incident Actions dated [DATE] at 7:41 AM revealed immediate post-incident action was for an evaluation of R,[DATE]'s wheelchair. Resident Incident Follow-up Report dated [DATE], revealed R,[DATE] was transferred to the emergency room for evaluation and treatment and was admitted to the hospital. Hospital History and Physical dated [DATE] at 4:03 PM, revealed R,[DATE] had a 3 centimeter (cm) laceration overlying the left eyebrow with five sutures and large ecchymosis (bruising) surrounding the left eye with extension to the left eyebrow. Hospital Progress Notes dated [DATE] at 11:48 AM, revealed R,[DATE] had the [DIAGNOSES REDACTED]. The same note revealed R,[DATE] had a repeat computerized tomography (CT) scan showed an worsening of the subdural hematoma with a midline shift (shift of the brain past its center line). Discharge Planning social work note dated [DATE] at 12:07 PM indicated family did not want patient to return to the nursing home facility and a sitter was placed at ,[DATE]'s bedside for patient safety. In review of the hospital Discharge Planning social work note dated [DATE] at 4:59 PM, R,[DATE]'s family did not feel there was enough staff at the facility to care of him because of him falling several times. Discharge Planning social work note dated [DATE] at 10:53 AM, revealed the hospital had contacted the NH and they were willing to re-admit R,[DATE] under hospice care, but patient's wife expected the patient to be one on one at the facility, which was unrealistic. [DATE] at 2:00 PM, CNA H was interviewed and stated sometimes they felt the Magnolia Lane unit was not adequately staffed. [DATE] at 9:54 AM, R,[DATE]'s family member E was interviewed and stated he died from the fall at the facility; family member E added the facility was very understaffed and she was very unhappy when the facility took her husbands alarm off because it was bothering other people. R,[DATE]'s Certification Of Vital Record dated [DATE], revealed he was pronounced dead on [DATE] at 5:50 PM due to a complication of subdural hematoma (type of intracrainal hemorrhage); manner of death was due to a fall at a care facility on [DATE], on or about 7:40 AM. Activity Director L was interviewed on [DATE] at 8:35 AM and stated the staff on Magnolia Lane unit were responsible for providing all resident activities. [DATE] at 12:05 PM, NHA A and DON B were interviewed indicated there were always 2 staff members assigned to the Magnolia Lane unit. During the same interview, NHA A was asked if they had considered increasing staff on the Magnolia Lane unit due to the number of R,[DATE]'s unwitnessed falls; NHA A stated the only way they would increase supervision was by doing a one to one, and that was something the facility did not do. NHA A stated during the same interview that she had made it clear to R,[DATE]'s family before he was admitted to the facility that they do not provide one to one staffing. In review of R,[DATE]'s Resident Incident Report's and investigations, he had 15 falls while he was a resident at the facility: 11 out of 15 falls were in the dining room, 9 of which were unwitnessed in the dining room, and a total of 13 out of 15 falls for R,[DATE] were unwitnessed.

This citation pertains to MI 863. Based on interview and record review, the facility failed to ensure residents were free from physical restraints use for purpose of convenience, in 1 of 4 residents reviewed for falls (Resident #1-401), resulting in falls, constipation and incontinence. Findings include: Departmental Notes 5/22/18 at 5:47 PM indicated Resident #1-401 (R1-401) arrived to the facility with his daughter and an alarm to his wheelchair and bed were put into place per daughters request. R1-401's Minimum Data Set (MDS) 3.0, dated 7/6/18 revealed he was admitted to the facility on [DATE], and the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, was 6 (score of 00-07 indicated severe impairment). The same MDS assessment indicated R1-401 required extensive assistance (resident involved in activity, staff provide weight-bearing support) of one person physical assist in Bed Mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), Transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), Eating, Toilet Use (how resident uses the toilet or urinal, transfers on/off toilet, cleanses self after elimination; adjusts clothes), Personal Hygiene (combing hair, brushing teeth, shaving, washing/drying face and hands). The same MDS assessment revealed R1-401 had the diagnoses of [MEDICAL CONDITION], anxiety disorder, and high blood pressure. Resident Incident Report and investigation dated 6/23/18 at 6:15 PM revealed R1-401 had fell in his room, alarm was sounding, and staff were unable to reach resident prior to the fall, the fall was not witnessed. The same investigation indicated R1-401 was referred to hospice and a medication review was going to be completed to prevent future falls. Departmental Notes dated 6/20/18 at 5:40 PM, indicated R1-401 had been working with therapy on gait training. R1-401's Physician's Telephone Orders dated 7/20/18 at 8:00 PM, indicated therapy was discontinued effective 6/26/18. DON B was interviewed on 9/20/18 at 12:05 PM and stated a scheduled walking program was not developed for R1-401 following the discontinue of therapy services. Resident Incident Report and investigation dated 6/29/18 at 12:45 PM revealed R1-401 had fell when he tripped over his wheelchair foot pedals in the dining room. In the Certified Nurse Assistant's (CNA) statement attached to the 6/29/18 fall investigation, R1-401 was sitting in the in his wheelchair in the dining room eating his lunch when the CNA left to assist another resident in their room, CNA heard R1-401's chair alarm sounding, the CNA responded to the alarm in the dining room and found R1-401 on the lying on the floor. R1-401's Physician's Telephone Orders dated 7/19/18 at 11:00 AM indicated a Broda (specialty reclining chair) chair was ordered for comfort. There was no [DIAGNOSES REDACTED]. 9/20/18 at 12:05 PM, a therapy assessment of R1-401's Broda chair was requested from DON B; in which was not provided prior to survey exit. Resident Incident Report and investigation dated 7/19/18 at 11:45 PM revealed R1-401 had fell in the dining room and sustained a laceration to his left eyebrow when .trying to stand up from Broda chair. The same investigation report indicated the fall was unwitnessed and the alarm was not on per care plan. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.15, (MONTH) (YEAR), section P, included CMS's definition of a physical restraint was any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. The same source included examples of a physical restraint were chairs that prevent rising, as a physical restraint, by placing the resident in an recumbent position that restricted rising. The same source indicated there was no evidence that the use of physical restraints would prevent, reduce or eliminate falls and reducing physical restraints may decrease the risk of falling. Resident Incident Report and investigation dated 7/24/18 at 6:30 AM revealed R1-401 had fell in the dining room from the Broda chair and was unwitnessed. The same investigation indicated the night shift CNA had just left the unit and the day shift CNA was in another resident's room providing care. The attached investigation indicated R401-1 was restless starting at 3:00 AM and multiple attempts to stand from Broda. Resident Incident Report and investigation dated 7/24/18 at 6:45 PM revealed R1-401 had fell in the dining room and was unwitnessed. The same investigation revealed R1-401 had finished eating dinner at 6:30 PM and was alone and