Every finding on record at The Villa at Traverse Point

This deficient practice pertains to Intake #3120666.Based on observation, interview, and record review, the facility failed to:Complete comprehensive bed rail assessments to determine initial resident need and continued need for bed rails,Trial or provide rationale against less restrictive alternatives to bed rail use,Assess all residents with bed rails for risk of entrapment and ensure the absence of bed entrapment zones through consistent and scheduled measurements by facility staff, and/orEnsure informed consent was obtained prior to installation of bed rails.This deficient practice resulted in an Immediate Jeopardy (IJ) due to the death of one Resident (#1) and the likelihood of entrapment and/or serious harm for four additional Residents (#2, #3, and #4) out of four residents reviewed for bed rails.Findings include:The IJ began on 7/25/26 at 4:40 AM when Certified Nursing Assistant (CNA) B discovered Resident #1 deceased in his private room, with his head wedged between the mattress and bed rail, his upper body suspended, and his lower body resting on the floor.The Nursing Home Administrator (NHA) was notified of the IJ on 8/18/26 at 1:38 PM. At that time, a written plan of correction for removal was requested from the facility. This surveyor confirmed by observation, interview, and record review the immediacy was removed on 8/18/26 at 5:20 PM, however, noncompliance remains at the potential for more than minimal harm due to sustained compliance which has not been verified by the State Agency (SA).Resident #1 (R1):Review of the Electronic Medical Record (EMR) revealed R1 was a [AGE] year-old male with initial admission to the facility on 7/2/25 with diagnoses including cerebral infarction (stroke), aphasia (a neurological communication disorder that impairs the ability to speak and understand speech), vascular dementia, hemiplegia and hemiparesis affecting the right side (weakness and/or partial or total paralysis), and restlessness and agitation. Review of R1's most recent Brief Interview for Mental Status (BIMS) assessment, dated 6/25/26, revealed a score of 0, indicative of severe cognitive impairment.Review of an intake received by the SA on 7/28/26, read, in part: .the resident was found with his head/neck wedged between the handrail and mattress and his body hanging off the bed. His head was very swollen and appeared to be possible asphyxiation or breaking his neck. He has rolled out of his bed before, usually due to being wet and needing to be changed. This resident is known to yell/call out often and is often ignored by CAN[s] and nursing staff.Review of R1's EMR revealed the following progress notes:7/25/26 at 6:14 AM by the NHA: Received a call from LPN [Licensed Practical Nurse] at facility working that [R1] had passed away in his sleep (0450)-DNR [4:50 AM - Do Not Resuscitate] code status. All notifications made.7/25/26 at 7:03 AM by LPN A: [R1] was observed at 0300 [3:00 AM] for incontinent rounds. At 0450 [4:50 AM], Cena [certified nursing assistant] found [R1] unresponsive. Nurse assessed resident. No vitals present. Administrator, Physician and family notified.7/25/26 at 14:46 [2:26 PM] by Registered Nurse (RN) P: Body was released at 0930 [9:30 AM] to [Funeral Home and Cremation Service].On 8/18/26 at 9:43 AM, a phone interview was conducted with LPN A who confirmed she was notified by CNA B that she could not wake R1 on the morning of 7/25/26. LPN A stated upon entry into the room, It looked like he thrashed, so his body was out of bed, and his head was against the [enabler] bar. the side of his face was against the bedrail.On 8/18/26 at 10:35 AM, a phone interview was conducted with CNA B who verified was on duty in the early morning hours of 7/25/26. CNA B recalled she received report from CNA N and CNA O, who were coming off their shifts, that R1 had just been assisted with incontinence care and was sleeping in bed. CNA B stated R1 typically called for assistance around 4:30-5:00 AM, so when it was getting close to 5:00 AM and she hadn't heard from him, she thought it was unusual and went to check on him. CNA B described entering R1's room and observing the bottom half of R1's body on the floor mat next to his bed and his head wedged between the mattress and railing. CNA B stated, It looked like he had tried to throw himself out of bed and his head got caught. I was pretty sure he wasn't there [alive] anymore. He had no color; I got the nurse right away. CNA B explained she and LPN A moved R1 to the floor for further assessment and noticed bruising and pressure marks across his face from the bed rail. CNA B stated the NHA arrived later that morning and concluded R1 died in his sleep. When asked about R1's behaviors, CNA B said he had a history of throwing himself out of bed.On 8/18/26 at 10:11 AM, an interview was conducted with CNA K who stated she observed R1 lying in bed after receiving postmortem care. CNA K stated, He [R1] had a line with bruising on the side of his face from the [enabler] bar. His face was really puffy and swollen. When asked about R1's behavioral history, CNA K explained, He was always throwing himself off the bed, that's why he had a [fall] mat and a low bed. he rolled out of bed all the time. He probably rolled off the bed and got his head stuck in between there [mattress and enabler bar] and got his neck broke or suffocated. CNA K was asked the purpose of R1's enabler bar if he continued to roll out of bed and she surmised it left for a place to clip the call light.On 8/18/26 at 10:21 AM, an interview was conducted with Staff F who stated she also observed R1 lying in bed after receiving postmortem care. Staff F stated, His eyes were puffy, top and bottom, he had bruising on his face, and red splotches on his jaw all the way down to his chin. Staff F stated the bruising correlated to where R1's face was pushed up against the bed rail. Staff F continued, He suffered. He did not look like a peaceful dead person. It looked like he struggled. From the look of his face and eyes, he was puffy and had an indentation and red splotches. He looked like he was in that position for a long time. That's the part I can't handle. I was not comfortable with what I saw. Staff F explained R1 frequently yelled out and was therefore ignored at times due to his difficult behaviors.Review of R1's EMR revealed the following behaviors leading up to his death on 7/25/26:7/15/26 at 14:04 [2:04 PM]: Res [resident] experineced [sic] increased behaviors this shift including long wpisodes [sic] of yelling out, throwing items in his room, removing clothing, and striking staff members while providing cares. resident was transferred to his bed per his request. Numerous episodes of intentionally rolling out bed onto his floor mat noted with no injury noted.7/11/26 at 18:30 [6:30 PM]: Resident continues to have increased behaviors. Resident yelling, throwing things, ripping off his clothes and tearing his breifs [sic], attempts to roll self out of chair and bed.6/29/26 at 20:36 [8:36 PM]: Resident had an unwitnessed fall. Resident was laid down in bed after staff provided care. Within a few minutes, resident had rolled out of bed on to the padded floor mat.6/28/26 at 18:24 [6:24 PM]: Resident continues to have increased behaviors, yelling, throwing things, cursing at staff, ripping off brief, hitting things, trying to roll self out of bed and chair.6/17/26 at 18:42 [6:42 PM]: Resident with multiple episodes of behaviors today including throwing items at staff, yelling out, trashing around in wheelchair. Resident was placed in bed and rolled self out of bed.On 1/21/26 an Assist Rail Screening was completed by Registered Nurse (RN) J which read, in part: Reason screening is needed (check all that apply):The following criteria were selected by the assessor: a. The resident has an alteration in safety awareness due to cognitive decline. b. the resident is on medication that can alter safety awareness. c. the resident has a history of falls from bed. h. the resident is incontinent of bladder or bowel.Further review of the Assist Rail Screening read, in part: Recommendations: side rails(s) indicated to promote mobility and independence. 1/4 side rail two sides.The Assist Rail Screening did not document less restrictive alternatives to bed rail use, evaluate the risk of entrapment within the critical zones, evaluate the cognitive and physical status of the resident, or obtain informed consent from the resident and/or resident representative.On 8/18/26 at 12:14 PM, an interview was conducted with RN J who verified she completed R1's Assist Rail Screening on 1/21/26. When asked about the clinical rationale behind the 1/4 rail recommendations for R1, RN J stated, Anybody who needs assistance with bed mobility gets them. RN J was asked if entrapment zones were measured by maintenance before the installation of bed rails and on a periodic basis. RN J replied, I don't know, that's their job.On 8/18/26 at 11:55 AM, an interview was conducted with Maintenance Director/Staff I who verified he installed bed rails after receiving orders from clinical staff. Staff I indicated he conducted routine maintenance checks on the bed rails which included inspecting connectors, verifying the function of the spring-latch knob assembly, replacing any missing parts, and observing for any sign of general wear and tear. When asked if he completed any measurements for entrapments zones at any point during installation or rounds, Staff I' stated, No.On 8/18/26 at 12:27 PM, an interview was conducted with CNA D regarding R1's mobility status. When asked if R1 utilized the bed rails for mobility, they replied, Not really, just to hit.On 8/18/26 at 12:52 PM, an interview was conducted with the NHA who verified LPN A had notified her of R1's death on the morning of 7/25/26. The NHA confirmed there was bruising on R1's face from lying against the bed rail but didn't consider the death suspicious. When asked about R1's behavior, the NHA confirmed R1 had a history of rolling out of bed multiple times per day. The NHA confirmed Assist Rail Screenings should be completed quarterly. When asked if R1 was re-assessed for bed rail safety after repeatedly rolling out of bed, the NHA stated she was uncertain. The NHA stated entrapment zones should be measured on an ongoing basis by the maintenance department.On 8/18/26 at 3:55 PM, an interview was conducted with the Regional Director of Clinical Operations (RDCO) who agreed the Assist Rail Screen was inadequate in evaluating the necessity and safety for bedrails for the resident population.Resident #2 (R2)Review of R2's EMR revealed a most recent admission to the facility on 5/12/26 with diagnoses including cerebral palsy, hemiplegia affecting the right side, dementia, history of traumatic brain injury, and reduced mobility. Review of R2's most recent BIMS assessment, dated 8/10/26, revealed a score of 7, indicative of severe cognitive impairment.Review of R2's EMR revealed he had an activated healthcare durable power of attorney (DPOA).An Assist Rail Screening completed on 5/12/26 read, in part: Recommendations: side rails(s) indicated to promote mobility and independence. 1/4 side rail one side.The Assist Rail Screening did not document less restrictive alternatives to bed rail use, evaluate the risk of entrapment within the critical zones, evaluate the cognitive and physical status of the resident, or obtain informed consent the DPOA. Resident #3 (R3)Review of R3's EMR revealed initial admission to the facility 7/14/26 with diagnoses including dementia, metabolic encephalopathy (a brain dysfunction caused by an underlying systemic illness, toxin, or chemical imbalance), and a cognitive communication deficit. Review of R3's most recent BIMS assessment, dated 7/16/26, revealed a score of 5, indicative of severe cognitive impairment.An Assist Rail Screening completed on 7/15/26 read, in part: Recommendations: side rails(s) indicated to promote mobility and independence. 1/4 side rail one side.Review of R2's EMR revealed a court-appointed guardian that oversaw her care.The Assist Rail Screening did not document less restrictive alternatives to bed rail use, evaluate the risk of entrapment within the critical zones, evaluate the cognitive and physical status of the resident, or obtain informed consent from the court-appointed guardian.Resident #4 (R4)Review of R4's EMR revealed initial admission to the facility 8/3/26 with diagnoses including arthritis of the knee, congestive heart failure, and major depressive disorder. Review of R4's most recent BIMS assessment, dated 8/5/26, revealed a score of 4, indicative of severe cognitive impairment.An Assist Rail Screening completed on 7/15/26 read, in part: .Side Rails are not indicated at this time.On 8/18/26 at 3:12 PM, R4 was observed sleeping in bed. Quarter bed rails were observed installed on both sides of the bed. R4 was unable to state the purpose of the bed rails.Review of facility policy titled, Bed Rail Device Guideline, revised 7/19/17, read, in part: It is the practice of this facility to identify and reduce risks and hazards commonly associated with bed rail use. the facility will also ensure individual bed rail evaluations are performed on a regular basis. Individual bed rail evaluations will include data collection analysis and determination of potential alternative to bed rail use. When bed rail(s) are deemed necessary and appropriate, the facility will provide education to the resident or resident's representation pertaining to the risk and benefits of bed rail use. The facility's priority is to ensure safe and appropriate bed rail use. Bed rails (also referred to as side rails, bed side rails, and safety rails) are constructed of metal or rigid plastics, and are available in various sizes (e.g., full length rails, half rails, quarter rails). the frail or elderly who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., have an increased likelihood of entrapment. The increased risk is largely due to unsafe moving about the bed, or ill-advised attempting to exit from the bed. Additionally, untimely responses to care needs, (e.g. toileting, repositioning, pain management, etc.) increases the risk of entrapment. Bed entrapment occurs when a resident is caught between the mattress and bed rail or within the bed rail itself. Technical issues, such as the proper sizing of mattresses, fit and integrity of bed rails or other design elements (e.g., wide spaces between bars in the bed rails) can also affect the risk of resident entrapment . Mattress compression widens the space between the mattress and rail. When a resident is between the mattress and rail, the mattress can re expand and press the chest, neck, or head against the rail. The objective of the bed rail use guideline is to determine if resident use is safe and appropriate. The interdisciplinary team will use data collected from regular bed inspections and individual bed rail evaluations to bolster care planning and positive resident outcomes. OVERVIEW OF THE U.S. FOOD AND DRUG ADMINISTRATION'S POTENTIAL ZONES OF BED ENTRAPMENT. Zone 3: Between the Rail and the MattressThis area is the space between the inside surface of the bed rail and the mattress, and if too big it can cause a risk of head entrapment. FDA recommended space: less than 4 3/4.1. RESIDENT EVALUATION. Upon admission, readmission or change of condition, residents will be screened to determine : . the need for special equipment or accessories (e.g. side rails). Evaluate the resident to identify appropriate alternative prior to installing bed rails d. Evaluate the resident for risk of entrapment from bed rails prior to installation. f. The facility will document ongoing need for the use of a bed rail and the least restrictive alternative. g. Review the risk and benefits with resident and resident representative. h. Obtain informed consent i. Obtain physician order for medical symptom evaluated and need for bed rail use.The IJ that began on 7/25/26 was removed on 8/18/26 at 5:20 PM when the facility took the following actions to remove the immediacy:Affected Residents/Other Residents at risk:Resident 1 no longer resides at the facility; however review of Resident 1's medical record, during root cause analysis, was completed as part of this plan. On August 18, 202[6], all 82 residing residents were physically assessed for grab bars on the bed. Specifically:Resident has been assessed for cognitive awareness to safely use the grab assist rail for intended purpose.Resident has the functional capacity to utilize assist bars safely to reposition or transfer from bed.Risk of entrapment was reviewed and deemed low due to residents functional ability and understanding of the assist rail.35 residents had grab assist rails removed47 residents were deemed appropriate to keep for mobility The facility beds have the grab assist bars as a part of the bed system. Therefore, residents without the approval for assist bars had the grab assist bars zip tied under bed to prohibit raising of the rail. Orders and care plans were updated accordingly. All newly admitted residents will be assessed for the benefit of grab assist rails for mobility. If approved for grab assist bars, they will have the appropriate orders, evaluation and care plan.Grab assist bars are [sic] will have measurements documented in TELS by the maintenance director quarterly for the residents approved for grab assist rails.The facility's Grab Bar policy has been reviewed and deemed appropriate. All staff working on 8/18/2026 day shift have been educated on Grab Bar policy, and the remaining shifts will be educated by the NHA and DON prior to working their next shifts.Starting August 18, 2026, newly admitted residents will be audited by the NHA and DON during admission to ensure that the resident was assessed appropriately for grab bars.

This deficient practice pertains to Intake #3120666.Based on interview and record review, the facility failed to ensure an unexpected death was reported to the State Agency (SA) for one Resident (#1) of four residents reviewed for accident and incident reporting.Findings include: Resident #1 (R1):Review of the Electronic Medical Record (EMR) revealed R1 was a [AGE] year-old male with initial admission to the facility on [DATE] with diagnoses including cerebral infarction (stroke), aphasia (a neurological communication disorder that impairs the ability to speak and understand speech), vascular dementia, hemiplegia and hemiparesis affecting the right side (weakness and/or partial or total paralysis), and restlessness and agitation. Review of R1's most recent Brief Interview for Mental Status (BIMS) assessment, dated [DATE], revealed a score of 0, indicative of severe cognitive impairment.Review of an intake received by the SA on [DATE], read, in part: .the resident was found with his head/neck wedged between the handrail and mattress and his body hanging off the bed. His head was very swollen and appeared to be possible asphyxiation or breaking his neck. He has rolled out of his bed before, usually due to being wet and needing to be changed. This resident is known to yell/call out often and is often ignored by CNA[s] [certified nursing assistants] and nursing staff.Review of R1's EMR revealed the following progress notes:[DATE] at 6:14 AM by the NHA: Received a call from LPN [Licensed Practical Nurse] at facility working that [R1] had passed away in his sleep (0450)-DNR [4:50 AM - Do Not Resuscitate] code status. All notifications made.[DATE] at 7:03 AM by LPN A: [R1] was observed at 0300 [3:00 AM] for incontinent rounds. At 0450 [4:50 AM], Cena [certified nursing assistant] found [R1] unresponsive. Nurse assessed resident. No vitals present. Administrator, Physician and family notified.[DATE] at 14:46 [2:26 PM] by Registered Nurse (RN) P: Body was released at 0930 [9:30 AM] to [Funeral Home and Cremation Service].On [DATE] at 9:43 AM, a phone interview was conducted with LPN A who confirmed she was notified by CNA B that she could not wake R1 on the morning of [DATE]. LPN A stated upon entry into the room, It looked like he thrashed, so his body was out of bed, and his head was against the [enabler] bar. the side of his face was against the bedrail.On [DATE] at 10:35 AM, a phone interview was conducted with CNA B who verified was on duty in the early morning hours of [DATE]. CNA B recalled she received report from CNA N and CNA O, who were coming off their shifts, that R1 had just been assisted with incontinence care and was sleeping in bed. CNA B stated R1 typically called for assistance around 4:30-5:00 AM, so when it was getting close to 5:00 AM and she hadn't heard from him, she thought it was unusual and went to check on him. CNA B described entering R1's room and observing the bottom half of R1's body on the floor mat next to his bed and his head wedged between the mattress and railing. CNA B stated, It looked like he had tried to throw himself out of bed and his head got caught. I was pretty sure he wasn't there [alive] anymore. He had no color; I got the nurse right away. CNA B explained she and LPN A moved R1 to the floor for further assessment and noticed bruising and pressure marks across his face from the bed rail. CNA B stated the NHA arrived later that morning and concluded R1 died in his sleep. When asked about R1's behaviors, CNA B said he had a history of throwing himself out of bed.On [DATE] at 10:11 AM, an interview was conducted with CNA K who stated she observed R1 lying in bed after receiving postmortem care. CNA K stated, He [R1] had a line with bruising on the side of his face from the [enabler] bar. His face was really puffy and swollen. When asked about R1's behavioral history, CNA K explained, He was always throwing himself off the bed, that's why he had a [fall] mat and a low bed. he rolled out of bed all the time. He probably rolled off the bed and got his head stuck in between there [mattress and enabler bar] and got his neck broke or suffocated.On [DATE] at 10:21 AM, an interview was conducted with Staff F who stated she also observed R1 lying in bed after receiving postmortem care. Staff F stated, His eyes were puffy, top and bottom, he had bruising on his face, and red splotches on his jaw all the way down to his chin. Staff F stated the bruising correlated to where R1's face was pushed up against the bed rail. Staff F continued, He suffered. He did not look like a peaceful dead person. It looked like he struggled. From the look of his face and eyes, he was puffy and had an indentation and red splotches. He looked like he was in that position for a long time. That's the part I can't handle. I was not comfortable with what I saw. Staff F explained R1 frequently yelled out and was therefore ignored at times due to his difficult behaviors.On [DATE] at 12:52 PM, an interview was conducted with the NHA who verified LPN A had notified her of R1's death on the morning of [DATE]. The NHA confirmed there was bruising on R1's face from lying against the bed rail but didn't consider the death suspicious and therefore did not report it to the SA. The NHA stated, There were no signs of abuse. I don't necessarily think it [death] was unexpected.Review of an Event Report, completed [DATE] at 4:50 AM by the NHA, read, in part; Nursing description: Unanticipated Death.Review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, effective [DATE], read, in part: .It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

This deficient practice pertains to Intake #3120666.Based on interview and record review the facility failed to investigate an unexpected death for one Resident (#1) of four residents reviewed for abuse and neglect.Findings include:Resident #1 (R1)Review of the Electronic Medical Record (EMR) revealed R1 was a [AGE] year-old male with initial admission to the facility on [DATE] with diagnoses including cerebral infarction (stroke), aphasia (a neurological communication disorder that impairs the ability to speak and understand speech), vascular dementia, hemiplegia and hemiparesis affecting the right side (weakness and/or partial or total paralysis), and restlessness and agitation. Review of R1's most recent Brief Interview for Mental Status (BIMS) assessment, dated [DATE], revealed a score of 0, indicative of severe cognitive impairment.Review of an intake received by the SA on [DATE], read, in part: .the resident was found with his head/neck wedged between the handrail and mattress and his body hanging off the bed. His head was very swollen and appeared to be possible asphyxiation or breaking his neck. He has rolled out of his bed before, usually due to being wet and needing to be changed. This resident is known to yell/call out often and is often ignored by CNA[s] [certified nursing assistants] and nursing staff.Review of R1's EMR revealed the following progress notes:[DATE] at 6:14 AM by the NHA: Received a call from LPN [Licensed Practical Nurse] at facility working that [R1] had passed away in his sleep (0450)-DNR [4:50 AM - Do Not Resuscitate] code status. All notifications made.[DATE] at 7:03 AM by LPN A: [R1] was observed at 0300 [3:00 AM] for incontinent rounds. At 0450 [4:50 AM], Cena [certified nursing assistant] found [R1] unresponsive. Nurse assessed resident. No vitals present. Administrator, Physician and family notified.[DATE] at 14:46 [2:26 PM] by Registered Nurse (RN) P: Body was released at 0930 [9:30 AM] to [Funeral Home and Cremation Service].On [DATE] at 9:43 AM, a phone interview was conducted with LPN A who confirmed she was notified by CNA B that she could not wake R1 on the morning of [DATE]. LPN A stated upon entry into the room, It looked like he thrashed, so his body was out of bed, and his head was against the [enabler] bar. the side of his face was against the bedrail.On [DATE] at 10:35 AM, a phone interview was conducted with CNA B who verified was on duty in the early morning hours of [DATE]. CNA B recalled she received report from CNA N and CNA O, who were coming off their shifts, that R1 had just been assisted with incontinence care and was sleeping in bed. CNA B stated R1 typically called for assistance around 4:30-5:00 AM, so when it was getting close to 5:00 AM and she hadn't heard from him, she thought it was unusual and went to check on him. CNA B described entering R1's room and observing the bottom half of R1's body on the floor mat next to his bed and his head wedged between the mattress and railing. CNA B stated, It looked like he had tried to throw himself out of bed and his head got caught. I was pretty sure he wasn't there [alive] anymore. He had no color; I got the nurse right away. CNA B explained she and LPN A moved R1 to the floor for further assessment and noticed bruising and pressure marks across his face from the bed rail. CNA B stated the NHA arrived later that morning and concluded R1 died in his sleep.On [DATE] at 10:11 AM, an interview was conducted with CNA K who stated she observed R1 lying in bed after receiving postmortem care. CNA K stated, He [R1] had a line with bruising on the side of his face from the [enabler] bar. His face was really puffy and swollen. When asked about R1's behavioral history, CNA K explained, He was always throwing himself off the bed, that's why he had a [fall] mat and a low bed. he rolled out of bed all the time. He probably rolled off the bed and got his head stuck in between there [mattress and enabler bar] and got his neck broke or suffocated.On [DATE] at 10:21 AM, an interview was conducted with Staff F who stated she also observed R1 lying in bed after receiving postmortem care. Staff F stated, His eyes were puffy, top and bottom, he had bruising on his face, and red splotches on his jaw all the way down to his chin. Staff F stated the bruising correlated to where R1's face was pushed up against the bed rail. Staff F continued, He suffered. He did not look like a peaceful dead person. It looked like he struggled. From the look of his face and eyes, he was puffy and had an indentation and red splotches. He looked like he was in that position for a long time. That's the part I can't handle. I was not comfortable with what I saw. When asked if the facility investigated to determine R1's cause of death, Staff F replied, There was no investigation done, it was just hush-hush. I was pretty upset; I felt there was no investigation into it.On [DATE] at 12:52 PM, an interview was conducted with the NHA who verified LPN A had notified her of R1's death on the morning of [DATE]. The NHA confirmed there was bruising on R1's face from lying against the bed rail but didn't consider the death suspicious. The NHA stated staff were verbally interviewed when she arrived at the facility on the morning of [DATE], but no formal witness statements were made.Review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, effective [DATE], read, in part: .It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. PROCEDURE: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. a. Investigation of abuse:When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: i. Who was involved, ii. Residents' statements. iii. Resident's roommate statements (if applicable) iv. Involved staff and witness statements of events v. A description of the resident's behavior and environment at the time of the incident vi. Injuries present including a resident assessment vii. Observation of resident and staff behaviors during the investigation viii. Environmental considerations. The results of the investigation will be recorded and attached to the report.

Based on observation, interview and record review, the facility failed to keep kitchen equipment, including cooking and cold holding equipment, in a state of good operational repair and failed to maintain general cleanliness of kitchen equipment. These deficient practices have the potential to increase the risk of food borne illness among all residents who consume food from the kitchen. Findings include:On 7/20/2026 at 10:57 AM Dietary Manager (DM) M stated that the two lower cooking ovens below the gas range do not work and have not worked for a very long time. DM M also stated that the lower of the two ovens on the upright double oven is not working. DM M stated that the issue had been put into the maintenance request notification system, stating that the equipment was broken and needed to be repaired.On 7/20/2026 at 11:20 AM, a large container of sliced American Cheese was observed with a dispose by date of 30 days from the date of opening on the exterior of the container. The unopened packages of cheese had dispose-by dates pre-printed on the packages stating the items were good until September, prior to opening. DM M stated they could not get packages any smaller than these from their distributor and that the exterior of the package stated it was good until September. When asked about dating and labeling of potentially hazardous foods, DM M stated potentially hazardous foods were kept no longer than three days. When asked why the opened slices of cheese had a dispose by date of 30 days, DM M stated due to the large quantity of cheese in these packages, they go off the use by date listed on the outsides of the cheese packaging, before the plastic packaging is removed. On 7/20/2026 at 11: 30 AM the gasket was observed not tight fitting and fully attached to the door of the upright refrigerator. On 7/20/2026 at 11:48 AM the ceiling of the walk-in cooler was observed with damage to a seam and condensation was dripping down onto the floor of the walk-in cooler, just past a cart containing food items. On 7/20/2026 at 12:00 PM the vent hood over the dish machine was observed soiled with grease and debris, with grease having dripped down onto the top of the dish machine, and the interior of the dish machine had a buildup of minerals. The caulking around the dish room drainboard where it attaches to the wall was black with mildew.On 7/20/2026 at 12:15 PM the bowl drains at the prep sink and three compartment sink were noted very soiled, and in poor repair being no longer smooth, durable and easily cleanable, and the drainpipes coming from below these sinks were soiled.On 7/21/2026 at 11:20 AM the tabletop upright stand dough mixer was observed with a plastic bag covering it. DM M said that the bag is to keep the mixer clean after it gets cleaned, and that the unit is not used very often. After the plastic bag was removed, the slicer was observed with food debris on the splash guard area above the bowl of the casing. Record review of policy Quick Reference Tool: Clean & Sanitary Issued 9/01/2021 3. All food contact surfaces will be cleaned and sanitized after each use. 4. The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces.According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of the facility and resident care equipment, resulting in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents in the facility. Findings Include:On 7/21/2026 at 9:20 AM the wheelchair scale in Spa 3 was observed with missing paint and a rusty metal surface where the paint was missing.On 7/21/2026 at 9:22 AM the floor behind the washing machine and the cover over the floor drain trough were noted soiled with an accumulation of debris. Dietary Manager (DM) M stated that this was to be maintained by maintenance staff. On 7/21/2026 at 9:46 AM the wheelchair scale in Spa 1 was observed with missing paint and a rusty metal surface where the paint was missing. Directly behind the wheelchair scale, a ten-inch rectangular ceramic cove base tile was missing.On 7/21/2026 at 10:00 AM the hopper in the laundry soiled linen room was observed with a missing splash shield. During this observation, Maintenance Director (MD) 'L' stated there should be one on this unit to protect the staff, just like the other two hoppers in the facility.

