Every finding on record at The Villa at Rose City

This Citation Pertains to Intake 3071455. Based on interview and record review, the facility failed to operationalize procedures to ensure accurate completion of skin assessments for one resident (Resident #701) of three residents reviewed. Findings include:Resident #701:Review of intake documentation dated as received 6/23/26 revealed Resident #701 was currently at the hospital. The intake detailed, (Resident #701) has bruising on their leg. Two weeks ago, (Certified Nursing Assistant [CNA] D) grabbed (Resident #701) and threw them into a wooden chair. There was an altercation at the nurses' station, and (Resident #701) hit (CNA D). As a result, (CNA D) grabbed (Resident #701) from behind and threw them into a chair. (Resident #701) still has bruising on their right anterior upper thigh. On 7/14/26 at 8:30 AM, an interview was completed with Social Services Director A. When queried regarding Resident #701, Director A revealed the Resident recently returned to the facility from a stay in an inpatient psychiatric facility. An interview was completed with Resident #701 on 7/14/26. When queried if something happened involving CNA D, Resident #701 stated, Yes. Resident #701 stated it happened in front of the nurses' station, in the middle of the night. When queried what happened, Resident #701 stated, I slapped (CNA D) and kind of yelled and they threw me at the chair, and I got a bruise on my right leg and my back. Resident #701 continued, I still have the bruise on my leg. Resident #701 was wearing shorts and pointed out the bruising. A fading, purplish colored bruise, approximately the size of a baseball was observed on the front of Resident #701's right thigh. With further inquiry, Resident #701 stated, I hit the chair and then I went to the floor. Review of facility provided Incident and Accident (I and A) Reports revealed an incident involving CNA D and Resident #701 falling occurred on 6/14/26 at 9:30 PM. The I and A report for the fall detailed the Resident had no injuries observed at time of incident. Review of Resident #701's Nursing: Weekly Skin Check/Skin Condition assessment documentation in the Electronic Medical Record (EMR) revealed the following:- 6/17/26: No documentation of bruising on the assessment- 7/1/26: Bruised documented- 7/8/26: No documentation of bruising on the assessment An interview and review of Resident #701's EMR was completed with the Facility Administrator on 7/15/26 at 10:00 AM. When queried how often skin assessments should be completed, per facility policy/procedure, the Administrator responded, Weekly. When asked if bruising should be documented on the skin assessments, the Administrator replied, Yes. When queried regarding the bruise on Resident #701's thigh and lack of documentation on the weekly skin assessments, the Administrator reviewed the documentation and confirmed they were not completed accurately. The Administrator stated, The bruise is still there. When queried why the bruise was not documented, the Administrator was unable to provide an explanation. Review of facility policy/procedure entitled, Skin Protection Guideline (Effective: 7/7/21) revealed, Purpose: To provide evidenced based practice standards for the care and treatment of skin. To ensure residents that admit and reside at our facility are evaluated and provided individualized interventions to prevent, reduce and treat skin breakdown. Guideline. Inspection of skin daily with cares and weekly by a licensed nurse. Monitoring of Skin Integrity: Skin will be observed daily during care by the nursing assistants. Weekly skin observation by a licensed nurse.

This Citation Pertains to Intake Number 3031745. Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure that allegations of abuse were reported for one resident (Resident #701) of three residents reviewed.Findings include:Resident #701: Review of intake documentation dated as received on 5/26/26 revealed Resident #701 called a mental health/suicide hotline today due to suicidal thoughts. During the call, Resident #701 told the hotline worker that Certified Nursing Assistant (CNA) B grabbed them by the jaw and pushed them to the floor in the bathroom. The intake documentation indicated Resident #701 was experiencing pain from the incident. The intake was a referral from Adult Protective Services (APS) and did not specify the date the Resident called the hotline. A review of Facility Reported Incidents (FRIs) from May 2026 revealed no allegations of staff to CNA abuse had been reported by the facility. On 6/16/26 at 9:22 AM, Resident #701 was observed alone in their room, lying in bed and an interview was completed. When queried if they recalled calling a mental health or suicide hotline, Resident #701 replied, Yes because I feel suicidal and depressed. When asked if any facility staff had ever pushed them or hurt them, Resident #701 indicated they had. When queried what happened, Resident #701 stated, (CNA B) pushed me on the toilet and I pushed them back because I was defending myself and (CNA B) grabbed me by my jaw. Resident #701 proceeded to demonstrate how CNA B had grabbed their jaw by grabbing their own jaw in rough manner by placing one hand under the chin with the fingers around their jaw and lower face. When queried what they were doing before this happened and where they were, Resident #701 became visibly upset and stated, I want to go to a psych hospital, I want to talk to (Social Work Director [SWD] A). Resident #701 was reassured that SWD A to come talk to them and the Resident's room was exited. SWD A was located and informed of interview with Resident #701 and that the Resident asking for them. While walking to Resident #701's room with SWD A, the Resident was observed in the hallway and verbalized they were looking for SWD A. At 9:37 AM on 6/16/26, an interview was completed with Resident #701 and SWD A. Resident #701 told SWD A, I slapped (CNA B) and indicated it was self-defense. Resident #701 then told SWD A that CNA B had grabbed their jaw and pushed them. Resident #701 demonstrated how CNA B grabbed their face. SWD A asked Resident #701 where it happened and replied, I was in the bathroom. When queried regarding Licensed Practical Nurse (LPN) C and LPN D being in the bathroom, Resident #701 verbalized they had laughed. SWD A then asked Resident #701 when it had happened and the Resident stated, That was a couple weeks ago. That was a week ago. Resident #701's thoughts and verbalizations became very scattered and the Resident stated, I cant take it. I need to get my meds. SWD A assisted the Resident out of their office to find their nurse. An interview was conducted with SWD A on 6/16/26 at 9:47 AM. When queried if they were aware of the abuse allegation pertaining to CNA B and Resident #701 prior to today, SWD A stated, I did know about it. With further inquiry, SWD A verbalized the facility Administrator and Director of Nursing (DON) were also aware and stated, I think they did a soft file (internal investigation) about the allegation. Record review revealed Resident #701 was originally admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, pain, weakness, falls, schizoaffective, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and dependent upon staff for toileting and bathing. The MDS further detailed Resident #701 did not display any physical or verbal behaviors directed towards others but displayed other behavioral symptoms not directed toward others one to three days. Review of Resident #701's Electronic Medical Record (EMR) revealed the following documentation: - 5/24/26 at 10:16 AM: Behavior Note. Resident was being assisted to the bathroom by CNA. Upon applying brief, hit CNA in the face and was screaming. Resident stated didn't want brief applied. Resident was educated on the importance of having a brief on and allowed CNA to put apply brief. - 5/24/26 at 2:22 PM: Behavior Note. (Resident) frequently yelling out/screaming during shift. Refusing cares, verbally and physically abusive to staff. Making accusations against staff members, difficult to redirect at times. - 5/24/26 at 5:30 PM: Behavior Note. Res came to desk stating wanted to die and to call crisis hotline. Call placed, res spoke to counselor, requested to be sent to hospital, stating was going to starve themselves to death or drown themselves in the toilet. After talking to counselor, res wheeled self back down to room with no further outbursts at this time. - 5/26/26 at 4:28 PM: Social Services. followed up with resident regarding weekend behaviors and concerns reported by staff. During the conversation, resident became tearful at times and was noted to become easily sidetracked from the topic being discussed. provided emotional support and verbal redirection, which was effective. Resident was cooperative with intervention and able to return to the conversation with prompting. Resident was observed out of room throughout the day visiting with staff appropriately. No signs or symptoms of acute distress noted during this shift. Resident denied any immediate needs or concerns when asked. Due to ongoing behavioral and psychiatric concerns, referral information was sent to 18 inpatient psychiatric facilities for review and possible placement. Staff will continue to monitor resident's mood, behaviors, and safety, and provide redirection and support as needed. Interdisciplinary team remains aware of resident status. On 6/16/26 at 10:39 AM, an interview was completed with the facility Administrator and DON. When queried if they were aware of Resident #701 making an allegation of abuse involving CNA B, both the Administrator and DON confirmed they were aware. When queried if the facility had completed an investigation, the Administrator stated, We didn't do an investigation really because it was witnessed by staff. Any facility investigation documentation related to the abuse allegation was requested at this time. An interview was conducted with CNA B on 6/16/26 at 11:04 AM. CNA B was asked what shift they normally work and replied, 6:00 AM to 6:30 PM. When queried if they recalled an incident involving Resident #701, CNA B verbalized they did and stated it was a couple weeks ago. When asked what happened, CNA B revealed Resident #701 was in the hallway yelling that they needed to be changed and they assisted the Resident into the big bathroom/shower room on the East End of the facility. CNA B revealed Resident #701 was on the toilet and stated, I had taken their brief off and went to get washcloths. (Resident #701) stood up and started yelling that they didn't want to. When asked what the Resident didn't want to do, CNA B indicated they were not sure if the Resident did not want to get washed up or if they did not want to get dressed. CNA B stated, (Resident #701) started yelling out and the nurses came in. CNA B continued, (Resident #701) hit me and told me they hated me. When asked what nurses came into the bathroom, CNA B revealed it was LPN C and LPN D. CNA B was then asked where they were when LPN C and LPN D entered the shower/bathroom and replied, I was standing in front of (Resident #701) putting their brief on while they were standing up. When asked if either nurse saw Resident #701 hit them, CNA B stated, I am not sure because I had my back to them and I had the curtain pulled. When queried regarding the Resident reporting an allegation of abuse, CNA B confirmed they were aware of the allegation and stated, Night shift said (Resident #701) called the suicide hotline and told them that I hit them. CNA B was asked when they were told that Resident #701 said they had hit them, CNA B responded, I'm not sure if it was that same day or the next day when I came in. When queried if the Administrator or DON had talked to them regarding the allegation, CNA B replied, They just pulled me aside and told me I would have to write a statement. When asked what day the Administrator and DON told them that, CNA B replied, I think it was the next day. When queried if they had touched the Resident's face and/or jaw at any time while assisting the Resident in the bathroom, CNA B responded, No. When asked if they pushed the Resident, CNA B stated, No. CNA B was then asked if Resident #701 had become unsteady and/or if they had a near fall in the bathroom where they had had to grab them, CNA B responded that they had not. When asked if they were instructed not to care for Resident #701 following the allegation, CNA B replied, No. CNA B verbalized the other CNA staff kinda took over caring for Resident #701 but they were never told they could or should not. When asked if they had been suspended pending an investigation of the allegation, CNA B replied, No. An interview was completed with Unit Manager LPN G on 6/16/26 at 11:35 AM. When queried if Resident #701 had reported an allegation of abuse to them, LPN G replied, (Resident #701) came by and said that the day before they had an altercation with (CNA B). LPN G was asked what Resident #701 told them and stated, (Resident #701) said (CNA B) pushed them on the toilet and they started hitting (CNA B) in self-defense. When asked where the incident had occurred, LPN G replied, (Resident #701) said it happened in the big bathroom (shower room). LPN G stated, After (Resident #701) left my office, I went and talked to (the facility Administrator). When queried what time Resident #701 reported the incident to them, LPN G stated, It was early. I get here between 7:00 and 7:30 (AM) and it was like boom, before 8:00 (AM). An interview was completed with LPN C on 6/16/26 at 12:17 PM. When queried if they recalled an incident involving Resident #701 and CNA B, LPN C verbalized they did. LPN C was asked what happened and said, Me and (LPN D) were at the nurses' station and we heard blood curdling screams from the shower room. LPN C indicated they went into the shower room and saw CNA B attempting to put a brief on Resident #701. When queried what they first saw upon entering the shower room, LPN C stated, Resident #701) was sitting on the toilet, (CNA B) bent down trying to put on brief and (Resident #701) slapped (CNA B) in the face. When queried if Resident #701 said anything to them, LPN C stated, No. When queried if they heard CNA B say anything to Resident #701, LPN B replied, I don't think so. Maybe just like I gotta put your brief back on, I got you all cleaned up. When asked if they were present in the room with Resident #701 and CNA B the entire time care was provided, LPN C responded they were not. On 6/16/26 at 12:29 PM, an interview was completed with LPN D. When asked if they recalled an incident involving Resident #701 and CNA B, LPN B responded they did. When queried what they observed, LPN D revealed they were sitting at the nurses' station and heard screaming from the shower room. LPN D indicated they went to the shower room and saw (Resident #701) standing there yelling at (CNA B). When queried if they saw CNA B push, grab, or hit Resident #701, LPN D responded they did not. When asked if they were present in the shower room the entire time care was being provided, LPN D responded they were not. An interview was completed with LPN K on 6/16/26 at 1:09 PM. When queried if they recalled an incident involving Resident #701 and CNA B, LPN K stated they heard about it but didn't do anything with it because it was vague. When asked what they heard, LPN K revealed they heard Resident #701 said CNA B hit them when they were on the phone with the suicide hotline. When queried if other staff were aware of the allegation, LPN K stated, Everybody heard about it. An interview was completed with the Administrator and DON on 6/16/26 at 4:00 PM. When queried why the abuse allegation was not reported to the State Agency, the Administrator stated, Because (Resident #701) recanted and there was no abuse. With further inquiry, the Administrator stated Resident #701 has a history of changing their story. When queried where Resident #701 calls the suicide helpline from, the DON and Administrator revealed they call from the nurses' station phone. When asked if the Resident requires assistance to call the hotline, the Administrator replied, Yes, sometimes we have to hold the phone because (Resident #701) shakes. When asked how staff were aware of the incident, prior to LPN G reporting the allegation to them, neither the Administrator nor the DON provided an explanation. When queried when an allegation of abuse should be reported, the Administrator and DON both indicated allegations should be reported immediately. When asked who the nurse and/or staff member was that assisted Resident #701 to call the suicide hotline, the Administrator revealed they did not know. With further inquiry, the DON stated, We will educate staff regarding reporting, but we addressed it as soon as we found out. When queried again why the allegation was not reported, the Administrator reiterated there was nothing to report because the Resident recanted the allegation. When asked why Resident #701 verbalized an allegation of abuse when interviewed today if they recanted their allegation, the Administrator did not provide further explanation. Review of facility policy/procedure entitled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property (Effective 11/28/17) revealed, It is the practice of the facility to encourage and support. reporting of suspected acts of abuse. G. Reporting and Response. It is the policy. that 'abuse' allegations are reported. will ensure that all alleged violations. are reported immediately, but not later than 2 hours after the allegation is made. Procedure: Internal reporting. Employees must always report and 'abuse' or suspicion of 'abuse' immediately to the Administrator. Report the results of all investigations to the administrator or his or her designated representative and to other officials. including immediate reporting to the State Survey Agency.

This Citation Pertains to Intake 3031745. Based on interview and record review, the facility failed to ensure allegations of abuse were thoroughly investigated and residents were protected from further potential abuse for one (#701) of three residents reviewed. Findings include:Review of intake documentation dated as received on 5/26/26 revealed Resident #701 called a mental health/suicide hotline today due to suicidal thoughts. During the call, Resident #701 told the hotline worker that Certified Nursing Assistant (CNA) B grabbed them by the jaw and pushed them to the floor in the bathroom. The intake documentation indicated Resident #701 was experiencing pain from the incident. The intake was a referral from Adult Protective Services (APS) and did not specify the date the Resident called the hotline. On 6/16/26 at 9:22 AM, Resident #701 was observed alone in their room, lying in bed and an interview was completed. When queried if they recalled calling a mental health or suicide hotline, Resident #701 replied, Yes because I feel suicidal and depressed. When asked if any facility staff had ever pushed them or hurt them, Resident #701 indicated they had. When queried what happened, Resident #701 stated, (CNA B) pushed me on the toilet and I pushed them back because I was defending myself and (CNA B) grabbed me by my jaw. Resident #701 proceeded to demonstrate how CNA B had grabbed their jaw by grabbing their own jaw in rough manner by placing one hand under the chin with the fingers around their jaw and lower face. When queried what they were doing before this happened and where they were, Resident #701 became visibly upset and stated, I want to go to a psych hospital, I want to talk to (Social Work Director [SWD] A). Resident #701 was reassured that SWD A to come talk to them and the Resident's room was exited. SWD A was located and informed of interview with Resident #701 and that the Resident asking for them. While walking to Resident #701's room with SWD A, the Resident was observed in the hallway and verbalized they were looking for SWD A. At 9:37 AM on 6/16/26, an interview was completed with Resident #701 and SWD A. Resident #701 told SWD A, I slapped (CNA B) and indicated it was self-defense. Resident #701 then told SWD A that CNA B had grabbed their jaw and pushed them. Resident #701 demonstrated how CNA B grabbed their face. SWD A asked Resident #701 where it happened and replied, I was in the bathroom. When queried regarding Licensed Practical Nurse (LPN) C and LPN D being in the bathroom, Resident #701 verbalized they had laughed. SWD A then asked Resident #701 when it had happened and the Resident stated, That was a couple weeks ago. That was a week ago. Resident #701's thoughts and verbalizations became very scattered and the Resident stated, I can't take it. I need to get my meds. SWD A assisted the Resident out of their office to find their nurse. An interview was conducted with SWD A on 6/16/26 at 9:47 AM. When queried if they were aware of the abuse allegation pertaining to CNA B and Resident #701 prior to today, SWD A stated, I did know about it. With further inquiry, SWD A verbalized the facility Administrator and Director of Nursing (DON) were also aware and stated, I think they did a soft file (internal investigation) about the allegation. Record review revealed Resident #701 was originally admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, pain, weakness, falls, schizoaffective, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and dependent upon staff for toileting and bathing. The MDS further detailed Resident #701 did not display any physical or verbal behaviors directed towards others but displayed other behavioral symptoms not directed toward others one to three days. Review of Resident #701's Electronic Medical Record (EMR) revealed the following documentation: - 5/23/26 at 10:12 AM (Saturday): Behavior Note. (Resident) cont. (continue) with multiple verbal/physical behaviors this am. Observed ambulating down hall, refusing assist from staff, yelling and swearing at them. Redirection difficult and unsuccessful. cont. on and off with said behaviors throughout early am. At approx. 0730 (AM) became upset, yelling out 'I want the f*ck out of here! I'm going to kill myself!'. began to scream loudly and went back to room. nurse was then called to res room. Upon entering room, this nurse observed bed remote cord loosely looped around (Resident's) neck. Staff removed cord and all other cords removed from room.new order to ship res to ER. - 5/24/26 at 10:16 AM (Sunday): Behavior Note. Resident was being assisted to the bathroom by CNA. Upon applying brief, hit CNA in the face and was screaming. Resident stated didn't want brief applied. Resident was educated on the importance of having a brief on and allowed CNA to put apply brief. - 5/24/26 at 2:22 PM (Sunday): Behavior Note. (Resident) frequently yelling out/screaming during shift. Refusing cares, verbally and physically abusive to staff. Making accusations against staff members, difficult to redirect at times. - 5/24/26 at 5:30 PM (Sunday): Behavior Note. Res came to desk stating wanted to die and to call crisis hotline. Call placed, res spoke to counselor, requested to be sent to hospital, stating was going to starve themselves to death or drown themselves in the toilet. - 5/26/26 (Tuesday): Physician/NP/PA Progress Note. Late Entry. Encounter for ER visit on 4/23 (sic) for behavioral concerns of suicidality. seen today for a significant change in condition evaluation following an ER transfer prompted by escalating behavioral disturbances and expressed suicidal ideation. has a history of borderline personality disorder with longstanding behavioral episodes; however, behaviors have significantly escalated over recent days. has exhibited frequent verbal and physical aggression toward staff including screaming, profanity, striking a CNA during ADL care, and refusing cares. Between episodes, transitions rapidly to a calm, pleasant demeanor - smiling and engaging cooperatively with peers and staff. has been observed ambulating independently and refusing staff assistance, with redirection largely ineffective during acute episodes. The precipitating event for ER transfer occurred when (Resident) yelled out that wanted to kill herself, followed by staff discovering a bed remote cord loosely looped around her neck. The cord was immediately removed, and all cords were removed from room. - 5/26/26 at 4:28 PM (Tuesday): Social Services. followed up with resident regarding weekend behaviors and concerns reported by staff. During the conversation, resident became tearful at times and was noted to become easily sidetracked from the topic being discussed. provided emotional support and verbal redirection, which was effective. Resident was cooperative with intervention and able to return to the conversation with prompting. Resident was observed out of room throughout the day visiting with staff appropriately. No signs or symptoms of acute distress noted during this shift. Resident denied any immediate needs or concerns when asked. Due to ongoing behavioral and psychiatric concerns, referral information was sent to 18 inpatient psychiatric facilities for review and possible placement. Staff will continue to monitor resident's mood, behaviors, and safety, and provide redirection and support as needed. Interdisciplinary team remains aware of resident status. Further review of progress note documentation in Resident #701's EMR revealed the Resident had previously attempted and/or became physically aggressive with a staff member on 2/7/26 and 5/16/26. An interview was conducted with Human Resources (HR) Director E on 6/16/16 at 10:37 AM. During the interview, the Administrator called HR Director E's phone and was heard asking if they had a statement from CNA B related to Resident #701's allegation of abuse. Director E responded by saying they did not complete interviews related to abuse investigations. On 6/16/26 at 10:39 AM, an interview was completed with the facility Administrator and DON. When queried if they were aware of Resident #701 making an allegation of abuse involving CNA B, both the Administrator and DON confirmed they were aware. When queried if the facility had completed an investigation, the Administrator stated, We didn't do an investigation really because it was witnessed by staff. Any facility investigation documentation related to the abuse allegation was requested at this time. An interview was conducted with CNA B on 6/16/26 at 11:04 AM. CNA B was asked what shift they normally work and replied, 6:00 AM to 6:30 PM. When queried if they recalled an incident involving Resident #701, CNA B verbalized they did and stated it was a couple weeks ago. When asked what happened, CNA B revealed Resident #701 was in the hallway yelling that they needed to be changed and they assisted the Resident into the big bathroom/shower room on the East End of the facility. CNA B revealed Resident #701 was on the toilet and stated, I had taken their brief off and went to get washcloths. (Resident #701) stood up and started yelling that they didn't want to. When asked what the Resident didn't want to do, CNA B indicated they were not sure if the Resident did not want to get washed up or if they did not want to get dressed. CNA B stated, (Resident #701) started yelling out and the nurses came in. CNA B continued, (Resident #701) hit me and told me they hated me. When asked what nurses came into the bathroom, CNA B revealed it was LPN C and LPN D. CNA B was then asked where they were when LPN C and LPN D entered the shower/bathroom and replied, I was standing in front of (Resident #701) putting their brief on while they were standing up. When asked if either nurse saw Resident #701 hit them, CNA B stated, I am not sure because I had my back to them and I had the curtain pulled. When queried regarding the Resident reporting an allegation of abuse, CNA B confirmed they were aware of the allegation and stated, Night shift said (Resident #701) called the suicide hotline and told them that I hit them. When queried if the Administrator or DON had talked to them regarding the allegation, CNA B replied, They just pulled me aside and told me I would have to write a statement. When asked what day the Administrator and DON told them that, CNA B replied, I think it was the next day. When queried if they had touched the Resident's face and/or jaw at any time while assisting the Resident in the bathroom, CNA B responded, No. When asked if they pushed the Resident, CNA B stated, No. CNA B was then asked if Resident #701 had become unsteady and/or if they had a near fall in the bathroom where they had had to grab them, CNA B responded that they had not. When asked if they were instructed not to care for Resident #701 following the allegation, CNA B replied, No. CNA B verbalized the other CNA staff kinda took over caring for Resident #701 but they were never told they could or should not. When asked if they had been suspended pending an investigation of the allegation, CNA B replied, No. The facility investigation documentation related to the abuse allegation was received from the Administrator on 6/16/26 at 11:30 AM. The investigation documentation included the following: - Unsigned Phone Statement from LPN D dated 5/26. The statement detailed, (CNA D) and (CNA C) at desk- heard (Resident #701) yelling. Both went down to (Resident's) room. (Resident #701) was standing up with (CNA B) in bathroom. (Resident #701) was yelling because didn't want their pants pulled up. (CNA B) told (Resident #701) needed pants pulled up in order to go out into hallway. (Resident #701) allowed (CNA B). Was calm. (Resident #701) proceeded to hallway. Voiced no complaints about (CNA B) throughout shift.The statement did not include the date that the incident occurred.- Unsigned Phone Statement from LPN C dated 5/26. The statement detailed, (LPN C) was sitting at nurses station and read resident yelling. Upon entering (Resident #701's) room, (CNA B) was in bathroom with (Resident #701) attempting to pull up brief and (Resident #701) started hitting (CNA B) in the face while yelling. (LPN C) intervened and assisted with getting brief on. Resident then come out into hallway and was calm. Resident never reported (CNA B) hit them or was rough with them during cares.The statement did not include the date that the incident occurred. - Typed Statement, dated 5/26/26, and signed by SWD A. The statement specified, SWD met with (Resident #701) and (Regional Corporate Administrator F) in the administrative office to address a reported allegation involving staff. (Resident #701) stated that a staff member (CNA B) pushed them and grabbed their face while assisting them to the toilet and that other staff members (LPN C) were present and did not intervene. When further explored for clarification, SWD asked resident to confirm the accurate of the report and encouraged honesty to ensure appropriate follow-up. Resident then stated, No indicating the allegation was not accurate. Resident later expressed apology for stating the allegation and repeated that they like the staff member. During conversation, resident was intermittently tearful and easily distracted.The signed statement did not include a time of the interview. An interview was completed with Unit Manager LPN G on 6/16/26 at 11:35 AM. When queried if Resident #701 had reported an allegation of abuse to them, LPN G replied, (Resident #701) came by and said that the day before they had an altercation with (CNA B). LPN G was asked what Resident #701 told them and stated, (Resident #701) said (CNA B) pushed them on the toilet and they started hitting (CNA B) in self-defense. When asked where the incident had occurred, LPN G replied, (Resident #701) said it happened in the big bathroom (shower room). LPN G was queried regarding Resident #701's emotional state when they told them what happened and stated, (Resident #701) was very upset. LPN G continued, (Resident #701) told me that they didn't want (CNA B) to take care of them. With further inquiry, LPN G revealed Resident #701 seemed concerned that they were going to get in trouble for hitting (CNA B) because they kept saying it was self-defense, it was self-defense. LPN G was asked if Resident #701 told them if anyone else was present when the incident occurred, LPN G responded that they did not. LPN G then stated, After (Resident #701) left my office, I went and talked to (the facility Administrator). When queried if they provided a written statement related to the allegation, LPN G replied, No, I don't think so. When queried what time Resident #701 reported the incident to them, LPN G stated, It was early. I get here between 7:00 and 7:30 (AM) and it was like boom, before 8:00 (AM). When asked the date or day of the week Resident #701 reported the allegation to them, LPN G revealed they were not sure. When queried regarding Resident #701's normal behavior and if they tend to change their recollection of events over time, LPN G stated, Yeah. (Resident #701) is consistently inconsistent. LPN G was asked if CNA B was working on the day that Resident #701 reported the abuse allegation to them and replied, I think so, yes.A review of staffing assignment sheets was completed. Per the staffing assignment sheets provided, CNA B, CNA H, CNA I and CNA L worked 5/25/26 on Resident #701's unit during the day shift.The staffing sheet for 5/26/26 revealed CNA B and CNA I were also assigned to Resident #701's unit during the day shift. An interview was completed with CNA H on 6/16/26 at 11:54 AM. When queried if they recalled an incident involving Resident #701 on May 24th or May 25th, CNA H stated, (Resident #701) was having one of those days. When asked to clarify what that meant, CNA H responded that the Resident was up and down and yelling. When asked if they heard or seen anything involving Resident #701 in the bathroom, CNA H responded that they had not witnessed anything. When asked if they had ever seen Resident #701 be violent towards staff, CNA H responded, No. When queried if they recalled working on 5/25/26, CNA H responded that they did not. An interview was completed with CNA I on 6/16/26 at 12:00 PM. When queried if they recalled an incident involving Resident #701 and CNA B in the shower/bathroom, CNA I indicated they were aware and stated, I worked the next day. When queried how they were made aware of the incident, CNA I replied, Nurse informed me of the incident and said to do cares in pairs with (Resident #701) for now. When queried what time the nurse told them that, CNA I replied, That was like at 6:00 AM. CNA I stated, The nurse said that they had called the suicide hotline (with Resident #701). When asked the name of the nurse who had told them that, CNA I responded, (Nurse M). An interview was attempted to be completed with Nurse M on 6/16/26 at 12:10 PM. A voicemail with return phone number was left but a return call was not received by the conclusion of the survey. An interview was completed with LPN C on 6/16/26 at 12:17 PM. When queried if they recalled an incident involving Resident #701 and CNA B, LPN C verbalized they did. LPN C was asked what happened and said, Me and (LPN D) were at the nurses' station and we heard blood curdling screams from the shower room. LPN C was asked to clarify where the shower room was and indicated it is the main shower room on the unit. LPN C revealed there are toilets in the shower room that residents use. LPN C indicated they went into the shower room and saw CNA B attempting to put a brief on Resident #701. LPN C stated, We talked to (Resident #701) and told them that they really needed to put on their brief. When queried what they first saw upon entering the shower room, LPN C stated, Resident #701) was sitting on the toilet, (CNA B) bent down trying to put on brief and (Resident #701) slapped (CNA B) in the face. When queried if Resident #701 said anything to them, LPN C stated, No. When asked if CNA B said anything to Resident #701, LPN B replied, I don't think so. Maybe just like I gotta put your brief back on, I got you all cleaned up. LPN B was asked if they assisted CNA B with Resident #701's care and/or to get them dressed at this time and replied they did not. LPN C stated they just talked to the Resident. When asked if they were present in the room with Resident #701 and CNA B the entire time care was being provided, LPN C responded they were not. On 6/16/26 at 12:29 PM, an interview was completed with LPN D. When asked if they recalled an incident involving Resident #701 and CNA B, LPN B responded they did. When queried what they observed, LPN D revealed they were sitting at the nurses' station with LPN C and heard screaming from the shower room. When asked, LPN D revealed Resident #701 was using the toilet located in the main shower room on the unit. LPN D verbalized they went to the shower room and saw (Resident #701) standing there yelling at (CNA B). When queried what they saw when they entered the shower room, LPN D stated, If I remember correctly, (Resident #701) was standing up and (CNA B) was bent down. LPN D was asked what occurred and if they provided any assistance and replied, (CNA B) said everything was fine and we (LPN C and LPN D) went out. When asked how Resident #701 was when they came out of the shower/bathroom, LPN D stated, (Resident #701) was still crying. When asked, LPN D stated, (Resident #701) never said anything to me about what happened. LPN D was then asked if they saw Resident #701 hit CNA B and stated, Not that I remember. When queried if they saw CNA B be physically aggressive and/or physically abusive to Resident #701, LPN D verbalized they did not. When asked if they were present in the shower room the entire time care was being provided, LPN D responded they were not. An interview was conducted with CNA M on 6/16/26 at 12:43 PM. When queried if they were aware of an incident involving Resident #701 and CNA B in the shower/bathroom, CNA M responded, I did not see it, but I heard about it. When queried what they heard, CNA B refused to answer stating they did not want to spread gossip. An interview was completed with LPN K on 6/16/26 at 1:09 PM. When queried if they recalled an incident involving Resident #701 and CNA B, LPN K stated they heard about it but didn't do anything with it because it was vague. When asked what they heard, LPN K revealed they heard Resident #701 said CNA B hit them when they were on the phone with the suicide hotline. When queried if other staff were aware of the allegation, LPN K stated, Everybody heard about it. A follow-up interview was completed with SWD A on 6/16/26 at 2:10 PM. When queried what day and time they were notified of the abuse allegation pertaining to Resident #701 and CNA B, SWD A revealed it was the date of their note and stated, I did it in the morning, not sure what exact time. When asked who notified them of the allegation, SWD A replied, I was alerted in the morning. Report is at 9:00 AM, I'm unsure if it was before or after (report) that I talked to (Resident #701). An interview was completed with the Administrator and DON on 6/16/26 at 4:00 PM. When queried where Resident #701 calls the suicide helpline from, the DON and Administrator revealed they call from the nurses' station phone. When asked if the Resident requires assistance to call the hotline, the Administrator replied, Yes, sometimes we have to hold the phone because (Resident #701) shakes. When asked who the nurse was that assisted the Resident to contact the suicide helpline when they told the helpline about the abuse allegation, the Administrator stated they did not know. The Administrator and DON were then asked how staff were aware of the abuse allegation prior to Resident #701 reporting the allegation to LPN G, the Administrator and DON did not provide an explanation. When queried why they did not talk to other staff and residents as part of a comprehensive investigation, the Administrator responded that Resident #701 recanted and there was no abuse. When queried if individuals who experience abuse may recant their allegation due to fear of retaliation, a response was not provided. When asked why Resident #701 verbalized an allegation of abuse when interviewed today if they recanted their allegation, the Administrator did not provide further explanation. The Administrator and DON then revealed that Resident #701 has been going through a mental health crisis, and the facility is attempting to find psychiatric inpatient placement. When asked if increasing resident behaviors has the potential to increase the risk of abuse, the DON confirmed and verbalized understanding. When queried why the investigation completed did not include an interview with the alleged perpetrator, the Administrator revealed they were unable to locate the form. When asked why the phone interview forms for both LPN C and LPN D specified the incident occurred in the Resident's room bathroom when all the staff verbalized it occurred in the main shower/bathroom, the Administrator revealed they thought it had happened in their Resident's room but did not provide further explanation. When asked if the alleged perpetrator, CNA B was suspended and removed from the building immediately when they were notified of the allegation, the Administrator stated, No. When asked why not, the Administrator stated, The staff took it upon themselves to make sure (CNA B) didn't have (Resident #701). When queried how they protected the other residents in the building from potential abuse if the alleged perpetrator remained in the building working during the investigation, the Administrator indicated they understood but reiterated Resident #701 recanted their allegation which made it a mute issue. Review of facility policy/procedure entitled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property (Effective 11/28/17) revealed, It is the practice of the facility to encourage and support. reporting of suspected acts of abuse. E. Investigation. The investigation is the process used to try to determine what happened. The designated facility personal will begin the investigation immediately. The investigation will include: Who was involved; Residents' statements. Involved staff and witness statements. Protection. The alleged perpetrator will immediately be removed. Employers accused of alleged abuse will be immediately removed from the facility and will remain removed pending the results of a thorough investigation.