unattended. The same investigation included the nurse's statement that indicated she was tending to another resident at the time of R1-401's fall. The same investigation indicated R1-401 was trying to walk just before he fell . According to the IDT note, attached to the same investigation, R1-401 had bathroom urgency due to constipation. Resident Incident Report and investigation dated 7/25/18 at 2:30 PM revealed R1-401 had fell from his bed in his room while attempting to self transfer, his brief was wet, the fall was unwitnessed and the bed alarm was not in use at the time of the fall as instructed on the care plan. IDT review of actions taken following the fall included moving the bed against the wall. DON B was interviewed on 9/20/18 and stated a restraint assessment was not completed when R1-401's bed was placed against the wall. DON B stated during the same interview, that R1-401 could still get out on the other side of the bed, and they didn't consider the bed against the wall as a restraint. Resident Incident Report and investigation dated 7/28/18 at 9:30 AM revealed R1-401 had fell in the dining room from the Broda chair, alarm was sounding, fall was unwitnessed. The Fall Scene Investigation Report attached to the incident report indicated prior to the fall R1-401 was in his Broda chair eating breakfast. Resident Incident Report and investigation dated 8/20/18 at 1:00 PM revealed R1-401 had fell in the dining room when attempting to pick food off the floor while in the Broda chair and the Broda chair tipped over on the its side. The same report revealed R1-401 sustained a abrasion on his left cheek. The same report indicated the CNA was making a resident's bed and the nurse was feeding another resident in that residents room at the time of R1-401's fall. Attached to the incident report, post incident actions included lateral supports were placed in Broda chair to assist with proper posture. Resident Incident Report and investigation dated 8/23/18 at 7:41 AM revealed R1-401 was found in the dining room lying face down on the left side of his face in blood, sustained a laceration to the left side of his forehead and the fall was unwitnessed. The same report indicated prior to the fall, R1-401 was left alone and unattended in the Broda chair and in the dining room drinking coffee. Facility Departmental Notes dated 8/23/18 at 12:08 PM revealed R1-401 was .found laying on the left side of his face in blood on floor, flat with his eyes not moving approx (approximately) one min. (minute) extremities not moving. Possible neck injury. Gauze applied to left eye with light pressure without moving resident to determine active bleeding. Facility Departmental Notes dated 8/23/18 at 12:13 PM indicated R1-401's fall occurred 8/23/18 at 7:40 AM. According to a CNA statement, attached to R1-401's incident report dated 8/23/18 at 7:40 AM, R1-401 was in the dining room prior to R1-401's fall and he .continuely (sic) tried to stand up out of his chair but was unsucessful (sic) . and at around 7:30 AM another resident turned on his call light and began yelling; Nurse Assistant reported to the nurse that she was going to help another resident in his room. The same statement indicated that the nurse was at the medication cart counting medications with another nurse; and while the Nurse Assistant was helping the other resident, R1-401 .was able to get out of chair an (and) was found on floor by nurse. On 9/21/18 at 9:35 AM Licensed Practical Nurse (LPN) K was interviewed and stated she worked the night shift, on 8/22/18 through 8/23/18 (11:00 PM to 7:00 AM shift), and had left the Magnolia Lane unit prior to R1-401's fall on 8/23/18 at 7:40 AM. LPN K stated during the same interview, she was at the View nurses station when she heard a page related to a fall on Magnolia Lane. Post-Incident Actions dated 8/23/18 at 7:41 AM revealed immediate post-incident action was for an evaluation of R1-401's wheelchair. Resident Incident Follow-up Report dated 8/23/18, revealed R1-401 was transferred to the emergency room for evaluation and treatment and was admitted to the hospital. Hospital History and Physical dated 8/23/18 at 4:03 PM, revealed R1-401 had a 3 centimeter (cm) laceration overlying the left eyebrow with five sutures and large ecchymosis (bruising) surrounding the left eye with extension to the left eyebrow. Hospital Progress Notes dated 8/24/18 at 11:48 AM, revealed R1-401 had the diagnoses of traumatic subarachnoid hemorrhage (bleeding in space that surrounds brain), traumatic subdural hematoma (collection of blood outside the brain caused by severe head injury), left sided and right sided facial fractures. The same note revealed R1-401 had a repeat computerized tomography (CT) scan showed an worsening of the subdural hematoma with a midline shift (shift of the brain past its center line). R1-401's Certification Of Vital Record dated 9/10/18, revealed he was pronounced dead on 8/31/18 at 5:50 PM due to a complication of subdural hematoma (type of intracrainal hemorrhage); manner of death was due to a fall at a care facility on 8/23/18, on or about 7:40 AM.

This citation pertains to MI 863. Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, in 1 of 4 residents reviewed for falls (Resident #,[DATE]), resulting in increasing the risk of falls and contributing to residents death (#,[DATE]). Findings include: Departmental Notes [DATE] at 5:47 PM indicated Resident #,[DATE] (R,[DATE]) arrived to the facility with his daughter and an alarm to his wheelchair and bed were put into place per daughters request. R,[DATE]'s Minimum Data Set (MDS) 3.0, dated [DATE] revealed he was admitted to the facility on [DATE], and the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, was 6 (score of ,[DATE] indicated severe impairment). The same MDS assessment indicated R,[DATE] required extensive assistance (resident involved in activity, staff provide weight-bearing support) of one person physical assist in Bed Mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), Transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), Eating, Toilet Use (how resident uses the toilet or urinal, transfers on/off toilet, cleanses self after elimination; adjusts clothes), Personal Hygiene (combing hair, brushing teeth, shaving, washing/drying face and hands). The same MDS assessment revealed R,[DATE] had the diagnoses of [MEDICAL CONDITION], anxiety disorder, and high blood pressure. R,[DATE]'s Admission MDS assessment dated [DATE] indicated, during a 7-day look back period, he was occasionally incontinent (less than 7 episodes of incontinence) of bladder and a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) had not been attempted on admission/entry or reentry or since urinary incontinence was noted in the facility. The same MDS assessment revealed R,[DATE] was continent of bowel. Bladder and Bowel Patterning Worksheet dated ,[DATE] through ,[DATE] assessment was missing documentation for all seven days and there was no documentation at all on ,[DATE] and ,[DATE]. In review of R,[DATE]'s care plans, there was no care plan to decrease urinary incontinence. R,[DATE]'s fall care plan dated [DATE] instructed I require extensive assist for transfers and toileting PRN (as needed) and the risk for skin breakdown dated [DATE] instructed to Provide incontinence care as needed . Resident Incident Report and investigation dated [DATE] at 5:00 PM revealed R,[DATE] was found on the floor in his room, on his hands and knees, sustained a skin tear to his left elbow, and was unwitnessed by facility staff. The same investigation indicated R,[DATE] had to use the restroom, that his alarm was sounding, he was attempting