Based on observation, interview, and record review, the facility failed to ensure residents received assistance with Activities of Daily Living (ADL), specifically bathing and showering, for four of four Residents (#3, #7, #27, & #76) reviewed for ADL care. Findings include: Resident #3 (R3)On 7/20/26 at 11:43 AM, during the initial tour of the facility, R3 was observed in his room with pieces of food on his shirt and lap, and his hair was disheveled with an overall unkempt appearance. During a phone interview, R3's Power of Attorney (POA) J stated she believed staff may be ignoring his care needs due to his behaviors. Review of R3's electronic medical record (EMR) showed a task indicating scheduled showers at least twice weekly on Mondays and Thursdays. Review of R3's shower and bath documentation for a four week period revealed multiple missed scheduled showers with no documented refusals, clinical contraindications, or alternative bathing provided. Resident #7 (R7)On 7/20/26 at 11:47 AM, during an interview, R7 stated he did not receive his shower on Saturday. He explained he was supposed to be showered every 72 hours, and Saturday, 7/18/26, would have been his scheduled day. Review of R7's EMR indicated a task for showers every 72 hours. Review of his shower and bath documentation revealed his last recorded shower/bath was on 7/15/26, indicating he had missed two scheduled showers with no documented refusals, clinical contraindications, or alternative bathing provided. During an interview on 7/22/26 at 8:35 AM, the Social Services Designee (SSD) H acknowledged when residents do not receive showers as scheduled, it can negatively affect how they feel about themselves. SSD H further stated, being able to shower would affect her own sense of well being, and felt residents deserved the same consideration. Resident #67 (R76) On 7/20/26 at 12:30 PM, an interview was conducted with R76 in her room and was asked about staffing services. R76 stated I have not been getting my showers twice a week like I am scheduled for and neither is my roommate [R27]. I just feel so dirty and unkept without a shower twice a week. Review of R76's shower task, dated 5/22/26 through 7/21/26, revealed 18 opportunities for a shower on Tuesday and Friday. The documentation showed R76 only received 9 of her scheduled showers. Review of R76's Minimum Date Set (MDS), dated [DATE], revealed no rejection of cares. Review of R76's progress notes, dated 5/22/26 through 7/21/26, revealed no progress notes indicating why a shower was not completed or any documented refusals of care. Resident #27 (R27) On 7/22/26 at 8:00 AM, an interview was conducted with R27 in her room regarding showers and replied, If I refuse, it is because I had a visitor, but I would go at a different time if they asked and no one comes back to ask. Review of R27's shower task, dated 5/25/26 through 7/21/26, revealed 16 opportunities for a shower on Tuesday and Friday and the documentation showed R27 only received five of her scheduled showers. Review of R27's Minimum Date Set (MDS), dated [DATE], revealed no rejection of cares. Review of R27's progress notes, dated 5/25/26 through 7/21/26, revealed no progress notes indicating why a shower was not completed or any documented refusals of care. On 7/22/26 at 8:10 AM, an interview was conducted with Certified Nurse Aide (CNA) G, who is one of the designated shower aides and was asked if R76 ever refused a shower. CNA G replied, No. We try our best to ensure showers are completed, but sometimes we can't get to everyone and then ask the following day. On 7/22/26 at 8:15 AM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked if completing showers were a concern and replied, Well we did have a concern showers were not being done and so we started to schedule two aides to complete showers. The NHA was then asked if she was aware showers continue to be a concern and replied, I was not aware and I will look into the matter. Review of policy titled, Activities of Daily Living (ADLs), dated 5/7/20, read in part, Purpose: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, our facility provides necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminish was unavoidable. Guideline: In accordance with the comprehensive assessment, together with respect for individual resident needs and choices our facility provides care and services for the following activities: Hygiene: Bathing, dressing, grooming and oral care.

Based on observation, interview, and record review the facility failed to store medications in a safe and secure manner for 4 Residents (#9, #42, #21, #8) of 18 residents reviewed and three of five treatment/medication carts reviewed for medication storage.Findings include:Resident #9 (R9)On 7/20/26 at 11:00 AM, an observation was made of R9 lying in bed in his room. Triamcinolone Acetonide cream 0.1%, Nystatin external cream 100,000 unit per gram (two tubes), and Ketoconazole external shampoo 2% (all topical treatment creams to treat skin irritation) were observed sitting on the nightstand of R9.On 7/20/26 at 11:02 AM, an interview was conducted with R9 in his room who was asked how long he had been in the facility. R9 replied, I have been here for two weeks.Review of R9's electronic medical record revealed no safety assessment for self-administration of medications. Resident #42 (R42)On 7/20/26 at 11:25 AM, an observation was made of R42 lying in his bed in his room. Two tablets of gabapentin 600 milligram (mg) pills, two tablets of acetaminophen 500 mg in a medication cup, a Zicam nasal spray, and an eye lubricant dropper were observed sitting on the bedside table of R42.On 7/20/26 at 11:30 AM, during an interview Unit Manger / Licensed Practical Nurse (LPN) A was asked if R42 had a safe self-administration of medication assessment and replied, No, I don't see one.On 7/20/26 at 11:32 AM, during an interview, the nurse for R42, Registered Nurse (RN) E was asked who dispensed the medications for R42 and what they were. RN E replied, The midnight nurse did. The medications are acetaminophen 500 milligrams two tablets and gabapentin 600 milligrams two tablets.Review of R42's electronic medical record revealed no assessment for safe self-administration of medications. Resident #21 (R21)On 7/20/26 at 11:40 AM, an observation was made of R21's unoccupied room. R21 had a medication cup with two pills on top of his bedside table and a clear glass with light red liquid and sediment in the bottom of the glass.On 7/20/26 at 11:45 AM, an interview was conducted with RN E who was asked what the medications were and why they were left in R21's room. RN E replied, He [R21] does not like to take all his medications at the same time and leave certain ones for later. The medications are pancreatic medication and irritable bowel medication.Review of R21's MAR, dated July 2026, revealed RN E dispensed the medications found in R21's room on his bedside table.On 7/20/26 at 11:52 AM, an interview was conducted with LPN A who was asked if R21 had an assessment for safe self-administration of medication and replied, No. LPN A was asked if nurses should be leaving medications at the bedside and replied, No, medications should not be left and nurses should be ensuring they are taken before leaving the residents' room.Review of R21's electronic medical record revealed no assessment for safe self-administration of medications. Resident #8 (R8)On 7/20/26 at 12:10 PM, an observation was made of 8's room. R8 was sitting in his wheelchair. An observation was made of R8's nightstand which had Voltaran arthritis cream and anti-fungal powder.Review of R8's electronic medical record revealed no assessment for safe self-administration of medications. On 7/20/26 at 12:20 PM, during an interview, the Nursing Home Administrator (NHA) was asked if treatment creams should be locked in the medication cart and replied, Treatment creams should be stored and locked in the treatment carts and medication carts are to be locked if left unattended. On 7/20/26 at 4:19 PM, an observation was made of a medication cart located on station two. The medication cart was found to have six medication cups preset with two tablets of acetaminophen 500 milligrams in each medication cup without a label. The station two medication cart were also found to have a dozen loose pills in the second and third drawers.On 7/20/26 at 4:21 PM, during an interview, RN D was asked if she should be presetting medications into medication cups, what they were, and why they were not labeled. LPN A replied, No. It is acetaminophen 500 mg two tabs.On 7/21/26 at 7:35 AM, an observation was made of the station one treatment cart which was unlocked and unattended.On 7/21/26 at 7:38 AM, an interview was conducted with RN C who was asked why the treatment cart was unlocked and replied, No, it should be locked if not in use or unattended.On 7/21/26 at 7:40 AM, an interview was conducted with the NHA who was asked if treatment and medication carts should be locked if unattended and replied, Yes.On 7/22/26 at 8:00 AM, an observation was made of the station two medication cart unlocked and unattended.On 7/22/26 at 8:03 AM, and interview was conducted with RN E who was asked why the medication cart was left unlocked and unattended and replied, I just. I didn't mean to leave it unlocked.Review of policy titled, Medication Administration - General Guidelines, dated May 2022, read in part, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.Administration.14) Residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications.18) The resident is always observed after administration to ensure that the dose was completely ingested.Review of policy titled, Storage of Medications and Medical Supplies, dated 12/2017, read in part Policy Statement: The facility shall store all drugs and biologicals and medical supplies in a safe, secure, and orderly manner.Review of policy titled, Storage of Medications and Medical Supplies, dated 12/2017, read in part Policy Statement - The facility shall store all drugs and biologicals and medical supplies in a safe, secure, and orderly manner.9. Compartments.containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review the facility failed to ensure safety with self-administration of medication was established for two Residents (#21 & #42) of two residents reviewed for self-administration of medication.Findings include:Resident #42 (R42)On 7/20/26 at 11:28 AM, R42 was observed lying resting in his bed with his eye covered with a cloth. R42 had a medication cup with four white tablets lying on his bedside table.On 7/20/26 at 11:30 AM, an interview was conducted with Unit Manger/Licensed Practical Nurse (LPN) A who was asked if R42 had a safe self-administration of medication assessment. LPN A replied, No, I don't see one.On 7/20/26 at 11:32 AM, an interview was conducted with Registered Nurse (RN) E who was R42's nurse. RN E was asked who dispensed the medications for R42 and what they were. RN E replied, I'm not sure who did. The medications are acetaminophen 500 milligrams two tablets and gabapentin 600 milligrams two tablets.Review of R42's medication administration record (MAR), dated July 2026, revealed RN E dispensed the medications found in R42's room on his bedside table and the medications documented were confirmed as reported by RN E.Resident #21 (R21)On 7/20/26 at 11:40 AM, an observation was made of R21's unoccupied room. R21 had a medication cup with two pills on top of his bedside table and a clear glass with light red liquid and sediment in the bottom of the glass.On 7/20/26 at 11:45 AM, an interview was conducted with RN E who was asked what the medications were and why they were left in R21's room. RN E replied, He [R21] does not like to take all his medications at the same time and leaves certain ones for later. The medications are pancreatic medication and irritable bowel medication.Review of R21's MAR, dated July 2026, revealed RN E dispensed the medications found in R21's room on his bedside table and the medications documented were confirmed as reported by RN E.On 7/20/26 at 11:52 AM, an interview was conducted with LPN A who was asked if R21 had a safe self-administration of medication assessment completed and replied, No. LPN A was asked if nurses should be leaving medications at the bedside and replied, No, medications should not be left and nurses should be ensuring they are taken before leaving the residents' room.On 7/20/26 at 12:20 PM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked if nurses should be leaving medications at the bedside and replied, No. Nurses are to make sure medications are taken at the time they are dispensed. The NHA was asked if any residents had a safe self-administration of medication assessment and replied, I am not sure. I would have to look.Review of policy titled, Medication Administration - General Guidelines, dated May 2022, read in part, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.Administration.14) Residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications.18) The resident is always observed after administration to ensure that the dose was completely ingested.

Based on observation, interview, and record review the facility failed to assess, monitor, and implement orthotic devices for one Resident (#5) of two residents reviewed for limited range of motion.Findings include:Resident #5 (R5)During a room visit on 7/20/2026 at 12:43 PM, R5 was observed in bed with her right fist clamped tightly closed and the forefinger and thumb were observed extended. R5's feet were elevated on a pillow with only socks on. R5 did have a palm protector (soft device shaped like a carrot) in front of her on her bedside table.A review of the medical record revealed R5 was admitted on [DATE] with diagnoses including a stroke affecting the right side. The current Physician orders for R5 written on 7/2/25 read [brand name] boots (designed to support and align the foot and ankle for those with weakness and provide stability and relieve pressure on heels) bilaterally while in bed every shift for skin integrity. There were no Physician orders written for a palm protector/carrot to prevent worsening of contractures.During a room visit on 7/21/2026 at 11:23 AM, R5 was observed in bed with her right fist clamped tightly closed. R5 was in bed and her feet were observed resting on a pillow with heels floating. R5 was wearing socks and did not have [brand name] boots on.The medical record also included a care plan with a focus of: SKIN: Resident has potential for skin breakdown r/t (related to) incontinence and limited mobility. The interventions for this focus included, B/L (bilateral or both sides) [brand name] boots while in bed. The care plan included a focus revealing R5 was resistive to care at times, The resident is resistive to/refusing care as evidenced by declining showers, to wear [brand name] boots for skin integrity, and turning/repositioning Date Initiated: 01/22/2026.During an interview on 7/21/2026 at 12:03 PM, Registered Occupational Therapist (OTR) I was asked about the orthotic devices (carrot and [name brand] boot) involved in R5's regimen. OTR I was not sure where the past records had gone as the therapy companies have changed 3 times. OTR I stated if a resident had a palm protector/carrot, they should have an order.During an interview on 7/21/2026 at 12:16 PM, the Director of Nursing (DON) reviewed the medical record and did not see instructions listed on the task list for placement of a carrot/palm protector. The DON and Registered Nurse (RN) F reviewed the Treatment Administration Record (TAR) and noted the nurse had initialed [brand name] boots were currently in place. RN I and this surveyor then visited R5 at 12:20 PM on 7/21/2026 and discovered [brand name] boots were on the dresser behind R5 and not on her feet. R5 was asked where the carrot/palm protector had come from (observed labeled with her name). R5 stated the carrot came from downstairs (in therapy).During a room visit on 7/22/2026 at 9:26 AM, R5 was observed in bed and was not wearing the [name brand] boots which were observed sitting behind her on her dresser. The Treatment Administration Record (TAR) had been signed by a staff nurse indicating bilateral [brand name] boots were in place while in bed for skin integrity. R5 stated she did not want to wear them today however, the record did not reflect the refusal so the facility could potentially develop effective interventions in response to refusals. During an interview on 7/22/2026 at approximately 10:00 AM, RN A and RN I stated the [brand name] boots were not always worn. They reviewed the medical record and acknowledged a nurse had signed the TAR indicating the resident was wearing [brand name] boots when observations revealed R5 was not wearing them. RN A stated she could not find an order for the carrot/palm protector and there should be an order.

Based on observation, interview and record review, the facility failed to ensure safe storage of smoking paraphernalia for two Residents (#39 & #42) of five residents reviewed for smoking.Findings include:Resident #39 (R39)On 7/21/26 at 12:20 PM, an observation was made of R39 in his room where a bag of tobacco, with approximately 34 rolled cigarettes were observed on his dresser and a purple vape was observed on his bedside table.Review of R39's social services comprehensive evaluation, dated 5/28/26, did not include a vape under smoking materials nor did it indicate R39 was safe to keep a vape in his possession.Resident #42 (R42)On 7/21/26 at 11:28 AM, R42 was observed lying in bed, resting with his eye covered with a cloth. R42 had a lighter and two-name brand cigarettes lying on his bedside table.On 7/21/26 at 11:35 AM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked if it was safe for residents to have a vape and other cigarette paraphernalia laying out in their rooms, including lighters. The NHA replied, They are their own person and they should have a lock box in their rooms and smoking items should be locked and not in plain sight.On 7/22/26 at 8:05 AM, an observation was made of R39's room and a purple vape remained on his bedside table.Review of policy titled, Smoking Guideline, dated 11/28/17, read in part .Procedure.9. Smoking materials including lighters and cigarettes will be securely stored.

Based on interview and record review, the facility failed to provide the necessary behavioral healthcare services per provider recommendations, including individual counseling, to attain or maintain the highest practical physical, mental, and psychosocial well-being for one Resident (#10) out of three residents reviewed for mood and behavior.Findings include:Resident #10 (R10)Review of R10's Electronic Medical Record (EMR) revealed initial admission to the facility on 2/18/26 with diagnoses including post-traumatic stress disorder (PTSD), major depressive disorder, sleep disorder, below knee amputation of the left leg, and delusional disorder. Review of R10's most recent Minimum Data Set (MDS) assessment, submitted 6/8/26, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition.On 7/20/26 at 12:07 PM, R10 was observed sitting in a wheelchair in his private room with two below-the-knee amputations (BKAs). R10 stated the most recent amputation was of his right leg which occurred on 4/22/26 after many other failed medical interventions to save the limb. R10 confirmed a diagnosis of significant PTSD stemming from both childhood trauma and time serving in the armed forces.Review of a Psychiatry Initial Evaluation written on 3/18/26 by Physician Assistant (PA) K read, in part: .[R10] was noted with PTSD, depression, anxiety, delusional disorders, insomnia, and suicidal ideations. He had reported multiple flashbacks multiple times daily related to traumatic events in the past . He was noted with symptoms of paranoia. Facility staff today reports that he is chronically behavioral. They often find him to be anxious and confrontational.Review of a Psychiatry Follow Up note written on 4/20/26 by PA K read, in part: .Staff reports to me today that [R10] has an amputation plan for his right foot with consult by multiple specialists noted. He has apparently been refusing some preop [preoperative] instructions and has endorsed to staff significant exacerbation of depression and anxiety symptoms. Patient was seen lying down in bed in room for extensive visit. He endorses significant exacerbation of depressive symptoms given his upcoming right foot amputation. His depression appears to be significant. Reports emotional, sexual, and physical abuse in childhood and during military service. Witnessed domestic violence disputes before military service. Reports significant trauma during military service. Currently endorsing significant exacerbation of depressive symptoms related to upcoming right foot amputation. Reports uncontrolled anxiety and insomnia with poor appetite. PTSD symptoms reported as stable but with frequent exacerbations of memories and flashbacks. Previously declined psychotherapy but now agrees to psychotherapy initiation with social worker or psychologist - referral requested.Review of a Psychiatry Follow Up note written on 5/21/26 by PA K read, in part: .Previously declined psychotherapy but now agrees to psychotherapy initiation with social worker or psychologist - referral requested.Review of R10's EMR and provider notes revealed no evidence of a referral to a social worker or psychologist per PA K's recommendation.On 7/22/26 at 9:45 AM, a follow-up interview was conducted with R10 who confirmed a referral was never made to a social worker or a psychologist. R10 indicated the previous facility social worker had resigned from the position and the referral process was lost in the shuffle. R10 stated, I just wanted to talk to somebody. I felt like other people were just pushing pills on me. R10 confirmed psychotherapy was an intervention he wanted to pursue.On 7/22/26 at 10:06 AM, an interview was conducted with Registered Nurse/Unit Manager (RN/UM) F regarding the referral process. RN/UM F indicated the social worker would have been responsible for the referral process and the scheduling of psychotherapy appointments. RN/UM F confirmed the previous social worker resigned in mid-April (2026) and concluded the referral from PA K most likely was overlooked after her resignation.On 7/22/26 at 10:10 AM, an interview was conducted with Social Services Designee (SSD) H regarding behavioral health services for R10. SSD H stated her first day of employment at the facility was 5/11/26 and was uncertain if a psychotherapy referral had been made for R10. SSD H stated she would further investigate and inform this Surveyor if the referral had been made. There was no follow up by SSD H by the time of survey exit.Review of the facility policy, Mood and Behavior Guideline, effective 11/18/17, read, in part: .The objective of the Mood and Behavior Guideline is to provide a plan of care that is individualized to the residents needs based upon the comprehensive assessment by the interdisciplinary team. This plan of care will include medically related social services to address mood and behavioral health services to attain or maintain the highest practicable well-being. The Interdisciplinary Team will initiate and continue care coordination for each resident by reviewing with the resident, resident representative and review of the medical record, making recommendations as applicable for: a. Referrals to behavior management committee b. Behavioral health services c. Psychological evaluations and clinical evaluation based on assessment.

This deficient practice pertains to Intake 2808680.Based on interview and record review, the facility failed to obtain informed consent from the responsible party before prescribing a psychotropic drug to one Resident (#1) of three Residents reviewed for planning and implementing care.Findings include:Review of a complaint submitted to the State Agency (SA) on 3/19/26 read, in part: .[Resident #1] was admitted for intense physical therapy after sustaining a fall on the ice. During his stay [Resident #1] did not see the therapy room ONE time. he couldn't do anything because he was so drugged inappropriately.Resident #1 (R1)Review of R1's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/30/26 with diagnoses including fracture of the fourth thoracic vertebra, encephalopathy (a disturbance of brain function causing confusion, memory loss and coma in severe cases), traumatic subarachnoid hemorrhage (a type of stroke characterized by bleeding between the brain and the membrane protecting it), and mild neurocognitive disorder.Review of a document titled, Activation of DPOAH (Durable Power of Attorney for Healthcare)/Advanced Directive revealed an activation date of 1/20/26.On 4/7/26 at 9:08 AM, an interview was conducted with R1's Durable Power of Attorney for Healthcare, DPOAH B, regarding treatment decisions. DPOAH B indicated R1 was given an antipsychotic drug, Seroquel, that she did not approve of. DPOAH B stated, He's [R1] an old guy, that's a vicious drug. You shouldn't give a drug like that to a person his age. When queried as to whether she signed a consent allowing the administration of Seroquel, DPOAH B stated, I would never consent, ever, to giving that drug.Review of a document titled, CONSENT-Antipsychotic Medication Informed Consent indicated verbal consent for use of Seroquel was obtained from R1 on 2/2/26 rather than DPOAH B.Review of R1's EMR revealed an admission Note written on 1/30/26 at 14:53 [2:53 PM] that read, in part: .[R1] arrived to facility via facility transport. [R1] noted with acute metabolic encephalopathy, possibly dementia with behavioral disturbance, resident incapable of making informed decisions.Review of R1's Medication Administration Record (MAR) revealed the following: SEROquel Oral Tablet 25 MG (milligrams) (Quetiapine Fumarate) Give 2 tablet by mouth one time a day for acute metabolic encephalopathy, initiated 1/30/26. SEROquel Oral Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet by mouth one time a day for acute metabolic encephalopathy, initiated 1/30/26.Review of R1's EMR revealed an Interdisciplinary Team note written on 2/12/26 at 10:52 AM that read, in part: Met with [DPOAH B] and two other family members re: (regarding) [R1's] POC (plan of care). [DPOAH B] upset stating she had not been informed of any COC (continuity of care) for [R1]. [DPOAH B] upset stating [R1] was sedated, and doesn't knowwhy [sic] he is on Seroquel to begin with. Family members stated. they wanted [R1] him off of it [Seroquel] completely.On 4/7/26 at 12:42 PM, an interview was conducted with Social Services Director (SSD) F who confirmed she was responsible for medication consent forms. SSD F stated whoever is responsible for making medical decisions should sign the consent form, whether it be the resident or resident representative/DPOA. When asked why R1's DPOAH had not signed the Antipsychotic Medication Informed Consent, SSD F stated it was likely a clerical error.On 4/7/26 at 2:15 PM, an interview was conducted with the Nursing Home Administrator (NHA) who understood concerns related to obtaining informed consent from the correct party prior to administration of a psychotropic medication. Review of the facility policy titled, Psychotropic Medications Guideline, revised 5/30/25, read, in part: .Residents who have admitted with or have changes to their psychotropic medication regimen will have an informed consent obtained. The resident and/or responsible party have the right to accept or decline the initiation of or increase in a psychotropic medication.

Based on observation, interview, and record review, the facility failed to ensure the correct therapeutic diet was prescribed for 4 Residents (#36, #43, #321, & #325) of 10 residents reviewed for nutritional concerns. This deficient practice resulted in the potential for unmet nutritional needs and the potential for health complications. Findings include: Resident #36 (R36) R36 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hypertension, chronic kidney disease and history of a stroke. On 5/6/25 at 12:26 PM, the lunch tray for R36 was observed and included a tray card which read in part, Diet Order: Regular Texture, Consistent Carbohydrate, No Added Salt, Fluids thin. The tray included a packet of salt. Resident #43 (R43) R43 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, atrial fibrillation, and chronic obstructive pulmonary disease. The physician orders included a diet order dated 7/19/24 of No Added Salt (NAS), regular texture, *Thin consistency, double protein portions. On 5/6/25 at 12:27 PM, the lunch tray for R43 was observed with Certified Nurse Aide (CNA) F. The tray card indicated a Diet Order: Regular Texture, No Added Salt, Fluids thin. The tray included a packet of salt. Resident #321 (R321) R321 was admitted to the facility on [DATE] with physician orders including a diet order of No Added Salt (NAS), Regular texture, Regular Thin liquids consistency. On 5/6/25 at 12:22 PM, the lunch tray for R321 was observed with the Registered Dietitian (RD) G. The tray card indicated a Diet Order: Regular Texture, No Added Salt, Fluids Thin. The tray included a packet of salt. RD G stated, He should not have gotten that (the salt packet). Resident #325 (R325) R325 was admitted to the facility on [DATE] with diagnoses including acute congestive heart disease, acute respiratory failure, and hypertension. R325's physician orders included a diet order written on 4/30/25 of Consistent Carbohydrate/NAS, Regular texture, Regular Thin liquids consistency, double protein portions. On 5/6/25 at 12:23 PM, the lunch tray for R325 was observed with the RD G. The tray card indicated a Diet Order: Regular Texture, Consistent Carbohydrate, No Added Salt, Fluids Thin. The tray included a packet of salt. RD G stated, That is not right, and she removed the salt packet from the tray. RD G said that the dietary department was not following the tray cards and salt should not be on those trays with No Added Salt diets. The Diet Manual titled Dining RD: Diet Manual for Long Term Care 2022 was presented and read in part: No Added Salt Diet Indications for Use: . The diet follows the Regular Diet, avoids adding the use of salt at the table, and avoids sending salt packets on the meal trays served in the rooms.

Based on interview and record review, the facility failed to obtain consent for an antipsychotic medication prior to initiation for one Resident #324 (R324) of five residents reviewed for antipsychotic medications. This deficient practice resulted in R324 not giving consent prior to initiation of medication. Findings include: Resident #324 (R324) Review of the Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with active diagnoses that included bipolar disorder, type 2 diabetes mellitus, and unsteadiness on feet. R324 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of intact cognition. A review of physician orders included Haloperidol (antipsychotic) 10 mg . Give 1 tablet by mouth one time a day every Monday, Wednesday and Friday for bipolar diagnosis. Review of the Medication Administration Record (MAR) for April 2025 revealed R324 had received the antipsychotic medication on 4/30/25. Review of the MAR for May of 2025 revealed R324 received the antipsychotic medication on 5/2/25, 5/5/25, and 5/7/25. Review of the EMR revealed R324 did not sign a consent for the antipsychotic medication. During an interview on 5/8/25 at 9:47 a.m., Social Services Director (SSD) E reported she completes consents with residents on admission or when the medication is ordered. SSD E reviewed the EMR for R324 and reported the consent had not been completed. During an interview on 5/8/25 at 9:52 a.m., the Director of Nursing (DON) acknowledged the consent for the antipsychotic medication was not in the EMR and had not been completed. Review of document titled Use of Anti-psychotic Medications read in part, .the resident, family, and or surrogate decision maker must be educated (verbal and or written information according to facility protocol) about the use of antipsychotic drugs .