Based on observation, interview and record review, the facility failed to ensure a sanitary environment for 1 of 1 resident reviewed for clean environment (Resident #18) and a safe environment for all residents currently residing in the facility.Findings Include: Resident #18: Review of the resident's Face Sheet, nursing notes dated 2/26 through 4/26, and care plans dated 10/24/23, revealed Resident #18 was 76 years-old, admitted to the facility on [DATE], alert but not able to make own healthcare decisions, dependent on staff for Activities of Daily Living and exhibited extensive behaviors; Fall Risk care plan dated 10/24/23, revealed his mattress was on the floor due to a fall history with behaviors. The resident's diagnoses included, chronic lung disease, adjustment disorder, depression, stroke, and Hemiplegia of the right side. The resident put himself on the floor often and had his mattress kept on the floor due to behaviors and preferences. Observation made on 4/21/26 at 8:00 a.m., revealed a mattress sitting directly on the floor. The resident's floor was noted to be very dirty with dried liquid areas by the door and the head of the bed and several pieces of paper with dirt, debris and scuff marks throughout the room. During an interview on 4/22/26 at 7:40 a.m., Director of Housekeeping A stated They (Housekeeping staff) do clean early in the morning about 6:30 a.m. that hall gets done first. Director of Housekeeping A said the resident's room should be cleaned early in the morning and as needed due to his mattress being on the floor. Review of the facility daily cleaning duties (un-dated) revealed resident's floors were to be cleaned daily. On 04/20/2026 at 9:27am observed a chemical feed downstream of an atmospheric vacuum breaker (AVB) at the utility sink located in the kitchen janitor's closet. On 04/20/2026 at 10:28am observed a chemical feed downstream of an atmospheric vacuum breaker (AVB) at the utility sink located in west nursing station janitor's closet. On 04/20/2026 at 10:32am observed a chemical feed downstream of an atmospheric vacuum breaker (AVB) at the utility sink located in east nursing station janitor's closet. According to the State of Michigan's 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve). According to the State of Michigan's 2008 Cross Connection Manual on chemical feeder backflow prevention, Another concern with a hose being run from a faucet to the dispenser is that many times a valve is installed on the hose downstream of an AVB, which is not allowed since AVBs cannot be subject to continuous pressure.

Based on interview and record review, the facility failed to implement and operationalize a comprehensive antibiotic stewardship program, incorporating a facility wide system to monitor, track, and ensure accountability for antibiotic use including consistent use and documentation of standardized tools/criteria for antibiotic therapy resulting in the potential for inappropriate antimicrobial use and the development of resistant organisms for all 68 facility residents. Findings include:A review of the facility IC program was completed on 4/22/26 at 10:02 AM with Unit Manager IC Registered Nurse (RN) Z. When queried if the facility utilized standardized criteria for infections, IC RN Z responded, McGeer. All facility IC information and surveillance data for November 2025 was requested and reviewed with RN Z at this time. Documentation provided included a line list, mapping tool, and a summary. The line list for November 2025 did not include if the infection met McGeer criteria for treatment. A review of the November 2025 Summary did not indicate the number of infections which met criteria and did not include any information pertaining to the appropriateness of treatment. When queried regarding the line listing and summary not including whether the infection meet criteria for treatment, RN Z indicated all infections met criteria. With further inquiry, RN Z revealed a McGeer form is completed in the Electronic Medical Record (EMR) for all residents who are started on an antibiotic. RN Z verbalized they do not maintain copies of the form as it is available in the EMR. When queried how they knew and tracked if the infection met McGeer criteria when it was not listed on the line list, RN Z verbalized all infections met criteria. Review of the line list revealed Resident #80 was included on list for two infections. The first infection was listed as a facility acquired Upper Respiratory Infection (URI). Per the line list, the infection onset date was 11/11/25 and they received Azithromycin (antibiotic) from 11/16/25 to 11/20/25. The signs and symptoms of infection were listed as fever but did specify the date of the fever. The second infection for Resident #80 was listed as community acquired gastritis with an onset date of 11/7/25. Per the line list, Resident #80 received Micafungin (anti-fungal medication) from 11/7/25 to 11/18/25. A causative organism was not included on the line list.Upon request, RN Z provided Resident #80's electronic Nursing: McGeer Infection Symptom Tracking form, dated 11/14/25 at 12:04 PM. Review of the form revealed the Resident's signs and symptoms of respiratory infection were observed on 11/14/25 and the Health Care Provider (HCP) was notified that day. Per the documentation on the form, Resident #80 did not meet the criteria for treatment of an upper or lower respiratory infection. When queried regarding the line list specifying the Resident's signs and symptoms of infection starting on 11/11/15 not matching the date listed on the McGeer form, RN Z was unable to provide an explanation. When queried regarding the infection not meeting criteria for treatment, RN Z reviewed Resident #80's documentation and confirmed the infection did not meet criteria. When asked if this was addressed with the HCP, RN Z revealed it was not. Upon request for the McGeer Infection Symptom Tracking form for Resident #80's community acquired gastritis diagnosis, RN Z responded they did not have one. When asked why they did not have a form, RN Z stated, Don't do for residents who are admitted on antimicrobial treatment. When queried how the facility ensures the Resident is receiving the correct treatment if they are not utilizing standardized criteria, RN Z responded that the HCP continues the medications ordered from the hospital. No further explanation was provided. RN Z was asked if they obtain records and cultures from the hospital for residents admitted on antimicrobial therapy and indicated they are able to request the results. Further review of the line list revealed a resident was admitted to the facility with a Urinary Tract Infection and received Zofran (antibiotic) from 11/1/25 to 11/2/25. The line listing specified there was no growth under organism. When asked, RN Z responded that a Nursing: McGeer Infection Symptom Tracking form had not been completed because the Resident was admitted to the facility with the UTI on antibiotic therapy. When queried why the Resident was receiving an antibiotic if their culture and sensitivity showed no growth, RN Z did not provide further explanation. RN Z was asked why the monthly summary did not include an analysis of antibiotic use including appropriateness of antibiotics for all residents receiving antimicrobial treatment and how the facility ensures appropriate treatment to prevent unnecessary or inappropriate antibiotic use, RN Z did not provide an explanation but indicated they will be more in-depth in their analysis. When queried regarding addressing inappropriate antibiotic use with the HCP including in the summary, RN Z indicated the HCP makes the final decision regarding treatment, but they will be addressing concerns with them going forward. An interview was conducted with the Director of Nursing (DON) on 4/22/26 at 12:11 PM. The DON was asked if residents admitted to the facility on antimicrobial treatment should be evaluated for appropriate treatment using a standardized criteria and responded, Yes. The DON was informed that McGeer criteria was not being completed for residents admitted to the facility on an antibiotic. The DON responded that it should be completed for every resident who receives an antibiotic whether or not treatment is initiated in the facility. When queried regarding the monthly summary not addressing resident infections who do not meet criteria for treatment, including Resident #80, the DON verbalized understanding of concerns. Facility policy/procedure related to antibiotic stewardship was requested during the entrance conference on 04/20/26 at 9:08 AM but not received by the conclusion of the survey. Review of facility policy/procedure entitled, Infection Prevention and Control Guideline (Effective: 11/18/17) did not address antibiotic stewardship.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings includeOn 04/20/2026 at 9:12am during the initial kitchen tour with Certified Dietary Manager (CDM) P, observed chopped tomatoes without datemarking in the two-door refrigerator. During this observation, CDM P was interviewed on when the tomatoes were chopped, and she stated she didn't know. According to the facility's policy on labeling and dating foods, Refrigerated food prepared in the healthcare community is labeled with the date to discard or to use by. This includes leftovers. The discard/use by date will be a maximum of six days after preparation. The day of preparation is counted as Day 1.According to the 2022 Food Code, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.On 04/20/2026 at 9:21am observed calcium buildup on interior walls of ice machine in the kitchen. During this observation, CDM P was interviewed on how often the ice machine is cleaned, and she answered that she wasn't sure, but she thinks it's every month.On 04/20/2026 at 10:09am interview with Maintenance Director Q, and he stated that the ice machine is cleaned every 3 months.Record review of the facility's ice machine cleaning logs found that the task description is listed as Ice Machines: Check filters (if present), clean coils, sanitize interior, delime as necessary and it was marked as completed on 1/31/2026, 10/31/2025, 7/31/2025, 4/30/2025. According to the FDA 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.On 04/20/2026 at 11:57am observed two dirty cups sitting in the basin of handwashing sink, located in the kitchenette. According to the FDA 2022 Food Code, 5-205.11 Using a Handwashing Sink, A handwashing sink shall be maintained so that it is accessible at all times for employee use .A handwashing sink may not be used for purposes other than handwashing .An automatic handwashing facility shall be used in accordance with manufacturer's instructions.On 04/20/2026 at 12:07am during lunch observation, ranch was temped at 44 F and salad made with lettuce, tomato and cheese was temped at 49 F using a thermometer probe. During this observation, CDM P was interviewed on what cold holding temperature should be and she stated 41 F. According to the facility's policy on cold holding, it states Hot foods will be plated at 135 F or higher and cold foods will be plated at 41 F or lower.According to the FDA 2022 Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained: .at 5 C (41 F) or less.

Based on interview and record review, the facility failed to implement and operationalize a comprehensive Infection Control (IC) program incorporating outcome and process surveillance, comprehensive data collection, tracking of potential infections, analysis, and trend identification resulting in the potential for spread of microorganisms and illness to all 68 facility residents. Findings include:A review of the facility IC program was completed on 4/22/26 at 10:02 AM with Unit Manager IC Registered Nurse (RN) Z. RN Z was asked what one of the most important things that staff can do to prevent infections is and replied, Hand Hygiene. When queried how they monitor to ensure staff are performing hand hygiene appropriately, RN Z indicated observation. When queried if the facility utilized a standardized criteria for infections, IC RN Z responded, McGeer.All facility IC information and surveillance data for November 2025 was requested from RN Z at this time and a review was completed. RN Z provided a line list, mapping tool, and a summary. No process surveillance documentation was provided.The printed infection line list for November 2025 only included residents treated with antimicrobial therapy and did not include carry-over infections from October 2025. The line list did not indicate if the infection meet criteria for treatment with an antimicrobial agent. The line list included 29 infections for 25 residents. The line list did not delineate if the residents with UTIs had indwelling urinary catheters. When queried regarding the line list not indicating if the UTI was associated with an indwelling urinary catheter, RN Z replied, I put that (catheter associated UTIs) on a different sheet. The line list included a total of 5 UTIs with four UTIs being facility acquired. A review of the mapping tool revealed 29 infections including 5 UTIs. When queried how they identified potential spread and/or trends if carry over infections were not included, RN Z revealed they track carry over infections on a separate line list. The carry over infection line list for November 2025 was provided at this time. When asked what the mapping tool is used for, RN Z revealed it is used as a quick visual guide to identify possible infection trends. When queried if carry-over infections from the previous month are able to be spread to others, RN Z indicated they could. RN Z was then asked why carry-over infections were not included on the mapping tool for identification but did not provide an explanation. The IC summary for November 2025 detailed, The facility had 29 residents treated with antibiotics in November. 17 residents were started on antibiotics in-house, 12 were admitted on antibiotics. Of the 17 Facility-initiated antibiotics: UTI - 4 (prevalence 6.25%); Skin - 3 (prevalence 4.68%); Respiratory - 9 (prevalence 14.06%); Other (Shingles) - 1 (prevalence 1.56%). Of the 15 Community-acquired antibiotic; Sepsis (infection causing extreme, exaggerated response throughout the body) - 2; Osteomyelitis (infection of the bone) - 3; Gastritis (inflammation of the stomach lining)- 1; Respiratory - 4; Skin - 1; UTI - 1. When queried regarding the monthly summary document specifying there were 12 residents admitted on antibiotic in one place and 15 in another, RN Z reviewed the information and responded that there were 12 residents admitted on antibiotic therapy and they had made an error. Review of the residents with facility-acquired urinary tract infections (UTI) revealed three of the four infections listed Escherichia coli (bacteria found in intestines and stool) as the causative organism of the UTI. A review of the IC mapping revealed the residents with UTIs caused by Escherichia coli resided in the same wing of the facility. A review of the IC summary for the month specified, Trends. UTIs were slightly up from 3 in October to 4. No new bacteria species identified, No MDROs (Multidrug Resistant Organisms) in urine. The summary did not address Escherichia coli in the urine. RN Z was asked if they identified a trend related to the three residents with UTIs caused by Escherichia coli and responded that the residents did not all reside on the same hall of the facility. When asked if the residents resided on the same wing of the facility, RN Z confirmed they did. When queried if the same staff on that wing worked with the residents in all the halls where the Escherichia coli UTIs were identified, RN Z confirmed they did. When queried if the UTIs were a potential infection trend, RN Z verbalized they were and stated, I don't know how I missed that. With further inquiry, RN Z stated, It was an oversight. When asked how they are able to identify and educate to prevent spread of infection when trends are not identified, RN Z verbalized understanding but did not provide further explanation. The line listing identified Resident #29 as having shingles (viral infection), receiving treatment with Bactrim DS (antibiotic), and being placed on contact precautions. The line listing did not specify when the contact precautions were implemented. When queried why the resident was treated with an antibiotic for a viral infection, RN Z indicated that was what the Health Care Provider (HCP) ordered. A review of the IC summary did not include any information explaining the rationale for treatment of a viral infection with an antibiotic (treatment for bacterial infections). RN Z verbalized the HCP diagnosed Resident #29 with shingles from a physical exam, but a laboratory swab diagnostic test was not completed. When queried why Resident #29 was not placed in airborne and contact precautions and if the shingles was disseminated, RN Z responded that it was localized. When queried if the Resident was immunocompromised, RN Z did not respond. RN Z then verbalized they were unaware that shingles infections required airborne precautions. The Centers for Disease Control (CDC) Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions: Guidelines for Isolation Precautions: Appendix A (February 2025) was reviewed with RN Z at this time. RN Z revealed the Resident's shingles lesions were on their leg and able to be covered. RN Z was then asked how they tracked possible infections and/or residents with signs/symptoms of infections who do not receive antimicrobial treatment and stated, We do not track potential infections. When queried how they identify possible infections before they can spread if they do not track potential infections and/or residents with signs/symptoms of infection who are not receiving antimicrobial treatment, RN Z did not provide an explanation. When queried regarding process surveillance such as audits completed for the month of November 2025, RN Z revealed they did not complete any IC audits/process surveillance for November 2025. When asked why no process surveillance was completed, RN Z replied, I don't know what happened. I get pulled to the floor a lot especially on nights. When queried regarding IC education for facility staff pertaining to identified IC concerns, RN Z revealed no IC education was completed for the month related to any identified IC concerns. An interview was conducted with the Director of Nursing (DON) on 4/22/26 at 12:11 PM. When queried if the facility should be tracking potential infections/residents with signs/symptoms of infection as part of the IC program, the DON verbalized they should. The DON was informed of lack of tracking of potential infections, inaccurate data on monthly analysis, lack of process surveillance, lack of infection trend identification for November 2025 and lack of follow-up education to prevent further infections. The DON verbalized understanding of all concerns. No further explanation was provided. Review of facility policy/procedure entitled, Infection Prevention and Control Guideline (Effective: 11/18/17) revealed, Guideline: It is the practice of this facility's Infection Prevention and Control Program (IPCP). to prevent recognize and control the onset and spread of infection. includes a system for preventing, identifying, reporting, investigating, and controlling infections.

Based on observation, interview and record review, the facility failed to ensure the dignity of 4 of 6 residents reviewed for dignity (Residents #5, #26, #45 and #62).Findings Include:Resident #45: On 4/20/26 at 9:46 AM, Resident #45 was observed in their room, lying in bed on their back with their eyes closed. A urinary catheter drainage bag was observed on the left side of the bed, towards the room door. The urinary drainage bag was not contained in a bag and did not have a dignity cover in place. Resident #45's urine was very dark and the color of coke. Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses which included left femur fracture, heart failure and respiratory failure. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required moderate to total assistance to complete ADLs with the exception of eating and oral care. The MDS further detailed the Resident had an indwelling urinary catheter. Review of Resident#45's EMR revealed a care plan entitled, Foley: Resident requires use of an indwelling catheter r/t (related to) acute urinary retention (Initiated: 3/9/26). The care plan included the intervention, Keep draining bag covered to promote privacy (Initiated: 3/9/26). An interview was completed with the Director of Nursing (DON) on 4/21/26 at 2:22 PM. When queried regarding facility policy/procedure related to urinary catheter drainage bags, the DON stated, Cath drainage bags should be in dignity bags. Review of facility policy/procedure entitled, Quality of Life - Dignity (Revised 12/2016) revealed, Policy . 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered . Review of the facility Resident Rights policy dated 12/2016, stated Resident's shall be cared for in a manner that promotes quality of life and dignity; and enhances quality of life, dignity, respect and individuality. Review of the facility Call Light policy dated 11/2013, stated When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. Review of the facility Call System policy dated 9/2022, stated Calls for assistance are answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately. Resident #5: Review of the Face Sheet, nurse's notes dated 2/26 through 4/26, and care plans dated 3/25, revealed Resident #5 was 61 years-old, admitted to the facility on [DATE], alert and able to make own healthcare decisions, and dependent on staff for Activities of Daily Living/ADL's. The residents diagnosis included, low back pain, muscle wasting, muscle weakness, osteomyelitis, sacral wound, urinary catheter in place, adjustment disorder, major depression and chronic kidney disease. Observation was done on 4/21/26 at 7:45 a.m., of resident in herbed with her urinary catheter bag within sight of the open door. The residents catheter bag did not have a concealed privacy cover on it; there was approximately 1/4 of the bag full of urine at this time. Also, there was several areas of dried blood on the right upper bottom sheet. During an interview done on 4/21/26 at 7:45 a.m., the resident said the blood was from last night, and stated, I am waiting for them to come and change my sheet, it's just got some blood on it. My IV started bleeding last night. They have to get people up I guess. During an interview done on 4/21/26 at 1:30 p.m., Regional Nurse, RN B stated We need to have a privacy bag (on the residents catheter bag), During an interview done on 4/21/26 at 1:58 p.m., the Director of Nursing stated The catheter should be in a dignity (privacy) bag, that's a problem. Resident #26: Review of the Face Sheet, physician active orders dated 4/26, and nurses notes dated 4/26, revealed Resident #26 was 80 years-old, not able to make own healthcare decisions, admitted to the facility on [DATE], and was dependent on staff for ADL's. The residents diagnosis included, major stroke, chronic lung disease, ulcerative colitis, chronic pancreatitis, respiratory failure, Lupus disease, major depression, heart failure, kidney disease, viral hepatitis and malignant neoplasm of endometrium. During an interview done on 4/21/26 at 7:40 a.m., the resident stated, Sometimes food is cold, I have not asked to have it warmed up, I usually get something that you can eat cold. The resident said she orders cold foods due to foods not being served hot. During the confidential resident Group meeting held on 4/21/26 at 11:00 a.m., 4 of 5 resident attendees said the facility served them cold food; they said they did not want to get anyone in trouble so they did not complain. Review of the facility Resident Council Minutes dated 12/5/25, 1/27/26, 2/25/26, and 3/25/26, revealed documentation of resident complaints of cold food being served. Resident #62: Review of the Face Sheet, physician current orders dated 4/26, and care plans dated 5/21/25, revealed Resident #62 was 77 years-old, was admitted to the facility on [DATE], had a guardian in place, and was dependent with all ADL's. The residents diagnosis included, Alzheimer's Disease, diabetes, Dementia, Major depression, wonder, adjustment disorder, spinal stenosis and chronic pain syndrome. The resident had a respiratory, visual and auditory deficit, was a fall risk, and was an elopement risk due to wondering behavior. Review of the residents Fall care plan dated 11/18/25, stated Keep frequently used items within reach, including the residents call light. Observation made on 4/21/26 at 7:37 a.m., revealed the resident in bed with his call light hanging over the electrical call light system on the wall. The call light was approximately 4 to 4.5 feet from the resident, he was unable to reach it and his room door was shut at the time. During an interview done on 4/21/26 at 7:42 a.m., Nursing Assistant H stated Yes, he can use his call light. Review of the facility Nursing Competency sheet (un-dated), reveled education regarding dignity and stated Understanding better service excellence and how to embed it as a nurse; understand the importance of resident dignity and how to maintain it in this role.

Based on observation, interview and record review, the facility failed to provide fresh fluids at bedside for one resident (Resident #49) of six residents reviewed for bedside fluids. Findings include. Resident #49: On 4/20/2026, at 11:06 AM, Resident #49 was lying on their bed awake. There was one Styrofoam cup noted on their nightstand. The cup appeared to have brown liquid in it and the cup had a date written on it of 4/18. There was an empty coke bottle on their overbed table. Resident #49 provided they got it out of the machine. There were no other fluids at bedside. On 4/20/2026, at 11:55 AM, Certified Nursing Assistant (CNA) S was asked if Resident #49 had been provided a cup of water and CNA S provided that Resident #49 usually only wants chocolate milk. On 4/20/2026, at 11:59 AM, an observation along with CNA S of Resident #49's Styrofoam cup. CNA S was asked what the date and fluid was and CNA S offered, 4/18 and it's chocolate milk. CNA S reassured the resident they would get a new cup of milk for them as it was old. Resident #49 stated, they just gave it to me and it's half full. On 4/21/2026, at 3:30 PM, a record review of Resident #49's electronic medical record (EMR) revealed an admission on [DATE] with diagnoses that included cerebral infarction (stroke), Dementia and Major Depressive disorder. Resident #49 required assistance with Activities of Daily Living (ADL's) and had severely impaired cognition.

Based on observation, interview and record review, the facility failed to ensure that one (Resident #5) of 5 residents reviewed for medication storage were properly stored.Findings Include: Resident #5: Review of the Face Sheet, nurse's notes dated 2/26 through 4/26, and care plans dated 3/25, revealed Resident #5 was 61 years-old, admitted to the facility on [DATE], alert and able to make own healthcare decisions, and dependent on staff for Activities of Daily Living. The residents diagnosis included, low back pain, muscle wasting, muscle weakness, osteomyelitis, sacral wound, urinary catheter in place, adjustment disorder, major depression and chronic kidney disease. Review of the residents Mood problem care plan dated 11/11/24, revealed staff were to administer mediations as ordered and monitor for side effects. Review of the facility medication Preparation and General Guidelines policy dated May 2022, revealed all resident medications were to given per the 5 Rights of Medication Administration (including proper identification of any medication and documentation of all medications/treatments (including checking the TAR-Treatment Medication Record) prior to giving. No medications or topical treatments were to be left at the bedside or any place in residents room unattended.Observation was done on 4/21/26 at 8:00 a.m., in the residents room. Next to the sink sitting on the counter was a small cup of liquid approximately 1/4th full of Diakins (used for wound care). On the cup was written with black marker the word Dankins, no top on the cup, and no resident name or any dates were found on the cup.During a second observation done on 4/21/26 at 11:30 a.m., was found a opened and partly used tube of Dicofenac Sodium Topical 1% (used for arthritis pain/discomfort); this was seen sitting on the residents bedside table, with no name and no dates on the tube.Review of the residents orders dated 11/24 through 4/26, revealed documentation that Dicofenac Topical cream was ordered for the resident on 11/11/24, and discontinued on 1/6/25.Review of the residents EMAR (Electronic Medication Administration record) and TAR (Treatment Administration Record) dated 4/26, revealed no order or documentation of the resident getting Dicofenac topical cream.Review of the resident orders dated 12/14/26, revealed Dankins was to be used on the residents sacral wound as a treatment. Review of the EMAR dated 4/26, revealed staff were using the Dankins on her sacral wound as ordered.During an interview done on 4/22/26 at 11:15 a.m., East Unit Manager, LPN stated It (the Dicofenac) was discontinued, it should not have been in her room and the Dankins should not have been in a cup her room, I don't know what to say.

Based on observation, interviews and record reviews, the facility failed to prevent the development of facility-acquired Deep Tissue Injuries (DTI) for two residents (Resident #6, Resident #29) of 6 residents reviewed for wounds.Findings include: Resident #6:Record review of Resident #6's 2/12/2026 significant change Minimum Data Set (MDS) section M: Skin conditions noted that the resident was at risk of developing pressure ulcers/injuries, but that the resident had no unhealed pressure ulcers/injuries at the time of the assessment. During an observation on 04/20/2026 at 9:46 AM, Resident #6 was sleeping/resting on top of the covers on the bed with regular socks on her feet. There were gray soft boots (Prafo boots) with Velcro straps located in the wheelchair at bedside. The protective boots were not on the resident while in the bed. Resident #6's heels were resting on the mattress. The state surveyor observed slight right ankle/foot swelling. There were no extra pillows noted in room for heel elevation or offloading. Record review of Resident #6's progress notes, dated 2/5/2025 at 8:08PM, noted a fall on 2/3/2026 that resulted in a fracture of the left fifth metatarsal and was assessed of the left foot with some bruising and edema, painful to the touch, range of motion was limited with pain and weakness . tired/lethargic appearing. Record review of progress note, dated 3/12/2026 at 4:21PM, revealed that upon skin assessment the resident was noted to have a blister that was irregular in shape and size. Surrounding skin is red in color and blanchable. Blister is likely from resident wearing orthopedic boot with gripper socks and was caused by friction Progress note dated 3/22/2026 at 10:59 AM, skin/wound: Resident continues with abrasions to lower back and left buttocks. Also continues with area to left foot with current treatment . Progress note 4/10/2026 at 00:30AM noted to be lethargic and tired this shift . 4/13/2026 at 8:47Am resident very lethargic AM medications not given at this time . On 4/15/2026 at 3:53PM residents noted to have fluid filled blister to right heel. Approximately 4.00 x 4.00 cm in size, Area cleansed with normal saline and betadine and covered with dry dressing . Record review of Resident #6's 'Wound Assessment Details Report', dated 4/15/2026, revealed that on 03/12/2026 a left outer foot facility-acquired blister to back of left heel and a new facility-acquired right heel blister measuring 4.0 x 4.0 cm. In an observation on 04/20/2026 at 3:10 PM, Resident #6 was observed in bed asleep with no gray soft boots (Prafo boots) on, feet/heels were resting on the mattress. No pillow to elevate heels and no boots on. Observation of the resident's room located the soft gray boots (Prafo boots) on top of the closet/wardrobe behind the entrance door. In an observation on 04/21/2026 at 7:22 AM with Registered Nurse K, the resident was in bed with no covers on and her legs/heels were on the mattress again. The soft heel protector boots (Prafo boots) were off while resident was in bed off. Observation and interview were conducted on 04/21/2026 at 11:33 AM of Resident #6 with Registered Nurse K. Observation of resident's heels bilateral revealed a right heel- with a blood-filled blister, deep tissue injury, dark black in color betadine on the blister, The blister was fifty-cent-coin sized. It was estimated at 3.5 inches long and 2 inches wide and stuck up 1/2 inch or more. RN K stated that it it was not there when RN K worked last week. Observation o the left heel revealed an anterior dime=sized, and dried deep tissue injury. Also, the back of the heel has a dark deep tissue injury, dime-sized in appearance. RN K stated that the right heel deep tissue is a new injury. Record review of the facility's 'Prevention of Pressure Injuries' policy, dated 4/2020, revealed that the purpose of the procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Skin Assessment: (3.) Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living (ADLs). B. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) E. Reposition resident as indicated on the care plan. Device related pressure injuries: review selected medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device. Monitor regularly for comfort and signs of pressure-related injury . Resident #29:Observations and an interview were conducted on 04/20/2026 at 9:54 AM with Resident #29 accepting the state surveyor observing care. Resident #29 was being prepared for a Hoyer transfer to a wheelchair. During the observation the surveyor noted a Krelix dressing on the left foot heel area with no date, time or initials. Observation of the dressings on the left foot with no dates or time noted, were observed by Certified Nursing Assistants (CNA) H and R. Record review of Resident #29's Minimum Data Set (MDS) dated [DATE] section M: Skin conditions, revealed that the resident was at risk of developing pressure ulcers/injuries but had no actual observed pressure ulcers/injuries. Record review of Resident #29's 'Wound rounds' page in the electronic medical record (EMR) revealed on 01/14/2026 a left heel pressure injury. Record review of the 1/14/2026 'Weekly Skin Check/Skin Condition' form noted a 1.0 cm x 1.0 cm pressure area, dark purple in color, and redness to bilateral heels. Observation and interview were conducted on 04/22/2026 at 7:52 AM with the Licensed Practical Nurse (LPN) Unit Manager D of Resident #29's facility-acquired pressure injury to the left heel. LPN D stated that the left heel wound was facility acquired and that it is healing. LPN D was taken to Resident #29's room and observed the dressing to the left heel. Observation of the left heel dressing, undated again, revealed that krelix and the 2 x 2 border dressing with betadine were removed. Observation revealed an open area with flaked off skin, deep tissue injury was noted. LPN D stated that there should have been a date, time and initials of the staff member performing the dressing change on the dressing. Record review of the facility's 'Wound Care' policy, dated 4/2026, revealed that the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Steps in procedure: (9.) [NAME] the dressing with initials, time, and date. Record review of the facility's 'Moving and Positioning' policy, undated, revealed pressure injuries can occur in high-risk areas such as bony prominences or where a bone is lying directly on top of another bone. Bony prominences are the areas of the body where a bone lies close to the skin's surface, such as the back of the head, shoulders, elbows, heels, ankles, tops of the toes, hips, and coccyx (i.e., tailbone). These areas are most susceptible to developing pressure injuries because they have the leastamount of cushioning. Placing pillows or other specialized equipment reduces the pressure inthese areas and also helps to prevent the resident from rolling out of position Moving residents must be done carefully because their skin can easily be damaged by improper handling. Due to the effects of aging on the integumentary system, older adults can develop pressure injuries from friction and shear when repositioned or from lying in one position for long periods of time in bed. Pressure injuries (formerly called pressure ulcers or bedsores) are localized damage to the skin or underlying soft tissue, usually over a bony prominence, as a result of intense and prolonged pressure and/or shear . If a resident is highly susceptible to pressure injuries of the heels, they may have specialized soft foam boots that support the ankles and keep the heels floated off the bed. A foot cradle may also be used to keep sheets and blankets off the tops of the toes if the resident has a history of skin injury in that area.

Based on observation, interview and record review, the facility failed to assess, monitor and document wound care for two residents (Resident #12, Resident #75) and improperly used a positioning device for one resident (Resident #5) out of three residents reviewed for quality of care, resulting in old, undated wound dressings and no physician's orders for a positioning device. Findings include. Resident #75: On 4/20/2026, at 1:20 PM. Resident #75 was sitting in their wheelchair in their room. They had on an occlusive dressing on their left elbow/forearm that was dated 4/17. Resident #75 stated, he bumped it when he fell the day before. On 4/20/2026, at 1:28 PM, an observation with Nurse U of Resident #75's left elbow dressing was conducted. Nurse was asked what the date was on the dressing and Nurse U stated, 4/17. Nurse U removed the dressing. There was an approximate 1 centimeter (cm) by 1 centimeter skin abrasion. The wound bed was red and shiny. Nurse Ucleansed the area with normal saline and a 4 x 4 cloth which revealed a small amount of bloody drainage noted to the cleansing cloth. Nurse Ustated, they would call the doctor and place an order for treatment to the abrasion. On 4/21/2026, at 10:45 AM, a record review of Resident #75's electronic medical record revealed a readmission on [DATE] after a two-day hospital stay with diagnoses that included Diabetes Mellitus, Pneumonia and Covid Positive. Resident #75 required assistance with Activities of Daily Living and had intact cognition. A review of the Nursing: Admission/re-admission . Skin Evaluation Date: 4/19/2026 revealed General . Skin Integrity . Open Areas . was check marked. There was further notation . Additional Comments: Skin tear noted to left elbow measuring 1cm X 1cm x 0 cm. Bruising noted throughout arms, legs, and left buttock. No other open areas noted at this time . Left elbow Treatment in Place . Is there an order for all wounds that require a treatment? . Yes . was check marked. The Skin Evaluation was started on 4/19/2026 and locked (completed) on 4/20/2026 14:21 (2:21 PM) by Nurse Y. A review of the Physician orders revealed no skin treatment order to Resident #75's left elbow until after Nurse Uassessed the skin tear on 4/20/2026. On 4/22/2026, at 10:10 AM, the Director of Nursing (DON) was asked why Nurse Y would document a skin tear assessment and that there was an order to care the wound on 4/19/2026 without fulfilling the order and leaving the old bandage on the skin tear and the DON offered, he will have to strike it out if it's incorrect documentation. Resident #5: Review of the Face Sheet, nurse's notes dated 2/26 through 4/26, and care plans dated 3/25, revealed Resident #5 was 61 years-old, admitted to the facility on [DATE], alert and able to make own healthcare decisions, and dependent on staff for Activities of Daily Living. The resident's diagnosis included, low back pain, muscle wasting, muscle weakness, osteomyelitis, sacral wound, urinary catheter in place, adjustment disorder, major depression and chronic kidney disease. Observation made on 4/21/26 at 12:45 p.m., in the resident's room revealed, a dark blue positional device/wedge on the floor at the bottom of the resident's bed. The blue wedge/positional device was noted to be dirty. During an interview done on 4/21/26 at 12:45 p.m., the resident stated They (staff) use it to get me off my hip, and for my butt; they put it on and take it off. Review of the resident's physician orders and care plans (dated 2/25, thorough 4/26), revealed no order for this device/wedge. Review of the resident's care plans from 11/25 to 4/26, revealed no documentation of a positional device or wedge. During an interview done on 4/21/26 at1:00 p.m., OT C reviewed the resident's orders and stated, There is no order or care plan for that positional device, it's not from therapy. During an interview done on 4/21/26 at 1:48 p.m., East Unit Manager, LPN D stated There should not be any positional devices in her room, I don't know where it came from, there is no order and it's not on the care plans. I am going to take it out of there. During an interview done on 4/21/26 at 2:50 p.m., Charge Nurse, LPN G stated I do have her hall, I have no idea where it (blue positional device) came from, I did not see it in there. During an interview done on 4/22/26 at 8:00 a.m., the Director of Nursing said there should not be a wedge/device on her bed (Resident was on an Easy Air mattress-air mattress for decrease pressure on sacral area for wound healing). During a phone interview done on 4/22/26 at 8:25 a.m., mattress company representee E stated It's for sure going to affect the way it alternates for larger people; do not use wedges other then on head or feet areas with that mattress she is on. Resident #12: In an observation and interview on 04/20/2026 at 9:39 AM with Licensed Practical Nurse (LPN) F, it was observed that the right forearm had a 4x4 boarder dressing in place with no date or initials on the dressing. Resident #12 was seated up in wheelchair in her room and could not recall when the dressing was applied or by whom. LPN F was not aware that the resident had a dressing to the right forearm. Resident #12 stated that the lift sling ripped her skin open. Observation on 04/21/2026 at 7:19 AM by the state surveyor of Resident #12's right-forearm noted 4x4 boarder dressing in place with no date or initials appears to be the same dressing as the previous day, Resident #12 stated that nobody changed it. Observation and interview on 04/21/2026 at 12:32 PM with Licensed Practical License (LPN) D unit manager was taken to the main ding room to observe Resident #12's right forearm dressing. LPN D observed a 4x4 boarder dressing with no date, time or initials on the dressing of right forearm. In an interview and record review of Resident #12's medical record revealed that there were physician orders for treatment and there was no order for a dressing to the right forearm. LPN D stated that there is no treatment on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). Record review of Resident #12's Incident report. dated 4/17/2026, revealed that a staff member alerted the nurse to a skin tear on the residents' right forearm approximately 3.5cm x 1.5cm, tear from Hoyer pad during transferring. Record review of the 'Wound Care' policy, dated 4/2026, revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Steps in procedure: (9.) [NAME] the dressing with initials, time, and date.