to self transfer and became weak and fell to the floor. The same investigation included the interdisciplinary department team's (IDT) interventions/corrective actions taken, that included R,[DATE]'s door was to remain open at all times as resident allowed. R,[DATE]'s Risk for Falls care plan dated [DATE] indicated he was stand-by-assist for all ambulation. [DATE] Initial Psychiatric Consult revealed R,[DATE] had the diagnoses of dementia with behavior disturbance, anxiety and an unspecified mood disorder. Recommendations included Klonopin (benzodiazepine) 0.5 milligrams (mg) twice daily and Klonopin 0.5 mg daily as needed for 14 days for anxiety; and to continue [MEDICATION NAME] (anticonvulsant) sprinkles 250 mg three times a day for unspecified mood disorder. Resident Incident Report and investigation dated [DATE] at 6:45 PM revealed R,[DATE] had fell in the dining room and the fall was unwitnessed. In an interview on [DATE] at 10:45 AM, Registered Nurse (RN) D stated R-401 was constantly trying to get up out of his wheelchair. R,[DATE]'s Physician's Telephone Orders dated [DATE] at 12:15 PM included to increase Klonopin to 0.5 mg three times daily. R,[DATE]'s Physician's Telephone Orders dated [DATE] at 7:30 PM indicated to increase [MEDICATION NAME] sprinkles 250 mg to four times daily. R,[DATE]'s Physician's Telephone Orders dated [DATE] (no time ordered), indicated to administer Klonopin 0.5 mg, additionally every 24 hours. Resident Incident Report and investigation dated [DATE] at 9:15 AM revealed R,[DATE] had fell in the hallway, alarm sounding as resident was attempting to get up from his wheelchair, sustained an abrasion to the left knee and his fall was unwitnessed. Resident Incident Report and investigation dated [DATE] at 8:45 AM, revealed R,[DATE] had fell when in the dining room attempting to sit in a stationary chair, an abrasion was noted on his back. R,[DATE]'s Physician's Telephone Orders dated [DATE] at 11:00 AM, indicated to increase Klonopin to 0.75 mg three times daily. Resident Incident Report and investigation dated [DATE] at 4:45 PM, revealed R,[DATE] had fell on his left side in the dining room hitting a stationary chair before he fell to the floor and sustained a hematoma (collection of blood outside blood vessels, a bump) on the left side of his forehead, redness on the left shoulder, back and cheek. The same report revealed R,[DATE]'s alarm had been sounding prior to his fall. Resident Incident Report and investigation dated [DATE] at 6:15 PM revealed R,[DATE] had fell in his room, alarm was sounding, and staff were unable to reach resident prior to the fall, the fall was not witnessed. The same investigation indicated R,[DATE] was referred to hospice and a medication review was going to be completed to prevent future falls. Departmental Notes dated [DATE] at 5:40 PM, indicated R,[DATE] had been working with therapy on gait training. R,[DATE]'s Physician's Telephone Orders dated [DATE] at 8:00 PM, indicated therapy was discontinued effective [DATE]. DON B was interviewed on [DATE] at 12:05 PM and stated a scheduled walking program was not developed for R,[DATE] following the discontinue of therapy services. Resident Incident Report and investigation dated [DATE] at 12:45 PM revealed R,[DATE] had fell when he tripped over his wheelchair foot pedals in the dining room. In the Certified Nurse Assistant's (CNA) statement attached to the [DATE] fall investigation, R,[DATE] was sitting in the in his wheelchair in the dining room eating his lunch when the CNA left to assist another resident in their room, CNA heard R,[DATE]'s chair alarm sounding, the CNA responded to the alarm in the dining room and found R,[DATE] on the lying on the floor. Resident Incident Report and investigation dated [DATE] at 2:15 PM revealed R,[DATE] had fell in the dining room and had injured his left elbow again presenting as a skin tear, and was unwitnessed. R,[DATE]'s Physician's Telephone Orders dated [DATE] at 11:00 AM indicated a Broda (specialty reclining chair) chair was ordered for comfort. There was no [DIAGNOSES REDACTED]. [DATE] at 12:05 PM, a therapy assessment of R,[DATE]'s Broda chair was requested from DON B; in which was not provided prior to survey exit. Resident Incident Report and investigation dated [DATE] at 11:45 PM revealed R,[DATE] had fell in the dining room and sustained a laceration to his left eyebrow when .trying to stand up from Broda chair. The same investigation report indicated the fall was unwitnessed and the alarm was not on per care plan. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.15, (MONTH) (YEAR), section P, included CMS's definition of a physical restraint was any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. The same source included examples of a physical restraint were chairs that prevent rising, as a physical restraint, by placing the resident in an recumbent position that restricted rising. The same source indicated there was no evidence that the use of physical restraints would prevent, reduce or eliminate falls and reducing physical restraints may decrease the risk of falling. R,[DATE]'s Physician's Telephone Orders dated [DATE] at 3:15 AM, indicated an order for [REDACTED]. On [DATE] at 12:05 PM, DON B stated scheduled toileting was not implemented for R,[DATE]. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.15, (MONTH) (YEAR), section H indicated incontinence increased the risk of falls and injuries and many incontinent residents (including those with dementia) respond to a toileting programs, especially during the day. Resident Incident Report and investigation dated [DATE] at 6:30 AM revealed R,[DATE] had fell in the dining room and was unwitnessed. The same investigation indicated the night shift CNA had just left the unit and the day shift CNA was in another resident's room providing care. R,[DATE]'s (MONTH) (YEAR) Medication Administration Record [REDACTED]. R,[DATE] did not receive 18 doses of Klonopin in (MONTH) (YEAR). There was no documentation in R,[DATE]'s MAR indicated [REDACTED]. DON B was interviewed on [DATE] at 11:00 AM and stated she was not aware Klonopin was not administered in (MONTH) (YEAR), stated there were no medication error reports and the physician was not notified of R,[DATE]'s omitted Klonopin doses. On [DATE] at 12:05 PM DON B was interviewed regarding R,[DATE]'s missed Klonopin doses, for the above dates, in (MONTH) (YEAR) and stated the MAR's were not reviewed in behavior management meetings. Social Services Director G was interviewed on [DATE] at 8:15 AM and stated she was not aware of R,[DATE]'s Klonopin not being administered on the dates indicated above in (MONTH) (YEAR). During the same interview, Social Services Director G confirmed R,[DATE]'s missed doses were not discussed in behavior management meetings. Behavioral Health Follow-up Progress Note dated [DATE] from 12:56 PM to 1:22 PM, revealed staff reported R,[DATE] fell that morning and was awake and wandering all last night. Nursing Home Administrator (NHA) A and DON B were interviewed on [DATE] at 12:05 PM and stated they didn't recall implementing a sleep log/diary for R,[DATE] to assess his sleep habits. Resident Incident Report and investigation dated [DATE] at 6:45 PM revealed R,[DATE] had fell in the dining room and was unwitnessed. The same investigation revealed R,[DATE] had finished eating dinner at 6:30 PM and was alone and unattended. The same investigation included the nurse's statement that indicated she was tending to another resident at the time of R,[DATE]'s fall. Resident Incident Report and investigation dated [DATE] at 2:30 PM revealed R,[DATE] had fell from his bed in his room, his