Based on observation, interview, and record review the facility failed to provide food in a manner that was a palatable (preferable) temperature for 15 of 27 residents interviewed. This deficient practice resulted in frustration with meals and the potential for weight loss and diminished nutrition. Findings include: During an interview on 6/10/24 at 11:22 a.m., CR609 stated Often times the food is cold or cool CR609 stated I do ask them to warm up the food, but some food is rubbery when it gets warmed. During an interview on 6/10/24 at 11:30 a.m., CR610 was asked about the temperature and palatability of the food. CR610 stated the food is cold. During an interview on 6/9/24 at 3:13 p.m., CR614 was asked about the temperature and palatability of the food. CR614 stated the food is cold. During a confidential group interview on 6/10/24 at 2:00 p.m., 12 Resident who remained confidential per request (CR600, CR601, CR602, CR603, CR604, CR605, CR606, CR607, CR608, CR611, CR612, and CR613) of 27 residents agreed the food is not palatable due to cold temperatures of food. CR602 stated the food is cold when the staff bring it to CR602's room as they are served last. CR602 stated the vegetables are over-cooked and mushy. CR600 stated the bread or buns get soggy and mushy when the bread is on a plate near items with water in it. CR601 stated salt and pepper are not available on meal trays. During an interview on 6/11/24 at approximately 12:30 p.m., the NHA (Nursing Home Administrator) acknowledged residents had food temperature concerns that were brought to him from resident council meetings. The NHA stated It is something we have to work on. 13791 On 6/09/24 at approximately 3:45 PM, the steam table was observed to have been set up for the evening meal. A full sized pan was observed in one of the steam wells covered with aluminum foil. [NAME] B was asked what was in the pan and was identified as Brussels spouts and had been placed in the steam table about 15 minutes ago. The temperature of the spouts was measured to be 201 F. When asked when the evening meal was to begin, [NAME] B stated it would be in about an hour. The Brussels spouts were observed to be over cooked, mushy lacking full nutritive value.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 76 residents. Findings include: On [DATE] between 1:10 PM and 2:00 PM, initial observations of the kitchen were made. During this period, two stainless steel pans of sliced ham steaks were observed sitting on a food preparation table. No staff were in the kitchen preparing food. Dietary Assistant (DA) C was in the dish washing room conducting dish washing and was interviewed at this time and asked the whereabouts of kitchen staff. DA C stated they were outside on break. The temperature of the ham steaks was measured with a metal stem digital probe thermometer and found to be between 54 F and 61 F. A pan of ham steaks observed in the walk in refrigerator was found to have a temperature of 48 F. During the same initial observations, a stainless steel pan of tuna salad was observed to have a plastic wrap cover with dates of ,d+[DATE] and ,d+[DATE]. An interview with DA C was conducted at approximately 1:40 PM and learned the product was expired and was subsequently disposed of. The wire rack shelves in both the [NAME] (brand name) and Traulsen (brand name) refrigerators were observed to have the coating worn off and had become rusted and uncleanable. On [DATE] between 2:15 PM and 2:30 PM, the pantry refrigerators for Station I and Station II containing residents' food were observed. The station II refrigerator contained six meat and cheese sandwiches had expiration dates of ,d+[DATE]. Also in the Station II refrigerator was a bag from a local fast food chain with food inside. The bag was lacking any identification related to whom it belonged or any dates of placement or expiration, Station I pantry refrigerator contained a dozen eggs, not procured from an approved source, and were noted to be colored eggs. An interview with nursing staff G revealed the eggs had been brought in by one staff from their chicken farm, for another staff member. The eggs were observed to still have soiled shells in the carton. On [DATE] at approximately 4:00 PM, staff were observed to be placing food in the steam table in the main dining room. It was observed there were no hand towels at the only hand sink available to food service staff. Again on [DATE] at 7:00 AM the hand towel dispenser was observed to be empty. An interview with [NAME] F was conducted at this time and asked if there were any hand towels who then stated I guess not. At the noon meal at approximately 11:45 AM the dispenser was still empty. This was brought to the attention of Certified Dietary Manager (CDM) A who promptly filled the dispenser. On [DATE] between 11:30 AM and 12:00 noon, [NAME] F was observed entering and exiting the door between the kitchen and the dining room where the steam table and food service was conducted. [NAME] F took a pair of gloves out of a box and placed them on her hands without washing her hands. On [DATE] at approximately 11:45 AM, the temperature of a container of pureed chicken, as identified by [NAME] F was measured and found to be 115 F. An interview with [NAME] F was conducted at this time and shown the temperature of the chicken, [NAME] F only replied Oh. When asked what the holding temperature was supposed to be, [NAME] F did not reply. At this same time, two ham and cheese sandwiches were observed sitting on a metal cart adjacent to the steam table. The internal temperature of the sandwiches was measured to be 51 F. No attempt at keeping the sandwiches cold was being made. The FDA Food Code 2017 states: ,d+[DATE].16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S,d+[DATE].19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in ,d+[DATE].11(B) or reheated as specified in ,d+[DATE].11(E) may be held at a temperature of 54oC (130oF) or above;P or (2) At 5 C (41 F) or less ,d+[DATE].12 Hand Drying Provision. Each HANDWASHING SINK or group of adjacent HANDWASHING SINKS shall be provided with: (A) Individual, disposable towels; (B) A continuous towel system that supplies the user with a clean towel; ,d+[DATE].14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S ,d+[DATE].12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (H) Before donning gloves to initiate a task that involves working with FOOD;

Intake: MI00141230 Based on interview and record review, the facility failed to implement abuse policies to report and investigate allegations of abuse for one Resident (R2) of three residents reviewed for abuse. This deficient practice resulted in the delay of investigation and the potential for continued abuse for facility residents. Findings include: Review of R2's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnose including depression, weakness, and pain. R2's Annual Minimum Data Set (MDS) assessment revealed she scored a 10/15 on the Brief Interview for Mental Status (BIMS) score indicative of mild cognitive impairment. Review of R2's Activity of Daily Living (ADL) care plan dated 11/17/22 read, in part, .Toileting: Resident required total dependence for toileting, check and change, provide peri-care Date Initiated: 8/23/23. Transfers: Resident requires Total/Hoyer .date initiated 11/17/22 . Review of the complaint filed with the state agency on 11/30/27 read, in part, Complainant states three days ago resident (R2) was sexually abused by resident (R3). Complainant states she went to do a two-hour check on the residents and found that (R2's) brief was open and there was paper towel in her vagina covered with feces. She states she notified two nurses and filed a complaint with the DON (Director of Nursing). The DON told the complainant that the concerns would be turned into the Administrator the next day. Complainant states she still hasn't heard anything back from the Adm. (Administrator) . An interview was conducted with the Nursing Home Administrator (NHA) and DON on 12/5/23 at approximately 10:00 a.m. The NHA and DON stated that they were notified of concerns between R2 and R3, and that R3 was trying to be helpful towards R2 when she begins to holler out for assistance. The NHA and DON stated that they did not believe it was a concern of abuse. An interview was conducted with Certified Nurse Aide (CNA) A on 12/5/23 at 11:57 a.m. CNA A stated that they were working the same hallway as R2 and R3 and was one of two CNAs to discover paper towel with feces in R2's brief on 11/26/23. CNA A stated R2 was completely dependent on staff for assistance with peri-care and could not have performed these actions by herself. CNA A stated that when the paper towel was discovered, they told Registered Nurse (RN) B and RN C immediately and notified the DON by text message. CNA A stated they felt that they were dismissed by the nurses and DON about these findings. CNA A stated that when R2 was asked who did this, she pointed to her roommate (R3). An interview was conducted with RN B on 12/5/23 at 12:15 p.m. When asked if CNA A had reported an allegation of abuse between R2 and R3, RN B stated, Yes, they did. RN B then stated that they were working overtime and attempting to complete their charting before going home and did not follow up with the allegation. RN B stated that she believed CNA A also notified RN C of the allegation and that RN C was responsible for following through. A phone call interview was attempted to RN C on 12/5/23 at 12:22 p.m. There was no return phone call before the exit date on 12/5/23. An interview was conducted with CNA D on 12/5/23 at 12:23 p.m. CNA D confirmed that she was working the same hallway that R2 and R3 lived on and was responsible for their care that evening. CNA C stated that she and CNA A went to do a check and change on R2, as R2 was dependent on two staff members for cares and discovered that her brief had been detached. CNA D stated that she found this suspicious because R2 was no longer able to perform these tasks. CNA D stated that when her and CNA A went to remove the brief from under R2, there was 2-3 paper towels in her brief covered in feces and a wrapped-up paper towel in her vagina. CNA D instructed CNA A to go notify the nurses. CNA D stated that when CNA A returned to continue care for R2, they stated that the nurses would notify the DON. CNA D stated that when asked who did this, R2 pointed to her roommate (R3). CNA D stated that following this incident, she had not been interviewed by any management or the abuse coordinator. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property policy dated 11/28/17 read, in part, .Investigation: It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated . a) Investigation of abuse. When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: who was involved, Residents statements, Resident's roommate statements (if applicable), involved staff and witness statements of events, A description of the resident's behavior and environment at the time of the incident, Injuries present including a resident assessment, Observation of resident and staff behaviors during the investigation, Environmental considerations .All staff must cooperate during the investigation to assure the reside is fully protected .Internal Reporting: Employees must always report any Abuse or suspicion of abuse immediately to the Administrator. The administrator will involve key leadership personnel as necessary to assist with reporting, investigation and follow up. The administrator will report to the Medical Director .

Based on observation, interview and record review, the facility failed to employ a dietary manger with the appropriate skills to carry out the food and nutrition services, as evidenced by the lack of having the proper credentials of a certified Dietary Manager (CDM) and being able to demonstrate adequate knowledge related to the operations of the kitchen. This deficient practice has the potential to create unsanitary conditions in the kitchen and result in menus which are inadequate for the dietary requirements of all 71 residents. Findings include: On 8/22/23 at approximately 10:30 AM, during the initial tour, Kitchen Manager (KM) A was interviewed related to certification as a dietary manager. KM A stated he was not a Certified Dietary Manager (CDM) but had recently taken the Serve Safe class. The following observations and interviews were made regarding determining KM As competency of the facility's kitchen manager: On 8/23/23 at approximately 11:41 AM Kitchen Manager (KM) A was observed as he entered the kitchen from the dining room, wearing gloves, then lifted the lid to a large 30 gallon garbage can and replaced the lid. KM A then walked into the dish room and began handling clean cups and glasses to be taken into the dining room for the noon meal service. KM A failed to wash his hands following the handling of the garbage can lid and the clean meal service wares. An interview was conducted at this same time with KMA, who was asked if he was aware of what he did wrong. KM A was unaware that he had failed to wash his hands. On 8/22/23 at approximately 10:15 AM, during the initial tour of the kitchen, it was observed the facility utilized a high temperature dish machine for the washing, rinsing and sanitizing of the food service equipment. Dietary Aide (DA) H was observed operating the dish machine and asked how the machine was monitored or tested to ensure proper sanitizing of food contact surfaces. DA H stated they simply read the gauges on the machine and record the readings. When asked if there were any devices, such as an irreversible thermometer or strips available to test the sanitizing cycle, DA H stated he was not aware of any. An interview was conducted immediately with KM A related to the testing of the dish machine and the availability of testing devices. KM A stated the facility did not have anything to test the machine with. When asked to demonstrate the last time the machine had been tested and shown to properly sanitize food contact surfaces, KM A was unable to find any documentation. KM A stated the facility had not had any since he arrived, and had been over two months. On 8/23/23 at approximately 8:15 AM, observations were made of the walk in cooler. Observed were: A large (greater than two gallons) stainless steel pan, labeled refried beans with a date of 8/22; A large stainless steel pan with no label (appeared to be ground beef) with a date of 8/22; and a stainless steel pan of pulled pork dated 8/20. The temperature of the refried beans was measured, using a steel probe digital thermometer and found to be 45 F; the ground beef was measured to be 43 F, and the pulled pork was 41 F. An interview with KM A was conducted at this time and was learned the ground beef was taco meat and was prepared on 8/22, as were the refried beans. KM A stated the containers were supposed to be labeled with an expiration date. Documentation of proper cooling was requested from KM A, who then reviewed the production sheets and reported no cooling documentation had been conducted for the refried beans, taco meat or the pulled pork. A review of the production sheets for the individual days identified on the pans was conducted and verified there was no documentation for any of the three products. KM A stated he would dispose of the products. On 8/23/23 at approximately 9:05 AM KM A approached this surveyor, in the presence of the Nursing Home Administrator (NHA) in the corridor and stated he had located the cooling log for the pulled pork. At approximately 9:10 AM, a document titled <food vendor company name and logo> Cooling Log was reviewed. The document contained a single entry dated 8/22, and identified the pulled pork being cooled. No time was or temperature was entered to show the product had reached 41 F in the required time frame. Further, the date on the pulled pork container in the walk in cooler was dated 8/20, and the cooling log indicated the date of the cooling process entry was 8/22. When this was brought to the attention of KM A and asked to reconcile the discrepancy, no explanation was offered. On 8/22/23 at approximately 2:00 PM, an interview was conducted with KM A related to the testing of sanitizing chemicals used in the three compartment sink and buckets for the wiping clothes. When asked how the solutions were tested , KM A stated We use strips. When asked how it was tested , and the product being used, KM A stated, parts per million.' KM A could not identify the chemical being used. KM A then pulled out QT _40 strips, used for testing Quaternary products, then produced chlorine test strips. When asked again which test strips were used and what the chemical being tested was, KM A walked to the three compartment sink, pointed to the container on the floor and stated That. We measure for that. The container was reviewed with KM A and shown the product contained Lactic Acid as the sanitizing chemical. KM A stated I didn't know that. When asked why directions for measuring and testing Quaternary (quat) solutions was posted over the sink, and a dispenser containing quat test strips was adjacent to the sink. KM A did not respond.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure staff person washed their hands after being potentially contaminated. 2. Failing to ensure the high temperature dish machine was being tested for proper sanitization of food contact surfaces. 3. Failing to properly cool potentially hazardous foods after cooking and before being served. 4. Failing to properly clean the exterior rind of melons prior to cutting and serving. 5. Failing to maintain kitchen/food service equipment in a sanitary manner. 6. Failing to ensure food brought in from outside the facility, for residents, was labeled and safe for consumption. 7. Failing to ensure the person in charge (PIC) was knowledgeable about food service sanitation issues in the kitchen. These deficient practices have the potential to result in food borne illness among any and all 71 residents of the facility. Findings include: 1. On 8/23/23 at approximately 11:41 AM Kitchen Manager (KM) A was observed as he entered the kitchen from the dining room, wearing gloves, then lifted the lid to a large 30 gallon garbage can and replaced the lid. KM A then walked into the dish room and began handling clean cups and glasses to be taken into the dining room for the noon meal service. KM A failed to wash his hands following the handling of the garbage can lid and the clean meal service wares. An interview was conducted at this same time with KMA, who was asked if he was aware of what he did wrong. KM A was unaware that he had failed to wash his hands. FDA Food Code 2017 states: 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; 2. On 8/22/23 at approximately 10:15 AM, during the initial tour of the kitchen, it was observed the facility utilized a high temperature dish machine for the washing, rinsing and sanitizing of the food service equipment. Dietary Aide (DA) H was observed operating the dish machine and asked how the machine was monitored or tested to ensure proper sanitizing of food contact surfaces. DA H stated they simply read the gauges on the machine and record the readings. When asked if there were any devices, such as an irreversible thermometer or strips available to test the sanitizing cycle, DA H stated he was not aware of any. An interview was conducted immediately with KM A related to the testing of the dish machine and the availability of testing devices. KM A stated the facility did not have anything to test the machine with. When asked to demonstrate the last time the machine had been tested and shown to properly sanitize food contact surfaces, KM A was unable to find any documentation. KM A stated the facility had not had any since he arrived, and had been over two months. FDA Food Code 2017 states: 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing. (A) In manual WAREWASHING operations, a TEMPERATURE MEASURING DEVICE shall be provided and readily accessible for frequently measuring the washing and SANITIZING temperatures (B) In hot water mechanical WAREWASHING operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the UTENSIL surface temperature. 3. On 8/23/23 at approximately 8:15 AM, observations were made of the walk in cooler. Observed were: A large (greater than two gallons) stainless steel pan, labeled refried beans with a date of 8/22; A large stainless steel pan with no label (appeared to be ground beef) with a date of 8/22; and a stainless steel pan of pulled pork dated 8/20. The temperature of the refried beans was measured, using a steel probe digital thermometer and found to be 45 F; the ground beef was measured to be 43 F, and the pulled pork was 41 F. An interview with KM A was conducted at this time and was learned the ground beef was taco meat and was prepared on 8/22, as were the refried beans. KM A stated the containers were supposed to be labeled with an expiration date. Documentation of proper cooling was requested from KM A, who then reviewed the production sheets and reported no cooling documentation had been conducted for the refried beans, taco meat or the pulled pork. A review of the production sheets for the individual days identified on the pans was conducted and verified there was no documentation for any of the three products. KM A stated he would dispose of the products. On 8/23/23 at approximately 9:05 AM KM A approached this surveyor, in the presence of the Nursing Home Administrator (NHA) in the corridor and stated he had located the cooling log for the pulled pork. At approximately 9:10 AM, a document titled <food vendor company name and logo> Cooling Log was reviewed. The document contained a single entry dated 8/22, and identified the pulled pork being cooled. No time was or temperature was entered to show the product had reached 41 F in the required time frame. Further, the date on the pulled pork container in the walk in cooler was dated 8/20, and the cooling log indicated the date of the cooling process entry was 8/22. When this was brought to the attention of KM A and asked to reconcile the discrepancy, no explanation was offered. FDA Food Code 2017 states: 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less 4. On 8/22/23 at approximately 11:25 AM, cook F was observed cutting up slices of watermelon and cantaloupe. An interview was conducted at this time with F to learn the process of cleaning the exterior of the melons prior to slicing. F stated the melons were simply put under some running water before slicing. F acknowledged the facility did not have a process to ensure the exterior rind had been properly cleaned, using a brush and/or a disinfecting solution, prior to pushing the knife through the rind and into the fruit center. FDA Food Code 2017 states: 3-302.15 Washing Fruits and Vegetables. (A) Except as specified in (B) of this section and except for whole, raw fruits and vegetables that are intended for washing by the CONSUMER before consumption, raw fruits and vegetables shall be thoroughly washed in water to remove soil and other contaminants before being cut, combined with other ingredients, cooked, served, or offered for human consumption in READY-TO-EAT form 5. On 8/22-23/23 observations of the kitchen equipment were made. The walk in cooler and walk in freezers were observed to have a silver seam tape hanging from the ceiling throughout both units. The gaskets on the [NAME] single door refrigerator, adjacent to the cooking equipment, was observed to have black mold in the accordion folds; the gaskets on the two door Traulsen refrigerator were torn and cracked; the three compartment sink was showing corrosion on the bottom of the sinks at the edges. The floor drain located under the three compartment sink was observed to have excessive garbage/food material as well as black mold growing on the drain pipes, with one of the drain pipes being from the ice machine. On 8/22/23 at approximately 1:45 PM, the nourishment room, near the south courtyard door, containing an ice machine was observed. The drain from the ice machine was draining into a plastic coffee cup on the floor under the counter the ice dispenser was located, and the wall, near the floor, to the left of the machine, was deteriorating due to water damage. Other food service items were stored in this room as well. FDA Food Code 2017 states: 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications 6. On 8/22/23 at approximately 10:55 AM, the nourishment room, near the front entrance and across from the nurses' station, was observed to have a refrigerator containing food for residents, brought in from outside sources. Two pint jars, containing, what appeared to be a tomato based food was observed on the shelf in the refrigerator. The product had a name, but was not labeled with a date it was brought in or when it was to be disposed of. This product was not commercially canned and prepared, rather, was a home canned product. A review of the facility's policy: Personal Food Guidelines dated 3.12.2018 was conducted. This policy stated: Food brought from outside sources by residents, friends or family will be stored in a designated location and labeled as such, separately from facility food. Labeling will include: Product name, Recieved date, use by date (no longer than 3 days), staff member's initials, Resident name. 7. On 8/22/23 and 8/23/23, throughout the observations of the kitchen, KMA was unable to demonstrate knowledge related to the use and testing of the sanitizing compounds used in the three compartment sink and wiping buckets, as well as testing of the high temperature dish machine. KM A failed to monitor staff related to the cooling of potentially hazardous food and ensuring the kitchen equipment was maintained in a clean and sanitary manner. On 8/22/23 at approximately 2:00 PM, an interview was conducted with KM A related to the testing of sanitizing chemicals used in the three compartment sink and buckets for the wiping clothes. When asked how the solutions were tested , KM A stated We use strips. When asked how it was tested , and the product being used, KM A stated, parts per million.' KM A could not identify the chemical being used. KM A then pulled out QT _40 strips, used for testing Quaternary products, then produced chlorine test strips. When asked again which test strips were used and what the chemical being tested was, KM A walked to the three compartment sink, pointed to the container on the floor and stated That. We measure for that. The container was reviewed with KM A and shown the product contained Lactic Acid as the sanitizing chemical. KM A stated I didn't know that. When asked why directions for measuring and testing Quaternary (quat) solutions was posted over the sink, and a dispenser containing quat test strips was adjacent to the sink. KM A did not respond. FDA Food Code 2017 states: 2-102.11 Demonstration. Based on the RISKS inherent to the FOOD operation, during inspections and upon request the PERSON IN CHARGE shall demonstrate to the REGULATORY AUTHORITY knowledge of foodborne disease prevention, application of the HAZARD Analysis and CRITICAL CONTROL POINT principles, and the requirements of this Code. The PERSON IN CHARGE shall demonstrate this knowledge by: (A) Complying with this Code by having no violations of PRIORITY ITEMS during the current inspection; (B) Being a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM; or (C) Responding correctly to the inspector's questions as they relate to the specific FOOD operation. The areas of knowledge include: (1) Describing the relationship between the prevention of foodborne disease and the personal hygiene of a FOOD EMPLOYEE; (2) Explaining the responsibility of the PERSON IN CHARGE for preventing the transmission of foodborne disease by a FOOD EMPLOYEE who has a disease or medical condition that may cause foodborne disease; (4) Explaining the significance of the relationship between maintaining the time and temperature of TIME/TEMPERATURE CONTROL FOR SAFETY FOOD and the prevention of foodborne illness; (5) Explaining the HAZARDS involved in the consumption of raw or undercooked MEAT, POULTRY, EGGS, and FISH; (6) Stating the required FOOD temperatures and times for safe cooking of TIME/TEMPERATURE CONTROL FOR SAFETY FOOD including MEAT, POULTRY, EGGS, and FISH; (11) Explaining correct procedures for cleaning and SANITIZING UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT;

THIS CITATION WILL HAVE THREE PARTS (A.; B.; C) EACH WITH INDIVIDUAL DEFICIENT PRACTICE STATEMENTS DPS A This citation pertains to intake MI00138612 Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed to ensure proper hand hygiene was performed 1). while assisting 1 resident (R21) to eat, 2). during medication administration/foley catheter care for 1 resident (R26), and resident specific equipment was intact for 1 resident (R21) of 18 residents reviewed for infection control, resulting in the potential of cross-contamination, and harborage of infectious diseases in a vulnerable population of 71 residents. Findings include: Hand Hygiene R21 According to the Minimum Data Set (MDS) 7/13/2023, R21 scored 2/15 (cognitively impaired), on his BIMS (Brief Interview Mental Status), required total dependence on one-person's physical assistance to transfer between surfaces and move about in the facility in a mobility device, with diagnoses that included dementia and a psychotic disorder. During an observation and interview on 8/22/23 at 1:00 PM Certified Nursing Assistant (CNA) N was assisting R21 with eating breakfast. The CNA lifted both resident's heels and felt the bottoms of them with her bare hands then continued to feed the resident without performing hand hygiene. While feeding the resident, CNA N dropped food on the floor and cleaned it up with a napkin from the resident's tray and continued to feed the resident without performing hand hygiene. While feeding R21, the CNA dropped R21's built-up fork on the floor, picked it up and set it on his tray, and continued feeding the resident without performing hand hygiene. CNA N stated, I did not think about cleaning my hands when I did that. I was nervous you were watching me. R26 According to the Minimum Data Set (MDS) 8/7/2023, R26 scored 15/15 (cognitively intact) on her BIMS (Brief Interview Mental Status), with diagnoses that included a neurogenic bladder and multiple sclerosis. During an observation and interview on 8/24/2023 at 8:15 AM, Registered Nurse (RN) L was passing morning medications to R26. R26 had a foley catheter hanging off the left side of the bed. R26 stated, I think my catheter bag is full. Look at this. R26 pulled her catheter tubing up from under the bed covers with yellow urine in it. RN L placed the medication cups on the bedside table, leaned over the resident and with both bare hands, took hold of the catheter tubing and pulled up the catheter bag stating, The bag is full and needs to be emptied. I'll have a CNA (certified nursing assistant) do it. Without performing hand hygiene, RN L picked up the medication cup with pills in one hand and in the other hand picked up the resident's personal drinking bottle, handing both to her. After the resident took her medication, RN L moved the bedside table closer to her. Meanwhile, R26's roommate asked for assistance with her breakfast. Without performing hand hygiene, RN L assisted setting up the roommate's breakfast tray. RN stated, I should have washed my hands after I touched the catheter for infection control. During an interview on 8/24/2023 at 12:20 PM the DON stated, Gloves should be worn when touching a foley catheter. Hands should be washed before and after touching a foley catheter. (R26's) foley catheter should not have been touched by the RN's bare hands. Equipment R21 According to the Minimum Data Set (MDS) 7/13/2023, R21 scored 2/15 (severely cognitively impaired), was totally dependent on physical assistance from staff to transfer between surfaces and transport around the facility with the use of a type of wheelchair (Geri-chair). R21 diagnoses included dementia. During an observation and interview on 8/22/2023 at 1:00 PM, R21's high-backed wheelchair had foam exposed to the environment through torn and missing material on the arms of the chair. CNA N stated, (R21) sits in it and goes out in the facility a couple of days a week. 45123 B.) Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene was performed during care provided for 3 of 4 residents reviewed for infection control practices. This deficient practice resulted in the potential for the development and spread of infection, and complications associated with infections. Findings include: This citation is related to intake #MI00138172. On 8/22/23 at approximately 10:30 AM, during entrance conference the infection control policies were requested from the Nursing Home Administrator (NHA). On 8/23/23 at 4:18 PM, a second request was made for infection control policies to the NHA. The policies requested were transmission-based precautions, infection surveillance, immunizations (influenza, pneumococcal, and Covid-19 for residents), antibiotic stewardship and over all infection control facility wide. Resident #17 (R17) On 8/24/23 at 8:06 AM, an observation was made of the NHA. The NHA was observed adjusting the catheter tubing of R17 off the floor without gloves on. After the NHA was finished adjusting R17's catheter he failed to immediately sanitize his hands. The NHA then walked down the hallway, entered room [ROOM NUMBER] briefly, and then exited. The NHA next proceeded to walked out down the hallway to the front of the building by the Director of Nursing (DON) office and touched his face/nose area and entered DON's office. On 8/24/23 at 8:15 AM an interview was conducted with the DON. The DON confirmed the NHA should have worn gloves to adjust R17's urinary catheter and should have used hand sanitizer or washed his hands immediately after he was finished. On 8/24/23 at 3:04 PM, a third request was made for current infection control polices to the Director of Clinical Operations. Review of facility policy, Infection Surveillance Guideline, dated 11/28/17, revealed a document that had not been revised or updated in over a year. Review of facility policy, Guideline for Standard and Transmission-based Precautions, dated 11/9/20, revealed a document that had not been revised or updated in over a year. Review of facility policy, Influenza Vaccination Guideline, dated 11/28/17, revealed a document that had not been revised or updated in over a year. Review of facility policy, Guideline for Administering Pneumococcal Vaccination, dated 4/1/22, revealed a document that had not been revised or updated in over a year. Review of facility policy, Infection Prevention and Control Guideline, dated 11/28/17, revealed a document that had not been revised or updated in over a year. Review of the surveillance monitoring for the infection control program, dated January 1, 2023 through July 31, 2023, revealed the most recent outbreak was June 2023 with Covid-19. 13791 C. Based on interview and record review, the facility failed to develop a comprehensive Water Management Plan (WMP) to address the control and spread of Legionella bacteria in the facility water system. The failure to develop a comprehensive Water Management Plan has the potential for the proliferation and transmission of Legionella in the circulating water of the building and the spread of Legionella infections in all 71 residents. Findings include: On 8/22/23 at 2:45 PM, a review of the facility's Legionella Plan was conducted. The following components were absent from the facility WMP: A. Designation of a Water Management Team (WMT). B. An assessment of the facility's water system to identify risk locations. C. Identification of control points where effective mitigation measures can used. D. Identification of set critical limits related to the risk areas identified and which can be controlled. E. Identification of defined control measures and locations related to risk and the critical limits which are set. F. Implementation of regular scheduled mitigation program. G. An evaluation process to determine how the WMP is functioning. On 8/23/23 at approximately 9:35 AM an interview was conducted with Maintenance Supervisor (MS) C regarding the facility's Legionella control program and water management plan. MS C stated that there was no documentation regarding any interventions to mitigate risk areas in the building for Legionella. C. Based on interview and record review, the facility failed to develop a policy and implement a procedure for the laundry department to ensure proper disinfection was occurring when transmission based precaution (TBP) sourced laundry was present in the facility. This failure has the potential to result in the transmission of pathogens to all 71 residents through the laundry process if proper disinfection parameters are not met. Findings include: On 8/23/23 at approximately 9:15 AM, observations of the laundry area were conducted with Environmental Services manager (ESM) D. ESM D described the cycles on the washing machines used to control TBP sourced (also referred to as isolation rooms) laundry. ESM D identified Cycle 3 as the cycle which was to be used and thought it contained a higher level of bleach. When asked about testing for the concentration of chlorine (bleach), ESM D stated that no testing or documentation was done to ensure the proper concentration was met during this cycle. ESM D stated that she was not aware of any policy or procedure that required this testing and documentation. As indicated above, during the review of the surveillance monitoring for the infection control program, it was noted the facility had an outbreak of Covid-19 in June of 2023, and required proper handling and disinfection of Transmission Based Precaution sourced laundry.