Based on observation, interview and record review, the facility failed to ensure that oral care was provided for one resident (Resident #71) of three residents reviewed for Activities of Daily Living (ADL) care. Findings include:Resident #71:On 4/20/26 at 9:50 AM, Resident #71 was observed in their room. The Resident was in bed, positioned on their back. The Resident's hair was unkempt and uncombed. While speaking, Resident #71's teeth were observed to have a significant, visible amount of build up on them. When queried if they are able to brush their teeth themselves, Resident #71 revealed they need help. Resident #71 stated, Not brushed my teeth since been here. With the Resident's permission, a tour of their bathroom and room was completed. One unopened toothbrush was observed in the top drawer of the Resident's dresser.Record review revealed Resident #71 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required set-up and clean-up assistance to complete oral hygiene.Review of Resident #71's Electronic Medical Record (EMR) revealed a care plan entitled, ADLs. requires assist with daily care needs r/t (related to) altered mobility, pain (Initiated: 4/14/26). The care plan included the intervention, Assist resident with ADLs (Initiated: 4/14/26).On 4/22/26 at 8:39 AM, an interview was completed with the Director of Nursing (DON). When queried if Residents, who require assistance. should be offered and assisted to complete oral care on a daily basis, the DON responded that staff should provide oral care. The DON was asked if toothbrushes are changed on a routine basis and responded that a new toothbrush is provided as needed and requested. The DON was informed of Resident #71 stating they had not brushed their teeth since being admitted to the facility as well as observation of their toothbrush being unopened and the visible substance build up on their teeth. When asked, the DON verbalized that was not a standard of care and they would address the concern.Review of facility policy/procedure entitled, Activities of Daily Living (ADL), Supporting (Revised: March 2018) revealed, Policy. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2.Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview and record review, the facility failed to ensure accurate documentation of care per professional standards of practice for one resident (Resident #2) of one resident reviewed for Peripherally Inserted Central Catheters. Findings include: On 04/20/26 at 10:07 AM, Resident #2 was observed in their room in bed and an interview was completed. When asked if they were being treated for an infection, Resident #2 responded that they were taking an oral antibiotic. With further discussion, Resident #2 revealed they were admitted to the facility with a PICC (Peripherally Inserted Central Catheter- catheter inserted into the arm and feed to the hard for long-term intravenous (IV) therapy) line and IV antibiotics. When queried if they still had the PICC line, Resident #2 verbalized it was removed at the facility. A PICC line was not observed in either of the Resident's upper extremities. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included heart disease, Congestive Heart Failure (CHF), diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD), and Lymphedema (chronic condition causing swelling and skin changes typically in the lower extremities). Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required moderate to total assistance to complete ADLs with the exception of oral care and eating. The MDS further specified the Resident was not receiving intravenous medications. Review of Resident #2's Electronic Medical Record (EMR) revealed an active care plan entitled, (Resident #2) is at risk for infection R/T (related to) PICC (Initiated: 4/2/26). The CP included the interventions:- Dressing changes to IV site as ordered (Initiated: 4/2/26)- Flush PICC per protocol (Initiated: 4/2/26)- Monitor PICC site for redness, drainage, swelling, and increase in pain (Initiated: 4/2/26)Review of documentation in Resident #2's EMR revealed an order to remove the Resident's PICC line was received on 4/7/26. The only nurses note related to the discontinuation of the PICC line was. has completed antibiotic course. gave orders to remove PICC line. A review of Resident #2's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2026 revealed the Resident received their last dose of IV antibiotics on 4/6/26 at 10:00 PM and the PICC line was last flushed on 4/7/26 at 11:00 AM. Review of Resident #2's EMR revealed Daily Skilled Nurses Note documentation specifying, Resident is receiving skilled services for. Medication Management/IV Therapy. on:- 4/9/26 at 12:46 PM- 4/10/26 at 10:37 AM- 4/16/26 at 11:08 PM- 4/17/26 at 5:18 PM- 4/18/26 at 10:16 AM- 4/20/26 at 1:30 PM- 4/20/26 at 11:17 PM- 4/21/26 at 11:58 PM Further review revealed a Care Management assessment note dated 4/14/26 at 9:52 AM which detailed, An Ongoing or Discharge Care Management meeting was held. medical barriers to the resident's discharge plan which include. IV antibiotics. An interview was completed with Unit Manager/Infection Control Registered Nurse (RN) Z on 4/22/26 at 7:21 AM. When queried if Resident #2 was receiving IV antibiotics, RN Z responded they were not. RN Z explained the Resident had a PICC line and was receiving IV antibiotics when they were admitted but it had been removed when the IV antibiotics were completed. RN Z was asked when the PICC line was removed and replied, Came in with three days left on IV and then PICC was removed. Resident #2's Daily Skilled Nurses Note documentation was reviewed with RN Z at this time. When queried why nursing staff were documenting IV therapy as a reason for skilled therapy when the Resident is not receiving IV medications, RN Z replied, Medication Management/IV therapy is one box so they must be checking that. When queried how Resident #2's other medications qualified for skilled nursing care, RN Z revealed they did not know. When asked why not all nursing staff indicated a reason for skilled care was medication management/IV therapy on the assessment, RN Z was unable to provide an explanation and indicated they would need to look into it. When queried regarding the Resident having an active care plan for a PICC line, RN Z revealed the care plan should have been discontinued when the PICC line was removed. On 4/22/26 at 8:39 AM, an interview and review of Resident #2's EMR documentation was completed with the Director of Nursing (DON). When queried if nursing documentation in the EMR should accurately reflect the Resident's condition, the DON verbalized it should and stated accurate documentation is a standard of care. When queried if Resident #2 currently had a PICC line, the DON confirmed they did not. A review of Daily Skilled Nurses Note documentation was completed at this time. When queried why some nursing staff were documenting Medication Management/IV Therapy as a reason for the Resident requiring skilled services, the DON verbalized the documentation was inaccurate and Resident #2 was not skilled for medication management. When queried regarding the inaccurate documentation, the DON verbalized understanding of the concern. A policy/procedure was requested at this time. Review of facility policy/procedure entitled, Charting and Documentation (Revised: 11/2020) revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's electronic medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on interview and record review, the facility failed to update care plans in a timely manner for one resident (Resident #49) of 3 residents reviewed for care plans.Findings include: Resident #49: On 4/20/2026, at 11:06 AM, Resident #49 was lying on their bed awake. The room was dark and the blind was pulled closed. On 04/21/2026, at 8:45 AM, Resident #49 was resting on their bed awake. There was a small bucket of bird seed on the floor. The blind was pulled closed. Resident #49 asked surveyor to pull back the shade to look out the window to see the bird feeder as they offered, they fill the feeder every other day or every other month. On 4/21/2026, at 3:30 PM, a record review of Resident #49's electronic medical record revealed an admission on [DATE] with diagnoses that included cerebral infarction (stroke), Dementia and Major Depressive disorder. Resident #49 required assistance with Activities of Daily Living (ADL) and had severely impaired cognition. A review of the The resident Leisure Preferences are he chooses how to spend his day. He enjoys visit from friends and family. Enjoys feeding and watching birds out his window. Date Initiated: 03/09/2024 Goal Resident will participate in choses activities Date Initiated: 11/06/2025 Target Date: 06/14/2026 Interventions Discussion Groups Very small groups Date Initiated: 09/10/2024 Exercise/Sports Going for walks Date Initiated: 03/09/2024 Having visitors very small groups Date Initiated: 03/09/2024 Hobbies Working and tinkering Date Initiated: 03/09/2024 Music Date Initiated: 09/10/2024 Outdoor activities I like to go outside. I like to go for walks. Date Initiated: 03/09/2024 Outings I sometimes go out with my close friends if they come and get me. Date Initiated: 03/11/2025 Sensory Programs Pet Therapy Date Initiated: 09/10/2024 Television: TV Land, comedies, Date Initiated: 03/09/2024 Volunteering I volunteered to help take care of some plants in the plant nursery on the west end of the building. I water them and turn them to get even lighting. Date Initiated: 03/11/2025 On 4/22/2026, at 8:13 AM, Resident #49 was not in their room. Their blind was opened wide. The bird feeder was full of bird seeds. On 4/22/2026, at 8:28 AM, a record review of Resident #49's Recreational Services: Admission/Quarterly/Sig Change Date: 3/9/3036 assessment revealed the following: . How important is it to you to do your favorite activities? Somewhat important was check marked. Describe resident's favorite activities, special accomplishments and/or new interests. Resident does enjoy watching out his window, spending time with his longevity companion. Additional Comments Resident choses how to spend his day and prefers to be in his room but visits whit his roommate regularly, talks with staff and comes out to common area to people watch. Resident enjoys feeding and watching the birds out his window and gets visits by his friends occasionally . Remains appropriate/current as per current care plan. There was no mention on the care plan regarding feeding the birds or ensuring the blind was open. On 4/22/2026, at 10:54 AM, Longevity Companion (LC) V was interviewed regarding Resident #49. LC V provided they visit three times a week and will help with filling the bird feeder. LC V provided they document in their own program. On 4/22/2026, at 12:10 PM, Activities Director W was asked if the facility had plants for the residents to water and AD W pointed to above the tall storage cabinets in the activity room. AD W planned to follow up. The plants appeared out of reach without a step stool or ladder. On 4/22/2026, at 12:14 PM, AD W entered the conference room and was asked what Resident #49 liked to do and AD W stated, he feeds the birds. AD W was asked if Resident #49 had plants to water would they like that. Both AD W and the Director of Nursing (DON) were alerted that the care plan stated he liked to water plants and that it doesn't reflect that he feeds the birds. The DON voiced to AD W to provide Resident #49 with a plant in their room. On 4/22/2026, at 12:27 PM, Resident #49 was not in their room. AD W was observed in the room opening the blind. There was no plant in the resident's room. AD W was asked if the plants were real and AD W provided some are fake and some are real.

Based on record review, the facility failed to provide a Stop Date for an as-needed (prn) antipsychotic medication (Ativan) for one resident (Resident #21) of five residents reviewed for unnecessary medications, resulting in no 14-day Stop Date. Findings include.Resident #21: On 4/22/2026, at 1:29 PM, during medication administration task, Resident #21's physician's orders were reviewed and revealed: Ativan Oral Tablet 0.5 MG (milligrams) Lorazepam Give 1 tablet by mouth every 6 hours as needed for anxiety Start Date: 4/4/2026 The End Date column was blank. On 4/22/2026, at 12:30 PM, a record review of Resident #21's electronic medical record (EMR) revealed an admission on [DATE] with diagnoses that included Diabetes Mellitus, Adjustment disorder with Anxiety and Depressed Mood. Resident #21 required assistance with Activities of Daily Living (ADL) and had intact cognition. A review of the care plan (resident) has a terminal/end stage prognosis and requires hospice care provided by (hospice company) Date Initiated: 12/30/2025 . Interventions . Hospice and facility will coordinate plans of care to manage symptoms such as nausea, agitation, pain, uncomfortable breathing, pressure ulcer prevention interventions, nutrition and hydration needs, and psychosocial interventions. Date Initiated: 01/05/2026 . A review of the progress notes revealed: 4/4/2026 18:26 Nurse Note . PRN Ativan reinstated as ordered. A further review of the progress notes revealed no further notations on the PRN Ativan order.

Based on observation, interview and record review, the facility failed to provide sanitary nebulizer storage for one resident (Resident #2) and provide safe oxygen administration for one resident (Resident #77) of two residents reviewed for respiratory medication needs. Findings include. Resident #2: On 04/20/26 at 10:07 AM, Resident #2 was observed in their room in bed. A nebulizer machine was observed on the dresser next to the resident's bed. The nebulizer tubing was observed going into the top dresser drawer. A nebulizer mask was sitting in the drawer. The mask was uncontained and connected with visible fluid present in the medication administration chamber. An interview was completed at this time. When queried if they were receiving nebulizer treatments, Resident #2 confirmed that they were. Record review revealed that Resident #2 was admitted to the facility on [DATE] with diagnoses which included heart disease, Congestive Heart Failure (CHF), diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD), and Lymphedema (chronic condition causing swelling and skin changes typically in the lower extremities). Review of the MDS assessment, dated 4/9/26, revealed that the Resident was cognitively intact and required moderate-to-total assistance to complete ADLs with the exception of oral care and eating. Review of Resident #2's Electronic Medical Record (EMR) revealed a care plan entitled, Respiratory: Resident has potential for difficulty in breathing. (Initiated: 4/2/26). The care plan included the intervention, Administer medications/treatments as ordered (Initiated: 4/2/26). Review of Resident #2's Medication Administration Record (MAR) for April 2026 revealed the Resident had an order for DuoNeb (prescription inhalation medication used to treat shortness of breath) breathing treatments every six hours from 4/12/26 to 4/19/26. On 4/21/26 at 12:05 PM, Resident #2 was observed in their room in bed. The nebulizer administration mask was observed in the top drawer of their dresser, connected with visible fluid in the mediation administration chamber. An interview was conducted with the Director of Nursing (DON) on 4/21/26 at 1:53 PM. When queried regarding the facility policy/procedure for storage of nebulizer treatment administration equipment following use, the DON stated, Should rinse and let air dry on a paper towel and then put in a bag which gets changed weekly. The DON was informed of observation of Resident #2's nebulizer mask and stated, That is a concern. Resident #77: On 4/20/2026, at 11:00 AM, Resident #77 was sitting in their wheelchair in their room. They had oxygen on via a nasal cannula. On 4/20/2026, at 11:20 AM, Resident #77 was noted to be gone out of their room. The oxygen cannula was lying on the floor with the concentrator running. On 4/20/2026, at 11:30 AM, Nurse U was asked if they knew where Resident #77 was and Nurse U offered, out of the building at dialysis. On 4/20/2026, at 11:35 AM, an observation of Resident #77's oxygen nasal cannula that was running and on the floor was conducted with Nurse U. Nurse U was asked if that was normally on the floor while running and Nurse U provided oh, I will take care of that. Nurse U donned personal protective equipment and discarded the tubing and shut off the concentrator. On 4/21/2026, at 11:00 AM, a record review of Resident #77's electronic medical record revealed a readmission 4/14/2026 with diagnoses that included Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD) and Dependence on Renal Dialysis. Resident #77 required assistance with daily care needs and had intact cognition. A review of the Resident has oxygen therapy r/t(related to) COPD Date Initiated: 04/15/2026 . Interventions . OXYGEN SETTINGS: O2 via N/C at 2-4 LPM . There was no intervention noted regarding oxygen safety instructions. According to the American Lung Association Oxygen Safety Guidelines, . Turn off your oxygen when you're not using it .

Based on observation, interview, and record review, the facility failed to ensure that the sanitizer for the wiping cloths, used to sanitize food preparation areas, was at the correct concentration for disinfection. Findings include: During a tour of the dietary department on 3/4/25 at 9:42 AM with Certified Dietary Manager (CDM) A, the red sanitizer bucket was observed with a wiping cloth immersed in solution ready to use. The wiping cloths were used to sanitized dietary counters and food preparation areas. CDM A tested the solution to determine the amount of sanitizer present. The quaternary ammonium sanitizing chemical measured 50 - 100 ppm (parts per million). CDM A stated the proper sanitizer level was 200-400 ppm. During a tour of the dietary department on 3/5/25 at approximately 1:30 PM with CDM A, the red sanitizer bucket was observed with a wiping cloth immersed in solution ready to use. The sanitizer bucket was again tested by CDM A. It did not register any quaternary ammonium sanitizer present as the test strip did not change color. CDM A tried a new test strip dispenser, but it again registered zero ppm. CDM A stated it was the change of shift, and the sanitizer bucket should be emptied, but with the wiping cloth immersed, it appeared ready for use. The CDM stated there was not a written procedure for the sanitizing process. On 3/5/25 at 2:02 PM, CDM A provided a newly formulated undated guide titled Sanitizer Sink Procedure. It read in part, .Compare strip to color chart, Must be between 200-400ppm. During a tour of the dietary department on 3/6/25 at 11:00 AM, CDM tested the sanitizer bucket. The quaternary ammonium sanitizing chemical measured zero indicating there was no disinfectant present in the solution to sanitize and yet contained a wiping cloth immersed ready for use. The FDA Food Code 2017 States: - 3-304.14 Wiping Cloths . (B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114; - 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness. A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under S7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, P and shall be used as follows: .C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24oC (75oF), P (2) Have a concentration as specified under S 7-204.11 and as indicated by the manufacturer's use directions included in the labeling, P and (3) Be used only in water with 500 MG/L hardness or less or in water having a hardness no greater than specified by the EPA-registered label use instructions; - 4-702.11 Before Use After Cleaning. UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning.

Based on observation, interview and record review, the facility failed to ensure that medications and medical supplies were secured, stored and disposed of per professional standards of practice in one of two medication storage rooms, one of two medication carts, and one treatment cart. Findings include: A tour of the C and D hall medication cart was completed with Licensed Practical Nurse (LPN) B on [DATE] at 7:29 AM. A container of undated glucometer testing strips were observed in the top drawer of the medication cart. When queried if the strips should be dated when opened, LPN B verbalized they should and indicated the glucometer controls were completed by night shift staff. On [DATE] at 9:30 AM, the treatment cart positioned near the C hall entrance was observed to be unlocked and unattended by staff. No staff were present at the nurses' station. At 9:33 AM on [DATE], Registered Nurse (RN) H approached the nearby medication cart but did not address the unlocked treatment cart. RN H was then queried regarding the treatment cart and confirmed it was unlocked. A tour of the treatment cart was completed with RN H at this time. The treatment cart contained both prescription and OTC treatment medications. The following open and expired items were present in the cart: - Open and undated package of calium alginate wound dressing - Open and undated package of Xeroform petroleum wound dressing - Open and undated package of Xeroform impregnated with 3% Bismuth Tribromophenate and petroleum The above wound care dressings were partially used and/or cut. When queried if wound care dressing packages are supposed to be opened, undated, partially used and in the cart, RN H stated, Ugh, gross. No. The following expired items were present in the treatment cart: - Nine Hydralock SA 6 X 10 inch wound dressings; Expired: [DATE] - 74 Adhesive Tape Remover Pads; Expired: [DATE] - Prescription Mycostatin (antifungal) cream container; Quantity 120 for Resident #50; the pharmacy label specified, Discard [DATE]. - Prescription Mycostatin (antifungal) cream container; Quantity 120 for Resident #15; Expired [DATE] RN H was asked if Resident #15 was receiving the prescription cream and stated, (Resident #15) has been getting. When queried the last time the topical medication treatment was administered to Resident #15, RN H replied, Today. With further inquiry, RN H confirmed the expired cream was utilized. A tour of the [NAME] End Medication Room was completed on [DATE] at 12:05 PM. There were multiple items observed under the sink including emergency lights and cords, medication disposal solution jug, and another jug labeled, Save Coffee Grounds Please in sharpie. The following expired items were present in the medication room: - Multiple home medications for various residents - Five green top laboratory blood tubes; Expired: [DATE] - Three blue top laboratory blood tubes; Expired: [DATE] - Six blue top laboratory blood tubes; Expired: [DATE] - One 1 milliliter (mL) [NAME] point tuberculosis (TB) syringe; Expired: ,d+[DATE] - 0.5 mL [NAME] point insulin syringe; Expired: ,d+[DATE] The medication refrigerator in the medication room contained multiple vaccines including influenza and pneumococcal. Refrigerator temperature monitoring was completed one time per day. An interview was completed with the Director of Nursing (DON) on [DATE] at 12:41 PM. When queried if supplies should be stored under the sink in the medication room, the DON stated, There shouldn't be anything under the sink. The DON was then queried regarding multiple resident's expired home medications and expired supplies in the medication room and verbalized that expired supplies should be disposed of. When asked how often a medication refrigerator, containing vaccines, temperature should be checked, the DON stated, Once a day. When queried regarding CDC (Center for Disease Control) recommendations related to temperature monitoring of refrigerated vaccines, the DON reviewed the facility policy/procedure and stated, Twice a day. Review of facility policy/procedure entitled, Medication Storage in the Facility (Dated [DATE]) revealed, Medications and biologicals are stored safety, securely and properly, following manufacturer's recommendations . Procedures . B . Medications rooms, carts and medication supplies are locked when not attended by persons with authorized access . H. Outdated, contaminated, or deteriorated medications . are immediately removed . disposed . Temperature . F. The facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per CDC guidelines . Expiration Dating . C. Certain medications or package types such as . blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency .

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for management and care of a Peripherally Inserted Central Catheter per standards of practice for one resident (Resident #124) of one resident reviewed. Findings include: On 3/4/25 at 12:30 PM, Resident # 124 was observed in their room in bed. The Resident had a neck immobilizer brace in place. An IV pump and pole were positioned on the right side of the Resident. A 250 milliliter (mL) bag of 0.9% normal saline solution containing 1.75 grams (g) of Vancomycin (antibiotic) with approximately 40 mL of solution remaining in the bag was hung on the pole and fed into the IV pump but not connected to the Resident. When queried, Resident #124 revealed they had spinal fusion surgery which was why they had to wear the neck brace. When queried regarding the IV antibiotic, Resident #124 revealed had an infection. When queried regarding IV access, Resident #124 revealed they had a PICC line and moved their shirt sleeve to show a PowerPICC line in their right upper arm. The transparent Tegaderm dressing covering the PICC line insertion site was undated, lose and peeling. Resident #124 was asked when the dressing had been changed last and indicated they were not sure of the date. Record review revealed Resident #124 was admitted to the facility on [DATE] with diagnoses which included cervical spinal fusion, osteomyelitis of the cervicothoracic vertebrae (infection of the spine), and antibiotic use. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident required none to moderate assistance to complete Activities of Daily Living (ADLs). The MDS further detailed the Resident had intravenous (IV) access. Review of Resident #124's Health Care Provider (HCP) orders and Medication Administration Record (MAR) revealed the following: - Sodium Chloride Flush Intravenous Solution 0.9 % (Sodium Chloride Flush) Use 10 milliliters four times a day for before and after antibiotic administration . (Start Date: 2/25/25) - Heparin Lock Flush Solution 10 units/mL Use 5 mL intravenously two times a day for per protocol . Use 5 mL as final flush in non-valved lines . (Start Date: 2/25/25) - IV PICC line change dressing every 7 days . every Wednesday . per protocol (Start Date: 2/26/25) Per the MAR, the PICC line dressing was changed on 2/26/25. Review of Resident #124's hospital Patient Summary Discharge Instructions, Orders and Medications dated 2/24/25 revealed, Complete Medication List . list of medications for you to use at home. Take only the medications listed below . New Medications . Sodium chloride (sodium chloride 0.9% injectable solution) 10 milliliters (mL) IV flush every 8 hours . Vancomycin 1.75 g (IV) solution every 12 hours . How to care for your PICC . Flush the PICC as told . Keep the PIICC dressing dry and secure it with tape if the edges stop sticking to your skin . Preventing Other Problems. Do Not use a syringe that is less than 10 mL to flush the PICC . How to care for your PICC dressing: Keep your PICC dressing clean and dry . Your PICC dressing needs to be changed if it becomes loose or wet . On 3/5/25 at 8:45 AM, Resident #124 was observed in their room. The Resident was receiving vancomycin IV infusion via the PICC line in their right upper extremity and the dressing over the PICC line insertion site was undated, loose, and peeling. On 3/6/25 at 7:09 AM, Resident #124 was observed in their room. The Resident was receiving vancomycin IV infusion via the PICC line in their right upper extremity. An interview was completed with the Director of Nursing (DON) on 3/6/25 at 8:07 AM. When queried if the transparent dressing over PICC line insertion site should be loose and peeling, the DON stated, No. When asked if the dressing should be dated, the DON replied, I don't know if the policy stated that. The DON was informed of observations of Resident #124's PICC line dressing at this time but did not provide further explanation. When queried why the facility was flushing Resident #124's PowerPICC line with heparin, the DON indicated that was the protocol and HCP order. The DON was then asked if flushing a PICC line with heparin is evidence based best practice and stated it is. When queried why Resident #124's hospital discharge documentation specified the PICC line should be flushed with 10 mL normal saline and not heparin, the DON did not provide further explanation. On 3/6/25 at 9:57 AM, an interview was conducted with Licensed Practical Nurse (LPN) B. When queried if they were going to flush Resident #124's PICC line, LPN B stated, Already did it. LPN B was then asked what they used to flush the Resident's PICC line and opened the medication cart. LPN B presented a prefilled 10 mL syringe of normal saline and a prefilled 5 mL syringe of Heparin 10 units/mL. LPN B was asked to describe the process in which they flush the PICC line and stated, Heparin is second. When asked to clarify if they were saying they flushed the PICC with the normal saline flush followed by the 5 mL syringe of heparin, LPN B verified. When asked if a 5 mL flush syringe is appropriate to use with a PICC line, LPN B indicated that was what the facility pharmacy had sent. Upon request for a facility policy/procedure pertaining to PICC line care and maintenance, the facility provided a pharmacy procedure entitled, 005-J: Flushing Midline and Central Line IV Catheters (May 2022;) . Flushing . 1. Flush open ended (non-valved) catheters with normal saline and heparin . 2. Flush closed ended (valved) catheters with normal saline . Technique: 1. Always use a syringe barrel size of 10 mL or greater when flushing . Flushing when giving medication with SASH (saline, administer medications, saline, heparin) method . 16. Connect 10 mL syringe containing heparin . A study conducted by [NAME], [NAME], Atem, Nair, Warkola, and [NAME] (2025) showed consistent results with previous research studies and literature reviews to recommend discontinuation of heparin use and implementation of normal saline only as a flush and locking agent in routine PICC line care. Reference: [NAME], L., [NAME], M., Atem, F., Nair, K., Warkola, R, & [NAME], M. (2025). Heparin Versus Saline: A Comparative Study to Support Practice Change Within an Organization. Journal of Infusion Nursing, 48, 11-16. https://doi.org/10.1097/[NAME].0000000000000569

This Citation pertains to Intake Number MI00147582. Based on observation, interview and record review, the facility failed to provide appropriate supervision, follow and implementtimely interventions for three residents (Resident #1,Resident #2 and Resident #3) of three residents reviewed for falls, resulting in repeated unwitnessed falls, an eyebrow laceration, right hip and left hip fractures with the likelihood of further falls and/or injuries. Findings include: Resident #1: On 10/23/2024, at 10:00 AM, Resident #1 was resting in a reclined geri-chair in the therapy room with the speech therapist. On 10/23/24, at 10:10 AM, a record review of Resident #1's electronic medical record revealed an admission on 9/6/24 with diagnoses that included intellectual disability, repeated falls and Dementia. Resident #1 had severely impaired cognition and required assistance with all Activities of Daily Living. A review of the Fall Risk Evaluation Admission 9/6/2024 revealed total score is 16 Total score of 5 or above is HIGH RISK. A review of the Physical Therapy PT Evaluation & Plan of Treatment Start of Care: 9/8/2024 revealed . Ambulation Walk 10 feet = Supervision or touching assistance . A review of the Fall - Unwitnessed . 09/13/2024 11:00 . This nurse called to nursing station, observed staff hoyering res into w/c. Res had fallen and obtained laceration to left brow. Res was assessed by DON, no further injuries noted. Resident unable to give description . Res assessed and received laceration to left brow, area cleansed, Res sent to ER for eval for need of stitches. Confused Gait Imbalance Impaired Memory Balance Problem were all check marked. A review of the corresponding IDT progress note revealed IDT met to discuss resident fall. Root cause determined to be poor safety awareness d/t dementia diagnosis, has history of falls. Intervention for resident to be supervised with ambulation. Care plan reviewed and updated. A review of the Fall - Unwitnessed . 10/9/2024 1350 (1:50 PM) . CNA went to get resident up to take to lunch and when she went in room resident was sitting in wheelchair and said that she fell . Resident had no c/p at this time Resident stated she fell . After lunch RN attempted to get resident out of wheelchair. Resident was able to stand but unable to walk, right leg would give out. (physician) notified and Xray ordered . Injury location Right trochanter (hip) . Confused Gait Imbalance Weakness/Fainted Balance Problem were all check marked. A review of the progress notes revealed: 9/23/2024 . Sutures removed from left eyebrow . 10/7/2024 12:30 . Resident has been becoming increasingly restless. She is pacing and wandering into others rooms . 10/9/2024 14:14 Resident stated she fell in room prior to lunch. No injuries noted or c/o of pain at that time. After lunch resident returned to unit and was unable to walk. Resident could stand but when attempt to walk right leg would give out. Resident would grab right leg as if it was painful. Xray ordered. No visible injuries noted. 10/9/2024 17:30 . X-ray came out Right Hip fx (fracture) present notified DON and (physician) resident sent to hospital via (ambulance). 10/15/2024 11:34 IDT met to discuss resident fall. Root cause determined to be poor safety awareness r/t dementia, and unsteady gait. Intervention for lipped mattress to be placed in bed. Resident had Xray ordered immediately, with results of fracture, send to ED for further eval/treatment. Care plan reviewed and updated accordingly. 10/13/2024 14:59 Resident readmitted from (hospital), assisted from gurney to bed to recliner chair due to restlessness . 10/15/2024 17:50 Late Entry: Admission visit for right hip pain status post ORIF (open reduction internal fixation) . Open reduction internal fixation is a surgical repair of the hip fracture. A review of the facility provided Investigation Form 10/11/2024 revealed CONTRIBUTING FACTORS AND INTERVENTIONS . Resident with multiple falls prior to admission . A review of the care plan revealed Focus Fall Risk: (resident) is high risk for falls r/t weakness, incontinence, poor safety awareness Date Initiated: 09/06/2024 . Interventions Anticipate and meet the resident's needs. Date Initiated: 09/06/2024 Environment: Keep my room free of potential fall hazards - clutter, spills, tripping hazards, poor lighting, etc. Date Initiated: 09/10/2024 Follow facility fall protocol. Date Initiated: 09/10/2024 Gripper socks to be utilized unless wearing hard/rubber soled shoes Date Initiated: 09/10/2024 Ortho B/P's x 2 days Date Initiated: 09/13/2024 PT to evaluate and treat as ordered or PRN. Date Initiated: 09/10/2024 Focus The resident has had an actual fall with injury Date Initiated: 09/13/2024 . Interventions Date and description of other interventions put in place after a fall: 9/13/24-Supervised when awake while in common areas, sent to ED for stitches to L eyebrow 10/9/24-Xray ordered, New med order rec'd, Lipped mattress, floor mat in place. Date Initiated: 09/13/2024 Resident #2: On 10/23/24, at 11:35 AM, Resident #2 was in their room in their wheelchair. Their family was present. Resident #2 denied they fell and hurt themselves and their family reminded them they fell and broke their hip. A review of Resident #2's electronic medical record revealed an admission on 09/26/2024 with diagnoses of Chronic obstructive pulmonary disease, Dementia and repeated falls. Resident #2 had severely impaired cognition and required assistance with Activities of Daily Living. A review of the Fall Risk Evaluation Admission 9/26/2024 revealed total score is 18 Total score of 5 or above is HIGH RISK. A review of the Fall-Unwitnessed . 10/2/2024 21:00 . CNA going to answer call light on C-Hall, when she swa resident seated on floor, called for nurse assistance. This nurse entered room and observed resident lying on her L side, in between her w/c and bed. Legs outstretched, w/no immediate injuries observed. States I tried going by myself but I'm too weak. Unable to state if she was attempting to transfer to bed or bathroom . Confused was check marked. A review of Fall-Unwitnessed . 10/5/2024 09:23 . Resident from across hall called out to writer, Writer observed (resident) laying on the floor, on her right side, with her food tray across the front of her, bed table on it's side, (resident) stretched out towards the bathroom door, hold her left hip complaining of pain . Stated she did not remember than stated she was trying to go to the bathroom . assessed resident for injury, neuros started, lifted with mechanical lift back in to bed. Attempted to assess for injury to left hip but will not allow writer to straighten legs. Once in bed straighten legs, complaining of pain, grabbing hip . Impaired Memory was check marked. A review of the SBAR-Fall . 10/05/2025 . Resident attempted to self transfer to restroom falling on to the floor unwitnessed. Feet close to bed body extend toward restroom door, Resident laying on right side when observed by writer, bed side table tipped over food tray above head . A review of the Fall-Unwitnessed . 10/12/2024 . Staff entered room alerted by resident yelling out. Resident [NAME] on floor on abdomen next to bed in lowest position on mat next to bed with head toward window. Resident incontinent at time of fall. Resident c/o left hip pain. Resident description I was going to the bathroom . immediate action take . new intervention to toilet before breakfast and have resident up in w/c for breakfast. Obtaining x-ray left hip per order . Injury Location Left trochanter (hip) . Confused Impaired Memory were check marked. A review of the Radiology Report Date of Service 10/12/2024 3:07 PM revealed Results: there is an intertrochanteric fracture at the hip. Conclusion: Fractured hip . A review of the progress revealed 10/16/2024 16:18 . Resident returned from hospital via ambulance. Assisted into bed. No c/o pain, staples to left leg have dry dressing covering . A review of the care plan revealed Focus The resident is at risk for falls r/t impaired cognition, deconditioning Date Initiated: 09/26/2024 Goal The resident will be free of minor injury through the review date. Date Initiated: 09/26/2024 Interventions Anti roll backs in wheelchair Date Initiated: 10/23/2024 Anticipate and meet (resident) [NAME] to deter attempting to self transfer Date Initiated: 09/26/2024 Environment: keep my room free of potential fall hazards - clutter, spills, tripping hazards, poor lighting, etc. Date Initiated: 09/27/2024 Follow facility fall protocol. Date Initiated: 09/27/2024 Gripper Socks to be utilized unless wearing hard/rubber soled shoes Date Initiated: 09/27/2024 keep bed in lowest position while I am resting Date Initiated: 09/27/2024 Padded floor mat to exposed side/sides of bed when resting Date Initiated: 09/27/2024 . Focus The resident has had an actual fall with no injury, fall with major injury 10/1/2024 Date Initiated:10/02/2024 Goal The resident will resume usual activities without further incident through the review date. Date Initiated: 10/02/2024 Interventions Date and description of other intervention put in place after a fall: 10/2/24-Bed moved against wall on right side. Resident to transfer with left side which is her strong side. 10/5/24-Resident to be offered to eat at the nurses station or dining room [ROOM NUMBER]/12/24-Xray; up for all meals, toileted before meals, bed flipped against the wall. Will be moved closer to the nurses station when bed becomes available. Grab bars added per family request as well. Date Initiated: 10/14/2024 Resident #3: On 10/23/24, at 9:30 AM, Resident #3 was resting in their low bed. There was a mat to the floor on the right side of the bed. The left side of the bed was pushed against the wall. On 10/23/24, at 10:30 AM, a record review of Resident #3's electronic medical record revealed an admission on 07/16/2024 with diagnoses that included Dementia, Diabetes and recent subdural hematoma. Resident #3 had severely impaired cognition and required assistance with Activities of Daily Living. A review of the Fall Risk Evaluation Admission 7/16/2024 revealed total score is 9 Total score of 5 or above is HIGH RISK. A review of Fall - Unwitnessed . 8/5/2024 . Call light activated. CNA entered room and immediately called for nurse assistance. Resident lying on floor next to bed, w/his head in between bed and nightstand. He's alert, taking, w/no obvious s/s of injury. Resident unable to give Description . Confused Gait Imbalance Impaired Memory were all check marked. A review of the SBAR-Fall Effective Date: 8/05/2024 . Call light activated, CNA entered room and immediately called for nurse assistance. Resident lying on floor next to bed, w/ his head in between bed and nightstand. He's alert, talking, w/no obvious s/s of injury. Unable to state what occurred. ROM and neuro-checks WNL. Refusing full set of vitals at the time d/t confusion. Full skin assessment completed, some redness to L ear observed, skin intact . A review of Fall-Unwitnessed . 8/6/2024 19:00 . CNA walking passed resident room and notified nurse of incident. Entered room and observed resident lying on floor next to bed, on his L side. He's alert and talking w/ no obvious injuries observed. Resident unable to give description . Immediate action taken . Non-compliant w/ wearing grippy socks, confused . A review of Fall-Witnessed . 8/17/2024 20:20 . This nurse head others calling out for help and observed resident laying on his back near nurses station. CNA who was sitting at nurses station stated she observed him falling backwards from standing and fell mostly on his back. Resident unable to give account of events r/t dementia . Resident assisted to bed with use of Hoyer lift . Impaired Memory was check marked. A review of the SBAR-Fall . 8/17/2024 . Resident was observed getting up from seated area and observed slipping and falling backwards. Resident was barefoot at time of fall . A review of Fall-Unwitnessed . 8/18/2024 22:50 . Nursing staff entered room to provide care for resident he was noted to be laying on mat next to bed with head toward door. Resident unable to give description . Immediate action taken . Brief was soiled w/ urine and feces . Confused Gait Imbalance Impaired Memory were check marked. A review of Fall-Unwitnessed . 9/1/2024 19:05 . A review of the SBAR-Fall . 09/01/2024 . At 1845 CNA was walking down C hall and called for nurse assistance. Entered resident's room, observed him seated on floor mat next to bed, alert w/no immediate injuries observed. Unable to state what occurred. ROM, neuro-checks and vitals all WNL. Brief was soiled w/urine and feces. Assisted into bed to provided personal hygiene. No injuries observed to skin and no s/s of pain . A review of the focus (resident) is high-risk for falls r/t poor safety awareness: confusion Date Initiated: 07/16/2024 . Interventions Non-slip material to wheelchair cushion. Date Initiated: 10/01/2024 Anticipate and meet the resident's needs. Date Initiated: 07/16/2024 Assist with routine toileting and PRN to help prevent self-transfers Date Initiated: 07/16/2024 Environment: keep room free of potential fall hazards - clutter, spills, tripping hazards, poor lighting, etc Date Initiated: 07/16/2024 Follow facility fall protocol. Date Initiated: 07/16/2024 Gripper socks to be utilized unless wearing hard/rubber soled shoes Date Initiated: 07/16/2024 If resident becomes restless/agitated, bring res into communal area for increased supervision. If resident refuses, remain with resident until directed by nurse Date Initiated: 07/16/2024 PT evaluate and treat as ordered or PRN. Date Initiated: 07/16/2024 The resident needs activities that minimize the potential for falls while providing diversion and distraction. Date Initiated: 07/16/2024 On 10/23/24, at 11:30 AM, Resident #3 remained in the same position. On 10/23/24, at 11:55 AM, CNA C and CNA E in to assist Resident #3 with incontinent care. CNA E offered that Resident #2 ate breakfast in bed and remained in bed since. On 10/23/24, at 1:00 PM, the Director of Nursing (DON) was interviewed regarding the sampled residents and their multiple falls. The DON was asked if there was anything else the facility could have done to prevent the unwitnessed falls and DON responded, well, I cant have one to one while they are in their rooms. Prior to exit, the DON was asked to provide the day of the most recent unwitnessed fall in the facility and the DON, stated, yesterday. A review of the facility provided Fall Evaluation Safety Guideline Effective Date: 11.28.17 revealed . A fall evaluation is used to identify individuals who have predicting factors for falls . Involve interdisciplinary (IDT) on: Individualized assessment for safety Identification of Hazards Need for Supervision Development and implementation of interventions to reduce accidents . Guideline for Evaluation May include: . Fall history . Impaired mobility/functional status Incontinence Cognitive status Mood or behavior indicators . If the evaluation finds the resident at risk, implement resident specific interventions/precautions .