brief was wet, the fall was unwitnessed and the bed alarm was not in use at the time of the fall as instructed on the care plan. IDT review of actions taken following the fall included moving the bed against the wall. DON B was interviewed on [DATE] and stated a restraint assessment was not completed when R,[DATE]'s bed was placed against the wall. DON B stated during the same interview, that R,[DATE] could still get out on the other side of the bed, and they didn't consider the bed against the wall as a restraint. Resident Incident Report and investigation dated [DATE] at 9:30 AM revealed R,[DATE] had fell in the dining room, alarm was sounding, fall was unwitnessed. R,[DATE]'s Physician's Telephone Orders dated [DATE] at 10:00 AM, revealed orders to increase Klonopin to 1 mg three times daily due to anxiety and to discontinue his chair alarm. DON B was interviewed on [DATE] at 9:25 AM and stated R,[DATE]'s alarm was discontinued because it agitated other residents and caused a resident to resident altercation. DON B confirmed in the same interview Resident R,[DATE] was not agitated by chair alarm. R,[DATE]'s Physician's Telephone Orders dated [DATE] at 11:00 AM indicated to decrease [MEDICATION NAME] (used to treat high blood pressure) from 30 mg to 25 mg daily and to check orthostatic blood pressures (obtained in lying, sitting, and standing position to assess possible volume depletion.) and pulse every shift for one day. In review of R,[DATE]'s medical record, there was no evidence of orthostatic blood pressure documentation. Assistant Director of Nursing (ADON) C was interviewed on [DATE] at 3:30 PM and stated she was not able to locate orthostatic blood pressure monitoring, but did present a worksheet titled View Station, first shift [DATE] with laying, sitting and standing blood pressures that was not part of the medical record. ADON C stated in the same interview, she could not find evidence that orthostatic blood pressures were assessed on afternoon and night shifts. ADON C stated in the same interview she was not able to locate any restraint assessments completed for R,[DATE]. Resident Incident Report and investigation dated [DATE] at 1:00 PM revealed R,[DATE] had fell in the dining room when attempting to pick food off the floor while in the Broda chair and the Broda chair tipped over on the its side. The same report revealed R,[DATE] sustained a abrasion on his left cheek. The same report indicated the CNA was making a resident's bed and the nurse was feeding another resident in that residents room at the time of R,[DATE]'s fall. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.15, (MONTH) (YEAR), section J, indicated a previous fall, especially a recent fall, recurrent falls, and falls with significant injury are the most important predictors of risk for future falls and injurious falls; and when planning for care, evaluate staffing needs for residents who are at risk for falls. Resident Incident Report and investigation dated [DATE] at 7:41 AM revealed R,[DATE] was found in the dining room lying face down on the left side of his face in blood, sustained a laceration to the left side of his forehead and the fall was unwitnessed. The same report indicated prior to the fall, R,[DATE] was left alone and unattended in the dining room drinking coffee. Facility Departmental Notes dated [DATE] at 12:08 PM revealed R,[DATE] was .found laying on the left side of his face in blood on floor, flat with his eyes not moving approx (approximately) one min. (minute) extremities not moving. Possible neck injury. Gauze applied to left eye with light pressure without moving resident to determine active bleeding. Facility Departmental Notes dated [DATE] at 12:13 PM indicated R,[DATE]'s fall occurred [DATE] at 7:40 AM. According to a CNA statement, attached to R,[DATE]'s incident report dated [DATE] at 7:40 AM, R,[DATE] was in the dining room prior to R,[DATE]'s fall and he .continuely (sic) tried to stand up out of his chair but was unsucessful (sic) . and at around 7:30 AM another resident turned on his call light and began yelling; Nurse Assistant reported to the nurse that she was going to help another resident in his room. The same statement indicated that the nurse was at the medication cart counting medications with another nurse; and while the Nurse Assistant was helping the other resident, R,[DATE] .was able to get out of chair an (and) was found on floor by nurse. On [DATE] at 9:35 AM Licensed Practical Nurse (LPN) K was interviewed and stated she worked the night shift, on [DATE] through [DATE] (11:00 PM to 7:00 AM shift), and had left the Magnolia Lane unit prior to R,[DATE]'s fall on [DATE] at 7:40 AM. LPN K stated during the same interview, she was at the view nurses station when she heard a page related to a fall on Magnolia Lane. Post-Incident Actions dated [DATE] at 7:41 AM revealed immediate post-incident action was for an evaluation of R,[DATE]'s wheelchair. Resident Incident Follow-up Report dated [DATE], revealed R,[DATE] was transferred to the emergency room for evaluation and treatment and was admitted to the hospital. Hospital History and Physical dated [DATE] at 4:03 PM, revealed R,[DATE] had a 3 centimeter (cm) laceration overlying the left eyebrow with five sutures and large ecchymosis (bruising) surrounding the left eye with extension to the left eyebrow. Hospital Progress Notes dated [DATE] at 11:48 AM, revealed R,[DATE] had the diagnoses of traumatic subarachnoid hemorrhage (bleeding in space that surrounds brain), traumatic subdural hematoma (collection of blood outside the brain caused by severe head injury), left sided and right sided facial fractures. The same note revealed R,[DATE] had a repeat computerized tomography (CT) scan showed an worsening of the subdural hematoma with a midline shift (shift of the brain past its center line). Discharge Planning social work note dated [DATE] at 12:07 PM indicated family did not want patient to return to the nursing home facility and a sitter was placed at ,[DATE]'s bedside for patient safety. In review of the hospital Discharge Planning social work note dated [DATE] at 4:59 PM, R,[DATE]'s family did not feel there was enough staff at the facility to care of him because of him falling several times. Discharge Planning social work note dated [DATE] at 10:53 AM, revealed the hospital had contacted the NH and they were willing to re-admit R,[DATE] under hospice care, but patient's wife expected the patient to be one on one at the facility, which was unrealistic. On [DATE] at 9:54 AM, R,[DATE]'s family member E was interviewed and stated he died from the fall at the facility; family member E added the facility was very understaffed and she was very unhappy when the facility took her husbands alarm off because it was bothering other people. R,[DATE]'s Certification Of Vital Record dated [DATE], revealed he was pronounced dead on [DATE] at 5:50 PM due to a complication of subdural hematoma (type of intracrainal hemorrhage); manner of death was due to a fall at a care facility on [DATE], on or about 7:40 AM. On [DATE] at 12:05 PM, NHA A and DON B were interviewed indicated there were always 2 staff members assigned to the Magnolia Lane unit. During the same interview, NHA A was asked if they had considered increasing staff on the Magnolia Lane unit due to the number of R,[DATE]'s unwitnessed falls; NHA A stated the only way they would increase supervision was by doing a one to one, and that was something the facility did not do. NHA A stated during the same interview that she had made it clear to R,[DATE]'s family before he was admitted to the facility that they do not provide one to one staffing.