This citation pertains to Intakes #MI 046, #MI 044, #MI 222, #MI 046, and #MI 044. Based on observation, interview, and record review, the facility failed to ensure freedom from abuse for 10 Residents (#27, #50, #42, #35, #6, #18, #56, #64, #3, and #171) of 25 residents reviewed for abuse. This deficient practice resulted in pain, bruising, humiliation, embarrassment, fearfulness, increased anxiety, frustration, and feelings of being unsafe in the facility based on a reasonable person standard for residents with impaired cognition and verbalizations by cognitively intact residents resulting in an Immediate Jeopardy (IJ) to vulnerable resident's health and safety. The IJ was identified on [DATE] at 4:30 p.m., and it began on [DATE] when Resident #35 was first identified with bruising and swelling around her left wrist and allegations of potential abuse were not reported to the state agency, staff were not identified as potential perpetrators and continued to mistreat and abuse residents in the facility, and a complete investigation was not performed to identify the source of the injury of unknown origin. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy on [DATE] at 2:55 p.m., and a verbal request for an immediacy abatement plan was made to the NHA at that same time. Findings include: Resident #27 Review of Resident 27's Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #27 was admitted to the facility on [DATE] with active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #27 scored 14 of 15 on the Brief Interview for Mental Status (BIMS), reflective of intact cognition, and was able to clearly verbalize care needs. Resident #27 required dependent, two-person assistance with transfers, and extensive one to two-person assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #27 required a wheelchair for mobility. During an interview on [DATE] at 12:26 p.m., when asked about the care and treatment provided by staff, Resident #27 stated, [Certified Nurse Aide (CNA) F] is horrible! . He man handles me (is rough) when he dresses me. Resident #27 stated, You are almost afraid to open your mouth. He is like cruel or mean. I try to say, 'Please get my sling', (or) 'Don't forget my sling', and CNA F will say, I KNOW!! During the continued interview on [DATE] at 12:35 p.m., Resident #27 reported overhearing CNA I in the next room shouting at Resident #50, You just shut up and grab those things. Resident #27 said she also heard [CNA I] yell at Resident #50 and told him if he rang the call light one more time, [CNA I] would rip the call light out of the wall. Review of an Employee Discipline Form, Customer Service, and Speech in Public disciplinary education dated and signed [DATE] by CNA I revealed the following, I part: 1. Job performance/Behavior Deficiency: Made an inappropriate comment to a resident that was poor customer service. Specific Results Required for Acceptable Improvement: Speak with residents appropriately in a way consistent with good customer service. Failure to correct may result in progressive discipline leading up to and including termination . Speech in Public education included: .Sound carries further than you think. Frustration is understandable but be mindful of thinking and speaking . Documentation did not include any Resident involved with these concerns. Resident #27 stated, during that same interview on [DATE] at 12:35 PM, [CNA JJ] is dealing with a lot of frustrations and then she will come in and take it out on me. Resident #27 said she defecates (poops) on a pad placed underneath her on the bed. When asked why, Resident #27 said it was too much waiting for them to find a sling to get her out of bed. Resident #27 said recently [name of CNA JJ] had put a pad under her (for catching the bowel movement) when Resident #27 did not have to have a bowel movement and she told CNA JJ that she did not have to poop. CNA JJ told her to stay in bed longer and see if she could go (poop) for her. Resident #27 turned on the call light, and CNA JJ walked past her room, and asked Have you had a BM?. Resident #27 told CNA JJ that she did not have to have a bowel movement, so CNA JJ said Then I will come back when you have a BM. Resident #27 said she stayed in bed all day that day, and since that day CNA JJ would sarcastically ask if Resident #27 had to have a BM. During a repeat interview on [DATE] at12:21 p.m., Resident #27 asked me to come into her room, to shut the door, and whispered, I am afraid they are going to retaliate against me. Resident #50 Review of Resident #50's MDS assessment, dated [DATE], revealed Resident #50 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #50 scored 15 of 15 on the BIMS reflective of intact cognition and was able to verbalize care needs. Resident #50 required one-person physical assistance with dressing, toileting, and personal hygiene, was independent in eating and bed mobility, and required supervision with transfers, and walking in room and hallways with a walker. During an interview on [DATE] at 1:10 p.m., Resident #50 was asked about any mistreatment in the facility. Resident #50 stated, Yes, staff have been disrespectful. They get right in my face and say 'SHUT UP! SHUT UP!'. I am tired of it. They can't talk to me in a normal voice. They yell at me. 'Yell' is a small voice - they shout at me. I have talked to (facility) administration, but it seems like (it is) falling on deaf ears. Nothing happens . They (facility staff reported for potential abuse) should have been suspended, especially when they grabbed my arm. Resident #50 said facility staff CNA J had grabbed his arm causing a bruise on his right arm. When asked why CNA J had grabbed his arm, Resident #50 stated, [CNA J] told me I was not listening to her. During the same interview on [DATE] at approximately 1:15 p.m., Resident #50 said [CNA F] gets right in my face (and says), I said shut the F*ck *p!. Resident #50 quietly asked this Surveyor to make sure no one was outside the door listening to what he was saying, and stated, [CNA] F has ears listening on everything. Resident #50 said that he was afraid of CNA F and commented that he would normally challenge him (CNA F), but he was [AGE] years old, and too old to be fighting. During a repeat interview on [DATE] at 1:05 p.m., Resident #50 confirmed it was CNA I who threatened to rip the call light out of the wall if he rang the call light one more time, confirmed CNA J grabbed his arm causing a bruise, and confirmed CNA F . gets in his face and screams . Resident #50 said he has told the charge nurse, the floor nurse, and the Nursing Home Administrator (NHA) when he could find him but that it doesn't matter what he says because nothing changes. Resident #50 stated, I asked them if they could just move me so I could get away from them. I was really afraid of him (CNA F) . During an interview on [DATE] at 1:15 p.m., the NHA reported to the survey team that CNAs F and J had been suspended and reported to the State of [State Name] for the allegations of abuse identified and reported to the facility administration by the survey team on [DATE], during the survey. Resident #35 Review of Resident #35's MDS assessment, dated [DATE], revealed Resident #35 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35 scored 7 of 15 on the BIMS reflective of moderately impaired cognition. Resident #35 required extensive two-person assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #35 used a walker or wheelchair for mobility. During an interview on [DATE] at 5:13 p.m., CNA F confirmed there was a Resident (#35) who had a bruise found on their wrist/hand. CNA F said he had worked the day or two before taking care of Resident #35 and the bruise was not present on their left wrist at that time. As soon as he saw the bruise, CNA F reported it to the nurse and pictures were taken. CNA F stated, You could just see a horseshoe (bruise pattern) on their wrist. The NHA was informed the same night, and witness statements were completed. Review of Resident #35's progress note, dated [DATE] at 23:06 (11:06 p.m.), revealed the following in part: .Staff went into room to take care of her and found that her left wrist was bruised and bruised completely around her wrist . Review of two photographs taken on [DATE], and documented in the Electronic Medical Record (EMR) included the following information regarding Resident #35's wrist bruise: Time of 22:37 (10:37 p.m.), .Bruise . Minutes old . Not Set . The two black and white photographs show an elevated, and what appeared to be swollen discoloration that nearly surrounded Resident #35's left wrist. Review of Witness Statements related to Resident #35's left wrist bruise included the following: 1. CNA F, [DATE], I worked on Saturday night and when we changed the resident in [room number] we didn't notice any bruise on her arm. When we went to change the resident in [room number] (on Sunday) we noticed a bruise on her left forearm by her wrist. We informed the nurse, and he took pictures of the bruise. 2. Registered Nurse (RN) Z, [DATE], Worked Saturday with resident and did not notice bruising on her left wrist. Worked with resident Sunday, which she slept most of the shift. The staff came and got me to look at her wrist later that Sunday night to look at her wrist. I took a couple of pictures and assessed for swelling, pain, and mobility. Resident could not tell me how it happened . During an interview on [DATE] at 5:45 p.m., the NHA and Director of Nursing (DON) acknowledged there was a file about that. When asked if a bruise similar in shape to someone's hand would be suspicious, the NHA stated, I would have to look back at the file. The DON stated, I would find that a suspicious bruise on Resident #35's wrist. It would be a bruise of unknown origin and further investigated. No incident report was completed, nor was an investigative summary present in the investigative file. During an interview on [DATE] at 4:30 p.m., the NHA reviewed the photographs of Resident #35's left wrist and confirmed that the wrist did appear to be a hand grip on the wrist and appeared slightly swollen in the picture. When asked what he would do if he received a similar picture and allegation of abuse, the NHA said he would report it immediately. The NHA and DON confirmed Resident #35's bruise of unknown origin was not reported to the State Agency (SA) prior to discovery of the incident by this Surveyor. During a telephone interview on [DATE] at 2:17 p.m., when asked about any potential abuse that may have occurred resulting in Resident #35's left wrist bruise, Staff G reported hearing and seeing CNA E on [DATE], come around the corner of the nurse's station and loudly say Resident #35 had disrespected him, and he was not going to take care of her anymore. CNA E changed Resident #35's brief after a bowel movement and Resident #35 had attempted to smear feces on CNA E. He appeared angry and agitated to Staff G. Staff G expressed concern over Resident #35's bruised wrist . after what had been going on around here (repeated allegations of abuse and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff G was not asked for, nor did she complete, a witness statement related to Resident #35's bruise. Review of CNA E's Timecard for [DATE] Saturday before the bruise appeared on [DATE], revealed he worked on [DATE] from 2:35 p.m. to 7 a.m., for a total of 15.08 hours. During an interview on [DATE] at 04:14 p.m., the DON was asked if the facility had completed an investigation of Resident #35's bruise, since brought to light by the survey team. Regional Director Q, also present during the interview, reported CNA F was terminated from employment at the facility. The DON said the employees involved no longer work at the facility and he felt the situation had been properly handled. When asked if the DON had knowledge of the observations of Staff G on [DATE] (day before bruise identified) related to CNA E and Resident #35, the DON reported being unaware of that information. When asked what difference that information would have made in the completion of his abuse investigation for this Resident, the DON stated, If I had first-hand knowledge of the bruise, at the front line of this investigation and had knowledge of the nature of the injury, the timeline of the reported behavior before the injury and a statement of a witness I would have to substantiate that. Resident #42 Review of Resident #42's Significant Change MDS assessment, dated [DATE], revealed Resident #42 was readmitted to the facility on [DATE], with active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #42 scored 15 of 15 on the BIMS, reflective of intact cognition and was able to clearly make needs known. Resident #42 required extensive, two-person assistance with bed mobility, transfers, dressing, toileting, and one-person physical assistance with personal hygiene. Resident #27 did not ambulate and required a wheelchair for mobility. Review of Resident #42's progress notes, revealed the Resident was readmitted to the facility on [DATE] following a surgical below the knee amputation (BKA) of the right leg. Review of the facility Incident Report submitted to the State Agency detailed the following [DATE] incident involving Resident #42: . [PT (Physical Therapist) MM] heard the resident (Resident #42) express pain by saying ow . CENA NN (1099 Contract Nurse) asked resident to roll this way and roll that way. Resident replied I can't do it, to which CENA NN replied by asking resident to bend his leg to enable him to be changed due to brief being wet . PT MM was assisting Resident #42's roommate, behind the room curtain, and could clearly hear the interaction occurring. Review of PT MM's Witness Statement, signed [DATE], revealed the following, in part: I was treating a patient in [Room Number] when the CENA came in to answer the light. I then told her that 'He is wet and needs to get changed.' I then started hearing the patient (Resident #42) screaming in pain as he was getting changed. I heard the CENA ask the Pt. (patient) to 'roll this way, roll that way', and Pt kept on screaming in pain and saying, 'I can't, I can't do it. The CENA then said something about 'Well I can't do this if you can't do it and bend your leg'. Pt kept on screaming in pain and finally said 'STOP', 'GET YOUR HANDS OFF ME', 'GET OUT'. Then the CENA stated, Hey Therapy can you tell him to move so I can change him . Review of Social Workers (SW) PP's Witness Statement, dated [DATE], revealed the following, in part: .Rehab Director OO informed SW that he and PT MM reported concerns to abuse coordinator (NHA). SW followed up with abuse coordinator on ,d+[DATE]. Review of a typed document, signed (typed signature) and dated [DATE] by the NHA, revealed the following, in part: I received a call from Regional Director Q that she had feedback that PT MM was adamant that abuse occurred between CENA NN and [Resident #42]. I met with PT MM .and he stated he had shared a concern he had (regarding potential abuse) and that he did have a determination on abuse . Review of the Staff Follow-Up form, signed and dated [DATE], revealed the following staff education for CNA NN: Resident concern regarding care: Customer service lacking in terms of resident-centered care. Relevant education provided previously to employee: Further related concerns have potential to result in termination of contract. During an interview on [DATE] at 5:33 p.m., Human Resources (HR) Director U was asked about CNA NN's departure from employment at the facility. HR U said CNA NN had threatened (retaliated for reporting concern with potential abuse) PT MM in the facility parking lot and been terminated from employment. During an interview on [DATE] at 12:47 p.m., when asked if he had any concerns with verbal or physical abuse while in the facility, Resident #42 said there had been two staff members that were rough with him. Resident #42 stated, I had a sore on my foot that got infected, gangrene set in and went into the bone. They took my right leg off, six inches below the knee, and I had just returned from the hospital. I was sitting in my wheelchair . these two guys (CNA D and CNA E - both 1099 individually contracted CNAs) came in because I had my light on and wanted to be put to bed. These two guys picked me up under my armpits and threw me on the bed, and said, You are a [NAME]. You are evil. Resident #42 said he was told by management (NHA) the two guys were no longer working, but Resident #42 said he had seen them in the hallways. Resident #42 told the NHA that he did not want them near him because of the way they treated him and what they said to him. Resident said it was extremely painful, on his newly amputated right leg, and he told them to get out of his room. Resident #42 expressed fearfulness of further mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 4:04 p.m., the NHA confirmed he had investigated CNA D and CNA E and considered this a customer service infraction, not abuse. Both staff were educated on [DATE], by the DON. During this interview, the NHA said they were not able to terminate the 1099 contract CNA's because they would threaten to sue the facility for termination of their contracts. The contracts for both CNA D and CNA E expired on [DATE]th, 2022. During an interview on [DATE] at 5:45 p.m., the DON and NHA were asked if there were any concerns with the individually contracted 1099 CNA staff. The DON stated, The 1099 staff (including CNAs D and E) came with their own way of doing things. I tried to work with a few of them (1099 contract CNAs) .but they were un-coachable . They came and went as they pleased. They were rude to staff. The other problem we had was [Resident #42]. There are two separate occasions (with abuse allegations against 1099 contract staff: CNA NN and CNAs D and E). The DON said the 1099 CNAs would not do what they were supposed to do for the residents. The DON acknowledged refusing to provide needed care and services to the facility residents was potentially neglect. Review of the Investigation Summary dated [DATE] concluded: Abuse has not been substantiated. Staff denied the allegations and other residents did not share concerns regarding the two CNAs. The CNAs were educated on care and customer service prior to return. Review of the Employee Coaching Form for both CNAs D and E, both dated and signed on [DATE], revealed the following education, in part: Safe Transfer Technique: Slick (sliding) Board, Mech (mechanical) Lift, Customer Service . The form was completed and signed by the DON, with attachments related to the education. Review of the facility Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property policy, effective date [DATE], revealed the following, in part, .Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation, or misappropriation shall immediately report to the Nursing Home Administrator. The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements immediately ., Verbal Abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability ., .Mental Abuse includes but is not limited to, humiliation, harassment, threats of punishment, deprivation .or comments about a resident or a resident's needs ., .Mistreatment means inappropriate treatment or exploitation of a resident, .Neglect is the failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress ., . Residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection . The facility is to monitor staff for burnout, which could lead to the potential maltreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility will protect reporting individuals from potential retaliation . Resident #6 Review of Resident #6's Minimum Data Set (MDS) assessment, dated [DATE], showed an admitted [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6 required at least two staff physical assistance for the following: bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. One staff assistance was needed for eating. The same MDS assessment showed transfers between bed and chair, or wheelchair were not steady, and Resident #6 could only stabilize with human assistance. The Brief Interview for Mental Status (BIMS) score was ,d+[DATE] which was reflective of intact cognition. During an initial tour interview on [DATE] at 2:44 p.m., Resident #6 was asked if they had experienced any abuse and/or if they felt safe in the facility. Resident #6 indicated that they did not and explained why. Resident #6 said around the end of March or beginning of [DATE], two male Certified Nurse Aides (CNA C and CNA D) were performing a full body lift from an electric wheelchair to the bed. Resident #6 explained how they felt the two CNA's were impaired with marijuana use since they were not paying attention, had a strong and distinct odor of marijuana, and red colored eyes. Resident #6 said while the transfer was in progress, and the two CNAs were talking about personal matters over top of him, the lift started to shift and tilt which caused Resident #6's head to lower and their feet to raise. Resident #6 said their right arm was completely dangling outside of the sling. Resident #6 described the fear of falling, hopelessness, and feelings of panic they had felt at that time. Resident #6 said they'd desperately attempted to swing all possible strength to secure their feet/legs around the end of the transfer lift to prevent from falling. Resident #6 said they had talked with the same CNA's in the past and told them they should not be working impaired. When this Surveyor asked what either CNA C or CNA D said after he talked to them previously about suspected marijuana use, Resident #6 said CNA C said, Oh, what do you mean?. During the same interview on [DATE] at 2:44 p.m., Resident #6 said that when the same two CNA's (CNA C and CNA D) had previously worked, they left him in a soiled brief of urine and feces for over four hours during the night. Resident #6 said that he relayed his incontinence concern to an unidentified, female nurse at 6:30 a.m. and was told the next shift would help (him). Resident #6 also explained how CNA C, twice in one day, had abruptly left the bedside while being assisted with eating and didn't return until one hour later. Resident #6 expressed feelings of being very upset, feelings of being defenseless since they can only use their voice. Resident #6 said they felt targeted by CNA C and CNA D since he had voiced concerns. Resident #18 According to the Minimum Data Set (MDS) assessment, dated [DATE], showed Resident #18 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The same MDS assessment indicated one staff physical assistance was needed for bed mobility, transfers, walking, dressing, toilet use, and hygiene. Resident #18 had both upper and lower functional limitations in ROM (range of motion). The Brief Interview for Mental Status (BIMS) score was ,d+[DATE] which resulted in intact cognition. During an interview on [DATE] at 3:11 p.m., Resident #18 was asked about an altercation which occurred between CNA D and CNA DD on [DATE]. Resident #18 said he was sitting in his room watching TV when he heard a commotion playing out in the hallway. Resident #18 went out into the hallway to see what was happening when he saw CNA D push CNA DD against the wall by her upper chest/neck. Resident #18 said he was upset to see a man put his hands on a woman and attempted to stop what was happening. Both CNA D and CNA DD were shouting and using foul language towards one another. Resident #18 described how CNA D pulled out his cellphone and said he was going to record CNA DD when CNA DD smacked the cellphone out of CNA D's hand. Resident #18 said they (CNA D and CNA DD) took it up front (fighting). Resident #18 reported seeing CNA D later the same night and had noticed that CNA D was wearing a hospital bracelet. During the same interview on [DATE] at 3:11 p.m., Resident #18 was asked if he had any other concerns with staff when he mentioned a time when CNA C grabbed him by the neck to spin him around during a pivot transfer. Resident #18 said CNA C was alone and had not used a gait belt. Resident #18 said he expressed to CNA C that he was very upset, and that CNA C told him, 'You're ok. Another instance mentioned involved CNA D and CNA E where Resident #18 believed them to be under the influence of marijuana. Resident #18 said he'd told both of them not to use marijuana while they were working. When asked why he felt the two CNA's had used marijuana, Resident #18 responded that he could smell it on them. Resident #18 said when CNA C and CNA E were working, they would clip his call light to the wall so he could not access it for assistance. This Surveyor asked if he had ever reported his concerns, Resident #18 responded that he told the Director of Nursing (DON) in June (2022) what was going on: CNA's were leaving the building on extended breaks during the night, CNA's marijuana use, personal cellphone use with CNA's around him, taking his call light away (clipped to wall) making it inaccessible to reach, and not getting assistance for getting ready for bed until after midnight or 1:00 a.m. (bedtime preference between 9:30 p.m.-10 p.m.). When asked what the DON response was to his concerns, Resident #18 said that the DON indicated he would look into it but never followed-up. Resident #18 also recalled notifying the Nursing Home Administrator (NHA) when an unidentified, female CNA told him that he needed to find another place to live because the facility was not equipped for his injury. Resident #18 said he did not want for that same CNA to ever enter into his room again. Resident #18 said the same female, unidentified, day-shift CNA returned to his room while he was having a window visit with his son. Resident #18 said that he was very mad, depressed, and felt hopeless since he did not have another place to go. During an interview on [DATE] at 6:15 p.m. with the (former) Nursing Home Administrator (NHA) and DON were asked about any concerns with contracted CNA's. The DON said there was a gamut of problems. When asked to elaborate, the DON said the CNA's would come in and do things their own way rocking the boat. The DON said the facility let their contracts run out. The DON identified concerns involving CNA D and CNA E such as being rude to staff, taking extra breaks, and when the nurse asked for them to do something-they wouldn't do it. The DON said they (night shift contracted CNAs) kind of operated with an attitude. The DON also said the same CNA's would argue with the nurses, would not take vital signs, and name calling about (facility name). The DON acknowledged an investigation by State CNA Licensing Board had occurred which involved Resident #6's transfer which almost resulted in a fall. The DON also said CNA C took long breaks, showed up late for work, was argumentative with staff and used marijuana. The DON said he performed audits (unable to provide evidence when Surveyor requested) and reported to work at 5 a.m. to oversee the same CNAs. When asked if improvement occurred, the DON responded that they were un-coachable and un-trainable. Marched to their own drum. During an interview on [DATE] at 8:39 a.m., Registered Nurse (RN) N said some residents were screened for potential abuse concerns on [DATE] due to an allegation of physical mistreatment which was a Facility Reported Incident. RN N said that she screened Resident #18 and learned of CNA D and E were inappropriate with him by use of foul language, talking on their cellphones in his room, and referring to other staff as hicks. Resident #18 said he did not want either CNA D or CNA E to provide any cares for him. RN N said she also screened Resident #6 who relayed rough treatment by CNA C, CNA D, and CNA E and an unsafe transfer. RN N said she was aware of statements made in the hallway that CNA C and CNA D had withheld meal trays for both Resident #6 and Resident #18. RN N said she verbally reported the residents' concerns to the DON. During an interview on [DATE] at 4:46 p.m., Regional Director (Staff) Q, with Regional Director of Clinical Operations/RN R, said the facility had identified there was a concern with their leadership following guidance for abuse concerns. Staff Q said residents were screened and additional concerns were identified by their team regarding residents and their NHA not fully investigating abuse concerns. Four additional resident abuse concerns were identified. Staff Q confirmed the facility's policy was to immediately suspend any staff involved in an allegation of abuse and to begin an investigation. Staff Q said it would not be acceptable for staff to be using marijuana when working. During an interview on [DATE] at 6:28 p.m. Staff U said they received a video clip from [DATE] on their work cellphone regarding a staff to staff altercation from CNA C. Staff U acknowledged viewing the video but denied knowledge of whether residents had witnessed the event. Upon review of the video on [DATE] during the 6:28 p.m. interview with Staff U, Resident #18 was visualized and heard speaking. The two staff involved in the verbal and physical altercation involved CNA D and CNA DD. The altercation took place in a resident care hallway. Another unidentified, female resident was visualized in the hallway that was a witness to the altercation RN RR was also observed within the video clip. Staff U was asked if the police were notified by the facility and responded they were not aware. Staff U indicated the facility did not have evidence of a police report. During an interview on [DATE] at 2:52 p.m., Staff U when asked if the facility had notified the police on [DATE] of the altercation between CNA C and CNA DD, responded, they believed CNA D had called the police. When asked if witness statements were completed, Staff U [TRUNCATED]