Based on interview and record review, the facility failed to ensure adequate staff training and supervision during facility van transportation and appropriate emergency medical response for one (#216) of one resident reviewed resulting in the wheelchair lift platform not being raised during Resident removal from the facility transportation van, Resident #216 being pulled out of the van in their wheelchair without the platform lift elevated, falling, and experiencing unnecessary pain, lacerations, multiple soft tissue injuries, a cervical spine (neck) fracture, and psychosocial distress utilizing the reasonable person concept. Findings include: An interview was conducted with Anonymous Witness M on 2/16/24 at 10:00 AM. Witness M verbalized concerns regarding Resident #216 being pushed out of the facility wheelchair van in the parking lot. Per Witness M, a facility staff member did not put the ramp up on the wheelchair van when they attempted to remove the Resident from the van resulting in the Resident falling and breaking their neck. Witness M revealed they were also concerned because the facility staff moved the Resident into the facility before calling the ambulance and had not reported the incident to the State agency. Record review revealed Resident #216 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included depression, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), weakness, and difficulty walking. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, required substantial to maximum assistance for transfers, and utilized a wheelchair for mobility. Per the face sheet, Resident #216 was discharged to another nursing home on 6/1/23. A review of documentation in Resident #216's Electronic Medical Record (EMR) revealed the following: - 6/7/23 at 4:48 PM: SNF to ED Handoff Form . Resident fell off lift from wheelchair van in chair approx. 2 feet . Reason(s) for transfer: Laceration to left great toe, difficulty turning neck, pain in both shoulders and arms . - 6/7/23 at 5:25 PM: Post-Fall Evaluation . Post Fall Follow-up . Is there new pain post fall? Yes . Pain Scale is at: 9 . generalized and severe pain neck, head and shoulders . Injury . Yes . Abrasion . Bruise . Cut . Laceration . multiple abrasions and bruising with laceration see SBAR for completer description . Pain . New . increase due to fall . Pain prior to fall controlled with medication Resident sent to ER for treatment and evaluation . resident c/o (complain) of pain with bilateral arm movements and turning head to right . - 6/7/23 at 6:43 PM: Health Status Note . Resident sent out to hospital at 1640 (4:40 PM) due to fall from transport van, multiple bruises, and abrasions, laceration to right great toe. C/o of shoulder pain both shoulders, bump to back of head and c/o of difficulty turning head to right. - 6/7/23 at 7:03 PM: Resident was being removed from van when both resident and transporter fell to pavement. - 6/13/23 at 7:07 PM: SBAR - Fall . Brief description . Transport was returning resident to facility when both resident and transporter fell out of back of van to pavement . Any injury noted? Yes . Location . Vertebrae (upper-mid) Bruising mid back spine . Right hand (back) abrasion with bruising thumb and knuckles . Left hand (back) abrasion index finger, knuckles, thumb with bruising . Right buttock large bruise . Left buttock bruise . Left knee (front) bruising . Right lower leg (front) bruising inner right shin . Back of head hematoma c/o (complain of) of difficulty turning head to right . Right toe(s) abrasions . Right toe(s) great toe with approx. 2-inch laceration . Left toe(s) abrasions . Right shoulder (rear) Right shoulder bruising with pain . Left shoulder (rear) bruising with pain . hematoma to left upper arm near shoulder painful to touch . left rib bruising . right rib bruising . Type of injury . Swelling . Bruising . Laceration . Hematoma . Decreased Mobility/ROM (Range of Motion) . Pain . Yes . Pain elicited by . Passive ROM . general pain all over severe pain in shoulders, neck and head . Send to ER . Facility Incident and Accident reports for Resident #216 were requested. The facility provided a file which included the following: - Incident and Accident Report, dated 6/7/23: Fall . Location: Outside on facility grounds . Description: Transport was getting resident out of van and both fell to the ground . Immediate Action Taken: Resident was assessed (for) injury. Vitals taken. Right foot was cleaned and bandaged for injury to right great toe. Resident taken to (hospital ER) . Injuries . Abrasion: Left finger(s) . Abrasion: Right fingers . Other (Describe): . in notes at bottom . Level of Pain . 10 (out of 10- worst possible pain) . Alert . Wheelchair bound . Mental Status: Orientated to Person . Situation . Injuries Reported Post Incident: Abrasion: Right toes; Abrasion: Left toes; Abrasion; Left Fingers, Abrasion: Right Fingers; Bruise: Vertebrae (upper-mid); Bruise: Right iliac crest (rear); Bruise: Left iliac crest (rear); Bruise: Right buttocks; Bruise: Left buttocks; Bruise: Right knee (front); Bruise: Left knee (front); Bruise: Right lower leg (front); Bruise: Right shoulder (rear); Fracture: Vertebrae (upper-mid); Hematoma: Back of head; Hematoma: Left upper arm . Other Info: Resident being removed from transport van and both resident and transporter (CNA Q) fell to the ground . Witnesses: (CNA Q) . - Typed, undated summary: On June 7, 2023, Transporter (Certified Nurse Assistant [CNA]) Q was moving (Resident #216) in their wheelchair from the back of the van onto the lift. (CNA Q) wheeled patient from van and didn't realize the rear lift was still in the down position. (CNA Q) stepped off the back of van with (Resident #2216) in wheelchair off the ledge and both fell to the ground. (CNA Q hit the ground first with (Resident #216) sill in their wheelchair, landed on top of them. Receptionist (Staff V) was approaching as the incident occurred and immediately called for assistance. (Registered Nurse [RN] W), (CNA Y), (CNA X) immediately assessed (Resident #216) for pain and injuries then lifted (Resident #216) with mechanical lift into wheelchair. (Resident #216) was then directly lifted into bed for further assessment. After further evaluation, (Resident #216) then complained of shoulder pain . transferred to hospital . - Written, undated statement by RN W: Around 4:30 PM, I was called from another resident room to front of building. (Resident #216) was laying on back with blanket under head. Was told resident and transporter fell out of van. Approx. 2 feet. Resident was assisted up with Hoyer (mechanical lift) to wheelchair and taken back to room for evaluation. Multiple bruising to arms, legs, buttocks, side of hands, and feet. Abrasions to fingers and toes. Hematoma to back of head and upper left arm. Laceration the length of right great toe. Resident c/o (complain of) neck pain, head pain 10/10 (worse possible pain) and pain to arms and shoulders 9/10, Resident set to hospital after notifying Doctor for further evaluation and possible sutures to toe . - Written statement by CNA Y, dated 6/7/23 (no time): I was standing at the nurses' station around 4:30 PM when (Staff V) yelled to me for help. I ran out behind them. I seen (Resident #216) and (CNA Q) on the ground. The nurses (RN I), (RN W) and (Licensed Practical Nurse [LPN] Z) checked Resident . Hoyered (Resident #216) back into wheelchair . - Written statement by CNA Q, dated 6/7/23 at 4:20 PM: I transported three residents back to the facility at 4:20 PM. Two residents . were unloaded safely and brought back to their rooms with the help from (Staff V). (Resident #216) was the last one to get out sine they were sitting in the middle part of the van . I used the passenger side door to get back in the van to get resident not realizing the van list is still position to the ground. I pulled resident's wheelchair to get to the platform and we were both on the ground. I had the wheelchair with the O2 (oxygen) tank and the resident on top of me. (Staff V) saw me and the resident on the ground and they immediately called for help. Resident was assessed and was put back in their chair . - Written statement by CNA Q, dated 6/13/23 (no time): I sat with (Resident #216) at 6:28 PM while I was waiting to be seen by and ED provider. At 7:40 PM, Residents family arrived in room. (Family AA) was there ans said they couldn't understand how it happened. (Family AA) looked at me and asked if I was there when it did. I said I was and informed them that I was the one who transported (Resident #216). I explained to them what happened, apologized for what happened . - Written statement by CNA X, dated 6/7/23 at 4:30 PM: I was coming down hall when a resident had pointed to the window and said 'Look!!' I looked out the window and seen (CNA Q) and (Resident #216) laying on the ground behind the van. I ran out to help. We hoyered (Resident #216) back into chair, transferred to bed. An interview was conducted with CNA G on 3/20/24 at 2:09 PM. When queried if they were working on 6/7/23 when there was an incident involving Resident #216, CNA G stated, I was the transporter at that time. When asked what happened, CNA G stated, On the way back (to the facility), I had two more residents in the back. (Resident #216) was sitting closer to me. When asked to clarify if they were saying they were transporting three residents back to the facility, CNA G confirmed they were. CNA G revealed they had to pick up an extra resident on the way back to the facility. When asked what happened when they got to the facility, CNA G revealed they got the other resident's out of the van and stated receptionist Staff V helped me and took the first resident in. CNA G continued, For some reason, I didn't put the platform up after I got the first resident out and took them back to their room. I went back and went through the door to get (Resident #216). When asked what they meant when they said door, CNA G indicated they went through the side entrance door of the van. CNA G revealed they proceeded to unhook Resident #216's wheelchair after they reentered the van through the side door and stated, I backed them out the back. In my head, the platform was up. CNA G continued, I didn't even look, I was just backing up. The next thing I knew, I was on the ground and the wheelchair and (Resident #216) and the oxygen were on top of me. CNA G verbalized they pushed the Resident off of them after they fell . CNA G was asked what time it happened and replied, It was close to 4:30 PM. CNA G stated, I believe it was the receptionist who came out and found us on the ground. CNA G indicated they believed Staff V called for help. CNA G stated, We had nurses and aides out there too and then they brought (Resident #216) in and assessed them. CNA G relayed the Resident was then transported to the hospital. When asked how far they fell , CNA G replied, I believe it was a two-foot drop. When asked if they received any education and/or disciplinary actions following the occurrence, CNA G revealed they do not drive anymore. CNA G was asked if the Resident was injured and stated, (Resident #216) broke their neck. They already had a fracture. CNA G revealed they had no injuries, other than being sore, following the incident. An interview was completed with Resident #216's Family Member AA on 3/20/24 at 2:30 PM. When queried regarding the incident involving Resident #216 and the transportation van on 6/7/23, Family AA stated, (Resident #216) fractured the vertebrae in their neck and got stitches in their toe. Family AA stated, (Resident #216) wasn't being taken care of (at facility) and fell out (of the van) backwards. When asked if they were informed of what had occurred by the facility, Family AA revealed a facility nurse contacted them and informed them the Resident had fallen from the van during removal and had been sent to the hospital. Family AA indicated they did not realize what actually happened until they got to the hospital. When queried what happened at the hospital, Family AA revealed Resident #216 had to be transferred from the local hospital to a larger hospital. When asked why the Resident was transferred, Family AA revealed the Resident needed to see a specialist for their neck and was at the larger hospital for a week or two. Family AA specified the fracture could have been prevented if facility staff would have done what they were supposed to do. On 3/21/24 at 8:33 AM, an observation of the transportation van was completed. A measurement of the back of the van to the group revealed the distance was 28 inches. An interview was conducted with the Director of Nursing (DON) on 3/21/24 at 8:43 AM. When queried regarding facility investigation completion, the DON revealed the Administrator had completed the investigation. The Administrator was out of state and unavailable. When queried regarding other Residents in the van, the DON stated, I didn't know there was anyone else. When asked if the facility had documentation of demonstration and check offs of van transportation for loading and unloading residents for CNA G the DON stated, No check offs. The transportation schedule for Residents on 6/7/23 was requested at this time. At 8:50 AM on 3/21/24, the DON approached this Surveyor and stated there was one other Resident who had been transported on the day of the incident, but they had been removed from the van prior to the fall. When queried regarding CNA G stating there had been three residents, the DON indicated they just spoke to CNA G and confirmed there were only two residents. A follow up interview was completed with CNA G on 3/21/24 at 8:57 AM. When asked if there were two or three residents in the transportation van on 6/7/23 when the incident occurred involving Resident #216, CNA G stated there was (discharged Resident #1) and then I had to pick up (discharged Resident #2). CNA G stated, I wasn't expecting to pick up (discharged Resident #2) so I got (discharged Resident #1) out of their wheelchair and sat them on the seat. When asked what they did with the wheelchair, CNA G revealed they folded it up. When queried why they told the DON there were only two residents in the transportation van, CNA G indicated they had forgot. Review of CNA G's education and training completion documentation prior to 6/7/23 revealed no documentation of van lift use and competency. An interview was completed with Staff V on 3/21/24 at 9:20 AM. When queried if they were working on 6/7/23, Staff V confirmed they were. When asked what happened, Staff V stated, I saw (CNA G) pull in. It was such a traumatic thing. Upon request, Staff V was provided a copy of their witness statement for review. Staff V then stated, (CNA G) got the one (resident) off and I wheeled them where they needed to go. When asked, Staff V was unable to recall the name of the resident they took into the facility. When queried what time it was, Staff V stated, It had to be right around 4:30 PM because that is when I leave. Staff V revealed they went back out to see if CNA G needed more help before they left for the day and stated, As soon as I walked out, I seen them on the ground. I ran back in and hollered for help. When asked, Staff V revealed they were going back to see if CNA G needed more help before they left for the day. When asked what they observed when they exited the building, Staff V stated, (CNA G) was on their back on the ground and the Resident was on the ground next to them on their back. When asked where Resident #216's wheelchair was, Staff V revealed they did not recall seeing the wheelchair. When asked, Staff V stated both CNA G and Resident #216 were on the concrete outside of the building on their backs with the Resident closest to the door. Staff V was asked if either the Resident or CNA G were touching the platform that raises and lowers and stated It (platform) was flat. When asked what they meant, Staff V stated, It was parallel with the van exit, like it was never lowered. Staff V continued, The back of the platform had the lip, (CNA G) may have tripped and pulled (Resident #216) down. When asked, Staff V reiterated they were certain the platform was up and parallel with the back of the van. Staff V was asked to draw a picture. The picture showed both CNA V and Resident #216 past the end of the raised platform on the concrete with Resident #216 closest to the door of the facility. Staff V then stated, Both of them hit their heads. When queried regarding Resident #216, Staff V stated, The Resident was moaning and was obviously in a lot of pain. Staff V revealed CNA G was more concerned about the Resident. Staff V was asked what happened next and stated, (LPN Z) and (CNA X) came out. I think (CNA X) seen from a Resident room. At 9:36 AM on 3/21/24, Staff V re-entered the conference room and indicated they made a mistake during their previous interview. When asked what they meant, Staff V stated, It (platform) was down, not up. When asked, Staff V stated both the Resident and CNA G were on the concrete past the end of the platform on their backs. No further explanation and/or description was provided when asked. An interview was completed with LPN Z on 3/21/24 at 9:41 AM. When queried if they were working on 6/7/23, LPN Z replied that they were. LPN Z was asked if they recalled the incident involving Resident #216 and the transport van on that day, LPN Z stated, I know (Resident #216) had an appointment and (CNA G) had taken them. LPN Z stated the receptionist had yelled for help and they responded along with other staff. When queried what they observed, LPN Z stated, (Resident #216) was on the ground and revealed there were multiple people outside at that time. LPN Z stated, Somebody got the Hoyer and indicated the Resident was placed in their wheelchair using the lift. When queried who got the Resident off the ground and into the wheelchair using the Hoyer lift, LPN Z replied, The aides (CNAs). When queried if they had completed an assessment of the Resident, LPN Z replied, (RN W) would have done an assessment. LPN Z was then asked where Resident #216's oxygen tank and wheelchair were at when they observed the Resident and stated, on the ground next to them. When asked the position of the platform, LPN Z indicated it was down. On 3/21/24 at 10:03 AM, an interview was completed with CNA X. When queried regarding the incident on 6/7/23 involving Resident #216 and the transport van, CNA X revealed they did not see it happen and stated, A resident alerted me to them being on the ground. CNA X indicated they looked out the window and both CNA G and Resident #216 were on the ground and the wheelchair was tipped sideways. CNA X stated, I went out and by the time I got there, (CNA G) was up. When asked what happened next, CNA X stated, We had to grab the Hoyer to get (Resident #216) up. When queried if Resident #216 was in pain, CNA X stated, Oh yeah. CNA G was asked who transferred the Resident in the Hoyer lift and revealed it was the CNA staff but was unable to recall staff names. When asked how they got the Resident into the sling, CNA X replied, We had to roll (Resident #216). When queried if Resident #216 expressed pain and/or discomfort when being rolled and transferred in the Hoyer, CNA X replied, Yeah and stated Resident #216 was grimacing. CNA X was asked if anyone braced and/or supported the Resident's head and neck when the Resident was being rolling and transferred in the Hoyer, CNA X replied, Not that I remember. At 10:13 AM on 3/21/24, an interview was completed with the DON. When asked, the DON revealed the facility has some video camera surveillance. When queried regarding footage of the incident involving Resident #216 and the transport van on 6/7/23, the DON stated there were no cameras in the front of the building and no footage of the incident. An interview was conducted with RN W on 3/21/24 at 12:07 PM. When queried what occurred on 6/7/23 involving Resident #216, RN W stated, I was called up front because an employee and Resident on the ground. RN W then stated, I knew the Resident was hurt pretty bad. We sent them out to the hospital, and they never came back. When asked how the Resident was hurt pretty bad, RN W replied, Lacerations and pain. When asked Resident #216 was bleeding, RN W stated, Yes. I can't remember if the laceration was on their head, and they had pain. When queried if they assessed the Resident when they were outside, RN W revealed they listened to their lungs, got vital signs, and asked where hurt. When asked if the Resident was having pain, RN W indicated they were and stated, (Resident #216) was a tough person and didn't like to complain. When asked what they did next, RN W stated, Hoyered (Resident #216) up and took them to their room and did a more thorough assessment. When queried if the Resident's neck was immobilized prior to moving the Resident, RN W stated, I don't think so. RN W was asked if they considered applying a cervical collar (c-collar) for immobilization and replied, We don't have c-collars. When asked if they considered using a backboard, rather than the Hoyer lift, to transfer the Resident due to the mechanism of the fall and potential extent of injuries, RN W stated, I don't think we even have one. When asked why they did not call EMS immediately, when the Resident was outside rather than moving them, RN W stated, I don't know. We had to get (Resident #216) inside to assess them. When queried regarding the location of the wheelchair and the oxygen tank, RN W indicated they did not know and stated, I don't know if (Resident#216) was in the wheelchair originally. When asked what they meant, RN W revealed they did not know if the Resident was seated in their wheelchair when they fell out of the transport van. When queried regarding the Resident's position when they first saw them, RN W stated, Think maybe (Resident #216) was sitting but I'm not sure. On 3/21/24 at 12:26 PM, an interview was conducted with the DON. The DON was asked what their expectations of nursing staff in response to an incident when a resident is pulled out of a wheelchair van backwards directly onto the pavement and stated, A full head to toe (assessment), vital signs, neuros. When queried why Resident #216 was moved and transferred using a Hoyer lift without cervical spine immobilization, the DON stated, (Resident #216) didn't complain of pain right away. The DON was then asked why documentation specified the Resident complained of generalized and severe pain neck, head and shoulders but did not indicate the Resident had no pain initially and did not provide an explanation. When queried why the Resident was transferred using a Hoyer lift and without cervical spinal immobilization, the DON stated, That is the standard. When asked what they meant, the DON revealed it was the standard to use a Hoyer lift for a Resident who fell . When queried if being pulled out of a wheelchair van backwards in a wheelchair onto the concrete/pavement was a typical mechanism of injury for a fall, the DON confirmed it was not. The DON was then asked if the facility had cervical spinal immobilizers (c-collars) and stated, No. When asked why Resident #216 was moved, when the facility did not have the equipment to provide cervical spinal immobilization, and the SBAR assessment specified Resident #216 was having severe pain, the DON stated, I was not there. The DON indicated the Resident was transferred to the hospital in a timely manner. When queried if the Resident was transferred from the ground to a wheelchair using a Hoyer lift and then from the wheelchair to their bed, the DON confirmed and asked, Would a couple of minutes make a difference? When queried regarding cervical spinal immobilization, the DON stated, Yes, I agree the movement may have made a difference. Review of EMS documentation revealed dated 5/7/23 reviewed EMS was called at 5:00 PM by the facility for a fall at the facility. The EMS report detailed, Primary Impression: Multiple injuries . Fall with injury . Distress: Moderate Fall . 2 feet . Mechanism of Injury: Blunt . Trauma . Assessment Time: 5:06 PM . Narrative: Dispatched for a fall . Arrived to find (Resident #216) sitting on edge of bed. Staff on scene states that (Resident) was being taken out of the wheelchair van on the lift when they fell off the lift approximately 2 feet up . fell on another employee . States has laceration on foot . Goose egg noted to right side of head. Swelling and pain to left upper arm . bruising noted to both legs, hands, and feet. 4 cm (centimeter) laceration to right foot, toenail ripped off big toe on left foot . A second EMS report was received and revealed Resident #216 was transferred from the local hospital to a tertiary hospital for specialty services on 6/8/24 at 2:45 AM. Review of Resident #216's hospital documentation revealed the following: - 6/7/23 at 5:39 PM: ED Provider Notes . Review of Systems . Musculoskeletal: Positive for back pain and neck pain. Skin: Positive for wound . Laceration to right great toe, multiple abrasions to hands and feet . Positive for headaches . C-Collar has been applied. Does have pain with palpation. There is ecchymosis and point tenderness noted approximate T1 (First Thoracic Spine Vertebra) . Comments . There are multiple abrasions noted to the dorsal surface of toes and fingers. There is a laceration noted to the dorsal surface of great toe that will require repair . Patient has history of dementia and is a poor historian . alert to person and place . does recall the fall . Laceration Repair . Laceration details: Location . R big toe. Length (cm): 3 . Depth (mm): 3 . Repair method: Sutures . Medical Decision Making: Patient has been seen and evaluated in the emergency department for a fall . out of a van from the floor level onto the ground . did sustain a C2 (Second Cervical Spinal Vertebra) fracture . also has multiple abrasions noted to hands and feet . right great toe laceration requiring repair . I did speak with the radiologist regarding CT (Computed Tomography scan) of the C-spine as has had previous neck fracture in the past. This is a new fracture when compared to most recent CT. I did speak with (Specialist Physician) at (Tertiary hospital) and the patient will be transferred as a trauma for further evaluation and treatment . - 6/7/23 at 5:49 PM: ED Triage Notes (Nursing) . Patient fell at (facility). Ems states patient fell forward out of wheelchair onto a staff member. Patient did hit head . L arm pain, laceration to R foot and part of L great toenail removed in fall . - 6/7/23, Resulted 10:35 PM: CT cervical spine without contrast (trauma age >65) . There is a new tip of C2 spinous process fracture with 3 mm of distraction of the tip fragments . Final Result . 1. New tip of C2 spinous process fracture . - 6/7/23, Resulted 10:24 PM: CT head without contrast .Head trauma, moderate-severe . There is a right posterolateral frontal scalp hematoma . Final Result . Right lateral scalp hematoma . Review of facility policy/procedure entitled, Patient Transport Van: Safety Policy (no date) did not include any information pertaining to loading and/or unloading residents utilizing the wheelchair platform.