This citation is related to intake MI 008. Based on observation, interview and record review the facility failed to provide facility staff supervision for 2 facility residents (Resident #17 and Resident #42) with known behaviors resulting in resident to resident altercation with laceration and sexual incident. Findings Include: Resident #17 On 7/18/18 at 11:53 AM review of the facility reported incident dated 5/17/18 at 14:11 PM, reflected: R17 and R58 had a resident to resident incident. The report reflected R17 approached a staff member and stated that he had made physical contact with another resident. The aide immediately went to the dining room and observed R58 with a laceration above his right eye, his nose was red and blood was observed. R58 was assessed by nursing and stated, I'm okay. R17 was taken off of the unit with a staff member and stated that he was anxious. The admission MDS completed on 4/27/18 reflected R17 wandered, had symptoms of disorganized thinking, inattention, and other behavioral symptoms not directed toward others. R17 wrote a statement on 5/17/18 at 12:45 PM which reflected: R58 got in my face, started saying to me Get out of my face. I then hit him in the face with a closed fist. He then went to hit me and I hit him first. I hit him 2 or 3 times and told him to stay out of my face. This happened in dining room. I know I shouldn't have touched him but he keeps doing this. On 07/18/18 at 02:33 PM R17 was asked if he had any disagreements or altercations with other residents, and denied having any. R17 was then asked if any facility residents had tried to hurt him and replied Yes, but could not identify who the resident was. When asked when it may have occurred, R17 revealed a year ago. R17 denied telling staff he hit someone or that any residents hit him. The behavior care plan for R17 with an onset date of 4/13/18 reflected, Resident has made threats to other residents. Behavior appears to-occur when his/her independence or physical self are being threatened. Resident paces often throughout the halls on his unit. He get agitated easily when he feels others are in his space. Resident has periods of not sleeping, which seems to be increase his agitation and anxiety. Resident is in need for long term care. Interventions prior to the 5/17/18 incident included: Reassure resident that staff are there to help him, redirect resident when he is getting irritated by other residents, remove resident from current area if there is tension between residents, provide diversional activities for resident: take for a walk, visits with his wife, be aware of situations which may bother resident's need for independence: having other who are intrusive to residents space and etc. On 07/18/18 at 04:46 PM R58 was observed in his room cleanly groomed and dressed with slippers on. His bed was against the wall and low to the floor. R58 denied having any pain. No marks, redness or swelling were noted near R58's eye, nose or face. R58 was asked if he recalled getting in a fight with another resident, or if someone hit him in face. R58 replied, The big company's get us. R58 was not able to recall the altercation dated 5/17/18. On 07/19/18 at 09:41 AM Competency Evaluated Nursing Assistant (CENA L) was queried about the incident dated 5/17/18. CENA L revealed she was working the day of the incident, but did not witness it, both R17 and R58 were irritated that day. R58 was upset with himself, and was wandering back from his room to dining room. R17 used to wander around too. R17 told me he just Fu**** that old man up. I was the only one back there (Magnolia Hall), and I was helping R33 off the toilet. I asked R33 to hold on and R58 was standing in the hallway. They (R17 and R58) both had been pacing the floor. R58 said he was fine and he had a bloody eye, and it was red. You could tell he had been punched in the eye. The nurse was out and on another hall, View Hall. I was the only one on the hall. The nurse came back on the hall when I radioed for help. R58 was moved back to Meadow. Also, that R17 never said why he hit him (R58). On 07/19/18 at 09:55 AM the facility's incident sheet dated 5/17/18 without a time was viewed. The incident sheet reflected R17 stated to CENA L, Sorry for F***ing that guy up babe. Immediate actions taken: separated from other resident. assessed for injury. MD (Medical Doctor), spouse, abuse coordinator and Assistant Director Of Nursing (ADON C) notified. Follow up dated 5/18/18 reflected Re-initiation of [MEDICATION NAME] d/t failed GDR (Gradual Dose Reduction). R58's incident report sheet dated 5/17/18 without a time reflected, Narrative: CENA notified nurse of statement another resident made, nurse assessed this resident's injuries. bruises to R (Right) eye and abrasions to bridge of nose. Immediate actions taken: assessed, face cleansed. MD spouse, abuse coordinator and ADON notified. LPN T was working the day of the incident. R58's care plan was updated. R58's care plan was updated to reflect Res immediately separated . Assess for signs/symptoms of emotional distress/injury x 72 hours room location changed 5/17/18. The Census List provided on 7/19/18 at 07:52 AM by Director Of Nursing (DON B) reflected 2 residents that were total assist, 2 residents who required 1 person assistance, and 4 independent residents resided on Magnolia Hall. Resident #42 Review of the incident report on 07/18/18 at 11:37 AM reflected on 4/18/18 at 10:22 AM ADM A reported a facility reported incident related to R42 and R36. It was reported there was a resident to resident incident. The report reflected R42 and R36 were standing at the end of the hallway, with R42's back toward staff and R36 was facing R42. The Activity Director noted R42 with his right arm motioning toward his genitals and rushed to investigate. R42 penis was observed out the top of his pants with a full erection. R42 was masturbating, holding R36's left middle finger with his right hand. When separating the residents R36 stated, Five more minutes. R42 was immediately placed on 1:1 supervision. R36 was immediately assessed with [REDACTED]. Investigation initiated. On 07/18/18 at 02:12 PM R36 was observed to be asleep. On 07/18/18 at 02:42 PM R42 was interviewed and asked if he recalled the incident with R36. R42 denied knowing R36. When questioned about exposing himself to R36 and touching his penis while holding R36's hand, R42 denied exposing himself to a female resident. R42 stated, Absolutely Not. R42 was asked if he had any incidents or altercations with any resident since he had been a resident. R42 replied, That's not me, I would not do any of it. R42 then started walking up and down the hall, went towards his room stating, Will this take me down. I hate this place. MDS completed on 6/11/18 reflected R17 had symptoms of being short tempered, easily annoyed, physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others. The Behaviors care plan for R42 with a problem onset date 5/30/18 reflected: Resident has made threats to staff and other residents. Behavior appears to occur when resident is restless or not able to understand what is going on around him. Resident has a recent history of having sexual inappropriate behaviors. Resident appears to have a lack of understanding of his surroundings. Resident can become very agitated and disruptive for no apparent reason. Resident is in need of long term care. Interventions included: Notify nurse immediately when resident is being intrusive to other residents. Contact Social Worker if resident is unable to be redirected. Provide a space where resident can have some get away time and still be in visually sight by staff. Provide feedback to resident immediately when resident displays disruptive behaviors. Be aware of situation, emotional status, and behaviors before an incident occurs, and etc. On 07/18/18 at 04:57 PM Activities Director (AD I) was interviewed and asked to recall the incident that occurred on 4/18/18. AD I revealed, I was at the end of the hall and they were at the opposite end in view as I tuned the corner. I could see his shoulder and back and part of her, and I saw a hand motion and immediately B-lined down and separated them. I gave her (R36) hand hygiene and called ADM A. AD I was asked if R42 private area was touching R36. AD I replied, He had her hand and was masturbating with the same hand. I did not see her hand touch his penis. The nurse was passing meds, and there was a fall going on around the corner. AD I denied that R36 was distraught, she was telling me 5 more minutes. AD I denied knowing or seeing R42 previously doing that (masturbating/exposing himself) with another resident. On 07/18/18 at 05:16 PM AD I returned with an incident log reflecting a resident whose room was near by the day of the incident that had a fall dated 4/18/18 at 0931. On 07/19/18 at 08:23 AM R36 was interviewed. R36 was asked if she had any incidents or problems with any male or female residents. R36 replied, No. R36 was then asked if she recalled a man grabbing her finger or hand and replied, I don't remember that. R36 was then asked if she recalled if a man exposed his private parts/penis in front of her and she replied, No, I don't remember that. Why are you asking me that. Writer ceased questions. On 07/19/18 on 09:19 AM review of the Electronic Medical Record (EMR) reflected R42 was admitted to the facility on [DATE] and R36 was admitted on [DATE]. 07/19/18 09:20 AM the incident dated 4/18/18 at 09:35 AM reflected the description of the incident as noted above, but included the location. The incident occurred on the Meadow Hall (memory care unit residents & cognitively declined residents). Also that, Doctor and family notified. Immediate Actions Taken: Res immediately separated and R42 placed on 1:1 supervision and added to R42's care plan. R42 was admitted to an in-patient psych hospital for evaluation. Resident sent to DNP for in-patient evaluation and treatment. The Census List provided on 7/19/18 at 07:52 AM by DON B reflected 2 residents that were total assist, 5 residents who required 1 person assistance, 3 residents who required 2 person assistance, 1 resident required Stand By Assistance (SBA), 1 resident required 1 person SBA and 8 independent residents resided on Magnolia Hall. CMS Centers for Medicaid and State Operations Survey & Certification Group Reasonable Person Concept: The absence of a reaction from a cognitively impaired resident who lacks the ability to understand and react to most stimuli, including those affected by the situation, does not make the deficiency any less serious. In this case, the survey team should use the reasonable person concept to determine the severity level of psychosocial outcome for that person. The reasonable person concept is described as follows: In cases where residents are unable to speak for themselves, the survey team should assess how most people would react to the situation in question.