This citation refers to intakes MI# 222, 046, and 044. Based on observation, interview, and record review, the facility failed to ensure that all allegations of abuse were fully investigated for six Residents (#3, #35, #50, #64, #65, #171) out of 25 reviewed for abuse and neglect. This deficient practice resulted in incomplete abuse investigations which resulted in perpetrators being allowed to continue working putting the entire resident population at risk. Findings include: Resident #171 A review of a facility incident report investigation provided by the Administrator on 6/29/22 revealed the following: . On 4/28/22 at 6:30 AM, CNA (CNA D) was walking along the hall to do rounds and observed (Resident #171) seated on the floor through the doorway. CNA (CNA D) said that the call light was not on and the resident was not calling out . Resident was position across from their bed leaning against the dresser. CNA (CNA D) then got LPN (LPN T and the CNA (CNA E) . Resident was assisted from the floor. Resident's walker was next to the bed and their concentrator was running with the tubing stretched toward resident but was off due to the tubing not being long enough to reach resident at their position from the bed . LPN (LPN T) was interviewed and stated that she had been in the room previously in the night . (Roommate of Resident #171) said he (roommate) was in bed through the night and had the curtain pulled so he did not witness anything on (Resident #171's) side of the room . Resident did not report complaints of pain initially but when therapy staff went to resident's room to being therapy session later that morning, resident was unable to complete session due to pain . Resident was diagnosed with left [CONDITION(S)] at the hospital . Staff had seen resident prior to fall and resident was lying in bed with no concerns . Further review of this report and witness statements revealed no investigation into the last time Resident #171 had been observed by staff. Per the report, the video surveillance of the hallway was not reviewed to determine how long Resident #171 had been lying on the floor without his oxygen infusing. The investigation failed to rule out neglect of this resident which resulted in a fall with fracture and a lack of oxygen. A review of a Post-Fall Evaluation completed by LPN T on 4/28/22 revealed the resident reported a pain level of 0, was oriented to person, place, time and situation, and could move all extremities with no issues. A review of the Radiology report for Resident #171 dated 4/28/22 revealed, Acute mildly displaced transcervical left [CONDITION(S)]. The left femur is foreshortened . A review of Resident #171's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of his 5/22/22 MDS assessment revealed he scored 15/15 on the BIMS assessment indicating intact cognition. On 6/28/22 at 6:07 p.m., the DON was asked about the fall on 4/28/22 and the investigation file he had completed. The DON reported that he did the fall investigation and that the administrator had done the investigation regarding the injury from the fall. The DON was asked about the conflicting statements and the lack of note about the last time the staff had seen and cared for the resident, but provided no answer. When asked if the camera footage had been reviewed to determine the last time the Resident was cared for in order to rule out neglect, the DON reported he had not reviewed the camera footage from that particular incident. On 6/29/22 at 4:01 p.m., an interview was conducted with Occupational Therapist (OT) BB who worked with Resident #171 the morning of 4/28/22. When asked about the morning, OT BB reported, When I got there he was sitting in an arm chair. He said he was fine, and that he 'thought he took a fall last night'. When asked if the Resident reported any pain, OT BB reported the resident said, It really hurts and reported 10 out of 10 and 20 out of 10 on the pain scale. OT BB reported she wasn't even able to assist the Resident to stand. Resident #3 A review of Resident #3 medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 6/16/22 MDS assessment revealed she scored 15/15 on the BIMS assessment, indicating intact cognition and required the extensive assistance of one staff for transfers, bed mobility, and personal hygiene tasks. A review of an investigation for Resident #3 revealed the following: Incident date: 6/16/22 . Resident expressed concerns . about CNA (Name of CNA F) being mean and rude to her, trying to intimidate her, yelling at her, cursing in her room, having a bad attitude, throwing things, and refusing to do her care/ADL (activities of daily living) the way she asks and insists on doing it 'his' way .6/28/22 (Name of Administrator) spoke with resident Summary of Findings: Residents concerns were consistent with staff approach and customer services. Resident concerns were approximately one month ago and staff member had been educated on the relevant areas since resident said the concern occurred. Concerns were determined to not be abuse . Resolved date: 6/27/22 . On 6/27/22, CNA F was asked about the allegations that Resident #3 had reported about him. CNA F was unaware of the allegations and reported that the Administrator had never interviewed him about it. On 6/27/22 at approximately 5:00 p.m., the Administrator was asked about the allegations made by Resident #3. The administrator reported that he talked to Resident #3 and she didnt have any further concerns, and that CNA F had already been educated from a different situation. When asked if he had interviewed CNA F about the allegations, the Administrator reported that he had not. Resident #65 A review of a Facility Investigation dated submitted on 3/29/22 involving Resident #65 revealed the following: .On 3/28/2022, resident stated they received a pill that did not look like the [MEDICATION(S)] they are scheduled. Resident stated the pill they received was white and round like an [MEDICATION(S)] but did not have the same markings. When asked if the nurse was present in the room at the time, the resident replied that they had not asked the nurse about it. Resident said they did ultimately take the pill and continued that the taste was different from an [MEDICATION(S)] when they bit into it The resident said they had taken a picture of the pill with their phone which was shown to (name of Administrator). The picture showed a pill that did not have a marking on the visible side. The nurse was (LPNX) and she was suspended pending investigation. (LPN X) was interviewed and stated she did not give resident anything other than what was ordered . The narcotic counts were reviewed in the building and no concerns were noted . A PRN Tylenol was given to the resident at 1:22 AM and the resident had taken a photo of the pill with their phone at 1:27 AM. The photo matched the description of a Tylenol. The resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #65's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of her 3/10/22 Minimum Data Set (MDS) assessment revealed she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating intact cogntion and had received scheduled pain medication. A review of the March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A PRN Tylenol 650 mg was documented as given on 3/27/22 at 1:22 a.m., with effectiveness marked as U meaning unknown per the key. On 7/6/22 at 12:20 p.m., an interview was conducted with Resident #65. When asked about the investigation into the medication concern, Resident #65 reported that it was not the first time that she had a concern with her medications and LPN X. Per resident #65, LPN X had given her a similar white unmarked pill earlier in the month, but she took it because she told her it was her [MEDICATION(S)]. Resident #65 further reported it was the second time it happened, and she bit into it and knew that it was not [MEDICATION(S)] or anything else she was taking, and that she reported the concern. Resident #65 was asked if it was a prn Tylenol, but she denied that it was and reported that she had not asked for an as needed medication at that time. When asked what the facility had told her about the outcome of the investigation, Resident #65 reported they told her that they were watching her (LPN X). Per Resident #65, LPN X was no longer working in the building. Further review of Resident #65's Controlled logs for March 2022 revealed the following: The [MEDICATION(S)] 5 mg log received 3/7/22 revealed on 3/10/22 LPN X had wasted one dose as Dosage change not given but it was not signed by a second nurse to verify. Per the record there were 21 remaining doses on 3/10/22. LPN X and RN Z signed the disposition of doses on 3/10/22 but did not indicate the number of doses that were disposed. On the [MEDICATION(S)] 10 mg log received on 3/3/22 revealed that two dose on 3/21/22 at 0000 and 0600 had no name of the person giving the medication noted. On the [MEDICATION(S)] 10 mg log received on 2/24/22, the last 5 lines (line 21-25) had no date of when they were dispensed. Further review of the controlled medication logs for March 2022 revealed 25 Residents with discrepancies and errors, indicating a through investigation into the allegation of missing narcotics had not been completed. Resident #50 Review of Resident #50's MDS assessment, dated 6/2/2022, revealed Resident #50 was admitted to the facility on [DATE], and scored 15 of 15 on the BIMS reflective of intact cognition. Resident #50 was able to verbalize care needs. During an interview on 6/27/22 at 1:10 p.m., Resident #50 was asked about any mistreatment in the facility. Resident #50 stated, Yes, staff have been disrespectful. They get right in my face and say 'SHUT UP! SHUT UP!'. I am tired of it. They can't talk to me in a normal voice. They yell at me. 'Yell' is a small voice - they shout at me. I have talked to (facility) administration, but it seems like (it is) falling on deaf ears. Nothing happens . During a repeat interview on 6/28/22 at 1:05 p.m., Resident #50 confirmed it was CNA I who threatened to rip the call light out of the wall if he rang the call light one more time, confirmed CNA J grabbed his arm causing a bruise, and confirmed CNA F . gets in his face and screams . Resident #50 said he has told the charge nurse, the floor nurse, and the NHA (when he could find him) but it doesn't matter what he says because nothing changes. During an interview on 6/27/22 at 5:45 p.m., when asked about any concerns with CNA F the NHA stated, We thought professionalism was the issue with [CNA F] . I told him (CNA F), 'You have to fake it. He comes off flat. He does communicate like that in general . He does work a lot of shifts. There has to be an element of fatigue . so we shifted him to days and we provided education . The NHA acknowledged he had been informed of allegations of potential abuse related to Resident #50 and CNA F, but no allegations had risen to the level that the NHA felt needed to be reported to the State Agency. The NHA acknowledged complete investigations were not completed, and CNA F was not removed from resident care until the survey team identified multiple allegations of potential abuse for multiple residents including Resident #50. Resident #35 Review of Resident #35's MDS assessment, dated 5/12/2022, revealed Resident #35 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35 required extensive two-person assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. During an interview on 6/27/2022 at 5:13 p.m., CNA F confirmed there was a Resident (#35) who had a bruise found on her wrist/hand. CNA F said he had worked the day or two before taking care of Resident #35 and the bruise was not present on her left wrist at that time. As soon as he saw the bruise, CNA F reported it to the nurse and pictures were taken. CNA F stated, You could just see a horseshoe (bruise pattern) on her wrist. The NHA was informed the same night, and witness statements were completed. During an interview on 6/27/2022 at 5:45 p.m., the NHA and Director of Nursing (DON) acknowledged there was a file about that. When asked if a bruise similar in shape to someone's hand would be suspicious, the NHA stated, I would have to look back at the file. The DON stated, I would find that a suspicious bruise on Resident #35's wrist. It would be a bruise of unknown origin and further investigated. A complete investigation was not conducted to ascertain any potential perpetrators related to Resident #35's bruised left wrist identified on 5/15/22. No incident report was completed, nor was an investigative summary present to show the facility's determination regarding Resident #35's injury of unknown origin. Resident #64 Resident #64's face sheet revealed an original admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #64's MDS dated [DATE] contained a BIMS score of 13/15, indicating Resident #64 remained cognitively intact. During an interview with Registered Nurse (RN) G on 06/27/22 at 03:11 p.m., RN G said there had been an incident involving Certified Nurse Aide (CNA) C with Resident #64. RN G was unable to recall the date the incident had happened. RN G reported she had heard CNA C yelling at Resident #64. RN G entered Resident #64's room and observed CNA C in Resident #64's face screaming at her to get off the floor. RN G clarified Resident #64 often laid on the floor and this was included in her care plan. RN G reported she had tried to intervene and remove CNA C from Resident #64's room but he only became more agitated. RN G said she had to physically remove CNA C from Resident #64's room and voiced concerns that he would become physically abusive. RN G said she ensured Resident #64 was all right and then immediately verbally notified the former Nursing Home Administrator about the incident. RN G said the state CNA licensing department had been in to investigate the incident but was unable to provide any furhter information. During an interview with the former Nursing Home Administrator (NHA) and the former Director of Nursing (DON) on 6/28/22 at 3:22 p.m., it was confirmed RN G had notified the former NHA of the incident which had occured concerning CNA C and Resident #64. The former NHA reported he had went down and talked to Resident #64 about what had taken place. The former NHA said he did not gather witness statements from RN G, CNA C, Resident #64, or other individuals who may have been able to provide information regarding the incident. The former NHA said his impression was that CNA C had needed further customer service education and did not feel as though his behavior was abusive. The NHA was aware the state CNA licensing department had been in the facility to investigate CNA C. The former NHA reported he thought CNA C needed more customer service education but did not feel as though the incident that had taken place would be considered abuse and had reported the incident to the state agency. The former DON said he had no knowledge of the extent of the incident which had occured and had not felt the need to report it to the state agency. The facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property policy, dated 11.28.17, contained the following information in part: E. INVESTIGATION ABUSE POLICY REQUIREMENTS: It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated, PROCEDURE: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. a. Investigation of abuse: When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: i. Who was involved ii. Residents' statements a. For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings. iii. Resident ' s roommate statements (if applicable) iv. Involved staff and witness statements of events v. A description of the resident ' s behavior and environment at the time of the incident vi. Injuries present including a resident assessment vii. Observation of resident and staff behaviors during the investigation viii. Environmental considerations *All staff must cooperate during the investigation to assure the resident is fully protected .

This citation pertains to Intake #MI 222 Based on observation, interview, and record review, the facility failed to ensure assistance with incontinence care and showers for ten dependent Residents (#18, #24, #34, #64, #61, #14, #30, #33, #56, and #51) of 25 residents reviewed for Activity of Daily Living (ADL) assistance. This deficient practice resulted in actual harm for Resident #18 with the development of moisture associated skin damage (MASD) due to prolonged skin contact with urine and/or feces. Resident #18 had the likelihood of discomfort and feelings of embarrassment, frustration, and anger. Findings include: Resident #18 According to the Minimum Data Set (MDS) assessment, dated 4/14/22, showed Resident #18 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The same MDS assessment indicated one staff physical assistance was needed for bed mobility, transfers, walking, dressing, toilet use, hygiene, and bathing. Resident #18 was occassionally incontinent of urine and was marked for MASD. Resident #18 had both upper and lower functional limitations in ROM (range of motion). The Brief Interview for Mental Status (BIMS) score was 15/15 which resulted in intact cognition. During an interview on 7/05/22 at 3:22 p.m., Resident #18 was asked about the skin breakdown to their right buttocks. Resident #18 said they were repeatedly left lying in a soiled brief and/or wet (bed) pad when their urinal spilled over in the bed. When asked if staff were informed of their toileting needs, Resident #18 responded, staff would say 'be there in a minute' and he said he had very long delays with repeated times exceedingly more than one hour and up to four hours on night shift. During an interview on 6/29/22 at 5:36 p.m., with the Director of Nursing (DON) confirmed Resident #18 had developed skin breakdown to the right buttocks which worsened from 4/12/22 to 5/15/22. Review of Resident #18's Focus Care Plan, 7/6/21, read in part, actual ADL self care performance deficit r/t (related to) spinal cord injury-quadriplegic .Bathing: showers are Mon/Thurs/Sat PM (afternoon) intervention dated 4/8/22. During an interview on 7/6/22 at 1:19 p.m., Licensed Practical Nurse (LPN) KK was asked to review Resident #18's weekly wound care photos in May 2022. LPN KK agreed that the surrounding feces should have been cleansed before a photo was taken of the uncovered wound. Resident #24 Resident #24's face sheet contained a most recent admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24's Minimum Data Set (MDS) dated [DATE] contained a Brief Interview for Mental Status (BIMS) of 15/15, which indicated Resident #24 was cognitively intact. The MDS Functional Status section revealed Resident #23 required physical help in part of bathing activity with the assistance of one person. On 06/27/22 at 02:56 p.m., an observation of Resident #24 was made. Her hair appeared shiny and flat. Resident #24 said she was supposed to receive a shower three times a week but had not been given a shower in two weeks. Further review of Resident #24's Eletronic Medical Record (EMR) on 6/28/22 included a look back of a 30 day period for the Task: Bathing- Resident prefers to shower - Monday, Wednesday, Saturday on PM shift which revealed Resident #24 received a shower on the following dates: 6/1/22, 6/4/22, 6/8/22, and 6/10/22. A refusal was documented for 6/20/22 and Not Applicable was documented for 6/10/22 and 6/22/22. On 07/06/2 at 9:28 a.m., Former Director of Nursing (DON) /current NHA was unable to clarify what not applicable meant. He said he had been educating staff not to use not applicable because it was ambiguous. Resident #34 Resident #34's face sheet included an admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #34's MDS dated [DATE] contained a BIMS score of 13/15, indicating Resident #34 was cognitively intact. The functional status section of the MDS for the bathing self-performance section indicated the activity itself did not occur. The bathing support provided indicated the ADL activity itself did not occur. On 6/27/22 at 3:11 p.m., Registered Nurse (RN) G reported there was an issue with residents receiving showers at this time. RN reported Resident #34 had started crying one day because she had not received a shower for a couple of weeks and RN G had then given her a shower. During an interview on 06/28/22 at 08:51 a.m., Resident #34 reported she often went two weeks between the times when she received a shower. Resident #34 said she liked to get her showers and not receiving them made her feel badly about herself. Resident #34 stated, I always feel better after my shower. Resident #61 Resident #61 face sheet revealed an admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #61 was cognitively intact. The MDS functional status indicator revealed Resident #61 required extensive assistance with one person assist for toileting. On 06/29/22 at 09:05 a.m., Resident #61 told this Surveyor that she had requested to get assistance to get out of bed to go to the bathroom to have a bowel movement, but now it was too late. Resident #61 said she had not been able to wait for assistance any longer and had to defecate in her bed. Resident #61 reported this had not been the first time she had not received assistance in time and had to defecate in her bed. Resident #61 said she often lays there for hours waiting for assistance for toileting. Resident #61 said she had undergone back surgery recently and required the use of a back brace when getting out of bed. Resident #61 felt that because of the need for the brace to be applied when getting her out of bed, the staff felt it was more convenient to give her a bedpan to use instead of getting her up. Further review of Resident #61's Electronic Medical Record (EMR) revealed a care plan dated 6/8/22 which contained the following information, in part, The resident has (Specify) actual for an ADL self-care performance deficit r/t T7 fracture, The resident will demonstrate the appropriate use of ([NAME] Brace and FWW) [a brace applied to the trunk portion of the body to provide support and prevent further back injury and a front wheeled walker] to increase ability in (transfers and mobility) through the review date . Toileting: Resident requires assistance with clothing and wiping .Toileting: Resident requires physical assistance with toileting . Resident #64 Resident #64's face sheet revealed an original admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #64's MDS dated [DATE] contained a BIMS score of 13/15, indicating Resident #64 remained cognitively intact. On 06/27/22 at 02:26 p.m., Resident #64 was observed in bed, her hair appeared uncombed and oily. Resident reported she was getting showers but was not sure how often. On 6/28/22, a look back for the previous 30 days for the Task: Bathing: Prefers to shower Tuesday and Saturday Morning. Female staff only revealed Resident #64 had reviewed one shower on 6/4/22. There were no not applicable or refusals documented. Resident #64's care plan with the most recent revision dated 6/4/21 contained the following information, in part, The resident has potential for an ADL self-care performance deficit r/t [related to] Aggressive Behavior, Dementia .The resident will demonstrate/ allow the appropriate help to increase ability in ADL'S through the next review date. Bathing: (specify) .BATHING/SHOWERING: The resident is able to: do upper body care needs 1 assist with lower body Resident has 2 showers a week and tends to refuse one regularly. Female staff to provide the assistance needed for bathing . Resident #14 Resident #14's EMR contained an admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #14's MDS assessment dated [DATE] contained a BIMS score of 13/15. The functional status section contained the following information, bathing self performance requires physical help in part of bathing activity. bathing with support provided. On 06/27/22 at 02:42 p.m., Resident #14 reported she was only receiving a shower one time a month. On 6/28/22, a look back for the previous 30 days for the Task: Bathing: prefers showers in the afternoon after 2:00 pm Scheduled Wednesday and Saturday. Requires extensive assist and shower chair for showers revealed Resident #14 received showers on 6/4/22, 6/8/22, 6/11/22, and 6/22/22. There were no documented refusals or non applicable. Resident #14's care plan dated 7/6/20 contained the following information, in part, The resident has potential for an ADL self-care performance deficit r/t weakness, right sided weakness .Bathing: Prefers showers 2x weekly in the afternoon. Resident uses a shower chair and requires extensive assist for bathing such as max assist with LE and UE bathing, set up for face washing and please remove dentures nightly and clean for res . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Res needs max assist with this. Report any changes to the nurse. BATHING/SHOWERING: Provide sponge bath when a full bath or shower cannot be tolerated. Use no rinse shampoo caps to wash hair . Resident #56 Resident #56's face sheet revealed an admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #56 was cognitively intact. During an interview on 06/29/22 at 11:03 a.m, Resident #56 said she was supposed to get a shower three times a week but was not receiving showers consistently. During this interview, Resident #56's hair appeared to be uncombed and flat. A look back of the previous 30 days on 6/28/22 for the Resident prefers to shower on Tuesday, Thursday and Saturday during the morning shift. Requires extensive assist of one staff documentation revealed Resident #56 had received a shower on 6/2/22, 6/4/22. 6/9/22, 6/19/22, and 6/21/22. Resident #56's care plan with the most recent revision date of 5/25/22 contained the following information, in part, The resident has an ADL self-care performance deficit r/t [CONDITION(S)], generalized weakness, bilateral chronic humerus fracture, gait instability, dizziness/unsteadiness secondary to chronic [CONDITION(S)] and [CONDITION(S)] .Bathing: requires the extensive assistance of one staff. Prefers to shower/bath on Tuesday, Thursday, Saturday mornings .BATHING/SHOWERING: Provide sponge bath when a full bath or shower cannot be tolerated. BATHING/SHOWERING: The resident requires extensive assist by 1 staff with showering 3x/week and as necessary. During an interview with Certified Nurse Aide (CNA) L and CNA M on 07/06/22 at 08:58 a.m., CNA L said residents were not receiving showers as often as they were scheduled due to lack of available assistance to get the showers completed. CNA M said it was very disappointing the showers were not getting their scheduled showers and it had to make the residents feel unclean and badly about themselves. Resident #30 Review of Resident #30's Face Sheet, printed on 6/27/22, revealed she was admitted to the facility on [DATE]. Review of Resident #30's Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #30's Minimal Data Set (MDS), no date, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates she was cognitively intact. On 6/27/22 at approximately 1:49 PM, an observation was made of Resident #30 sitting outside of her room in her wheelchair, and her hair was disheveled and unkept. Resident #30 was asked if she received a shower since she has been at the facility and responded, No showers, but I once had a bed bath. Review of Resident #30's care plan, dated 5/2/22, revealed, The resident has actual / potential for ADL (activities of daily living) self-care performance deficit related to chronic pain, decreased mobility. Bathing: Wednesday / Sunday AM. A review of Resident #30's Tasks from May 29, 2022 through June 30, 2022, read in part, To be showered on Wednesdays and Sundays in the AM. Review of Resident #30's Tasks from May 29, 2022 through June 30, 2022, revealed no documentation that showers had occurred on: 6/19/22, 6/22/22, 6/26/22 and 6/29/22. Review of Resident #30's Progress Notes from May 2022 through June 2022, lacked any documentation as to why she did not receive a scheduled shower on the above dates. Resident #33 Review of Resident #33's Face Sheet, printed on 6/30/22, revealed she was admitted to the facility on [DATE]. Review of Resident #33's Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/27/22 at approximately 12:44 PM, Resident #33 was observed sitting on her bed in a hospital gown. Resident #33's hair appeared to be greasy and not combed. On 6/30/22 at approximately 1:10 PM, an observation was made of Resident #33. Resident #33 was in her room sitting on her bed in a hospital gown. Her hair was not combed and she had left over food on her face in the corner of her mouth from lunch. A review of Resident #33's MDS, no date, revealed a BIMS score of 14, which indicates she was cognitively intact. On 6/30/22 at approximately 1:15 PM, an interview was conducted with Resident #33. Resident #33 was asked if she had received a shower since being admitted to the facility and responded, No shower or bed bath since she got here and no sanitizer prior to meals. Resident #33 was asked is she had ever refused a shower since being at the facility and responded, No. Review of Resident #33's Care Plan, date initiated 5/4/22, read in part, The resident has actual / potential for an ADL self-care performance deficit related to decreased mobility from fracture. Bathing: Wednesday / Sunday PM. Review of Resident #33's Tasks from 5/29/22 through 6/30/22, revealed the following: a.) 5/29/22, not showered, but received a bed bath, b.) 6/1/22 not showered - marked not applicable, c.) 6/5/22 missing documentation - not showered, d.) 6/8/22 marked resident refused - not showered, e.) 6/12/22 missing entry - not showered, f.) 6/15/22 marked resident refused - not showered, g.) 6/19/22 missing entry - not showered, h.) 6/22/22 marked refused - not showered, and i.) 6/26/22 a missing entry - not showered (missed 9 out of 9 showers and only received one bed bath during this 30-day look back time period). Review of Resident #33's Progress Notes from 5/4/22 through 6/30/22, lacked any documentation as to why Resident #33 did not receive her scheduled showers. Resident #61 Review of Resident #61's Face Sheet, printed on 6/30/22, revealed she was admitted to the facility on [DATE]. Review of Resident #61's Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/27/22 at approximately 1:05 PM, Resident #61 was observed lying in her bed uncombed and messy hair. A review of Resident #61's MDS, no date, revealed a BIMS score of 14, which indicates she was cognitively intact. On 6/27/22 at approximately 1:07 PM, an interview was conducted with Resident #61. Resident #61 was asked about showers and responded, I have been here since the 6th and have not had a shower or a bath. They are short staffed. You wait and wait and wait for someone to come and answer your call light. Resident #61 also stated that Last week I complained about not getting a showered. Review of Resident #61's care plan, dated 6/6/22, read in part, The resident has actual for an ADL self-care performance deficit related to T7 fracture. Bathing: Physical Assist. Bathing / Showering: Provide sponge bath when a full bath or shower cannot be tolerated. Bathing / Showering: The resident requires (extensive assistance) by (2) staff with (SPECIFY bathing / showering) (as scheduled) and as necessary. Review of Resident #61's Tasks from 6/6/22 through 7/2/22, read in part, Bathing Tuesday / Thursday / Saturday PM. The number of shower opportunities were 12 and 11 showers were not completed during the 30-day look back period between 6/6/22 and 7/2/22. On 6/28/22 at approximately 8:30 AM, and interview was conducted with the Director of Nursing (DON). The DON was asked if there was enough staff to complete the ADL care (showers) for residents that were currently residing in the facility. The DON stated that, The mangers audit them (shower tasks) weekly [The DON could not provide any audits]. The DON then stated, They were not any longer doing the audits. The managers review refusals and typically bed baths are not done. If missed, then there should be documentation on reasoning why not completed. If there is a pattern with CNAs habitually not doing showers, then they are educated and disciplined as needed [No education or disciplines provided to surveyor during interview]. The DON also remarked that, If staff census is low then it is common that showers are not completed and if staff is staffed well or high then they get done. It waxes and wanes. At times they do hold admits if staff is low and the DON just communicated with corporate to hold admits and they normally work with the facility regarding this. They lose of staff hinders showers. The shower task is recorded into the POC if completed on a different date as a prn (as needed) task. Review of facility policy titled Activities of Daily Living, effective date 05/07/2020, read in part, Purpose: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, our facility provides necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. In accordance with the comprehensive assessment, together with respect for individual resident needs and choices our facility provides cares and services for the following activities: Hygiene: Bathing, dressing, grooming and oral care.