Based on observation, interview, and record review, the facility failed to implement and operationalize policies and procedures to ensure adequate supervision for fall prevention and management for three residents (Resident #18, Resident #36, and Resident #40) of eight residents reviewed, resulting in a lack of implementation of meaningful interventions to prevent falls, Resident #36 and Resident #40 experiencing multiple falls including falls with fracture, emergency medical treatment, unnecessary pain, and the likelihood for decline in overall health. Findings include: Resident #18: On 3/19/24 at 11:10 AM, Resident #18 was observed sitting in their room in a Broda chair (wheeled, reclining chair with head rests and elevating solid leg rests used for positioning). A Hoyer (mechanical lift) sling was under them, and their call light was not within reach. The Resident was noted to have upper and lower extremity contractures. An interview was completed at this time. When queried if they had fallen in the facility, Resident #18 indicated they had but did not provide further details. When asked when they fell , Resident #18 smiled but not provide a verbal response. On 3/20/24 at 2:01 PM, Resident #18 was observed in their room. The Resident was in bed, positioned on their back with their eyes closed. The left side of the Resident's bed was against the wall and a wedge style cushion was in place under the fitted sheet. Review of the CMS-802 Form indicated Resident #18 had not fallen at the facility. Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Central Pontine Myelinolysis (CPM- neurological disorder which causes destruction of the substance which protects nerve fibers), heart disease, Tourette's disorder, bipolar disorder, pain, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired, had impaired mobility in both upper and lower extremities, and was dependent upon staff to complete all Activities of Daily Living (ADL's) including turning and repositioning. The MDS revealed the Resident had no falls. Review of Resident #18's Electronic Medical Record (EMR) revealed a care plan entitled, The resident is high risk for falls r/t (related to) debility (Initiated: 6/5/23). The care plan included the interventions: - Ensure bed brakes are locked (Initiated: 12/14/23) - Anticipate and meet the resident's needs (Initiated: 6/5/23) - Follow facility fall protocol (Initiated: 12/14/23) A second care plan entitled, The resident has had an actual fall . (Initiated: 8/2/23) was noted and included the following intervention, Date and description of other interventions put in place after a fall: 8/1/23: Neuros per protocol, low bed, mats on floor while in bed; 2/28/24: Bed rotated as resident prefers to roll onto R. side (Initiated: 8/2/23) The care plan entitled, The resident has an alteration in musculoskeletal status r/t BLE (Bilateral Lower Extremity) and BUE (Bilateral Upper Extremity) contractures (Initiated: 11/20/23) included the intervention, Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance (Initiated: 11/20/23). Review of Resident #18's EMR revealed the Resident was assessed to be a high risk for falls on 6/5/23, 8/1/23, 11/1/23, 2/9/24, and 2/28/24. Progress note documentation detailed: - 8/1/23 at 9:30 PM: Post-Fall Evaluation . New pain post fall: Yes . Resident stated . 'right side of face hurt' . New Interventions . Bed in lowest position, mat placed by bed, square wedge cushion placed under sheet to prevent resident from rolling out again . Additional Comments: Asked Hospice if resident could get an increase in liquid morphine . related to at times, resident lifts head and bangs it down on bed and keeps repeating until body gets closer and closer to the edge of the bed . - 8/1/23 at 11:30 PM: Health Status Note .nurse heard resident yell 'help, help, I'm on the floor!' . entered room and observed resident on the floor lying next to the bed, face was turned on the right side facing the bathroom, right arm was outstretched behind them partly under the bed, and left arm was underneath chest. This nurse called for CNA, who was down the hallway, to get the Hoyer lift (mechanical lift which uses a sling to transfer individuals). Res. was assisted back into bed by Hoyer lift and assess for injury . Res. denied pain other than to the right side of face which was laying on and was slightly red . Intervention is to have bed in lowest position, have mat next to bed, and square wedge cushion is to be placed under sheet to prevent res. from rolling out of bed . - 2/28/24 at 12:50 AM: Post-Fall Evaluation . New Intervention . A new wedge system to keep resident from rolling out of bed . - 2/28/24 at 1:17 AM: Fall . nurse heard a 'help me, help me' down short-A hall, then hurried to resident's room and observed resident lying in prone position on the mat with face/head turned towards the door. Bed in was in lowest position. This nurse asked res. what happened, and res. stated 'I fell out of bed, help me up, hurry, get me up!' Res. was turned over onto back so CAN's (Certified Nursing Assistants) could assist into bed . Review of facility provided Incident and Accident (I and A) reports for Resident #18 revealed the following: - 8/1/23 at 9:30 PM: Un-Witnessed (Fall) . nurse heard resident yell 'help, help, I'm on the floor!' Upon entering room . observed resident lying on the floor on stomach, next to bed with right arm in back of them slightly under the bed, left arm was under chest and face was turned to the right side towards the bathroom door, laying on their right cheek . resident was lifted back into bed by Hoyer and assessed for injuries . Right side of resident's face/cheek was slightly red where they were laying on it . Bed placed in lowest position. Mat placed next to bed. Square wedge cushion placed under sheet to prevent resident from rolling out of bed . No injuries observed at time of incident . Predisposing Situation Factors Restless/Agitation . Other Info: Resident kept lifting head off bed and letting it fall back on bed and kept repeating this last night . - 2/28/24 at 12:50 AM: Fall . Resident's Room . nurse heard resident yell 'help me, help me' . to resident's room to note resident lying on the floor mat next to bed in a prone position while laying on the right side of face with head turned toward the door Residents arms and hands were under abdomen. The wedge cushion used under the bed sheet to prevent resident from rolling out of bed was on the floor half under bed. The light was off. The blanket and sheet were on the floor partly wrapped up in resident's legs. Resident yell 'get me off of this floor, hurry up, get me up!' . Immediate Action Taken . Bed rotated as resident prefers to roll onto right side, preventing rolling out of bed . Predisposing Physiological Factors . Incontinent . None . Predisposing Situation Factors . Restless/Agitation . None . Pain . An interview and review of Resident #18's falls was completed with the Director of Nursing (DON) on 3/25/24 at 11:07 AM. When queried regarding the Resident's fall on 8/1/23, the DON indicated the Resident fell out of their bed. The DON then stated that as fall mat was implemented as the intervention following the fall. When queried why the wedge indicated in the post fall interventions and observed under the Resident's fitted bed sheet was not included in the active care plan, an explanation was not provided. The post fall evaluation documentation specifying Hospice was contacted to request additional pain medication (morphine) as the Resident had been lifting and banging their head down the bed and moving themselves closer to the edge of the bed the night prior to the fall and the night they fell . The DON stated, That's fair when asked where documentation was located showing indicating the Resident was having pain, what non-pharmacological interventions were attempted, and why the concern was not addressed when first identified on 7/31/23 prior to the Resident falling. When queried if additional supervision/monitoring was implemented, the DON indicated there was not. No further explanation was provided. When queried if they had additional investigation documentation pertaining to the Resident's fall on 2/28/24, the DON provided statements from two CAN's. Review of the statements revealed the Resident had last been seen by staff at 10:00/10:15 PM and was found on the floor at 12:50 AM. When queried how often staff should visually observe as well as turn and reposition dependent Residents, the DON replied every two hours. The DON was then asked why it had been over two hours since the Resident was seen by staff, per the statements, the DON did not provide an explanation. Resident #36: On 3/19/24 at 11:43 AM, Resident #36 was observed in the hallway of the facility. The Resident was propelling themselves in their wheelchair towards the exit door at the end of the hallway. There were no footrests in place on the Resident's wheelchair. Resident #36 was pleasantly confused and did not provide meaningful responses to questions when asked. At 12:00 PM on 3/19/24, Resident #36 was not present in their room. An observation of their room revealed the Resident had a raised edge mattress in place. On 3/20/24 at 11:00 AM, Resident #36 was observed sitting in their wheelchair in the activity room of the facility. The Resident's wheelchair did not have footrests in place. The Resident was pleasantly confused and did not provide meaningful responses to questions when asked. Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbance, cerebral infarction (stroke), weakness, and repeated falls. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required maximum to total assistance to complete all ADL's with the exception of eating. The MDS further revealed the Resident had impaired Range of Motion (ROM) in one upper extremity and had one fall with no injury since the prior MDS assessment completion. Review of Resident #36's EMR revealed a care plan entitled, The resident has had an actual fall. The care plan included the interventions: - 2/2/23- fall-assist res. into a stationary chair when in the activity room; 4/18/23- post fall med review, therapy referral; 6/30/23 - Encourage to keep wheelchair at bedside and to place gripper socks on while in bed, PT eval, med review; 7/12/23 - apply gripper strips to side of bed, post-fall med review; 7/30/23 - offer to take to rest room twice during the night, encourage to keep gripper socks on while in bed; 8/11/23 - 1 assist with transfers in activity room; 9/25/23 - Commode with side rails to be placed above toilet. Neuros completed. X-ray's; 10/7/23 - Medication review, encourage call light use, toilet with evening first rounds; 10/14/23 - Toilet twice nightly and put a night light in room; 11/23/23- mat at bedside; 2/7/24: Resident to be visualized by staff when OOB (Out of Bed). Seated in common areas (Initiated: 7/30/23) - Continue interventions on the at-risk plan (2/17/23) - Encourage resident to be in commons area when awake and up to wheelchair to aid in the prevention of falls (Initiated: 10/9/23) - Mat next to bed to aid in the prevention of injury should resident attempt to self-transfer from bed (Initiated: 11/23/23) - Resident to be one of the first residents up in the morning and taken commons area (Initiated: 11/23/23) - When staff is not at nurse station take resident to activities (Initiated: 2/7/24) A second care plan entitled, (Resident #36) is at risk for falls r/t (related to) instability, shuffling gait, medication use, dementia, lack of coordination, repeated falls, impaired mobility, and poor safety awareness (Initiated: 7/12/23). The care plan included the interventions: - Ensure bed brakes are locked (Initiated: 7/7/22) - Anticipate and meet needs (Initiated: 7/7/22) - Commode to be place over resident's toilet to aid in the prevention of falls (Initiated: 9/26/23) - Encourage resident to make sure has good grip shoes on or grippy socks (Initiated: 4/18/23) - Grip strips next to bed (Initiated: 7/12/23) - Review information on falls and attempt to determine cause of falls. Record possible root causes. Alter and/or remove any potential causes if possible. Educate family/caregivers/IDT as to causes (Initiated: 4/18/23) Resident #36 had another care plan entitled, (Resident #36) had limited physical mobility r/t disease processes (Initiated: 7/7/22). The care plan included the intervention, Uses Wheelchair (ensure foot pedals are in place) (Initiated: 10/19/23). On 3/21/24, Resident #36 was observed sitting the hallway of the facility, across from the nurses' station in their wheelchair in the same place and position at 8:30 AM and 10:36 AM. The Resident's wheelchair was noted to have bilateral footrests in place at this time. Review of facility provided I and A reports revealed no additional investigation documentation and/or witness statements for any fall other than the fall on 10/14/23. Any additional documentation related to the Resident #36's falls was requested from the Director of Nursing (DON). Review of provided I and A and EMR documentation revealed Resident #36 had 11 falls from 6/30/23. Review of the falls revealed the following: - 6/30/23 at 4:15 AM: Resident #36 had an unwitnessed fall in their room/bathroom. Per the Fall note dated 6/30/23 at 4:47 AM, Staff responded to resident's bathroom call light and observed resident lying on the floor of bathroom . resident lying on right side with head under the handrail and feet out of the doorway . pain to right hip . was heading to urinate prior to falling. Encouraging resident to keep walker at bedside for use with all ambulation and will encourage use of gripper socks while in bed for safer nighttime transfers. Predisposing factors listed on the I and A form included poor lighting, transferring without assistance, and improper footwear. The intervention, Encourage to keep wheelchair at bedside and to place gripper socks on while in bed . was added to Resident #36's care plan on 6/30/23. - 7/11/23 at 3:15 PM: Resident #36 had an unwitnessed fall in their room. The Fall note dated 7/11/23 at 3:15 PM revealed, Resident was sitting on buttocks and was leaning on left arm for support in doorway facing toward the hallway . legs were extended in front of them into the hallway . walker was next to them . Regular socks on with no shoes on . Review of I and A documentation revealed predisposing factors included impaired memory and improper footwear. The intervention, Apply gripper strips to side of bed was added to the care plan on 7/12/23. - 7/30/23 at 1:36 AM: Resident #36 had an unwitnessed fall in their bathroom. Per witness statements, CAN's U heard someone calling out while checking on other residents and observed (Resident #36) sitting on the floor behind the door at approximately 1:45 AM. The Incident Note dated 7/30/23 at 1:54 AM detailed, (Resident #36) had the door open enough to see they were sitting on the floor. The note revealed staff were unable to open the door enough to enter the room and had to have the Resident slide back from the door. After entering the room, Resident #36 was observed sitting at an 85-degree angle with back toward the bed and with their legs straight out. The Resident had no pants on and was wearing regular socks. An IDT Note dated 8/2/23 at 3:38 PM detailed, IDT reviewed fall .fall likely r/t room change. prior care planned interventions were not transferred to new room. Maintenance to apply gripper strips in new room. The care plan intervention added following the fall was offer to take to rest room twice during the night, encourage to keep gripper socks on while in bed. - 8/11/23 at 10:30 AM: Resident #36 had an unwitnessed fall in the Activity Room. Per Health Status Note, the Resident was observed sitting on floor next to the table in the activity room . facing towards the hall, legs were outstretched in front of them. Rolling chair behind (Resident) . had attempted to sit on the chair, the chair rolled back, and res fell to the floor, landing on buttocks . did c/o (complain of) left hip pain while on floor, however once Hoyered (mechanical lift) up and placed in chair res denied any pain . The intervention implemented on the Post-Fall Evaluation was Resident education not to use chairs that roll. The I and A dated 8/1/23 at 11:31 AM indicated the Predisposing factors included incontinence, poor vision, weakness, ambulating without assist, and seating. Upon request for additional investigation documentation related to the fall from the DON, staff statements were provided. The statements revealed the fall was unwitnessed. Per Activity Staff T's statement, they saw Resident #36 on the floor when they sat down after gathering residents and assisting with beverages. The intervention, 1 assist with transfers in activity room was added to the care plan. - 9/25/23 at 11:40 PM: Resident #36 had an unwitnessed fall in their bathroom. The Incident Note dated 9/26/23 at 3:30 AM detailed, Nurse was called into resident's room last night at 2340 (11:40 PM). Res. observed sitting on bathroom floor with legs outstretched in front of them next to the toilet . leaning against the door frame . The floor was wet around res., who was wearing just a blouse and low-cut regular socks. Res. did not have a pull-up on . The Resident did not use any assistive devices to transfer to the bathroom. The I and A specified the Resident's left lower leg and buttocks hurt with bending and raising the leg and the immediate actions included, Mat placed next to bed and [NAME] moved away from bed. Predisposing factors were listed as poor lighting, wet floor incontinent, and had improper footwear. The intervention, Commode to be place over resident's toilet was added to the Resident's care plan on 9/26/23. - 10/7/23 at 11:23 AM: Resident #36 had an unwitnessed fall in their room. Per I and A form dated, 10/7/23 at 11:23 AM, Resident #36 fell in their room while trying to get up from bed to go to the bathroom and there were no witnesses. Predisposing factors listed included poor lighting, incontinence, and transferring independently. There were no nurses notes in the EMR related to the fall and no interventions were implemented. - 10/7/23 at 9:45 PM: Resident #36 had an unwitnessed fall in their room. Per documentation, facility staff were notified by another resident that Resident #3 was on the floor. Resident #36 was on the floor halfway out of their room door on their left side on the floor. Their walker was lying on the floor, and they did not have appropriate footwear in place. The Resident had left sided rib pain following the fall. An IDT note dated 10/10/23 at 3:29 PM revealed the intervention implemented following the fall was, resident to be toileted first round by CAN's (Certified Nursing Assistants) on night shift and education on call light use. - 10/14/23 at 1:30 AM: Resident #36 had an unwitnessed fall in the bathroom which resulting in a comminuted (severe break in which the bone splits into three or more pieces) displaced open fracture of the left thumb and distal phalanges (long bones in fingers) which required sutures and laceration of the right wrist which necessitated sutures. Resident #36's SBAR-Fall documentation dated 10/14/23 at 1:30 AM revealed the Resident's pain level was eight out of 10 (10 being the worst imaginable pain) at 4:08 AM on 10/14/23 (note: Resident #36 was not in the facility at 4:08 AM). The Resident's pain was in their right side of chest (ribs) . left hip . laceration site, right hand-palm - stated, 'I think I broke my back' on initial observation, but unable to pinpoint then stated pain to left side, .thumb laceration . The Resident's injuries were documented as Right hand -palm- Laceration . Left thumb deep laceration with abnormal traction of thumb. The Health Status Note dated 10/14/23 at 2:15 AM detailed, Another res. heard a thud and this resident yell for help, then called for the CAN's . nurse entered room and noted res. sitting on the floor of the bathroom with the left side of face leaning against the plastic waste basket. Res. was bleeding moderately and complaining that hands hurt. This nurse noted a bad laceration on the dorsal side of right hand, with a skin flap bent back revealing muscle. Area cleaned gently and dressed with a nonstick Telfa pad and Kerlix wrapped around hand to stop the bleeding. Resident's left thumb was bent at an angle and also cut with part of muscle hanging out. Area cleaned gently and dressed with a nonstick Telfa pad and Kerlix wrapped around hand to stop the bleeding . EMS arrived at 0200 (AM) . The I and A form dated 10/14/23 at 1:30 AM specified, Resident's left thumb was bent backward at an unusual angle and was moderately bleeding with muscle hanging out. There was blood on resident's shirt, arms, and legs, besides all over the floor. Resident was not wearing gripper socks .Immediate Action Taken: Resident cleaned up . Right hand laceration was cleaned and dressed . Left thumb was cleaned and dressed . Notes: Resident has a laceration around left thumb with muscle hanging out, which was angled backward in an unusual position . also had a recent fall this month, was educated to call for assistance when having to use the bathroom; however, resident has dementia and forgets to call for help . Predisposing factors listed included poor lighting and balance, confused, gait imbalance, and improper footwear. Review of left-hand X-ray, dated 10/14/23 at 3:32 AM from the hospital revealed, Findings . There is a comminuted fracture of the mid and distal first proximal phalanx that is angulated dorsally and radially. There is also comminuted and displaced fracture at the base of the first distal phalanx . Comminuted and displaced fractures of the left first proximal and distal phalanges. A Health Status Note dated 10/14/23 at 10:20 AM detailed, Resident returned from (hospital at) approximately 0730 AM. via EMS. Resident alert with confusion. Left hand with open displaced fx (fracture) to L thumb requiring some sutures. Resident with thumb splint in place with Kerlix. Residents L thumbnail with some bleeding noted at nail. Dressing in place. R (right) hand laceration with 4 sutures and steri strips in place. Resident looking at hands and asked, 'what happened'. Resident does not remember having fall. Resident with facial grimacing . - 10/16/23 at 12:21 PM: IDT Note . IDT members met to discuss fall. Root cause determined to be confusion and need to toilet. Immediate interventions to send to ED to eval and treat. Resident to be toileted twice nightly by staff and assist to bathroom. The Resident's care plan was updated to include the intervention, Toilet twice nightly and put a night light in room following the fall on 10/14/23. Review of facility-provided Verification of Investigation Form signed by the DON on 10/18/23 detailed, Resident said they were trying to go to the bathroom and slipped and fell . was complaining of left thumb pain and right hand. Resident typically requires 1 assist and uses a wheelchair for assistance. All care plan interventions at the time of the fall were in place and being used . History: Resident has poor situational and safety awareness due to dementia . Summary . Due to resident's inability to comprehend declines . tried to ambulate to bathroom independently. Resident did not use call light and did not turn on bathroom light. Resident fell d/t poor lighting and inappropriate safety awareness. - 10/17/23: A Fall (post) progress note dated 10/17/23 at 11:39 AM was present in Resident #26's EMR. The note specified, Res observed sitting on floor next to the table in the activity room. Res was facing towards the hall, legs were outstretched in front of them. Rolling chair behind . Res had attempted to sit on the chair, the chair rolled back, and res fell to the floor, landing on buttocks. An IDT Note dated 10/17/23 at 11:40 AM detailed, IDT met to discuss resident fall. Root cause determined to be resident independently transferring, and unsafe seating d/t wheeled chair. Interventions to be 1 assist with all transfers while in activities, and resident is not to sit on wheeled furniture . Note: An I an A form for a fall on 10/17/23 was not provided. - 11/23/23 at 10:42 AM: Per SBAR- Fall documentation in the EMR, Resident #36 had an unwitnessed fall in their room at 6:58 AM and facility staff were notified by the Resident's roommate that they were on the floor. Resident #36 was found sitting on buttocks between w/c (wheelchair) and bed facing door. Resident #36 informed staff they were attempting to go to the bathroom without assistance. The Post Fall Evaluation form for this fall detailed there was a noted pattern to falls in which falls occur in resident's room or restroom. The intervention implemented following the fall was Resident #36 was to be one of the first residents up in the morning and was to be taken to commons area of the facility. Note: An I and A Report was not received for this fall. - 2/7/24: Per an Incident Note dated 2/7/24 at 5:43 PM, Resident #36 fell in area of the facility at 2:50 PM while attempting to stand without assistance. The Resident hit their head and suffered a bloody right lower lip. The Resident was drowsy and incontinent at time of fall. The note detailed the Resident's Durable Power of Attorney DPOA) was notified and verbalized that Resident #36 Resident #36 had 19 falls within a short time while at the facility. The intervention implemented following the was to take resident to activities when staff are not at the nurses' station. The note indicated the fall was witnessed but the intervention added to the care plan was Resident to be visualized by staff when OOB and to be Seated in common areas. Note: An I and A Report was not received for this fall. An interview and review of Resident #36's falls was completed with the DON on 3/25/24 at 12:22 PM. When queried regarding the identified root cause of Resident #36's fall on 6/30/23, the DON indicated the Resident was getting up to use the bathroom without assistance. When queried the last time the Resident was assisted to the bathroom and/or observed by facility staff, the DON revealed documentation and stated they did not know. When queried regarding predisposing factors for the fall including improper footwear and poor lighting, the DON indicated gripper socks while in bed was added to the Resident's care plan. When asked why the poor lighting was not addressed, the DON replied, I don't know. The DON was then asked about the Resident's fall on 7/11/23 and revealed the Resident had been in bed and attempted to get up on their own. When queried regarding the lack of non-slip footwear/grippy socks per the Resident's care plan, the DON confirmed the Resident did not have grippy socks in place but did not provide further explanation. When asked when the Resident was last observed by staff, the DON revealed documentation and revealed they were unsure. When queried regarding the Resident's fall on 7/30/23 including the IDT note on 8/2/23, the DON revealed the Resident's status was changed to long term and they were moved rooms. A review of the Resident's census revealed the Resident was moved to a room further from the nurses' station than their prior room. When queried, the DON confirmed the room was further from the nurses' station. The DON was asked if that was a good placement for someone with a high fall risk and stated, It was the only available room for long term placement that was appropriate. With further inquiry, the DON revealed the grippy strips on the floor were not moved to the Resident's new room which may have contributed to their fall. When queried regarding the Resident's footwear, the DON confirmed the Resident did not have grippy socks in place as care planned. No further explanation was provided. When queried regarding the fall on 8/11/23, the DON revealed the Resident had tried to sit on a rolling style office chair in the activity room. When queried why Resident #36, who was assessed to be a high fall risk, was left unattended in the Activity Room, the DON revealed staff were gathering Residents for an upcoming activity and were in and out of the room. When queried regarding the added intervention of 1 assist with transfers in activity room when the Resident was already care planned to have one assist for all transfers, the DON revealed the Resident liked to sit in a regular chair when completing activities and needed assistance to transfer to a regular chair. When asked how that was different than requiring one assist with all transfers, the DON verified it was not. The DON was asked about Resident #36's fall in their bathroom on 9/25/23. When queried why a fall mat was added if the Resident fell in their room, the DON was unable to provide an explanation. The DON stated a commode over the toilet was added after IDT review of the fall. When asked when the Resident was last toileted and observed by staff, the DON was unable to provide a response. The DON was then asked why the planned care plan intervention of grippy socks was not in place but was unable to provide justification. When queried regarding poor lighting being listed as predisposing factor for the fall again and why it was not addressed after this fall, no explanation was provided. When queried, the DON confirmed Resident #36 had two unwitnessed falls in their room on 10/7/23. When asked about the lack of interventions following the fall at 11:23 AM on the care plan, the DON confirmed. When queried regarding the Resident's fall with fracture on 10/14/23, the DON confirmed the Resident had a fall with significant injury. The DON was asked about the Verification of Investigation Form indicating all care planned interventions were in place when the Resident was not wearing grippy socks and was out of bed without assistance, the DON verified the Resident had gotten out of bed without assistance and did not have appropriate footwear in place. The DON was then asked about the form indicating the fall cause was determined to be poor lighting again, the DON stated, This is when we realized the lighting was an issue. When asked how they just realized lighting was an issue after the fall with fracture when it was identified as a predisposing factor on multiple prior falls, no further explanation was given. When queried why increased monitoring and supervision had not been implemented for Resident #36 due to the number of falls, a response was not provided. The DON was then asked if Resident #36 was able to effectively utilize the call light due to their dementia and revealed the Resident did not remember to use it. When asked a different type of call light, such as a touch pad, had not been attempted, the DON stated, Didn't think about it. Review of facility policy/procedure entitled, Fall Evaluation Safety Guideline (Effective: 11/28/17) revealed, Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately . Residents who are evaluated as being at risk for falls will be identified and individualized fall precautions will be developed for each resident. Preventative measures shall be taken to decrease the number of falls whenever possible . Fall related to toileting needs -Provide a night light -Bed is locked and in lowest position -Clear pathway to the bathroom -Footwear to

Based on observation, interview, and record review, the facility failed to implement and operationalize policies and procedures for pressure ulcer (wounds caused by pressure) prevention and management and care, including timely and appropriate wound identification for four residents (Resident #22, Resident #23, Resident #30, and Resident #37) of seven residents reviewed, resulting in a lack of proper identification and care of Resident #22's and Resident #23's pressure ulcers, Resident #30 developing an unstageable Deep Tissue Injury (DTI- area of damage to underlying tissue with unknown depth) pressure ulcer, and Resident #37 developing a DTI pressure ulcer, unnecessary pain, and the likelihood for further pressure ulcer development and a decline in overall condition. Findings include: Resident #23: On 3/19/24 at 3:57 PM, an interview was conducted with Certified Nursing Assistant (CNA) O. When queried regarding Residents with pressure ulcers and/or wounds, CNA O stated, (Resident #23) has something. With further inquiry, CAN's O indicated they were unsure what type of wound the Resident had. On 3/19/24 at 4:00 PM, an observation occurred of Resident #23 in their room. The room was dark with the lights off. The Resident was in bed, positioned on their back, wearing a hospital style gown The Resident's eyes were open. Resident #23 made eye contact when spoke to but provided non-sensical responses to questions. An alternating air mattress was noted on the bed. An interview was conducted with CAN's T on 3/20/24 at 8:39 AM. When queried regarding residents with pressure ulcers, CAN's T stated, (Resident #23) had open sores on their bottom. When asked if the wounds were caused from pressure, CAN's T indicated they were. Record review revealed Resident #23 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included right sided hemiplegia and hemiparesis (one sided paralysis), dysphagia (difficulty swallowing), and aphasia (difficulty to use or comprehend language) following cerebral infarction (stroke), weakness, falls, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and was dependent upon staff for completion of all Activities of Daily Living (ADL's) with the exception of eating. The MDS further revealed the Resident was at risk for pressure ulcer development, did not have any pressure ulcers, but did have Moisture Associated Skin Damage (MASD) at the time of assessment completion. The Review of Resident #23's care plans revealed a care plan entitled, (Resident #23) has actual impairment to skin integrity AEB (As Evidenced By): MASD (Moisture-Associated Skin Damage) right and left buttock (Initiated: 2/1/24). The care plan was changed on 2/1/24 from, (Resident #23) actual impairment to skin integrity AEB: Stage 2 pressure ulcer right buttock. Review of Resident #23's care plans revealed the Resident had a care plan titled, (Resident #23) has actual impairment to skin integrity AEB: Stage 2 pressure ulcer right buttock which was changed on 2/1/24 to (Resident #23) has actual impairment to skin integrity AEB (As Evidenced By): MASD (Moisture-Associated Skin Damage) right and left buttock (Initiated: 2/1/24). The care plan included the following interventions: - Evaluate and treat per physician's orders (Initiated: 2/13/24) - Apply barrier cream per facility protocol to help protect skin from excess moisture (Initiated: 2/13/24) - Educate resident/family/caregivers of causative factors and measures to prevent skin injury (Initiated: 2/13/24) - Encourage good nutrition and hydration in order to promote healthier skin (Initiated: 2/13/24) - Identify/document potential causative factors and eliminate/resolve where possible (Initiated: 2/13/24) - Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal . to MD (Initiated: 2/13/24) On 3/20/24 at 8:45 AM, Resident #23 was observed sitting in a wheelchair in their room. Resident #23 made eye contact and made non-sensical verbal responses when spoke to. When asked if they were able to move their legs, Resident #23 did not move their legs and shook their head to indicate no. Review of Resident #23's Wound Evaluation and wound image documentation in the EMR revealed an assessment dated [DATE] at 2:21 PM. The evaluation detailed, MASD . Right Gluteus - Medial . Deteriorating - 9 months old . In-House Acquired . Length: 2.47 cm . Width: 0.93 cm . Wound Bed . Granulation . Exudate . Light . Serosanguineous . Edges . Non-attached . The attached wound picture with measuring sticker was noted to be off center in the image. The wound was oval shaped with distinct edges and visible depth. The wound bed in the image was light pink and red in color with white tissue at the 12 and 5 o'clock positions. The initial date of the wound specifically identified and unable to be determined and a review of progress note documentation was completed. The following documentation was present in Resident #23's EMR: - 3/13/24 at 9:27 AM: Skin Observation . Resident has NO NEW skin issue(s) observed. 0 (Zero) . Skin turgor with good elasticity . Skin temperature is warm (normal). Skin moisture is normal. Skin condition is normal. Continues with treatment to buttocks. - 3/6/24 at 9:28 AM: Skin Observation . Resident has NO NEW skin issue(s) observed. 0 (Zero) . Skin turgor with good elasticity . Skin temperature is warm (normal). Skin moisture is normal. Skin condition is normal. - 2/15/2024 15:23 Type: *IDT . Residents MASD wounds on buttocks are worsening at this time. Resident will be started on pro-stat (nutritional supplement for individuals with increased protein needs, malnutrition, and pressure ulcers) per (physician) and resident will be encouraged to lay down between meals at this time. Treatment orders will continue to be the same . - 2/1/24 at 3:12 PM: Nursing Evaluation . skin integrity concerns. 0 (zero) . - 1/18/24 at 3:23 PM: IDT . Wound is almost healed, will continue to monitor weekly at this time. No further concerns . - 11/26/23 at 12:58 AM: Skin/Wound Note (Narrative) . Upon rounding on resident and changing hydrocolloid dressing (wound care dressing used for mildly exudating wounds to provide a moist wound healing environment) 2 more areas of open skin noted next to current open area on right buttock. Dressing increased to larger size . - 10/29/23 at 5:37 PM: Nursing Evaluation Quarterly assessment . Skin Integrity: The resident does not have skin integrity concerns . Resident get excoriation to buttock due to incontinence, ointment applied as preventive . - 9/29/23 at 2:56 PM: IDT (Interdisciplinary Team) . MASD noted to R buttock, wound previously closed, continues with incontinence, and wound has opened back up. Surrounding wound is boggy and white/purple . - 9/27/23 at 12:16 AM: Skin Observation . Resident has NO NEW skin issue(s) observed. 0 . L (left) buttock: open area 0.5 cm in length, 0.2 cm wide, slough noted in wound bed, area cleansed, and current treatments applied. - 8/23/23 at 1:28 AM: Skin Observation . Resident has NO NEW skin issue(s) observed. 0 . Skin temperature is warm (normal). Skin moisture is normal. Skin condition is normal. Left buttock open area has healed to small pin-like open area, cream applied. - 8/15/23 10:50 AM: Skin/Wound Note (Narrative) LATE ENTRY . wound NP (Nurse Practitioner) in facility this day and resolved buttock wound . - 7/29/23 at 4:47 PM: Nursing Evaluation . Skin Integrity: The resident has skin integrity concerns. 0 (zero) . - 7/26/23 at 3:13 PM: Skin Observation . Resident has NO NEW skin issue(s) observed. 0 . Skin moisture is normal. Skin condition is normal. Continue to apply cream to buttocks . - 7/19/23 at 3:24 AM: Skin Observation . Resident has NEW skin issue(s) observed. 1 . Small open areas on bilateral inner buttocks . Skin moisture is normal. Skin condition is normal . - 3/20/23 at 9:26 PM: Physician . Progress Note . Right gluteal wound Stage III. Skin Intact . - 3/2/23 at 3:15 PM: Physician . Progress Note . Right gluteal wound . Stage III (open wound with full thickness tissue loss). 3.0 (cm) x 1.0 (cm) . Authored by Wound Care Physician. An interview was completed with Registered Nurse (RN) J on 3/20/24 at 11:10 AM. When queried if the facility had a wound care nurse, RN J revealed they did not. When queried regarding Resident #23's wound, RN J stated, I believe (Licensed Practical Nurse [LPN] R) is doing that today. On 3/20/24 at 11:13 AM, an interview was completed with LPN R. When queried regarding Resident #23's wound care treatment, LPN R confirmed they were completing wound care measurements and treatments. A request to observe Resident #23's wound was completed at this time. On 3/21/24 at 10:22 AM, Resident #23 was observed sitting in their wheelchair in the Activity room of the facility. On 3/21/24 at 3:12 PM, an observation of Resident #23's wound was completed with LPN R. The Resident was in bed and positioned on their side. The wound bed was elongated and slightly larger than a half dollar. The wound had visible depth and defined borders. The wound bed was pink and red with white colored tissue on the lateral side, from approximately 12 o'clock to 4 o'clock. The wound was noted to be located over the bony prominence of the ischial tuberosity (bony prominence in lower pelvis) on the right gluteus. The periwound was discolored and darkened with a reddened area proximal to the open wound. An interview was conducted with LPN R following the wound care observation. When queried why the wound was not classified as a pressure ulcer, LPN R replied the wound had been there was a long time and had opened and closed. LPN R then stated the wound had recently deteriorated and a new treatment had been ordered. When asked if an area could begin as MASD and then become a pressure ulcer, LPN R stated it could. LPN R was asked if the wound was over a bony prominence and had defined borders and confirmed it was. LPN R was asked again how the wound was not a pressure ulcer and replied, It could be. When queried why there were no depth measurements of the wound documented, LPN R revealed the facility utilizes the wound imaging system for wounds and it does not measure wound depth. No further explanation was provided. Resident #30: On 3/19/24 at 3:57 PM, an interview was conducted with Certified Nursing Assistant (CAN's) O. When queried regarding Residents with pressure ulcers, CAN's O stated, (Resident #30) has something on their heel. With further inquiry, CAN's O revealed the area on their heel was black from the Resident's heel dragging when they were in their wheelchair. When asked if the Resident was able to move both of their legs, CAN's O revealed the Resident had a stroke which affected their left side. When queried how the Resident's foot was dragged, CAN's O specified the Resident did not usually have foot pedals in place on their wheelchair. Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses which included depression, Chronic Obstructive Pulmonary Disease (COPD), heart failure, and hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, had one sided upper and lower extremity impaired Range of Motion (ROM), and required substantial to total assistance to complete Activities of Daily Living (ADL's). The MDS further revealed the Resident was at risk for pressure ulcer development but did not have any pressure ulcers at the time of assessment completion. Review of Resident #30's Electronic Medical Record (EMR) revealed the Resident had a care plan entitled, The resident has potential for impairment to skin integrity r/t (related to) diabetes, obesity, impaired mobility, neuropathy (Initiated: 4/3/23). The care plan included the interventions: - Apply barrier cream per facility protocol to help protect skin from excess moisture (Initiated: 4/10/23) - Encourage that heels are elevated while resident is lying in bed . (Initiated: 4/10/23) - Change bedding/clothing if moist (Initiated: 7/18/23) - Dietary Consult as needed (Initiated: 4/10/23) - Encourage/assist with turning and repositioning (Initiated: 4/10/23) - Monitor skin when providing cares, notify nurse of any changes in skin appearance (Initiated: 4/10/23) The Resident did not have a care plan in place related to a current pressure ulcer/alteration in skin integrity. Further review of Resident #30's EMR revealed the Resident had a pressure ulcer on the left heel in May 2023 which had healed. Review of documentation in Resident #30's EMR revealed the following: - 3/13/24 at 9:37 AM: Skin Observation . Resident has NO NEW skin issue(s) observed. 0. Skin turgor with good elasticity. Skin color is normal for ethnic group. Skin temperature is warm (normal). Skin moisture is normal. Skin condition is normal. - 3/15/24 at 3:10 PM: Health Status Note . left heel is redden (sic) and soft, comfort foam applied for cushioning. Res to wear heel boots at all times. (Spouse) notified, voiced concern that heel has opened many times when resident walks even short distances. Resident #30's EMR did not contain wound assessment documentation. Review of Resident #30's health care provider orders revealed the Resident did not have an active order for heel boots. On 3/20/24 at 11:54 AM, Resident #30 was observed being pushed down the hallway of the facility in their wheelchair by Therapy Staff N toward the dining room. The Resident had a soft heel boot in place on their left foot and a regular foot covering in place on their right foot. After taking Resident #30 into the dining room, an interview was completed with Therapy Staff N. When queried why Resident #30 had a heel boot in place on their left foot, Therapy Staff N stated, I'm not sure. Therapy Staff revealed the Resident's foot is a bit internally rotated and indicated the heel boot may be related to that. On 3/20/24 at 4:40 PM, an interview was completed with CAN's Q. When queried regarding observation of Resident #30 with a heel boot in place on their left foot only, CAN's Q replied, Supposed to have a bandage on heel. When asked the reason for the bandage, CAN's Q indicated they were not sure. An interview was completed with Unit Manager Licensed Practical Nurse (LPN) R on 3/20/24 at 4:41 PM. When queried regarding Resident #30's left heel, LPN R stated, I wasn't here and revealed they were unaware of any concerns regarding the Resident's heel. When queried regarding the progress note dated 3/15/4 in Resident #30's EMR, LPN R reviewed the progress note documentation. When queried if there was any documentation after the note on 3/15/24, LPN R confirmed there was no additional assessment documentation. Upon request, an observation of Resident #30's left heel was completed with LPN R at this time. Upon entering Resident #30's room, the Resident was observed sitting in a wheelchair in their room with their feet directly on the floor. When queried regarding their left heel, Resident #30 stated it hurt. When asked how long it had been hurting, Resident #30 replied, About a week. LPN R removed the heel boot and sock on Resident #30's left foot. There was no bandage in place over the Resident's heel. The medial edge of the heel was dark red in color with a deep, dark, purplish colored area, slightly larger than a dime was present in the center of the dark red area. When queried if the dark red area was blanchable, LPN R proceeded to press on the area and stated, No. Following the wound care observation, LPN R was queried regarding the wound and stated that it was an unstageable pressure ulcer. When queried regarding the facility policy/procedure related to notification of alteration in skin integrity and implementation of treatments/interventions, LPN R stated, Usually reported to the Unit Manager and then the DON (Director of Nursing). LPN R then stated, Was supposed to have a foam cushion in it and did not have it. When queried regarding staff statements related to the pressure ulcer, LPN R did not provide an explanation. When queried if Resident #30 had an order in place for the heel boot, LPN R confirmed there was no order for the heel boots. The DON entered LPN R's office at this time. When queried regarding the unstageable pressure ulcer on Resident #30's heel, the DON stated, It wasn't brought to my attention. After reviewing Resident #30's EMR, the DON stated, I do remember talking about this on Friday and indicated they did not see the area the nurse had identified on Resident #30's left heel and planned to follow up, but had not. When queried why there was no follow up assessment documentation of the pressure ulcer, the DON revealed there should have been. No further explanation was provided. 22927 Record review of the facility 'Skin Protection Guideline', dated 7/7/2021, the purpose was to provide evidenced based practice standards for the care and treatment of skin. To ensure residents that admit and reside at our facility are evaluated and provided individualized interventions to prevent, reduce and treat skin breakdown. here was no mention of 'Moisture Associated Skin Damage' within the facility skin management procedure. Record review of the National Pressure Injury Advisor Panel (NPIAP) staging tool (undated) revealed that there was no mention of a Moisture Associated Skin Damage. Resident #22: Observation on 03/19/24 at 10:54 AM of Resident #22 lying in bed on his back with the head of the bed elevated estimated above 30-degree angle, Resident appears asleep. Roommate is awake and stated he doesn't roll over, that's how he sleeps on his back. In an observation on 03/19/24 04:32 PM the state surveyor observed Resident #22 to be ambulating in the main hallway with gray sweat pants on and what appeared to be 2-3 red spots noted on the back of the pants on lower aspect of the buttock region. Record review of Resident #22's OBRA quarterly Minimum Data Set (MDS) dated [DATE] revealed a younger special-needs gentleman who admitted to the facility on [DATE]. Record review of Resident #22's electronic medical record revealed a skin/wound evaluation dated 3/19/2024 at 11:07 AM and noted right ischial tuberosity wound in-house acquired measurements: length 0.81cm X width 0.79cm. Review of the percent-changed graph noted the wound started on 8/1/2023. Record review of left ischial tuberosity in-house acquired evaluation dated 3/6/2024 developed over a year prior, measurements: length 2.72cm X width 1.27cm. Observation on 03/20/24 at 08:31 AM with Certified Nurse Assistant L, who had just given Resident #22 a morning shower, revealed there were observed 4 open areas, with bleeding. Observation of the 4 open wound areas revealed red beefy tissue with depth noted. Resident #22 was asked if the 4 open wounds were painful, and he shook his head up and down for yes. In an observation on 03/20/24 at 08:35 AM, Registered Nurse (RN)/infection control/Unit manager E came into the shower room on the west unit to assess the wounds of Resident #22. RN E applied calaseptine cream to all open areas. RN E stated that the facility called the wounds moisture associated skin damage. Resident #37: Record review of Resident #37's quarterly Minimum Data Set (MDS) dated [DATE] revealed section M: skin conditions revealed that the resident #37 was admitted with one unstageable pressure injury and also developed another unstageable pressure injury while residing at the facility. In an interview on 03/19/24 at 03:33 PM with Resident #37 revealed that she did have bilateral heel pressure injuries. Resident #37 stated that she was in the hospital and the right heel sore just showed up. Then she came back to the facility and a while later (months) after being back at the facility the left heel got a sore also. Resident #37 stated that she was so sick during the time that they just didn't keep the feet off the mattress. Resident #37 stated that she does get wound clinic treatments for the heel wounds. Record review of Resident #37's left heel pressure injury in-house acquired evaluation, dated 3/13/2024, revealed the area of the left heel pressure injury status as deteriorating and over 7 months old. Measurements: length 3.78cm X width 2.38cm, no depth measurements were taken. Area measurement of 6.83cm covered most of the left heel. Record review of Resident #37's 'Skin & Wound Evaluation' form dated 3/20/2024 at 12:02 PM revealed pressure staged as deep tissue injury and in-house acquired, measuring 8.5cm area, length 3.6cm X width 3.1cm. No depth was measured. Progress was noted as stalled. Observation and interview on 03/20/24 at 08:16 AM with the Registered Nurse/Unit manager (RN/UM) E the surveyor Observation of bilateral heels had a plain gauze dressing wrapped in white Kerlix gauze and taped. The old dressing was removed and observation of the right heel being black in color. Observation of the left facility acquired pressure injury revealed the left heel had drainage noted to the old dressing which was removed. RN E applied wound cleanser with 4 x 4 gauze and then patted dry. RN E then applied Dermacal (treatment) to wound bed, cut to size, and covered with 4 x 4 gauze, Resident #37 stated that she went to the wound clinic last Tuesday 3/12/24. RN E stated that the dressing was removed the day prior by the Director of Nursing who took it off yesterday and did not apply the complete dressing. RN E proceeded to apply the Unna boot with Zinc and calamine 3inX10yards. that is changed one time weekly. This dressing was not in place at the beginning of the wound observation. In an interview on 03/20/24 at 08:16 AM, during the bilateral heel dressing changes Resident #37 revealed that she stated she got the wounds from lying in bed and goes to the wound clinic now. Resident #37 stated she got the wounds from here (facility), they just showed up. Resident #37 stated that the wounds are painful. At the pain clinic they debride/scrape them, and it hurts.