This citation refers to Intake #MI 463. Based on observation, interview and record review, the facility failed to prevent a burn with blistering for one resident (#19) out of one resident reviewed [MEDICAL CONDITION] in injury to the skin with the potential for infection. Findings include: Resident #19 Resident # 19 (R19) was admitted on [DATE] with the [DIAGNOSES REDACTED]. In addition, R19 had a cognitive communication deficit. The Brief Interview for Mental Status score (BIMS) was 6 out of a potential 15 points which indicated severe cognitive impairment. On 7/17/18 at 2:00 PM, an observation of R19 was made. He was in his room in a wheelchair. R19 appeared thin. R19 was dressed and groomed. There were no odors about his person. He was wheeling himself around his room and chatting with his roommate and his roommate's wife. When queried about his burn, he could not remember if he was offered a clothing protector when he was given his hot water to drink on the day he spilled the hot water and burned himself. On 7/18/18 at 10:00 AM, a record review of the Hot Liquid Safety Evaluation form occurred. According to the documentation, R19 was evaluated on 12/1/17, 3/20/18, 5/3/18 and 6/20/18. A review of the form revealed instructions that two or more checkmarks in the risk factor column indicated a risk for spills of hot liquids. The only check mark for all the review dates was in the box labeled Cognition which meant R19 was not considered at risk [MEDICAL CONDITION] each assessment. A row in the form was titled Total # of Check Marks and had the number one (1) listed for each assessment date. In addition, in the risk factor section of the form, there was written documentation stating legally blind which did not contain a checkmark. There was no indication on the form that R19 had a [DIAGNOSES REDACTED]. Interventions checked on the form included: * Hot liquids to have a lid when leaving the kitchen. (MONTH) remove upon delivery to resident. * Temperature of liquids not to exceed 155 degrees. * Offer resident to wear clothing protector/lap protector. An interview with Assistant Director of Nursing C (ADON) was done on 07/18/18 at 03:57 PM. ADON C stated, according to the hot liquid assessment, Resident # 19 was not at risk when she assessed him in (MONTH) (YEAR). ADON C stated she was unable to comment regarding his hot liquid assessment beyond her assessment on (MONTH) (YEAR). On 07/18/18 at 04:45 PM, Unit Manager/Licensed Practical Nurse (LPN) N was interviewed about (LPN) Ns assessments on R19's hot liquid evaluation form on 5/3/18 and 6/20/28. LPN N reviewed the form and stated R19 was not considered a burn risk based on what LPN N checked off on the evaluation form. LPN N indicated R19 had a religious requirement to have hot water brought to him at around 4:00 PM in a thermos from the facility kitchen. Then R19 would slowly sip the hot water directly from the thermos and pray while sitting at his overbed table in his room. When (LPN) N was queried about what could have been done to avoid the burns, LPN N stated R19 currently wears a protector to chest and leg. LPN N said R19 needs 60 sips of hot water for cleansing purposes. The water is presented to the resident in a thermos for him to drink. It's a long process for the resident to drink the hot water as he prays and sips while in the wheelchair at the bedside table. Resident doesn't drink out of a cup - he sips the hot water directly from the thermos. Staff ensure the resident is now using the clothing protectors. The resident drinks the hot water daily. Resident declines to exit the room during meals but spends time wheeling around the facility between meals. LPN N stated the resident often prays before taking his meds awaiting direction from the Lord whether he should take his meds. LPN N was asked if this was possibly a hallucination on the part of R19 and LPN N indicated he did not think the resident was hallucinating that God spoke to him (R19). According to LPN N, R19's wounds are closed. new skin growth was observed and there were no scabs. On 7/19/18 at 10:00 AM, a record review of the Hot Liquids Policy, dated (MONTH) (YEAR), indicated, under the title Prevention, Residents should be offered a clothing protector for each meal and Dietary staff will offer lids for all hot beverages. On 7/19/18 at 10:15 AM, a record review of the skin breakdown care plan, problem onset of 5/7/18, had written documentation 6/20/18 Burn to right upper thigh. Resolved 7/6/18. 6/20/18 Treatment ordered by MD (physician) Nsg (signed by nursing staff). On 7/19/18 at 10:20 AM, a record review of the evaluation notes by the Medical Director (MD) R noted MD R was asked by nursing staff to evaluate patient's right thigh [MEDICAL CONDITION]. Per nursing staff, he spilled hot water. MD Rs assessment was Moist burn because of hot water. On 7/19/18 at 10:00 AM, a record review of MD Rs orders indicated nursing staff should Monitor (R) lateral thigh for S/S (signs and symptoms) of infection QD (daily) until burn and blisters resolve. On 7/19/18 at 2:30 PM, a discussion of R19'[MEDICAL CONDITION] with Administrator A occurred. Administrator A indicated there was a meeting of the interdisciplinary team to discuss R19's burns. No new information regarding [MEDICAL CONDITION] shared. According to the Mayo Foundation for Medical Education and Research, 1998-2012, when the first layer of skin has been burned through and the second layer of skin (dermis) also is burned, the injury is called a second-degree burn, blisters develop, skin takes on an intensely reddened, splotchy appearance and there is severe pain and swelling.