This Deficient Practice Statement has two parts: Deficient Practice 1: Based on interview and record review, the facility failed to ensure that narcotic pain medication was given per standards of practice during end of life care for one Resident (#172) out of five residents reviewed for closed records. This deficient practice resulted in Resident #172 receiving medications without documented indications for use. Findings include: A review of Resident #172 medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of his [DATE] Minimum Data Set (MDS) assessment revealed he scored ,d+[DATE] on the Brief Interview for Mental Status (BIMS) assessment indicating intact cognition, and was not on any scheduled pain medication. A review of a [DATE] Provider note revealed, . He (Resident #172) required numerous amounts of [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] doses to achieve comfort. Patient seen today in follow-up. Patient is currently resting in bed at this time. Minimally responsive. Actively dying . Continue with current scheduled and as needed (PRN) doses of [MEDICATION(S)], patient does not have any facial grimacing at this time and appears comfortable. A review of Hospice documentation revealed the following: [DATE] 3:31 p.m . (Resident #172) is found lying on his side in bed, sleeping soundly, unresponsive, unlabored breathing, relaxed facial expression, (Name of Resident #172) appears peaceful . Facility staff (RN O) report (Resident #172) has been comfortable and resting peacefully all day. She has been administering 0.25 mL [MEDICATION(S)] Q (every) ,d+[DATE] hours, 0.25 mL [MEDICATION(S)] Q one-two hours. Given his current peaceful state RN encouraged facility staff to space out PRN (as needed) doses closer to every 4 hours unless symptoms of agitation, pain, or shortness of breath resume. So the staff verbalizes understanding and will modify medication routine. [DATE]. Call received from (RN O at (name of Facility) . stating that (Resident #172) passed at 1815 (6:15 p.m.). No family present. This RN offered visit but was declined by facility. A review of Resident #172's [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE] -10:03 am - 0.5 mg [MEDICATION(S)] prn 10:02 am - 5 mg [MEDICATION(S)] prn 11:16 am - 10 mg [MEDICATION(S)] prn 11:17 am - 0.5 mg [MEDICATION(S)] prn 12:00 - 5 mg [MEDICATION(S)] scheduled 12:48 pm 1 mg [MEDICATION(S)] - one time order 1:30 pm - 10 mg [MEDICATION(S)] prn 2:10 p.m. - 0.5 mg [MEDICATION(S)] prn 3:30 pm - 0.5 mg [MEDICATION(S)] prn 3:30 pm - 10 mg [MEDICATION(S)] prn 3:50 pm 1 mg [MEDICATION(S)] 4:50 pm 0.5 mg [MEDICATION(S)] prn 4:51 pm - 10 mg [MEDICATION(S)] prn 6:12 pm 0.5 mg [MEDICATION(S)] prn 6:12 p.m. - 10 mg [MEDICATION(S)] prn 8:00 pm - 0.5 mg [MEDICATION(S)] scheduled 8:00 pm - 5 mg [MEDICATION(S)] scheduled And on [DATE]: (Midnight) 0000 - 0.5 mg [MEDICATION(S)] prn 0000 - 5 mg [MEDICATION(S)] scheduled 0000 - 10 mg [MEDICATION(S)] prn 2:15 am 1 mg [MEDICATION(S)] prn 3:55 am - 0.5 mg [MEDICATION(S)] prn 4:00 am - 5 mg [MEDICATION(S)] scheduled 6:10 am - 0.5 mg [MEDICATION(S)] prn 6:22 am - 10 mg [MEDICATION(S)] prn 8:00 am - 0.5 mg [MEDICATION(S)] scheduled 8:00 am - 5 mg [MEDICATION(S)] scheduled 8:25 am - 0.5 mg [MEDICATION(S)] prn 8:25 am - 10 mg [MEDICATION(S)] prn 9:35 am - 0.5 mg [MEDICATION(S)] prn 9:35 am - 10 mg [MEDICATION(S)] prn 10:55 am - 0.5 mg [MEDICATION(S)] prn 10:55 am - 10 mg [MEDICATION(S)] prn 12:00 - 5 mg oxy scheduled 12:20 PM - 0.5 mg [MEDICATION(S)] prn 2:46 pm - 0.5 mg [MEDICATION(S)] prn 2:46 pm - 10 mg [MEDICATION(S)] prn 4:00 pm - 5 mg [MEDICATION(S)] scheduled 5:20 pm - 10 mg [MEDICATION(S)] prn Per review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the controlled narcotic log also revealed that the 10 mg dose of [MEDICATION(S)] revealed it was pulled on at 6:15 p.m. A review of the death certificate also reported the time of death as 6:15 p.m. on [DATE]. On [DATE] at 2:26 p.m., a phone interview was conducted with Physician CC. When asked about Resident #172 being given continuous pain and anxiety medication despite lack of documented indication, Physician CC reported it would not be good if the indication for use wasn't documented. Physician CC also reported that the facility and the pharmacy should be able to recognize diversion before the state agency does. On [DATE] at 3:15 p.m., the DON was interviewed about Resident #172's medication administration on [DATE] the day he expired. When asked about narcotics at end of life, the DON reported that he would not be surprised if they hastened death, so they could go comfortably. When asked about Resident #172 getting multiple dose of [MEDICATION(S)] and [MEDICATION(S)] despite a lack of documentation and the hospice nurse stating he was resting peacefully, the DON stated that the only time they (medications) should be held was if there were any signs of adverse events. The DON was asked about the discrepancies of the times, dates, and missing doses between the MAR's and the controlled logs and he reported that he was not aware of any issues. When asked if he as the DON did audits or checks to monitor for diversion, the DON stated that the controlled logs were sent to medical records. When asked how diversion could be monitored if no one ever checked them, the DON reported that he was only notified if the counts didn't zero out or if there is an allegation regarding missing medications. The DON reported there had been no concerns regarding missing medications. Deficiency Practice Statement #2 Based on observation, interview, and record review the facility failed to provide quality of care related to following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in missed dressing changes for wound care on residents with wound care orders. Findings include: Resident #30 Review of Resident #30's Face Sheet, printed on [DATE], revealed she was admitted to the facility on [DATE]. Review of Resident #30's Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 1:49 PM, Resident #30 was observed sitting in her wheelchair just outside of her room in the hallway. Resident #30 was noted to have bilateral (both) lower leg bandages; one dated [DATE] and the other without a date. Resident #30's right lower leg had fluid showing through her dressing, which was serosanguineous (a thin watery fluid that is pink in color). On [DATE] at 1:50 PM, an interview with Resident #30 was conducted. Resident #30 was asked when her lower leg dressings were changed and why she only had one dated and responded, The nursing staff changes them and when they do one they do the other. Resident #30 had to look at her dressing to see the date as she did not recall the staff completing the dressing change that day. A review of Resident #30's Physician Order, dated [DATE], read in part, Skin checks weekly in the morning Mondays. Physician Order, dated [DATE], read in part, Wound care: Bilateral LE (lower extremities): Cleans legs with NS (normal saline), apply triad, then xeroform to open areas, then cover with ABD (abdominal) pad and Kerlix wrap then wrap with coban. Scheduling details - once a day at 0800 (8AM) [Order discontinued on [DATE]]. Further review of Resident #30's Physician Order, dated [DATE], read in part, Wound care: Bilateral LE (lower extremities): Cleans legs with NS (normal saline), apply triad, then xeroform to open areas, then cover with ABD (abdominal) pad and Name brand wrap then wrap with Name brand (self-adherent wrap). Scheduling details - two times a day at 0800 (8AM) and 2000 (8PM). A review of Resident #30's Braden Scale for Predicting Pressure Sore Risk Assessment, dated [DATE], revealed a score of 12, which indicates a high risk of developing pressure sores. On [DATE], a review of Resident #30's Weekly skin assessments form the date of her admission on [DATE] through [DATE] revealed a missing skin assessment on [DATE]. Review of Resident #30's Treatment Administration Record (TAR) for [DATE], revealed that dressing changes were not completed as ordered on: [DATE], [DATE], [DATE] and [DATE]. Further review of the TAR for [DATE], revealed a 09 chart code [indicates other / see nurses note] on dates [DATE] and [DATE]. A review of Resident #30's Progress notes for [DATE], revealed a nursing note on [DATE] at 19:06 (7:06 PM), read in part; Notified NOC (night) nurse that treatment needs to still be done for today. Resident #30's Progress Notes lacked any follow-up note from night shift nurse that dressing had been completed on [DATE]. Resident #30's Progress Notes lacked any documentation for the missing dressing change on [DATE]. Review of Resident #30's TAR for [DATE], revealed that dressing changes had not occurred on: [DATE], [DATE] and [DATE]. Further review of the TAR for [DATE], revealed an 09 chart code on dates [DATE] and [DATE] and lacked any progress notes for these days. Review of Resident #30's TAR for [DATE], revealed missing lower leg dressing changes for afternoon shift on: [DATE], [DATE] and [DATE]. A review of Resident #30's care plan initiated [DATE], read in part, Change bilateral leg dressings twice a day with xeroform. ABD pads, Name brand wrap and Name brand wrap. The resident has actual impairment to skin integrity on bilateral legs .Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor skin when providing cares. Resident #53 Review of Resident #53's Face Sheet, printed on [DATE], revealed he was admitted to the facility on [DATE]. Review of Resident #53's Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at approximately 2:30 PM, an observation was made of Resident #53 sitting by the nurses station up in his wheelchair resting quietly. Review of Resident #53's Physician Order, dated [DATE], read in part, Dressing changes to upper back. left shoulder, and sacrum. Cleanse with wound cleaner and apply comfort border dressing - every day shift. A second order dated [DATE], read in part, Dressing changes to upper back. left shoulder. Cleanse with wound cleaner and apply comfort border dressing - every day shift. A third order dated [DATE], read in part, Per wound clinic wet to dry dressing with Dakin's solution, cover with ABD pad BID (twice daily). Review of Resident #53's MAR for [DATE], printed on [DATE], revealed missing documentation for dressing changes for the first two orders mentioned above on dates: [DATE], [DATE], [DATE], [DATE] and [DATE]. Comparing the MAR for [DATE] to the third physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #53's Progress Notes were reviewed for [DATE] and lacked any documentation as to why his dressing changes were not completed. Review of Resident #53's Care Plan, initiated on [DATE], read in part; Monitor for and report any signs and symptoms of infection to practitioner .Wound Clinic: dressing: wet to dry with Dakin's solution cover with ABD. The resident has actual impairment to skin integrity related to stage III sacral ulcer, spine ulcer and skin tear Left shoulder - present on admission. Evaluate and treat per physician orders. On [DATE] at approximately 8:00 AM, an interview was conducted with the Director of Nursing (DON). The DON was asked what his expectation was for wound care orders and dating dressing changes and responded, Orders should be followed as ordered and if the order is for once a day, then the dressing is to be changed once a day and if not completed then a nursing note is placed in the progress notes indicating as to why it was not completed. The dressing should be dated the day it is changed. Review of facility policy titled Skin Protection Guideline, dated [DATE], read in part; Purpose: To provide evidenced based practice standards for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Monitoring of Skin Integrity: Weekly skin observations by licensed nurse.

This citation pertains to intake# MI 044 and MI 222 Based on observation, interview, and record review, the facility failed to ensure that complete investigations for falls were conducted and interventions were implemented for three Residents (#171, #18, and #11) out of ten Residents reviewed for falls. This deficient practice resulted in falls with major injury and the potential for subsequent major injuries. Findings include: Resident #171 A review of a facility incident report investigation provided by the Administrator on 6/29/22 revealed the following: . On 4/28/22 at 6:30 AM, CNA (CNA D) was walking along the hall to do rounds and observed (Resident #171) seated on the floor through the doorway. CNA (CNA D) said that the call light was not on and the resident was not calling out . Resident was position across from their bed leaning against the dresser. CNA (CNA D) then got LPN (LPN T and the CNA (CNA E) . Resident was assisted from the floor. Resident's walker was next to the bed and their concentrator was running with the tubing stretched toward resident but was off due to the tubing not being long enough to reach resident at their position from the bed . LPN (LPN T) was interviewed and stated that she had been in the room previously in the night . (Roommate of Resident #171) said he (roommate) was in bed through the night and had the curtain pulled so he did not witness anything on (Resident #171's) side of the room . Resident did not report complaints of pain initially but when therapy staff went to resident's room to begin therapy session later that morning, resident was unable to complete session due to pain . Resident was diagnosed with left [CONDITION(S)] at the hospital . Staff had seen resident prior to fall and resident was lying in bed with no concerns . Further review of this report and witness statements revealed no investigation into the last time Resident #171 had been observed by staff. Per the report, the video surveillance of the hallway was not reviewed to determine how long Resident #171 had been lying on the floor without his oxygen infusing. The investigation failed to rule out neglect of this resident which resulted in a fall with fracture and a lack of oxygen. A review of a Post-Fall Evaluation completed by LPN T on 4/28/22 revealed the resident reported a pain level of 0, was oriented to person, place, time and situation, and could move all extremities with no issues. A review of the Radiology report for Resident #171 dated 4/28/22 revealed, Acute mildly displaced transcervical left [CONDITION(S)]. The left femur is foreshortened . A review of Resident #171's medical record revealed he admitted to the facility on [DATE] with diagnoses including chronic [CONDITION(S)], chronic obstructive pulmonary disease ([CONDITION(S)]), and repeated falls. A review of his 5/22/22 MDS assessment revealed he scored 15/15 on the BIMS assessment indicating intact cognition. On 6/28/22 at 6:07 p.m., the DON was asked about the fall on 4/28/22 and the investigation file he had completed. The DON reported that he did the fall investigation and that the administrator had done the investigation regarding the injury from the fall. The DON was asked about the conflicting statements and the lack of note about the last time the staff had seen and cared for the resident, but provided no answer. When asked if the camera footage had been reviewed to determine the last time the Resident was cared for in order to rule out neglect, the DON reported he had not reviewed the camera footage from that particular incident. On 6/29/22 at 4:01 p.m., an interview was conducted with Occupational Therapist (OT) BB who worked with Resident #171 the morning of 4/28/22. When asked about the morning, OT BB reported, When I got there he was sitting in an arm chair. He said he was fine, and that he 'thought he took a fall last night'. When asked if the Resident reported any pain, OT BB reported the resident said, It really hurts and reported 10 out of 10 and 20 out of 10 on a pain scale. OT BB reported she wasn't even able to assist the Resident to stand. There was no investigation to determine whether the resident fell due to unmet care needs, or how long he was on the floor waiting for staff to find him. Resident #18 According to the Minimum Data Set (MDS) assessment, dated 4/14/22, showed Resident #18 had the following diagnoses: [CONDITION(S)], stroke, [CONDITION(S)], and depression. The same MDS assessment indicated one staff physical assistance was needed for bed mobility, transfers, walking, dressing, toilet use, and hygiene. Resident #18 had both upper and lower functional limitations in ROM (range of motion). The Brief Interview for Mental Status (BIMS) score was 15/15 which resulted in intact cognition. Resident #18 had one noted previous fall. During an interview on 7/5/22 at 3:31 p.m. Resident #18 said they had sustained a fall when assisted by Staff SS when ambulating with a standing walker. Resident #18 said Staff SS let go of their gait belt to open the door to the smoking area. Resident #18 lost their balance and fell to the ground striking their head. Resident #18 said Staff SS and someone from the Activity Department immediately got a lift to get them off the floor. Review of facility provided, Full QA Report dated 1/30/22 at 6:45 p.m., read in part, Head Trauma-Back of Head Left side .less than 1 cm (centimeter) bump. During an interview on 7/6/22 at 9:54 a.m., Registered Nurse (RN) N said the facility's fall policy included the following: Fall Evaluations, Progress Notes, completion of a Full QA Report, initiation of Witness Statements, and implementation of neurological checks with a head injury. RN N was asked to review Resident #18's electronic medical record (EMR) for any nursing neurological assessments regarding the fall sustained on 1/30/22 at 6:45 p.m. RN N said they were unable to locate any neurological sheets in the EMR. During an interview on 7/6/22 at 12:25 p.m., the Director of Nursing (DON) confirmed no witness statements were completed involving Resident #18's fall on 1/30/22 at 6:45 p.m. The DON verified ongoing nursing neurological checks were not initiated/completed with Resident #18 having had injury to their head. The DON provided a blank copy of a Neurological Flow Sheet undated, which showed vital signs and neuro checks would be completed every fifteen minutes for one hour then every thirty minutes for one hour then every hour for four hours and then every four hours for 24 hours. Review of Resident #18's Care Plan, date initiated 1/19/22, read in part, has activity involvement r/t (related to) resident ambulating with personal walker goes to activities of choice . Resident #11 Review of Resident #11's MDS assessment, dated 4/1/22, showed the following diagnoses: hypertension, [CONDITION(S)], [CONDITION(S)], diabetes, and fracture. Resident #11 required two staff to assist with transfers and one staff assistance with bed mobility, toilet use, and personal hygiene. The same MDS assessment identified both bowel and urine incontinence. The BIMS score was 15/15 which reflected intact cognition. Two or more falls without injuries were identified. During a telephone interview on 6/28/22 at 2:31 p.m., RN G said Resident #11 sustained a fall in their room and she saw CNA D and CNA E close the room door. RN G entered the room and observed both CNA D and CNA E lifting Resident #11 by the arms off the floor. RN G felt Resident #11 was man-handled. RN N was present when RN G told CNA D and CNA E to stop since Resident #11 needed to be assessed before they were moved. RN G said both CNA D and CNA E left the room. When asked why CNA D and CNA E would have closed the door after Resident #11's fall, RN G responded she had no doubt they would have never reported the fall and simply returned Resident #11 back to bed. Review of Resident #11's, Full QA Report dated 6/13/22 at 6:55 p.m., read in part, Position When Found-sitting on floor next to bed. CNA D, CNA E, and RN N were not listed as witnesses in the report and no Witness Statements were provided.

Based on interview and record review, the facility failed to ensure that interventions were in place to prevent skin breakdown for one high risk for pressure ulcer Resident (#803) out of three Residents reviewed for skin. This deficient practice resulted in the development of two pressure ulcers and the potential for further skin breakdown and decline. Findings include: A review of Resident #803's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of her 7/6/21 Minimum Data Set (MDS) assessment revealed she scored 14/15 on the Brief Interview for Mental Status (BIMS) assessment indicating intact cognition. A review of Section F of this assessment revealed she had no breakdown of skin or pressure ulcers on admission to the facility. Further review of this MDS revealed she required extensive assist of two or more staff for bed mobility. A review of Resident #803's 6/24/21 Nursing Evaluation under Section B. Skin Integrity revealed the following, .heels need float and needs side to side to prevent breakdown . This assessment documented no current areas of breakdown. A review of Resident #803's care plan for skin initiated 6/24/21 revealed, Resident has actual impairment to skin integrity cervical spine r/t (related to) post surgical. The resident has actual impairment to skin integrity of bilateral buttocks r/t fragile skin . Further review of the interventions on this care plan revealed no interventions to turn the resident to turn and reposition the resident to offload the pressure or to use any pressure offloading devices. An intervention of Ensure that heels are elevated while resident is lying in bed was initiated on 7/8/21 despite the assessment dated [DATE] indicating the need for it. There were no interventions regarding an air mattress. A review of Resident #803's task section for Skin Observation revealed that a staff had noted a red area on 7/7/21 at 19:50 p.m. (7:50 p.m.). A review of a Wound Assessment Details Report for Resident #803 revealed the following 7/8/21 6:52 p.m . coccyx . skin tear . Blanchable [CONDITION(S)] - 40%, Bright pink or red -50%, slough non-adherent 10% . length 10.0 cm (centimeters). Width: 10.0 cm . On 8/4/21 at 3:45 p.m., the Director of Nursing (DON) provided information on Resident #803's pressure ulcer and reported that they did not feel that the coccyx area was a pressure ulcer and were considering it a skin tear. A review of Resident #803's 7/12/21 hospital progress note revealed, She (Resident #803) also has decubitus wounds upon admission .multiple decubitus wounds, unstageable, present on admission, wound care consult in . A review of a hospital Wound/Skin/Ostomy care note dated 7/12/21 revealed, Location: Sacrococcygeal. Size: 12.0 x 14.0 cm. Stage: DTI (Deep Tissue Injury) . Hospital Acquired: NO. Present on Admission: YES . Location: R Posterior thigh. Size: 3.0 x 6.0 cm. Stage: DTI .Hospital Acquired: NO. Present on Admission: YES . Upon review of the photograph take on 7/12/21 of the coccyx/sacrococcygeal wound, the wounds present open at approximately stage 3. On 8/5/21 at 1:18 p.m., a phone interview was conducted with Registered Nurse (RN) A. When asked about Resident #803's skin breakdown, RN A reported that the Resident did have a new spot during her stay, but reported that she was in and out of the building on leave and could no recall the details. RN A stated, She did to my knowledge have a new open area. RN A reported that Resident #803 was limited due to the brace she was wearing after her neck surgery. When asked about the lack of interventions in place to prevent the breakdown, RN A reported that Resident #803 had an air mattress to reduce pressure. When asked if she had in fact observed the Resident on an air mattress as there was no physicians' orders, documentation of use, or care plan regarding it, RN A reported that she had the feeling the mattress arrived just as the Resident was being sent out to the emergency room . A review of the facility policy titled, Skin Management Guideline dated 11/28/17 revealed, . All residents admitted to the facility will be evaluated for actual and potential skin integrity issues . A comprehensive individual evaluation guides the: Identification of residents at risk . provides an ability for the facility to develop and implement a care plan that reflects each resident's identified needs. Identify interventions to stabilize, reduce or remove underlying risk factors .

This citation contains 2 Deficient Practice Statements. Based on observation, interview and record review, the facility failed to provide appropriate [MEDICAL CONDITION] (a tube inserted through the neck into the windpipe to serve as an airway) care according to facility policy and professional standards of practice for one Resident (#55) of one resident reviewed for [MEDICAL CONDITION] care. This deficient practice resulted in Immediate Jeopardy, placing Resident #55 at risk for serious harm, injury or death when (1) on [DATE] Resident #55 was admitted to the facility with a [MEDICAL CONDITION] and no physical orders were in place for suctioning, emergency care or assessment of Resident #55's [MEDICAL CONDITION], (2) no evaluation had been completed to evaluate Resident #55's self-care of the [MEDICAL CONDITION], and (3) the staff assigned to Resident #55's care did not have the required training or competencies to care for a resident with a [MEDICAL CONDITION]. The Immediate Jeopardy (IJ) began on [DATE] when Resident #55 was admitted to the facility with a [MEDICAL CONDITION] in place. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy on [DATE] at 11:05 a.m., and a plan of abatement for removal of the IJ was requested at that time. The Immediate Jeopardy which began on [DATE] was removed on [DATE] at 4:33 p.m., when the facility provided a plan for the care and assessment of Resident #55's [MEDICAL CONDITION]. The facility identified the appropriate equipment needed for emergency re-cannulation and orders were placed in Resident #55's electronic health record (EHR) and immediately initiated. In addition, the facility had initiated training and competency assessments for staff related to the care of a resident with a [MEDICAL CONDITION], emergency response to accidental decannulation, the need for supplies at the bedside, and had assessed Resident #55's self-care of the [MEDICAL CONDITION] to determine the Resident's knowledge and competence. The deficient practice remained at an isolated level of no actual harm with the potential for more than minimal harm for Resident #55 due to the need for the facility to (1) complete the [MEDICAL CONDITION] care training and competency assessment of all nursing staff and (2) provide validation of compliance regarding assessment of Resident #55's self-care practices and nursing assessment of Resident #55's [MEDICAL CONDITION], as directed in the abatement plan. Findings include: Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #55's minimum data set (MDS), dated [DATE], revealed Resident #55 needed extensive assistance with personal hygiene and one-person physical assistance with bed mobility and transfers. An observation on [DATE] at 2:35 p.m., revealed Resident #55 awake, sitting up in bed. Further observation revealed Resident #55 had a metal [MEDICAL CONDITION] in place with what appeared to be a plug inserted into the visible portion of the cannula (tube). A Bilevel Positive Airway Pressure ([MEDICAL CONDITION]) machine (a machine used to push [MEDICATION NAME] air into the lungs) was observed positioned on Resident #55's nightstand, on the left side of Resident #55's bed. Attached to the [MEDICAL CONDITION] machine was tubing with an attached [MEDICAL CONDITION] mask (mask that fits over the [MEDICAL CONDITION] site) with connected oxygen tubing leading to a portable oxygen concentrator at the foot of Resident #55's bed. The tubing and [MEDICAL CONDITION] mask were hanging on the left upper handrail of Resident #55's bed. No suctioning equipment, artificial manual breathing unit (AMBU bag, used for providing breaths in resuscitation efforts) or back-up [MEDICAL CONDITION] kit or replacement canula was observed to be present in Resident #55's room. In an interview at the time of the observation, Resident #55 reported they (Resident #55) cared for the [MEDICAL CONDITION], without direction or oversight of facility staff. Resident #55 reported cleaning the canula (removeable tube inserted into the windpipe) twice weekly and around the flange (outer, visible portion of [MEDICAL CONDITION] that stabilizes the tube) every 90 days or if, it smells. On [DATE] at 3:00 p.m., a review of Resident #55's care plan revealed the following, in part: The resident has altered respiratory status, difficulty breathing (related to) [MEDICAL CONDITION] secondary to [MEDICAL CONDITION], obstructive sleep apnea (obstruction causing breathing to be cut off), hypoventilatio[DIAGNOSES REDACTED] (shallow breathing), date initiated [DATE] . The resident has shortness of breath (related to) OSA (obstructive sleep apnea). A review of Resident #55's physician's orders [REDACTED].#55) Oxygen via NC (tube used to administer oxygen thought the nose) 2 L (liters) during the day and 6 L (liters) at night [MEDICAL CONDITION] (mask that covers the [MEDICAL CONDITION] to deliver oxygen and pressure management). Further review of the physician orders [REDACTED].#55's [MEDICAL CONDITION]. During an interview on [DATE] at 8:40 a.m., Registered Nurse (RN) J reported being the nurse assigned to the care of Resident #55. RN J confirmed Resident #55 had a [MEDICAL CONDITION] due to having severe obstructive sleep apnea related to obesity. RN J reported Resident #55 provided their own care of the [MEDICAL CONDITION]. RN J reported being unaware if there was a back-up [MEDICAL CONDITION] kit (tube and insertion equipment) available at Resident #55's bedside to use in the case of accidental dislodgment or removal of Resident #55's [MEDICAL CONDITION]. During the interview, RN J accompanied this Surveyor to Resident #55's room. Upon looking around the room, RN J reported there was no emergency kit (back-up kid and insertion equipment) or suctioning equipment located in Resident #55's room. When asked what they would do in the event Resident #55's [MEDICAL CONDITION] was accidentally pulled out, RN J reported, we would transfer to (the) hospital really quickly. I don't do that. In an interview on [DATE] at 8:50 a.m., the DON reported the facility did not have a replacement canula for the size and type of Resident #55's [MEDICAL CONDITION] to use in the case of accidental dislodgement or removal. The DON reported being unsure if any of the [MEDICAL CONDITION] equipment, including replacement tubes, were compatible with Resident #55's [MEDICAL CONDITION]. The DON confirmed Resident #55 had been admitted to the facility on [DATE] and orders for the type of back-up [MEDICAL CONDITION] and availability of the equipment should have been requested at that time. When asked what best practice was for identifying the resources needed to appropriately care for a resident with a [MEDICAL CONDITION], the DON reported they (the DON) would not speak to the care of Resident #55 as the Resident was admitted prior to their (the DON) employment with the facility. The DON was asked to review Resident #55's EHR and treatment administration record (TAR) at the time of the interview and confirmed no assessments or care of Resident #55's [MEDICAL CONDITION] had been completed. The DON reported they were aware RN J had not completed the required annual training on [MEDICAL CONDITION] care or been assessed for competency prior to being assigned to the care of Resident #55 on [DATE]. On [DATE] at 9:50 a.m., RN F reported being the Unit Manager for the unit on which Resident #55 currently resided. RN F reported finding a back-up [MEDICAL CONDITION] in Resident #55's room. An observation on [DATE] at 9:52 a.m., revealed an unopened, size 6, plastic [MEDICAL CONDITION] positioned in a pink tub on Resident #55's nightstand. In an interview at the time of the observation, Resident #55 reported there had been times when the [MEDICAL CONDITION] had become clogged and required suctioning. No suctioning equipment was observed in Resident #55's room. Resident #55 confirmed there was not suctioning equipment or an obturator (tube insertion equipment) available in the room. Resident #55 reported if the [MEDICAL CONDITION] needed to be suctioned, they would have to ask for staff assistance and wait for the equipment to be brought in to suction the tube. On [DATE] at 9:55 a.m., RN F was asked how they knew the size 6, plastic [MEDICAL CONDITION] observed at Resident #55's bedside was compatible with the size of the Resident's current, metal [MEDICAL CONDITION]. RN F reported being unsure what size tube Resident #55 required to provide adequate ventilation for the Resident. RN F reported considering referring Resident #55 to an Ear, Nose and Throat (ENT) specialist physician for evaluation of the Resident's [MEDICAL CONDITION] but that the referral had not yet been made. When asked what the concern was if the back-up tube was incompatible with Resident #55's [MEDICAL CONDITION], RN F confirmed the tube could be too big to fit into the stoma (hole in the neck and windpipe) or the tube could be too small to open the Resident's airway resulting in Resident #55 not being able to breathe. RN F confirmed staff were not completing assessments of Resident #55's [MEDICAL CONDITION] or confirming Resident #55 had completed care of the [MEDICAL CONDITION]. A review of the undated facility policy, titled, [MEDICAL CONDITION] Care, revealed the following, in part: Purpose: To provide adequate [MEDICAL CONDITION] site care: Maintain patent airway, to facilitate the therapeutic exchange of gases. Prevent the transmission of pathogenic micro-organisms thus decreasing (facility-acquired) infections. Policy: Stoma (opening in neck where tube is inserted) care for [MEDICAL CONDITION] should be done every shift and (as needed) unless otherwise ordered. Assessment: General guidelines for assessment may include but are not limited to: Observe for signs and symptoms of infections; Observe characteristics of secretions; Observe for signs of dislodged trach. A review of the undated facility policy, titled, CPR and Rescue Breathing for a Patient with a [MEDICAL CONDITION], revealed the following, in part: If no breathing - a. suction [MEDICAL CONDITION], b. change [MEDICAL CONDITION] it is plugged or dislodged, c. secure a resuscitation bag to [MEDICAL CONDITION] give 2 breaths. Based on observation, interveiw and record review, the facility failed to appropriately assess respiratory status of a resident with a respiratory disease for one Resident (#13) of one resident reveiwed for respiratory status. This deficient practice resulted in the potential for respiratory complications for Resdient #13. Findings include: On [DATE] at 9:46 AM, the station 3 cart was observed with Registered Nurse (RN) J and revealed an unopened Breo Ellipta 200 mcg (microgram)/25 mcg inhaler which was ordered to start on [DATE] according to RN J. An opened Breo Ellipta 100 mcg/25 mcg inhaler was observed opened and dated. RN asked to look for an opened Brio Ellipta 200 mcg/ 25 mcg inhaler for Resident #13, and RN J stated one could not be found. When asked how often the Breo Ellipta 200 mcg/ 25 mcg inhaler was supposed to be administered to Resident #13, RN J stated it was supposed to be once daily like the previous order Breo Ellipta 100 mcg/ 25 mcg inhaler which RN J stated was discontinued on [DATE]. A review of the [DATE] Medication Administration Record [REDACTED] Breo Ellipta Aerosol Powder Breath Activated ,[DATE] MCG/INH (inhaler) . 1 puff inhaled orally one time a day for [MEDICAL CONDITIONS] -Order Date- [DATE] 1111 (11:11 AM) -D/C (discontinue) Date- [DATE] 1034 (10:34 AM) Breo Ellipta Aerosol Powder Breath Activated ,[DATE] MCG/INH . 1 puff inhale orally one time a day for [MEDICAL CONDITION] -Order Date- [DATE] 1334 (1:34 PM) According to the [DATE] MAR for Resident #13, Breo Ellipta was not given at all on [DATE]. According to the Medscape Drug Information Phone Application accessed on [DATE], Breo Ellipta is indicated for once daily maintenance treatment for [REDACTED]. On [DATE] at 9:10 AM, in an interview with Registered Pharmacist (RPh) DD, when asked if this was a Breo Ellipta 200 mcg/ 25 mcg was a new medication, RPh stated it was an increase in the medication because she was receiving Breo Ellipta 100 mcg/25 mcg inhaler prior to the dispense date of [DATE] for the increased dose. When asked if any other Breo Ellipta 200 mcg/25 mcg inhalers were sent to the facility which could account for why the increased dose inhaler remained unopened, RPh stated there was only the one sent. A total of 6 days of receiving the Breo Ellipta 200 mcg/25 mcg inhaler were signed out and only the Breo Ellipta 100 mcg/25 mcg inhaler was available for Resident #13 to receive. Ultimately the wrong dose appeared to be given from [DATE] - [DATE]. Resident #13 received no Breo Ellipta at all on [DATE] per the [DATE] MAR. A total of seven medication errors were discovered as a result. On [DATE] at 9:24 AM, an interview with Nurse Practitioner (NP) AA revealed the following: When asked the potential impact of receiving the wrong dose or no dose of Breo Ellipta medication for Resident # 13, NP AA stated Persistent congestion symptoms. When asked if there was any immediate high risk effect to Resident #13, NP AA stated there was not an immediate danger. NP AA stated Resident #13 had been having congestion complaints and that was why she had increased the medication. A review of the [DATE] Treatment Administration Record (TAR) revealed no assessment of breath sounds with administration of a total of 4 separate inhalers ordered. A review of a copy of the Lippincott procedure for Metered Dose Inhalers provided by the DON, no date, pages 501 - 502, read in part: .Compare the medication label with the order in the patient's medical record . Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route to reduce the risk of medication errors . Assess the patient's breath sounds to obtain a baseline for comparison . Assess the patient's breath sounds after medication administration . determine his response to the medication .