This Citation pertains to Intake Number MI00133950. Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #105) from 3 residents reviewed for falls. Resident #105 had a history of falls prior to admission and had two falls at the facility (on 01/07/23 and on 01/08/23) resulting in two fractures (Left distal radius fracture and left occipital fracture), hospitalization and pain. Findings Include: Resident #105: Review of the facility Face Sheet, Brief Interview for Mental Status (BIMS), dated 1/6/23), Fall Risk Evaluation dated 1/5/23, medical progress notes dated 1/5/23 through 1/9/23, revealed Resident #105 was [AGE] years-old, alert to self only with a BIMS of 3 (1 to 9= uninterviewable, 3=severe cognitive decline), had an evaluation score of 21 (at High Risk) for falls, with poor safety awareness; full code status and admitted on [DATE]. The resident had a history of falls with injury prior to admission to the facility. The resident's diagnosis upon admission included, recent preadmission fall with traumatic subdural hematoma (brain bleed) with neurosurgery, psychosis, metabolic encephalopathy, dementia with behavioral disturbances, and repeated falls with supervision and assistance needed for Activities of Daily Living (ADL's), transfers and ambulation. Review of facility nurse's notes dated 1/5/23, documented Resident admitted ; appears alert with confusion. Oriented to self, not aware of time, location, or circumstances. Full code at this time. Resident argumentative at times, mostly noted when (Resident #105) doesn't understand. Ambulated independently despite repeated education to seek assistance. Resident unable to remember to use call light. Review of the facility admission MDS (Minimum Data Set, resident assessment tool dated 1/13/23-Resident not in facility at this time, discharged to hospital), reported the Resident #105 was supervision and one physical assist for transfers and toileting. Review of the facility Physical Therapy notes dated 1/6/23, reported Recent head injury (just prior to admission to facility) causing new cognitive impairment and ataxia (impaired coordination caused by recent medical condition). Patient presents with balance deficits, decreased dynamic balance, decreased functional capacity, decreased safety awareness, decreased static balance, gross motor coordination deficits, postural alignment control deficits, safety awareness deficits, strength impairments and motor control deficits. Review of the facility Occupational Therapy notes dated 1/6/23, reported reduced dynamic balance and increased need for assistance from others. Review of the facility's Resident #105's cognitive care plan dated 1/5/23, reported impaired cognitive function/dementia or impaired thought r/t (related to) dementia; communicate with the resident regarding resident's capabilities. Review of the facility's Resident #105's high risk for fall's care plan dated 1/6/23, reported high risk for falls r/t dementia, poor safety awareness, hx (history) of falls; follow facility fall protocol (facility Fall Evaluation safety Guideline dated 11/28/17), anticipate and meet the resident's needs. Resident First Fall at Facility on 1/7/23: Review of the facility Incident Report dated 1/7/23, reported Resident #105 had a fall and was observed crawling on her knees on 1/7/23 at approximately 10:30 p.m. Review of Nursing Assistant/CNA L written statement dated 1/7/23, reported Around 10:30 pm, I was coming out of (another resident's room) when I saw (Resident #105) crawling in the middle of C-Hall. Review of the facility Nurse (LPN, H) statement (un-dated) reported The night resident observed walking in hallway several times (on 1/5/23) and staff assisted her back to bed without difficulty. Resident was seeking to go home; the following night (1/6/23) was my second night working with (Resident #105). I had received in report (from the hospital on 1/5/23) that her Seroquel (anti-psychotic medication, side effects: light-headiness, blurred vision, dizziness, problems moving) was discontinued from recommendation from social worker. I informed (Medical Director J) that resident remained restless and exit seeking at night and (Medical Director J) agreed to restart medication (the Seroquel). The night of the 7th (1/7/23), resident (Resident #105) was reported to this nurse by day nurse as having had increased behaviors and was given Ativan tabs ordered PRN (as needed-antianxiety medication, side effects: drowsiness/dizzy). Resident continued to have behaviors at start of shift wandering and combative with staff, so Ativan was given before resident was assisted to bed. Resident (#105) was later observed at around 10:30 p.m. crawling on hands and knees out of her room attempting to go into room across the hall. Asked resident how she came to be on the floor; I fell , I was trying to go to the bathroom. (Medical Director J) was made aware of fall and new orders to increase Depakote (seizure medication, side effects: dizziness, memory and mood changes, blurred vision). Residents Second Fall at Facility on 1/8/23: Review of the facility Incident Report dated 1/9/23, documented Patient (Resident #105) tried to stand from wheelchair while in her room near sink area. Unsuccessful transfer, patient complained of pain to wrist and right shoulder. Patient sent to ER for evaluation. Hospital completed series of x rays and reported on 1/9/23 at 3:30p of a hip and wrist fracture. The Incident report was completed on 1/9/23 (day after resident fell ). Review of nurses (LPN, H) notes (un-dated) reported on 1/8/23, (Resident #105) sat in w/c (wheelchair) and both this nurse and CNA (Nursing Assistant/ F) assisted her with toileting. Then this nurse reported behavior to (Medical Director J), overheard resident yelling no repeatedly to CNA asking to help her into bed. CNA (CNA F) left resident (#105) in w/c at her request and came just outside room to tell this nurse (Nurse H) she refused to go to bed then we both heard resident yell out as she fell . Observed resident sitting on floor in front of sink stating that her wrist hurt, wanting ice. Ice pack provided and placed to resident satisfaction (Medical Director J) made aware of fall and ordered Ativan IM (intermuscular) to be given. EMS (Emergency Medical Service) called at that time from residents' bedside and was transferred to ER (emergency room ) for being un-responsive. Review of the facility physician order dated 1/9/23 at 02:07 (2:07 a.m.), reported Ativan Injection Solution 2 MG/ML inject 0.1 ml intramuscularly STAT for agitation dose not administered. Resident unresponsive; transferred to ER. Review of hospital records dated 1/10/23, reported Left distal radius fracture, left occipital fracture, potential for right hip fracture. Due to frequent falls and other comorbidities, the family has elected to start hospice care. Review of facility fall investigation report for 1/8/23 (un-dated) reported CNA (F) went to the nurse's station to report refusal of care to the nurse (Nurse H) 10 ft away approx. and get her assistance. Less than 30 seconds later res. (resident #105) could be heard yelling. Resident was observed by (Nurse H) sitting on the floor in front of sink. Currently resident at the hospital because she is 1:1 (one-on-one for supervision). Review of the facility CNA F's written statement dated 1/8/23, documented I helped resident (Resident #105) off the toilet into her wheelchair. I asked the resident if she wanted to lay down, she began to yell at me saying no, no, no. I went down the hall to tell the nurse she did not want to lay down. Just as I told the nurse we heard a noise coming from down the hall we walked into her room, and I observed the resident laying on her back on the floor. During a phone interview done on 2/2/23 at 8:43 a.m., CNA F stated When I got on shift, I got report (Resident #105) was restless and combative and confused. She was standing up in the hallway with the nurse, I got her in her wheelchair. I wheeled her to her bed, she started yelling, she didn't want to lay down. I told her you can sit in your wheelchair. I told her let us know when she wanted to go to bed (Resident #105 had a BIMS of 3 and was combative at this time). I assumed she would come out in the hallway. I walked out of the room, talked to (Nurse H) and told her she would not lay down and we heard a bump. Her wheelchair had rolled out from behind her, it rolled back. I did not lock her wheelchair because it's a restraint. She was sitting on her bottom leaning against the sink. I left her alone in the room to notify the nurse. When this surveyor asked CNA F if she could have used the call light or hollered for assistance she stated, I probably should have hollered out for somebody. During an interview done on 2/3/23 at 10:38 a.m., Nurse H revealed CNA F did leave the residents room and leave her alone to come to inform her she would not go to bed. Nurse H said CNA F should not have left the resident alone in her room when she was trying to get up. Resident #105 had fallen the day prior to her 1/8/23 fall and had an extensive history of falls and behaviors with decreased cognition assessed and confirmed by facility staff. During an interview done on 2/2/23 at approximately 9:00 a.m., the Administrator stated (Resident #105) could un-lock it (her wheelchair); she was folding clothes the first night she was here, she was able to un-lock her wheelchair. During an interview done on 2/2/23 at 9:30 a.m., Director of Rehab Services PTA K was asked by this surveyor if a locked wheelchair was a restraint and she stated, locking a wheelchair is not a restraint, more safety. Review of the facility Restraint Use policy dated 4/21/20, reported Physical Restraint: any manual method, physical or mechanical device, equipment, or material that meets all of the following: Is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts freedom of movement or normal access to his/her body. Review of the facility Fall Evaluation Safety Guideline policy dated 11/28/17, reported Identification of resident risk for accidents on admission: Utilize medical history and physical exam, observe resident in environment, individualized assessment for safety need for supervision. Falls Relates to Confusion: Place confused and/or risk residents close to the nursing station for observation and/or provide with diversional and targeted individualized activity. Multiple Falls: Keep resident in view during high risk times, if possible (this includes bring residents up to the nurse's station for close observation), Review the direct caregivers and ask them for intervention ideas. Refer to Therapeutic Recreation for activity intervention during high-risk movement groups, hydration, group activity, etc. (this includes documenting interventions prior to medication use).

This Citation is linked to Intake Number MI 914 This citation has two separate Deficient Practice Statements (DPS) A and B: DPS A: Based on interview and record review, the facility is placed in Immediate Jeopardy for its 1) Failure to assess and monitor, 2) Failure to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice led to actual death for Resident #2 who had a significant drop in blood pressure, became hypoglycemic and unresponsive. Resident #2 was transported to the local hospital by local Emergency Medical Services (EMS) for further evaluation and emergency medical treatment. Immediate Jeopardy: The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator and the Director of Operations were notified of the Immediate Jeopardy on [DATE] at 5:50 PM. The Immediate Jeopardy was abated or removed on [DATE]. Non-compliance remained at the lower scope and severity of potential for harm that was not immediate jeopardy due to the other residents affected by the deficient practice, and until sustained compliance had been verified. Findings include: Resident #2: Review of intake documentation pertaining to Resident #2 detailed, (Resident #2) went to the facility on [DATE] for rehab after surgery to repair a broken hip. Family wanted her closer to home, down state where they live, but the decision was made when we were not present. On [DATE] (Resident #2) was found to be non-responsive at the facility and taken by ambulance to the local hospital. (Resident #2) was found to have circulatory failure, central nervous system failure or compromise, metabolic crisis, shock and renal failure. This was also noted on [DATE] by local hospital physician, patient in acute renal failure with a glomerular filtration rate (GFR) 13 (severely low). (Resident #2 had hip surgery here 10 days ago and discharged to rehab with normal GFR. The patient began complaining to the (hospital) nurse of buttock pain. When nurse rolled (Resident #2) to change her (Resident #2) she (hospital nurse) noticed a large developing pressure ulcer with serosanguinous discharge. I (hospital physician) observed this and it appeared that no one at the facility had checked on this because it's quite obvious to have been there a while. I'm (hospital physician) adding [MEDICATION(S)] at this time and (Resident #2) will be admitted by the Hospitalist. (Resident #2) was found to have evidence of acute renal failure as well as a urinary tract infection. (Family member) commented to the nurse that (Resident #2's) catheter bag looked very cloudy. She (hospital nurse) commented that it was clear compared to when (Resident #2) was admitted . We (family) were told (Resident #2) that (Resident #2) was so dehydrated that (Resident #2) required four bags of intravenous fluids (through the vein fluid replacement) to rehydrate (Resident #2). Also note: large decubitus ulcer stage IV debrided to sacral facia layer with a scalpel and forceps. Minimal bleeding identified. A large amount of foul-smelling fat tissue was removed. Dilute iodine dressing placed as wet-dry to desiccate the adjacent necrotic tissue for staged debridement. Completion wound size 10.0 x 6.0 x 2.0 centimeters. That is a very large wound - too large to go unnoticed for ten days. On [DATE] at 1:01 PM, an interview was completed with Resident #2's Family Member Witness L. When queried regarding Resident #2, Witness L stated, (Resident #2) died two days later after she (Resident #2) was admitted to the hospital from the facility from being found non-responsive. When asked what happen, Witness L stated that (Resident #2) originally fell at home and broke her hip and was sent to the facility for rehab, (Resident #2) was normal prior to that and had normal kidney function and when she (Resident #2) was discharged from the hospital she was stable. Witness L indicated they were concerned (Resident #2) was not getting proper hydration as (Resident #2) was found to have very low blood pressure and was dehydrated and non-responsive. Witness L stated she was not happy that (Resident #2) was going to be at the facility for rehab and wanted her closer to where she (Witness L) lived so that family could see her (Resident #2). Witness L stated that the decision to place her (Resident #2) was made when they (family) were not present. Witness L stated she was surprised to find out that (Resident #2) had a large pressure ulcer and felt that the facility was not doing their job at repositioning and monitoring her (Resident #2). Witness L stated that (Resident #2) was supposed to be discharged soon to an assisted living place after her (Resident #2) discharge from the facility. Review of Resident #2's Electronic Medical Record (EMR) progress notes titled nursing evaluation dated [DATE] at 15:01, reveals she was a new admission to the facility and post operative left hip there for rehab. Review of Resident #2's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - No orders documented for baseline labs to be obtained; (complete blood count, comprehensive metabolic [admission labs] and hemoglobin A1C) [for diabetes mellitus monitoring]. - Diuretic 40 mg to be given orally twice daily, insulin six units subcutaneously, an oral diabetic blood sugar lowering agent 1000 mg orally twice daily, blood pressure reducing medication 50 mg orally and a second blood pressure reducing agent 3.125 mg orally twice daily (start date) [DATE]. - Perform finger stick blood glucose monitoring twice daily for seven days with times indicated for 8:00 AM and 8:00 PM. Review of Resident #2's EMR for blood glucose monitoring checks revealed that on [DATE] no blood glucose monitoring was done at 4:00 PM or at 8:00 PM, only one was done in the morning on [DATE], none completed on the [DATE], none completed on [DATE] and none completed on [DATE] (start date) [DATE]. - Monitor incision to left hip every day, every day shift between 6:00 AM and 18:00 PM (start date) [DATE]. - Obtain vital signs (blood pressure, pulse, respirations, temperature and oxygen level) every shift between 6:00 AM and 6:00 PM and 6:00 PM and 6:00 AM (start date) [DATE]. Review of Resident #2's EMR under vital signs from admission on [DATE] until her discharge on [DATE], revealed no documentation for vital signs for dates and shifts as follows: [DATE] evening shift missing, [DATE] evening shift missing, [DATE] evening shift missing, [DATE] evening shift missing and [DATE] evening shift missing. Review of Resident #2's EMR revealed the following care plans and interventions: Care plan: The resident has an alteration in cardiovascular function, need for continued monitoring related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan included intervention: - Monitor lab values as ordered. Report abnormalities to physician .Monitor, document, report as needed any signs and symptoms of [CONDITION(S)] in residents receiving diuretic therapy: Fatigue, muscle, weakness, diminished appetite, nausea and vomiting and [CONDITION(S)], Monitor potassium levels (Initiated: [DATE]). Care plan: Focus: The resident has diabetes mellitus with the need for continued monitoring (Initiated: [DATE]). Goal: Will be free from any [CONDITION(S)] through the review date ([DATE]). The care plan included intervention: - Monitor lab values as ordered. Report any abnormalities to physician (Initiated: [DATE]). Care Plan: Focus: The resident has actual impairment to skin integrity surgical incision to left hip/thigh and suspected deep tissue injury (SDTI) to buttocks (Initiated: [DATE]). Goal: The resident will have no complications related to documented skin impairment (Initiated: [DATE]). The care plan included intervention: - Ensure that heels are elevated while resident is lying in bed. Encourage/assist with turning and repositioning every ,d+[DATE] hours (Initiated:[DATE]). Care Plan: The resident is at risk for falls related to decreased mobility and history of falls (Initiated: [DATE]). The care plan included interventions: - Review medications associated with fall risk, such as diuretics, anti-epileptics, hypnotics, analgesics, and antidepressants. Discuss possibility of dose reduction with medical doctor (MD) if appropriate (Initiated: [DATE]). - Encourage the resident to stay properly hydrated, educate that dehydration increases risk for falls (Initiated: [DATE]). Care Plan: The resident has limited physical mobility (Initiated:[DATE]). The care plan included intervention: - Provide supportive care, assistance with mobility as needed. Document assistance as needed (Initiated:[DATE]). Care Plan: The resident has an activities of daily living (ADL) self-care performance deficit related to decreased mobility (Initiated: [DATE]). The care plan included interventions: - BATHING/SHOWERING: The resident requires what assistance by staff with bathing/showering (Initiated: [DATE]). - BED MOBILITY: The resident requires what assistance by staff to turn and reposition in bed (Initiated: [DATE]). - PERSONAL HYGIENE: The resident requires assistance by staff with personal hygiene and oral care (Initiated: [DATE]). - TOILET USE: The resident requires assistance by staff for toileting (Initiated: [DATE]). - Monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function (Initiated: [DATE]). Care Plan: The resident has decreased tissue perfusion (Initiated:[DATE]). The care plan included intervention: - Obtain and monitor lab/diagnostic work as ordered. Report results to medical doctor and follow up as indicated (Initiated: [DATE]). Care Plan: Potential for weight fluctuations related to fluid volume changes and diuretic use (Initiated: [DATE]). Goal: The resident will maintain a stable weight range of 150 pounds with a 5-pound fluctuation and adequate nutritional status through review date (Initiated: [DATE]). The care plan included intervention: - Obtain and document weights per medical doctor orders and facility protocol: (Initiated: [DATE]). - Evaluate any weight changes. Determine percentage changed and follow facility protocol for weight change (Initiated: [DATE]). Care Plan: The resident has the potential for alteration in comfort due to decreased mobility (Initiated: [DATE]). - Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss (Initiated: [DATE]). Review of Resident #2's EMR revealed the following progress note and assessment/evaluation documentation: - [DATE] at 3:01 PM: Nursing Evaluation .The reason for the evaluation is admission .I broke my hip and I'm here for that .full code .Vital Signs: weight 163.0 pounds ([DATE]) at 3:09 PM .blood pressure ,d+[DATE], temperature 97.3 degrees, pulse 73 - regular, respirations 18 and oxygen saturation 95 percent with nasal cannula (oxygen delivery device for the nose) .verbalized call light use. Is unable to verbalize/demonstrate use of bed controls .see wound care notes for details on pressure area on buttock area .neurological: is alert, is oriented to person, place and situation .catheter is indwelling .does not do own catheter care .date of last bowel movement [DATE] .the resident needs assistance with activities of living daily care. - [DATE] at 10:51 AM: Daily Skilled Note: Resident is receiving skilled services for: Physical therapy, occupational therapy, post-surgical care. Special precautions: hip precautions. Cognition: Orientation Person/Situation. The resident requires supervision for safety .The resident requires substantial/max assistance for bed mobility .The resident requires supervision/touching while eating. There has not been a change in the resident's baseline cognition. Notifications, Orders, and Interventions related to Cognition: Has lucid times and then has confusion at times. Removing oxygen frequently and needs ongoing monitoring and assist to replace .The resident requires substantial/max assistance for bed mobility .Post-Surgical Care: Type of Surgery: Orthopedic Site: L-Lower Extremity Hip surgery Skin/Wound: No documentation charted on: New Skin Alteration(s): and / or Existing Skin Alterations: - [DATE] at 1:15 PM: Skin Observation .skin issues site other (specify) and description buttocks with SDTI. Note: No measurements were documented at this time. - [DATE] at 8:15 AM: Skin/Wound Note .She is considered moderate risk for the development of pressure injuries as she scores a 15 on the Braden scale. Due to her current injuries and weakness, feel she is high risk .She has SDTI to her buttocks .Every 2 hour turn schedule in place with buttocks to be floated .Will continue with current interventions and adjust accordingly. - [DATE] at 11:00 AM: Care Management Note .Son would like her to go to an assisted living facility. She would like to go home .The anticipated discharge date is [DATE]. - [DATE] at 23:01 PM: Daily Skilled Note . Resident is receiving skilled services for: Physical Therapy Occupational Therapy Special precautions: Cognition: Orientation: Person .There has not been a change in the resident's baseline cognition The resident requires substantial/max assistance for bed mobility .The resident requires partial/moderate assistance while eating. - [DATE] at 9:10 AM: Daily Skilled Note .Cognition: no new orders confused at times low bed .The resident is 100% dependent for bed mobility .The resident eats independently .The resident is 100% dependent while toileting .Neurological: Abnormal Neuro Check Findings: alert and oriented x one .Bed in low position at this time. Gets confused at times per night shift, will monitor. - [DATE] at 12:01 PM: Health Status Note .Resident passed whole meds in bowels this afternoon. - [DATE] at 8:06 PM: Daily Skilled Note .Cognition: Orientation: Person The resident requires supervision for safety. There has not been a change in the resident's baseline cognition .The resident requires substantial/max assistance for bed mobility . The resident requires partial/moderate assistance while eating. The resident requires substantial/max assistance while toileting .participates in therapy as tolerated. Note: No documentation under Skin/Wound: New skin Alteration(s) or Existing Skin Alterations that Resident #2 had her post-surgical site assessed on this day or any other wounds. - [DATE] at 8:24 AM: Care Management Note .The resident's plan for living arrangements have not changed .The anticipated discharge date has changed due to the following: Son is looking for assisted living and home care for discharge. - [DATE] at 9:49 AM: Daily Skilled Note .Cognition: Orientation: Person Not Oriented x four .There has not been a change in the resident's baseline cognition . Neurological: Abnormal Neuro Check Findings: alert to self and some of the situation .Mood/Behavior: pleasant, sleeps a lot . Gastrointestinal/[CONDITION(S)]: Gastrointestinal Alterations: [CONDITION(S)] Alterations: Abnormal Urine Characteristics: bladder-catheter patent and no concerns bowels loose. - [DATE] at 11:09 AM Comprehensive Nutritional Assessment .Height 65.0 inches ([DATE]), weight 150.2 pounds lying down ([DATE]) scale: wheelchair .Weight changes % gain or loss resident has not had 1 month gain or loss 5% or greater .On admission [DATE] noted to have 2 plus pitting [CONDITION(S)] to bilateral lower extremities. No further [CONDITION(S)] noted. Note: The facility provided no evidence of monitoring for biochemical data such as labs to monitor for diabetes mellitus, wound healing, [CONDITION(S)] and fluid and electrolyte imbalances. Resident #2's original weight 163.0 pounds on admission (5% of 163.0 pounds = 8.15 pounds); current weight for comprehensive nutritional assessment is 150.2 pounds: 150.2 - 163.0 = -12.8 pounds in five days; that is a 4.65 pounds more than a 5% weight loss. - [DATE] at 3:00 PM Health Status Note .Spoke with doctor regarding catheter, new order to discontinue. Resident aware. - [DATE] at 23:09 PM: Daily Skilled Note .Cognition: Orientation: Person Place Time Situation. Note no documentation under; Skin/Wound: New skin Alteration(s) or Existing Skin Alterations that Resident #2 had her post-surgical site assessed on this day or any other wounds. - [DATE] at 11:35 AM: Daily Skilled Note .Cognition: Orientation: Person .The resident requires substantial/max assistance while transferring .Gastrointestinal Alterations: (No documentation) . Dressing changed to coccyx multiple times this shift related to loose stools and bowel incontinence. Note: No documentation under Skin/Wound: New skin Alteration(s) or Existing Skin Alterations that Resident #2 had her post-surgical site assessed on this day or any other wounds. - [DATE] at 8:59 AM: Skin Observation .skin issues site other (specify) and description buttocks with unstageable. Note: No measurements were documented at this time. - [DATE] at 4:54 PM: Appointments Note .The resident had 2 loose stools. Had to cut it short today due to being uncomfortable and in pain. - [DATE] at 2:46 PM: Skin/Wound Note .Regarding: status of the residents wound to buttocks. The resident is having multiple loose stools a day causing wound to deteriorate. - [DATE] at 23:45 PM: Daily Skilled Note .Resident is receiving skilled services for: Physical Therapy Occupational Therapy GI/GU, [CONDITION(S)] Post-Surgical Care .The resident requires partial/moderate assistance while eating .Gastrointestinal Alterations: Diarrhea There is a change in Gastrointestinal status: Continued diarrhea since admission [CONDITION(S)] Alterations: Abnormal Urine Characteristics: There is no change in GU status. The resident has an indwelling catheter. There are no concerns related to the Indwelling Catheter Evaluation. Note: Resident #2's indwelling catheter was discontinued on [DATE]. - [DATE] at 8:45 AM: Daily Skilled Note .Cognition: Orientation: Person .No concerns noted related to diabetic related evaluation/observations. Note: No documentation for mood, gastrointestinal alterations, [CONDITION(S)] alterations, neurological abnormalities and / or existing skin alterations i.e.: buttock wound. - [DATE] at 2:03 AM: Skilled Nursing Facility to Emergency Department Handoff .Full Code. Resident noted difficult to rouse. Blood pressure ,d+[DATE]. Placed in Trendelenburg (lowering the head and raising the feet) and blood pressure increased to ,d+[DATE]. Resident also have profuse amount diarrhea. Reason for transfer treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Note: Last set of vital signs prior to that documented on the skilled daily for nurses dated [DATE] morning shift. Review of Resident #2's EMR progress notes titled Daily Skilled Note, revealed multiple times where the same vital signs were used from the prior day indicating that vital signs were not taken in a timely manner. Examples as follows: on [DATE] the same blood pressure was used from the previous day, on [DATE] the blood pressure from [DATE] was used and the same temperature from the prior day was used, on [DATE] the same blood pressure from [DATE] was used again and the same temperature from [DATE] was used again, on [DATE] the prior days vital signs were used for this day, on [DATE] the vital signs were used from the day shift and the night shift completed the skilled daily note, on [DATE] the vital signs were used from the day shift and the night shift completed the skilled daily note, and on [DATE] the vital signs recorded for this skilled daily note were from the prior day. Further record review revealed a skilled daily note completed for [DATE] at 23:25 PM and the resident was not even present in the facility at this time. On [DATE] at approximately 11:30 AM, an interview was conducted with the Director of Nursing (DON). The DON was asked if there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was asked about the missing vital signs in the EMR and responded; If they are not documented, then they were not done. On [DATE] at approximately 11:55 AM, an interview with Medical Director. The Medical Director was asked why Resident #2 was not started on potassium as she was taking a diuretic which would deplete her potassium level and responded, That would have been started in the hospital and hospital discharge papers do not state why she was not on potassium. The Medical Director was asked if he was aware of critical lab values of potassium of 2.9 (normal value is 3.5 - 5.1), glucose 25 (normal range 70 - 110) and glomerular filtration rate 15.6 (kidney function normal range 60 - 200) and responded, I should have gotten communication via text or phone, and I do not see one. The Medical Director was then asked how critical labs are communicate with him and responded, typically called from local hospital to the facility and or to him. The Medical Director was asked if he decreased Resident #2's [MEDICATION(S)] on [DATE] and responded, My note says I saw Resident #2 on that day and started her on [MEDICATION(S)] (diabetic oral agent) because of her kidney function lab. The Medical Director was asked how often he wanted blood glucose monitoring for Resident #2 and responded, Twice a day. The Medical Director was then asked why Resident #2's blood glucose monitoring had been discontinued after seven days and responded, I do not know why they were discontinued, and I am not sure why this was done. Further interview with Medical Director and states, I should have gotten baseline labs and will change to obtain baseline labs. The Medical Director was asked if he was aware that Resident #2 had a buttocks wound and responded, I knew Resident #2 had a wound, but I did not visualize it. On [DATE] at approximately 3:15 PM and interview was conducted with the Director on Nursing (DON). The DON was asked if there were any standing orders for new admission and responded, No. The DON was then asked if there was an admission policy for new admissions and responded, No. Review of Resident #2's Task List not dated, revealed no documentation of any turning and repositioning to be completed by facility staff. Note: Care Management Note dated [DATE] at 8:24 AM, read in part; Noted max assistance for bed mobility. On [DATE] at approximately 3:35 PM, an interview was conducted with the Director of Operations. The Director of Operations was asked for a look back on the Tasks for Resident #2 regarding her turning and repositioning to ensure that this task was being met by facility staff. The Director of Operations responded, The facility is unable to pull custom tasks. The Director of Operations was then asked is she could prove the task of turning and repositioning was done every two to three hours and responded, No. An interview was conducted with Registered Nurse (RN) Unit Manager C on [DATE] at 5:15 PM. When queried what nursing staff assess and document as part of the facility Daily Skilled Evaluation for Residents admitted to and receiving skilled care services at the facility, RN C stated, Charting is based on why here. With further inquiry, RN C revealed charting and assessment is limited. RN C was asked to explain what limited meant and revealed it would be easier to demonstrate in the Electronic Medical Record (EMR) assessment/evaluation documentation form. At this time, RN C accessed a Skilled Daily Evaluation form in the EMR. The reason for the resident's admission to the facility was pre-populated in the top box of the form. RN C stated, Charting is based on the admit diagnoses. When queried if they assess other body systems such as cardiac, neurological, and/or respiratory through nursing assessment including auscultation, RN C reiterated they only assess and document on the reason for the resident's admission to the facility. RN C was then queried regarding facility policy/procedure related to documentation. When asked if they document by exception or if they document normal assessment findings, RN C revealed they document all assessment findings. When asked if they were saying they document normal findings, RN C replied, Yes. Review of Resident #2's discharge from the local hospital on [DATE], reveals a weight of 163.4 pounds, blood pressure ,d+[DATE], pulse 76, temperature 97.8, labs completed on [DATE] glomerular filtration rate of greater then 60 (reference range greater than 59) and discharged in stable condition. Review of Resident #2's admission to the local hospital on [DATE], reveals glucose 11 and acute renal failure with a glomerular filtration rate of 13. Review of provider note on [DATE] from the emergency department, read in part She had hip surgery ten days ago and discharged to rehab with a normal glomerular filtration rate. The patient began to develop buttocks pain. When the nurse rolled her to change her, she noticed a large developing pressure ulcer with serosanguinous discharge. I observed this and it appears that no one at the facility had checked on this because it's quite obvious to have been there a while. Review of local hospital consultation note for decubitus ulcer dated [DATE], read in part; She presented through the emergency department last night with [CONDITION(S)] and mental status change. She was found to have evidence of acute renal failure and well as urinary tract infection. An incidental large necrotic sacral decubitus ulcer was also identified .Surgical consultation was requested for management .There is a large area of gangrenous skin and dermis with over the sacrum measuring 13 x 8 centimeters. There is a break in the necrotic skin with necrotic fat and foul-smelling purulence beneath. Review of Resident #2's hospital documents titled Progress Note dated [DATE], read in part; Found down at nursing home. Shock likely [MEDICATION(S)] (urinary tract infection untreated spreads to the kidneys). Large necrotic sacral wound. Review of Resident #2's hospital documents titled Nursing Note date [DATE], read in part; 2234: Asystole (lack of heartbeat) noted on monitor. No blood pressure, pulse or respirations. Time of Death pronounced. Review of Resident #2's hospital document titled Details of Hospital Stay dated [DATE], read in part; Is a [AGE] year-old female with history of hypothyroid, Insulin Dependent Diabetes Mellitus Type 2, .[CONDITION(S)], status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient altered and unable to provide meaningful history. Per report was found down at nursing home with large dry necrotic sacral wound and brought to ED for further management. In the ED she was found to be hypoglycemic, blood glucose of 11 which was replaced. She was responsive and alert but confused.Urine looked purulent on Foley insertion, Urinalysis with significant pyuria bacteriuria . large necrotic wound overlying upper sacral region which looked dry with overlying black eschar, no purulence or surrounding [CONDITION(S)]. Started on broad spectrum antibiotics, .dual pressors, [MEDICATION(S)] . Magnesium replaced. Lined central and arterial and admitted for continued care . She was intermittently supported with boluses of [MEDICATION(S)]. Her creatinine did not improve . Her blood pressure did improve slightly however mentation declined and she appeared increasingly mottled. Family discussion was held .Decision made to withdraw care and end aggressive life prolonging therapies especially given grim prognosis and low likelihood of return to normal functioning and independence, which she would not have wanted. Asserted new treatment goal of maintaining comfort. Started on [MEDICATION(S)] with [MEDICATION(S)] as needed, [MEDICATION(S)] push on withdrawal of pressors. Patient passed peacefully with family at bedside. On [DATE] at approximately 3:20 PM, a request was made for any policies related to pressure ulcers, weights, critical lab values, blood glucose monitoring and congestive heart failure from the DON. The DON responded, The facility does not have policies on congestive heart failure and critical lab values. The accepted Abatement Plan included the following actions to be initiated or taken and to be verified onsite by the State Agency prior to exiting. Resident #2 no longer resides at the facility. 56 residents reside in the facility. On [DATE] residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], residents with CHF have had their care plans reviewed and updated as appropriate. On [DATE], current resident weights were validated to be up to date. On [DATE], residents that admitted to the facility within the past 14 days were reviewed for completion of admission weights per policy. On [DATE], an audit was initiated on residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], an audit was initiated on residents to review vital signs orders and updated per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Beginning on [DATE], residents that admit to the facility will have two nurses reconcile admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Beginning on [DATE], residents receiving diuretic therapy have received record reviews with physician consultation to ensure appropriate lab monitoring is in place was initiated. On [DATE], the guidelines for weight monitoring and diabetes have been reviewed and are current. On [DATE], education was initiated. The DON/ designee will educate all licensed nursing staff on orders related to frequency of vital signs, diabetes monitoring, CHF monitoring, medication reconciliation, and weight monitoring. This facility employs 15 licensed nurses, currently 5 licensed nurses have completed the education. All remaining licensed nurses will receive education prior to working their next scheduled shift. On [DATE], the QAPI team reviewed the education and training plan for licensed nursing staff. This team will ensure that all licensed nurses are educated. Policy and procedure were reviewed on [DATE] and deemed appropriate. On [DATE], the Medical Director reviewed and provided input in the formulation of this abatement plan. Beginning [DATE], the DON/ designee will conduct random observations 5 times per week for completeness of weights, diabetic monitoring, obtaining vital signs, CHF monitoring, and vital sign documentation. Any identified concerns are immediately addressed. The results of these audits will be reviewed monthly by the facility Quality Assurance Performance Improvement (QAPI) committee for patterns, trends, and continued recommendations for process monitoring and continued improvement. The Administrator is responsible to ensure these actions are taken. On Monday, [DATE], the initiation of the above-listed Abatement Pla [TRUNCATED]