This citation pertains to MI 974. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 2 of 5 residents reviewed for falls (Resident #2 and Resident #8), from a total of 15 sampled residents, resulting in repeated falls with injuries of unknown origin for both Resident #2 and Resident #8. Findings include: In an interview, on 6/21/16 at 3:30 PM, Nurse Aide I reported she worked full time on the locked dementia unit/Memory Unit. When asked about behaviors on the Memory Unit, Nurse Aide I said, A lot of people (residents) wander into other's rooms. (Resident #12) wanders into people's bathrooms. Nurse Aide I reported staff try to keep the residents with the worst behaviors in the Dining/Activities Room so they can keep an eye on them, but said, It's hard to keep them distracted .If there are 2 Aides and one goes to lunch and the nurse goes to get something, there is only 1 aide in there for 24 people. On 6/22/16 at 4:30 AM during the midnight shift observation, upon arrival to the locked dementia/Memory Care Unit, this Surveyor observed Nurse Aide K walk quickly to a cupboard in the Dining/Activities Room, unlock it, pull out 2 gait belts, and hand one of the gait belts to Nurse Aide J. In an interview, on 3/22/16 at 4:45 AM, Nurse Aide J said, I don't know why (Nurse Aide K) handed me a gait belt, I am wearing mine. According to the facility Gait/Transfer Belt Agreement & Policy, (not dated), .I understand that the Gait/Transfer Belt is part of my uniform and shall be on my person at all times. In an interview in the locked dementia unit (Memory Unit), on 6/22/16 at 4:45 AM (during the midnight shift), Nurse Aide J reported, there were currently 22 residents residing in the Memory Unit and she and Nurse Aide K worked there alone with an LPN/Licensed Practical Nurse in the building they could call, but the LPN wasn't back there much because she had only one medication to administer during the night in the Memory Unit, around 11:00 PM. Nurse Aide J stated 5 residents in the Memory Unit were 2 person assist with transfers. Nurse Aide J stated 5 residents in the Memory Unit were 2 person assist with transfers; when both aides were occupied, there was no one supervising the other 20 residents. In an interview, on 6/22/16 at 5:55 AM, LPN/Licensed Practical Nurse M said, To decrease falls (in the Memory Unit) .we need more workers. It's hard to entertain them (residents) .A lot of yelling goes on . When asked if the Nurse Aides were supposed to use gait belts, LPN M said, They (Nurse Aides) are supposed to have gait belts on at all times. Further, LPN M said, (Resident # 3) is a good candidate for a 1 to 1 supervision. On 6/22/16 at 4:30 AM, this Surveyor observed a [AGE] year old boy L sitting at a facility computer in the dining room/activity room in the locked Memory Unit playing a video game. Boy L told this Surveyor he had come to work that night with Nurse Aide K, his aunt. When asked if he enjoyed talking with the residents, Nephew L shrugged his shoulders, and kept playing the video game. Resident #12 was sitting approximately 4 feet away at a nearby table; he was not engaged in any activity, and according to According to the Minimum Data Set, dated dated [DATE], Resident #12 had severe cognitive impairment, and [DIAGNOSES REDACTED]. And, according to Resident #12's Care Plan, dated 3/19/16, I have a history of physically aggressive behaviors directed towards staff and others . It was also documented on this Care Plan, 6/16/16 - Altercation with other resident. In an interview in the locked dementia unit (Memory Unit), on 6/22/16 at 4:45 AM, Nurse Aide J reported, there were currently 22 residents residing in the Memory Unit and she and Nurse Aide K were worked there alone with an LPN/Licensed Practical Nurse in the building they could call, but the LPN had only one medication to administer during the night in the Memory Unit, around 11:00 PM. Nurse Aide J stated 5 residents in the Memory Unit were 2 person assist with transfers. In an interview, on 6/22/16 at 2:50 PM, LPN/Licensed Practical Nurse H was asked being interviewed about a fall that occurred in the Memory Unit and she commented, We never have enough staff back there (Memory Unit) .I don't know what to do. I think we could use more supervision. I really do . In an interview, on 6/22/16 at 3:30 PM, Nurse Aide I commented on the lack of activities and supervision to the residents in the Memory Unit. Nurse Aide I said it was not a safe environment because, If there are only 2 aides and ones goes to lunch and the nurse (if off the unit) .that aide is back there all alone with all of those residents. In an interview in the locked dementia unit (Memory Unit), on 6/22/16 at 5:00 AM (during the midnight shift), Nurse Aide K reported, Last night (a day before), (Resident #1) was screaming 'Shut up' at (Resident #27) and trying to pull her out of the chair. (Resident #27) just kept crying . When asked if she thought Resident #1 was abusing Resident # 27, Nurse Aide K said, Yes, I do. However, Nurse Aide K said she did not document the incident and did not report it to anyone because, .too busy to chart all incidents. I don't think I'm the only one who doesn't (chart/report). When asked why she and others were not documenting and reporting behaviors and incidents, Nurse Aide K replied, .it feels like it just gets shoved under the rug .Some incidents get reported and some don't. If you tell them (management) someone got slapped, they come back and ask them (the residents) what happened. It doesn't' help. They (the residents with dementia) don't understand. In an interview in the locked dementia unit (Memory Unit), on 6/22/16 at 5:00 AM, Nurse Aide K reported, Last night (a day before), (Resident #1) was screaming 'Shut up' at (Resident #27) and trying to pull her out of the chair. (Resident #27) just kept crying . When asked if she thought Resident #1 was abusing Resident # 27, Nurse Aide K said, Yes, I do. However, Nurse Aide K said she did not document the incident and did not report it to anyone because, .too busy to chart all incidents. I don't think I'm the only one who doesn't (chart/report). When asked why she and others were not documenting and reporting behaviors and incidents, Nurse Aide K replied, .it feels like it just gets shoved under the rug .Some incidents get reported and some don't . In an interview, on 6/23/16 at 7:15 AM, DON/Director of Nursing B reported she did not know Nurse Aide K was (dividing her attention) by babysitting Nephew L in the Memory Unit during the night on 6/22/16. In an interview, on 6/23/16 at 3:05 PM, Administrator A reported she thought the Memory Unit was being adequately supervised on the midnight shift because the nurse was back there passing medications during the night. Administrator A reported she was unaware that Nurse Aide K had brought Nephew L to work during the night and allowed him the use of the facility computer 6/22/16. Administrator A reported the facility had no surveillance cameras. According to a physician progress notes [REDACTED].#3 got agitated .now temporarily in the dementia unit .Labs shows greater than 1000,000 organisms a E. coli (urinary tract infection) .Started on Levaquin (antibiotic) . ( ) Resident #2 Resident #2 resided in the Memory Unit. According to Resident #2's MDS/Minimum Data Set, dated dated [DATE], she was admitted to the facility on [DATE], had moderate cognitive impairment had no mood or behavior problems, needed staff assistance with transfers, ambulation, and mobility, and had [DIAGNOSES REDACTED]. Review of Resident #2's Physician order [REDACTED].