Based on observation, interview, and record review, the facility failed to implement appropriate interventions to prevent the development of an unstageable pressure ulcer, and failed to implement appropriate positioning for an unstageable pressure ulcer for one Resident (#14) of three residents reviewed for pressure ulcers. This deficient practice resulted in actual harm, with the development on an unstageable pressure ulcer, and the potential for worsening of a pressure ulcer for a high risk resident (Resident #14). Findings include: Review of Resident #14's MDS (Minimum Data Set) assessment, dated 12/21/20, revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #14 required extensive two-person assistance with bed mobility, transfers, and toileting. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 13/15, indicating Resident #14 was cognitively intact. The skin conditions assessment revealed Resident #14 was at risk for the development of pressure ulcers/injuries. Review of Resident #14's Braden admission assessment (a standardized assessment which calculates risk of pressure injury) , dated 12/10/20, provided by the Director of Nursing (DON), revealed Resident #14 scored a '14', which placed her at moderate risk of developing skin breakdown. More specifically, the assessment showed Resident #14 was occasionally moist (skin), had slightly limited sensation, was bedfast (in bed majority of day), had very limited mobility, and had a potential problem with friction and shearing. This assessment showed Resident #14 had several risk factors for developing a pressure injury. The Braden score on 3/17/21 was 13, which continued to classify Resident #14 as being at moderate risk for pressure injuries, or their progression during the time of this survey. Review of Resident #14's Care Plan, accessed 3/18/21, revealed, Focus: The resident has actual impairment to skin integrity related to .suspected deep tissue (pressure) injury of left heel .Date initiated: 12/10/2020 .Ensure that heels are elevated while resident is lying in bed - use 'heels up' blue gel mat to elevate heels . Review of Resident #14's physician orders, accessed 3/18/21, revealed, Resident to wear (Brandname of) positional boot (positional support which offloads the heel) to left foot when out of bed. There was no order for the blue gel mat or any positional device to use while in bed. Review of Resident #14's physician progress notes [REDACTED].Diagnosis, Assessment, and Plan: .Deep tissue injury. Left heel wound stable, eschar (dead tissue within or covering a pressure wound which classifies it as unstageable) lifting around the edges, no drainage, no signs and symptoms of infection, continue to elevate heels . Review of Resident #14's wound weekly skin documentation dated 3/14/21 revealed, .Stable eschar to heel. Heels elevated in bed and protective boots worn while up in chair . Review of Resident #14's wound weekly skin documentation dated 2/24/21 revealed, .Left heel .Heel has necrotic (dead tissue) skin wound. Skin is blackened. Left heel has been raised up and floated so it does not come in contact with any surface . During an observation on 3/17/21 at approximately 4:00 p.m., Resident #14's left heel was observed with Resident #14's permission with Registered Nurse (RN) I. Resident #14's left foot was positioned in plantar flexion (toe pointed down) directly on the mattress, with the left heel digging into the bed. A blue gel positional support was at the foot of Resident #14's bed on the floor. The pressure ulcer to the left heel was observed with RN I. The wound was about 1.5 centimeters round with a dark brown center with no drainage, per RN I. The wound was covered in eschar, with clean borders, no drainage, and appeared unstageable. During an observation on 3/17/21 at approximately 5:19 p.m., Resident #14's left heel was observed with Resident #14's permission with Resident #14's nursing unit manager, RN F. Resident #14's heels were observed directly on the mattress, with the left heel pressing into the bed. The blue gel positional support was at the foot of Resident #14's bed on the floor. RN F was asked if this was of concern and stated, Yes, it's a concern. RN F positioned Resident #14's bilateral heels on the positional support. Resident #14 was observed and appeared to tolerate the support for at least three minutes. Resident #14 did not remove the blue gel support or report any discomfort. During an observation on 3/18/21 at 10:30 a.m., Resident #14 was observed awake with her Physical therapy assistant, (PTA) KK by her bed. PTA KK reported he just arrived to do a wound treatment. Surveyor and PTA KK observed the blue gel foam mat under Resident #14's knees, with her heels pressing into the mattress. The left foot was observed in plantar flexion and the right foot was positioned in external rotation. PTA KK was asked if this foot positioning was a concern. PTA KK concurred, and positioned Resident #14's heels off the mattress by moving the blue gel foam pad under Resident #14's ankles/calves, offloading the heels. Resident #14 was awake, and was asked if the blue foam support was comfortable. Resident #14 stated, Not really, but I can tolerate it. The left ankle wound was observed with PTA KK with Resident #14's permission. The wound was about the size of a penny and was circle shaped, dark brown/black in color; eschar was observed covering the wound. The wound was clean with even borders and no drainage. It appeared to remain unstageable. Resident #14's assigned Certified Nurse Aide, (CNA) R, was asked if Resident #14 tolerated her heels being positioned off the mattress on the blue foam support. CNA R regularly worked with Resident #14, and stated, Yes, she does tolerate it and does not kick it away. Resident #14's nurse arrived, RN P, and showed Surveyor a (Brand name) positional boot with heel protector which was reportedly to be worn on the left foot when Resident #14 was up in her wheelchair (not while in bed). Both staff confirmed there was no other device staff used to position Resident #14's heels off the bed. Review of Resident #14's wound summary, provided by the Director of Nursing (DON) on 3/18/21, revealed, 3/17/2021, 11:47 p.m. Status: Active. Clinical Stage: Deep Tissue Pressure Injury (DTPI). Tissue types: Necrotic (dead skin) Firm Adherent (to wound) = 100%. Exudate: None. Infection present: No. Length 1.5 cm (centimeter), Width 1.5 cm, Depth unknown . This note confirmed Resident #14 had an unstageable pressure ulcer when these observations were made on 3/17/21 due to the necrotic tissue noted. Review of Resident #14's wound summary dated 3/10/2021, 8:27 p.m. revealed, .(DTPI). Tissue types: Necrotic (dead skin) Firm Adherent = 100%. Exudate: None. Infection present: No. Length 1.5 cm, Width 1.5 cm, Depth unknown . Review of Resident #14's progress note dated 12/24/20 at 13:32 (1:32 p.m.) revealed, Observed dark purple area on resident's left heel measuring 3.00 cm by 2.5 cm. Skin intact. Unit manager notified. Obtained heels up cushion for res (Resident #14) to use to float heels (lift heels off of bed mattress) . This note demonstrated the pressure injury was facility-acquired as Resident #14 was admitted to the facility on [DATE]. Review of Resident #14's physician orders [REDACTED]. This order remained active. Review of Resident #14's physician progress notes [REDACTED]. Patient to keep heels off of bed when she is in bed . Review of Resident #14's skin assessment, dated 12/31/20, revealed, .Unstageable wound. Left heel . No further description of the wound being classified as unstageable was found until a 1/20/21 weekly skin progress note. The wound summary document continued to classify the wound as a DTPI through March 17, 2021, the date the document was requested/printed. Review of Resident #14's weekly skin progress note dated 1/20/21 at 17:41 (5:41 p.m.) revealed, .Left heel black drying eschar prior blood filled, noted skin intact, no signs of infection noted . During an interview on 3/17/21 at approximately 4:30 p.m. with Resident #14's unit manager, RN F, the EMR was reviewed and it was confirmed Resident #14's left heel wound was facility-acquired and developed from a DTPI on 12/24/20 to an unstageable heel pressure ulcer on 12/31/20. During an interview on 3/22/21 at 5:04 p.m. with Registered Dietician (RD) B, it was confirmed Resident #14's left heel pressure ulcer was facility-acquired and developed from a DTPI on 12/24/20 to an unstageable heel pressure ulcer on 12/31/20. Review of Resident #14's physician orders [REDACTED].#14 to promote wound healing until 1/08/21, over two weeks after the left heel wound was discovered on 12/24/20. Review of Resident #14's current Care Plan, accessed 3/22/21, revealed, Provide re-education to resident on the preventative measures in place, heels up gel mat, turning and repositioning, incontinent care needs, barrier cream, res (resident) to report any new or worsening pain, discomfort. Staff to report any refusal or if res not using appropriately or removes devices once placed to nurse immediately. Date initiated 3/21/21 . During an interview on 3/17/21 at 12:56 p.m., Resident #14's nurse, RN I was asked about the development of Resident #14's pressure ulcer to her left heel, and if it was avoidable. RN I stated, I believe it was on Christmas Eve. We were notified it was suspected to be a DTPI .I don't believe her heels were being floated appropriately; they were using pillows and not using the gel mats as they are quite thick. I believe she has boots (positioning boots) now .If her heels had been floated with a more effective device we could have avoided it (the skin breakdown) . During an interview on 3/17/21 at 4:53 p.m., the nursing unit manager, RN F was asked if Resident #14's heels should be off the bed. RN F stated, Yes, and (the same) for anyone who's at a significant risk of breakdown. RN F confirmed no matter what the device, Resident #14's heels should always be floated (off the mattress) while in bed. During an interview on 3/22/21 at 11:16 a.m , the DON with NP AA were asked about Resident #14's pressure ulcer and if it was avoidable. The DON confirmed Resident #14 did not start the nutritional supplement right away and didn't have the DTPI when she was admitted here. The DON explained Resident #14 was supposed to be discharged and no one including the physician team realized she was still in the facility so the timely prescription for a nutritional supplement was missed. It was clarified Resident #14 and her representative unexpectedly decided to stay in the facility private pay as therapy benefits (insurance coverage) had been exhausted (completed). During an interview on 3/22/21 at 11:53 p.m., NP AA stated, On Christmas Eve (December 24th, 2020) I was notified of the wound. I didn't know she (Resident #14) was staying (in the facility); I probably would have ordered a set of labs if there was a wound and reviewed them in that 10 day (initial admission) period. She (Resident #14) had a medical work up (including labs) on January 12th (2021) (nearly three weeks after admission.) .We had the New Year's holiday that weekend. I found out a week (Resdient #14) had not left the facility. NP AA was asked if they had concerns about Resident #14's heels observed (specifically the left heel) pressing into the bed mattress on three occasions during the survey. NP AA responded, Yes, I absolutely have concerns about her foot (left heel) pushing into the mattress. The DON further clarified, .If we have someone not going home we need to have our social worker notify (NP AA). It was the perfect storm with the holiday. We discussed this in the morning clinical (meeting) so we don't have that lack of communication. Normally we would communicate that to (SW M). We have reviewed how we can better communicate to (SW M). Review of the policy, Skin Management Guideline, dated 11/28/17, revealed, Purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce, and treat skin breakdown. It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities to wounds according to industry standards of care .Interventions for prevention, removing, and reducing predicting factors and treatment for [REDACTED].Elevating heels: For residents who cannot turn and reposition themselves, for residents who have diminished sensory perceptions of the lower extremities that may affect and (sic - an) independent ability to turn, reposition, and off load pressure. Offloading devices may vary, may include pillows, and should be selected based on resident comfort and positioning needs .

This citation refers to Intakes MI# 138, 460, 242, 046, 384, 240 This citation includes two deficient practices: 1) Based on interview and record review, the facility failed to ensure that adequate supervision was provided to prevent the elopement of two Residents (#28, #33) out of two Residents reviewed for elopement. This deficient practice resulted in two Residents eloping from the facility. 2) Based on observation, interview, and record review, the facility failed to: Provide adequate supervision for safety to prevent falls; failed to investigate the root cause of falls and develop and implement appropriate interventions to prevent further falls and falls with injury for four Residents (#27, #28, #44, #324) out of six Residents reviewed for falls. This deficient practice resulted in repeated falls with subsequent injuries requiring hospitalization . Findings include: Resident #27 A review of Resident #27's medical record revealed he admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the facility census revealed that the resident had expired on [DATE]. Per the medical record he admitted to Hospice services on [DATE]. A review of Resident #27's Minimum Data Set (MDS) assessment dated [DATE] revealed he scored ,[DATE] on the Brief Interview for Mental Status (BIMS) assessment indicating moderately intact cognition, and required supervision and set-up help for dressing. A review of a Facility Reported Incident (FRI) investigation revealed the following information: .Date/Time Incident Discovered: [DATE] 11:43 AM . Investigator: (The Administrator). Incident Summary: Resident (#27) had fallen in room. Nurses assessed resident and resident had complaint of pain in right arm. Resident sent to ER (emergency room ) for evaluation . On [DATE], RN ((Registered Nurse) J) observed (Resident #33), who is married to and lives with (Resident #27), walking fast from their room. (RN J) noticed (Resident #33)'s fast face and asked (Resident #33) where she was going and she replied, I need a man to pick (Resident #27) up. (RN J) went to room with (Resident #33) and observed (Resident #27) on the floor on his right side . Resident (#27) was alert and oriented and sated he had hit his head and face but did not lose consciousness. (Resident #27) described the event by saying I went to the bathroom, felt dizzy, and I guess I fell , Resident did not have walker and call light was not on (Resident #27) had a 2 cm (centimeter) laceration to bridge of nose .Resident was transported to ER and [DIAGNOSES REDACTED]. Resident care plan was reviewed and updated post-fall. The facility investigation is complete. Abuse is not substantiated . This investigation included no times of any of the events of this incident. It also included no witness statements, from RN J or from the Certified Nurses Aide (CNA) Y who was assigned to his care, nor was CNA Y even identified in the investigation. This investigation also did not discuss the other fall interventions that were care planned to be in place to prevent falls, nor did it note the last time that Resident #27 had been checked on by staff. A review of the Resident #27's progress note written by RN J date [DATE] revealed, .This nurse entered room [ROOM NUMBER] and observed (Resident #27) laying on the floor on his right side with moderate amount of blood on res's hands, face and the floor . Res (Resident) had on regular socks and did not have his walker . A review of Resident #27's progress note dated [DATE] upon his return from the ER revealed, Received phone call from (emergency room ), res has: 1) RT (right) humoral neck fracture . 2) broken nose, 3) laceration to the bridge of the nose sutured . A review of Resident #27's care plan for falls initiated [DATE] revealed, .non-skid socks/footwear (initiated [DATE]) . A review of his Activities of Daily Living (ADL) care plan initiated [DATE] revealed, Assist the resident to choose simple comfortable clothing that enhances the residents ability to participate in the task. Resident requires limited assistance x1 (staff) for dressing upper and lower body . A review of Resident #27's ADL tracker revealed that on the mornings of ,[DATE], ,[DATE], ,[DATE], and ,[DATE] the Resident required limited assistance of one staff for the dressing task. The resident was listed as not available for dressing on the morning of [DATE], the morning of the fall, by CNA Y. This shows that since signing on with hospice the Resident was requiring more assistance with his ADL's, including dressing. A review of the Fall Incident and Accident report for Resident #27 on [DATE] revealed, .Possible causative factors: Gait instability. Footwear: improper . Management review: Administrator. [DATE] Resident did have fracture. Reported to state. No breach of CP (care plan). DON/ADON: Not reviewed . A review of Resident #27's fall history revealed two other falls. An Incident and Accident report dated [DATE] revealed, . staff found resident laying at the foot of his bed on his left side, oxygen off and barefoot, incontinent . An incident and accident report dated [DATE] revealed, Observed sitting on floor with back against his wife bed. Stated 'the bed moved and I fall down landing on my butt.' . Resident had no shoes on .What footwear was in use at the time of the event by the Resident? Socks: Regular. No shoes on On [DATE] at 2:22 p.m., an interview was conducted with CNA Y. When asked what happened, CNA Y reported that it had been a normal day, had gotten report from the other staff, had went in to give out waters and pick up breakfast trays. CNA Y stated that she had went to take a 15 minute break and by the time she came back from her break she saw the emergency responders taking Resident #27 away. CNA Y reported that she was shocked and felt very guilty. When asked about whether Resident #27 used the call light, CNA Y stated, No. He doesn't use the call light. When asked if Resident #27 had been dressed for the day or not, CNA Y stated, He was dressed, but was unable to recall if he was wearing socks, grippy socks, or shoes. On [DATE] at 3:01 p.m., an interview was conducted with the Senior Regional Administrator V, who when asked about the missing witness statements stated, I thought that they would be in the file with the investigation. On [DATE] at 4:05 p.m., an interview was conducted with the Director of Nursing (DON), who when asked about the fall investigations reported it was the unit managers who did the investigation, and then the team would review it. When asked about which CNA had documented that the Resident was unavailable for dressing on the morning of [DATE] when Resident #27 had his fall, she reported it was CNA Y. On [DATE] at approximately 5:00 p.m.,the DON reported that CNA Y had clocked in at 6:44 a.m., and clocked out at 4:06 p.m., but had not punched out for a lunch during her shift. When asked if that was normal to not punch out for a lunch, the DON stated, No, they should be punch out for their lunch. On [DATE] at 5:20 p.m., the Director of Clinical Operations/Registered Nurse (RN) L reported that she had been able to come up with a vague timeline of events for Resident #27's fall on [DATE]: between 9:,[DATE]:15 a.m., CNA Y had removed breakfast trays from Resident #27's room. At 9:55 a.m., Resident #27 was found on the floor. At 10:00 a.m., the family and physician were notified. At 10:33 Resident #27 was sent to the emergency room . On [DATE] at 9:30 a.m., an interview was conducted with the Administrator, who had conducted the investigation for Resident #27's fall on [DATE]. When asked about why he had put the time of 11:43 a.m. as the time of the incident when staff reported that it had occurred at 10:00 a.m., the Administrator reported that it was likely because that was when himself had found out about it. When asked why there were no times listed (when the resident was last checked, when found, when sent out, etc), he stated, I just included the events that occurred. I didn't have times. When asked about the missing witness statements, the Administrator stated, Well (RN J) had a note (in the medical record). And no staff had stated concerns. When asked if he had interviewed CNA Y, the Administrator reported that he had not because she had not been on the floor at the time the Resident was found. On [DATE] at 9:44 a.m., an interview was conducted with RN J. When asked about Resident #27's fall and his caretaker for the day (CNA Y) not being around at the time of the fall, RN 'Y reported that CNA's usually let the nurses know when they were going on break. When asked if CNA Y had informed her that she was leaving the unit for a break for lunch, RN J stated, I don't remember if she told me or not. When asked what Resident #27 was wearing when she found him on the floor, RN Y could only report that he was wearing clothes, but couldn't not remember what he was wearing. Resident #324 A review of Resident #324's medical record revealed she admitted to the facility on [DATE], went to the hospital on [DATE] after a fall. Resident #324 was readmitted on [DATE] and discharged to another facility on [DATE]. A review of Resident #324's [DATE] Quarterly MDS assessment revealed she scored ,[DATE] on the BIMS assessment indicating severely impaired cognition. A review of an [DATE] progress note revealed, This writer was alerted by Speech Therapist that the resident was on the floor. Resident was on her knees facing the bed with wheelchair behind her. Upon entering the room within minutes, resident was sitting in the wheelchair folding towels. Charge nurse asked resident if she had fallen. She stated I plead the fifth . A review of the incident and accident report for this event listed no new intervention to prevent future falls. A review of a progress note dated [DATE] revealed, This writer was alerted by staff that resident was on the floor behind nursing station desk. Resident was observed sitting on the floor with w/c behind her and bedside table in front of her. Resident stated I was trying to take care of the dinner dishes on the tray and it moved, I fell and sat down. No apparent injuries noted . A review of an [DATE] progress note revealed, Resident was observed sitting on the floor in front of her w/c. She was working on a puzzle by the nurses station and a piece fell on the floor and she reached for the piece and slid out of the w/c. Resident stated I slid . A review of the incident and accident report for this event listed no new intervention to prevent future falls. A review of an [DATE] progress note revealed, Resident was observed by CNA to be sitting on the floor in front of station 1 soiled utility room. When asked if her head hit anywhere, resident stated, No. Resident denies pain or injury. When asked what she was trying to do, said, going to the office. Resident assessed, assisted up and back to bed . A review of the incident and accident report for this event listed no new intervention to prevent future falls. A review of an [DATE] progress note revealed, Resident is c/o pain in the right hip area rating a 9 out of 10 using the ,[DATE] scale. This nurse asked the resident why she thought her hip was hurting and the resident stated I fell down last night. This nurse asked the resident what she was attempting to do when she fell down and she replied I was going up the hill over there. There has been no c/o pain prior to this time from the resident. As recommended and ordered by the on-call physician, the resident was sent to MMC ER for further evaluation. A review of a [DATE] progress note revealed, This writer placed call to daughter/(Family Member Z) to review current fall interventions. Current interventions in place include: bed in the lowest position when in bed, padded mat beside bed, auto lock brakes on wheelchair, not slip mat between wheelchair cushion and seat of wheelchair, gripper socks worn when in bed as resident allows/tolerates, not slip shoes/slipper when out of bed. Also toileting upon rising, before/after meals, during AM/PM care, at HS (hour of sleep) and offer q 2 (every 2) hours during the night, frequent safety checks . A review of a [DATE] progress note revealed, Resident confused and very impulsive. Very poor safety judgement. In hallway outside dayroom facing double doors. Sitting on edge of w/c pushing items behind her in chair. Slid off seat to floor. States someone pushed me. No other resident or staff near her at the time. Skin inspection negative for injury . A review of the incident and accident report for this event listed no new intervention to prevent future falls. A review of the medical record revealed no Fall Risk Assessment was completed after this fall. A review of a [DATE] progress note revealed, Resident stood up from w/c wheelchair and fell backwards onto floor near Station#3 desk. Asked resident what happened. She stated I tripped over my feet Asked resident if she was in pain , replied my head hurts a little She pointed to the spot, she did have a small red lump size of dime . A review of the incident and accident report for this event listed I cannot think of anything that we aren't already doing as the intervention to prevent future falls. A review of the medical record revealed no Fall Risk Assessment was completed after this fall. A review of a fall incident and accident report for [DATE] revealed, 7:30 a.m . Resident at nurses station in w/c. Got up independently, lost balance and sat on floor . This fall was listed as witnessed yet there were no witness statements as to what had happened. A review of the incident and accident report for this event listed no new intervention to prevent future falls. A review of the medical record revealed no Fall Risk Assessment was completed after this fall. A review of a progress note dated [DATE] revealed, . (Resident #324) was on the floor in the day rm (room). Entered rm to observe client sitting on her butt in the day rm and trying to get up using meeting table in the center of the room. Her wheel chair was half under the side table against Right hand wall. Client denied pain or discomfort . A review of the incident and accident report for this event listed Root cause was resident self transfer in an area with decreased supervision . The new intervention listed, Freq (frequent) checks on clients (Residents) whereabouts q (every) 15 min (minutes) for shift. A review of a progress note dated [DATE] revealed, 2230 (10:30 p.m.)-Resident found sitting upright on floor in bedroom, bleeding from left elbow. Asked resident what she was doing, her reply was I had to get over to the other bed. Left elbow had large skin tear . A review of the incident and accident report for this event (occurred on [DATE]) revealed, Checking on resident q 15 min. as the new intervention. Evidence of 15 minute checks were not in the investigation or medical record. A review of a [DATE] progress note revealed, Loud thud heard like someone hitting a wall . (Resident #324's) legs seen in BR (bathroom) doorway. (Resident #324) observed sitting up on buttocks facing the door and pulling at handrail to get up, . helped her to toilet . RN entered rm to see client sitting on the toilet, clothed with 1 cm (centimeter) laceration on Left lateral side of head near eye, client able to move all extremities, grips are equal, c/o (complaints of) H/A (head ache). Stated she fell but could not elaborate. Client denied pain except for a H/A on her eye, laceration cleansed with soap and water, steri strips applied, covered with bad aid . Client began to c/o Left foot hurting, raised bruise noted on Lateral arch, tender to touch . Schedule x-ray of Left foot. Call to client's daughter/(Family Member Z) and informed of occurrence and complaints as well as PCP (primary care physician) orders. She expressed disappointment that our facility does not use alarms/sensors that would have possibly prevented this occurrence and she wanted a copy of any occurrence reports. I informed her I would pass on her concerns/requests to the manager.A review of the incident and accident report for this event under management review revealed, Res with fall, unassisted that may have been in response to the bathroom . There were no new interventions listed on the Fall Scene Investigation Report, but did include Res was sent to ER (emergency room ) for eval (evaluation) - laceration with steri strips, (negative) xray to ankle . A review of a [DATE] progress note revealed, SW (Social Worker M) followed up with residents daughter (Family Member Z) re: (regarding) her concerns with resident's recent falls. Daughter states that her biggest concern is the falls at night. Daughter also states she would be half-way ok with fall alarms. SW explained that fall alarms are considered a restraint and that we are unable to utilize them at (Name of Facility). Daughter responded, well then I need a different answer. SW informed (Family Member Z) that the clinical team is addressing the concerns and will follow up with (Family Member Z) . On [DATE] at 2:31 p.m., an interview was conducted with Unit Manager/ RN G. When asked about Resident #324's falls and fall investigations stated, I would just talk with the nurse and the CNA's and check the TSI (fall incident and accident reporting system) as done. The nurses on the floor do them. We go over them and input the interventions. When asked when fall risk evaluations were supposed to be completed, RN G stated, After each fall. When asked when new interventions for falls were supposed to be developed and implemented, RN G stated, After every fall. On [DATE] at 4:25 p.m., an interview was conducted with the DON, who when asked about Resident #324's frequent falls, missing interventions and incomplete fall assessments, the DON stated that it was the nurses on the floors responsibility to fill out the incident and accident reports, and that the team would review them. A review of Resident #324's care plan for falls, initiated [DATE] revealed, The Resident is high risk for falls r/t (related to) weakness, dementia, toxic [MEDICAL CONDITION], anxiety, hypertension, [MEDICAL CONDITION], previous falls . Ensure assistive device (such as cane, walker) is within reach when in a chair or bed ([DATE]) . non-skid socks/footwear ([DATE]) . when resident attempts to stand ask what they would like to do, and then assist them to complete their desired task ([DATE]) . Anticipate and meet the resident's needs ([DATE]). Bed in the lowest position when in bed ([DATE]) .Ensure the residents call light is within reach . ([DATE]) .Gripper socks worn when in bed, as resident allows/tolerates ([DATE]) .have staff assist resident to call family . when resident show s/sx (signs and symptoms) of increase anxiety ([DATE]) . Nonskid material between wheelchair cushion and seat ([DATE]) . Padded floor mat beside the bed when resident is in bed ([DATE]) . Resident enjoys working on jigsaw puzzles. Encourage to work on puzzles when sitting in the wheelchair ([DATE]) . Resident to wear non skid slippers (her preference of footwear) when out of bed ([DATE]) . When resident completes her meals, remove meal tray out of her room ([DATE]) . Non slip material between wheelchair seat and cushion ([DATE]) . There were on interventions regarding need for supervision, or regarding the 15 minute checks discussed after the [DATE] fall. New interventions were not added for each subsequent fall. Resident #33 A review of Resident #33's medical record revealed she admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of her [DATE] Annual MDS assessment revealed she scored ,[DATE] on the BIMS assessment indicating impaired cognition. A review of an incident and accident report dated [DATE] revealed the following: Staff observed resident standing at front door knocking to come in. Resident stated, That man left me out. I was looking for my car. Resident was assisted back into facility without any difficulties . An inservice sign in sheet for an all staff education were dated [DATE] and stated, When entering or exiting the facility, ensure that the door is shut and secured to prevent a resident from eloping. A review of an incident and accident report dated [DATE] revealed, At 13:15 I (RN J) I went to lunch and at about 13:50 (1:50 p.m.,) I was notified by Station 1 nurse that as he was leaving the building (through Station 1 entrance) he saw (Resident #33) walking up the walkway (outside of the building). He let her in the building. Res (resident) stated she was looking for her car . A review of the all-staff education given [DATE] revealed, When exiting the facility you must stop, turn around, and ensure the door behind you is completely closed and no residents are following you out of the building. This elopement was nearly identical to the elopement that occurred on [DATE]. A review of her [DATE] Elopement Risk Evaluation revealed she scored 5.0 (low risk), with no history of attempts. A review of the next Elopement Risk Evaluation dated [DATE] (after the elopement) revealed she scored 15.0 (high risk). The quarterly Elopement Risk Evaluation had not been completed in July or August, and was not completed until after the elopement had occurred on [DATE]. On [DATE] at 4:00 p.m., an interview was conducted with former Administrator (NHA) X regarding Resident #33's two elopements. NHA X stated, For the first one, he (Activities Director CC) was redirecting her (Resident #33) back to her room, and then he went to leave. He didn't have his hearing aides on that day and he didn't hear her (leave behind him). He felt really bad about it. For the second one (elopement on [DATE]) she used her foot. (CNA K) was in the hallway and was rushing out. The receptionist had just stepped away. On [DATE] at 4:20 p.m., the Senior Regional Administrator/NHA V and the Director of Clinical Operations/ RN W were asked for more information on the elopements. When asked about how Resident #33 could have just slipped out behind Activities Director CC without noticing her, NHA V stated, If he opened it wide enough she could have gone through (before the door closed and locked).' On [DATE] at 4:32 p.m., an interview was conducted with RN I who had been up at the nurses station at her medication cart at the time of the Resident #33's [DATE] elopement. When asked if she had noticed the Resident had been standing near the front entrance, RN I reported that she had not. When asked if Resident #33 had a habit of coming to the front door, RN I reported that she would often ambulate to the front door and then head back to her room, and that she would be looking for things or her husband. On [DATE] at 3:17 p.m., Resident #33 was observed to be walking with her 4-wheeled walker and pushed through the hallway double doors and ambulated up to the front door. Resident was standing a few feet away from the door with her coat draped over her walker seat and was staring out the door. On [DATE] at 3:40 p.m., RN W was asked about new interventions put in place after each elopement. RN W reported that the Isolation (for COVID-19) unit was relocated, and was located between Resident #33's room and the front door to the left. She reported that the stop sign on the door decreased her behavior of trying to get to the front door. When asked what had happened for the [DATE] elopement, RN W stated, She went the long way around (the building) to the front door. On [DATE] at 8:37 a.m., an interview was conducted with Activities Director CC who had been the person who had let Resident #33 out the door during the [DATE] elopement. Activities Director CC stated, She had previously been looking for her car. A lot of people were saying (to her) that it was in parking lot. I told them not to do that. That day she was too (looking for her car). I said to her that she never had one (parked at the facility) and to go talk to her husband. I was leaving, out the front door. I didn't see her. When asked if Resident #33 had ever eloped in past, Activities Director CC stated, I think it was just perfect timing. When asked what new intervention was put in place and educated to staff, Activities Director CC reported that the staff was told to redirect Resident #33 if you saw her by the door. On [DATE] at 4:25 p.m., an interview was conducted with the DON regarding Resident #33's [DATE] elopement. The DON reported that CNA K had told her that she had observed Resident #33 closer to her office door and not right beside the door. When asked what education had been done to prevent a future elopement of the same type, the DON stated, To make sure when you close the door to look (for Residents). When asked what she would have expected CNA K to do, the DON stated, That she would have looked behind her. On [DATE] at 9:07 a.m., an interview was conducted with CNA K. When asked about the elopement on [DATE], CNA K stated, I didn't even know it was me till I got back in. I was rushing out to go to break. I'm constantly rushing. Apparently she went through the door (behind me). When asked if she had observed Resident #33 near the door when she left, CNA K reported that she had not. When asked if she had received the education back on [DATE] regarding Resident #33's first elopement, CNA K stated Yes, It was to look behind you and make sure the door is completely closed. When asked what new interventions had been implemented, CNA K stated, They just said to stand and wait till the door closes completely. A review of the facility policy titled Wandering and Elopement Guideline dated [DATE] revealed, . Upon admission, re-admission, through quarterly review and change in condition our residents will be evaluated for potential elopement risk to determine appropriateness of placement within the facility . Resident #28 - Elopement A review of the [DATE] elopement investigation provided by the facility revealed the following: Resident #28 was a [AGE] year old admitted to the facility on [DATE]. Resident #28 had a Brief Interview of Mental Status (BIMS) assessment of 5 out of 15 (severely impaired). The summary of the incident stated, on Monday [DATE] at 8:33 PM, Resident #28 exited the facility through the dining room egress door. The door alarm was sounding and at 8:35 PM Certified Nurse Aide (CNA) S immediately investigated and noted resident sitting on the ground approximately 15 feet from the door. Resident #28 was assisted into the facility at 8:38 PM and the Former Nursing Home Administrator (NHA) X was notified. The investigation also indicated Resident #28 was wearing tennis shoes, knit slacks and a Christmas sweater. The investigation also indicated a follow-up Wander Elopement Risk assessment was completed following the incident. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 required supervision of one assist for walking in room/unit corridors and transfers. A review of the Electronic Medical Record (EMR) assessment section revealed the reason for the [DATE] Wander Elopement Risk assessment was reentry. A review of the Census section of the EMR for Resident #28 revealed Resident #28 was readmitted to the facility on [DATE]. Further review of the Wander Elopement Risk assessments revealed no assessment in direct response to the actual elopement which occurred on [DATE]. A review of the incident report for the elopement on [DATE] revealed Resident #28 eloped from the facility dining room egress door unwitnessed and was found outside the building on [DATE] at 7:40 PM approximately 10 feet from the bottom of a ramp. A walker was located on the side walk next to Resident #28. The incident report also noted Resident #28 was only wearing gripper socks, which conflicted with the facility investigation findings. Based on the description of where the resident was located on the incident report, the distance from the dining room egress door was 30 feet. Resident #28 also sustained a fall in the parking lot area. The incident report indicated the weather at the time of the incident was 25 degrees Fahrenheit and cloudy, and for the time of day, would have been after dark. On [DATE] at 2:42 PM, an interview with CNA S revealed the following: When asked where CNA S was prior to the elopement, CNA S stated, I was coming back from break, and I pulled into the parking lot and pulled to the back of the parking lot. When asked if there was anyone out in the parking lot, CNA S stated, I did not see anybody outside that should not have been. When asked what happened next, CNA S stated, So then I came into the building to the break room and I heard it (alarm) coming in and then went to put my stuff away, came back out and still heard it (alarm). So I went looking for it thinking it might have been an iPad or something like that. I headed toward station one and could not locate the sound. So I headed back and when I opened the door to the dining room, I heard the alarm and saw the door open. I went to the door and saw (Resident #28) sitting on the ground in the snow, and saw the walker tipped over. It was still snowing at the time and it was enough to make it slick. When asked what the conditions of the walk way were, CNA S stated it was slippery for her to walk. When asked how this was assessed, CNA S stated she tried to run to respond and couldn't because of how slick it was. Then I called for help on my phone. When asked why CNA S had to call on her cell phone, CNA S stated no one else had responded. (Resident #28) tried to beat us up while we were trying to get her back in. It was really cold out, and (Resident #28) had just grippy socks on her feet, but was fully dressed. She must have been cold. When asked where Resident #28 was located when found, CNA S stated Resident # 28 was down off the sidewalk approximately three sidewalk segments from the ramp sitting in the snow. When asked where Resident #28 was sitting, CNA S stated Resident #28 was in the parking lot in a parking space. When asked why it was so difficult for her to figure out where the alarm was coming from, CNA S stated the alarm was really hard to hear because there was music in the kitchen that was .really blaring. On [DATE] at 3:20 PM, an interview with Registered Dietitian (RD) B stated she knew she got out the dining room egress door, and the alarm sounded. When asked why the doors to the dining area were closed, RD B stated the dining room was closed to residents at that time. When asked if it would be difficult to hear the door alarm with the doors closed, RD B stated there was some type of alarm on the doors from the dining area to the living area at one point, but stated they were taken off sometime around September. When asked why they were taken off, RD B stated she did not know. RD B stated that would be a question for Former Nursing Home Administrator (NHA) X. On [DATE] at 3:24 PM, an interview with Former NHA X revealed the following: When asked about alarms on the doors to the dining area from the resident living area, NHA X stated he remembered having to go out and obtain door alarms for the dining room because of a fall which happened in the dining room while the dining room was shut down. When asked who's decision it was to put the alarms up and why, NHA X stated his regional clinical support person stated he needed to go out and buy the alarms to prevent someone from falling in the dining room while it was closed and to prevent a resident from not being readily discovered after a fall in the dining room. When asked when the (TRUNCATED)