Based on observation, interview, and record review, the facility is placed in Immediate Jeopardy for its failure to implement a complete Infection Control Program designed to provide a safe environment and to help prevent the spread of COVID-19 (Coronavirus Disease of 2019) and other communicable diseases and/or infections. This deficient practice has five noted deficiencies: COVID-19 1. Identify and delineate positive COVID-19 residents from persons under investigation (PUI-residents who have recently recovered and/or had been exposed to COVID-19 without testing positive. 2. Follow transmission-based precautions for staff and residents for COVID-19 positive and PUI residents. 3. Implement the proper use of Personal Protective Equipment (PPE) for COVID-19 and PUI residents. Infection Control Program 4. Ensure infection control walk through's occurred for both laundry and the kitchen. 5. Collect, monitor, and analyze infection control data. These deficient practices resulted in the potential for the transmission of infectious organisms and cross contamination which had the potential to affect all 49 residents. Immediate Jeopardy (IJ): The Immediate Jeopardy began on 11/11/2021. The Immediate Jeopardy was identified on 11/30/2021. The Nursing Home Administrator was notified of the Immediate Jeopardy on 11/30/2021 at 2:23 PM. The Immediate Jeopardy was abated or removed on 12/02/2021, effective 11/30/2021 The Immediate Jeopardy began on 11/11/21 at between approximately 11:00 a.m. and 12:00 p.m., when, per an interview with the Director of Nursing (DON) and Infection Preventionist/Registered Nurse (RN) I on 11/30/21 8:57 AM, it was reported on 11/11/21, eleven residents had been COVID-19 positive. and were moved to the east end of the facility and combined with PUI/COVID-19 status unknown along COVID-19 negative residents. The B Hall had full capacity as PUI residents became COVID-19 positive. As a result, COVID-19 residents were also housed down the long and short A hall. The Nursing Home Administrator (NHA), the DON, and the Regional Director of Clinical Services (Staff Member T) were notified of the immediate jeopardy on 11/30/21 at 2:23 p.m. The Immediate Jeopardy was removed on 12/02/21 09:01 a.m., after the review of the initial implementation of the accepted abatement plan. However, a lower scope and severity of widespread potential for more than minimal harm that is not immediate jeopardy, pending on-site verification of the plan of correction. Findings include: COVID-19: On 11/29/21 at 11:41 a.m., the DON explained the designated COVID-19 unit was the entire east end of the building, which included the short and long A hall and the B hall. The DON said there were some residents who had recently recovered from COVID-19. These residents were considered negative, but also PUI (people under investigation). The DON reported there were also residents who were COVID-19 negative (therefore not PUI) housed down these halls. The DON said PPE should be worn in the COVID-19 positive rooms and the PUI rooms. N-95 masks (special respirator mask worn to prevent the spread of COVID-19) and face shields should be worn in the facility. During the initial tour of the east end of the facility on 11/29/21 from 1:14 p.m. to 1:20 p.m., the following observations were made: There were no fire doors, curtains, or other barriers separating the short and long A halls and the B hall. There was not a designated area for donning and doffing PPE upon entry to the east end of the facility or signage posted instructing individuals on the proper use of PPE. A sign on the door of room A-4 which read, Door must remain closed at all times along was signage instructing individuals that this resident was on droplet transmission-based precautions was observed. The door was observed to be approximately 2/3 open (when a resident is diagnosed with COVID-19, the room door must remain closed at all times per Center for Disease Control (CDC) guidelines). Resident #30 (COVID-19 status unknown due to line listing timeline not identifying which date he was cleared) was observed sitting next to the nurse's station within the line of vision of two nurses. Resident #30 was not wearing a mask; staff did not encourage Resident #30 to wear a mask. Upon request of the nurse, Resident #30 was taken back to his room by Certified Nurse Aide (CNA) O to use the bathroom. Resident #30's door had a sign which read Door must remain closed at all times along with transmission-based precautions instructing individuals of the need to wear PPE when entering. An unsampled resident was observed entering the unit from the outside after smoking, propelling himself in a wheelchair past room A-9 (Resident # 39's COVID-19 positive room) and into room A-11. Room A-9 had signage posted notifying individuals the resident housed in this room was on transmission based (droplet) precautions along with informing individuals the door must remain closed at all times. The door to room A-9 was observed to be open approximately 12 inches. A PPE cart which held the PPE was not observed outside to the room. An observation of an unidentified housekeeper cleaning room A-7 was made. The door to this room had signage posted which notified individuals that the resident in this room was on transmission based (droplet) precautions and the door must remain closed at all times. The door to this room was observed to be open all the way. The resident room doors on hall B were all observed to be closed. Some of the doors had yellow sticky notes with resident names on them. Rooms 30, 28, 31, 21, 25, 26, and 29 had signs informing individuals that the residents were on transmission based (droplet) precautions and the doors to the rooms should be closed along with small purple sticky notes with a positive sign. PPE carts were not observed either inside or outside of these rooms. On 11/19/21 at approximately 1:20 p.m., CNA R was asked to clarify if the signs on the doors meant the residents with signs on the doors meant the resident in that room was COVID-19 positive or if they were PUI. CNA R thought the signs meant the residents in these rooms may be COVID-19 positive but was not sure. CNA R said it seemed as though residents were removed from transmission-based precautions too soon in some cases because several of the residents still seemed ill even after they were taken off precautions. During a follow up interview with CNA O on 11/29/21 at approximately 1:25 p.m., CNA O was asked why the door to A-4 was open. CNA O said the door should be closed and was not sure why the door had been open. When asked if Resident #30 should be out of his room, next to the nurse's station, CNA O said Resident #30 should be in his room but it was difficult to keep him in his room. CNA O said Resident #30 had not been wearing a mask on when out of his room. On 11/29/21 at approximately 1:50 p.m., Resident #34 was seen leaving room B-29 without a mask and ambulated down the hall to the nurse's station and requested his cigarettes so he could go outside to smoke. On 11/29/21 at approximately 1: 45 p.m. a list of residents housed on the A and B halls was requested from Licensed Practical Nurse (LPN) U. LPN U reported she could get one but wasn't sure if it would be accurate at this time. On 11/30/21 at 8:33 a.m., this Surveyor was screened for COVID-19 at the time of entry to the facility. The staff member did not require this Surveyor to don an N-95 mask at the time of entry. During an interview with the DON, and Infection Control Nurse I on 11/30/21 at 8:57 a.m., it was reported the outbreak occurred on 11/11/21. Per the guidelines of the health department, there were three tiers of resident in the east end of the building as follows-1. COVID-19 positive residents,2. PUI residents, and 3. regular residents. PPE should be worn when providing care to the COVID-19 positive and PUI residents. PPE should be changed between providing care to residents. Residents should remain in their room. Findings regarding the observation of Resident #30 and the doors being open to the transmission-based precaution rooms were shared. The DON said Resident #30 should not have been out of his room without a mask and said she could not make excuses as to why staff had not encouraged him to wear a mask outside of his room. If the doors had signage posted, and if there was a PPE cart, those residents were considered positive for COVID-19. PUI residents should also be considered COVID-19 positive and transmission based precautions should be followed until COVID-19 was ruled out. The DON and Infection Control Nurse I said gloves should be worn and changed along with handwashing between transmission based-precaution rooms. The DON voiced concerns regarding cross contamination between residents due to transmission-based precautions not being implemented along with the proper PPE being used. The DON and Infection Control Nurse I were asked how staff were made aware of the need to change PPE. The DON said if there was a PPE cart outside the room, they were to change PPE. The DON and Infection Control Nurse I were asked what type of education had been provided to staff regarding how to differentiate between COVID-19 positive residents and PUI residents. Neither the DON or Infection Control Nurse I were unable to voice when education had taken place and what the content of the education was. Infection Control Nurse I said she had not performed observations of staff donning and/or doffing PPE when leaving transmission-based precaution rooms. The DON and Infection Control Nurse I were unable to provide documentation pertaining to staff education relating to the identification of COVID-19 positive and PUI residents as well as the appropriate PPE for both residents and staff. The DON and Infection Control Nurse I said the facility followed CDC recommendations for removing COVID-19 residents from transmission-based precautions, which meant a resident had to be symptom free for 24 hours past the ten days. When RN I was asked what happened if a resident had a fever for the first few days, Infection Control Nurse I said, I'll have to look that up. The DON and Infection Control Nurse I said they had not been able to have dedicated staff (staff members who were scheduled only to work the COVID-19 unit) for the east end of the building. A review of the COVID-19 spread sheet on 11/30/21 revealed Residents #11 (B hall-room [ROOM NUMBER]) ,#12 (B hall room [ROOM NUMBER]),#16 (A hall-room [ROOM NUMBER]) #23(B hall- room [ROOM NUMBER]) , #46 (B hall-room [ROOM NUMBER]),#50 (B hall- room [ROOM NUMBER]), #52 ( B hall-room [ROOM NUMBER]), #17 (B hall-room [ROOM NUMBER]), #34 (B hall-room [ROOM NUMBER]) #30 (A hall- room [ROOM NUMBER]), and #32 (A hall-room [ROOM NUMBER]) were cleared of transmission based precautions on either 11/29/21 or 11/30/21. The DON and RN I were unable to specify which date the residents were considered COVID-19 positive, but reported they remained PUI due to their recent recovery. Residents #9 (A hall- room [ROOM NUMBER]), #21(A hall-room [ROOM NUMBER]), #42 (A hall-room [ROOM NUMBER]), #39 (A hall-room [ROOM NUMBER]), #60 (A hall- room [ROOM NUMBER]), #47 (A hall- room [ROOM NUMBER]), #59 A hall-room [ROOM NUMBER]) ,#26 ( A hall- room [ROOM NUMBER]), and #10 (D hall- room [ROOM NUMBER]) were all COVID-19 positive. An email dated 11/12/21 from Health Department Nurse (RN V) contained the following information, in part, Per CDC guidelines, you have to Identify Space in the facility that is being Dedicated to Monitor and Care for Residents with Confirmed [CONDITION(S)] [Severe Acute Respiratory Syndrome]-Cov-2 [COVID-19] infection. The location of the COVID-19 care unit should ideally be physically separated from other rooms or units housing residents without confirmed [CONDITION(S)]-CoV-2 infection. In which after discussion is located on B Hall and meets that guideline .Additionally we discussed identify HCP [Health Care Providers] who will be assigned to work only on the COVID-19 care unit when it is in use .HCP dedicated to the COVID-19 care unit (e.g. NA [Nursing Assistant] and nurses) should also be performing cleaning and disinfection of high- touch surfaces and shared equipment when in the room for resident care activities. An additional email dated 11/17/21 from RN V to the DON contained the following information, in part, Due to positive cases exceeding your capacity in your COVID-19 unit, what we discussed would be your best option. I recommend separating residents by 3 groups (as much as possible) 1. Positive residents 2. Negative residents who have known or suspected exposure 3. Negative residents with no known exposure. Best practice would be to have dedicated staff assigned to these 3 groups. Positive residents and Residents that have known/suspect exposure should be placed in quarantine and proper PPE should be utilized. Please review the CDC guidance linked below for additional guidance. A copy of the facility's Guidelines for Standard and Transmission-based Precautions with the most recent revision date of 11/9/20 revealed the following information, in part, Purpose: to provide a guideline for ensuring standard and transmission-based precautions are to be followed to prevent the spread of infections, in accordance with CDC requirements .standard precautions represent the infection prevention measures that apply to all resident car, regardless of suspected or confirmed infection status of the resident, in any setting where healthcare is being delivered .Standard precautions include hand hygiene, use of PPE (e.g. gloves, gowns, facemask) .Staff must perform hand hygiene (even if gloves are used): before and after contact with the resident, .after removing personal protective equipment . Droplet precautions Use droplet precautions as recommended . for residents known or suspected to be infected with pathogens transmitted by respiratory droplets . that are generated by a patient who is coughing, sneezing, or talking .Ensure that residents are physically separated (i.e. 6 feet apart) from each other Change protective attire and perform hand hygiene between contact with patients .Don a mask upon entry into the resident room .Limit transport and movement of patients outside of the room to medically necessary purposes. If transport or movement of patients in any healthcare setting is necessary, instruct resident to wear a mask . The facility's Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus 9 COVID-19) policy with the most recent revision date of 7/7/21 contained the following information, in part, Guideline it is the practice of the this facility to minimize exposures to respiratory pathogens and promptly identify residents with Clinical features and Epidemiological Risk for COVID-19 and to adhere to Feral and State/Local recommendations .Full PPE should be worn per CDC guidelines for the care of any resident with known or suspected COVID-19 .Anytime residents leave their room, they are expected to wear a facemask Prompt detection, triage and isolation of potentially infected residents .A resident with known or suspected COVID-19, immediate infection prevention and control measures will be put into place. For resident on droplet precautions, staff don gloves, gown, facemask, and eye protection .If widespread COVID-19 transmission occurs in the facility, healthcare personnel should wear full PPE for the care of all residents irrespective of COVID-19 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Patients and residents who must regularly leave the facility for care should wear face masks when outside of their rooms. Residents suspected of COVID-19 infection will be placed in quarantine for fourteen (14) days, transmission-based precautions, and monitored for signs and symptoms of COVID-19 .The following are additional measures that will be taken to identify the correct type of PPE: Post signs on the door or wall outside of the resident room to clearly describe the type of precaution needed and required PPE. Make PPE, including facemask, eye protection, gowns, and gloves available immediately outside resident room .Patients and residents who must regularly leave the facility for care/medical treatment .should wear face masks when outside of their rooms .monitoring and surveillance facility actions should be tracked by the IP/Designee. A summary of these actions should be included in the monthly infection control summary to the QAPI committee for review and further recommendations. In addition to monthly summary, the following activities should be considered daily by the IP/designee: review of residents presenting with acute onset of respiratory symptoms; this review includes symptoms and consultations with primary care provider as applicable. Review of any staff call-ins related to respiratory illness .record keeping of the above activities to include mapping the area in the facility where symptoms are being identified .random observations of hand hygiene by staff to ensure appropriate technique is used, random observation of staff donning and doffing appropriate PPE (standard, contact, and/or droplet). Random observation of environmental cleaning . Infection Control Program: A review of the most recent four months of monthly infection control documentation (August 2021- November 2021) did not contain the following elements of the infection surveillance program: process surveillance as evidenced by lack of observations which include but are not limited to observations of care, audits of handwashing, walk through's of laundry and kitchen. All of which identify potential infection control issues such as ineffective cleaning products or techniques, and incorrect infection control practices, and potential environmental concerns. outcome surveillance- tracking the data to identify any potential clusters or outbreaks monitoring- complete and thorough line listing data collection i.e. staff call ins data analysis- thorough analysis of data collected and use of data to correct potential infection control issues. During an interview with the DON, and Infection Control Nurse I on 11/30/21 at 8:57 a.m., Infection Control Nurse I said she was not aware of the need to do walk through's of the kitchen, laundry room, and resident care areas of the building to identify potential infection control concerns and areas that needed improvement. Infection Control Nurse I was not aware of the need to perform observations of care such as donning and doffing and handwashing. On 11/30/21 at 8:10 a.m., CNAs N and O were observed on the COVID positive unit setting up and passing meal trays with no gloves on. Both CNA's set up and delivered multiple trays to different rooms, gloveless. room [ROOM NUMBER] (Where Resident #39 resided at the time) had 3 personal protective gowns hanging on the back (inside) of the door. RN P was observed setting up medications without gloves and delivering them to a resident in room [ROOM NUMBER], then returning to the medication cart and setting up the next resident's medications without gloves on. No hand hygiene was observed for any of the 3 staff in the hall, once outside rooms. Both CNA N and O continued to set up and pass meal trays in other rooms with no gloves. All three staff went into and out of rooms with the same gowns, N 95 masks and face shields on. Resident #58, in room [ROOM NUMBER] was asked if she had COVID-19. The Resident was alert and oriented, and said she did not have COVID-19. But, she had pneumonia. The Resident stated frustration that staff did not tell her anything and she didn't understand why staff wore personal protective equipment (PPE). The Resident's room door had signs on the outside explaining PPE use and droplet precautions. The room did not have a purple paper with a + sign on it. The door was closed and there were 3 disposable PPE gowns on the inside of it. Observations made on 11/29/21 showed some room doors on the unit had droplet precautions signs on the doors and some did not. Some rooms had a purple paper with a + sign on the door and some did not. Some room doors were closed and some were not. On 11/29/21 at 2:04 p.m. Resident #32 was observed in their room in a wheelchair, unable to converse coherently. The Resident wore oxygen via nasal cannula, but the nose prongs were out of the nose and against the left cheek. A full lunch tray was at the Resident's side, untouched, but set up and cold. On 12/1/21 at 9:32 a.m., the Director of Nursing (DON) confirmed Resident #32 passed away that morning of COVID-19. Infection Control Monthly Data Collection: Review of the facility Infection Control monthly residents infections line listings dated 9/21, 10/21 and 11/21, revealed the data was incomplete regarding if residents infections met the facility criteria of an infection ([NAME] Infection Criteria used), the comment section of the listings was approximately 95% left blank, and no data was documented regarding residents who had returned from the hospital on antibiotics due to infections, if they were discontinued or continued by the facility physician. Infection Control Nurse I was not able to explain each residents infections when questioned by this surveyor. Review of the facility Infection Control Monthly Analyzing of infection data done on 12/6/21, revealed total infection rates and numbers, no analyzing of the monthly data was documented. During an interview done on 12/6/21 at 12:25 p.m., Infection Control Nurse, RN I stated I was doing the line listing and analyzing like the Infection control Nurse did before me. No one taught me how to do this job. I was sick and not doing the infection control line listing in November (11/21) Laundry Area: Observation was done 11/29/21 at 12:10 p.m., of the facility laundry area accompanied by Director of Housekeeping and Laundry H. The following observations of the facility Laundry area are as follows: -At 12:10 p.m., a partly drank orange drink in bottle was observed in the clean linen room were residents clean clothing was kept. During an interview done on 11/29/21 at 12:12 p.m., Director of Laundry H stated No food is supposed to be in here (in the clean laundry room). -At 12:13 p.m., paint was observed chipping off the ceiling in the clean laundry room, directly over the clean non-covered resident clothing. -At 12:13 p.m., a large box of dirty shoes and boots were observed in the residents clean laundry room; they were touching the clean resident clothing. During an interview done on 11/29/21 at 12:14 p.m., Director of Laundry H stated It (the box of shoes and boots) probably shouldn't be here. -At 12:18 p.m., two large washers (washer #1 and #2) were observed to have an excessive amount of white/light gray crusty build-up on the bottom of the washers doors. It was picking off when the doors was open and closed. This was build-up from water minerals due to water leakage from the washer doors. During an interview done on 11/29/21 at 12:18 p.m., Laundry Aide G was asked by this surveyor if Infection Control Nurse I did walk-through's in the laundry room and she stated I don't see anyone do a walk-through ' s. -At 12:20 p.m., in the short hallway between the facility washers and the laundry room entrance door was observed a large yellow barrel with standing water in it (no cover); it was approximately 1/2 full of water. Observation revealed the ceiling in the laundry room was leaking. During an interview done at 12:20 p.m., Director of Maintenance E, stated It's (the laundry room ceiling) been awhile like that; the coupler is leaking a little bit, for about a year. -At 12:24 p.m., the Administrator was brought to the facility laundry room to see the leak. During an interview done on 11/29/21 at 12:26 p.m., the facility Administrator stated I did not know about this (the ceiling leaking in the laundry room and standing water in the barrel). During an interview done on 12/6/21 at 10/10/21, Infection Control Nurse I stated No I am not doing laundry room walk-through's. Upon request, no policy was given to this surveyor regarding laundry room and kitchen walk-through's. Review of the facility Infection Control Job Description (un-dated), stated The Infection Preventist is responsible for the facility's Infection Prevention and Control Program. This includes over-site of all activities related to infection prevention, surveillance and control throughout their (facility name). Duties/responsibilities: Create a system of surveillance designed to identify possible communicable disease, infections and risk for outbreaks before they can spread to other persons in the facility. Ensure McGeer criteria is met for potential infections and treatment or consult with the physician regarding why the benefit outweighs the risk for treatment. Follow required Standard and Transmission based precautions to prevent spread of infections as well as when and how isolation should be used fro a resident. Assess the need for, develop, and present in-service education to appropriate team members to prevent infection through audit activities and education that include environmental, proper use of PPE. Assist with room assignments as necessary based on risk factors to decrease likelihood (of) a transmission. Conduct outbreak investigations. Required Skills/Abilities: Ability to analyze and collect data and prepare conclusive reports. Abatement Plan: The abatement plan dated 11/30/21 which was accepted on 12/2/21 at 9:01 a.m., contained the following information, in part, The following actions have been taken to ensure immediate correction of the items outlined during the annual survey that was initiated on November 29, 2021, with immediate jeopardy findings of F-880 called on November 30, 2021. Quarantine of Residents- Residents who have had a high-risk exposure have been isolated in place on East End, with guidance from the Health Department. Resident education- Residents who are in isolation related to being Covid positive, Covid recovered or in quarantine will be encouraged to remain in their room, redirected back to room and encouraged to wear a mask. Staff aware of Covid positive residents- The remaining Covid positive residents will be moved to a Covid unit that is clearly marked, behind closed doors. Staff PPE use- Staff working on the Covid positive unit will be immediately educated on the proper use of PPE when encountering Covid positive residents. 50 residents reside in the facility, all residents eligible for COVID-19 testing were tested on [DATE] with no additional positives. Residents are routinely monitored for signs and symptoms of COVID-19 Nursing staff have been educated on proper use of personal protective equipment, residents' activity on COVID-19 unit and encouraging residents to wear mask and remain in their rooms, identification of residents that are COVID-19 positive. On November 30, 2021, staff education was initiated competency evaluation for personal protective equipment. Prior to working their next scheduled shift, the remaining staff will be educated, and competency trained. The interdisciplinary team will be educated on proper cohorting of exposed residents that are negative, COVID-19 positive and non-exposed negative. QAPI team has reviewed the education and training plan for facility staff. This team will ensure that all staff are educated and competent prior to working with or caring for residents in transmission-based precautions. Policy and procedure were reviewed on November 30, 2021, and deemed appropriate. The medical director has reviewed and provided input in the formulation of this abatement plan. The DON and administrator will be responsible for daily audits and integrating the review through the QAPI process for monitoring of trends, patterns, and recommendations for continuation. The DON /designee will be responsible for monitoring the process weekly to ensure continued compliance. Completion date for all action items is 11/30/21.

Based on observation, interview, and record review the facility failed to prevent staff-to-resident verbal abuse for one resident (Resident #109) of four residents reviewed for abuse. This deficient practice resulted in Resident #109 being spoken to profanely and inappropriately by staff (Certified Nursing Aide E), causing mental anguish and fear, and the potential for other residents to be spoken to inappropriately and experience similar feelings. Findings include: Resident #109: A review of Resident #109's 'Face Sheet' with a print date of 3/3/21 revealed admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/12/21 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 13/15 indicating intact cognitive response. This MDS assessment revealed she required extensive assistance for transfers and toileting and was occasionally incontinent of bladder. On 3/2/21 at approximately 11:30 a.m., an interview was conducted with Resident #109 regarding the care she receives at the facility. Resident #109 stated that over the weekend she had an issue with a Certified Nurse Aide (CNA) E when she asked to be toileted. It was about 2 o'clock in the morning (2/28/21) and I turned my call light on to use the restroom. She (CNA E) came in and was very upset and asked me why I had to use the bathroom this early. I cannot control my bladder. She was upset and kicked something and started swearing (used the F___ word). I was very upset; I did not understand what I did wrong. We normally have a good relationship. She then left the room. When asked how this made Resident #109 feel, she stated, I am upset. I pay good money to be here and shouldn't be treated like this. I even tried to apologize to her, and she did not acknowledge it. I do not want her working with me if she is going to act this way. I don't deserve this. When asked if Resident #109 reported the incident to the facility, she stated that she had told two nurses and the administrator (NHA). During this interview it was noted that Resident #109 was visibly upset and had tears in her eyes while describing the incident on 02/28/21. On 3/2/21 at approximately 11:50 a.m., an interview with conducted with the NHA. When asked if the NHA had been made aware of a situation between Resident #109 and CNA E, the NHA confirmed that Resident #109 had spoken to her about what occurred on 02/28/21. The NHA stated they were investigating the incident but had not been in contact with CNA E at that time. The NHA believed that Resident #109 was upset with CNA E but did not state that she (Resident #109) felt abused. When asked if CNA E had been removed from the floor, the NHA stated, No. When asked what interventions were put in place for Resident #109, the NHA stated, We have instructed (CNA E) to not go into (Resident #109's) room at this time. On 3/2/21 at 1:52 p.m., a phone call was placed to CNA E with a return call message. CNA E did not return the telephone call by the survey exit. On 3/2/21 at 2:13 p.m., a phone interview was conducted with Registered Nurse (RN) F who worked with Resident #109 on the night of 02/28/21. When asked if RN F had been told there was an incident between Resident #109 and CNA E, RN F stated, When I went into (Resident #109's) room she told me that she did not know what her (CNA E's) problem is, but she is mad at me. When asked what interventions RN F had put in place to ensure appropriate safety for Resident #109, RN F stated that she told CNA E to not go into (Resident #109's) room for the rest of her shift. On 03/03/21 at 11:35 a.m., a follow up interview was conducted with Resident #109. When asked if she still had concerns with the care at the facility, Resident #109 became visibly upset again. She stated, She came back into my room last night to take care of my roommate. There was three of them (staff) in here. I do not understand, I am at the point of crying right now. Why was there three of them in here? My roommate and I only require two people to help us out. There was no need for her to be in here. I do not want her to be in my room, I get nervous now when I see her. I either want a room change or I want her to stop coming in here. I can't take this anymore. She was so loud. A review of Resident #109's 'Progress Note', dated 3/3/21 at 7:16 a.m. and written by RN F, read, .Later in shift the CNA (E) was helping residents' roommate while 2 other CNA's were with this resident and she complained that the CNA she was upset with, was too loud and disruptive. There was no interaction with the CNA (E) and this resident. During an interview on 3/3/21 at 3:00 p.m. the NHA could not confirm why CNA E entered into Resident #109's room when CNA E was instructed not to do so. A review of the facility's Abuse Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, dated 11/28/17, read, .an owner, licensee, Administrator, Licensed Nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident .Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .

Based on interview and record review, the facility failed to collect/perform a urinary analysis and prevent a recurrent urinary tract infection [MEDICAL CONDITION] for one resident (Resident #106) and prevent a recurrent urinary tract infection for one resident (Resident #105), resulting in increased infections, antibiotic medications and hospitalization . Findings include: Record review of facility 'Infection Prevention and Control Guidelines', dated 11/2017, revealed that the guideline is to provide comprehensive infection control guidelines that establish a facility-wide system for the prevention, identification, investigation and control of infections or residents .definition of infection: the establishment of an infective agent in or on a suitable host, producing clinical signs and symptoms(e.g., fever, redness, heat, purulent exudates, etc.). Record review of facility 'Guideline for Antibiotic Stewardship', dated 10/2019, revealed the purpose of the antibiotic stewardship program was to take actions that will improve antibiotic use in order to reduce adverse events, prevent emergence of resistance, while leading to better outcomes for the residents . When a culture and sensitivity (C&S) is ordered: lab results will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. An antibiotic time out will be performed by the infection preventionist. This time out will be a reassessment of the ongoing need for and choice of an antibiotic and should be completed within 72 hours of initiation of antibiotics. This time out should include the following: Confirming a bacterial infection that will respond to antibiotics, confirmation that most appropriate antibiotic, dose, and route of administration has been ordered Record review of facility Infection Control line listing log for September 2020 revealed 9 urinary tract infections. Resident #106 was noted on 9/21/20 to have a urinary tract infection and was started on Keflex. No organism was listed. Resident #106: Record review of Resident #106 facility census stay record revealed that on 6/24/20 the resident was living in the facility and was not discharged from the facility until 9/24/2020 to the hospital. Record review of 8/8/20 at 5:01 PM progress note revealed: Foley (catheter) leaking around urethral opening. Removed and new Foley catheter inserted. 18 French with 20 cc balloon. Draining yellow urine with sediment. Record review of Progress note dated 8/9/20 at 9:24 AM revealed: Urine is light yellow with a lot of sediment. Record review of progress note dated 8/12/20 at 3:47 PM noted yellow urine with sediment. Record review of Resident #106's progress note, dated 8/20/20 at 6:28 PM, revealed: Resident on Leave of Absence (LOA) for urology appointment. Physician examined this resident, new orders given to night nurse. Record review of Resident #106's Urology progress notes located within the electronic medical record revealed that on 8/20/20 the urologist wrote: To remove Foley catheter and if less than 400 cc or uncomfortable replace Foley and notify urologist. Check U/A (Urinalysis) post void. Record review of Resident #106's progress note, dated 8/21/20 at 5:58 AM, revealed new orders received from urologist for Foley catheter removal. The Foley catheter was removed, and the nurse noted to monitor Post Void Residual (PVR). Record review of Resident #106's progress note, dated 8/21/20 at 4:16 PM, noted that the Foley catheter was reinserted. There was no documented urinalysis collection noted. Record review of Resident #106's uploaded medical results labs revealed that there were no urinalysis results noted for the month of August 2020 September 2020. Record review of Resident #106's progress noted dated 8/28/20 at 15:14 PM (7 days after catheter was reinserted) writer noted notifying the urologist office about the reinsertion of Foley catheter. Record review of Resident #106's progress not dated 9/6/20 at 8:47 AM noted that the Foley (catheter) was patient with dark amber urine and moderate amount of whitish sediment. Record review of Resident #106's quarterly nursing evaluation note, dated 9/10/20 at 3:12 PM, noted a Foley catheter for urine retention, that the resident did not do (perform) his own catheter care and there was no signs or symptoms of infection. Record review of Resident #106's progress note, dated 9/20/20 at 10:31 AM, noted Foley catheter note draining properly, urine is a dark cream color, complained of bladder discomfort, bladder slightly distended. Foley was removed and with small amount of bright red blood discharged along with one clot about 1 inch long and 1/8 inch in diameter. On 9/21/20 at 3:00 PM Resident #106 was seen by the physician and started on Keflex 500 mg oral three times a day for 5 days. Urinalysis is pending. Facility acquired urinary tract infection. On 9/24/20 at 3:00 PM progress noted poor appetites did not eat breakfast or lunch and Family member request emergency room (ER) transfer and evaluation. Record review of Resident #106's Hospital record, dated 10/19/20, noted resident presented to the ER with confusion, weakness, found to have pseudomonas urinary tract infection. Urologist did a stent placement and resident was noted to have [MEDICAL CONDITION] also. Resident #105: Record review of Resident #105's electronic record for census days of stays revealed that the resident was admitted to the facility 1/1/2020 and had not been discharged or readmitted . Record review of the facility infection control line listing for the month of October 2020 noted that on 10/6/20 Resident #103 was noted to have odor and mucus in urine and some confusion and was start [MEDICATION NAME] (Keflex) antibiotic. No organism was documented on the log. Facility acquired urinary tract infection. Record review of Resident #105's urinalysis lab results for culture and sensitivity noted the organism of proteus mirabilis. Further review of the UA culture results did not note Keflex as an antibiotic of choice. Record review of the facility infection control line listing for the month of October 2020 noted that on 10/13/20 Resident #105 was noted to have confusion and was start [MEDICATION NAME] (Keflex) antibiotic. No organism was documented on the log only the note of 'not supported'. Record review of Resident #105's urinalysis lab results for culture and sensitivity noted the organism of gram-negative Bacilli isolated. Further review of the UA culture results did not note Keflex as an antibiotic of choice. An interview and record review on 10/20/20 at 9:51 AM with the Infection Preventionist/Registered Nurse A reviewed the September 2020 and October 2020 infection control line listing. Review of lines revealed Urinary tract infection were increasing. September 2020 had 9 urinary tract infections facility acquired. RN A stated it is Men and Women both. We had 9 UTI's in September. Mostly LTC residents. Yes Resident #106 was an in- house-acquired (infection). Resident #105 also had a facility-acquired infection, Yes both have catheters for [MEDICAL CONDITION].