#2 was taking Seroquel (antipsychotic) 50 mg at bedtime, Depakote (anti-seizure) 125 mg twice a day, Norvasc (anti-hypertensive) 5 mg once a day, Omeprazole (proton pump inhibitor used to treat reflux) 20 mg once a day, Hydrochlorothiazide (non-potassium diuretic) 12.5 mg once a day, Hydrodon-Acetaminophen 5-325 mg twice a day (narcotic pain medication); Resident #2 was also taking Namenda 10 mg twice a day and Articept 10 mg at bedtime (drugs to treat dementia). According to Davis's Drug Guide (2016), Many factors are associated with falls in the elderly, including frailty, disease, vision, polypharmacy (taking multiple medications), and certain medications. Below is a list of drugs associated with falls. Assess geriatric patients on these medications for fall risk and implement fall reduction strategies. Drugs on the list Associated with Increased Risk of Falls in the Elderly included: Seroquel, hydrochlorothiazide, Lexapro, Norvasc, Depakote, hydrocodone. According to the facility Falls Management Policy and Procedure (not dated), Procedure: 1. Assess and review risk factors for falls and injuries .Table 2-Medications More Commonly Associated with Falls .Post Fall .Nursing to complete per policy and procedure: a. Fall Tracking Form . According to Table 3 of the Falls Management Policy, entitled Checklist for assessing Fall Risk or Performing a Post-Fall Evaluation .Review resident's record for medication that could predispose to falls. stop or reduce the dosage of as many of these medications as possible . In a telephone interview, on 6/22/16 at 10:00 AM, Pharmacist O reported the facility should be reviewing medications after a fall. In an interview, on 6/22/16 at 4:45 PM, DON/Director of Nursing B reported, I don't pull out all the medications and review them after a fall. DN B stated she did not know what the Fall Tracking Form was. DON B said, We don't use it .I don't know why we got away from using it. When asked if the pharmacist or physician review medications after a fall, DON B said, No, only if I give them a list to review. Review of Resident #2's Incident/Accident Reports and Nursing Notes since 2/11/16 (past 4 months) revealed 9 documented incidents: · 2/11/16 - a witnessed fall; sustained skin tear · 2/24/16 - an unwitnessed fall - sustained laceration and bruise to nose · 3/17/16 - a witnessed fall; sustained skin tear · 3/21/16 - unwitnessed fall without injury · 4/28/16 - witnessed fall without injury · 5/28/16 - sustained injury of known origin/bruise to left eye, bruise to left knee, bruise left hand index finger/x-ray report possible non-displaced fracture of distal scaphoid ( fracture usually caused by a fall onto the palm of the hand) · 6/06/16 - hit on the nose by another resident during an altercation (reported and investigated by State Agency) · 6/16/16 - unwitnessed fall without injury Regarding the incident on 5/28/16 where Resident #2 sustained injury of known origin/bruise to left eye, bruise to left knee, bruise left hand index finger/x-ray report possible non-displaced fracture of distal scaphoid ( fracture usually caused by a fall onto the palm of the hand). In a a telephone interview, on 6/22/16 at 11:25 AM, Family Member P reported, They don't know how she (Resident #2) gets bruised. The lens on her left eye was missing (on 5/28/16). Her eye was 5x the size. I think someone hit her and knocked her down. They thought she had a broken nose (on 6/06/16); they told me a resident punched her in the nose . According to Nursing Notes, dated 6/15/16 at 12:09 AM, Bruising to face continues to heal and fade, yellow in color . And, Nursing Notes, dated 5/20/16, revealed Resident #2 additionally, had and altercation on 5/16/16 involving another resident that was reported/investigated by State Agency. In an interview, on 6/21/16 at 2:50 PM, LPN/Licensed Practical Nurse H reported she was working the first time on the Memory Unit on 5/28/16 between 4:00 PM - 4:30 PM when she found Resident #2 and Resident #12 behind the closed bedroom door of Resident #2 and she first saw Resident #2 had a baby spot in the crease of her eye (a bruise). When asked if Resident #2 and Resident #12 had been in a resident to resident altercation, LPN H said, It's always a possibility. When asked what she did to intervene, LPN H reported she left Resident #12 in Resident #2's room with the door open, did not provide 15 minute checks or 1 to 1 observation of either resident. LPN/Licensed Practical Nurse H commented, We never have enough staff back there (Memory Unit) .I don't know what to do. I think we could use more supervision. I really do . LPN/Licensed Practical Nurse H reported, (Resident #12) gets angry easy. I won't say he don't get agitated . When asked how she managed Resident #12's behaviors, LPN H replied, We just let him go. According to the Minimum Data Set, dated dated [DATE], Resident #12 was a male resident who had severe cognitive impairment, and [DIAGNOSES REDACTED]. And, according to Resident #12's Care Plan, dated 3/19/16, I have a history of physically aggressive behaviors directed towards staff and others . And, it was also documented on this Care Plan, 6/16/16 - Altercation with other resident. According to the Resident Incident Follow-up Report, dated 5/30/16, X-ray results received - possible nn-displaced fracture of the L (left) distal scaphoid. MD (unnamed physician) notified. New order received for ortho (orthopedic) consult and left wrist immobilizer .Unable to substantiate abuse, neglect, or misappropriation . In an interview, on 6/21/16 AT 4:20 PM, ADON/Assistant Director of Nursing C was asked if a broken wrist bone had been ruled out for Resident #2 and ADON C replied, It still a possible fracture. Resident #8 Resident #8 resided in the Memory Unit. According to the MDS, dated [DATE], Resident #8 was admitted to the facility on [DATE], had severe cognitive impairment, and was in hospice. According to a Fall Scene Investigation Report, dated 1/18/16, (Resident #6) post fall, pelvic fracture - unstable. Resident #8 sustained an unwitnessed fall on 1/26/16 (8 days later) and sustained a skin tear to her right shin and right middle finger. According to Incident/Accident Reports, Resident #8 had 5 additional falls and multiple skin tears in 46 days: Falls · 4/12/16 - witnessed fall with no injury · 4/19/16 - unwitnessed fall - left eye swollen · 4/29/16 - unwitnessed fall - laceration to leg · 5/27/16 (10:15 AM) - unwitnessed fall with no injury · 5/27/16 (7:55 PM) - unwitnessed fall with no injury Skin Tears · 4/12/16 - sustained skin tear to elbow · 5/20/16 - sustained skin tear to leg · 6/14/16 - sustained skin tear to left lower leg · 6/17/16 - sustained skin tear to right elbow · 6/28/16 - sustained skin tear to left shin Review of Resident #8's Medical Record, revealed the facility failed to provide increased supervision to prevent repeated falls and skin tears for Resident #8. According to a Behavior/Mood Symptom Tracking Tools, there was only one instance when staff increased supervision, but no evidence that staffing increased on the unit: dated 6/17/16 (one of the days she sustained a skin tear), (Resident #8) is refusing to stay in her chair so that she won't fall and hurt herself .Had to sit by her at all times . ( )