Based on observation, interview, and record review, the facility failed to prevent accident and injuries for one Resident (#101) of three residents reviewed. This deficient practice resulted in harm when Resident #101 sustained a fractured arm and uncontrolled pain after staff repositioned the Resident in an unsafe manner. Findings include: Resident #101's Face Sheet revealed an admission date of [DATE] and medical [DIAGNOSES REDACTED]. On 01/14/20 at 11:36 a.m., Resident #101 was observed in bed. A shoulder immobilizer was observed on their left shoulder. Resident #101 reported the left arm had been broken when the Certified Nurse Aides (CNAs) had repositioned them. Resident #101 stated, They (CNAs) normally use a draw sheet (for repositioning) .this time they (CNA)s didn't have a draw sheet and their hands weren't in the right place. I heard a popping sound in my arm. On 01/14/20 at 3:09 p.m., CNA C stated that on the morning of 01/03/20, CNA C and CNA D were preparing to provide incontinence care to Resident #101. There had not been not a draw sheet underneath Resident #101 to facilitate turning and repositioning. Resident #101 had insisted CNA C and CNA D place their hands underneath Resident #101's arms to boost Resident #101 up in bed. Resident #101 told CNA C there was a feeling of breaking (to the left arm). When asked how CNA C was trained to reposition residents, CNA C stated, I was trained to use a draw sheet .I should have put the draw sheet (under Resident #101), it's one of those things you look back on and feel so bad. I shouldn't have transferred (Resident #101) that way). On 01/14/20 at 3:34 p.m., the Director of Nursing (DON) and Regional Director of Clinical Operations were asked what how CNAs were trained to reposition residents in bed. The DON reported, with the two CNAs and a draw sheet to roll and reposition residents. When asked if a draw sheet should have been used to reposition Resident #101, the DON replied, The draw sheet was not used .at the request of (Resident #101). During an interview on 01/15/20 at 9:21 a.m., Emergency Department Registered Nurse (RN) A reported when Resident #101 arrived to the Emergency Department on 01/05/20, there was a dark purple bruise in the shape of a hand underneath Resident #101's left arm. RN A suspected the arm was broken. A review of Resident #101 Electronic Medical Record (EMR) revealed a progress noted dated 01/05/20 7:23 a.m. written by RN I containing the following information, Approx. (approximately) 0430 (4:30 a.m.) resident was sent via North Flight to ((facility name) medical center) d/t (due to) possible L (left) shoulder displacement that occurred two days earlier when resident asked CNAs to boost via her arm pits, and in doing so caused injury to resident L shoulder . Resident #101's 01/05/20 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 3/15 indicating Resident #101 was severely cognitively impaired. A review of the hospital Emergency Department summary dated 1/5/2020 revealed the following: (Resident #101) arrived via EMS for uncontrolled left arm pain. Patient reports that last Tuesday she was being boosted in bed underneath herarmpits by 2 medical assistants and she immediately screamed in pain. Reports that she heard something abnormal. Since last Tuesday she has been in significant pain and has been receiving her home [MEDICATION NAME] which is not helping at all . She describes the pain as a sharp 9 out of 10, nonradiating. The current nurse who is taking care of her today had her sent to the emergency department after a few doses of the [MEDICATION NAME] available did not help her.

Based on observation, interview, and record review, the facility failed to prevent accidents for two residents (#23 and #43), and failed to ensure the care plan was followed to prevent further falls for one Resident (# 52), of 20 residents reviewed for accidents and hazards. This deficient practice resulted in an actual injury and potential for further injury to residents. Findings include: Resident #43 A review of Resident #43's Face Sheet revealed an individual admitted to the facility 7/18/19. Resident #43 had a medical [DIAGNOSES REDACTED]. Resident #43's Minimum Data Set (MDS) reviewed a Basic Interview for Mental Status (BIMS) score of two indicating moderate cognitive impairment. Resident #43 was non interviewable. During an interview with Family Member (FM) U on 6/23/19 at 5:10 p.m., it was reported Resident #43 had sustained an injury to the leg and had to go to the hospital to get stitches. FM U reported the staff had not been following the care guidelines when the injury occurred. On 06/24/19 at 8:40 a.m. Resident #43 was observed being transferred from a wheelchair to bed by Certified Nurse Aide (CNA)s 'F and J. Resident #43 did not bear any weight on their legs, required maximum assistance, and a gait belt. Resident #43's injury was discussed during an interview with former Director of Nursing (DON) I on 06/24/19 at 4:58 PM. DON I reported Resident #43 had injured their leg on 5/4/19 during a transfer back to bed. DON I reported Resident #43 was a two person assist with transfers. DON I reported CNA K had not followed Resident #43's care plan and had transferred Resident #43 by themselves. Resident #43 bumped their leg on the bed frame during the transfer and had to be transferred to the hospital to control the bleeding which required stitches. On 06/25/19 at 9:59 a.m., CNA K was interviewed via telephone. CNA K reported Resident #43 had been a two person transfer but CNA K had performed the transfer without assistance because Resident #43 had been out of been out of bed for a long time and was tired. CNA K admitted the care plan had not been followed. CNA K noticed the injury after Resident #43 was placed back in bed. Resident #43's sock had a lot of blood on it. CNA K reported Resident #43 ended up going to the hospital because of the bleeding had to get stitches. A progress note dated 5/4/19 written by DON I contains the following information, Late Entry: Resident was assisted to bed by CNA and upon sitting on side of bed after the transfer, blood was observed on the floor .Blood was observed on the bed frame and it is reasonable to conclude that she bumped her leg on the bed during transfer causing a laceration to her leg . Resident #43's care plan dated 5/23/19 revealed the following, Transfers: Resident is a two person pivot transfer with gait belt . A review of the Emergency Department Note dated 5/4/19 revealed the following information, .Extremities reveal left lower extremity on the lateral side of calf with a deep 18 cm laceration. The laceration is at least 1.5-cm deep . An 18 cm laceration was repaired with 6 deep sutures and 14 horizontal mattress sutures. Resident #23 A review of Resident #23's Face Sheet revealed Resident #23 was admitted to the facility on [DATE]. Resident had a medical [DIAGNOSES REDACTED].#23's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three, indicating moderate cognitive impairment. Resident #23 was non-interviewable. During an interview with Family Member (FM) V on 6/23/19 at 5:39 p.m., FM V reported Resident #23 had a bruise on the inside of the inner thigh. FM V reported the facility informed FM V it was believed the bruise had been caused by the mechanical lift sling (equipment used for transferring residents that are not able to stand or pivot). FM V did not think Resident #23 was abused, however FM V did state, Sometimes they (staff) get in a hurry and don't do things the right way. On 6/24/19 at 9:10 a.m., Resident #23 was observed being transferred to the bed using the mechanical lift. A blue sling was used for the transfer. Resident #23's right inner thigh was observed to have a small round bruise purple in color approximately 0.5 cm diameter. The bruise did appear to align with where the sling had been during the transfer. On 6/24/19 at 9:19 a.m. CNA J was asked what the process was for ensuring the correct size sling was being used. CNA J did not know who performed the sling measurements and was not able to verify sling size measurements were taking place. On 6/24/19 at 9:30 a.m. Unit Manager/RN A was asked what the process was for measuring residents requiring a transfer sling. RN A reported there was not a process in place at this time. When asked if there was any way of knowing if Resident #23 had the correct sling in use since measurements were not performed, RN A replied, No. Resident #52 A review of the Electronic Medical Record (EMR) for Resident #52 revealed the most recent admission to the facility was on 4/4/19. A review of the History and Physical for Resident #52 revealed the following: (Resident #52) presented to (Local Hospital) after a fall. (Resident #52) developed [MEDICAL CONDITION] (rapid beating of top chambers of the heart) with rapid ventricular response (lower heart chambers attempting to follow top heart chambers) . (Resident #52) did develop rib fractures . Psych (psychiatric condition): Awake alert confused at baseline appears to have significant cognitive impairment does not have any memory of recent events . [DIAGNOSES REDACTED]. acute on chronic diastolic (congestive) heart failure . dementia without behavioral disturbance . ribs, multiple fractures . [MEDICAL CONDITION] with RVR (Rapid Ventricular Response) . fall, subsequent encounter . continue O2 for supplementation as needed . A review of a radiology report for Resident #52 dated 3/30/19 revealed . moderately displaced right lateral 7th and 8th rib fractures . Further review of the EMR for Resident #52 revealed two falls (on 5/2/19 and 6/11/19) since most recent admission to the facility, with no significant injuries related to falls. According to the EMR there was a fall which occurred at the assisted living level of care where Resident #52 sustained rib fractures. A review of an incident report for Resident #52 dated 5/2/19 revealed an unwitnessed fall where staff had heard Resident #52 yell out for help, and subsequently found Resident #52 on the floor next to the bed. Preventative measures included therapy (PT (physical therapy, OT (occupational therapy), ST (speech therapy)) . call light: encouraged and taught use of . toileted at least every two hours. Assistive devices and interventions in use at the time of the event were walker . wheelchair. Root cause was identified as . confusion and impulsive behavior but (Resident #52) continues to insist on being independent in preparation for her perceived discharge to assisted living . A review of an incident report for Resident #52 dated 6/11/19 revealed an unwitnessed fall where Resident # 52 was observed sitting on buttocks on the floor in front of the toilet. Preventative measures identified were call light: encouraged and taught use of . call light: kept within reach. Resident # 52 sustained a bruise to the right buttock. Root cause analysis was identified as resident had asked for privacy during toileting, staff honored the request, and Resident #52 attempted to self transfer. A new intervention was added to post a large print sign in the bathroom reminding Resident #52 to use the call light and ask for help. On 06/23/19 at 11:10 AM during a review of the room for Resident #52, there were foot pedals observed in two different spots on the floor. One foot pedal was located next to the bedside table, and the other foot pedal was on the opposite side of the bedside stand near the exit of the room. Both were in an area of being a potential tripping hazard. There was a foldable walker opened up and near the doorway to the room next to the foot pedal on the floor. There was a Kleenex laying on the floor between the recliner Resident #52 was sitting in, and the bedside table which was completely out of reach of Resident #52. The Kleenex box was also out of reach sitting on the bedside table. The bedside table was approximately 6 feet from the recliner Resident #52 was sitting in, and Resident #52 was in a reclined position. There were also other personal items, and a cup of fluid sitting on the bedside table. The call light was observed draped along the foot of the bed, and was also completely out of the reach of Resident #52. On 06/24/19 at 09:39 AM an interview with family member R revealed the following: Just prior to (MONTH) (Resident #52) had a fall and didn't recover very well from it. She had several ribs get broken. This is why she is no longer able to be on the assisted living side. On 06/24/19 at 08:08 AM Resident #52 was observed back in her room after eating breakfast in the main dining room. There were no means available to call for assistance for Resident #52. The call light cord was attached to the bed behind Resident #52. Resident #52 was facing the doorway to the room and positioned just inside the doorway. The bedside table was also out of reach for Resident #52 with a cup of fluid sitting on the surface. Resident #52 was calling out in a low voice Help, help. Registered Nurse (RN) M was located just outside the room near a medication cart, and this Surveyor was standing next to RN M when the calling out was initially detected. When asked if Resident #52 needed help, RN M went in the room and asked Resident #52 Do you need help? Resident #52 made a head nodding motion toward the bathroom for RN M. RN M asked Resident #52, Do you need to go to the bathroom? Resident #52 stated Yes. RN M stated, Can you hold on for a second, I have to go drop these (medications) off to another resident? Resident #52 stated that was ok. RN M returned to the room and asked if Resident # 52 was ready to go into the bathroom, and then stated she did not have to go. RN M then noticed the call light for Resident # 52 was not within reach. RN M removed the call light from the bed, clipped the call light to the clothing of Resident #52, and stated, If you need help, use this call light. Resident # 52 stated, Oh, thank you. RN M stated, You are welcome, and then left the room. RN M stated to this Surveyor Resident # 52 was still able to walk with assistance. A review of the printed Activities of Daily Living (ADL) care plan provided by the facility revealed Resident # 52 . requires physical assistance 1 with gait belt & walker (initiated 4/5/19) . for transfers. A review of the printed Fall Risk care plan provided by the facility revealed interventions including . encourage resident to stay properly hydrated, educate that dehydration increases risk for falls (initiated 4/5/19) . remind /show sign on wall to resident 'DO not get up by yourself' and 'Use call light cord for help (initiated 4/5/19) .

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT BILATERAL HEEL PRESSURE SORES FOR ONE (#5) OF EIGHT RESIDENTS WITH PRESSURE SORES IN A TOTAL SAMPLE OF 19 RESIDENTS. THIS FAILURE RESULTED IN HARM TO RESIDENT #5 WHEN SHE DEVELOPED A BLACK UNSTAGEABLE SORE ON HER RIGHT HEEL, AND A PARTIAL THICKNESS SKIN LOSS ON HER LEFT HEEL. FINDINGS INCLUDE: RESIDENT #5 WAS admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. ON A SKIN CARE assessment dated [DATE], RESIDENT #5 SCORED A 14, INDICATING A HIGH RISK AND WAS PLACED ON A "FRAGILE SKIN PROGRAM". THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED 1/7/10, SECTION M, SKIN CONDITION, IDENTIFIED RESIDENT #5 AS HAVING NO PRESSURE ULCERS, NOR ANY HISTORY OF RESOLVED PRESSURE ULCERS. THE SAME ASSESSMENT, SECTION G, PHYSICAL FUNCTIONING/STRUCTURAL PROBLEMS, IDENTIFIED RESIDENT #5 AS NEEDING LIMITED ONE PERSON PHYSICAL ASSIST TO WALK AND SECTION B, COGNITIVE SKILLS FOR DAILY DECISION MAKING, INDICATED DECISIONS POOR, CUES/SUPERVISION REQUIRED. ACCORDING TO THE NURSES NOTES FOR RESIDENT #5 DATED 7/8/10 AT 10:30 A.M., "NOTED A SILVER DOLLAR SIZE BLISTER ON BACK OF HEEL". ANOTHER NURSES NOTE DATED 7/9/10 AT 5:00 A.M. READS, "HAS AN INTACT FLUID FILLED BLISTER ON HER LEFT HEEL... BLISTER MEASURES 4 CM (CENTIMETERS) BY 3 CM AND IS CLEAR IN APPEARANCE. RESIDENT WAS NOTED WEARING HER SHOES WITHOUT SOCKS...." A PHYSICIAN NOTE FOR RESIDENT #5 DATED 7/9/10 READS, "WAS FOUND TO HAVE A LARGE BLISTER ON THE LEFT HEEL, THOUGHT TO HAVE COME FROM WEARING SHOES WITHOUT SOCKS." THE FACILITY'S CURRENT PREVENTIVE SKIN CARE PROCEDURE FOR ALL RESIDENTS READS, "ALL RESIDENTS WILL HAVE THEIR FEET AND SHOES ASSESSED FOR FIT AND COMFORT PRIOR TO AMBULATION TO ENSURE NO DEPENDENT [MEDICAL CONDITION] IS PRESENT OR OTHER CAUSES FOR IMPROPER SHOE FIT." THERE WAS NO EVIDENCE OF THIS INTERVENTION BEING IMPLEMENTED, RESULTING IN RESIDENT #5 DEVELOPING A BLISTER TO THE BACK OF THE LEFT HEEL. THE FRAGILE SKIN PROGRAM DOCUMENT READ, "1) A. A BUTTERFLY STICKER WILL BE PLACED ON THE RESIDENT'S NAME PLATE TO REMIND STAFF OF THE INCREASED SKIN RISK AND TO DIRECT THEM TO THE RESIDENT'S INDIVIDUAL CARE PLAN FOR COMPREHENSIVE INDIVIDUALIZED INTERVENTIONS FOR THE RESIDENT." THE ONLY INTERVENTIONS ON THE COMPREHENSIVE CARE PLAN DATED 7/9/10 SHOWED, "MUST WEAR SOCKS WHEN WEARING SHOES!", AND "BOOT LEFT FOOT WHEN IN BED/HS". NO INDIVIDUAL CARE PLAN WAS FOUND TO FLOAT RESIDENT #5'S HEELS TO RELIEVE PRESSURE. ON 10/18/10 AT APPROXIMATELY 1:45 P.M., RESIDENT #5'S HEELS WERE OBSERVED WHILE SHE WAS LAYING IN BED. THE LEFT HEEL WAS OBSERVED TO HAVE A PARTIAL LAYER SKIN LOSS MEASURING 1.4CM BY 1.0CM, WITH A WHITE AREA IN THE MIDDLE MEASURING .7CM BY .9CM, SURROUNDED WITH PINKISH GRANULATION. THE RIGHT HEEL WAS OBSERVED HAVING A DARK AREA THE SIZE OF A DIME. AT 2:30 P.M., RESIDENT #5 WAS OBSERVED LAYING ON HER BACK WITH HER EYES CLOSED. BOTH HER HEELS WERE OBSERVED LAYING DIRECTLY ON THE BED MATTRESS. NO BOOTS WERE IN PLACE, NOR WERE THE HEELS FLOATED OFF THE BED TO RELIEVE THE PRESSURE IN THE AREA. RESIDENT #5'S HEELS WERE OBSERVED AGAIN ON 10/20/10 AT APPROXIMATELY 10:30 A.M. THE BACK OF THE RIGHT HEEL NOW HAD A BLACK AREA MEASURING 1CM BY 1CM WITH INTACT SKIN. HER LEFT HEEL HAD A NEW THIN LAYER OF SKIN OVER THE HEEL. THE CHARGE NURSE STAFF "O" WAS INTERVIEWED AFTER THE OBSERVATION AT 10:35 A.M., AND STATED THAT SHE THOUGHT THE RIGHT HEEL HAD BECOME WORSE AND THE LEFT HEEL HAD IMPROVED SINCE OUR OBSERVATION TOGETHER ON 10/18/10 AT 1:45 P.M. ( ) --