Based on observation, interview and record review, the facility failed to supervise and prevent accident hazards and implement safety devices for 2 residents (#6, #56) of 20 residents reviewed for safety devices, resulting in Resident #6 sustaining a fall with a subdural hematoma (Head injury) and the potential for Resident #56 to have an injury from being pushed forward with no foot pedals (safety device) in place during transport. Findings include: Record review of facility 'Fall Evaluation Safety Guideline', effective date 11/28/2017, revealed that the intent of this guideline is the ensure this facility provides an environment that is free from hazards over which the facility has control and provide appropriate supervision to each resident as identified through the following process: Falls related to multiple falls- Trend falls for the resident; time of day, reason for fall, location of fall, etc . Keep resident in view during high risk times (supervision). Falls Prevention- Rounding, applied appropriate supervision, footwear, strength and balance, sleep evaluation is recommended. Involve interdisciplinary team: need for supervision, development and implementation of interventions to reduce accidents, Monitoring and evaluation for effectiveness/modification of approaches. Record review of the facility 'Falls and Fall Risk' Clinical Practice Guideline American Medical Directors Association, 2011 update, step 9: Monitor falling in patients with fall risk or fall history. Resident #6: Observation on 12/10/18 at approximately 10:30 AM of Resident #6's room revealed there to be a soft-shell tan helmet with ear loops and a black two snap chin strap laying on the bedside night stand. Record review of Resident #6's Minimum Data Set (MDS), dated [DATE], revealed a [AGE] year-old female with severe cognitive impairment with disorganized thinking. Behavioral assessment revealed physical, verbal and other behavioral symptoms toward others with rejection of care and wandering behavior that occurred every 4 to 6 days, but less than daily. Functional status assessments noted 'Walk in Room' (how resident walks between locations in his/her room) coded as (1) Supervision- oversight, encouragement or cueing with (2) one-person physical assist. Functional status assessment 'Walk in Corridor- (how resident walks in corridor on unit) coded as (3) extensive assistance- resident involved in activity, staff provide weight-bearing support) with (2) one-person physical assist. Active [DIAGNOSES REDACTED]. Falls since admission (8/ 17/2018) noted there were 3 falls. One fall with no injury and 2 falls with injury. Observation on 12/10/18 at approximately 10:40 AM, revealed Resident #6 was wandering on the East Wing hallway by herself, with a sad look on her face and she appeared to be ambulating aimlessly. Record review of Resident #6's admission history and physical note, dated 9/12/18, by the physician noted poor judgement with confusion. Plan was to continue hospice P[NAME] (Plan of Care). Record review of resident #6's accident/incident report, dated 11/16/18 at 11:00 AM, revealed the resident was observed standing at the treatment cart, lost her balance and fell , sustaining a cut to the right eye brow. Management review on the last page of the incident report noted physician did review medications again post 11/16/18's fall and made further adjustments. Resident continues to be up and about ad lib ambulating with a slow, unsteady gait. Record review of Resident #6's accident/incident report, dated 11/22/18 at 4:45 AM, revealed the resident was alone in her room when a Certified Nurse Assistant (CNA) heard a sound like a fall. Upon the CNA's arrival to room resident was noted getting up from the floor with bleeding from the back of the head. No other residents or staff were with Resident #6 when the CNA arrived at the room. The incident report noted footwear of regular socks (not gripper socks) and attempting to get out of bed unattended. Residents history of condition included Alzheimer's and falls. Possible causative factors identified gait instability. Management review on the last page of the incident report noted the root cause was determined to be from cognitive deficits associated with disease processes. Resident #6 was noted to be observed by staff lying on the floor of her room beside her bed with a small laceration on the back of her head. Resident #6 was noted to have on regular socks which could have been a contributing factor Continue close monitoring. Record review on 12/10/18 of Resident #6's 'Fall' care plan interventions, dated 8/28/2018, noted to ensure that Resident #6 is wearing appropriate footwear when ambulating. Record review of Resident #6's 'Fall' care plan revealed that there were care plan interventions implemented on 11/12/2018, of pull tab alarm to bedroom door that alarms when the Resident #6 closes the door. Intervention added on 11/19/18 for physician to review medications. There was no intervention added for the fall on 11/22/18. Record review of Resident #6's accident/incident report, dated 11/23/18 at 11:15 AM, revealed Resident #6 was ambulating in the hallway with spouse when her knees buckled and she had a fall to her knees. Possible causative factors included gait instability and medications greater than five. Management review on the last page of the incident report noted the root cause was determined to be from weakness/progressive decline related to disease process. Resident frequently closes her eyes when walking Continue to monitor. Record review of Resident #6's 'Fall' care plan revealed there were care plan interventions implemented on 11/12/2018, of pull tab alarm to bedroom door that alarms when the Resident #6 closes the door. Intervention added on 11/19/18, for physician to review medications. There was no intervention added for the fall on 11/23/18. Record review of Resident #6's accident/incident report, dated 11/26/18 at 00:18 AM, revealed Resident #6 was observed standing by the doorway of the room next to hers. Resident #6 moved toward the handrail as nurse (facility did not identified nurse) ran to assist her. Resident #6 was noted to bounce off the handrail and fell sideways-very stiff in posture. Resident #6 was noted to strike her right shoulder on the floor but did not hit her head. Activity at time of event was noted as wandering aimlessly, with current medications of anti-depressants, anti-psychotics, anti-anxiety and anti-hypertensive's. Possible causative factors were noted as gait instability, wandering, and confusion. Management review on the last page of the incident report noted the root cause was determined to be from cognitive declines associated with disease process. Resident lost balance and fell sideways and landed on right shoulder before staff could reach her to prevent (fall) Hospice was in and discussed different interventions with spouse. Spouse agreed to try hipsters and a helmet if it does not cause the resident distress. Hospice ordered a helmet and hipsters assigned on a trial basis to see how resident responded; continue to monitor closely. Record review of Resident #6's 'Fall' care plan revealed there were care plan interventions implemented on 11/12/2018, of pull tab alarm to bedroom door that alarms when the Resident #6 closes the door. Intervention added on 11/19/18 for physician to review medications. There was no intervention added for the fall on 11/26/18. Record review of Resident #6's accident/incident report, dated 11/27/18 at 09:30 AM, revealed the staff heard a loud noise and saw laundry barrel moving and Resident #6 face first on the floor behind barrel. Activity at time of event was noted as wandering aimlessly. Resident's history of condition included Alzheimer's and falls. Management review on the last page of the incident report noted the root cause was determined to be from loss of balance. Resident was observed by staff lying on the floor with the laundry barrel moving away from resident. Resident either leaned on barrel or lost balance or tripped. Medications were recently adjusted, and pain patch was initiated on 11/28/18, and Hospice staff spent most of the day walking with resident in the building. Record review of Resident #6's 'Fall' care plan revealed there were care plan interventions implemented on 11/12/2018, of pull tab alarm to bedroom door that alarms when the Resident #6 closes the door. Intervention added on 11/19/18 for physician to review medications. There was no intervention added for the fall on 11/27/18. Record review of Resident #6's accident/incident report, dated 12/12/18 at 03:35 AM, revealed the staff were sitting at the nurse's station and heard a thump sound. Staff came around the nurse's station and observed Resident #6 in hallway in front of her room on her knees and head. Resident then began to have a grand-mal type [MEDICAL CONDITION] approximately 30 seconds. Small amount of blood in residents mouth and unable to determine exact site. Hematoma noted to left side of forehead approximately diameter of a quarter and significantly raised. Resident unresponsive to verbal stimuli. The staff member began checking pupil's response which initially was sluggish and then over a few seconds began to quicken to a normal response. Resident #6's breathing was quick and blowing through lips. Left residents side briefly to get assistance and certified nursing assistant acquired vital signs. Blood pressure initially noted as very high, then rechecked and was in normal range. No other resident was near this resident at time of fall. No objects in place for resident to trip on. This (nurse) called 911 for emergency assistance Resident remained unresponsive but eyes open with respirations even and unlabored. The incident report noted that Resident #6 was assisted back to bed at 3:00 AM, and that the resident was in and out of bed several times during the night. Footwear at the time of the event was regular socks (not gripper socks). Activity at the time of the event was wandering aimlessly. Injury noted as major injury of hematoma to left side of forehead approximately the size of a quarter and raised 4-5 millimeters, unable to measure due to emergency situation. Record review on 12/12/18 of Resident #6's 'Fall' care plan interventions, dated 8/28/2018, noted to ensure that Resident #6 is wearing appropriate footwear when ambulating. Apply helmet if unsteadiness noted with balances and gait and if helmet is not causing her distress. Helmet in room, dated 12/6/18. In an interview on 12/12/18 at 8:00 AM the State surveyor was notified by the Director of Nursing (DON) B, that Resident #6 sustained a fall this AM at 3:30 AM with a subdural hematoma with bleed sent out to local hospital and then on to the major hospital due to brain bleed. The Director of Nursing stated that the helmet was not used. An interview on 12/12/18 at 8:56 AM with Licensed Practical Nurse (LPN) K Restorative nurse, revealed that a couple of weeks prior Resident #6 had a balance issue and was having some falls. LPN K stated that the facility did some medication adjustments and hospice put the resident on a pain patch and recommended a helmet. LPN K stated that the spouse was OK with the helmet, so hospice brought in the helmet. LPN K stated that she took the helmet to the resident's room and tried it on. LPN K stated that the spouse did not feel that it was necessary at that time. An interview on 12/12/18 at 9:33 AM, via phone with Licensed Practical Nurse (LPN) W, revealed: It happened at 3:30 AM in the hallway outside of her room. LPN W stated that the fall was witnessed by another resident who has dementia and was seated in the hall across from the nursing station and that it really didn't count as a witness. LPN W stated that she was seated behind the nursing station with her head down working on the computer when she heard a loud thump noise. LPN W stated that she looked up at the other resident seated across from the nursing station and noticed that resident was looking down the hall. LPN W stated that she got up walked around the desk and looked down the hall and saw Resident #6 on the floor with her head and knees with her face on the floor with her arms down by her side with her bottom up in the air. LPN W went to Resident #6 and saw a small amount of blood coming from Resident #6's mouth with a quarter size goose egg to the left side of forehead under her bangs that was raised up estimated 5 millimeters that was white/pink. Resident #6 did not say anything. LPN W stated that she walked up to Resident #6 and had her hands on the resident checking her over when Resident #6 started to have a [MEDICAL CONDITION]. LPN W stated that she did not believe Resident #6's was seizing prior or before that moment (prior to her fall). LPN W got up walked to the nurse's station to call for help and went back to the resident on the floor. LPN W stated at that time she rolled Resident #6 over and checked her pupil response which were sluggish and that it took a few minutes for the pupils to quicken up and be equal. LPN W stated that the [MEDICAL CONDITION] last 30 seconds. LPN W stated that the Certified Nurse Assistant (CNA) got vital signs (blood pressure) and the first one was a false read of 240/180 and that a re-check was done one minute later of 120/70 which was normal. LPN W stated that Resident #6's breathing became puffed/puckered lip breathing with spitting, and that the Resident #6 did not respond to staff. LPN W stated that Resident #6 had gotten up at 1:00 AM and wandered out to hallway and the CNA on the short hall took the resident back to bed immediately. At 3:00 AM Resident #6 had gotten back up and out into the hallway and was put back to bed. At 3:30 AM Resident #6 got back up again and fell . An interview on 12/12/18 at 10:50 AM with the Director of Nursing (DON), revealed that hospice services recommended the helmet for Resident #6. DON stated, that Resident #6 was very unsteady and that the facility adjusted the pain medications. The DON was asked what is appropriate footwear while ambulating. The DON responded grippy socks or shoes and reviewed where the accident/incident reports noted regular socks when the Resident #6 sustained falls. The DON was asked about post fall trending since most of Resident #6's falls seem to occur during the early morning shift between 2:00 AM and 12:00 PM. She was not able to answer. During an interview on 12/12/18 at 11:04 AM, via phone with the hospice services Registered Nurse (RN) GG revealed hospice fall precautions were hipsters (Padded hip pants) and soft-shell helmet. RN GG stated that she spoke to the spouse and the restorative aide and the spouse thought the resident would leave the helmet on better than the hipster pants. RN GG stated that the helmet arrived last week and that the facility was to do a trial period to see if the resident would leave the helmet on. Observation on 12/12/18 at 11:50 AM, of Resident #6's room, revealed the tan soft shelled helmet was in the same place with ear loops and a black two snap chin strap laying on the bedside night stand and white slip-on sneaker style shoes under the bed. An interview on 12/12/18 at 12:42 PM, with Restorative Licensed Practical Nurse (LPN) K revealed when asked about the helmet again, that the helmet came in a week ago and that it was tried on, but that the spouse said it was not necessary to use and that she told the spouse the facility would keep the helmet in the resident's room. Restorative Licensed Practical Nurse (LPN) K was asked if there was a trial period attempted or documented and LPN K stated that 'Not that I'm aware of, we didn't do a trial period. We left the helmet on the bedside table and put it on the care plan. LPN K stated that she had spoken to the hospice nurse and that the hospice ordered the helmet and brought it to the facility. In an interview on 12/12/18 at 1:25 PM, Physician EE revealed that Resident #6 was very high risk (for falls) with [DIAGNOSES REDACTED]. Physician EE stated dementia residents have no sense of day or night and that there usually is not enough staff on night shift to increase supervision. The survey team discussed with the physician activities for the dementia residents at night to include, a fidget blanket, memory/busy box, walking with resident, and bringing resident to the nursing station to keep an eye on the resident. Resident #56: Review of the Face Sheet, Minimum Data Set (MDS, assessment tool) dated 11/18, social service and nurses progress notes dated 11/9/18 through 12/10/18, revealed Resident #56 was [AGE] years old, recently currently admitted to the facility on [DATE], confused with a BIMS of 3 (cognitive assessment, 3 indicates decreased cognitive ability) and not able to make independent healthcare decisions, received oxygen therapy and was dependent on staff assistance for Activities of Daily Living (ADL's). The resident was unable to be interviewed due to decreased cognition. The resident's [DIAGNOSES REDACTED]. Review of the facility OT (Occupational Therapy) Evaluation & Plan of Treatment, dated 12/7/18, revealed the resident required glasses 24 hr., was oxygen dependent, had cognitive deficits and impaired safety awareness. Observation was made on 12/10/18 at 10:05 a.m., of the resident alone in her room sitting in her wheelchair watching TV. The resident did not have foot pedals on her wheelchair at the time of the observation; her foot pedals were observed sitting on the floor on the right side of her bed, next to the bedside table. Observation was made on 12/11/18 at 8:20 a.m., of the resident alone in her room sitting in her wheelchair watching TV. The resident did not have foot pedals on her wheelchair at the time of the observation; her foot pedals were observed on the floor on the right side of her bed, next to the bedside table. Observation was made on 12/11/18 at 9:20 a.m., of the resident sitting in her wheelchair in the facility therapy room. The resident did not have foot pedals on her wheelchair at the time. Observation was made on 12/11/18 at 9:23 a.m., of the resident's room revealed again her wheelchair foot pedals were sitting on the floor on the right side of her bed, next to the bedside table; the resident was in therapy at the time of this observation. During an interview done on 12/11/18 at 9:30 a.m., OT #1 N revealed she had pushed the resident from her room to the therapy room just prior to this surveyor's observation done on 12/11/18 at 9:20 a.m. and stated, I pushed her (the resident) down, I did not put her wheelchair pedals on. Review of the resident's facility Limited Physical Mobility care plan dated 11/8/18, stated Uses Wheelchair (ensure foot pedals are in place). This surveyor requested several times during the survey (exit: 12/12/18) the facility Foot Pedal policy of the Director of Nursing, with no policy given.

Based on interview and record review the facility failed to ensure treatment and care was provided in accordance with professional standards of practice by not performing a resident enema according to standard of practice and procedure, in one resident (Resident #50) of three residents reviewed for bowel care procedures. This deficient practice resulted in the need for surgical consult and treatment of [REDACTED]. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #50 was determined to be able to make himself understood, could understand what was being said to him, and scored 15/15 on the Brief Interview for Mental Status (BIMS) examination; indicative of intact memory, orientation, and recall. A complaint was called in to the state agency by Resident #50's friend/guardian (I). Guardian I was contacted by this Surveyor on 8/13/18 at 9:24 a.m. She reported Resident #50 had lacerations near his rectum after a nurse performed an enema on him on 8/5/18. She stated: (Resident #50) called me and told me that he awakened to this enema being done .he was bleeding. Guardian I indicated that the Director of Nursing (DON) had also contacted her to inform her of the lacerations and said she (DON) didn't know how they occurred. A review of the facility incident summary showed Resident #50 received a soap suds enema on 8/4/18 by Registered Nurse D (RN) and the facility investigation found the following: (RND) stated that she met some resistance when she attempted to insert the enema .She (RN D) was attempting to hold his buttocks together so he would retain the fluid and did not notice any injury to the rectum. The facility Conclusion revealed: Resident vacillated between awareness of procedure, stating he was educated and then stating he couldn't remember. (Resident #50 ) received pain medication prior to incident, likely impairing awareness of incident. Education and competency evaluations on enema administration with nursing (staff) completed. Injury related to improper nursing technique was noted . An interview was conducted with Resident #50 on 8/13/18 at 2:00 p.m. He stated: All I know is I was sleeping and I felt something with my back-side. I didn't know what was happening. I was screaming - it really hurt. She (RN D) kept going on and on .I yelled a lot at her and she said, 'just a little more.' It hurt .it hurt so bad. I was sound asleep. It doesn't seem right. I had to go today to see if they could fix it. They knocked me out and fixed it. It's like a lagering (sic) pain .I came in here to get better and now I have to go through this pain. It's hurt every day since (the incident). Progress notes were reviewed and a note dated 8/6/18 Skin and Wound Note revealed: Lacerations (to buttocks) measured this day. Inferior laceration measures: 0.9 X 2.3 X 3.1 cm (centimeters); superior (left) laceration measures: 1.9 X 0.6 X 0.9 cm; superior (right) laceration measures 2.3 X 1.1 X 1.2 cm. During an interview with Registered Nurse (RN) D on 8/14/18 at 10:09 a.m., she indicated, When I inserted the enema I did feel some resistance .did a rectal exam .Second time it didn't go in, then 3/4 of the way through he yelled 'stop.' I told him it was almost done. He was uncomfortable .he's non-compliant with laying down .I thought it was anxiety. RN D expressed remorse for not following enema procedure and causing Resident #50 any discomfort. An interview was conducted with Certified Nurse Aide (CNA) E on 8/14/18 at 10:32 a.m. CNA E reported: (RN D) woke him (Resident #50) .repositioned him. She inserted (enema) and stopped for a second .she reinserted it. He was yelling out, saying, 'no', saying 'stop' .I felt really uncomfortable because I don't like seeing that kind of thing (resident yelling out). CNA G came in to close the door because he was yelling. CNA G was interviewed on 8/14/18 at 10:45 a.m. and reported: We were all at the desk and all of a sudden I heard him screaming bloody murder. He belted out a long scream and then stopped .it happened again (screaming). Later we (CNA H & CNA G) went in there to change him and that's when we found blood. It (wounds) was splitting and bleeding. We went to report. An interview was conducted with CNA H on 8/14/18 at 10:55 a.m. CNA H reported: I was at the nurse station and I heard yelling, painful yelling .After breakfast we went in to help him .when we turned him it was a gruesome site. I was upset. Mostly because I had to tell him. He's worried, he's very worried. He didn't have a bowel movement until the next day. Resident #50 was seen at the wound care clinic on 8/8/18. The progress note from that visit read, in part: The patient has complaints of a new injury. The patient reports that on the night of (MONTH) 5th he was awoken in pain with a nurse trying to perform a soap suds enema. The patient reports he complained of pain to the anal area. The patient has continued to have pain. I think that the patient's wound is consistent with the traumatic history given. It is not likely the wound is pressure injury .The patient has a new full-thickness traumatic injury at the three o'clock positioning in relation to the anus .the wound is extremely painful to the patient .I discussed .with my supervising physician .best served by an exploration under gener al anesthesia. She thinks there might be a chance that the wound could be .repaired. On 8/14/18 at 2:40 p.m., an interview was conducted with the DON. She confirmed the lack of proper technique used on Resident #50 during his enema and reported beginning immediate education for all nursing staff.

BASED ON OBSERVATIONS, INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT AN ELOPEMENT WHEN ONE (#104) OF NINE SAMPLED RESIDENTS KNOWN AT RISK FOR ELOPEMENT, WAS FOUND APPROXIMATELY 0.1 TO 0.2 OF A MILE FROM THE FACILITY BY A HOMEOWNER, AND EXPERIENCED A BIMALLEOLAR FRACTURE (BROKEN ANKLE) AND DISLOCATION OF HER RIGHT ANKLE, RESULTING IN IMMEDIATE JEOPARDY TO THE HEALTH AND SAFETY FOR RESIDENT #104. THE IMMEDIATE JEOPARDY BEGAN ON 9/3/2011 AT APPROXIMATELY 12:30 A.M. WHEN THE FACILITY WAS NOTIFIED BY A HOMEOWNER, WHOSE RESIDENCE WAS REPORTED AS 200 YARDS FROM THE FACILITY, THAT RESIDENT #104 WAS FOUND IN THEIR FRONT YARD. UPON FACILITY STAFF ARRIVAL TO THE SCENE, RESIDENT #104 WAS NOTED TO BE SITTING ON THE GROUND WITH HER RIGHT FOOT EXTENDED AND GUARDED. RESIDENT #104 WAS REPORTED TO HAVE SUSTAINED INJURY TO HER RIGHT LOWER EXTREMITY AFTER "STEPPING INTO A HOLE." EVALUATION AT A LOCAL HOSPITAL CONFIRMED RESIDENT #104 HAD EXPERIENCED A BIMALLEOLAR FRACTURE AND DISLOCATION OF HER RIGHT ANKLE. THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 9/8/11 AT 4:30 P.M. THE IMMEDIATE JEOPARDY WAS REMOVED ON 9/9/11 WHEN THE SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING: 1. 9/3/2011 AT 12:30 A.M., TWO EXIT DOORS ON THE LOCKED/SECURED DEMENTIA UNIT AND 15 OTHER EXTERNAL DOORS FACILITY WIDE, WERE INSPECTED TO ENSURE ALL ALARMS WERE IN PROPER WORKING ORDER. 2. 9/3/2011 AT 12:35 A.M., RESIDENT #104 WAS IMMEDIATELY PLACED 1:1 WITH A FACILITY STAFF MEMBER UNTIL TRANSPORTED TO A LOCAL hospital on [DATE] FOR EVALUATION, AND ALSO REMAINED ON 1:1 WITH A FACILITY STAFF MEMBER ON RETURN to the facility on [DATE]. 3. A MOTION SENSOR ALARM WAS PLACED OVER RESIDENT #104'S BEDROOM WINDOW ON 9/3/2011 AT 6:00 A.M. 4. ON 9/3/2011 AT 6:00 A.M., RESIDENT #104'S WINDOW WAS SECURED WITH A CHAIN TO LIMIT ITS OPENING TO 4 INCHES. 5. 15 MINUTE CHECKS CONTINUE TO PRESENT ON RESIDENT #104. 6. BED AND WHEELCHAIR SENSOR ALARMS WERE IMPLEMENTED FOR RESIDENT #104 ON 9/3/2011 AT 8:00 A.M. 7. A MOTION SENSING ALARM DEVICE WAS PLACED NEXT TO RESIDENT #104'S BED ON 9/3/2011 AT 8:00 A.M. 8. THE BLUE CHAIR BELIEVED TO PROVIDE ACCESS TO THE WINDOW BY RESIDENT #104 WAS REMOVED FROM HER ROOM AT 1:00 A.M. ON 9/3/2011. 9. ON 9/3/2011 AT 6:00 A.M., WANDER RISK ASSESSMENTS WERE CONDUCTED ON 94 OF 94 RESIDENTS RESIDING AT THE FACILITY, INCLUDING RESIDENT #104. ALL RESIDENTS IDENTIFIED AT RISK FOR WANDERING, INCLUDING 21 OF 21 DEMENTIA UNIT RESIDENTS, AND 5 ADDITIONAL RESIDENTS WHO DID NOT RESIDE ON THE SECURE DEMENTIA UNIT, HAD CHAINS PLACED ON BEDROOM WINDOWS TO REDUCE THE OPENINGS TO APPROXIMATELY 4 INCHES. 10. MANDATORY INSERVICE EDUCATION FOR ALL FACILITY STAFF BEGAN ON 9/3/2011 WITH 115 OF 126 EMPLOYEES. THE 11 REMAINING STAFF MEMBERS NOT INSERVICED AS OF 9/9/2011 WERE SENT NOTIFICATION OF NEED TO COMPLETE THE INSERVICE UPON REPORTING FOR DUTY ON THEIR NEXT SCHEDULED DAY, AND WILL NOT BE ALLOWED TO WORK UNTIL THE EDUCATION IS COMPLETED. 11. ON 9/3/2011, A WANDERING RISK ASSESSMENT POLICY WAS DEVELOPED AND IMPLEMENTED WHICH ASSISTS STAFF WITH IDENTIFYING RESIDENTS AT RISK FOR WANDERING. IT INCLUDED INTERVENTIONS TO PREVENT POTENTIAL ELOPEMENT, INCLUDING USE OF WANDERGARD DEVICES, AND WINDOWS SECURED WITH CHAINS TO REDUCE SIZE OF OPENINGS. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 9/9/2011, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND CONTINUES AT THE LEVEL OF ISOLATED ACTUAL HARM, PENDING THE FACILITY'S ABILITY TO: 1. COMPLETE THE MANDATORY STAFF INSERVICING/TRAINING REGARDING ELOPEMENT RISK ASSESSMENT AND ASSOCIATED POLICY/PROCEDURE. 2. DEMONSTRATE THEIR ABILITY TO PREVENT RESIDENTS WHO ARE AT RISK FOR ELOPEMENT FROM EXITING THE FACILITY WITHOUT ADEQUATE SUPERVISION. 3. VERIFICATION BY THE STATE AGENCY FINDINGS INCLUDE: THE FACESHEET REVEALED RESIDENT #104 WAS AN [AGE] year OLD WOMAN admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE ADMISSION assessment dated [DATE], DOCUMENTED RESIDENT #104 WEIGHED APPROXIMATELY 86 POUNDS AND WAS 5 FEET TALL. THE MINIMUM DATA SETS ((MDS) dated [DATE], REVEALED RESIDENT #104 WAS SEVERELY COGNITIVELY IMPAIRED, EXPERIENCED BOTH LONG AND SHORT TERM MEMORY LOSS, REQUIRED SUPERVISION WHILE AMBULATING, AND HAD WANDERING BEHAVIORS THAT "PLACED HER AT SIGNIFICANT RISK OF GETTING TO A POTENTIALLY DANGEROUS PLACE, INCLUDING OUTSIDE OF THE FACILITY." ACCORDING TO THE CARE AREA ASSESSMENT (CAA) SUMMARY, SUBTITLE ADL (ACTIVITIES OF DAILY LIVING) FUNCTION, DATED 8/24/2011, RESIDENT #104 WAS "admitted HERE TO THE DEMENTIA UNIT FOR THE 24 HOUR STRUCTURED SETTING AND CLOSE SUPERVISION. SHE IS AN ELOPEMENT RISK AND HAS WANDERING TENDENCIES. SHE IS ABLE TO AMBULATE AD LIB WITHOUT ANY ASSISTIVE DEVICES. STAFF MONITOR HER WHEREABOUTS CLOSELY." THE CAA SUMMARY, SUBTITLE BEHAVIORAL SYMPTOMS, DATED 8/24/2011, INDICATED THE "RESIDENT'S SPOUSE REPORTS SHE HAD WANDERED AWAY FROM THEIR HOME NUMEROUS TIMES, AND LAST TIME THE POLICE WERE CALLED WHEN SHE COULD NOT BE IMMEDIATELY LOCATED. IT WAS THIS EVENT WHICH TRIGGERED THE FAMILY TO SEEK LONG TERM CARE PLACEMENT SO THAT 24 HOUR MONITORING COULD BE PROVIDED; THUS THE FACILITY WAS SOUGHT AS A RESULT OF AVAILABILITY OF A SECURE DEMENTIA UNIT PLACEMENT. RESIDENT HAS EXHIBITED SIGNIFICANT RESTLESSNESS AND WANDERING INCLUDING ATTEMPTING TO GO OUT EXIT DOORS, LEAVE UNIT, AND/OR ENTER RESTRICTED OR PRIVATE AREAS. SHE HAS REMOVED SAFETY DEVICES ROUTINELY." THE CAA SUMMARY, SUBTITLE FALLS, DATED 8/24/2011, INDICATED THE RESIDENT'S HUSBAND REPORTED THE RESIDENT HAD A SIGNIFICANT HISTORY OF FALLS IN THE 6 MONTHS PRIOR TO THE RESIDENT'S ADMISSION TO THE FACILITY; APPROXIMATELY 2 PER WEEK. THE CAA DOCUMENTED THE FALL RISK ASSESSMENT SCORE AS 12; A SCORE OF 10 OR HIGHER WAS CONSIDERED HIGH RISK. THE CARE PLAN INITIATED 8/31/2011, IDENTIFIED RESIDENT #104 AT RISK FOR ELOPEMENT AND FALLS, AND SPECIFIED THE RESIDENT RECEIVE DEMENTIA UNIT PLACEMENT FOR CLOSE/STRUCTURED SUPERVISION, APPLICATION OF A WANDERGARD SENSOR (SAFETY DEVICE UTILIZED FOR MONITORING RESIDENTS' MOVEMENTS), AND PLACEMENT OF AN OVER DOOR MOTION SENSOR AT THE ENTRY OF HER ROOM. ACCORDING TO THE INCIDENT AND ACCIDENT REPORT DATED 9/3/2011, AND THE FACILITY INVESTIGATION REPORT DATED 9/14/2011, RESIDENT #104 WAS FOUND ON 9/3/2011 AT APPROXIMATELY 12:30 A.M. BY A HOMEOWNER WHOSE RESIDENCE WAS REPORTED AS 200 YARDS FROM THE FACILITY. THE RESIDENT WAS REPORTED TO HAVE SUSTAINED INJURY TO HER RIGHT LOWER EXTREMITY AFTER "STEPPING INTO A HOLE". EVALUATION AT A LOCAL HOSPITAL REVEALED THE RESIDENT HAD EXPERIENCED A BIMALLEOLAR FRACTURE AND DISLOCATION OF HER RIGHT ANKLE. DURING AN INTERVIEW ON 9/8/2011 AT 10:50 A.M., A CERTIFIED NURSE AIDE (CNA, STAFF MEMBER #4) SAID, "PRIOR TO HER (RESIDENT #104) ELOPEMENT, SHE HAD A SENSOR OVER HER ROOM DOOR AND A WANDERGARD IN USE. I WAS ASSIGNED TO THE DEMENTIA UNIT THAT NIGHT. NO ALARMS WENT OFF THAT NIGHT AT THE UNIT ENTRANCE OR AT THE END DOOR (DOOR LEADING TO THE OUTSIDE OF THE BUILDING), OR THE SENSOR OVER THE DOOR TO HER ROOM. A NURSE (STAFF MEMBER #11) GOT THE CALL FROM THE HOMEOWNER TELLING US THE RESIDENT WAS DOWN THE ROAD FROM THIS FACILITY, ABOUT ONE TO TWO TENTHS OF A MILE AWAY. I WENT TO THE RESIDENT'S ROOM; THE DOORWAY ALARM WENT OFF. I IMMEDIATELY SAW THAT HER WINDOW WAS OPEN AND A BLUE CHAIR WAS OFF TO THE RIGHT SIDE A LITTLE BIT. THE SCREEN WAS STILL ATTACHED AT THE TOP, BUT IT EASILY SWUNG OPEN FROM THE BOTTOM. WHEN SHE GOT BACK HERE, I ASKED HER WHAT HAPPENED. SHE TOLD US WHEN SHE WALKED THROUGH THE FIELD, SHE STEPPED IN A HOLE AND BROKE HER ANKLE. SHE DIDN'T SAY HOW SHE GOT OUT." DURING AN INTERVIEW ON 9/8/2011 AT 11:35 A.M., A CNA (STAFF MEMBER 5) SAID, "THE RESIDENT (#104) WANDERED TO MY HOUSE ABOUT 12:30 A.M. OR 12:45 A.M. ON 9/3/2011. MY HUSBAND WENT OUTSIDE TO TELL OUR BARKING DOGS TO SHUT UP AND HE HEARD SOMEONE CALL OUT 'HELP ME.' I WAS AT THE DOOR. MY HUSBAND YELLED OUT TO ME TO CALL THE FACILITY. THE RESIDENT WAS ABLE TO GIVE HER NAME AND SHE WAS CARRYING A WHITE TOTE BAG WITH THE FACILITY'S NAME ON IT. SHE TOLD MY HUSBAND SHE'D BEEN WALKING HER DOG AND IT HAD RUN OFF. SHE SAID SHE WAS HEADED TO HER DAD'S HOUSE THROUGH THE WOODS. SHE SAID SHE HURT HER LEG AFTER SHE fell IN A HOLE. I NEVER ASKED HER HOW SHE GOT OUT OF THE FACILITY. HER RIGHT LEG WAS SWOLLEN, INJURED." DURING AN INTERVIEW ON 9/8/2011 AT 12:05 P.M., THE DIRECTOR OF NURSING (STAFF MEMBER #2) SAID, "SHE (RESIDENT #104) HAS BEEN HERE ABOUT A MONTH. SHE ABSOLUTELY HAD EXIT SEEKING BEHAVIORS. SHE HAD MADE ATTEMPTS TO LEAVE HERE THROUGH THE DOORS. SHE'S AGILE. I DIDN'T BELIEVE LEAVING THROUGH THE WINDOWS WAS EVEN POSSIBLE." DURING AN INTERVIEW ON 9/8/2011 AT 1:15 P.M., A NURSE (STAFF MEMBER #11) SAID, "SHE (RESIDENT #104) HAS MADE ATTEMPTS TO LEAVE THE BUILDING. ON 9/3/2011, NO ALARMS FOR HER WENT OFF. SHE HAD A WANDERGARD. THE UNIT IS LOCKED AT BOTH ENDS; THE FRONT HALLWAY AND BACK DOORWAY. LAST I SAW HER WAS ABOUT 11:45 P.M. NEXT I SAW HER SHE WAS IN STAFF MEMBER #5'S YARD. I ASKED HER WHAT HAPPENED AND SHE TOLD ME SHE STEPPED IN A HOLE. SHE COULDN'T TELL ME HOW SHE GOT OUT WHEN I ASKED. SHE JUST TOLD ME SHE WAS WALKING HOME." DURING AN INTERVIEW ON 9/8/2011 AT 1:35 P.M., THE NURSING HOME ADMINISTRATOR SAID, "WE KNOW THIS RESIDENT (#104) WENT OUT THE WINDOW; THE BRACKET AT THE WINDOW WAS BENT AND THE WINDOW WAS OPEN. SHE EITHER WENT OVER THE FENCE OR UNDER A GATE. WE HAVE NO IDEA JUST WHAT HAPPENED." ACCORDING TO THE NURSES NOTES DATED 9/3/2011 (UNTIMED), RESIDENT #104 WAS SENT TO A LOCAL HOSPITAL FOR EVALUATION. THE RADIOLOGIC REPORT OF THE LOCAL HOSPITAL EVALUATING RESIDENT #104, DATED 9/3/2011 AT 5:30 A.M., REVEALED THE resident sustained [REDACTED]. DURING AN UNANNOUNCED ON SITE INVESTIGATION CONDUCTED ON 9/9/2011, AN INITIAL TOUR OF THE FACILITY WAS COMPLETED. WINDOWS APPROXIMATELY 38 INCHES WIDE AND 34 INCHES FROM THE FLOOR, WERE OBSERVED TO OPEN MAXIMALLY TO 21 INCHES, LEAVING A MEASURED CLEARANCE OF 15 INCHES . THE SCREEN TO RESIDENT #104'S WINDOW WAS OBSERVED ON 9/7/2011 AT 4:55 P.M., WITH THE LOWER RIGHT HAND CORNER PUSHED ASIDE, AND TWO PULL PINS (ONE ON EACH SIDE OF THE WINDOW LOCATED ON THE UPPER THIRD OF THE ALUMINUM FRAME) THAT COULD BE UTILIZED TO REMOVE THE SCREEN FROM THE WINDOW FRAME. ( )